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Biomedical subjects

Mohit Bhandari

Publications and source records attributed to Mohit Bhandari.

At least 109 records · Page 6Linked to original sources
PubMed2003

Predictors of reoperation following operative management of fractures of the tibial shaft.

BACKGROUND: Accurate prediction of likelihood of reoperation in patients with tibial shaft fractures would facilitate optimal management. Previous studies were limited by small sample sizes and noncomprehensive examination of possible risk factors. OBJECTIVE: We conducted an observational study to determine which prognostic factors were associated with an increased risk of reoperation following operative treatment in a heterogeneous population of patients with tibial shaft fractures. DESIGN: Retrospective observational study. SETTING: Level 1 trauma center. METHODS: We identified 200 patients with tibial shaft fractures from two university-affiliated centers. Two reviewers independently abstracted data regarding 20 possible prognostic variables, reviewed preoperative and postoperative radiographs, and documented reoperations (defined as any surgical procedure </=1 year after the initial surgery that was aimed specifically at achieving bony union of the fracture, including bone grafts, implant exchanges, or débridement for infections). We chose a Cox proportion hazards model to conduct a survival analysis for time to reoperation and constructed a multivariable model to estimate the relative risk of reoperation and associated 95%confidence interval (CI) for each predictor variable. MAIN OUTCOME MEASURES: Time to reoperation following the initial surgery. RESULTS: Complete follow-up information was available for 192 of 200 (96%) patients. Three variables predicted reoperation: the presence of an open fracture wound (relative risk 4.32, 95% CI 1.76 to 11.26), lack of cortical continuity between the fracture ends following fixation (relative risk 8.33, 95% CI 3.03 to 25.0), and the presence of a transverse fracture (relative risk 20.0, 95% CI 4.34 to 142.86). CONCLUSIONS: We identified a set of three simple prognostic variables (open fracture, transverse fracture, and postoperative fracture gap) that can assist surgeons in predicting reoperation following operative treatment of tibial shaft fractures.

Adult↗
PubMed2003

Internal fixation versus arthroplasty of comminuted fractures of the distal humerus.

BACKGROUND: A comminuted distal humerus fracture in an older patient is a difficult clinical problem. Open reduction internal fixation (ORIF) carries the risks of nonunion, loss of fixation, infection, and stiffness. Arthroplasty carries the risks of loosening, infection, and periprosthetic fracture. Both procedures are technically challenging, and complications following these procedures are frequent. OBJECTIVE: To evaluate best available evidence to assist in guiding clinical decision making for ORIF versus arthroplasty of intraarticular distal humeral fractures in elderly patients. HIGHEST AVAILABLE EVIDENCE: 1. Case series of internal fixation or arthroplasty of acute interarticular distal humerus fractures in the elderly (level IV). 2. Review of expert opinion without explicit critical appraisal or controlled research (level V). STUDY IDENTIFICATION: 1. Computerized data search 1969-2003, Cochrane Database, OVID Search Engine. 2. Reviews of bibliographies of selected articles.

Aged↗
PubMed2003

Operative treatment of extra-articular proximal tibial fractures.

BACKGROUND: Extra-articular proximal tibial fractures are often the result of high-energy trauma with displacement and comminution. Most authors agree that operative management of these fractures is warranted to optimize patient outcomes. It is unclear, however, which surgical option (plate, nail, external fixator, or combination) is preferable. (1-17) OBJECTIVE: To evaluate the effect of alternative operative techniques in the management of extra-articular proximal third tibial fractures on rates of nonunion, malunion, infection, compartment syndrome, and implant failure. HIGHEST AVAILABLE EVIDENCE: 1. Intramedullary nail (level 3 prospective case series). 2. Plates (level 3 prospective case series). 3. External fixator (level 4 case series). STUDY IDENTIFICATION: 1. Cochrane Database: 0 articles. 2. PubMed Search: Proximal tibial fractures: 568 hits; And external fixation: 69 hits; And plate: 103 hits; And intramedullary nail: 77 hits. Clinical queries search: proximal tibial fracture (specificity/therapy): 1 hit; proximal tibial fracture (sensitivity): 24 hits. Systematic reviews: 3 hits (none relevant). 3. OTA website abstract database: 8 abstracts. Total number potentially relevant articles: 29 (following review of all study titles and abstracts). Total number included after review: 17 (1-17) .

Evidence-Based Medicine↗
PubMed2003

The risk of false-positive results in orthopaedic surgical trials.

The risk of concluding that the results of a particular study are true, when, in fact, they really are attributable to chance (or random sampling error) is underappreciated by investigators. This erroneous false-positive conclusion is designated as a Type I or alpha error. The extent to which randomized trials in surgery risk Type I errors is unclear. The current authors hand-searched four orthopaedic journals, six general surgery journals, and five medical journals to identify recently published randomized trials (within the past 2 years). Information on outcomes and statistical adjustment for multiple outcomes was recorded for each study. The risk of a Type I error was calculated for each study that did not explicitly state a primary outcome measure for the main statistical comparison. One hundred fifty-nine studies met the inclusion criteria for the study: 60 studies from orthopaedic journals, 49 studies from nonorthopaedic surgical journals, and 50 studies from medical journals. Of the trials that did not state a primary outcome measure, the risk of Type I errors (false-positive results) in orthopaedic and nonorthopaedic surgery journals (mean 37.3% +/- 13.3% and 37.6% +/- 10.5%, respectively) were significantly greater than medical journals (10.1% +/- 1.9%). In the current review of randomized trials in surgery and medicine, the following is reported: (1) reporting of primary outcomes in trials was inadequate; (2) one in three trials in surgery and one in 10 trials in medicine risked false-positive results; and (3) few trials in surgery and medicine considered adjustment for multiple comparisons.

Humans↗
PubMed2003

Glossary of evidence-based orthopaedic terminology.

As surgeons incorporate the philosophy of evidence-based orthopaedics into patient care, they need to become familiar with common terminology. A glossary of commonly used terms encountered among evidence-based orthopaedic practitioners is presented.

Epidemiologic Research Design↗
PubMed2003

Hierarchy of evidence: from case reports to randomized controlled trials.

In the hierarchy of research designs, the results of randomized controlled trials are considered the highest level of evidence. Randomization is the only method for controlling for known and unknown prognostic factors between two comparison groups. Lack of randomization predisposes a study to potentially important imbalances in baseline characteristics between two study groups. There is a hierarchy of evidence, with randomized controlled trials at the top, controlled observational studies in the middle, and uncontrolled studies and opinion at the bottom. This hierarchy has not been supported in two recent publications in the New England Journal of Medicine which identified nonsignificant differences in results between randomized, controlled trials, and observational studies. The current authors provide an approach to organizing published research on the basis of study design, a hierarchy of evidence, a set of principles and tools that help clinicians distinguish ignorance of evidence from real scientific uncertainty, distinguish evidence from unsubstantiated opinions, and ultimately provide better patient care.

Evidence-Based Medicine↗
PubMed2003

Designing, conducting, and evaluating journal clubs in orthopaedic surgery.

The first record of a journal club was that founded in 1875 by Sir William Osler at McGill University for the purchase and distribution of periodicals to which he could not afford to subscribe as an individual. Evidence-based medicine is becoming an accepted educational paradigm in medical education at various levels. An analysis of the literature related to journal clubs in residency programs in specialties other than orthopaedic surgery reveals that the three most common goals were to teach critical appraisal skills (67%), to have an impact on clinical practice (59%), and to keep up with the current literature (56%). The implementation of the structured article review checklist has been found to increase resident satisfaction and improves the perceived educational value of the journal club without increasing resident workload or decreasing attendance at the conference. Periodic evaluation of the conference and the institution of appropriate changes ensures that the journal club remains a valuable and successful part of the training program.

Curriculum↗
PubMed2003

Barriers to full-text publication following presentation of abstracts at annual orthopaedic meetings.

BACKGROUND: Oral presentations at national and international meetings offer an excellent forum for the dissemination of current research findings. However, publication rates of full-text articles after presentation of abstracts at international meetings have ranged from 11% to 78%, which suggests that at least 32% of the abstracts presented are never published as complete articles in peer-reviewed journals. In an effort to identify the reasons that surgeons had not had a paper published following presentation of their work at an international orthopaedic meeting, we conducted a survey of a cross section of authors of orthopaedic papers presented at a national meeting. METHODS: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. A computerized Medline and PubMed search established whether the abstract had been subsequently published as a full-text article. The authors of the abstracts that had not been subsequently published were surveyed to identify the reasons for the failure to publish. RESULTS: A total of 465 abstracts were presented at the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons in 1996. We surveyed the authors of 306 abstracts for which we were unable to locate a subsequent full-text publication on Medline. One hundred and ninety-nine investigators (65%) responded to the questionnaire. At the time of the survey, seventy-two manuscripts had been published, thirty-two had been submitted and rejected, fourteen were under consideration by journals, seven had been accepted for publication or were in press, and three were not recalled by the investigator. In addition, seventy-one abstracts (35.7%) of the 199 had not been submitted for publication. The authors of those abstracts were asked to indicate one or more reasons why they had not submitted a manuscript for publication. Thirty-three investigators (46.5%) indicated that they lacked sufficient time for research activities, twenty-two (31.0%) reported that the study presented at the meeting in 1996 was still in progress, fourteen (19.7%) believed that the responsibility for writing the manuscript belonged to someone else, and twelve (16.9%) reported that difficulties with co-authors who would not participate had impeded the completion of the manuscript. Nine investigators (12.7%) responded that the pursuit of publication was a low priority. CONCLUSIONS: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, we found that the failure to publish was due to one of three main reasons: (1) they did not have enough time to prepare a manuscript for publication (the reason most frequently given); (2) almost one-third of the studies that had not been submitted for publication were ongoing; and (3) relationships with co-authors sometimes presented a barrier to final publication. Thorough preparation before the study and the establishment of stricter guidelines to limit the presentation of preliminary data at national and international meetings may improve publication rates.

Abstracting and Indexing↗
PubMed2003

Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. A meta-analysis.

BACKGROUND: The optimal choice for the stabilization of displaced femoral neck fractures remains controversial, with alternatives including arthroplasty and internal fixation. Our objective was to determine the effect of arthroplasty (hemiarthroplasty, bipolar arthroplasty, and total hip arthroplasty), compared with that of internal fixation, on rates of mortality, revision, pain, function, operating time, and wound infection in patients with a displaced femoral neck fracture. METHODS: We searched computerized databases for randomized clinical trials published between 1969 and 2002, and we identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic textbooks, and personal files. Of 140 citations initially identified, fourteen met all eligibility criteria. Three investigators independently graded study quality and abstracted relevant data, including information on revision and mortality rates. RESULTS: Nine trials, which included a total of 1162 patients, provided detailed information on mortality rates over the first four postoperative months, which ranged from 0% to 20%. We found a trend toward an increase in the relative risk of death in the first four months after arthroplasty compared with the risk in the first four months after internal fixation (relative risk, 1.27). At one year, the relative risk of death was 1.04. The risk of death after arthroplasty appeared to be higher than that after fixation with a compression screw and side-plate but not higher than that after internal fixation with use of screws only (relative risk = 1.75 and 0.86, respectively; p < 0.05). Fourteen trials that included a total of 1901 patients provided data on revision surgery. The relative risk of revision surgery after arthroplasty compared with the risk after internal fixation was 0.23 (p = 0.0003). Pain relief and the attainment of overall good function were similar in patients treated with arthroplasty and those treated with internal fixation (relative risk, 1.12 for pain relief and 0.99 for function). Infection rates ranged from 0% to 18%, and arthroplasty significantly increased the risk of infection (relative risk, 1.81; p = 0.009). In addition, patients who underwent arthroplasty had greater blood loss and longer operative times than those who were treated with internal fixation. CONCLUSIONS: In comparison with internal fixation, arthroplasty for the treatment of a displaced femoral neck fracture significantly reduces the risk of revision surgery, at the cost of greater infection rates, blood loss, and operative time and possibly an increase in early mortality rates. Only larger trials will resolve the critical question of the impact on early mortality.

Arthroplasty↗
PubMed2002

Comparison of mortality between private for-profit and private not-for-profit hemodialysis centers: a systematic review and meta-analysis.

CONTEXT: Private for-profit and private not-for-profit dialysis facilities provide the majority of hemodialysis care in the United States. There has been extensive debate about whether the profit status of these facilities influences patient mortality. OBJECTIVE: To determine whether a difference in adjusted mortality rates exists between hemodialysis patients receiving care in private for-profit vs private not-for-profit dialysis centers. DATA SOURCES: We searched 11 bibliographic databases, reviewed our own files, and contacted experts in June 2001-January 2002. In June 2002, we also searched PubMed using the "related articles" feature, SciSearch, and the reference lists of all studies that fulfilled our eligibility criteria. STUDY SELECTION: We included published and unpublished observational studies that directly compared the mortality rates of hemodialysis patients in private for-profit and private not-for-profit dialysis centers and provided adjusted mortality rates. We masked the study results prior to determining study eligibility, and teams of 2 reviewers independently evaluated the eligibility of all studies. Eight observational studies that included more than 500 000 patient-years of data fulfilled our eligibility criteria. DATA EXTRACTION: Teams of 2 reviewers independently abstracted data on study characteristics, sampling method, data sources, and factors controlled for in the analyses. Reviewers resolved disagreements by consensus. DATA SYNTHESIS: The studies reported data from January 1, 1973, through December 31, 1997, and included a median of 1342 facilities per study. Six of the 8 studies showed a statistically significant increase in adjusted mortality in for-profit facilities, 1 showed a nonsignificant trend toward increased mortality in for-profit facilities, and 1 showed a nonsignificant trend toward decreased mortality in for-profit facilities. The pooled estimate, using a random-effects model, demonstrated that private for-profit dialysis centers were associated with an increased risk of death (relative risk, 1.08; 95% confidence interval, 1.04-1.13; P<.001). This relative risk suggests that there are annually 2500 (with a plausible range of 1200-4000) excessive premature deaths in US for-profit dialysis centers. CONCLUSIONS: Hemodialysis care in private not-for-profit centers is associated with a lower risk of mortality compared with care in private for-profit centers.

Health Services Research↗
PubMed2002

A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals.

BACKGROUND: Canadians are engaged in an intense debate about the relative merits of private for-profit versus private not-for-profit health care delivery. To inform this debate, we undertook a systematic review and meta-analysis of studies comparing the mortality rates of private for-profit hospitals and those of private not-for-profit hospitals. METHODS: We identified studies through an electronic search of 11 bibliographical databases, our own files, consultation with experts, reference lists, PubMed and SciSearch. We masked the study results before determining study eligibility. Our eligibility criteria included observational studies or randomized controlled trials that compared private for-profit and private not-for-profit hospitals. We excluded studies that evaluated mortality rates in hospitals with a particular profit status that subsequently converted to the other profit status. For each study, we calculated a relative risk of mortality for private for-profit hospitals relative to private not-for-profit hospitals and pooled the studies of adult populations that included adjustment for potential confounders (e.g., teaching status, severity of illness) using a random effects model. RESULTS: Fifteen observational studies, involving more than 26 000 hospitals and 38 million patients, fulfilled the eligibility criteria. In the studies of adult populations, with adjustment for potential confounders, private for-profit hospitals were associated with an increased risk of death (relative risk [RR] 1.020, 95% confidence interval [CI] 1.003-1.038; p = 0.02). The one perinatal study with adjustment for potential confounders also showed an increased risk of death in private for-profit hospitals (RR 1.095, 95% CI 1.050-1.141; p < 0.0001). INTERPRETATION: Our meta-analysis suggests that private for-profit ownership of hospitals, in comparison with private not-for-profit ownership, results in a higher risk of death for patients.

Hospital Mortality↗
PubMed2002

The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis.

BACKGROUND: The effect of low-intensity ultrasonography on fracture healing is controversial, and current management of fractures does not generally involve the use of ultrasound therapy. We describe a systematic review and meta-analysis of randomized controlled trials of low-intensity pulsed ultrasound therapy for healing of fractures. METHODS: We searched 5 electronic databases (MEDLINE, EMBASE, Cochrane Database of Randomised Clinical Trials, HealthSTAR and CINAHL) for trials of ultrasonography and fracture healing, in any language, published from 1966 to December 2000. In addition, selected journals published from 1996 to December 2000 were searched by hand for relevant articles, and attempts were made to contact content experts in the area of ultrasound therapy and fracture healing as well as primary authors of reviewed trials. Trials selected for review met the following criteria: random allocation of treatments; inclusion of skeletally mature patients of either sex with 1 or more fractures; blinding of both the patient and the assessor(s) as to fracture healing; administration of low-intensity pulsed ultrasound treatments to at least 1 of the treatment groups; and assessment of time to fracture healing, as determined radiographically by bridging of 3 or 4 cortices. Two reviewers independently applied selection criteria to blinded articles, and selected articles were scored for methodologic quality. The internal validity of each trial was assessed with the use of a 5-point scale that evaluates the quality of trial method on the basis of description and appropriateness of randomization and double-blinding, and assessment of study withdrawals and likelihood of bias. RESULTS: We identified 138 potentially eligible studies, of which 6 met our inclusion criteria. Agreement beyond chance of quality assessments of the 6 trials was good (intraclass correlation coefficient 0.77, p = 0.03). One trial was a repeat analysis of previously reported data, and 2 trials appeared to report on a shared group of subjects. Three trials, representing 158 fractures, were of sufficient homogeneity for pooling. The pooled results showed that time to fracture healing was significantly shorter in the groups receiving low-intensity ultrasound therapy than in the control groups. The weighted average effect size was 6.41 (95% confidence interval 1.01-11.81), which converts to a mean difference in healing time of 64 days between the treatment and control groups. INTERPRETATION: There is evidence from randomized trials that low-intensity pulsed ultrasound treatment may significantly reduce the time to fracture healing for fractures treated nonoperatively. There does not appear to be any additional benefit to ultrasound treatment following intramedullary nailing with prior reaming. Larger trials are needed to resolve this issue.

Adult↗