Ilyas S. Aleem

Clinical decision analysis: Incorporating the evidence with patient preferences

Decision analysis has become an increasingly popular decision-making tool with a multitude of clinical applications. Incorporating patient and expert preferences with available literature, it allows users to apply evidence-based medicine to make informed decisions when confronted with difficult clinical scenarios. A decision tree depicts potential alternatives and outcomes involved with a given decision. Probabilities and utilities are used to quantify the various options and help determine the best course of action. Sensitivity analysis allows users to explore the uncertainty of data on expected clinical outcomes. The decision maker can thereafter establish a preferred method of treatment and explore variables which influence the final clinical outcome. The present paper reviews the technique of decision analysis with particular focus on its application to clinical decision making.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study

OBJECTIVE To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. BACKGROUND Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. METHODS Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. RESULTS Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). CONCLUSIONS In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

OBJECTIVES To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. BACKGROUND Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. METHODS A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. RESULTS AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). CONCLUSIONS A multifaceted intervention improved compliance with a pediatric AP guideline.

What is a clinical decision analysis study

Decision making in clinical practice often involves the need to make complex and intricate decisions with important long-term consequences. Decision analysis is a tool that allows users to apply evidence-based medicine to make informed and objective clinical decisions when faced with complex situations. A Decision Tree, together with literature-derived probabilities and defined outcome values, is used to model a given problem and help determine the best course of action. Sensitivity analysis allows an exploration of important variables on final clinical outcomes. A decision-maker can thereafter establish a preferred method of treatment and explore variables which influence the final outcome. The present paper is intended to give an overview of decision analysis and its application in clinical decision making.

Cochrane in CORR(®): Surgical Versus Non-surgical Treatment for Thoracolumbar Burst Fractures Without Neurological Deficit.

T horacolumbar burst fractures account for approximately 45% of all major thoracolumbar traumatic injuries [9]. They most commonly occur secondary to an axial compression mechanism and are characterized by failure of the anterior and middle spinal columns. Clinical features of thoracolumbar burst fractures include acute back pain and possible damage to the nerve roots or spinal cord, but more than 50% of these injuries may present without neurological deficit [9]. Characteristic radiographic findings include anterior wedging of the vertebral body, increased interpedicular distance, and narrowing of the spinal canal due to retropulsed bone. The management of thoracolumbar burst fractures in patients without neurological deficits remains controversial [3]. Surgical stabilization and possible decompression may result in earlier mobilization, reduced time to hospital discharge, and faster return to work [9], but it may also expose patients to more-frequent early complications, an increased risk for subsequent revision surgery, and greater overall healthcare costs [9]. Nonoperative management including symptomatic pain control, early mobilization, and perhaps a brace may be A Note from the Editor-In-Chief: We are pleased to publish the next installment of Cochrane in CORR, our partnership between CORR, The Cochrane Collaboration, and McMaster University’s Evidence-Based Orthopaedics Group. In it, researchers from McMaster University and other institutions will provide expert perspective on an abstract originally published in The Cochrane Library that we think is especially important. (AbudouM, Chen X, Kong X,Wu T. Surgical versus non-surgical treatment for thoracolumbar burst fractures without neurological deficit. Cochrane Database Syst Rev. 2013;6:CD005079). Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Reproduced with permission. Each author certifies that they, or any members of their immediate families, have no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or the Association of Bone and Joint Surgeons. Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and The Cochrane Library (http:// www.thecochranelibrary.com) should be consulted for the most recent version of the review. This Cochrane in CORR column refers to the abstract available at: DOI: 10.1002/ 14651858.CD005079.pub3.

Cochrane in CORR (®): Ultrasound and Shockwave Therapy for Acute Fractures in Adults (Review).

F ractures cause considerable morbidity and often result in pain, loss of function, and decreased productivity [8]. Delayed union and nonunion complicate approximately 5% to 10% of fractures and often require further surgical or nonsurgical intervention [7]. A number of adjunct methods have been proposed to accelerate fracture healing, including low-intensity pulsed ultrasound (LIPUS). Ultrasound therapy delivers noninvasive soundwaves, which are believed to induce low-level micromechanical forces at the fracture site, stimulating the molecular and cellular responses in fracture healing [5, 13]. The first successful application of LIPUS for human nonunions was demonstrated in 1983 in a study that reported healing in 70% of 26 fractures [15]. In 1994 and 2000, the FDA approved ultrasound for accelerating the healing of acute fractures and existing nonunions [11]. This Cochrane Review systematically reviewed the best available evidence on LIPUS, high-intensity pulsed ultrasound, and extracorporeal shockwave therapy for acute fractures in adults. After evaluating 12 studies that enrolled a total of 622 patients with 648 fractures, no meaningful reductions with LIPUS in time to

Musculoskeletal trauma and all-cause mortality in India: a multicentre prospective cohort study

BACKGROUND There is little data in low-income and middle-income countries (LMICs) quantifying the burden of fractures and describing current practices. The aim of the study was describe the severity of musculoskeletal injuries in LMICS and identify modifiable factors that predict subsequent early all-cause mortality. METHODS We did a multicentre, prospective, observational study of patients who presented to 14 hospitals across India for musculoskeletal trauma (fractures or dislocations). Patients were recruited during an 8-week period, between November, 2011, and June, 2012, and were followed for 30-days or hospital discharge, whichever occurred first. Primary outcome was all-cause mortality with secondary outcomes of reoperation and infection. Logistic regression analyses were conducted to identify factors associated with all-cause mortality. FINDINGS We enrolled 4822 patients, but restricted analyses to 4612 (96%) patients who had complete follow-up. The majority (56·2% younger than 40 years old) of trauma patients were young (mean age 40·9 years [SD 16·9]) and 3148 (68%) were men. 2344 (518%) patients sustained trauma as a result of a road traffic accident. The most common musculoskeletal injury was a fracture (4514 [98%]) and 707 patients (15%) incurred an open fracture. Less than a third of musculoskeletal trauma patients (1374 [29%]) were transported to hospital by ambulance, and one in six patients (18%) arrived at the hospital later than 24 h after sustaining their injury. Over a third (239 [35%] of 707) of open fractures were definitively stabilised later than 24 h. 30-day mortality was 1·7% (95% CI 1·4-2·2) for all patients and 2·1% (95% CI 1·5-2·7) among road traffic victims (p=0·005). Musculoskeletal trauma severity including the number of fractures (3·1 [95% CI 2·4-3·9]) and presence of an open fracture (2·1 [95% CI 1·2-3·4]) significantly increased the odds of all-cause mortality. INTERPRETATION Musculoskeletal trauma severity, particularly road related, is a key predictor of subsequent mortality. Improvement in road safety policies, and improvements in access to emergency medical services and timely orthopaedic care are critical to mitigate the burden of injury worldwide. FUNDING Regional Medical Associates, AO International, Hamilton Health Sciences Trauma Fund.

Does sitting versus standing radiographic assessment of odontoid fractures matter? A case report

Fractures of the odontoid are the most common cervical spine injury in the geriatric population. The relationship between odontoid fracture displacement and postural change has not been previously described. We present the first described case of an elderly female patient with thoracic kyphosis and a type II odontoid fracture demonstrating significant fracture displacement with a postural change from sitting to standing. Various radiographic parameters are assessed and discussed in an attempt to characterize and explain this finding. We highlight the importance of regional and global spinal alignment and quantify physiologic odontoid fracture behavior with postural changes in this growing demographic. Upright radiographs in both sitting and standing positions may be considered when concern for odontoid fracture stability is questioned.

Does Resection of the Posterior Longitudinal Ligament Impact the Incidence of C5 Palsy after Cervical Corpectomy Procedures

Study Design. Retrospective review. Objective. To evaluate key risk factors for the development of C5 palsy after cervical corpectomy, including resection of the posterior longitudinal ligament (PLL). Summary of Background Data. Postoperative C5 palsy is a well-known complication after cervical spine surgery. It is unknown whether resection of the PLL affects the incidence of C5 palsy. Methods. We performed a retrospective review of 459 consecutive patients undergoing anterior cervical corpectomies over a 15-year period. Medical records were reviewed to gather demographic data, operative details, and the incidence of C5 palsy. We performed regression analyses to identify variables that predicted the development of C5 palsy. Results. Our final analysis included 397 patients (females 51.4%, mean age 55.6 ± 11.6 yrs). Anterior corpectomy alone was performed in 255 (64.2%) patients, and combined anterior and posterior fusion was performed in 142 (35.8%) patients. Twenty-four patients (6.0%) developed C5 nerve palsy. Univariable regression demonstrated age greater than 65 (odds ratio, OR 2.7, 95% confidence interval, CI 1.2 to 6.3), corpectomy of three or more levels (OR 6.3, 95% CI 2.1 to 18.9), presence of ossification of the PLL (OR 4.3, 95% CI 1.6 to 11.7), and complete or partial resection of the PLL (OR 2.6, 95% CI 1.0 to 6.7) predicted development of C5 palsy. Multivariable regression demonstrated that the odds of getting C5 palsy with complete or partial resection of the PLL is 4.0 times (95% CI 1.5 to 10.5) higher compared with patients with an intact PLL. There were no significant differences in C5 palsy rates based on surgical approach (anterior vs. anterior plus posterior), sex, smoking status, or diabetes. Conclusion. Age greater than 65 years, corpectomy of three or more levels, presence of ossification of the PLL, and complete or partial resection of the PLL significantly predicted the development of C5 palsy. Level of Evidence: 4

The Burden of Spine Fractures in India: A Prospective Multicenter Study

Study Design: Prospective cohort study. Objectives: The objectives of this study were (1) to determine the characteristics of patients sustaining spinal trauma in India and (2) to explore the association between patient or injury characteristics and outcomes after spinal trauma. Methods: In affiliation with the ongoing INternational ORthopaedic MUlticentre Study (INORMUS), 192 patients with spinal injuries were recruited during an 8-week period (November 2011 to June 2012) from 14 hospitals in India and followed for 30-days. The primary outcome was a composite of mortality, complications, and reoperation. This was regressed on a set of 13 predictors in a multiple logistic regression model. Results: Most patients were middle-aged (mean age = 51.0 years; median age = 55.5 years; range = 18.0 to 72.0 years), male (60.4%), injured from falls (72.4%), and treated in a private setting (59.9%). Fractures in the lumbar region (51.0%) were most common, followed by thoracic (30.7%) and cervical (18.2%). More than 1 in 5 (21.6%) patients experienced a treatment delay greater than 24 hours, and 36.5% arrived by ambulance. Thirty-day mortality and complication rates were 2.6% and 10.0%, respectively. Care in the public hospital system (odds ratio [OR] = 6.7, 95% CI = 1.1-41.6), chest injury (OR = 11.1, 95% CI = 1.8-66.9), and surgical intervention (OR = 4.8, 95% CI = 1.2-19.6) were independent predictors of major complications. Conclusions: Treatment in the public health care system, increased severity of injury, and surgical intervention were associated with increased risk of major complications following spinal trauma. The need for a large-scale, prospective, multicenter study taking into account spinal stability and neurologic status is feasible and warranted.