Many scientists worldwide are engaged in predicting the course of the COVID-19 pandemic, but the exact nature of this disease and the “novel” virus that causes it remains largely mysterious.
The numbers of confirmed cases in media reports are dependent on the extent of testing, which has varied markedly from region to region in North America. The scientific community has cautioned policymakers not to rely entirely on “observable” data (i.e., testing-confirmed COVID-19 cases) because such measures are likely to under-report the extent of the problem. That’s one reason why orthopaedic surgeon Mohit Bhandari, MD and his colleagues applied machine-learning tools to estimate the number of “unobserved” COVID-19 infections in North America.
The authors’ stated goal was to contribute to the ongoing debate on detection bias (one form of which can occur when outcomes—infections in this case—cannot be reliably counted) and to present statistical tools that could help improve the robustness of COVID-19 data. Their findings suggest that “we might be grossly underestimating COVID-19 infections in North America.”
The authors’ estimates relied on 2 sophisticated analyses: “dimensionality reduction” helped uncover hidden patterns, and a “hierarchical Bayesian estimator approach” inferred past infections from current fatalities. The dimensionality-reduction analysis presumed a 13-day lag time from infection to death, and it indicated that, as of April 22, 2020, the US probably had at least 1.3 million undetected infections, and the number of undetected infections in Canada could have ranged from 60,000 to 80,000. The Bayesian estimator approach yielded similar estimates: The US had up to 1.6 million undetected infections, and Canada had at least 60,000 to 86,000 undetected infections.
In contrast, data from the Johns Hopkins University Center for Systems Science and Engineering on April 22, 2020, reported only 840,476 and 41,650 confirmed cases for the US and Canada, respectively. Based on these numbers, as of April 22, 2020, the US may have had 1.5 to 2.02 times the number of reported infections, and Canada may have had 1.44 to 2.06 times the number of reported infections.
The authors emphasize that the “real” number of asymptomatic carriers cannot be determined without widespread use of validated antibody tests, which are scarce. Bhandari et al. conclude that policymakers should “be aware of the extent to which unobservable data—infections that have still not been captured by the system—can damage efforts to ‘flatten’ the pandemic’s curve.”
In response to the COVID-19 pandemic, an abundance of clinical orthopaedic information has been disseminated in a short period of time. Some of that has been compiled and commented upon here in OrthoBuzz.
On April 12, 2020, the editors of OrthoEvidence, led by Mohit Bhandari, MD, published a report of global recommendations that puts forth evidence-based principles to guide musculoskeletal care in the face of the coronavirus pandemic. The carefully referenced, 65-page report identifies pandemic-related best practices in outpatient care, elective procedures, urgent/emergent procedures, and peri-/postoperative care.
Nearly three-quarters of the 72 publications analyzed for the report were based on expert opinion and/or clinical experience; just over one-quarter were developed using evidence-based methods alone or a combination of evidence-based methods plus expert opinion. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, the report’s authors assign strength ratings for all the recommendations compiled in the review.
The detailed information is best digested from the report itself, but here is a summary of the report’s overarching recommendations for orthopaedic management at this time:
- Ensure patient and staff safety.
- Stay up-to-date about evolving clinical guidelines and your institution’s capacity issues.
- Prevent unnecessary use of personal protective equipment and make contingency plans for supply shortages.
- Schedule only urgent or emergent surgical cases.
- Perform only operative interventions that can be expected to have superior outcomes relative to nonoperative management.
- Convene teams to make decisions about definitive management in semi-urgent or controversial cases.
- Prevent unnecessary follow-up visits.
Editor’s Note: The Journal of Bone and Joint Surgery’s Robert Bucholz Resident Journal Club Grant provides selected orthopaedic surgery residency programs with funds that facilitate career-long skills in evaluating orthopaedic literature and its impact on clinical decision-making. The Journal is always interested in hearing how those funds have been used to enhance orthopaedic education. Here, Michael Perrone, MD describes how the University of Chicago’s Department of Orthopaedic Surgery and Rehabilitation Medicine used its grant this past academic year.
Our residency hosted Dr. Mohit Bhandari for two days. Dr. Bhandari is widely recognized as the world’s foremost authority in the translation of orthopaedic research into clinical practice. On the first day, he joined us for dinner at a local Chicago pizzeria, where we had a “Deep Dish-cussion” about several landmark articles within the orthopaedic literature. He provided his insights on the design, merits, and limitations of each paper, while also discussing each study’s clinical impact. Both residents and faculty alike found the discussion enlightening and educational.
The following morning, Dr. Bhandari delivered Grand Rounds to the entire department. His talk, “Fear Less, Do More,” gave us an inside look at the trials and tribulations of conducting large, multicenter studies and bringing them to publication. Throughout the talk, he encouraged residents and faculty to be ambitious in their pursuit of research and evidence-based practice.
There are few people with more experience or expertise within orthopaedic research than Dr. Bhandari, and his visit to our residency program was inspirational and enlightening. Such an experience would not have been possible without the generous support from JBJS.
Michael Perrone, MD
University of Chicago
The Canadian Institutes of Health Research (CIHR) recently awarded a $500,000 grant to an international trauma study called INORMUS (International Orthopaedic Multi-center Study in Fracture Care). According to lead researcher Mohit Bhandari, MD, of McMaster University in Canada, the observational cohort study hopes to enroll 40,000 patients; its goal is to determine both patient and institutional factors in developing nations such as China and India that help predict complications within 30 days after a fracture or dislocation.”From the data on our initial 6,000 patients, we found that some people wait up to four days to have an open fracture treated,” Dr. Bhandari told Orthopedics This Week. He added that in rural India, 30-day mortality after a fracture arising from a major traffic accident is 2%. “While 2% may not sound shocking,” Dr. Bhandari said, “imagine that many people coming into a US hospital with only a fracture and being dead within 30 days.”
For more information about INORMUS, click here.