Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures

BACKGROUND

There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications.

METHODS

We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879).

RESULTS

The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis.

CONCLUSION

We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Malaria in pregnancy: Meta-analyses of prevalence and associated complications

This review aims to assess the prevalence of malaria in pregnancy during antenatal visits and delivery, species-specific burden together with regional variation in the burden of disease. It also aims to estimate the proportions of adverse pregnancy outcomes in malaria-positive women. Based on the PRISMA guidelines, a thorough and systematic search was conducted in July 2023 across two electronic databases (including PubMed and CENTRAL). Forest plots were constructed for each outcome of interest highlighting the effect measure, confidence interval, sample size, and its associated weightage. All the statistical meta-analysis were conducted using R-Studio version 2022.07. Sensitivity analyses, publication bias assessment, and meta-regression analyses were also performed to ensure robustness of the review. According to the pooled estimates of 253 studies, the overall prevalence of malaria was 18.95% (95% CI: 16.95-21.11), during antenatal visits was 20.09% (95% CI: 17.43-23.06), and at delivery was 17.32% (95% CI: 14.47-20.61). The highest proportion of malarial infection was observed in Africa approximating 21.50% (95% CI: 18.52-24.81) during ANC and 20.41% (95% CI: 17.04-24.24) at the time of delivery. Our analysis also revealed that the odds of having anaemia were 2.40 times (95% CI: 1.87-3.06), having low birthweight were 1.99 times (95% CI: 1.60-2.48), having preterm birth were 1.65 times (95% CI: 1.29-2.10), and having stillbirths were 1.40 times (95% CI: 1.15-1.71) in pregnant women with malaria.

Diagnostic Accuracy of Intraoperative Brain Smear: A Meta-Analysis of Studies from Resource-Limited Settings

BACKGROUND

Intraoperative brain smear is an easy, rapid, and cost-effective technique for immediate diagnosis of brain tumors. Earlier studies have gauged its application on limited number of samples, but its diagnostic accuracy especially in low-resource settings, where its practice would be extremely helpful, is still undetermined. To investigate the diagnostic accuracy of intraoperative brain smear in resource-limited settings for diagnosis of brain tumors.

METHODS

A systematic search was conducted on PubMed, Google Scholar, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase for all articles utilizing intraoperative brain smears that were extracted. Studies from low- and middle-income countries (LMICs) with test performance characteristics were selected and subsequent values were summarized using a hierarchical summary receiver operating characteristic (ROC) curve via STATA and pooled using a random-effects model on MetaDiSc 2.0.

RESULTS

Twelve studies consisting of 1124 patients were identified. Six studies included both adult and pediatric population groups, while 4 investigated adults and 2 included pediatric patients. The pooled diagnostic odds ratio (OR) was calculated to be 212.52 (CI: [104.27-433.13]) of Bivariable pooled specificity and sensitivity were 92% (CI: [86%-96%]) and 96% (CI: [93%-98%]), respectively.

CONCLUSIONS

Our study shows that intraoperative brain smear is not only an accurate and sensitive diagnostic modality in resource-rich settings, but it is also equally useful in resource-limited settings, making it an ideal method for rapid diagnosis.

Outcomes of Patients with FLT3 Positive Acute Myeloid Leukaemia; an Experience from a Tertiary Care Hospital in Karachi, Pakistan

Introduction

Molecular genetic abnormalities in acute myeloid leukaemia (AML) are essential for disease diagnosis and determining prognosis and clinical course. Mutations in FLT3 and nucleophosmin (NPM) genes are the most frequent genetic abnormalities, which are also known to impact disease outcomes. FLT3 mutations have been identified in approximately 30% of de novo AML patients and are associated with poor prognoses. This study aimed to determine the response to induction chemotherapy, overall survival (OS) and relapse rate (RR) in patients with FLT3-positive AML.

Materials and Methods

In this study, a retrospective analysis was performed of 75 newly diagnosed patients with AML registered between January 2015 and July 2022. Patient demographics and clinical-haematological parameters were noted and molecular analysis for FLT3 ITD/TKD and NPM mutations was performed. All the patients received standard induction chemotherapy and their response to treatment, OS and RR were assessed.

Results

A total of 75 cases of AML were analysed. The mean age of the sample was 34.9 years, of which 65.3% were males and 34.7% were females. The patients were stratified into two groups: Those who were positive for FLT3 while negative for NPM (FLT3+/NPM-), representing 17.3% and those who were negative for both FLT3 and NPM (FLT3-/NPM-), representing 82.7% of cases. On day 28 post-induction, the complete remission rate was 69.2% in the FLT3 positive group and 77.4% in the FLT3 negative group. In the FLT3+/NPM- group, 55.6% of cases who were in remission at day 28 subsequently relapsed, compared to 50.0% of FLT3-/NPM- cases. The overall median survival time for the cohort and FLT3+ group was 1467 days, while that of the FLT3-group could not be estimated due to the very high survival rate.

Conclusion

No significant differences in outcomes were observed in patients who were FLT3 positive compared to those who were FLT3 negative.

Global geographic and gender disparities in stem cell-related surgical research: bibliometric review of the top 200 most-cited articles

Objectives

The study aimed to identify geographic and gender disparities in the quality, academic impact, and media attention of the top-cited articles related to stem cell-related surgical research.

METHODS

The following data was extracted for the top 200 most-cited articles (2011-2021): article- (including citation metrics and country of publication), journal- (including impact factor), and author-level (including corresponding author gender) variables. Article Altmetric Attention Score (AAS), a measure of mass mainstream and social media attention, was also recorded.

RESULTS

Most articles originated from high-income countries (HICs: 175 [87.5%]), with only 7 (3.5%) from lower-middle-income countries. Articles from non-HIC were published in journals with significantly lower impact factors (6.66 [3.75-9.46] vs. 23.2 [7.3-32.5]; p < 0.001) and AAS (7 [3-14.5] vs. 30 [11-83]; p < 0.001). Only 44 (22%) of articles were authored by a female corresponding author, with these having significantly fewer citations than those authored by a male (289 [250-400] vs. 331.5 [267.25-451.25]; p=0.031).

CONCLUSIONS

Even amongst the top-cited literature, our results demonstrate worrying disparities in the geographic origins of stem cell-related surgical research. The vast majority originates from HICs, with these articles being published in better journals and receiving greater media attention. We also identified significant gender disparities, with female representation being concerningly low and female-authored articles receiving significantly fewer citations.

The impact of the COVID-19 pandemic on the career choice of medicine: A cross-sectional study amongst pre-medical students in Pakistan

Background

The COVID-19 pandemic has significantly affected the lives of healthcare workers due to the frontline nature of their work. Their hard work and sacrifice have forged new perceptions of healthcare workers. These changes may potentially influence students' interest in medicine. This study explores how the COVID-19 pandemic has affected premedical students’ decisions to pursue medicine as a career.

Methods

A cross-sectional study using a self-designed online questionnaire was carried out amongst pre-medical students across Pakistan.

Results

A total of 1695 students from 93 public and private schools filled in the survey. After the onset of the COVID-19 pandemic, significantly more pre-medical students want to pursue medicine (60.7%–62.9%) and less are unsure (20.2%–17%). Students are significantly more likely to be motivated to pursue medicine due to altruistic benefits to society (57% vs. 62.7%) and be deterred by the risk of contracting infections on duty (10%–14.6%). There is a minor but significant increase in the popularity of internal medicine (17.1%–18.9%), public health (4.1% vs. 5.7%), emergency medicine (3.8% vs. 5.7%), pediatrics (3.8% vs. 4.7%), and radiology (2.1% vs. 2.9%). Most pre-medical students felt that doctors routinely undergo physical and emotional turmoil (84%).

Conclusions

Although awareness of hardships faced by medical professionals has increased, motivation to pursue medicine has grown. Through understanding trends in the motivations of students to pursue medicine, medical schools can accommodate the expectations of incoming students and reach out to potential applicants.

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More pre-medical students want to pursue medicine since the onset of the pandemic.

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The major motivation to pursue medicine remains altruistic.

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Since the pandemic, students are more likely to be deterred by occupational risks.

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Some specialties have become more popular choices since the pandemic.

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These include pediatrics, public health, and internal medicine.

Factors Influencing the Intention to Pursue Surgery among Female Pre-Medical Students: A Cross-Sectional Study in Pakistan

BACKGROUND

While gender disparities in surgery are documented worldwide, it is unclear to what extent women consider surgery as a career before embarking on their medical school journey. This study aimed to report the percentage of pre-medical women in Pakistan who intend to eventually specialize in surgery and assess the factors motivating and deterring this decision.

METHODS

An online survey was conducted among female pre-medical (high school) students across Pakistan. Multivariable logistic regression was performed to determine motivating and deterring factors associated with the intention to pursue surgery.

RESULTS

Out of 1219 female high-school students, 764 (62.7) intended to join medical school. Among these 764, only 9.8% reported an exclusive intent to pursue surgery, while just 20.3% reported considering other specialties in addition to surgery. Significant motivators to pursue surgery exclusively were the intellectual satisfaction of pursuing surgery (adjusted odds ratio: 2.302), having opportunities to travel internationally for work (2.300) and use cutting-edge technology (2.203), interest in the specialty of surgery (2.031), the social prestige of becoming a surgeon (1.910), and considering one's personality well-suited to surgery (1.888). Major deterrents included the lack of interest in surgery (adjusted odds ratio: 3.812), surgical education and training being too difficult (2.440) and lengthy (1.404), and the risk of aggressive behavior from patients (2.239).

CONCLUSION

Even before entering medical school, most female pre-medical students have already decided against considering a future surgical career. Deterrents likely stem from women being pressured to conform to deep-seated societal expectations to dedicate their time and energy to domestic responsibilities.