Comparing Clinical and Echocardiographic Outcomes Following Valve-Sparing Versus Transannular Patch Repair of Tetralogy of Fallot: A Systematic Review and Meta-analysis.

OBJECTIVES: Transannular patch (TAP) repair of tetralogy of Fallot (ToF) relieves right ventricular tract obstruction but may lead to pulmonary regurgitation. Valve-sparing (VS) procedures can avoid this but there is potential for residual pulmonic stenosis. We aimed to evaluate clinical and echocardiographic outcomes of TAP and VS repair for ToF. METHODS: A systematic search of the PubMed, Embase, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases was carried out to identify articles comparing conventional TAP repair and VS repair for ToF. Clinical and echocardiographic outcomes were meta-analyzed using random-effects models. RESULTS: 40 studies were included in this meta-analysis with data on 11,723 participants (TAP: 6,171; VS: 5,045). Participants that underwent a VS procedure experienced a significantly lower cardiopulmonary bypass time (MD: -14.97; 95% CI: -22.54, -7.41), shorter ventilation duration (MD: -15.33; 95% CI: -30.20, -0.46), and shorter lengths of both ICU (MD: -0.67; 95% CI: -1.29, -0.06) and hospital stay (MD: -2.30; 95% CI: [-4.08, -0.52). There was also a lower risk of mortality (RR: 0.40; 95% CI: [0.27, 0.60]) and pulmonary regurgitation (RR: 0.35; 95% CI: [0.26, 0.46]) associated with the VS group. Most other clinical and echocardiographic outcomes were comparable in the two groups. CONCLUSIONS: This meta-analysis confirms the well-established increased risk of pulmonary insufficiency following TAP repair, while also demonstrating that VS repairs are associated with several improved clinical outcomes. Continued research can identify the criteria for adopting a VS approach as opposed to a traditional TAP repair.

Hospital Resources and Practice Patterns for Congenital Cardiac Surgery in Pakistan: A Nationwide Status Report.

Objective: Low- and middle-income countries such as Pakistan bear the brunt of the global burden of congenital heart disease (CHD), This nationwide study assessed hospital resources and surgical practice patterns pertaining to CHD surgery across Pakistan. Methods: A nationwide hospital facility survey was conducted, targeting all health centers performing CHD surgery in Pakistan. Descriptive data analysis was performed, with categorical variables being presented as frequencies and percentages and continuous variables being reported as means and standard deviations. Results: Seventeen surgeons across 17 different centers participated in the study. Eight of 17 (47%) surgeons were under 45 years of age, while the rest were older than 45 years. More respondents were employed at public/government-owned hospitals (11/17, 65%) and at specialized cardiac centers (13/17, 76%), with a majority of centers reported as having a special ICU designated for congenital cardiac patients (11/17, 65%). With regard to operative volume, 7 of 17 (41%) centers reported more than 350 cases per year, with 7 of 17 reported >10 neonatal cases per year (6/12, 50%). Only one center reported national and international collaborations for research, most centers carrying out less than five research projects in a year. Conclusion: This study has identified key areas that require the attention of local administrative bodies as well as international organizations and societies. The existing centers in Pakistan are unable to meet the demands of the population, leaving a large number of untreated patients, especially for neonatal lesions.

Cardiac Children Hospital Early Warning ScoreVersus the Inadequate Oxygen Delivery Index for the Detection of Early Warning Signs of Deterioration.

To assess the utility of the Cardiac Children's Hospital Early Warning Score (C-CHEWS) in the early detection of deterioration. DESIGN: Single-center longitudinal pilot study. SETTING: Pediatric cardiac ICU (PCICU), Aga Khan University. INTERVENTIONS: C-CHEWS and Inadequate Oxygen Delivery (IDO2) Index calculation every 2 hours. PATIENTS: A total of 60 children (0 d to 18 yr old). MEASUREMENTS AND MAIN RESULTS: A single-center longitudinal pilot study was conducted at PCICU. All postoperative extubated patients were assessed and scored between 0 and 11, and these scores were then correlated with the IDO2 index data available from the T3 platform. Adverse events were defined as a need for cardiopulmonary resuscitation, or reintubation, and death. A total of 920 C-CHEWS and IDO2 scores were analyzed on 60 patients during the study period. There were 36 males and 24 females, and the median age of the study population was 34 months (interquartile range, 9.0-72.0 mo). Fourteen patients (23.3%) developed adverse events; these included 9 reintubations and 5 cardiopulmonary arrests, resulting in 2 deaths. The area under the curve (AUC) for C-CHEWS scores fell in an acceptable range of 0.956 (95% CI, 0.869-0.992), suggesting an optimal accuracy for identifying early warning signs of cardiopulmonary arrest. Whereas, IDO2 showed no discriminatory power to detect the adverse events with an AUC of 0.522 (95% CI, 0.389-0.652). CONCLUSIONS: The C-CHEWS tool provides a standardized assessment and approach to deteriorating congenital cardiac surgery patients in recognizing early postoperative deterioration.

Societal Preferences for Gender of Surgeons: A Cross-Sectional Study in the General Population of Pakistan.

BACKGROUND: Sociocultural norms and gender biases may result in surgeon gender preferences among the general public. This study aimed to understand preferences and perceptions related to surgeon gender among the general population in Pakistan, a lower-middle-income country. METHODS: A cross-sectional study was conducted by the Aga Khan University, Karachi, among the adult general population in Pakistan. Sequential mixed-mode data collection was performed via online dissemination on social media platforms and in-person surveying at different geographic locations in Karachi. RESULTS: Among 1604 respondents, 50% did not report having surgeon gender preferences in general. Among respondents with gender preferences, there was a highly significant preference for gender concordance across all surgical subspecialties (p <0.001) except cardiothoracic surgery and neurosurgery. Exceptions where women preferred a male surgeon were neurosurgery (59.7% vs. 40.3%; p <0.001) and cardiothoracic surgery (53.1% vs. 46.9%; p <0.001). Moreover, respondents felt more comfortable communicating with (67.6%) and being examined by (73.3%) gender concordant surgeons. Men more commonly perceived male surgeons as more competent (26% vs. 14.5%; p <0.001) and warmer (18.3% vs. 9.8%; p <0.001) than female surgeons. Nevertheless, the most important factors influencing selection of a surgeon were the surgeon's reputation (69.6%) and experience (50.5%). Most respondents (84.5%) believed that more females should practice surgery. CONCLUSION: While around half of respondents do not have gender preferences, a significant proportion prefers a gender concordant surgeon across subspecialties. In a society where conservative sociocultural norms play a significant role when seeking health care, this makes yet another compelling argument for gender parity in surgery.

Harassment and mental health in surgical training: a pilot survey of surgical trainees in Pakistan.

OBJECTIVE: To assess harassment among surgical trainees and its effects on mental health, and to explore its association with gender. METHODS: The nationwide cross-sectional pilot study was conducted by the Association of Women Surgeons of Pakistan from July to September 2019, and included surgical trainees of either gender working in both public and private hospitals. Data was collected using an anonymous online survey form to assess harassment and self-perceived burnout and depression. Data was analysed using SPSS 22. RESULTS: Of the 147 respondents, 49(33.3%) were males; 98(66.6%) were females; and 118(80.3%) were residents. Workplace harassment was reported by 80(54.4%) trainees. Among the males it was reported by 24(49%) and among the females by 56(57%) (p=0.349). Of those having faced harassment, 9(11.3%) reported it to the administration. Severe self-perceived burnout was reported by 102(69.4%) respondents, and severe self-perceived depression by 69(46.9%). Respondents experiencing bullying were more likely to report severe self-perceived burnout than those not experiencing bullying (p=0.02). Multivariable logistic regression showed female gender to be significantly associated with sexual harassment (odds ratio: 4.261 [95% confidence interval: 1.067-17.019]) and severe self-perceived depression (odds ratio: 5.052 [95% confidence interval: 1.187-21.503]). Need for a support group was identified by 134(91.2%) trainees. CONCLUSIONS: An overwhelming need was found for trainee surgeon support groups and other interventions targeted at improving the workplace environment for surgical trainees in Pakistan.

MALIGNANT OVARIAN GERM CELL TUMORS AT A TERTIARY CARE SETTING IN PAKISTAN.

BACKGROUND: Malignant Ovarian Germ Cell Tumours (MOGCT) are rare neoplasms and their behavior is unknown in South-East Asian population. METHODS: Case records of 66 patients from 1994-2007 with MOGCT were reviewed. Histology was based on WHO classification. Tumours were staged according to International Federation of Gynecology and Obstetrics (FIGO) system. Data was collected on age, histopathology, stage, alpha-feto protein (AFP) and B-human chorionic gonadotropins (B-hCG) levels, treatment, time to recurrence (TTR) and overall survival (OS). OS was the interval in months between date of diagnosis and last encounter while TTR was between the date of diagnosis and recurrence. OS was determined by Kaplan-Meier method. RESULTS: Median age of our patients was 18 years. Ninteen patients were in stage I, eight in II, twenty-one in III and eighteen in stage IV. Histologically, dysgerminoma was the most common diagnosis (22 patients) followed by teratoma in 16, yolk sac tumor in 15, mixed germ cell tumor in 12 while embryonal carcinoma was identified in only one patient. Median followup was 48 months (0.2-183). All patients underwent initial surgery. Fertility sparing procedures were performed in 75% patients. Thirty-four patients (57.62%) achieved complete remission while 16 (27.11%) had progressive disease. Seven (10.60%) patients relapsed, all within first 3 years. TTR was 11.2-32.5 months. OS for study population was 60 months. Sixteen (88%) of stage I while only 4 (26.6%) of stage IV patients were alive at median follow-up. CONCLUSIONS: MOGCT has good prognosis with conservative surgery and platinum chemotherapy. Fertility sparing surgery has become a standard in MOGCTs, so awareness should be raised amongst professionals for early referral to cancer care facility.