COVID-19 and Mortality in the Global Surgical Population: A Systematic Review and Meta-Analysis.

INTRODUCTION: To date, no systematic review or meta-analysis has comprehensively estimated the risk of mortality by surgery type on an international scale. We aim to delineate the risk of mortality in patients with COVID-19 who undergo surgery. METHODS: PubMed (MEDLINE), Scopus, OVID, the World Health Organization Global Literature on Coronavirus Disease, and Corona-Central databases were searched from December 2019 through January 2022. Studies providing data on mortality in patients undergoing surgery were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines for abstracting data were followed and performed independently by two reviewers. The main outcome was mortality in patients with COVID-19. RESULTS: Of a total of 4023 studies identified, 46 studies with 80,015 patients met our inclusion criteria. The mean age was 67 y; 57% were male. Surgery types included general (14.9%), orthopedic (23.4%), vascular (6.4%), thoracic (10.6%), and urologic (8.5%). Patients undergoing surgery with COVID-19 elicited a nine-fold increased risk of mortality (relative risk [RR] 8.99, 95% confidence interval [CI] 4.96-16.32) over those without COVID-19. In low-income and middle-income countries (RR: 16.04, 95% CI: 4.59-56.12), the mortality risk was twice as high compared to high-income countries (RR: 7.50, 95% CI: 4.30-13.09). CONCLUSIONS: Mortality risk in surgical patients with COVID-19 compared to those without is increased almost 10-fold. The risk was highest in low-income and middle-income countries compared to high-income countries, suggesting a disproportionate effect of the pandemic on resource-constrained regions.

A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease.

BACKGROUND: Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD. METHODS: The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS: Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I2 = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I2 = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I2 = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I2 = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I2 = 51.01%) was not associated with early readmission on meta-analysis of the available studies. CONCLUSIONS: The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.

Comparing the Perceptions of Reciprocal- and Near-Peer Objective Structured Clinical Examinations (OSCEs) in Medical Students.

INTRODUCTION: The Objective Structured Clinical Examination (OSCE) is utilized by medical schools to assess students' competency in clinical skills. Literature has shown that first-year students who were tutored by fourth-year students (MS4s; near-peer) in practice OSCEs reported self-perceived improvement in OSCE skills. There is a lack of research regarding the effectiveness of first-year (MS1) pairs for reciprocal-peer practice OSCEs. This study aims to assess if virtual reciprocal-peer OSCEs provide comparable learning opportunities to virtual near-peer OSCEs. METHODS: MS1 students were assigned to work with a near-peer or a reciprocal-peer for one week, and then switched protocols the second week. One student in each reciprocal-peer pair was assigned to act as a standardized patient (SP). Their partner took a history, interpreted physical exam findings, prepared a note, and gave an oral presentation. The pair then switched roles using a second case. The near-peer group followed the same procedure, without the reversal of roles. RESULTS: A total of 135 MS1s participated in the first week and 129 in the second week. Students agreed that working with a near-peer was more valuable than a reciprocal-peer in the following parameters: peer feedback (N=113, 89%), history-taking skills (N=101, 80%), physical exam skills (N=102, 81%), and note-writing skills (N=109, 89%). Pairwise comparison utilizing Wilcoxon signed-rank test indicated participants preferred the choice of a fourth-year student partner over an MS1 partner (Z=1.436, p<0.001). CONCLUSION: Participants found working with a near-peer increased confidence in their clinical skills and near-peer feedback was more valuable. Although MS1s found that watching and evaluating their peers in a reciprocal-peer exercise was beneficial, students overwhelmingly preferred working with MS4s due to more valuable feedback.

Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery.

Adverse cardiac events after laparoscopic bariatric surgery are rare, yet preoperative cardiology evaluation and testing remain common, resulting in the overuse of cardiac testing in low-risk patients. Our objective was to assess the frequency of, and factors associated with, overuse of preoperative cardiac testing in patients at low cardiac risk before laparoscopic bariatric surgery. We retrospectively reviewed data from 1,094 adult patients who underwent laparoscopic bariatric surgery at our institution from January 1, 2015, through December 31, 2019. The cardiac risk was determined using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk model. Multivariate logistic regression was used to evaluate risk factors associated with the overuse of cardiac testing in low-risk patients. Overall, 1,059 patients (96.8%) were estimated to be at low cardiac risk by the RCRI, and 1,094 (100%) were at low cardiac risk by NSQIP MICA. A total of 587 patients (51.8%) were referred to cardiology for preoperative evaluation, and 643 patients (56.7%) underwent one or more preoperative cardiac tests. Factors associated with overuse of preoperative cardiac testing in low-risk patients included preoperative cardiology referral (adjusted odds ratio 37.2, 95% confidence interval 25.3 to 54.7) and patient age (adjusted odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Overuse of preoperative cardiac testing was common in patients at low cardiac risk before laparoscopic bariatric surgery. Preoperative referral to cardiology was the most significant risk factor associated with the overuse of preoperative cardiac testing. Application of risk models such as the RCRI or NSQIP MICA at the time of bariatric program enrollment may reduce unnecessary preoperative cardiac testing in low-risk patients.