Predictors for success and failure in international medical graduates: a systematic review of observational studies.

BACKGROUND: International Medical Graduates (IMG) are an essential part of the international physician workforce, and exploring the predictors of success and failure for IMGs could help inform international and national physician labour workforce selection and planning. The objective of this study was to explore predictors for success for selection of IMGs into high stakes postgraduate training positions and practice and not necessarily for informing IMGs. METHODS: We searched 11 databases, including Medline, Embase and LILACS, from inception to February 2022 for studies that explored the predictors of success and failure in IMGs. We reported baseline probability, effect size in relative risk (RR), odds ratio (OR) or hazard ratio (HR) and absolute probability change for success and failure across six groups of outcomes, including success in qualifying exams, or certificate exams, successful matching into residency, retention in practice, disciplinary actions, and outcomes of IMG clinical practice. RESULTS: Twenty-five studies (375,549 participants) reported the association of 93 predictors of success and failure for IMGs. Female sex, English fluency, graduation recency, higher scores in USMLE step 2 and participation in a skill assessment program were associated with success in qualifying exams. Female sex, English fluency, previous internship and results of qualifying exams were associated with success in certification exams. Retention to work in Canada was associated with several factors, including male sex, graduating within the past five years, and completing residency over fellowships. In the UK, IMGs and candidates who attempted PLAB part 1, ≥ 4 times vs. first attempters, and candidates who attempted PLAB part 2, ≥ 3 times vs. first attempters were more likely to be censured in future practice. Patients treated by IMGs had significantly lower mortalities than those treated by US graduates, and patients of IMGs had lower mortalities [OR: 0.82 (95% CI: 0.62, 0.99)] than patients of US citizens who trained abroad. CONCLUSIONS: This study informed factors associated with the success and failure of IMGs and is the first systematic review on this topic, which can inform IMG selection and future studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021252678.

Epidemiology of adolescent idiopathic scoliosis in Isfahan, Iran: A school-based study during 2014-2015.

BACKGROUND: Scoliosis is a three-dimensional deformity of the spine with lateral curvature in addition to the rotation of vertebral bodies. The aim of the present study was to determine the prevalence of adolescent idiopathic scoliosis (AIS) in our society and its demographic-related factors. MATERIALS AND METHODS: This was a cross-sectional study that took place from November 2014 to March 2015 in Isfahan, Iran. During the period of study, 24 schools were randomly chosen from six zones by a simple random sampling method. In each school, about 120 students were randomly selected and evaluated. Anterior forward bending test and scoliometry were done in all students and suspicious ones referred to Alzahra spine clinic for further evaluation. The diagnosis of AIS was based on radiographic finding and Cobb angle more than 10°. Data about age, sex, height, body mass index, hand dominancy, and type of schoolbag were recorded. RESULTS: A total number of 3018 children were evaluated and 19 were diagnosed with AIS that showed the prevalence of 0.62%. None of the study variables had a significant relation with the presence of AIS. The cutoff point for the detection of AIS with scoliometry was calculated as 3.5, with a sensitivity of 73.7% and specificity of 86.7%. CONCLUSION: The prevalence of AIS in our area was 0.62%, which was lower than previous reports and did not have a relation with demographic factors; however, screening surveys identify a significant number of children with AIS who could benefit from preventive treatment.

Proton-Pump Inhibitors to Prevent Gastrointestinal Bleeding - An Updated Meta-Analysis.

BACKGROUND: The goal of this systematic review was to examine the efficacy and safety of proton-pump inhibitors for stress ulcer prophylaxis in critically ill patients. METHODS: We included randomized trials comparing proton-pump inhibitors versus placebo or no prophylaxis in critically ill adults, performed meta-analyses, and assessed certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations approach. To explore the effect of proton-pump inhibitors on mortality based on disease severity, a subgroup analysis was conducted combining within-trial subgroup data from the two largest trials and assessed credibility using the Instrument for Assessing the Credibility of Effect Modification Analyses. RESULTS: Twelve trials that enrolled 9533 patients were included. Proton-pump inhibitors were associated with a reduced incidence of clinically important upper gastrointestinal bleeding (relative risk [RR], 0.51 [95% confidence interval (CI), 0.34 to 0.76]; high certainty evidence). Proton-pump inhibitors may have little or no effect on mortality (RR, 0.99 [95% CI, 0.93 to 1.05]; low certainty). Within-trial subgroup analysis with intermediate credibility suggested that the effect of proton-pump inhibitors on mortality may differ based on disease severity. Subgroup results raise the possibility that proton-pump inhibitors may decrease 90-day mortality in less severely ill patients (RR, 0.89; 95% CI, 0.80 to 0.98) and may increase mortality in more severely ill patients (RR, 1.08; 95% CI, 0.96 to 1.20]. Proton-pump inhibitors may have no effect on pneumonia and little or no effect on Clostridioides difficile infection (low certainty). CONCLUSIONS: High certainty evidence supports the association of proton-pump inhibitors with decreased upper gastrointestinal bleeding. Proton-pump inhibitors may have little or no effect on mortality, although a decrease in mortality in less severely ill patients and an increase in mortality in more severely ill patients remain possible. (PROSPERO number CRD42023461695.).

Pharmaco-disparities in heart failure: a survey of the affordability of guideline recommended therapy in 10 countries.

AIMS: Heart failure with reduced ejection fraction (HFrEF) is treatable but guideline-directed medical therapy (GDMT) may not be affordable or accessible to people living with the disease. METHODS AND RESULTS: In this cross-sectional survey, we investigated the price, affordability, and accessibility of four pivotal classes of HFrEF GDMT: angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB) or angiotensin-neprilysin inhibitors (ARNI); beta-blockers; mineralocorticoid receptor antagonists (MRA); and sodium glucose co-transporter 2 inhibitors (SGLT2i). We sampled online or community pharmacies in 10 countries across a range of World Bank income groups, assessing mean 30 day retail prescription prices, affordability relative to gross national income per capita per month, and accessibility. We reported median price ratios relative to the International Reference Standard. We performed a literature review to evaluate accessibility to GDMT classes through publicly funded drug programmes in each country. HFrEF GDMT prices, both absolute and relative to the international reference, were highest in the United States and lowest in Pakistan and Bangladesh. The most expensive drug was the ARNI, sacubitril/valsartan, with a mean (standard deviation, SD) 30 day price ranging from $11.06 (0.81) in Pakistan to $611.50 (3.54) in United States. The least expensive drug was the MRA, spironolactone, with a mean (SD) 30 day price ranging from $0.18 (0.00) in Pakistan to $12.32 (0.00) in England. Affordability (SD) of quadruple therapy-ARNI, beta-blockers, MRA, and SGLT2i-was best in high-income and worst in low-income countries, ranging from 1.49 (0.00)% of gross national income per capita per month in England to 232.47 (31.47)% in Uganda. Publicly funded drug programmes offset costs for eligible patients, but ARNI and SGLT2i were inaccessible through these programmes in low- and middle-income countries. Price, affordability, and access were substantially improved in all countries by substituting ARNI for ACEi/ARB. CONCLUSIONS: There was marked variation between countries in the retail price of HFrEF GDMT. Despite higher prices in high-income countries, GDMT was more accessible and affordable than in low- and middle-income countries. Publicly funded drug programmes in lower income countries increased affordability but limited access to newer HFrEF GDMT classes. Pharmaco-disparities must be addressed to improve HFrEF outcomes globally.

Values and preferences towards medical cannabis among people living with chronic pain: a mixed-methods systematic review.

OBJECTIVE: To explore values and preferences towards medical cannabis among people living with chronic pain. DESIGN: Mixed-methods systematic review. DATA SOURCES: We searched MEDLINE, EMBASE and PsycINFO from inception to 17 March 2020. STUDY SELECTION: Pairs of reviewers independently screened search results and included quantitative, qualitative and mixed-methods studies reporting values and preferences towards medical cannabis among people living with chronic pain. REVIEW METHODS: We analysed data using meta-narrative synthesis (quantitative findings were qualitised) and tabulated review findings according to identified themes. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess certainty of evidence. RESULTS: Of 1838 initial records, 15 studies proved eligible for review. High to moderate certainty evidence showed that patient's use of medical cannabis for chronic pain was influenced by both positive (eg, support from friends and family) and negative social factors (eg, stigma surrounding cannabis use). Most patients using medical cannabis favoured products with balanced ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD), or high levels of CBD, but not high THC preparations. Many valued the effectiveness of medical cannabis for symptom management even when experiencing adverse events related to concentration, memory or fatigue. Reducing use of prescription medication was a motivating factor for use of medical cannabis, and concerns regarding addiction, losing control or acting strangely were disincentives. Out-of-pocket costs were a barrier, whereas legalisation of medical cannabis improved access and incentivised use.Low to very low certainty evidence suggested highly variable values towards medical cannabis among people living with chronic pain. Individuals with pain related to life-limiting disease were more willing to use medical cannabis, and preferred oral over inhaled administration. CONCLUSIONS: Our findings highlight factors that clinicians should consider when discussing medical cannabis. The variability of patients' values and preferences emphasise the need for shared decision making when considering medical cannabis for chronic pain.

Interventional treatments for chronic, axial or radicular, non-cancer, spinal pain: a protocol for a systematic review and network meta-analysis of randomised trials.

INTRODUCTION: Chronic, non-cancer, axial or radicular spinal pain is a common condition associated with considerable socioeconomic burden. Clinicians frequently offer patients various interventional procedures for the treatment of chronic spine pain; however, the comparative effectiveness and safety of available procedures remains uncertain. METHODS: We will conduct a systematic review of randomised controlled trials that explores the effectiveness and harms of interventional procedures for the management of axial or radicular, chronic, non-cancer, spine pain. We will identify eligible studies through a systematic search of Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science from inception without language restrictions. Eligible trials will: (1) enrol primarily adult patients (≥18 years old) with axial or radicular, chronic, non-cancer, spine pain, (2) randomise patients to different, currently available, interventional procedures or to an interventional procedure and a placebo/sham procedure or usual care, and (3) measure outcomes at least 1 month after randomisation.Pairs of reviewers will independently screen articles identified through searches and extract information and assess risk of bias of eligible trials. We will use a modified Cochrane instrument to evaluate risk of bias. We will use frequentist random-effects network meta-analyses to assess the relative effects of interventional procedures, and five a priori hypotheses to explore between studies subgroup effects. We will use the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome, including direct, indirect and network estimates. ETHICS AND DISSEMINATION: No research ethics approval is required for this systematic review, as no confidential patient data will be used. We will disseminate our findings through publication in a peer-reviewed journal and conference presentations, and our review will support development of a BMJ Rapid Recommendations providing contextualised clinical guidance based on this body of evidence. PROSPERO REGISTRATION NUMBER: CRD42020170667.

Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Review and Meta-Analysis.

A growing body of literature on the 2019 novel coronavirus (SARS-CoV-2) is becoming available, but a synthesis of available data has not been conducted. We performed a scoping review of currently available clinical, epidemiological, laboratory, and chest imaging data related to the SARS-CoV-2 infection. We searched MEDLINE, Cochrane CENTRAL, EMBASE, Scopus and LILACS from 01 January 2019 to 24 February 2020. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. Qualitative synthesis and meta-analysis were conducted using the clinical and laboratory data, and random-effects models were applied to estimate pooled results. A total of 61 studies were included (59,254 patients). The most common disease-related symptoms were fever (82%, 95% confidence interval (CI) 56%-99%; n = 4410), cough (61%, 95% CI 39%-81%; n = 3985), muscle aches and/or fatigue (36%, 95% CI 18%-55%; n = 3778), dyspnea (26%, 95% CI 12%-41%; n = 3700), headache in 12% (95% CI 4%-23%, n = 3598 patients), sore throat in 10% (95% CI 5%-17%, n = 1387) and gastrointestinal symptoms in 9% (95% CI 3%-17%, n = 1744). Laboratory findings were described in a lower number of patients and revealed lymphopenia (0.93 × 109/L, 95% CI 0.83-1.03 × 109/L, n = 464) and abnormal C-reactive protein (33.72 mg/dL, 95% CI 21.54-45.91 mg/dL; n = 1637). Radiological findings varied, but mostly described ground-glass opacities and consolidation. Data on treatment options were limited. All-cause mortality was 0.3% (95% CI 0.0%-1.0%; n = 53,631). Epidemiological studies showed that mortality was higher in males and elderly patients. The majority of reported clinical symptoms and laboratory findings related to SARS-CoV-2 infection are non-specific. Clinical suspicion, accompanied by a relevant epidemiological history, should be followed by early imaging and virological assay.