Women in spine surgery: can we change the society?

BACKGROUND: Although the number of educated women and physicians, and especially neurosurgeons, is increasing worldwide, the educational opportunities, careers, and beliefs concerning female neurosurgeon's status and abilities are undermined. To date, reported studies have focused on the conditions of the work environment, work-life balance, and the academic career of female neurosurgeons. In this study, we aimed to report the patients' viewpoint and how they choose spine physicians. METHODS: We conducted an international survey based on 19 questions in four languages (Bulgarian, Greek, English, and German). The responses of 413 individuals, unrelated to the medical field (sex, 315 female and 115 male individuals; one individual did not answer the question regarding the gender), were obtained. Except for the question regarding the patient's preference for the physician sex, the survey aimed to examine the factors that might be contributing to this choice, including education, age, heard/read recommendations/advertisements, knowledge regarding the work of the neurosurgeons/orthopedists, and their difference regarding spine surgery. RESULTS: The majority of the participants responded that they prefer male surgeons to treat their spine. The results showed a significant correlation between the choice of a male spine surgeon and heard/read advertisements/recommendations and knowledge regarding the work of the neurosurgeon. Despite the fact that education was not related to physician selection, it was an indirect factor that led to the final choice. CONCLUSION: Women in surgery, mainly in neurosurgery, are being treated by society in an unequal way. Female surgeons are still discriminated because of their gender. The most patients prefer female physicians to talk to, but still believe that they are incapable to perform spine surgery. We cannot stop this until we change our mindset and perception of reality.

Net clinical benefit of DOACs vs. usual anticoagulation treatment in venous thromboembolism and active cancer: systematic review and meta-analysis.

Patients with active cancer are at high risk of recurrent venous thromboembolism (VTE). Usual treatment includes low molecular weight heparin (LMWH), while vitamin K antagonists (VKAs) have also been used as substitutes for LMWH. Direct oral anticoagulants (DOACs) are considered a beneficial alternative to the usual treatment but are accompanied by an increased rate of bleeding compared to LMWH. We conducted a meta-analysis to evaluate the benefits and harms under a common denomination, namely the net clinical benefit (NCB), between DOACs and usual anticoagulation. The primary outcome was NCB-1, defined as non-fatal VTE, major non-fatal bleedings, and all-cause mortality). Co-primary outcomes were 1) NCB-2 (i.e., NCB-1 and clinically relevant non-major bleedings) and 2) NCB-3 (i.e., fatal or non-fatal VTE and major bleedings). A random-effects model was used to calculate outcome risk ratios and 95% confidence intervals (CI). Prospective Register of Systematic Reviews identification number CRD42021284238. We selected 8 studies (n = 4,4461 patients; mean follow-up, 6 months). The NCB-1 and -2 were not different between DOACs and usual anticoagulation, while the NCB-3 showed a reduction of 28% (95% CI, 10-42%), favoring DOACs. Recurrent VTE was reduced by 40% (95% CI, 25-53%) with DOACs than the usual treatment. Different bleeding outcomes and all-cause mortality were not different between treatments. All primary outcomes did not differ between DOACs and LMWH, while NCB-2 and NCB-3 were reduced with DOACs than VKAs. The NCB of DOACs was similar or more favorable to usual anticoagulation in patients with active cancer due to a substantial reduction of VTE and no bleeding excess.

Antidiabetic drugs and blood pressure changes.

New era antidiabetic drugs are characterized by cardiovascular safety, including specific outcome benefits observed in randomized clinical trials (RCTs). It has been postulated that the favorable effects of new antidiabetic agents are related both to better control of blood pressure (BP) levels and to activation of multiple anti-atherosclerotic properties. In this review, we aimed to assess whether antidiabetic drugs have a pressor effect in glucose control and outcome-oriented RCTs, and to summarize the activated pathophysiological mechanisms relevant to BP control following the use of different antidiabetic drug classes. We also tried to determine which, if any, are the BP-lowering effects of more intense vs less intense glucose-lowering strategy irrespectively of trial antidiabetic regimen. To provide more robust results and evidence-based argumentation, a meta-analysis of placebo-controlled antidiabetic drug RCTs was undertaken to estimate the ongoing BP reduction for all considered and each separate drug class alone. This quantitative synthesis might be helpful for the clinician 1) to select or avoid the use of some classes of antidiabetic agents with a potential favorable or adverse pressor effect, respectively 2) to organize the overall drug regimen in patients with diabetes mellitus and minimize side effects because of concomitant use of drugs with established pressor effect (i.e. antihypertensive agents). This review was also organized to indicate whether BP change associated with different antidiabetic treatments may explain the specific macrovascular outcome benefits. Between all antidiabetic drugs including exogenous insulin, only sodium-glucose cotransporter 2 inhibitors produce a clinically important BP-lowering effect, but this BP reduction alone cannot explain the observed cardiovascular benefit.

Postoperative Low Molecular Weight Heparin-induced Infection in Gastrointestinal Cancer Patients. A 2-year Single Centre Experience.

INTRODUCTION: Patients with gastrointestinal cancer are at high risk of developing thrombosis and postoperative infection. Antico-agulation therapy for such patients is provided by low molecular weight heparin (LMWH) and elastic stockings. The latter, however, is linked to immunoregulatory activities and immunosuppression in vivo and in vitro. AIM: Therefore, the present study aimed to examine the link between LMWH and infection in patients with gastrointestinal cancer. MATERIALS AND METHODS: The study is a retrospective report of 51 patients operated on at the Second Department of Surgery at Metaxa Cancer Hospital. The sample was divided into groups based on the presence or absence of diabetes and preoperative anticoagu-lation therapy. Afterwards, the data were statistically analysed. RESULTS: The results of the study show a statistically significant correlation between LMWH and infection. Moreover, the risk of infec-tion increases by 13.3% for each day of heparin intake. The theory of this correlation is explained in detail. CONCLUSIONS: The findings of the present study raise an essential question about postoperative management of cancer patients. How-ever, the study sample size is rather small so further studies with larger sample size are required to give greater credence to results.

Risk of hypertensive disorders in pregnancy following assisted reproductive technology: overview and meta-analysis.

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate "all orders" mixed stratification was considered. Sixty-six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order ("all orders") were increased following any invasive ART: GH (+79% [95% CI, 24%-157%]) and PE (+75% [95% CI, 50%-103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%-70%]). The risk of PHD following ART steadily increased independent of gestation order.

Effect of Low-Density Lipoprotein Cholesterol Lowering by Ezetimibe/Simvastatin on Outcome Incidence: Overview, Meta-Analyses, and Meta-Regression Analyses of Randomized Trials.

This analysis investigated the extent of different outcome reductions from low-density lipoprotein cholesterol (LDL-C) lowering following ezetimibe/simvastatin treatment and the proportionality of outcome to LDL-C reductions. The authors searched PubMed between 1997 and mid-June 2015 (any language) and the Cochrane Library to identify all randomized controlled trials comparing ezetimibe/simvastatin with placebo or less intensive LDL-C lowering. Risk ratios (RR) and 95% confidence intervals (CIs), standardized to 20 mg/dL LDL-C reduction, were calculated for 5 primary outcomes (fatal and nonfatal) and 4 secondary outcomes (non-cardiovascular [CV] death, cancer, myopathy, and hepatopathy). Five ezetimibe/simvastatin RCTs (30 051 individuals) were eligible, 2 comparing ezetimibe/simvastatin vs placebo and 3 vs less intensive treatment. Outcomes reduced almost to the same extent were stroke (RR: -13%, 95% CI: -21% to -3%), coronary heart disease (CHD; RR: -12%, 95% CI: -19% to -5%), and composite of stroke and CHD (RR: -14%, 95% CI: -20% to -8%). Absolute risk reductions: 5 strokes, 10 CHD events, and 16 stroke and CHD events prevented for every 1000 patients treated for 5 years. Residual risk was almost 7× higher than absolute risk reduction for all the above outcomes. All death outcomes were not reduced, and secondary outcomes did not differ between groups. Logarithmic risk ratios were not associated with LDL-C lowering. Our meta-analysis provides evidence that, in patients with different CV disease burden, major CV events are safely reduced by LDL-C lowering with ezetimibe/simvastatin, while raising the hypothesis that the extent of LDL-C lowering might not be accompanied by incremental clinical-event reduction.

Resistant hypertension and obstructive sleep apnea: the sparring partners.

Enhanced target organ damage and cardiovascular morbidity represent common issues observed in both resistant hypertension and obstructive sleep apnea. Common pathophysiological features and risk factors justify their coexistence, especially in individuals with increased upper-body adiposity. Impaired sodium handling, sympathetic activation, accelerated arterial stiffening, and impaired cardiorenal hemodynamics contribute to drug-resistant hypertension development in obstructive sleep apnea. Effective CPAP therapy qualifies as an effective "add-on" to the underlying antihypertensive pharmacological therapy, and emerging evidence underlines the favorable effect of mineralocorticoid antagonists on both resistant hypertension and obstructive sleep apnea treatment.