1
|
Zakaria M, Martins RS, Khan MU, Fatimi AS, Maqbool B, Fatimi SH. Operating Ethically: A Review of Surgical Ethics in Pakistan and Recommendations for the Way Forward. Cureus 2023; 15:e46789. [PMID: 37954730 PMCID: PMC10632743 DOI: 10.7759/cureus.46789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/14/2023] Open
Abstract
Medical ethics underpin the moral framework that delineates the professional relationship between physicians and their patients and thereby is an integral part of making patient-centric healthcare decisions. The concept of ethics is deeply embedded in the field of surgery as surgeons confront a myriad of dilemmas as a part of their routine, whether it be in a preoperative or postoperative environment. The current review aims to describe the state of surgical ethics in Pakistan, with the intent of encouraging dialogues about the ethical considerations relevant to the field surgery that will identify actionable areas for improvement. While most surgeons are aware of the traditional principles of ethics and their practice, their surgical and clinical decisions may fall short of these standards because of time constraints and prevailing cultural and religious beliefs and taboos. The rigorous application of ethical principles in areas of patient-related communication, such as consenting, trainee education, palliative and end-of-life care, and surgical innovation and research, will have significant implications for patients, surgeons, and society. Our review has identified the lack of formal bioethics education and insufficient oversight and ethical regulations to be at the core of inadequate ethical practices in Pakistan and has highlighted actionable areas to be addressed in the future.
Collapse
Affiliation(s)
- Maheen Zakaria
- Medical College, Aga Khan University Medical College, Karachi, PAK
| | | | | | | | - Baila Maqbool
- Department of Acute Care Surgery, University of New Mexico School of Medicine, Albuquerque, USA
| | | |
Collapse
|
2
|
Early Discontinuation, Results Reporting, and Publication of Gynecology Clinical Trials From 2007 to 2020. Obstet Gynecol 2022; 139:821-831. [DOI: 10.1097/aog.0000000000004735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/06/2022] [Indexed: 11/26/2022]
|
3
|
Azad TD, Feng AY, Mehta S, Bak AB, Johnson E, Mittal V, Esparza R, Veeravagu A, Halpern CH, Grant GA. Randomized Controlled Trials in Functional Neurosurgery-Association of Device Approval Status and Trial Quality. Neuromodulation 2019; 23:496-501. [PMID: 31828896 DOI: 10.1111/ner.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/07/2019] [Accepted: 10/30/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Randomized controlled trials (RCTs) have been critical in evaluating the safety and efficacy of functional neurosurgery interventions. Given this, we sought to systematically assess the quality of functional neurosurgery RCTs. METHODS We used a database of neurosurgical RCTs (trials published from 1961 to 2016) to identify studies of functional neurosurgical procedures (N = 48). We extracted data on the design and quality of these RCTs and quantified the quality of trials using Jadad scores. We categorized RCTs based on the device approval status at the time of the trial and tested the association of device approval status with trial design and quality parameters. RESULTS Of the 48 analyzed functional neurosurgery RCTs, the median trial size was 34.5 patients with a median age of 51. The most common indications were Parkinson's disease (N = 20), epilepsy (N = 10), obsessive-compulsive disorder (N = 4), and pain (N = 4). Most trials reported inclusion and exclusion criteria (95.8%), sample size per arm (97.9%), and baseline characteristics of the patients being studied (97.9%). However, reporting of allocation concealment (29.2%), randomization mode (66.7%), and power calculations (54.2%) were markedly less common. We observed that trial quality has improved over time (Spearman r, 0.49). We observed that trials studying devices with humanitarian device exemption (HDE) and experimental indications (EI) tended to be of higher quality than trials of FDA-approved devices (p = 0.011). A key distinguishing quality characteristic was the proportion of HDE and EI trials that were double-blinded, compared to trials of FDA-approved devices (HDE, 83.3%; EI, 69.2%; FDA-approved, 35.3%). Although more than one-third of functional neurosurgery RCTs reported funding from industry, no significant association was identified between funding source and trial quality or outcome. CONCLUSION The quality of RCTs in functional neurosurgery has improved over time but reporting of specific metrics such as power calculations and allocation concealment requires further improvement. Device approval status but not funding source was associated with trial quality.
Collapse
Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Swapnil Mehta
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Alex B Bak
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Eli Johnson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Vaishali Mittal
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rogelio Esparza
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
5
|
Peinemann F, Labeit A. Negative pressure wound therapy: A systematic review of randomized controlled trials from 2000 to 2017. J Evid Based Med 2019; 12:125-132. [PMID: 30460777 DOI: 10.1111/jebm.12324] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 10/22/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Negative pressure wound therapy (NPWT) proposes to provide better wound healing than standard wound management. Evidence quality of randomized controlled trials (RCTs) varies. METHODS We included participants with any kind of wounds and commercial as well as the homemade NPWT system. Comparators were any other wound dressing including variant NPWTs. We included RCTs randomizing patients or wounds in parallel or crossover designs. We searched PubMed and Cochrane Library on January 03, 2018. We assessed the risk of bias according to Cochrane and appropriateness of clinical endpoints according to the Food and Drug Administration (FDA). RESULTS We included 93 RCTs originating in 30 countries, 70 studies on open wounds and 23 studies on closed wounds. With respect to random sequence generation, we judged an unclear or high risk of bias in 50% (47 of 93) studies. With respect to allocation concealment, we judged an unclear or high risk of bias in 90% (84 of 93). We identified 41% (38 of 93) studies that based their conclusion on not appropriate endpoints. CONCLUSIONS High risk of bias concerning random sequence generation and allocation concealment limited the credibility of the majority of 93 included RCTs on NPWT. A low risk of bias can and should be achieved with both items, and we recommend to align future RCTs to Cochrane. Many primary clinical endpoints were deemed not valid for making inferences on the efficacy of NPWT. We recommend using patient-centered endpoints as requested by the FDA and suggested in the present systematic review.
Collapse
Affiliation(s)
- Frank Peinemann
- Children's Hospital, University Hospital, Cologne, Germany
- FOM University of Applied Science for Economics & Management, Essen, Germany
| | - Alexander Labeit
- Division of Population Health, Health Services Research and Primary Care, Faculty of Biological, Medical and Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
6
|
Broekman ML, Carrière ME, Bredenoord AL. Surgical innovation: the ethical agenda: A systematic review. Medicine (Baltimore) 2016; 95:e3790. [PMID: 27336866 PMCID: PMC4998304 DOI: 10.1097/md.0000000000003790] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/22/2016] [Accepted: 05/04/2016] [Indexed: 11/25/2022] Open
Abstract
The aim of the present article was to systematically review the ethics of surgical innovation and introduce the components of the learning health care system to guide future research and debate on surgical innovation.Although the call for evidence-based practice in surgery is increasingly high on the agenda, most surgeons feel that the format of the randomized controlled trial is not suitable for surgery. Innovation in surgery has aspects of, but should be distinguished from both research and clinical care and raises its own ethical challenges.To answer the question "What are the main ethical aspects of surgical innovation?", we systematically searched PubMed and Embase. Papers expressing an opinion, point of view, or position were included, that is, normative ethical papers.We included 59 studies discussing ethical aspects of surgical innovation. These studies discussed 4 major themes: oversight, informed consent, learning curve, and vulnerable patient groups. Although all papers addressed the ethical challenges raised by surgical innovation, surgeons hold no uniform view of surgical innovation, and there is no agreement on the distinction between innovation and research. Even though most agree to some sort of oversight, they offer different alternatives ranging from the formation of new surgical innovation committees to establishing national registries. Most agree that informed consent is necessary for innovative procedures and that surgeons should be adequately trained to assure their competence to tackle the learning curve problem. All papers agree that in case of vulnerable patients, alternatives must be found for the informed consent procedure.We suggest that the concept of the learning health care system might provide guidance for thinking about surgical innovation. The underlying rationale of the learning health care system is to improve the quality of health care by embedding research within clinical care. Two aspects of a learning health care system might particularly enrich the necessary future discussion on surgical innovation: integration of research and practice and a moral emphasis on "learning activities." Future research should evaluate whether the learning health care system and its adjacent moral framework provides ethical guidance for evidence-based surgery.
Collapse
Affiliation(s)
- Marike L. Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus Institute of Neurosciences
| | - Michelle E. Carrière
- Department of Neurosurgery, Brain Center Rudolf Magnus Institute of Neurosciences
| | - Annelien L. Bredenoord
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|