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\begin{document}

\title{Meta-analysis Derivation Concedes Clinical Significance in
Democratisation of Healthcare}



\author[1]{Mohamad Bashir}%
\author[2]{Mohammed Idhrees}%
\author[3]{Mostafa Mousavizadeh}%
\author[4]{Yousef Rezaei}%
\author[3]{Saeid Hosseini}%
\affil[1]{Royal Blackburn Teaching Hospital}%
\affil[2]{SRM Institutes for Medical Science Vadapalani}%
\affil[3]{Rajaie Cardiovascular Medical and Research Center}%
\affil[4]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\textbf{Meta-analysis Derivation Concedes Clinical Significance in
Democratisation of Healthcare}

Mohamad Bashir\textsuperscript{1}, MD, Ph.D; Idhrees
Mohammed\textsuperscript{2}, MD; Mostafa
Mousavizadeh\textsuperscript{3}, MD; Yousef Rezaei\textsuperscript{3},
MD; Saeid Hosseini\textsuperscript{3}, MD

\textsuperscript{1} Department of Vascular and Endovascular Surgery,
Royal Blackburn Teaching Hospital, Blackburn, UK

\textsuperscript{2} Institute of Cardiac and Aortic Disorders (ICAD),
SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu,
India

\textsuperscript{3} Heart Valve Disease Research Center, Rajaie
Cardiovascular Medical and Research Center, Iran University of Medical
Sciences, Tehran, Iran

\textbf{Corresponding Author:}

Mohamad Bashir, MD, PhD, MRCS

Department of Vascular and Endovascular Surgery

Royal Blackburn Teaching Hospital

Haslingden Rd, Blackburn BB23HH, UK

Email: drmbashir@mail.com

\textbf{Keywords:} Meta-analysis, publication bias, Meta-regression,
aorta, frozen elephant trunk

To the Editor: We appreciate Wu and colleagues'\textsuperscript{1}
letter submitted and entailed few critical points regarding the
published meta-analysis data and the credibility of conclusions
perceived. Thus, and in an attempt to demystify the confusion, we
summarized few pointers that Wu et al. need to consider in
interpretation of meta-analysis:

\begin{enumerate}
\tightlist
\item
  It's not a surprisingly practice that we pursue a rather scientific
  and stringent execution of thoughts and quality metric articles'
  assessment for clarity, quality, quantity, and critical appraisal
  components. Our extensive experience in publishing systematic reviews
  leans stringent data requirements to substantiate the objectives that
  had to be mandated. In contrary to what Wu et al\textsuperscript{1}
  perceived, publication bias is not a practice we follow to achieve
  desired outcomes. As such cognitive selective steps are adhered to and
  following quality metrics from published articles observed. The
  frequency of observational data declaring statistical significance in
  dire surgical experience as in Type A dissection is a reflection of
  current trends and practices. As such, it would be seemingly positive
  that publication bias is an unequivocal mannerism in constructing a
  rather niche meta-analysis. We have undoubtedly maintained a stream of
  thought to exclude any overlapped/duplicated population from the same
  institutions per se, alluding to extractable data for patients with
  isolated acute type A aortic dissection undergoing total arch
  replacement with frozen elephant trunk (FET). Concerns highlighted on
  this entity can easily be slotted into the following methodological
  nature of all meta-analyses. In concluding this section, as with all
  meta-analysis we published, we've implemented a dual-reviewer process
  including abstract screening upon selection of relevant studies as
  alluded to and aforementioned.\textsuperscript{2}
\item
  We follow a rather constructive approach of heteroscedasticity to
  overcome culpable heterogeneity in all meta-analysis we conducted. The
  idea to give small weighted regression to observation associated with
  higher variances to minimize potential residual is a substantial
  practice we follow. As such postoperative stroke and SCI were found to
  be I\textsuperscript{2}= 63.93\% and I\textsuperscript{2}= 19.56\%,
  respectively; however, we did not find any significant effect of
  subgroup analyses on the heterogeneity of pooled estimation of
  postoperative stroke. Our objectives and primary focus were on
  neurological outcomes, and as such, we performed a meta-regression
  analysis for those observed outcomes with variable heterogeneity.
  Additionally, there are many confounding factors that we were not able
  to extract from these observational studies to explore potential
  factors affecting the final meta-analysis. This is the limitation of
  the majority of a meta-analysis conducted. The lack of stringent
  criteria for randomization and the overwhelming unethical platform to
  conduct such studies which surely Wu et al\textsuperscript{1} would
  agree yield a rather homoscedasticity allowing a sequence of random
  variables to have a finite variance with time linear function.
  Compounding this notion is the lack of randomized clinical trials for
  FET procedure and the paucity of standard presentation of study
  results and baseline characteristics precluded us from a comprehensive
  exploration of confounding factors.
\item
  It's our practice that standardization and protocolization in
  meta-analysis are pursued, thus, we tried to extract data from the
  main text of the articles, however, we stumbled across different
  challenges that culpably allowed us to use a common denominator i.e.
  reading full-text, we used method section and the affiliation of the
  ethics committee for assigning the location of study institution,
  neither database affiliation and nor corresponding affiliations were a
  streamed thought amongst all contributors of this analysis. Moreover,
  Sun and colleagues,\textsuperscript{3}in their method section of their
  study had assigned ``patients underwent surgical treatment at Fuwai
  Hospital, Beijing, China''. Given this notion, we considered it as an
  affiliated study with Fuwai Hospital. It might be recommended that the
  adherence to the standards of the ethics committee and outcome
  reporting studies with a defined affiliation of the population would
  be imperative aiding future researchers and misleading endeavors. The
  large number of patients undergoing the FET procedure in Anzhen
  hospital has resulted in the publication of many articles with
  overlapped or even duplicated populations per se.
\item
  We have performed a univariate meta-regression to find a linear
  relationship between neurological outcomes and the utmost important
  variable associated with these events. Due to lack of data in the
  majority of studies and small sample size of included studies into the
  regression model, it is justifiable that implementation of a
  multivariate meta-regression analysis would be realistically
  unjustified and would render the desired characteristic and outcomes
  to be over-inflated disturbing our attempt to generate meaningful
  analysis in this evidence synthesis and precision healthcare era.
\end{enumerate}

\textbf{References}

1. Wu J, Sun T, Fan R. Methodological quality of a meta-analysis
precedes its clinical significance. \emph{J Card Surg} . 2021

2. Gartlehner G, Affengruber L, Titscher V, Noel-Storr A, Dooley G,
Ballarini N, K\selectlanguage{ngerman}önig F. Single-reviewer abstract screening missed 13
percent of relevant studies: A crowd-based, randomized controlled trial.
\emph{J Clin Epidemiol} . 2020;121:20-28

3. Sun L, Qi R, Zhu J, Liu Y, Zheng J. Total arch replacement combined
with stented elephant trunk implantation: A new ''standard'' therapy for
type a dissection involving repair of the aortic arch?
\emph{Circulation} . 2011;123:971-978

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