Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Revisiting nutrient cycling by litterfall—Insights from 15 years of litter manipulation in old-growth lowland tropical forest

The crucial role of tropical forests in the global carbon balance is underpinned by their extraordinarily high biomass and productivity, even though the majority of tropical forests grow on nutrient-poor soils. Nutrient cycling by litterfall has long been considered essential for maintaining high primary productivity in lowland tropical forests but few studies have tested this assumption experimentally. We review and synthesise findings from the Gigante Litter Manipulation Project (GLiMP), a long-term experiment in lowland tropical forest in Panama, Central America, in which litter has been removed from or added to large-scale plots for 15 years. We assessed changes in soil and litter nutrient concentrations in response to the experimental treatments and estimated nutrient return and nutrient use efficiency to indicate changes in nutrient cycling. The soil concentrations of most nutrients increased with litter addition and declined with litter removal. Litter removal altered nitrogen, potassium, manganese and zinc cycling, demonstrating the importance of litter inputs for maintaining the availability of these elements to plants. By contrast, litter addition only altered nitrogen cycling and, despite low concentrations of available soil phosphorus, the effects of litter manipulation on phosphorus cycling were inconsistent. We discuss potential mechanisms underlying the observed changes, and we emphasise the importance of decomposition processes in the forest floor for retaining nutrient elements, which partially decouples nutrient cycling from the mineral soil. Finally, by synthesising GLiMP studies conducted during 15 years of litter manipulation, we highlight key knowledge gaps and avenues for future research into tropical forest nutrient cycling