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

Population consequences of mutual attraction between settling and adult barnacles

1. Spatial patterns of recruitment were compared between populations of the rocky shore barnacles (Crustacea: Cirripedia) Semibalanus balanoides, an obligate cross-fertilizer, and Chthamalus montagui, which can self-fertilize. We tested the hypothesis that recruitment depends on a behaviourally mediated interaction at settlement between the effects of adult background density and adult spacing, which limit free space for settlement and mating opportunities, respectively. Recruitment to patches of cleared rock (10- or 30-cm diameter) was compared between replicate shores with background densities of adult barnacles classed as low (?20 per 25 cm2) and high (>4× low). Replicate patches were cleared of all barnacles surrounding a remnant cluster, comprising 0, 1, 2, 4, 8, 16 or 32 adults.2. For S. balanoides, settlement and subsequent recruitment over 5 months varied in direct proportion to remnant cluster size, except on the shore with the highest background density where recruitment was inversely proportional to cluster size. We interpret this inversion to indicate attraction to potential mates at low adult densities (positive density dependence, an Allee effect) switching to attraction to free space at high density (negative density dependence). The strengths and slopes of the regressions increased from shores with the lowest to the highest overall recruitment of barnacles, but retained significance over a five-fold range in recruitment. Positive effects of cluster size on recruitment were consistent between consecutive years, despite considerable variation in recruitment densities. In contrast, recruitment of C. montagui was generally more weakly proportional to cluster size, except for a strong positive correlation at the shore with the highest recruitment.3. Dispersion of recruits within treatment patches was accurately modelled by a computer simulation that allowed each barnacle to settle at random between fixed minimum and maximum distances from the nearest other settled barnacle. The model estimated threshold distances by maximum likelihood fit to observed recruitment into concentric annuli around the central adult cluster. Upper thresholds of separation corresponded to penis length for 65% of S. balanoides and 42% of C. montagui patches. Lower thresholds were ?2× cyprid length for 75% of S. balanoides patches, but were larger than this for C. montagui patches