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

Abstract 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

Coexistence of Ovarian Cancer and Renal Cell Carcinoma

Coexistence of ovarian cancer and renal cell carcinoma (RCC) is extremely rare. Only one case was diagnosed in a total of 584 patients with RCC from 1982 to 2002 at our hospital. A 58-year-old woman presented with an enlarged girdle length for 3 months. Computed tomography scan showed a right cystic adnexal mass measuring 10 × 10 cm, and another tumor measuring 3 × 2 cm at the right kidney. She underwent debulking surgery and radical nephrectomy. Pathologic examination revealed right ovarian clear-cell carcinoma with peritoneal, omental, and fallopian tube metastasis, and conventional clear-cell renal carcinoma. RCC was strongly positive in epithelial membrane antigen (EMA) staining and negative in estrogen receptors (ER), progesterone receptors (PR), 34bE12 (high molecular weight cytokeratin), and vimentin staining. Ovarian clear-cell carcinoma showed weakly positive results in EMA staining and negative results in ER, PR, 34bE12, and vimentin staining. Although chemotherapy was given, the patient died of disseminated ovarian cancer metastasis 20 months after operation. In conclusion, coexistence of RCC and ovarian cancer is rare and the pathogenesis remains to be clarified. [J Formos Med Assoc 2007;106(3 Suppl):S15-S19

High-output Heart Failure Resulting from an Obscure Traumatic Arteriovenous Fistula

Traumatic arteriovenous fistula (AVF) is not an uncommon disorder, but late discovery and the presentation of high-output heart failure is very rare. This patient did not know that he had traumatic AVF after a gunshot injury in the left thigh 14 years ago. The major presentation of the AVF was signs of heart failure. We performed surgical repair after making the diagnosis. The patient recovered with an uneventful course. This report stresses the importance of history-taking and physical examination in making the diagnosis of traumatic AVF

Prognostic factors for survival outcome after in-hospital cardiac arrest: An observational study of the oriental population in Taiwan

AbstractBackgroundIn-hospital cardiac arrest (IHCA) is a catastrophic complication for patients while admitted in a medical institution. The outcome of IHCA remains poor, and understanding of the prognostic factors for survival outcome after IHCA is lacking, specifically in an oriental population.MethodsA retrospective observational cohort study of 382 patients with IHCA who required resuscitation was conducted in an urban tertiary hospital in Taiwan. Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures.ResultsThe incidence of IHCA was 3.25 per 1000 admissions. These patients had a mean age of 67.2 ± 21.7 years and were mostly men (66.5%). The rate of successful ROSC was 66%, and the rate of survival to hospital discharge was 11.8%. A stepwise decrease in ROSC was observed with additional resuscitation efforts. Independent predictors for survival to hospital discharge were being female, a resuscitation duration of <20 minutes, and no use of epinephrine during resuscitation. A 68% ROSC success rate and an 84% survival to discharge rate was recorded in patients receiving resuscitation for <30 minutes. Young patients seemed the most likely to benefit from longer resuscitation attempts (>30 minutes), as observed in survival to hospital discharge.ConclusionBased on data from a single hospital registry in East Asia, a shorter duration of resuscitation was demonstrated to be a predictor of immediate survival with ROSC and survival to hospital discharge

Horizontal Variations in Photon Flux Density under a Chamaecyparis formosensis Matsum Plantation

[[abstract]]本研究主要目的為探討紅檜人工林內光合光子流密度之空間變異，以及不同冠層密度下透光率之變化，作為生態學及育林學相關研究之基礎。在棲蘭山區紅檜不同密度人工林內，就不同栽植密度區內設置2個樣區，株數分別為74與115株。每個樣區內各設置2條互相垂直的軌道，進行水平光度的取樣，取樣頻率為l秒l次，各樣點的水平間距為8cm，每月至少測量l次，從1998年10月到1999年6月止。雖然試驗地的天候變動劇烈，但是冠層下光度的頻度分布大多集中在弱光度區，高於50μmol m^(-2)s^(-1)的光度出現頻率偏低，但卻是林下累積光量最主要的來源，約佔林下總光量的76至59%。地理統計之半變異圖分析顯示，陰天時，林內無直射光源進入林床，冠層下方光度較為穩定，樣點間的相關性較高，各軌道的半變異量皆小於晴天時所得的結果。晴天時，第一樣區的光環境有較均質的變異，不因測量方向的不同而有不同的變異，亦即林下光環境的變異具有空間上的等方性，此區的可預測範圍約30cm；而在第二樣區中，則呈現出不同的結果，光度的變化梯度主要是沿著東西走向改變，兩軌道所得的結果呈現出強烈的空間異方性，軌道三的可預測範圍為70cm，但是軌道四受冠層結構影響，具有很大的碎塊效應，可預測範圍僅有16cm。陰天時，各軌道的可預測範圍均增大，且碎塊效應均下降，可預測範圍在500至l,500cm之間。在陰天時進行取樣，除可減少樣點的密度外，亦較不受測量方向的影響，所測得之林分平均透光率可以有較理想的推估品質。[[abstract]]The study aimed to investigate horizontal variations in photosynthetic photon flux density (PPFD) and transmittances under a Taiwan red false cypress (Chamaecyparis formosensis Matsum) canopy as the basis for ecological and silvicultural researches. We sampled two 0.04-ha plots according to tree densities, at 75 and 115 trees plot, respectively. In each plot there was a pair of perpendicular trams. The PPFD was sampled horizontally with moving quantum sensors (LI-190SZ) laid on the tram cable in 1-s intervals, and the distance between sampled points was 8 cm. We sampled at least 1 day per month from October 1998 to June 1999. The diurnal change in local weather conditions was acute, and most PPFD values under the canopy were lower than 50 μmol m^(-2)s^(-1). However, the few occurrences of higher PPFD values comprised a high proportion of the accumulated PPFD of from 59 to 76%. Horizontal variations in PPFD were analyzed by geostatistical technique of semivariogram construction. The results showed that PPFD under the canopy was more stable of cloudy days. The light environment of plot 1 on a sunny day appeared as space isotropy as contrasted to the space anisotropy of plot 2. The predicted range of plot 1 was 30 cm, which different between tram 3 and tram 4 of plot 2, at 70 and 16 cm, respectively. The predicable range was greater on cloudy days than on sunny days, and varied from 500 to 1,500 cm. Therefore, we obtained a higher quality of PPFD measurements on cloudy days

Outcomes and Prediction Models for Exclusive Prostate Bed Salvage Radiotherapy among Patients with Biochemical Recurrence after Radical Prostatectomy

Background: The addition of androgen-deprivation therapy (ADT) or pelvic radiation to prostate bed salvage radiotherapy (SRT) has been debated for prostate cancer patients with biochemical recurrence (BCR) after radical prostatectomy. This study aimed to assess the outcomes and propose prediction models for exclusive prostate bed SRT. Methods: This is a prospective observational cohort study with patients who underwent SRT with a pre-SRT PSA &lt; 1.5 ng/mL after radical prostatectomy. Patients were treated with 70-Gy SRT to the prostate bed exclusively. Kaplan–Meier survival analyses and Cox regression analyses were applied for depicting and predicting BCR-free survival, ADT-free survival, and metastasis-free survival (MFS). Regression-based coefficients were used to develop nomograms. Results: A total of 105 patients were included and 91 patients were eligible. The median follow-up period was 39 months. The 5-year BCR-free survival, ADT-free survival, and MFS were 37%, 50%, and 66%, respectively. Multivariable analysis showed that a pre-SRT PSA &lt; 0.45 ng/mL was the only independent factor associated with longer BCR-free survival (p = 0.034), while a PSA-DT &gt; 8 months had better ADT-free survival (p = 0.008). Patients with a PSA-DT &gt; 8 months showed a 100% MFS and a 43% 5-year absolute benefit in MFS than a PSA-DT ≤ 8 months. All patients with a pre-SRT PSA &lt; 0.45 ng/mL and PSA-DT &gt; 8 months were free from subsequent ADT and any metastasis. Conclusions: In patients with a PSA &lt; 0.45 ng/mL and PSA-DT &gt; 8 months for post-prostatectomy BCR, prostate bed SRT provided excellent outcomes without the need for concomitant ADT or pelvic radiotherapy

Long-term prognosis of patients with carbon monoxide poisoning: a nationwide cohort study.

BACKGROUND: Carbon monoxide poisoning (COP) often produces severe complications and can be fatal. Because this topic has not been well delineated, we investigated long-term prognoses of patients with COP (COP[+]). METHODS: In this retrospective nationwide cohort study, 441 COP[+] patients and 8820 COP[-] controls (120) from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. RESULTS: Thirty-seven (8.39%) COP[+] patients and 142 (1.61%) controls died (P<0.0001) during follow-up. Incidence rate ratios (IRR) of death were 5.24 times higher in COP[+] patients than in controls (P<0.0001). The risk of death was particularly high in the first month after COP (IRR: 308.78; 95% confidence interval [CI]: 40.79-2337.56), 1 to 6 months after (IRR: 18.92; 95% CI: 7.69-46.56), and 6-12 months after (IRR: 4.73; 95% CI: 1.02-21.90). After adjusting for age, gender, and selected comorbidities, the hazard ratio of death for COP[+] patients was still 4.097 times higher than for controls. Moreover, older age (≥30 years old), male gender, diabetes mellitus, hypertension, and low income were also independent mortality predictors. CONCLUSIONS: COP significantly increases the risk for long-term mortality. Early follow-up and secondary prevention of death are needed for patients with COP