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

Caracterización de pacientes pediátricos con Síndrome de Guillain-Barre

Introduction: Guillain-Barré syndrome is a neurological disease that includes a group of autoimmune disorders; it is considered the most frequent cause of polyneuropathy in childhood.Objective: to characterize pediatric patients with Guillain-Barré treated at the Roberto Rodríguez Fernández General Teaching Hospital, Moron, Ciego de Avila.Method: an observational, descriptive, longitudinal retrospective study was carried out in the period from January 2018 to January 2020. The universe consisted of 12 patients, working with all of them. Descriptive statistics were used and absolute and relative percentage frequencies were used as a summary measure of the information.Results: the most represented age group was 0-4 years with 6 patients and the male sex was present in 58,3 %. All 12 patients had muscle strength and mobility impairment. 41,7 % recovered within the first six months and as a consequence after treatment, 25% suffered cavus foot.Conclusions: a predominance was observed in the age group 0-4 years, male and white skin color. The predominant clinical symptoms were decreased muscle strength, mobility, and some activities of daily living. The most used rehabilitation treatment was functional training for activities of daily living. After the application of the clinical and rehabilitative treatment, recovery was observed in most of the patients in the first 6 months, and only some cases suffered sequelae.Introducción: el síndrome de Guillain-Barré es una enfermedad neurológica que incluye un conjunto de trastornos autoinmunes; es considerado la causa más frecuente de polineuropatía en la infancia.Objetivo: caracterizar los pacientes pediátricos con Guillain-Barré atendidos en el Hospital General Docente Roberto Rodríguez Fernández, Morón, Ciego de Ávila.Método: se realizó un estudio observacional, descriptivo, longitudinal retrospectivo en el período comprendido entre enero de 2018 a enero del 2020. Se trabajó con la totalidad del universo, conformado por 12 pacientes. Se utilizó estadística descriptiva y como medida de resumen de la información las frecuencias absolutas y relativas porcentuales.Resultados: el grupo de edad más representado fue el de 0-4 años con 6 pacientes y el sexo masculino estuvo presente en el 58,3 %. Los 12 pacientes presentaron afectación en la fuerza muscular y movilidad. El 41,7 % se recuperó dentro de los seis primeros meses y como secuelas luego del tratamiento el 25 % padeció pie cavo.Conclusiones: se observó predominio en el grupo de edad 0-4 años, del sexo masculino y del color de piel blanca. Los síntomas clínicos predominantes fueron la disminución de la fuerza muscular, la movilidad, y algunas actividades de la vida diaria. El tratamiento rehabilitador más utilizado fue el entrenamiento funcional para las actividades de la vida diaria. Luego de la aplicación del tratamiento clínico y rehabilitador, se observó recuperación en la mayoría de los pacientes en los 6 primeros meses, y solo algunos casos padecieron secuelas

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI) : a phase 3, placebo-controlled, randomised trial

Background: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. Methods: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Findings: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8–3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74–0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, p interaction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78–1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75–1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48–2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36–3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74–1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75–0·95, p=0·005, in contrast to patients without PCI where it did not, p interaction=0·012. Benefit was present irrespective of time from most recent PCI. Interpretation: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk