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

IMPROVED SYNTHESIS OF SUBSTITUTED PYRIMIDIN-2-ONE DERIVATIVES USING MICROWAVE AND ULTRASOUND IRRADIATION

ABSTRACT Various substituted 4-oxo-2-thioxo tetrahydropyrimidine, 2-oxo dihydropyrimidine, 3,6-disubstituted and 4,5-disubstituted tetrahydropyrimidin-2-one derivatives containing different functional groups have been synthesized under microwave and ultrasound irradiation. The 3,6-disubstituted derivatives were prepared by reacting substituted pyrimidine derivatives synthesized under ultrasound irridation, with ethybromoacetate and product formed was converted to respective hydrazide derivatives, which were further condensed with various aromatic aldehydes. The 4,5-disubstituted tetrahydropyrimidines derivatives were synthesized simply by reacting substituted pyrimidine derivatives synthesized using modified biginelli reaction with various aromatic amines. The IR, 1 H NMR and mass spectral data confirmed the structure of the newly synthesized compounds. Keywords: Biginelli reaction, pyrimidine, Microwave, Ultrasound. INTRODUCTION Pyrimidine is a parent group of various heterocyclic compounds, which have attracted attention for long time. Pyrimidine derivatives play a vital role in many biological processes, the ring system being present in nucleic acids, several vitamins and coenzymes, uric acid and other purines. Uracil, thymine, and cytosine are three of the six bases found in the nucleotides, which contain pyrimidine ring. It is evident from the literature that pyrimidine derivatives have been found to have various pharmacological activities. Pyrimidine ring is the backbone of several calcium channel blocker[1], antibacterial[2], antifungal Step-I:Synthesis of 5-carbonitrile-6-aryl-4-oxo-2-thioxo-1,2,3,4-tetrahydropyrimidine:[10 ] A mixture of ethyl cyanoacetate (0.01 mol), an aldehyde (0.01 mol) and thiourea (0.01 mol) in ethanol (20 ml) containing potassium carbonate (0.01 mol) was refluxed for 5 h. The potassium salt of product, which is precipitated during reaction, was collected and washed with ethanol and tetrahydrofuran. The crude salt was stirred in water at approximately 80° C; stirring was continued until the clear solution is obtained. After cooling the solution was acidify by acetic acid, and stirring was continued for 30 min. The deposited crystals thus formed were collected and washed well with water and dried in air. Recrystallization from acetic acid gave pure product. Desai Sujit Arun et al

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)