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

Cultura, memoria y transición alimentaria de un grupo de mujeres de una comunidad QOM en la localidad de Derqui

Fil: Terraza, Raúl. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Fil: Di Nardo, Sabrina. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Fil: Domínguez, Yanina. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Fil: Heinze, Gabriela. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Fil: Ruggirello, Florencia. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Fil: Wiedemann, Adriana. Universidad de Buenos Aires. Facultad de Medicina. Escuela de Nutrición, Argentina.Identificar, describir y analizar los cambios ocurridos en la alimentación de la comunidad Qom de Derqui, partido de Pilar, tomando como referencia a mujeres de la comunidad oriundas de la provincia de Chaco, de 40 años en adelante, y a mujeres más jóvenes nacidas en la provincia de Buenos Aires, entre 20 y 40 años de edad.To Identify, describe and analyze the changes that occurred in the diet of the Qom community of Derqui, Pilar, taking as reference women born in the province of Chaco, over 40 years old, and younger women born in the province of Buenos Aires, between 20 and 40 years old, as well

Territorios y producción en el noreste de la Patagonia

El enfoque territorial del desarrollo constituye una novedad que se está consolidando en la construcción y orientación de las políticas públicas para las zonas rurales de la Argentina. Existe cierto consenso en la potencia de este abordaje para superar el diseño de políticas basadas en un Estado protagonista casi excluyente y con una mirada sectorial, que muestra señales de agotamiento por los dispares resultados alcanzados en la mejora de las condiciones económicas y sociales. La re formulación de estas políticas para enfocarlas en el territorio con nuevas articulaciones interinstitucionales y con amplia participación social, en un modelo de aprendizaje colectivo, constituye una nueva aproximación para enfrentar el problema de comunidades que deben elegir nuevos senderos de desarrollo. Por otro lado, esta mirada permite rescatar una vieja tradición basada en el esfuerzo privado que existió y existe en la Argentina, que tiene reconocidos méritos y una enorme importancia socio-productiva y económica. Estos emprendimientos son impulsados por lo general por pequeños y medianos empresarios o por organizaciones asociativas como cooperativas con gran compromiso social, que logran construir empresas en el sentido de acciones o tareas que demandan esfuerzo y trabajo, que muestran capacidad de sustentación y de mejora del colectivo social que las integran. La articulación público-privada para el desarrollo de nuevas instituciones que actúen como verdaderos nodos de redes socio-técnicas densas en las que circulan los conocimientos codificados o tácitos desarrollados por el saber hacer de los productores y empresarios, sumados a investigadores e innovadores de todo tipo y naturaleza, el aumento del potencial de captar alternativas de financiamiento de grupos organizados, el incremento de la capacidad de agregar y retener valor “in situ” creando nuevos productos, la capacidad de organizarse para administrar recursos críticos como el agua y la vegetación en zonas áridas y el incremento de la capacidad de negociación comercial, son algunos de los atributos que presenta este abordaje de lo territorial. Este libro presenta trabajos realizados en el marco del proyecto de investigación “Políticas Públicas y Aglomeraciones Productivas” (04/V091), del Centro Regional Zona Atlántica de la Universidad Nacional del Comahue, dirigido por el Mg. Pablo Ricardo Tagliani y codirigido por el Mg. Héctor M. Villegas Nigra.EEA Valle InferiorFil: Alder, Maite. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Cariac, Germán E. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Gallego, Juan José. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Gallo, Silvia Laura. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Fuente, Gastón E. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Martin, Dario. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Nuñez, Adrián Humberto. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Viretto, Juan Pablo. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Main, Carlos Alberto. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Bouhier, Rodolfo Abel. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Carusso, Gabriel. Universidad Nacional del Comahue; ArgentinaFil: Di Nardo, Yanina. Instituto de Desarrollo del Valle Inferior; ArgentinaFil: Garcia Vinent, Juan Carlos. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Gilardi, María Elvira. Instituto de Desarrollo del Valle Inferior; ArgentinaFil: Giorgetti, Hugo. Provincia de Buenos Aires. Ministerio de Asuntos Agrarios. Chacra Experimental de Patagones; ArgentinaFil: Miñón, Daniel J. Universidad Nacional del Comahue; ArgentinaFil: Miñon, Daniel Pedro. Instituto Nacional de Tecnología Agropecuaria (INTA). Estación Experimental Agropecuaria Valle Inferior; ArgentinaFil: Perlo, Alberto Mario. Profesional Asociado de INTA; ArgentinaFil: Rodriguez, Gustavo D. Provincia de Buenos Aires. Ministerio de Asuntos Agrarios. Chacra Experimental de Patagones; ArgentinaFil: Tamburo, Leticia Gabriela. Instituto Nacional de Tecnología Agropecuaria (INTA). Gerencia de Monitoreo y Evaluación; ArgentinaFil: Villegas Nigra, Mario. Universidad Nacional del Comahue; Argentin

Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study

BackgroundPaediatric acute respiratory distress syndrome (PARDS) is associated with high mortality in children, but until recently no paediatric-specific diagnostic criteria existed. The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition was developed to overcome limitations of the Berlin definition, which was designed and validated for adults. We aimed to determine the incidence and outcomes of children who meet the PALICC definition of PARDS.MethodsIn this international, prospective, cross-sectional, observational study, 145 paediatric intensive care units (PICUs) from 27 countries were recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment. Patients were included if they had a new diagnosis of PARDS that met PALICC criteria during the study week. Exclusion criteria included meeting PARDS criteria more than 24 h before screening, cyanotic heart disease, active perinatal lung disease, and preparation or recovery from a cardiac intervention. Data were collected on the PICU characteristics, patient demographics, and elements of PARDS (ie, PARDS risk factors, hypoxaemia severity metrics, type of ventilation), comorbidities, chest imaging, arterial blood gas measurements, and pulse oximetry. The primary outcome was PICU mortality. Secondary outcomes included 90 day mortality, duration of invasive mechanical and non-invasive ventilation, and cause of death.FindingsBetween May 9, 2016, and June 16, 2017, during the 10 study weeks, 23 280 patients were admitted to participating PICUs, of whom 744 (3·2%) were identified as having PARDS. 95% (708 of 744) of patients had complete data for analysis, with 17% (121 of 708; 95% CI 14-20) mortality, whereas only 32% (230 of 708) of patients met Berlin criteria with 27% (61 of 230) mortality. Based on hypoxaemia severity at PARDS diagnosis, mortality was similar among those who were non-invasively ventilated and with mild or moderate PARDS (10-15%), but higher for those with severe PARDS (33% [54 of 165; 95% CI 26-41]). 50% (80 of 160) of non-invasively ventilated patients with PARDS were subsequently intubated, with 25% (20 of 80; 95% CI 16-36) mortality. By use of PALICC PARDS definition, severity of PARDS at 6 h after initial diagnosis (area under the curve [AUC] 0·69, 95% CI 0·62-0·76) discriminates PICU mortality better than severity at PARDS diagnosis (AUC 0·64, 0·58-0·71), and outperforms Berlin severity groups at 6 h (0·64, 0·58-0·70; p=0·01).InterpretationThe PALICC definition identified more children as having PARDS than the Berlin definition, and PALICC PARDS severity groupings improved the stratification of mortality risk, particularly when applied 6 h after PARDS diagnosis. The PALICC PARDS framework should be considered for use in future epidemiological and therapeutic research among children with PARDS.FundingUniversity of Southern California Clinical Translational Science Institute, Sainte Justine Children's Hospital, University of Montreal, Canada, Réseau en Santé Respiratoire du Fonds de Recherche Quebec-Santé, and Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care Medicine

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background: Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods: WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings: Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation: In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. Funding: European Society of Intensive Care Medicine, European Respiratory Society

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

Background Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. Methods WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. Findings Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0–4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2–6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. Interpretation In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates