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

Altos níveis de fitase em rações para frangos de corte

Avaliaram-se o desempenho, o coeficiente de digestibilidade da matéria seca (CDMS), da proteína bruta (CDPB), a retenção aparente de cálcio (Ca) e fósforo (P) e a energia metabolizável aparente corrigida para balanço de nitrogênio (EMAn) de dietas suplementadas com altos teores de fitase (FTU) para frangos, até 35 dias de idade. Foram utilizados 1848 pintos, distribuídos em delineamento inteiramente ao acaso, com sete tratamentos e oito repetições de 35 aves. Os tratamentos foram: T1: dieta-controle; T2: dieta com inclusão de 1.500FTU/kg; T3: 3.000FTU/kg; T4: 4.500FTU/kg; T5: 6.000FTU/kg; T6: 8.000FTU/kg e T7: 10.000FTU/kg de ração. No 10º e 28º dias de experimento, quatro e três aves, respectivamente, foram transferidas para gaiolas de metabolismo. A partir da inclusão de 4.500FTU/kg, o desempenho das aves de 1 a 35 dias foi semelhante ao das aves do grupo-controle (P>0,05). Não houve diferença (P>0,05) entre os tratamentos nos CDPB e nos valores de EMAn, porém, na fase inicial, observou-se maior aproveitamento da MS com os altos níveis de fitase (P<0,05). Em relação à retenção de Ca e P, houve efeito positivo da suplementação enzimática, com aumento significativo do uso desses minerais pelas aves. Concluiu-se que é possível suplementar altos teores de fitase valorando adequadamente os nutrientes da dieta

Variação aniônica da dieta sobre características ósseas de frangos de corte: resistência à quebra, composição orgânica e mineral

Avaliou-se a composição química e a resistência óssea do tibiotarso de frangos de corte aos 21 dias de idade. Foram determinados os percentuais ósseos de proteínas colagenosas (PC) e proteínas não colagenosas (PNC) e de cálcio, fósforo, potássio e sódio. Foram utilizados 650 pintinhos machos de marca comercial, alimentados com dietas à base de milho e farelo de soja. Foi utilizado delineamento em blocos ao acaso com cinco repetições e 26 aves por unidade experimental. Os tratamentos consistiram na suplementação da dieta basal com NH4Cl a fim de se obter cinco níveis -50; 0; 50; 100 e 150mEq/kg de balanço eletrolítico (BE). O nível de BE influenciou os teores de fósforo, potássio, sódio, PC e PNC, relação Ca:P e a resistência à quebra. A redução do balanço eletrolítico da dieta em nível inferior a 150mEq/kg influenciará negativamente a mineralização e a resistência óssea. A resistência à quebra do tibiotarso não está correlacionada com as concentrações dos minerais de forma individual, mas correlaciona-se negativamente com as concentrações de proteínas colagenosas e não colagenosas

Antiinflammatory therapy with canakinumab for atherosclerotic disease

BACKGROUND: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. METHODS: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P=0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P=0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P=0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P=0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P=0.31). CONCLUSIONS: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. Copyright © 2017 Massachusetts Medical Society