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

Rowell Syndrome: A Diagnostic Challenge

BACKGROUND: Rowell syndrome is a rare disease characterized by a combination of lupus erythematosus (LE) and erythema multiforme (EM)-like lesions and a characteristic immunologic pattern, including speckled pattern of antinuclear antibody (ANA), positive anti-Ro/SSA or anti-La/SSB, and positive rheumatoid factor (RF). This disease was first described in 1963, and to date, about 95 cases of EM-like lesions associated with LE have been described in the literature, with the majority of cases being reported in adult female patients. Here, we describe the case of a 17-year-old male patient exhibiting both systemic LE and EM lesions together with ANA and anti-Ro/SSA positivity who was successfully treated with systemic corticosteroids and hydroxychloroquine

Pre-clinical comparison of a high-definition 3-dimensional exoscope and an operating microscope: a prospective randomized crossover study

Objective: The high-definition 3D operating exoscope is a new tool for surgical visualization and magnification that was designed to replace the operating microscope. However, the paucity of studies that have prospectively compared the two systems has made it difficult to draw clear recommendations. The purpose of this study was to compare the operating exoscope and the operating microscope in first-time users in a pre-clinical setting. Methods: Twenty-eight consecutive medical students were prospectively enrolled and randomized in a crossover design. Each student performed four exercises that required basic microsurgical skills. A tailored questionnaire (Comparison Assessment Tool) was used to subjectively compare the two systems using a 5-point Likert scale. The time needed to perform each task was recorded. A post-intervention cross-sectional survey was conducted to assess the overall quality of the trial session. Results: The operating exoscope was preferred over the operating microscope by most of the students in all items of the Comparison Assessment Tool, particularly with regard to "focusing" and "image quality" (n = 25, 92.6%). A significant difference between groups was found in two exercises that were easier to perform with the operating exoscope. Most of the students considered the overall quality of the evaluation experience to be "very good" (n = 25, 92.6%). Conclusions: The exoscope allows first-time users to better perform basic microsurgical tasks in a simulated clinical scenario compared to the operating microscope. Further prospective comparative studies will be needed to validate our preliminary findings in an actual clinical scenario

Functional outcomes and complications of total glossectomy with laryngeal preservation and flap reconstruction: a systematic review and meta-analysis

Objective: To analyze the functional outcomes and complications of total glossectomy with laryngeal preservation and reconstruction with free or pedicled flaps.Methods: A search was conducted using Pubmed/MEDLINE, Cochrane Library, Scopus, and Google Scholar da-tabases. A single arm meta-analysis was performed for feeding tube dependence (FTD), tracheostomy depen-dence (TD), and speech intelligibility (SI) rates. Peri-operative sequels and complications were evaluated as secondary outcomes.Results: A total number of 642 patients (median age: 54.2 years; 95% CI 52.1-58) were included. Functional assessment was performed after a median of 12 months (n = 623/642; 95% CI 10.6-12). Overall, the cumulative FTD rate was 22.9% (n = 188/627; 95% CI 10.2-38.7), the TD rate was 7.3% (n = 95/549; 95% CI 1.9-15.8), and the SI was 91.1% (n = 314/409; 95% CI 80.7%-97.8). The cumulative complication rate was 33.1% (n = 592/642). Eighteen patients (n = 18/592; 3.0%) experienced a major fistula, while aspiration pneumonia occurred in 17 cases (n = 17/592; 2.8%).Conclusions: Total glossectomy with laryngeal preservation and pedicled/free flaps reconstruction may guarantee good functional results and an acceptable quality of life. Further prospective studies are advised to define clinical guidelines about proper patients' and flaps' selection

Complications of pectoralis major myo-cutaneous flap, anterolateral thigh flap and radial forearm free flap after total laryngectomy with partial pharyngectomy: a systematic review and network meta-analysis

Background: No consensus exists regarding the most effective reconstruction after total laryngectomy with partial pharyngectomy (TLwPP). This study aims to compare different reconstructive techniques (pectoralis major myo-cutaneous flap, PMMCF; anterolateral thigh flap, ALTF; radial forearm free flap, RFFF) after TLwPP in terms of pharyngocutaneous fistula (PCF), stenosis and feeding tube dependence (FTD) incidence. Methods: The Scopus, PubMed/MEDLINE, Cochrane Library, and Google Scholar databases were searched. A single-arm meta-analysis was performed for PCF incidence, stenosis incidence, and FTD incidence on the entire cohort. An arm-based network analysis was conducted to compare three different surgical interventions (PMMCF, ALTF, RFFF). Results: A total of 13 studies and 232 patients were included in the network meta-analysis. The lowest PCF absolute risk was measured for the RFFF (11.7%, 95% CI: 2.8%-33.4%), compared to the ALTF (13.4%, 95% CI: 4.5%-32.1%) and the PMMC (49.0%, 95% CI: 19.2%-79.3%). The RFFF showed a stenosis absolute risk of 0.0% (95% CI: 0.0%-1.1%), while a higher stenosis incidence was measured for the ALTF (5.7%, 95% CI: 0.8%-25.2%) and the PMMCF (11.6%, 95% CI: 0.8%-55.1%). The RFFF showed the lowest absolute risk of FTD incidence (6.8%, 95% CI: 0.5%-28.1%) compared to the other reconstructive techniques (PMMCF: 12.4%, 95% CI: 2.4%-42.1%; ALTF: 17.5%, 95% CI: 6.4%-38.9%). Conclusions: The RFFF seems the best choice for reconstruction of partial pharyngeal defects after TLwPP due to the lower incidence of PCF, stenosis and FTD compared to the ALTF and the PMMCF

Functional outcomes of soft palate reconstruction after oncologic surgery: a systematic review and meta-analysis

Objective: The aim of this study is to analyze functional outcomes of soft palate reconstruction after oncologic surgery. Methods: This study was conducted in conformity with the PRISMA statement. A single arm meta-analysis was performed for feeding tube dependence (FTD) (primary outcome), velopharyngeal insufficiency (VPI) and hypernasality (HN) (secondary outcomes) incidences. Results: A total of 510 patients (males: 77.75%, n = 353/454) with a median age of 58 years (n = 480/510; 95% CI 57.0-61.0) who underwent soft palate surgical resection with primary reconstruction were included. Overall, the cumulative FTD rate was 1.55% (n = 28/510; 95% CI 0.24-3.96%), the VPI rate was 22.18% (n = 119/379; 95% CI 12.99-33.02%), and the HN rate was 33.01% (n = 88/234; 95% CI 19.03-46.61%). Conclusions: Soft palate reconstruction results in a low incidence of FTD, and most patients resume a full oral diet. Both obturators, primary closure, local and free flaps seem good reconstructive options. Nevertheless, more specific postoperative functional deficiencies like VPI and HN owns higher incidences, potentially affecting the quality of the swallowing and speaking function and the patient's quality of life

Predicting the need for prophylactic gastrostomy in major head and neck cancer surgery: The PEG score

Background: To elaborate a preoperative score to predict the necessity of enteral nutrition at 28 days postoperatively in patients undergoing head and neck surgery. Methods: A total of 424 patients with oral cavity, oropharyngeal, laryngeal, and hypopharyngeal carcinoma were retrospectively enrolled and analyzed to identify preoperative predictors of prolonged postsurgical enteral feeding which were used to create a prediction model with an easy-to-use nomogram. Results: Five preoperative variables (body mass index, previous radiotherapy, preoperative dysphagia, type of surgery, flap reconstruction) were found to be independent predictive factors and were used to create a prediction model named PEG score together with the related nomogram. Accuracy, F1, and the area under the curve (AUC) were 0.74, 0.83, and 0.74. Different decision thresholds can be used to vary the sensitivity and specificity. Conclusions: The PEG score showed high prediction performances for modeling the need for enteral nutrition at 28 days postoperatively. Prospective studies are needed to define a personalized nutrition protocol

Role of BAG3 in cancer progression: A therapeutic opportunity. Turco MC: Corresponding Author

BAG3 is a multifunctional protein that can bind to heat shock proteins (Hsp) 70 through its BAG domain and to other partners through its WW domain, proline-rich (PXXP) repeat and IPV (Ile-Pro-Val) motifs. Its intracellular expression can be induced by stressful stimuli, while is constitutive in skeletal muscle, cardiac myocytes and several tumour types. BAG3 can modulate the levels, localisation or activity of its partner proteins, thereby regulating major cell pathways and functions, including apoptosis, autophagy, mechanotransduction, cytoskeleton organisation, motility. A secreted form of BAG3 has been identified in studies on pancreatic ductal adenocarcinoma (PDAC). Secreted BAG3 can bind to a specific receptor, IFITM2, expressed on macrophages, and induce the release of factors that sustain tumour growth and the metastatic process. BAG3 neutralisation therefore appears to constitute a novel potential strategy in the therapy of PDAC and, possibly, other tumours

Cell-Based Phenotypic Drug Screening Identifies Luteolin as Candidate Therapeutic for Nephropathic Cystinosis

BACKGROUND: Mutations in the gene that encodes the lysosomal cystine transporter cystinosin cause the lysosomal storage disease cystinosis. Defective cystine transport leads to intralysosomal accumulation and crystallization of cystine. The most severe phenotype, nephropathic cystinosis, manifests during the first months of life, as renal Fanconi syndrome. The cystine-depleting agent cysteamine significantly delays symptoms, but it cannot prevent progression to ESKD and does not treat Fanconi syndrome. This suggests the involvement of pathways in nephropathic cystinosis that are unrelated to lysosomal cystine accumulation. Recent data indicate that one such potential pathway, lysosome-mediated degradation of autophagy cargoes, is compromised in cystinosis. METHODS: To identify drugs that reduce levels of the autophagy-related protein p62/SQSTM1 in cystinotic proximal tubular epithelial cells, we performed a high-throughput screening on the basis of an in-cell ELISA assay. We then tested a promising candidate in cells derived from patients with, and mouse models of, cystinosis, and in preclinical studies in cystinotic zebrafish. RESULTS: Of 46 compounds identified as reducing p62/SQSTM1 levels in cystinotic cells, we selected luteolin on the basis of its efficacy, safety profile, and similarity to genistein, which we previously showed to ameliorate other lysosomal abnormalities of cystinotic cells. Our data show that luteolin improves the autophagy-lysosome degradative pathway, is a powerful antioxidant, and has antiapoptotic properties. Moreover, luteolin stimulates endocytosis and improves the expression of the endocytic receptor megalin. CONCLUSIONS: Our data show that luteolin improves defective pathways of cystinosis and has a good safety profile, and thus has potential as a treatment for nephropathic cystinosis and other renal lysosomal storage diseases.status: publishe