Nikotinposer - indhold og miljøkonsekvenser

Posemateriale og indhold. Nikotinposer er typisk fremstillet af en form for semi-syntetisk cellulose (såsom viskose fleece) hvortil der er tilsat et bindemiddel i form af en (bionedbrydelig) polymer, som smelter ved opvarmning og dermed forsegler posens kanter. Indholdet i poserne består ifølge produkternes varedeklarationer af nikotin, stabilisatorer og fortykningsmidler, pH regulerende midler, fugtmidler, smagsstoffer, sødemidler og konserveringsmidler. Ifølge studier beskrevet i litteraturen er der desuden påvist indhold af formaldehyd og ammonium i nogle nikotinposer.Nikotinposer som mulig del af plastforurening. Nikotinposernes semi-syntetiske cellulose-baserede materiale har FTIR-spektre som er sammenlignelige med vådservietter, engangskarklude og cigaretfiltre, som består af henholdsvis viskose og celluloseacetat. Den største grad af lighed mellem spektre blev observeret for cigaretfiltre. På trods af, at cellulose er et naturligt og forholdsvis nedbrydeligt materiale, så vil modifikationer af denne grad påvirke materialets egenskaber og miljøskæbne herunder nedbrydelighed. Af samme grund kan nikotinposer, ligesom cigaretfiltre, potentielt anses som værende en form for semi-syntetisk polymer og dermed ’plast’. Dog er der en flydende overgang fra naturlige til syntetiske polymerer, hvilket udfordrer en entydig kategorisering af forskellige semi-syntetiske materialer, herunder brugte nikotinposer, som værende plastaffald. Nikotinposers miljøskæbne under miljørelevante forhold bør undersøges yderligere og bortskaffelse i naturen bør uanset minimeres.Risiko for mennesker og miljø. Generelle helbredsrisici ved påtænkt brug af nikotinposer indgår ikke i denne rapport, men referencer til relevante kilder fremgår af teksten. I stedet diskuteres potentielle effekter i miljøet. Nikotinposer udgør en potentiel risiko for dyr ved indtagelse. Der findes eksempler på nikotinforgiftning af hunde som har ædt henkastede brugte nikotinposer. Grundet forventet langsom nedbrydning under miljørealistiske forhold kan der over tid ske en akkumulering af nikotinposer i miljøet. Langsigtede konsekvenser af dette, samt risiko for nikotinforgiftning af dyr i naturen, bør undersøges nærmere.Nikotinposer i kontekst af genanvendelse og cirkulær økonomi. Bortskaffelse af tomme nikotinpose dåser med brugte nikotinposer udgør et potentielt problem i forhold til genanvendelse. Dåsen er ofte fremstillet af polypropylen og kan genanvendes. Dog skal de brugte nikotinposer, som opsamles i låget, bortskaffes separat. Dvs. at dåserne skal tømmes inden de sorteres som plastaffald. Det er dog plausibelt at dette ikke altid sker, og at 1) dåserne ikke tømmes inden de sorteres som plastaffald eller 2) dåserne bortskaffes i restaffald. Forbrugsvaner i forhold til bortskaffelse bør undersøges nærmere og behovet for yderligere oplysning af forbrugere kan overvejes på denne baggrund.Fremtidige undersøgelser. Henkastede nikotinposer er et stigende problem grundet stigende forbrug kombineret med uhensigtsmæssig forbrugeradfærd. På trods af at de fleste nikotinposer bliver opsamlet og bortskaffet korrekt, ender en fraktion stadig i miljøet. Fremtidige undersøgelser af brugen af nikotinposer blandt den danske befolkning kan med fordel inkludere spørgsmål om adfærd i forhold til bortskaffelse, for på denne måde at få et estimat af omfanget af henkastede nikotinposer i naturen og i det offentlige rum. Dette kan også give et forbedret grundlag for vurdering af eventuelle miljøkonsekvenser – både af posemateriale men også posernes indhold herunder nikotin

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London