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

Do Different Semi-Occluded Voice Exercises Affect Vocal Fold Adduction Differently in Subjects Diagnosed with Hyperfunctional Dysphonia?

Objective: To observe the possible differential effects of 8 different semi-occluded vocal tract exercises on glottal contact quotient (CQ) as a measure of vocal fold impact stress. Patients and Methods: Eighty participants were divided into two groups: an experimental group with hyperfunctional dysphonia and a control group of vocally healthy subjects. The participants were recorded before, during and after the exercises. Electroglottographic samples were analyzed to obtain CQ. Results: For the experimental group, all exercises, except lip trills and tongue trills, had an overall significant effect when conditions before, during and after the exercises were compared. The CQ presented differently across the 8 semi-occluded postures during exercise for both groups. For the experimental group, most exercises increased the CQ during practice. Only lip and tongue trills demonstrated lower CQ during exercise. Conclusions: Different semi-occluded exercises differentially affect vocal fold adduction. Lip and tongue trills produced the lowest CQ. Therefore, they may be recommended for decreasing glottal adduction. A straw submerged 10 cm below the water surface presented the greatest CQ. A shallower depth led to a lower CQ, while deeper submersion produced a higher CQ. © 2015 S. Karger AG

Do Different Semi-Occluded Voice Exercises Affect Vocal Fold Adduction Differently in Subjects Diagnosed with Hyperfunctional Dysphonia?

Objective: To observe the possible differential effects of 8 different semi-occluded vocal tract exercises on glottal contact quotient (CQ) as a measure of vocal fold impact stress. Patients and Methods: Eighty participants were divided into two groups: an experimental group with hyperfunctional dysphonia and a control group of vocally healthy subjects. The participants were recorded before, during and after the exercises. Electroglottographic samples were analyzed to obtain CQ. Results: For the experimental group, all exercises, except lip trills and tongue trills, had an overall significant effect when conditions before, during and after the exercises were compared. The CQ presented differently across the 8 semi-occluded postures during exercise for both groups. For the experimental group, most exercises increased the CQ during practice. Only lip and tongue trills demonstrated lower CQ during exercise. Conclusions: Different semi-occluded exercises differentially affect vocal fold adduction. Lip and tongue trills produced the lowest CQ. Therefore, they may be recommended for decreasing glottal adduction. A straw submerged 10 cm below the water surface presented the greatest CQ. A shallower depth led to a lower CQ, while deeper submersion produced a higher CQ. © 2015 S. Karger AG

Nitrogen remote diagnosis in a creeping bentgrass golf green

Nitrogen fertilization is a key factor of the aesthetics and playability for golf greens. Nitrogen fertilization management is based on predetermined scheduled applications, set rates, or expected improvement in visual quality and green speed. As a consequence, the objective of this study was to obtain seasonal N application models (algorithms) based on remote sensing, optimizing playability and aesthetic quality. A 3-yr field study under Mediterranean conditions was conducted on an experimental ‘L-93’ creeping bentgrass (Agrostis stolonifera L.) USGA green, to examine effects of seasonal N fertilizer rates on color, clipping yields, and ball roll (green speed). The remote sensors used were a digital camera and reflectance meter (FieldScout CM1000 Chlorophyll Meter). From digital photographs, a dark green color index (DGCI) was calculated. All data were normalized (relative). For all seasons, a third-order polynomial response model was the best when using a CM1000 and a digital camera. Clipping yields and ball roll regressions were linear, increasing and decreasing when the N fertilizer rate increased, respectively. Ball roll and clipping relative values were correlated with both sensors. To fit a seasonal optimum N fertilizer rate model as a function of remote sensors and the other measured parameters, the intersection of models obtained from relative values of CM1000 and digital camera with ball roll and clipping was calculated, but ball roll was considered the most suitable. The model of the digital camera with automatic settings was less accurate and underestimated the optimum N rate. However, because the actual values of digital camera and CM1000 were correlated, converting DGCI values and applying CM1000 models enabled the obtaining of practically the same N fertilizer applications. A practical application procedure of these seasonal models for an entire golf course was also shown. Actual N recommendation applications with a quick remote diagnosis (CM1000) for creeping bentgrass golf green are feasible under similar management practices in Mediterranean environments. A digital camera can also be used successfully, but it should be better when its analysis is based on CM1000 models

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care