Pursuing a net-zero carbon future for all: Challenges for commercial real estate

The commercial real-estate industry faces both opportunities and challenges in reaching net-zero carbon goals. Successful low-carbon strategies rely on organizational decision-making, including cooperation between diverse groups of stakeholders. Not all landlords and tenants are equal, so a key challenge will be activating change across the industry as a whole

Broadband linearisation of high-efficiency power amplifiers

A feedforward-based amplifier linearization technique is presented which is capable of yielding significant improvements in both linearity and power efficiency over conventional amplifier classes (e.g. class-A or class-AB). Theoretical and practical results are presented showing that class-C stages may be used for both the main and error amplifiers yielding practical efficiencies well in excess of 30 percent, with theoretical efficiencies of much greater than 40 percent being possible. The levels of linearity which may be achieved are required for most satellite systems, however if greater linearity is required, the technique may be used in addition to conventional pre-distortion techniques

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study

Background: In 2020, ACIE Appy study showed that COVID-19 pandemic heavily affected the management of patients with acute appendicitis (AA) worldwide, with an increased rate of non-operative management (NOM) strategies and a trend toward open surgery due to concern of virus transmission by laparoscopy and controversial recommendations on this issue. The aim of this study was to survey again the same group of surgeons to assess if any difference in management attitudes of AA had occurred in the later stages of the outbreak. Methods: From August 15 to September 30, 2021, an online questionnaire was sent to all 709 participants of the ACIE Appy study. The questionnaire included questions on personal protective equipment (PPE), local policies and screening for SARS-CoV-2 infection, NOM, surgical approach and disease presentations in 2021. The results were compared with the results from the previous study. Results: A total of 476 answers were collected (response rate 67.1%). Screening policies were significatively improved with most patients screened regardless of symptoms (89.5% vs. 37.4%) with PCR and antigenic test as the preferred test (74.1% vs. 26.3%). More patients tested positive before surgery and commercial systems were the preferred ones to filter smoke plumes during laparoscopy. Laparoscopic appendicectomy was the first option in the treatment of AA, with a declined use of NOM. Conclusion: Management of AA has improved in the last waves of pandemic. Increased evidence regarding SARS-COV-2 infection along with a timely healthcare systems response has been translated into tailored attitudes and a better care for patients with AA worldwide

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

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

Owner-managed SME responses to innovative energy data and management tools: an action research case study

SMEs use more than 13% of global energy, so they are an important target to help achieve UK Net Zero targets. However, SMEs manage energy poorly, and little is understood about how to influence them to improve energy management. Responding to this challenge, from 2018-2020, the UK Government delivered an £8.8 million Non-Domestic Smart Energy Management Innovation Competition (NDSEMIC), which funded the development of innovative smart meter data-based energy management tools. This thesis presents an action research study exploring the question: How do owner-managed SMEs respond to the development and testing of new smart meter data-based energy management tools? The study involved working with one of the Competition participants, a technology innovation business, to inform the design of the tools from which a prototype was developed. Subsequently, the tools were tested, and other applications for smart meter and related data were explored with three owner-managed SMEs, two small independent chains of coffee-shops and cycle-shops and a coffee roastery business. The findings identify that SMEs respond entrepreneurially to developing and testing smart meter data-based tools. Entrepreneurial activities led to identifying new potential uses for the tools to those anticipated at the outset; identifying operational roles, such as managing quality, productivity and premises security. Entrepreneurialism theory, developed in SME business management research includes heuristics called Causation, Effectuation and Absence of Strategy. These heuristics are used to help better understand SME decision-making when responding to the development and testing of new energy management tools. These heuristics are recommended as a helpful approach to better conceptualise how to influence SME decision-making to improve energy management

Towards Net Zero in UK Commercial Real Estate: Key information, perspectives and practical guidance

Buildings are a major contributor to climate change and in the UK they are responsible for 23% of all carbon emissions (direct and indirect emissions totalling 118 MtCO2/year)1. 30% of these emissions come from non-domestic buildings and these comprise of approximately 70% from commercial buildings and 30% from public buildings. The majority of these buildings are provided by the commercial real estate industry and they are a fundamental building block of the economy. In the UK the sector is responsible for 2.4m direct and indirect jobs (1 in every 13 jobs), with an economic output of £116.1bn. Despite the importance of the sector and the significance of its emissions, it has been little researched by comparison to the domestic building sector in the UK. What we do know is that little progress has been made in decarbonising this sector beyond the fortuitous gains of lower carbon emissions from an electricity supply which is increasingly powered by renewable energy technologies. There are many reasons for this lack of attention and progress, but two stand out. Firstly, buildings in the sector are extremely diverse in size, type, age and users. This heterogeneity makes it di¥cult to undertake ‘representative’ research, the results of which can be directly applied to many thousands of similar buildings. That said, many of the technologies that could be deployed to decarbonise these buildings have been studied for decades, and their application is not beyond the technical expertise that exists within the sector and its service providers. So why hasn’t more progress been made? This leads to the second major reason, the division between owners and occupiers or the principle/agent dilemma that pervades the sector. Put simply, owners are reluctant to invest in measures that save energy and money for their tenants and tenants are unwilling to invest when they may not stay long enough to reap the rewards. The situation is, in reality, more complex and nuanced than this but the problem is nonetheless a fundamental one. There are glimmers of hope. The Net Zero objective is now featuring as a key component of Environmental, Social and Governance (ESG) in the commercial real estate sector and ESG is becoming a much more important factor for investment businesses and their investors. The UK government is considering what form regulation should take in the sector and has recently consulted on this. As the regulatory landscape becomes clearer it will add to the pressure from investors and drive greater consideration of the decarbonisation agenda. Added to this, many large occupiers are themselves setting clear targets for Net Zero and are beginning to engage with their landlords to work collaboratively through green leases and similar arrangements. This report examines the challenges facing the commercial real estate industry, it identifies many of the opportunities that exist to drive towards Net Zero, as well as the barriers that have to be overcome. Most of all it recognises that this is only partly a technical challenge and that success primarily depends upon the active engagement with and between people in the key stakeholder organisations

Characterisation of older patients that require, but do not undergo, emergency laparotomy:a multicentre cohort study

BackgroundOlder adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps).MethodsA multicentre cohort study (n=64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap).ResultsNoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0–88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were &gt;80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements.ConclusionsThis study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process

Evolving trends in the management of acute appendicitis during COVID-19 waves. The ACIE appy II study (vol 46, pg 2021, 2022)

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Global attitudes in the management of acute appendicitis during COVID-19 pandemic: ACIE Appy Study

Background: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. Methods: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. Results: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19\ub78 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6\ub76 and 2\ub74 per cent respectively before, but 23\ub77 and 5\ub73 per cent, during the pandemic (both P < 0\ub7001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. Conclusion: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2