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

Диагностика и профилактика осложнений cпортивной черепно-мозговой травмы

Sports-related traumatic brain injuries (TBI) accounts for up to 20 % of all injuries that are obtained by athletes and its incidence rises annually due to rise in population involving in sports, growing popularity of extreme sports and high level of motivation to achieve record results among young sportsmen. The aim of the review is to present the potential benefits of using microwave radiothermometry and craniocerebral hypothermia technologies in sports-related TBI. The review considers most common form of traumatic brain injury in athletes - mild TBI, which in turn can provoke a wide range of complications and negative consequences in near and delayed periods after the injury. The main shortcomings of programs for complication prevention in treatment and rehabilitation of athletes after TBI are considered, which do not take into account the peculiarities of injury mechanisms, its significant differences from household, road or criminal injuries with brain damage. Lack of objective methods of instrumental diagnosis for injury severity is also described. In addition, pathophysiological component characteristics of sports TBI is accentuated: frequency of repetition, increasement of brain and body temperature, peripheral redistribution of blood flow and hypocapnia, which significantly affects cerebral blood flow. Based on the analysis of the available scientific literature, it is elicited that TBI is an independent cause of cerebral hyperthermia development, which significantly aggravates the consequences of the injury. Conclusions. The authors propose an innovative way to use microwave radiothermometry method as a diagnostic tool for sports-related TBI. In addition, the review highlights the main recommendations for complications prevention by using craniocerebral hypothermia technology, which reduces overall physical and cerebral hyperthermia, and augments the resistance of cerebral cortex neurons to hypoxia and trauma. However, the authors believe that the described approaches in sports medicine are not used purposefully due to lack of awareness of sports team doctors and coaches.На долю спортивных черепно-мозговых травм (ЧМТ) приходится до 20 % всех спортивных повреждений, а встречаемость первых возрастает ежегодно за счет прироста числа людей, занимающихся спортом, растущей популярности экстремальных и контактных видов спорта, а также высокого уровня мотивации на достижение рекордных результатов среди молодых спортсменов. Основная цель данного обзора - представить возможности применения методики микроволновой радиотермометрии и технологии краниоцеребральной гипотермии в контексте спортивной ЧМТ. В обзоре рассмотренна наиболее часто встречающаяся форма ЧМТ у спортсменов - легкая ЧМТ, которая в свою очередь может спровоцировать развитие очень широкого спектра осложнений и негативных последствий как в ближайшем, так и отсроченном периоде после полученной травмы. Рассмотрены основные недостатки программ по профилактике осложнений при лечении и реабилитации спортсменов после ЧМТ, которые недостаточно учитывают особенности механизмов развития самой травмы, ее значимые отличия от бытовых, дорожных или криминальных травм с повреждением головного мозга. Авторами описана актуальная проблематика отсутствия объективных методов инструментальной диагностики тяжести травмы. Детализована патофизиологическая составляющая, характерная для спортивных ЧМТ: периодичность повторения, повышение температуры тела и мозга пострадавшего, периферическое перераспределение кровотока и гипокапния, которые значимо влияют на мозговой кровоток. На основании проведенного анализа имеющейся отечественной и зарубежной научной литературы можно сделать вывод, что черепно-мозговая травма является независимой причиной развития церебральной гипертермии, которая существенно усугубляет последствия полученной травмы. Выводы. Авторами предложен новаторский способ использования метода микроволновой радиотермометрии в качестве диагностического инструмента спортивных ЧМТ. Кроме того, в обзоре выделяются основные рекомедации для профилактики осложнений с использованием технологии краниоцеребральной гипотермии, которая позволяет снизить общую физическую и церебральную гипертермию, а также способствует повышению устойчивости нейронов коры головного мозга к гипоксии и травме. Однако авторы считают, что описываемые подходы в спортивной медицине используются нецеленаправленно и связано это с недостаточной осведомленностью тренеров и врачей спортивных команд

Management of coronary disease in patients with advanced kidney disease

BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P=0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P=0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P=0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction

Health status after invasive or conservative care in coronary and advanced kidney disease

BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of <30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, 120.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, 122.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, 121.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, 122.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially