Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

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

Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency

Aim Because of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI). Methods A working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category. Results and conclusions Recent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the ‘unlikely’ PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000–40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy

Atributos físico-químicos de um Latossolo do Cerrado brasileiro e sua relação com características dendrométricas do eucalipto Dendrometric parameters of eucalyptus and their relationship with physical-chemical characteristics of a Latosol in the Brazilian Cerrado

A resistência mecânica à penetração do solo exerce grande influência sobre o crescimento e desenvolvimento vegetal, uma vez que o crescimento das raízes e o rendimento das culturas variam de forma inversamente proporcional ao seu valor. Por outro lado, a matéria orgânica e o pH do solo também são atributos relevantes ao crescimento das plantas, pois estão diretamente ligados à disponibilidade de nutrientes do solo. No ano agrícola 2005/2006, na Fazenda Experimental de Ensino e Pesquisa da Faculdade de Engenharia/UNESP, município de Selvíria, MS (22 º 23 ' de latitude S; 51 º 27 ' de longitude W), em um cultivo de Eucalyptus camaldulensis, foram analisados: (a) características dendrométricas da planta: volume de madeira (VOL), perímetro à altura do peito (PAP) e altura (ALT); e (b) atributos do solo em profundidade: resistência mecânica à penetração (RP), umidade gravimétrica (UG), matéria orgânica (MO) e o pH, num Latossolo Vermelho distrófico do Cerrado brasileiro. O objetivo foi estudar as correlações lineares e espaciais entre essas variáveis, buscando determinar indicadores de qualidade do solo para o eucalipto. Dados do solo e da planta foram coletados em uma malha geoestatística com 122 pontos amostrais, numa área de 1,98 ha. Os atributos da planta apresentaram média e alta variabilidade dos dados, ao passo que os do solo mostraram variabilidade baixa, média e alta. Os atributos VOL, PAP, ALT, RP, UG, MO e o pH não variaram aleatoriamente, seguindo padrões espaciais bem definidos, com alcances entre 17 e 169 m. As correlações lineares simples entre as características da planta e os atributos do solo foram baixas, porém significativas entre os pares VOL vs RP1, VOL vs RP5, VOL vs MO2 e VOL vs pH1. Do ponto de vista espacial, ocorreu significativa variação inversa do VOL com a RP5 e o pH1. O pH do solo, amostrado de 0-0,15 m de profundidade, quando destinado à estimativa da produtividade de madeira do Eucalyptus camaldulensis, apresentou-se como potente indicador da qualidade do solo estudado de Selvíria.<br>Soil mechanical penetration resistance exerts a strong influence on plant development since the root growth as well as crop yield are inversely related to this variable. On the other hand, soil organic matter and pH are also relevant for plant development, for being directly linked to soil nutrient availability. In the 2005/2006 growing season, the following dendrometric parameters of Eucalyptus camaldulensis were analyzed: (a) wood volume (WV), (b) perimeter at breast height (PBH) and c) plant height (PH), and the soil attributes: a) mechanical penetration resistance (MP), b) gravimetric moisture (GR), (c) organic matters (OM) and (d) and pH in a Dystrophic Red Latosol of the Cerrado (savanna-like vegetation). The purpose was to study the linear and spatial correlations among these variables, and to obtain soil quality indices for eucalyptus. A geostatistical grid was installed to collect soil and plant data, with 122 sample points, in an area of 1.98 ha. The variability of the plant data was medium and high, while the variability of the soil data was low, medium and high. The attributes WV, PB, PH, MP, GR, OM, and pH did not change randomly. Rather, they followed well-defined spatial patterns, with ranges between 17 and 169 m. The simple linear correlations among the attributes (plant and soil) were low, however significant for the attribute pairs WV vs MP1, WV vs MP5, WV vs OM2 and WV vs pH1. From the spatial correlation viewpoint WV varied significantly, inversely proportional to MP5 and pH1. The soil pH, sampled from the 0-0.15 m layer (pH1), turned out to be the best quality indicator of the studied soil toward estimating eucalyptus wood yield