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

Does amygdaloid corticotropin-releasing hormone (CRH) mediate anxiety-like behaviors? Dissociation of anxiogenic effects and CRH release

The brain corticotropin-releasing hormone (CRH) circuits are activated by stressful stimuli, contributing to behavioral and emotionalresponses. The present study assessed anxiety-like responses andin vivoneurochemical alterations at the central nucleus of theamygdala (CeA) evoked by exposure to an unfamiliar (anxiogenic) environment. Also, the impact of anxiolytic treatments and thosethat affect CRH were assessed in this paradigm. Novel environment (new cage) markedly suppressed ingestion of a palatable snack.This effect was dose-dependently antagonized by diazepam and was utilized as an index of anxiety in the rodent. Although exposureto a novel environment also stimulated thein vivorelease of CRH and glutamate at the CeA, various CRH antagonists (e.g.ah-CRH,Ca-MeCRH, CP-154,526, antisauvagine-30, preproTRH178-199) did not attenuate the stressor-elicited behavioral suppression,although Ca-MeCRH was found to attenuate the freezing response elicited by contextual stimuli that were associated with previouslyadministered footshock. Moreover, central infusion of CRH failed to suppress snack consumption in the home cage. Althoughdiazepam had potent anxiolytic effects in this paradigm, this treatment did not prevent the stressor-associated release of CRH andglutamate at the CeA. Thus, while neural circuits involving CRH and⁄or glutamatergic receptors at the CeA may be activated by anunfamiliar environment, the data challenge the view that activation of these receptors is necessary for the expression of anxiety-likebehavioral responses. Rather than provoking anxiety, these systems might serve to draw attention to events or cues of biologicalsignificance, including those posing a threat to survival