Mimicking Mills’ syndrome: progressive spastic hemiparesis on upper motor neuron dominant amyotrophic lateral sclerosis

Mills’ syndrome is an idiopathic, slowly progressive, spastic hemiparetic variant of primary lateral sclerosis (PLS). Despite this classic definition, this syndrome has recently been suggested to be present on all the variants of motor neuron disease (MND) spectrum (ALS, PLS or UMNdALS). Authors presented a 63 years old male with history of gradually progressive right-side hemiparesis associated with dysarthria and dysphagia. Neurologic examination revealed intact cognition, weak bilateral orofacial muscles, marked right-side spasticity with hyperreflexia and mild sensory deficit, progressing to right-upper extremity atrophy upon follow-up. Relevant blood and CSF examinations were within normal limits. MRI of brain and cervical spine were unremarkable. electromyography (EMG), nerve conduction velocity (NCV), facial motor and blinks studies initially revealed no evidence of lower motor neuron involvement. Based on the revised El escorial criteria, patient was diagnosed as upper motor neuron dominant amyotrophic lateral sclerosis (UMNdALS) mimicking the classic PLS-Mills’ hemiparetic variant

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