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

Mild Encephalopathy With Partial Reversible Splenium Lesion Associated With SARS-CoV-2 Infection.

Viral-associated encephalitis/encephalopathy includes a wide spectrum of syndromes reported often in children. A rare form presents with mild encephalitis/encephalopathy and reversible splenial lesion(s). This report describes a case of this rare presentation associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in a 68-year-old woman. The patient presented to the hospital with altered mental status. Examination revealed mild encephalopathy with disorientation to date and time. Initial laboratory workup was significant for mild hypernatremia and acute kidney injury, and a polymerase chain reaction (PCR) test for SARS-CoV-2 was positive. MRI of the brain revealed an area of hyperintensity and water restriction in the corpus callosum. The patient was treated with tocilizumab, dexamethasone, and remdesivir. MRI of the brain five weeks later revealed partial resolution of the hyperintensity, and complete resolution of the restricted diffusion previously seen in the corpus callosum, which confirmed the diagnosis of mild encephalitis/encephalopathy with a reversible splenial lesion. We highlight the importance of recognizing this phenomenon in association with SARS-CoV-2 infection

Focal Cerebral Vasculitis due to SARS-CoV-2 Infection With a Robust Response to Intravenous Steroids.

INTRODUCTION: Severe and less common neurological manifestations of SARS-CoV-2 infection include acute ischemic stroke, intracerebral hemorrhage, central venous sinus thrombosis, and vasculitis. In this report, we present a case of a 42-year-old man with acute ischemic stroke due to SARS-CoV-2 infection-associated central nervous system vasculitis that improved with steroid therapy. CASE REPORT: A 42-year-old man with SARS-CoV-2 infection presented with non-fluent aphasia and right-sided hemiparesis. Computed tomography angiography revealed an occlusion of the proximal left middle cerebral artery (MCA), with acute infarcts in the left posterior parietal, lentiform nucleus, and cortical frontal cortex on magnetic resonance imaging (MRI). Patient developed pulmonary emboli and was discharged on apixaban and atorvastatin. Four weeks later, the patient presented with recurring symptoms and was found to have worsening left MCA stenosis. MRI and MR angiography revealed a penumbra within the left MCA territory and pruning of the distal branches with severe stenosis. Laboratory workup for autoimmune causes of vasculitis was unrevealing. High-dose intravenous steroid treatment was initiated. Subsequent MRI and MR angiography revealed improved flow in the left cerebral vasculature and no novel ischemic infarcts. CONCLUSION: Central nervous system vasculitis is a rare manifestation of SARS-CoV-2 infection. This case suggests that high-dose intravenous steroids may have a therapeutic role in this patient population. Steroid use, in combination with vasopressor support to augment cerebral blood flow, may prevent further stroke burden

The carboxy terminal coiled-coil modulates Orai1 internalization during meiosis

Regulation of Ca signaling is critical for the progression of cell division, especially during meiosis to prepare the egg for fertilization. The primary Ca influx pathway in oocytes is Store-Operated Ca Entry (SOCE). SOCE is tightly regulated during meiosis, including internalization of the SOCE channel, Orai1. Orai1 is a four-pass membrane protein with cytosolic N- and C-termini. Orai1 internalization requires a caveolin binding motif (CBM) in the N-terminus as well as the C-terminal cytosolic domain. However, the molecular determinant for Orai1 endocytosis in the C-terminus are not known. Here we show that the Orai1 C-terminus modulates Orai1 endocytosis during meiosis through a structural motif that is based on the strength of the C-terminal intersubunit coiled coil (CC) domains. Deletion mutants show that a minimal C-terminal sequence after transmembrane domain 4 (residues 260-275) supports Orai1 internalization. We refer to this region as the C-terminus Internalization Handle (CIH). Access to CIH however is dependent on the strength of the intersubunit CC. Mutants that increase the stability of the coiled coil prevent internalization independent of specific mutation. We further used human and Xenopus Orai isoforms with different propensity to form C-terminal CC and show a strong correlation between the strength of the CC and Orai internalization. Furthermore, Orai1 internalization does not depend on clathrin, flotillin or PIP2. Collectively these results argue that Orai1 internalization requires both the N-terminal CBM and C-terminal CIH where access to CIH is controlled by the strength of intersubunit C-terminal CC

The carboxy terminal coiled-coil modulates Orai1 internalization during meiosis

Regulation of Ca2+ signaling is critical for the progression of cell division, especially during meiosis to prepare the egg for fertilization. The primary Ca2+ influx pathway in oocytes is Store-Operated Ca2+ Entry (SOCE). SOCE is tightly regulated during meiosis, including internalization of the SOCE channel, Orai1. Orai1 is a four-pass membrane protein with cytosolic N- and C-termini. Orai1 internalization requires a caveolin binding motif (CBM) in the N-terminus as well as the C-terminal cytosolic domain. However, the molecular determinant for Orai1 endocytosis in the C-terminus are not known. Here we show that the Orai1 C-terminus modulates Orai1 endocytosis during meiosis through a structural motif that is based on the strength of the C-terminal intersubunit coiled coil (CC) domains. Deletion mutants show that a minimal C-terminal sequence after transmembrane domain 4 (residues 260–275) supports Orai1 internalization. We refer to this region as the C-terminus Internalization Handle (CIH). Access to CIH however is dependent on the strength of the intersubunit CC. Mutants that increase the stability of the coiled coil prevent internalization independent of specific mutation. We further used human and Xenopus Orai isoforms with different propensity to form C-terminal CC and show a strong correlation between the strength of the CC and Orai internalization. Furthermore, Orai1 internalization does not depend on clathrin, flotillin or PIP2. Collectively these results argue that Orai1 internalization requires both the N-terminal CBM and C-terminal CIH where access to CIH is controlled by the strength of intersubunit C-terminal CC.Other Information Published in: Scientific Reports License: https://creativecommons.org/licenses/by/4.0See article on publisher's website: http://dx.doi.org/10.1038/s41598-021-82048-z</p

Stroke in Airplane Passengers: A Study from a Large International Hub.

INTRODUCTION: Stroke in air travelers is being increasingly recognized. We report on stroke among passengers arriving at or transiting through a busy air travel hub. METHODS: The stroke database of the sole tertiary care center for stroke in a large busy international hub was interrogated. Demographic data of transit passengers, their stroke risk factors, stroke severity, National Institutes of Health Stroke Scale (NIHSS), acute stroke interventions, discharge status and outcome utilizing the Modified Raking scale (mRS) were retrieved and compared between passengers and non-passenger controls. RESULTS: Forty-three flight-related stroke patients were compared to 2564 non-passenger stroke patients. The mean age in the flight-related stroke group was 59.53±10.83 years, 30/43 (69.8%) were males. The stroke subtypes were ischemic in 30 (69.8%) patients, hemorrhagic in 9 (20.9%), and transient ischemic attack in 3 (7.0%), with one cerebral sinus venous thrombosis (2.3%). The mean NIHSS score was 7.79±6.44 in passengers, demonstrating moderate severity. Ten patients (23.3%) received thrombolysis, one (2.3%) received thrombectomy, and one (2.3%) received both thrombolysis and thrombectomy. Outcomes, 54.8% had a good outcome (mRS 0-2), and 45.2% had dependence/death (mRS 3-6). CONCLUSION: Air passengers with stroke were found to be older with more severe strokes and a higher probability of receiving acute stroke treatment compared to non-passengers. Increased awareness with appropriate and timely recognition and triaging of transit passengers with stroke is warranted