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

DETERMINATION OF CHEMICAL COMPOSITION AND METABOLIZABLE ENERGY VALUES OF SOME PROTEIN FEEDS FOR BROILER CHICKEN

We conducted a biological assay using the traditional method of excreta collection, with the purpose to determine the values of apparent metabolizable energy, apparent metabolizable energy corrected for nitrogen balance, and the chemical composition of six feeds: deactivated whole soybean with shuck; deactivated whole soybean without shuck; soy protein concentrate; extruded semi-whole soybean meal; soybean meal; and wheat gluten. We used 252 chicks of the Cobb 500 commercial lineage, from 14 to 24 days of age, distributed in a completely randomized design, with seven treatments (six test rations and a reference ration) and six repetitions with six birds per experimental unit. The five initial days were destined to the adaptation of the birds to the experimental rations, and the five final days were destined to excreta collection, which was carried out twice a day. The values of  apparent metabolizable energy corrected for nitrogen balance, based on natural matter determined in broiler chicken aged from 14 to 24 days old were as follows: deactivated whole soybean with shuck: 2797 kcal/kg; deactivated whole soybean without shuck: 3012 kcal/kg; soy protein concentrate:, 2554 kcal/ kg; extruded semi-whole soybean meal: 2467 kcal/kg; soybean meal: 2221 kcal/kg and wheat gluten: 3813 kcal/kg. Keywords: deactivated whole soybean; extruded semi-whole soybean meal; soy protein concentrate; soybean meal; wheat gluten

Determinação da composição química e dos valores de energia metabolizável de alguns alimentos proteicos para frangos de corte

Foi realizado um experimento, utilizando-se o método tradicional de coleta total de excretas, com o objetivo de determinar os valores de energia metabolizável aparente, energia metabolizável aparente corrigida pelo balanço de nitrogênio e composição química de seis alimentos: soja integral desativada com casca, soja integral desativada sem casca, concentrado proteico de soja, farelo de soja extrusada semi-integral, farelo de soja e glúten de trigo. Foram utilizados 252 pintos de corte da linhagem comercial Cobb 500, com 14 dias de idade, distribuídos em delineamento inteiramente casualizado, com sete tratamentos (seis rações testes e uma ração referência), seis repetições e seis aves por unidade experimental. Os cinco dias iniciais foram destinados à adaptação das aves às rações experimentais e os cinco dias finais à coleta total das excretas, realizada duas vezes ao dia. Os valores de energia metabolizável aparente corrigida pelo balanço de nitrogênio na matéria natural determinados em frangos de corte no período de 14 a 24 dias de idade foram os seguintes: soja integral desativada com casca: 2797 kcal/kg; soja integral desativada sem casca: 3012 kcal/kg; concentrado proteico de soja: 2554 kcal/kg; farelo de soja extrusada semi-integral: 2467 kcal/kg; farelo de soja: 2221 kcal/kg; glúten de trigo: 3813 kcal/kg.We conducted a biological assay using the traditional method of excreta collection, with the purpose to determine the values of apparent metabolizable energy, apparent metabolizable energy corrected for nitrogen balance, and the chemical composition of six feeds: deactivated whole soybean with shuck; deactivated whole soybean without shuck; soy protein concentrate; extruded semi-whole soybean meal; soybean meal; and wheat gluten. We used 252 chicks of the Cobb 500 commercial lineage, from 14 to 24 days of age, distributed in a completely randomized design, with seven treatments (six test rations and a reference ration) and six repetitions with six birds per experimental unit. The five initial days were destined to the adaptation of the birds to the experimental rations, and the five final days were destined to excreta collection, which was carried out twice a day. The values of apparent metabolizable energy corrected for nitrogen balance, based on natural matter determined in broiler chicken aged from 14 to 24 days old were as follows: deactivated whole soybean with shuck: 2797 kcal/kg; deactivated whole soybean without shuck: 3012 kcal/kg; soy protein concentrate:, 2554 kcal/kg; extruded semi-whole soybean meal: 2467 kcal/kg; soybean meal: 2221 kcal/kg and wheat gluten: 3813 kcal/kg

Is vitamin D3 transdermal formulation feasible? An ex vivo skin retention and permeation

Vitamin D-3 supplementation is important to prevent and treat hypovitaminosis that is a worldwide public health issue. Most types of supplementation are by oral route or fortification foods. The alternative route must be investigated, as transdermal route, for people with fat malabsorption or other diseases that impair the absorption of vitamin D-3. This study focused on verifying the feasibleness of vitamin D-3 skin retention and permeation with the presence of chemical penetration enhancers (soybean lecithin, isopropyl palmitate, propylene glycol, ethoxydiglycol, and cereal alcohol) at different pharmaceutical forms (gel and cream) through a human skin. The integrity of skin was evaluated by transepidermal water loss (TEWL) during the skin retention and permeation test. The combination of chemical penetration enhancers presented in cream did not compromise the skin, different from the gel that association of cereal alcohol and propylene glycol compromised the skin in 24 h. Gel formulation showed vitamin D-3 detection at stratum corneum in 4 h and at epidermis and dermis in 24 h. Vitamin D-3 demonstrated an affinity with the vehicle in the cream formulation and was detected at the skin surface. No active was found at receptor fluid for both formulations. In conclusion, the vitamin D-3 did not indicate feasibleness for transdermal use probably due to its physical-chemical characteristics such as high lipophilicity since it was not permeated through a human skin. Nevertheless, the transdermal route should be continuously investigated with less lipophilic derivates of vitamin D-3 and with different combination of penetration enhancers

Evaluation of in vitro and in vivo safety of the by-product of Agave sisalana as a new cosmetic raw material: development and clinical evaluation of a nanoemulsion to improve skin moisturizing

Agave sisalana (sisal) is the important global source of hard fiber, which is widely used in the production of wires, ropes, and handicrafts. The decortication process of the A. sisalana leaf produces large amounts of by-product that is discarded and can cause environmental damage. Studies have shown the potential of the by-product of A. sisalana in different applications. The aim of this study was to obtain a polysaccharide-enriched fraction (EF) from the by-product of A. sisalana, assess its safety in vitro and in vivo, to develop a cosmetic nanoemulsion and to evaluate its moisturizing clinical efficacy. EF was obtained and total sugar, total phenolic, and protein content were quantified. The safety of EF was determined using in vitro and in vivo assays. Nanoemulsions were developed and their stability evaluated for 90 days at different temperature conditions. The clinical moisturizing efficacy was evaluated by biophysical techniques using capacitance measurement and transepidermal Water loss. The fraction exhibited high concentrations of sugar (65.49 +/- 0.51%) and the presence of phenolic compounds (2.53 +/- 0.04%) as well as protein (0.04 +/- 0.01%). The EF did not exhibit potential cytotoxic or phototoxic effects and did not present the potential to induce skin irritant reaction in clinical tests. Nanoemulsion containing 40% oil phase, 50% aqueous phase and 10% surfactants, added fraction or not (vehicle), was stable for 90 days. The nanoemulsion containing 0.5% of the fraction increased the water content of stratum cornetun by 10.13% vs. vehicle and by 19.28% vs. baseline values and maintained skin barrier function after 5 h of a single application. The EF obtained from the industrial by-product of A. sisalana demonstrated a promising profile as a moisturizing cosmetic raw material. This is important because it shows the possibility to increase the commercial value to the industrial by-product of sisal, and thus reduce the environmental impact caused by the disposal of this material

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p<0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)

Erratum to: Guidelines for the use and interpretation of assays for monitoring autophagy (3rd edition) (Autophagy, 12, 1, 1-222, 10.1080/15548627.2015.1100356

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Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research