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

The relationship between TSH and systemic inflammation in extremely preterm newborns

Elevated thyrotropin (TSH) levels in critically ill extremely premature infants have been attributed to transient hypothyroidism of prematurity or non-thyroidal illness syndrome. We evaluated the hypothesis that relatively high TSH levels in the first 2 postnatal weeks follow recovery from systemic inflammation, similar to non-thyroidal illness syndrome. The study was conducted in 14 Neonatal Intensive Care Units and approved by each individual Institutional Review Board. We measured the concentrations of TSH and 25 inflammation-related proteins in blood spots obtained on postnatal days 1, 7, and 14. We then evaluated the temporal relationships between hyperthyrotropinemia (HTT), defined as a TSH concentration in the highest quartile for gestational age and postnatal day, and elevated levels of inflammation-related proteins. 880 newborns less than 28 weeks of gestation were included. Elevated concentrations of inflammation-related proteins during the first or second week did not precede day-14 HTT. Systemic inflammation on day 7 was associated with day-14 HTT only if inflammation persisted through the end of the 2 week period. HTT frequently accompanied elevated concentrations of inflammation-related proteins on the same day. The hypothesis that HTT follows recovery from severe illness, defined as preceding systemic inflammation, is weakly supported by our study. Our findings more prominently support the hypothesis that TSH conveys information about concomitant inflammation in the extremely premature newborn

Inflammation-initiating illnesses, inflammation-related proteins, and cognitive impairment in extremely preterm infants

Neonatal inflammation is associated with perinatal brain damage. We evaluated to what extent elevated blood levels of inflammation-related proteins supplement information about the risk of impaired early cognitive function provided by inflammation-related illnesses. From 800 infants born before the 28th week of gestation, we collected blood spots on days 1, 7 and 14, for analysis of 25 inflammation-related proteins, and data about culture-positive bacteremia, necrotizing enterocolitis (Bell stage IIIb), and isolated perforation of the intestine, during the first two weeks, and whether they were ventilated on postnatal day 14. We considered a protein to be persistently or recurrently elevated if its concentration was in the top quartile (for gestational age and day blood was collected) on two separate days one week apart. We assessed the children at 2years of age with the Bayley Mental Development Index (MDI). The combinations of NEC and ventilation on day 14, and of bacteremia and ventilation on day 14 consistently provided information about elevated risk of MD

Preference for infant-directed speech in preterm infants

The current study explores the effects of exposure to maternal voice on infant sucking in preterm infants. Twenty-four preterm infants averaging 35 weeks gestational age were divided randomly into two groups. A contingency between high-amplitude sucking and presentation of maternal voice was instituted for one group while the other group served as a yoked control. No significant differences were observed in sucking of the two groups, but the degree of pitch modulation of the maternal voice predicted an increase in the rate of infant sucking

Endogenous erythropoietin varies significantly with inflammation-related proteins in extremely premature newborns

INTRODUCTION: Erythropoietin, a pluripotent glycoprotein essential for erythropoiesis, fetal growth, and development, has recently been implicated in innate immune regulation. Data from the ELGAN Study allowed us to evaluate relationships between endogenous erythropoietin and 25 inflammation-related proteins in extremely premature newborns. METHODS: We measured the concentrations of 25 inflammation-related proteins and of erythropoietin in blood spots collected on postnatal days 1, 7, and 14 from 936 infants born before 28weeks gestation. We calculated the odds that infants with an inflammation-related protein in the highest quartile for gestational age and collection day had an erythropoietin concentration in the highest or lowest quartile. RESULTS: The proportion of children with inflammation-associated protein concentrations in the top quartile tended to increase monotonically with increasing quartile of EPO concentrations on 2 of the 3days assessed. To a large extent, on each of the 3days assessed, the odds ratios for an erythropoietin concentration in the top quartile were significantly elevated among those with an inflammation-related protein concentration in the top quartile. CONCLUSIONS: Our findings suggest that in very preterm newborns, circulating levels of endogenous erythropoietin vary significantly with circulating levels of inflammation-related proteins. Elevation of endogenous erythropoietin might not be an epiphenomenon, but instead might contribute to subsequent events, by either promoting or reducing inflammation, or by promoting an anti-injury or repair capability

Systemic inflammation, intraventricular hemorrhage, and white matter injury

To see if the systemic inflammation profile of 123 infants born before the 28th week of gestation who had intraventricular hemorrhage without white matter injury differed from that of 68 peers who had both lesions, we compared both groups to 677 peers who had neither. Cranial ultrasound scans were read independently by multiple readers until concordance. The concentrations of 25 proteins were measured with multiplex arrays using an electrochemiluminescence system. Infants who had both hemorrhage and white matter injury were more likely than others to have elevated concentrations of C-reactive protein and interleukin 8 on days 1, 7, and 14, and elevated concentrations of serum amyloid A and tumor necrosis factor-α on 2 of these days. Intraventricular hemorrhage should probably be viewed as 2 entities: hemorrhage alone and hemorrhage with white matter injury. Each entity is associated with inflammation, but the combination has a stronger inflammatory signal than hemorrhage alone

Systemic inflammation associated with mechanical ventilation among extremely preterm infants

Little evidence is available to document that mechanical ventilation is an antecedent of systemic inflammation in preterm humans. We obtained blood on postnatal day 14 from 726 infants born before the 28th week of gestation and measured the concentrations of 25 inflammation-related proteins. We created multivariable models to assess the relationship between duration of ventilation and protein concentrations in the top quartile. Compared to newborns ventilated for fewer than 7 days (N=247), those ventilated for 14 days (N=330) were more likely to have elevated blood concentrations of pro-inflammatory cytokines (IL-1β, TNF-α), chemokines (IL-8, MCP-1), an adhesion molecule (ICAM-1), and a matrix metalloprotease (MMP-9), and less likely to have elevated blood concentrations of two chemokines (RANTES, MIP-1β), a matrix metalloproteinase (MMP-1), and a growth factor (VEGF). Newborns ventilated for 7-13 days (N=149) had systemic inflammation that approximated the pattern of newborns ventilated for 14 days. These relationships were not confounded by chorioamnionitis or antenatal corticosteroid exposure, and were not altered appreciably among infants with and without bacteremia. These findings suggest that 2 weeks of ventilation are more likely than shorter durations of ventilation to be accompanied by high blood concentrations of pro-inflammatory proteins indicative of systemic inflammation, and by low concentrations of proteins that might protect from inflammation-mediated organ injury. Copyright © 2012 Elsevier Ltd. All rights reserved

Interinstitutional variation in prediction of death by SNAP-II and SNAPPE-II among extremely preterm infants

BACKGROUND: Illness severity scores predict death among infants admitted to NICUs. We know of no study limited to a population defined by an extremely low gestational age. METHODS: A total of 1467 infants born before the 28th postmenstrual week at 14 institutions were given Score for Neonatal Acute Physiology II (SNAP-II) and Score for Neonatal Acute Physiology Perinatal Extension II (SNAPPE-II) values based on data collected within the first 12 postnatal hours. All deaths in the intensive care nursery were identified. RESULTS: The rate of death before postnatal day 28 was 13% (interinstitutional range: 7%-20%), whereas the overall mortality rate was 18% (8%-31%). SNAP-II values, SNAPPE-II values, and mortality rates tended to decrease with increasing gestational age. Even within gestational age strata, however, the risk of death decreased with decreasing SNAP-II and SNAPPE-II values. The positive predictive values of most SNAP-II and SNAPPE-II cutoff levels were close to 30%. In general, institutions\u27 mortality rates increased with the proportions of infants whose SNAP-II values were \u3e/=30. CONCLUSION: The physiologic instability in the first 12 postnatal hours that is identified by illness severity scores conveys information about the risk of death among infants at the lowest gestational ages

The antecedents and correlates of necrotizing enterocolitis and spontaneous intestinal perforation among infants born before the 28th week of gestation

OBJECTIVE: To identify antecedents of medical necrotizing enterocolitis (mNEC), surgical NEC (sNEC), and spontaneous intestinal perforation (SIP) in newborns delivered before 28 weeks gestation. STUDY DESIGN: Prospective multicenter cohort study. During study period, 2002- 2004, women delivering before 28 weeks gestation at one of 14 participating institutions were enrolled. Well defined antenatal and postnatal variables were collected. Bivariate analyses were performed to identify candidates for developing multinomial multivariable time-oriented logistic regression models. RESULTS: Of the 1320 infants, 5% had mNEC, 6% had sNEC, and 4% had SIP. Antecedents of mNEC included mother\u27s identification as Black, consumption of aspirin during the pregnancy, and vaginal bleeding after the 12th week of gestation. For sNEC the antecedents were maternal self- support, obesity and anemia during the pregnancy, birth before the 24th week, birth weight ≤750gm, and receipt of fresh frozen plasma (FFP) during the first postnatal week. An infant was at increased risk of SIP if the placenta had increased syncytial knots, birth occurred before the 24th week, and received FFP during the first week. CONCLUSIONS: Maternal and neonatal characteristics might help identify at-risk ELGANs for NEC and SIP, who then may potentially benefit from targeted preventive strategies

Accuracy of the Bayley-II mental development index at 2 years as a predictor of cognitive impairment at school age among children born extremely preterm

OBJECTIVE: To describe the accuracy of the Bayley Scales of Infant Development-Second Edition (BSID-II) Mental Development Index (MDI) at 2 years of age for prediction of cognitive function at school age of children born extremely preterm. DESIGN: Study participants were enrolled in the Extremely Low Gestational Age Newborn Study between 2002 and 2004. Two-thirds of surviving children (n = 795) were assessed at 2 years with the BSID-II and at 10 years with an intelligence quotient (IQ) test. We computed test characteristics for a low MDI ( RESULTS: Almost two-thirds of children with a low MDI had a normal IQ (≥ 70) at 10 years. Concordance between MDI and IQ was highest among children with major motor and/or sensory impairment, and when MDI was adjusted for gestational age. CONCLUSION: Most children born extremely preterm with low BSID-II MDI at 2 years have normal intelligence at school age