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

Influencia del ritmo circadiano en el tamaño del infarto y estrategias de cardioprotección

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Medicina. Fecha de lectura: 01-07-2020Esta tesis tiene embargado el acceso al texto completo hasta el 01-01-202

El entrenamiento mediante simulación integrado en el programa del Grado de Medicina

El entrenamiento basado en la simulación consiste en sustituir la realidad por un escenario simulado en el que los alumnos pueden entrenarse para adquirir habilidades de liderazgo, comunicación, psicomotrices, de trabajo en equipo ó determinadas técnicas ó procedimientos de trabajo. Algunas de estas competencias son difíciles de adquirir mediante la enseñanza tradicional de la lección magistral. La práctica diaria habitual podría ser un escenario adecuado para mostrar y repetir algunas de estas competencias transversales, sin embargo, dada la importante carga de trabajo actual en ocasiones el alumno no tiene tiempo para practicar sobre lo visto y reflexionar sobre sus áreas de mejora. No hemos de olvidar que muchas de las técnicas y actuaciones médicas resultan invasivas y potencialmente lesivas en sí para el paciente por lo que es habitual que el alumno sólo llegue a observar y no se le permita practicar muchas de ellas. En el Hospital Universitario Quirón Madrid, hemos introducido la simulación como herramienta docente en todos los cursos donde hay formaciones clínicas del grado de Medicina. La nueva metodología ha sido valorada con excelente calificación por parte de los alumnos y una gran implicación y colaboración por parte de los docentes.SIN FINANCIACIÓNNo data 2014UE

Circadian variations of infarct size in acute myocardial infarction

Estudio retrospectivo unicéntrico que evaluó a 811 pacientes con un infarto agudo de miocardio. El estudio comparó el momento en el que presentaron el evento con el tamaño del infarto. Se pudo comprobar que los infartos fueron mas grandes en pacientes que lo padecieron durante la transición noche-día (entre las 6.00 y 12.00 am), resultados que ayudaron a interpretar el efecto cardioprotector de otras estrategias terapéuticas en pacientes con infarto de miocardio en ensayos clínicos posteriores.Background: The circadian clock influences a number of cardiovascular (patho)physiological processes including the incidence of acute myocardial infarction. A circadian variation in infarct size has recently been shown in rodents, but there is no clinical evidence of this finding. Objective: To determine the impact of time-of-day onset of ST segment elevation myocardial infarction (STEMI) on infarct size. Methods: A retrospective single-centre analysis of 811 patients with STEMI admitted between 2003 and 2009 was performed. Infarct size was estimated by peak enzyme release. The relationship between peak enzyme concentrations and time-of-day were characterised using multivariate regression splines. Time of STEMI onset was divided into four 6-hour periods in phase with circadian rhythms. Results: Model comparisons based on likelihood ratio tests showed a circadian variation in infarct size across time-of-day as evaluated by peak creatine kinase (CK) and troponin-I (TnI) concentrations (p=0.015 and p=0.012, respectively). CK and TnI curves described similar patterns across time, with a global maximum in the 6:00-noon period and a local minimum in the noon-18:00 period. Infarct size was largest in patients with STEMI onset in the dark-to-light transition period (6:00-noon), with an increase in peak CK and TnI concentrations of 18.3% (p=0.031) and 24.6% (p=0.033), respectively, compared with onset of STEMI in the 18:00-midnight period. Patients with anterior wall STEMI also had significantly larger infarcts than those with STEMI in other locations. Conclusions: Significant circadian oscillations in infarct size were found in patients according to time-of-day of STEMI onset. The infarct size was found to be significantly larger with STEMI onset in the dark-to-light transition period (6:00-noon). If confirmed, these results may have a significant impact on the interpretation of clinical trials of cardioprotective strategies in STEMIDepto. de MedicinaFac. de MedicinaTRUEpu

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Segmentation and supercycles: A catalog of earthquake rupture patterns from the Sumatran Sunda Megathrust and other well-studied faults worldwide

After more than 100 years of earthquake research, earthquake forecasting, which relies on knowledge of past fault rupture patterns, has become the foundation for societal defense against seismic natural disasters. A concept that has come into focus more recently is that rupture segmentation and cyclicity can be complex, and that a characteristic earthquake model is too simple to adequately describe much of fault behavior. Nevertheless, recognizable patterns in earthquake recurrence emerge from long, high resolution, spatially distributed chronologies. Researchers now seek to discover the maximum, minimum, and typical rupture areas; the distribution, variability, and spatial applicability of recurrence intervals; and patterns of earthquake clustering in space and time. The term “supercycle” has been used to describe repeating longer periods of elastic strain accumulation and release that involve multiple fault ruptures. However, this term has become very broadly applied, lumping together several distinct phenomena that likely have disparate underlying causes. We divide earthquake cycle behavior into four major classes that have different implications for seismic hazard and fault mechanics: 1) quasi-periodic similar ruptures, 2) clustered similar ruptures, 3) clustered complementary ruptures/rupture cascades, and 4) superimposed cycles. “Segmentation” is likewise an ambiguous term; we identify “master segments” and “asperities” as defined by barriers to fault rupture. These barriers may be persistent (rarely or never traversed), frequent (occasionally traversed), or ephemeral (changing location from cycle to cycle). We compile a catalog of the historical and paleoseismic evidence that currently exists for each of these types of behavior on major well-studied faults worldwide. Due to the unique level of paleoseismic and paleogeodetic detail provided by the coral microatoll technique, the Sumatran Sunda megathrust provides one of the most complete records over multiple earthquake rupture cycles. Long historical records of earthquakes along the South American and Japanese subduction zones are also vital contributors to our catalog, along with additional data compiled from subduction zones in Cascadia, Alaska, and Middle America, as well as the North Anatolian and Dead Sea strike-slip faults in the Middle East. We find that persistent and frequent barriers, rupture cascades, superimposed cycles, and quasi-periodic similar ruptures are common features of most major faults. Clustered similar ruptures do not appear to be common, but broad overlap zones between neighboring segments do occur. Barrier regions accommodate slip through reduced interseismic coupling, slow slip events, and/or smaller more localized ruptures, and are frequently associated with structural features such as subducting seafloor relief or fault trace discontinuities. This catalog of observations provides a basis for exploring and modeling root causes of rupture segmentation and cycle behavior. We expect that researchers will recognize similar behavior styles on other major faults around the world.Ministry of Education (MOE)National Research Foundation (NRF)Published versio

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a −$11 (95$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Use of Telemedicine for Post-discharge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review with Meta-analysis

Objective: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardised assessment tools are needed. Summary background data: Surgical site infection is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. Methods: The primary outcome of this study was surgical site infection reported up to 30-days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analysed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30-days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). Results: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs. 11.1%, P<0.001), which persisted after risk adjustment in a mixed-effects model (adjusted odds ratio: 0.73, 95% confidence interval 0.63-0.84, P<0.001). This association was consistent across sensitivity and subgroup analyses, including a propensity-score matched model. In nine eligible non-randomised studies identified, a pooled mean of 64% of patients underwent telemedicine follow-up. Upon meta-analysis, the SSI rate reported was lower with telemedicine (odds ratio: 0.67, 0.47-0.94) than in-person (reference) follow-up (I2=0.45, P=0.12), although there a high risk of bias in included studies. Conclusions: Use of telemedicine to assess the surgical wound post-discharge is feasible, but risks underreporting of SSI. Standardised tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally