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

Effects of phosphate binding with sevelamer carbonate on cardiovascular structure and function in patients with early chronic kidney disease

Serum phosphate has recently emerged as a cardiovascular risk factor in several populations, including patients with chronic kidney disease. Much of the adverse cardiovascular risk profile seen in chronic kidney disease can be attributed to structural heart disease, which appears to be driven by an increase in arterial stiffness. There is strong evidence linking phosphate to vascular calcification, which in turn causes arterial stiffening. In the following studies, phosphate is shown to be an independent predictor of renal function decline in patients with stage 2–4 chronic kidney disease. In addition, phosphate is shown to be independently associated with left ventricular mass, a predictor of cardiovascular morbidity and mortality. In the final study, the cardiovascular effects of reducing phosphate exposure with sevelamer carbonate, an oral, non-calcium-based phosphate binder, are assessed in a randomised, double blind, placebo-controlled trial of 120 patients with stage 3 chronic kidney disease. Although no demonstrable effects were seen on arterial stiffness, left ventricular mass, or left ventricular function, adherence to study medication was low given the high pill burden. Testing of this hypothesis may therefore require introduction of a therapy that effectively lowers phosphate exposure through a more acceptable dosing regimen

Efficacy And Safety Of The Subcutaneous Implantable Cardioverter Defibrillator: A Systematic Review

Background: Subcutaneous implantable cardioverter defibrillators (S-ICD) are an alternative to conventional transvenous implantable cardioverter defibrillators (TV-ICD) in patients not requiring pacing. We sought to define the efficacy and safety of S-ICD through literature review.Methods: We searched MEDLINE and EMBASE for studies evaluating efficacy and safety outcomes among patients undergoing S-ICD implantation. We performed narrative synthesis and pooled efficacy and safety outcomes across studies.Results: 16 studies were included with 5,380 participants (mean age range 33–56 years). Short-term follow-up data were available for 1670 subjects. The commonest complication was pocket infection, affecting 2.7% (range 0–19%). Other complications included delayed wound healing (0.6%), wound discomfort (0.8%), haematoma (0.4%) and lead migration (0.3%). A total of 3.8% (range 0–12%) of S-ICDs were explanted. The commonest reason for explant was pocket infection. Mortality rates in hospital (0.4%) and during follow-up (3.4% from 12 studies reporting, 2.1% per person-years) were low. The number of patients experiencing ventricular arrhythmia varied from 0 to 12%. Overall shock efficacy for treatment of ventricular arrhythmias exceeded 96%. Inappropriate shocks affected 4.3% (range 0–15%) of patients and was most commonly caused by T-wave oversensing.Conclusions: Although long-term randomised data are lacking, observational data suggest shock efficacy, peri-procedural and short-term complication rates of the S-ICD are similar to TV-ICD, making the S-ICD a suitable alternative in patients without an indication for pacing.<br/