The carbon footprint of critical care: a systematic review

PURPOSE

The provision of healthcare is a substantial global contributor to greenhouse gas (GHG) emissions. Several medical specialties and national health systems have begun evaluating their carbon emission contributions. The aim of this review is to summarise and describe the carbon footprint resulting from the provision of adult, paediatric and neonatal critical care.

METHODS

A systematic search of Embase, Cochrane and Web of Science was performed in January 2023. Studies reporting any assessment of the carbon footprint of critical care were included. No language restrictions were applied. GHG emissions from life cycle assessments (LCA) were reported, in addition to waste, electricity and water use. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed.

RESULTS

In total, 13 studies assessing and describing the environmental impact of 36 adult or paediatric intensive care units (ICUs) were included. Two studies described full LCAs, seven reported waste only, two provided audits of unused medical supplies, one reported electricity use, and one study described a Material Flow Analysis. The estimated carbon emissions from critical care range between 88 kg CO2e/patient/day and 178 kg CO2e/patient/day. The two predominant sources of carbon emissions in critical care originate from electricity and gas use, as well as consumables. Waste production ranged from 1.1 to 13.7 kg/patient/day in the 6 studies where mean waste could be calculated.

CONCLUSION

There is a significant carbon footprint that results from intensive care provision. Consumables and waste constitute important, measurable, and modifiable components of anthropogenic emissions. There remains uncertainty due to a lack of literature, several unstudied areas of carbon emissions from critical care units, and within measured areas, measurement and reporting of carbon emissions are inconsistent.

Furosemide in pediatric intensive care: a retrospective cohort analysis

Introduction

Furosemide is the most commonly used medication in pediatric intensive care. Growing data indicates improved hemodynamic stability and efficacy of furosemide infusions compared to intermittent injections, thereby suggesting furosemide infusions might be considered as first line therapy in critically ill, paediatric patients. The objective of this study is to examine furosemide treatment as either continuous infusions or intermittent injections and subsequent patient outcomes.

Methods

This is a retrospective cohort analysis of patients treated in a pediatric intensive care unit (ICU) over a nine year period (July 31st 2006 and July 31, 2015). Eligible patients were admitted to either the general pediatric or cardiac specific ICU for a duration of at least 6 hours and who received intravenous furosemide treatment.

Results

A total of 7,478 patients were identified who received a total of 118,438 furosemide administrations for a total of 113,951 (96%) intermittent doses and 4,487 (4%) infusions running for a total of 1,588,750 hours. A total of 5,996 (80%) patients received exclusively furosemide injections and 1,482 (20%) patients received at least one furosemide infusion. A total of 193 patients died during ICU admission, amounting to 87 (6%) of the 1,482 patients who received an infusion and 106 (2%) of the 5,996 who received intermittent injections. Multivariable regression analysis showed no statistically significant decrease in adjusted mortality for patients who received furosemide injections compared to furosemide infusions (aOR 1.20, CI 0.76-1.89).

Discussion

This retrospective study observed similar mortality for patients who received furosemide infusions compared to furosemide injections. More research on furosemide in the ICU could provide insights on fluid management, drug effectiveness, and pharmacologic stewardship for critically ill children.

O-145 Green Tea catechins EGCG and pro-drug of EGCG (Pro-EGCG) inhibit endometriosis through targeting molecules regulating macrophages and B cells

Study question

What are the therapeutic targets and mechanisms of green tea EGCG and Pro-EGCG in treating endometriosis?

Summary answer

EGCG and Pro-EGCG have unique molecular targets to regulate interactions of B cells, macrophages and endometriotic cells and limit the growth and development of endometriosis.

What is known already

Current treatments of endometriosis are mainly hormonal suppression and surgical ablation or removal. Our previous studies showed EGCG significantly inhibits development of experimental endometriosis in mice. Pro-EGCG is more effective than EGCG in term of anti-endometriosis, anti-angiogenesis and anti-oxidation (Wang, et. al., 2013; Xu, et al., 2011). Dysfunctional immunological activities of macrophages and B cells were found in women with endometriosis. The molecular targets, underlying mechanism and differential therapeutic efficacy of EGCG and Pro-EGCG, as well as their anti-inflammatory activities are still not known.

Study design, size, duration

Multiplexed Proteome Integral Stability Alteration (PISA) assay (Gaetani et al.,2019), followed by MS/MS was applied to identify the molecular targets of EGCG and Pro-EGCG in endometriotic cells. Pharmacological studies of EGCG and Pro-EGCG on endometriotic cell line and endometriosis models in mice were performed to characterise their anti-endometriosis and anti-inflammatory effects. Gene silencing and over-expression experiments were conducted to confirm the immunoregulatory mechanisms.

Participants/materials, setting, methods

Endometriotic (Hs832(C)T) cell lines in culture and lysate were treated for chemical proteomics analysis. SiRNA and overexpression vectors were transfected to the cells in vitro and lesions in vivo. Hs832(C).T, monocytic cells (THP-1) and control B cell (Raji null) lines were used for co-culture assays to study the interaction between endometriotic and immune cells in vitro. Endometriosis mice model was established for immunostaining and microarray analysis of lesions to characterise the molecular pathways in vivo.

Main results and the role of chance

MTDH and PXK were the strongest and most differential targets of EGCG and Pro-EGCG in both cells lysate and cell culture of Hs832(C).T, respectively. Gene silencing and overexpression of the protein targets in vitro and in vivo significantly altered expressions of downstream proteins, including BLK and EGF after PXK, and MYC and AKT after MTDH, as well as endometriosis-related genes such as VEGFC and MMP9. Co-culture assays of Hs832(C).T with Raji null or THP-1 induced macrophages showed that expressions of PXK, MTDH, downstream targets, and immune-related genes were significantly increased after incubation of recombinant proteins, but were significantly decreased after EGCG and Pro-EGCG treatment. M1 and M2 macrophages, as well as B cells were significantly reduced after the treatments in vitro and in vivo. Double immunofluorescent staining of lesions showed that CD68, CD163 or CD20 co-expressed with MTDH, PXK and downstream targets, and numbers of the co-expressed cells were significantly reduced after treatments in vivo. Microarray experiment further identified the upstream and downstream genes of MTDH or PXK contributing to the growth and development of endometriosis.

Limitations, reasons for caution

Results of this pharmacological and mechanistic study require clinical samples to validate the anti-endometriosis effects of EGCG and Pro-EGCG. Effects of other potential pharmaceuticals targeting the macrophages and B cells on endometriosis are needed.

Wider implications of the findings

The findings provide pharmacological and mechanistic data for future development of EGCG and Pro-EGCG as new treatment for endometriosis. This study shows that macrophage and B cell could be potential therapeutic targets for treatment of endometriosis, which opens up new horizon for the novel immunotherapy for endometriosis.

Trial registration number

NA

Combined Effect of Influenza Virus Infection and Urethan Treatment on the Incidence of Lung: Tumors in Mice

Swiss mice were intranasally infected with influenza A2 virus and treated with urethan in order to detect whether the joint action of the two agents would enhance the development of lung tumors. The average number per mouse of the typical lesions induced by the two treatments together with their location, their histological and histochemical characteristics and the percentage of death in the different groups of animals were recorded. Results indicated that 51.7 % of the mice infected with influenza virus and treated with urethan had both bronchial dysplastic lesions due to influenza virus, and tumors induced by urethan. In this group the number of tumors was smaller than in the mice treated with the carcinogen only and no invasive pulmonary carcinomas were observed. The dysplastic lesions caused by influenza A2 virus as well as the lung adenomas induced by urethan maintained their typical histological and histochemical characteristics even when occurring in a close position. The failure of urethan to enhance the induction of lung tumors in mice exposed to influenzal infection might be ascribed to the different primary sites of response of the pulmonary tissue to the two agents, i.e. the bronchial epithelium for influenza virus and the alveolar epithelium for urethan.

Concurrent intravenous drug administration to critically ill children: Evaluation of frequency and compatibility

PURPOSE

To evaluate the frequency of concurrent drug administration and drug-drug incompatibility of concurrently administered drugs in critically ill children based on available references.

MATERIALS AND METHODS

We retrospectively evaluated concurrent intravenous drug administration in children admitted to a single centre. Eligible patients included those admitted to the critical care unit for at least 6-hours in the ten-year period ending 30 July 2015 and received two or more IV drug administrations. Compatibilities were classified using local reference documents.

RESULTS

The 16,863 eligible patients were admitted to ICU for 2,212,326h and received 3,664,667 concurrent administrations. Concurrent infusions ran for 6,263,600h. There were 2,284,066 (62%) concurrent administrations; 334,144 (9%) were compatible, 293,856 (8%) were incompatible, 293,856 (8%) required pharmacist consultation, and 752,601 (21%) had 'unknown' compatibility. Individual patients received a median (IQR) of 33 (10-132) concurrent administrations, comprised of 7 (1-30) concurrent injections 1 (0-5) concurrent infusions and 13 (0-74) concurrently administered injections and infusions.

CONCLUSIONS

Concurrent IV-drug administration is frequent in critically ill children. Known incompatible concurrent administration occurs, however the compatibilities of many drug-drug pairs were unknown - adding complexity to routine bedside management and identifying information gaps for future research.

Conventional fascial technique versus mesh repair for advanced pelvic organ prolapse: Analysis of recurrences in treated and untreated compartments

117 women with severe pelvic organ prolapse (POP; stage > 2) were enrolled to elucidate a 24-month outcome of POP surgery, using conventional or mesh repair with 3 techniques. 59 patients underwent conventional repair and 58 underwent mesh repair. Two types of mesh were used: a trocar-guided transobturator polypropylene (Avaulta, Bard Inc.) and a porcine dermis mesh (Pelvisoft, Bard Inc.). Women with recurrences, who underwent previous unsuccessful conventional repair, were randomised. Primary outcome was the evaluation of anatomic failures (prolapse stage > 1) in treated and untreated compartments. Anatomic failure was observed in 11 of 58 patients (19%; CI 8.9-29) in the mesh group and in 16 of 59 patients (27.1%; p value = 0.3) in the conventional group. 9 of 11 failures in the mesh group (15.5%; CI 6.2-24.8) were observed in the untreated compartment (de novo recurrences), 14.3% in Pelvisoft and 16.7% in Avaulta arm, while only 1 recurrence in the untreated compartment (1.7%) was observed in the conventional group (odds ratio 10.6, p = 0.03).

Mantle exhumation along the Tirich Mir Fault Zone, NW Pakistan: pre-mid-Cretaceous accretion of the Karakoram terrane to the Asian margin

The left-lateral strike-slip Tirich Mir Fault, Chitral, NW Pakistan, is associated with a belt of periodotites, metagabbros and gneisses named the Tirich Boundary Zone (TBZ), separating the Late Palaeozoic-Mesozoic units of the East Hindu Kush from the Palaeozoic successions of the Karakoram block. These rocks were metamorphosed up to upper amphibolite facies conditions, followed by a greenschist facies overprinting, and then thrust on to very low grade metasediments; they were finally intruded at shallow levels by the mid-Cretaceous Tirich Mir pluton. Ultramafic rocks along the fault zone include well-preserved spinel lherzolites and harzburgites (Tirich Gol, Barum valley, Arkari Gol), whereas schistose serpentinites occur in the Rich Gol. Whole-rock analyses and mineral chemistry of olivine, clinopyroxene, orthopyroxene and spinel from these peridotites show a depleted signature. Microstructural and petrological features suggest a mantle origin for these ultramafic bodies, which equilibrated at temperatures ranging from 1000–1100°C. Periodotites are faulted against partially metamorphosed igneous bodies including hornblende-gabbros, hornblende cumulates and quartz-diorites. Metamorphic rocks of the TBZ, which lay south of the ultramafic-mafic complex, include quartzites, amphibolites, garnet-sillimanite (± kyanite ± K-feldspar)-biotite gneisses and mica schists, locally displaying migmatitic textures.

A sub-continental character of the peridotites indicated by low temperatures of equilibration and by the presence of a deep crustal sequence. These characters along with the absence of an ophiolitic sequence may suggest that the TBZ represents a fragmented crust-mantle boundary developed along a zone of attenuated continental crust. The TBZ is interpreted as a sheared lithospheric section of a Jurassic-Early Cretaceous orogenic complex, formed as a consequence of the accretion of the Karakoram terrane to the southern side of the Pamir belts, which were progressively accreted to the Asian margin.

High prevalence of Helicobacter pylori in liver cirrhosis: relationship with clinical and endoscopic features and the risk of peptic ulcer

In 153 consecutive patients with cirrhosis we assessed: (1) the prevalence of IgG to Helicobacter pylori and compared it with that found in 1010 blood donors resident in the same area; and (2) the relationships of IgG to Helicobacter pylori with clinical and endoscopic features and with the risk of peptic ulcer. The IgG to Helicobacter pylori prevalence of cirrhotics was significantly higher than in blood donors (76.5% vs 41.8%; P < 0.0005) and was not associated with sex, cirrhosis etiology, Child class, gammaglobulins and hypertensive gastropathy. In both groups, the prevalence of IgG to Helicobacter pylori was significantly higher in subjects over 40. Among patients with cirrhosis a significantly higher prevalence of Helicobacter pylori was found in patients with previous hospital admission (P = 0.02) and/or upper gastrointestinal endoscopy (P = 0.01) and patients with peptic ulcer (P = 0.0004). Multivariate analysis identified increasing age and male sex as risk factors for a positive Helicobacter pylori serology and no independent risk factors for peptic ulcer. The high prevalence of Helicobacter pylori-positive serology found in the present series is related to age and sex and might also be explained by previous hospital admissions and/or upper gastrointestinal endoscopy. Our results do not confirm the role of Helicobacter pylori as risk factor for peptic ulcer in patients with liver cirrhosis.

Peptic ulcer in patients with liver cirrhosis: a retrospective endoscopic and clinical study

AIM

It has been showed that peptic ulcer is more frequent in patients with liver cirrhosis, is associated with the severity of cirrhosis, and occurs without upper abdominal pain in up to 70% of patients and with complications in 29%. The aim of this study was to retrospectively assess the characteristics of peptic ulcer in a large series of patients with liver cirrhosis.

MATERIALS AND METHODS

In this retrospective study the consecutive records of 1,748 endoscopies, performed in patients with liver cirrhosis during a period of 14 years, were reviewed to evaluate the frequency and clinical characteristics of peptic ulcer.

RESULTS

The ulcer prevalence was 6.3%, and 77.5% of the ulcers were asymptomatic. Complications from ulcer were present in 29% of all patients and in 32% of those who has the first diagnosis of ulcer during the study. Patients with asymptomatic ulcer had a more decompensated cirrhosis. After healing, 20%-25% of the recurrent ulcers had complications while patients were on standard maintenance treatment.

CONCLUSIONS

This retrospective study confirms the high frequency of peptic ulcer in patients with liver cirrhosis. It also confirms that the peptic ulcer in these patients is very often asymptomatic and associated with concurrent complications, especially in those with more severe liver disease. The complication rate in recurrent ulcers was 20%-25%. However, due to the retrospective nature of this study, after ulcer healing the endoscopic follow-up was irregular. Regularly repeated endoscopy should be carried out in patients with liver cirrhosis and peptic ulcer to diagnose new and recurrent ulcers and to prevent related complications.

Chronic oral administration of lansoprazole does not affect the hypothalamic pituitary gonadal axis in healthy young men

OBJECTIVE

To assess the effects of chronic oral administration of standard doses of lansoprazole on the luteinizing hormone pulsatile pattern and on follicle stimulating hormone (FSH) and testosterone levels in young men.

DESIGN AND METHODS

Eleven healthy volunteers were studied on three separate occasions, before and after two 3-week periods of treatment with lansoprazole (30 mg every morning) or a placebo, according to a randomized, double-blind, double-dummy, cross-over design. On each study day, blood samples were taken every 15 min for 8 h. The pulsatile pattern of luteinizing hormone, mean concentrations of FSH and total testosterone plasma levels were determined for each patient using specific radioimmunoassays.

RESULTS

Lansoprazole did not significantly affect mean plasma levels, the pulsatile pattern of luteinizing hormone, or mean plasma concentrations of FSH and testosterone compared with the placebo.

CONCLUSIONS

This study indicates that chronic oral administration of standard doses of lansoprazole does not affect the concentrations of gonadal hypothalamic pituitary or sex steroid hormones.

Pharmacokinetics of single oral doses of feprazone in patients with rheumatoid arthritis or with impaired renal clearance

1. The pharmacokinetics of feprazone have been studied in 10 patients with rheumatoid arthritis (RA), and in a further six patients with renal impairment (RI) who were not suffering from rheumatoid disease. 2. For RA patients, the mean elimination half-life (t1/2) of feprazone after a single oral dose was 21 +/- 5 h (SD), the mean apparent clearance (Cl) was 0.012 +/- 0.009 l/h per kg, and the mean apparent volume of distribution (Vd) was 0.33 +/- 0.17 l/kg. Corresponding values for RI patients were 25 +/- 13 h, 0.016 +/- 0.011 l/h per kg, and 0.46 +/- 0.24 l/kg, respectively. 3. These results show no impairment of the elimination of feprazone in RA or RI patients; Vd and Cl are greater than in healthy young volunteers or elderly subjects, the AUC values are lower, but t1/2 values are similar in all groups. 4. It is suggested that the greater Cl and Vd, and lower AUC, in RA and RI patients may be due to renal insufficiency and decreased plasma protein binding of feprazone and its metabolite, or to induction of glucuronyl transferase activity by the prior medication, thus enhancing the formation of the major metabolite, the C(4)-glucuronide, and increasing drug elimination.

Competitive antagonism of isoprenaline-induced cardiac necroses by beta-adrenoreceptor blocking agents

Histological methods show that low doses of (±)-isoprenaline may produce cardiac necroses in the rat. The percentage of animals with focal necroses was related to the dose within the range 0·005 to 0·5 mg/kg administered subcutaneously. Therefore the heart-damaging effect of isoprenaline as well as the antagonistic effect of β-adrenoreceptor blocking agents could be evaluated quantitatively. Pre-treatment of animals with dichloroisoprenaline, pronethalol and propranolol produced a parallel displacement to the right of the dose-response line for isoprenaline. However, when lesions were already in progress, these agents were without protecting effect.

Results of Chemotherapy in Breast Cancer. Study Group for Therapy of Breast Cancer, Cancer Chemotherapy Committee, Italian Society of Cancerology

A summary of the results obtained by the Italian Breast Cancer Group in 122 patients with advanced breast cancer randomized over four different treatments: testosterone propionate, given i.m. 3 times a week at the dose of 100 mg per injection; cyclophosphamide, administered i.m. 25 times a month at the dose of 100 mg/day; testosterone + cyclophosphamide i.m. at the above doses; HMNT (4-hydroxy-17 methyl-19-nortestosterone) given i.m. 3 times a week at the dose of 100 mg/day. The criteria for patient selection and methods of evaluation were, with some modifications, these used by the American Breast Cancer Group. Objective improvements were observed in 26.9% of patients treated with testosterone propionate, in 15.6% of patients treated with cyclophosphamide, in 23.5% of those treated with testosterone + cyclophosphamide and in 20% of patients treated with HMNT. The most interesting result, worth of further evaluation, is that observed with the combined testosterone + cyclophosphamide therapy, which yielded the highest number of objective improvements in patients in menopause for less than one year.

Biological and Morphological Characteristics of a Lymphoblastic Leukemia of CFW Mice

The characteristics of a spontaneous lymphoblastic leukemia occurring in CFW inbred mice are described. This tumor develops in about 5 percent of more than 11 month-old mice, more frequently in females. It is successfully transplanted by subcutaneous or intraperitoneal injection of cells suspension in animals of the same strain only. Both primary and transplanted leukemias show a varying proportion of cells with aneuploid chromosome numbers, ranging from 39 to 42. Electron microscopic observations of the leukemic cells reveal the presence of intracytoplasmic virus-particles, usually situated in the Golgi zone. The virus has two membranes; the diameter of the outer membrane is about 75 mμ. The virus is similar to the A2 particles described by Dalton. The subcutaneous injection of cell-free filtrates of leukemic cells in less than 24 hour-old CFW mice was followed by the appearance of leukemia only in a limited number of mice. A preliminary investigation of the possible cross-resistance between this leukemia and that induced with Moloney virus in C3H mice showed that pretreatment with Moloney leukemia cells in CFW mice resulted in resistance against a subsequent isograft of CFW leukemia. However, a marked resistance occurred also following the pretreatment of CFW mice with lymphoid cells of normal C3H mice.