Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

The Healthy Fatty Index Allows for Deeper Insights into the Lipid Composition of Foods of Animal Origin When Compared with the Atherogenic and Thrombogenicity Indexes.

The aim of this research was to validate the effectiveness of the Healthy Fatty Index (HFI) regarding some foods of animal origin (meat, processed, fish, milk products, and eggs) typical of the Western diet and to compare these results with two consolidated indices (atherogenic-AI, and thrombogenic-TI) in the characterization of the nutritional features of their lipids. The fatty acids profile (% of total fatty acids and mg/100 g) of 60 foods, grouped in six subclasses, was used. The AI, TI, and HFI indexes were calculated, and the intraclass correlation coefficients and the degree of agreement were evaluated using different statistical approaches. The results demonstrated that HFI, with respect to AI and TI, seems better able to consider the complexity of the fatty acid profile and the different fat contents. HFI and AI are the two most diverse indices, and they can provide different food classifications. AI and IT exhibit only a fair agreement in regards to food classification, confirming that such indexes are always to be considered indissolubly and never separately, in contrast to the HFI, which can stand alone.

Improving the antinutritional profiles of common beans (Phaseolus vulgaris L.) moderately impacts carotenoid bioaccessibility but not mineral solubility.

Common beans are a common staple food with valuable nutritional qualities, but their high contents in antinutritional factors (ANFs) can decrease the bioavailability of (i) fat-soluble micronutrients including carotenoids and (ii) minerals. Our objective was to select ANF-poor bean lines that would not interfere with carotenoid and mineral bioavailability. To achieve this objective, seeds of commercial and experimental Phaseolus vulgaris L. bean lines were produced for 2 years and the bean's content in ANFs (saponins, phytates, tannins, total polyphenols) was assessed. We then measured carotenoid bioaccessibility and mineral solubility (i.e. the fraction of carotenoid and mineral that transfer into the aqueous phase of the digesta and is therefore absorbable) from prepared beans using in vitro digestion. All beans contained at least 200 mg/100 g of saponins and 2.44 mg/100 g tannins. The low phytic acid (lpa) lines, lpa1 and lpa12 exhibited lower phytate levels (≈ - 80%, p = 0.007 and p = 0.02) than their control BAT-93. However, this decrease had no significant impact on mineral solubility. HP5/1 (lpa + phaseolin and lectin PHA-E free) bean line, induced an improvement in carotenoid bioaccessibility (i.e., + 38%, p = 0.02, and + 32%, p = 0.005, for phytofluene bioaccessibility in 2021 and 2022, respectively). We conclude that decrease in the phytate bean content should thus likely be associated to decreases in other ANFs such as tannins or polyphenols to lead to significant improvement of micronutrient bioaccessibility.

Legumes and common beans in sustainable diets: nutritional quality, environmental benefits, spread and use in food preparations.

In recent decades, scarcity of available resources, population growth and the widening in the consumption of processed foods and of animal origin have made the current food system unsustainable. High-income countries have shifted towards food consumption patterns which is causing an increasingly process of environmental degradation and depletion of natural resources, with the increased incidence of malnutrition due to excess (obesity and non-communicable disease) and due to chronic food deprivation. An urgent challenge is, therefore, to move towards more healthy and sustainable eating choices and reorientating food production and distribution to obtain a human and planetary health benefit. In this regard, legumes represent a less expensive source of nutrients for low-income countries, and a sustainable healthier option than animal-based proteins in developed countries. Although legumes are the basis of many traditional dishes worldwide, and in recent years they have also been used in the formulation of new food products, their consumption is still scarce. Common beans, which are among the most consumed pulses worldwide, have been the focus of many studies to boost their nutritional properties, to find strategies to facilitate cultivation under biotic/abiotic stress, to increase yield, reduce antinutrients contents and rise the micronutrient level. The versatility of beans could be the key for the increase of their consumption, as it allows to include them in a vast range of food preparations, to create new formulations and to reinvent traditional legume-based recipes with optimal nutritional healthy characteristics.

In order to lower the antinutritional activity of serine protease inhibitors, we need to understand their role in seed development.

Proteases, including serine proteases, are involved in the entire life cycle of plants. Proteases are controlled by protease inhibitors (PI) to limit any uncontrolled or harmful protease activity. The role of PIs in biotic and abiotic stress tolerance is well documented, however their role in various other plant processes has not been fully elucidated. Seed development is one such area that lack detailed work on the function of PIs despite the fact that this is a key process in the life cycle of the plant. Serine protease inhibitors (SPI) such as the Bowman-Birk inhibitors and Kunitz-type inhibitors, are abundant in legume seeds and act as antinutrients in humans and animals. Their role in seed development is not fully understood and present an interesting research target. Whether lowering the levels and activity of PIs, in order to lower the anti-nutrient levels in seed will affect the development of viable seed, remains an important question. Studies on the function of SPI in seed development are therefore required. In this Perspective paper, we provide an overview on the current knowledge of seed storage proteins, their degradation as well as on the serine protease-SPI system in seeds and what is known about the consequences when this system is modified. We discuss areas that require investigation. This includes the identification of seed specific SPIs; screening of germplasms, to identify plants with low seed inhibitor content, establishing serine protease-SPI ratios and lastly a focus on molecular techniques that can be used to modify seed SPI activity.

Hybrid 3D-Printed and Electrospun Scaffolds Loaded with Dexamethasone for Soft Tissue Applications.

BACKGROUND: To make the regenerative process more effective and efficient, tissue engineering (TE) strategies have been implemented. Three-dimensional scaffolds (electrospun or 3D-printed), due to their suitable designed architecture, offer the proper location of the position of cells, as well as cell adhesion and the deposition of the extracellular matrix. Moreover, the possibility to guarantee a concomitant release of drugs can promote tissue regeneration. METHODS: A PLA/PCL copolymer was used for the manufacturing of electrospun and hybrid scaffolds (composed of a 3D-printed support coated with electrospun fibers). Dexamethasone was loaded as an anti-inflammatory drug into the electrospun fibers, and the drug release kinetics and scaffold biological behavior were evaluated. RESULTS: The encapsulation efficiency (EE%) was higher than 80%. DXM embedding into the electrospun fibers resulted in a slowed drug release rate, and a slower release was seen in the hybrid scaffolds. The fibers maintained their nanometric dimensions (less than 800 nm) even after deposition on the 3D-printed supports. Cell adhesion and proliferation was favored in the DXM-loading hybrid scaffolds. CONCLUSIONS: The hybrid scaffolds that were developed in this study can be optimized as a versatile platform for soft tissue regeneration.

Evaluation of Pulmonary Vein Fibrosis Following Cryoballoon Ablation of Atrial Fibrillation: A Semi-Automatic MRI Analysis.

Current guidelines recommend the use of cardiac magnetic resonance imaging (MRI) for the management of atrial fibrillation (AF). However, the widespread use of cardiac MRI in clinical practice is difficult to achieve. The aim of the present study is to assess whether cardiac MRI can be adopted to identify ablation-induced fibrosis, and its relationship with AF recurrences. Fifty patients undergoing AF cryoballoon ablation were prospectively enrolled. Cardiac MRI was performed before and 30 days after the index ablation. Commercially available software and a specifically designed image processing workflow were used to quantify left atrium (LA) fibroses. Thirty-six patients were finally included in the analysis; twenty-eight were analyzed with the dedicated workflow. Acute electrical isolation was achieved in 98% of the treated pulmonary veins (PVs). After a median follow-up of 16 months, AF recurrences occurred in 12 patients (33%). In both analyses, no differences were found between the subgroups of patients with and without recurrence in the variation of either LA fibrosis or fibrosis at the ostium of the PV, before and after ablation. The ability to predict arrhythmic recurrences evaluated via the ROC curve of the variations in both LA fibrosis (AUC 0.566) and PV fibrosis (AUC 0.600) was low. Cardiac MRI holds the potential to provide clinically significant information on LA disease and AF progression; however, LA fibrosis cannot be easily identified, either by currently available commercial programs or custom tools.

Elaboration and development of a realistic 3D printed model for training in ultrasound-guided placement of peripheral central venous catheter in children.

BACKGROUND: Simulation for training is becoming a trend topic worldwide, even if its applications are commonly limited to adulthood. Ultrasound-guided procedures require practice and experience-especially in the pediatric field, where the small size of the involved anatomical structures poses major problems. In this context, a realistic 3D printed pediatric phantom for training of the ultrasound-guided placement of peripheral central venous catheters in children was developed. MATERIALS AND METHODS: Starting from Computed Tomography scans of an 8 years-old girl, her left arm was virtually reconstructed-including bones, arteries, and veins-through a semi-automatic segmentation process. According to preliminary results, the most suitable 3D printing technologies to reproduce the different anatomical structures of interest were selected, considering both direct and indirect 3D printing techniques. Experienced operators were asked to evaluate the efficacy of the final model through a dedicated questionnaire. RESULTS: Vessels produced through indirect 3D printing latex dipping technique exhibited the best echogenicity, thickness, and mechanical properties to mimic real children's venous vessels, while arteries-not treated and/or punctured during the procedure-were directly 3D printed through Material Jetting technology. An external mold-mimicking the arm skin-was 3D printed and a silicone-based mixture was poured to reproduce real patient's soft tissues. Twenty expert specialists were asked to perform the final model's validation. The phantom was rated as highly realistic in terms of morphology and functionality for the overall simulation, especially for what concerns vessels and soft tissues' response to puncturing. On the other hand, the involved structures' US appearance showed the lower score. CONCLUSIONS: The present work shows the feasibility of a patient-specific 3D printed phantom for simulation and training in pediatric ultrasound-guided procedures.

Assessment of different manufacturing techniques for the production of bioartificial scaffolds as soft organ transplant substitutes.

Introduction: The problem of organs' shortage for transplantation is widely known: different manufacturing techniques such as Solvent casting, Electrospinning and 3D Printing were considered to produce bioartificial scaffolds for tissue engineering purposes and possible transplantation substitutes. The advantages of manufacturing techniques' combination to develop hybrid scaffolds with increased performing properties was also evaluated. Methods: Scaffolds were produced using poly-L-lactide-co-caprolactone (PLA-PCL) copolymer and characterized for their morphological, biological, and mechanical features. Results: Hybrid scaffolds showed the best properties in terms of viability (>100%) and cell adhesion. Furthermore, their mechanical properties were found to be comparable with the reference values for soft tissues (range 1-10 MPa). Discussion: The created hybrid scaffolds pave the way for the future development of more complex systems capable of supporting, from a morphological, mechanical, and biological standpoint, the physiological needs of the tissues/organs to be transplanted.

Comparison of Two Generations of Thoracic Aortic Stent Grafts and Their Impact on Aortic Stiffness in an Ex Vivo Porcine Model.

Objective: Little is known about the cardiovascular changes after TEVAR and regarding the impact on aortic stiffness for different stent graft generations specifically, following changes in device design. The present study evaluated the stent graft induced aortic stiffening of two generations of the Valiant thoracic aortic stent graft. Methods: This was an ex vivo porcine investigation using an experimental mock circulatory loop. Thoracic aortas of young healthy pigs were harvested and connected to the mock circulatory loop. At a 60 bpm heart rate and stable mean arterial pressure, baseline aortic characteristics were obtained. Pulse wave velocity (PWV) was calculated before and after stent graft deployment. Paired and independent sample t tests or their non-parametric alternatives were performed to test for differences where appropriate. Results: Twenty porcine thoracic aortas were divided into two equal subgroups, in which a Valiant Captivia or a Valiant Navion stent graft was deployed. Both stent grafts were similar in diameter and length. Baseline aortic characteristics did not differ between the subgroups. Mean arterial pressure values did not change after either stent graft, while pulse pressures increased statistically significantly after Captivia (mean 44 ± 10 mmHg to 51 ± 13 mmHg, p = .002) but not after Navion. Mean baseline PWV increased after both Captivia (4.4 ± 0.6 m/s to 4.8 ± 0.7 m/s, p = .007) and Navion (4.6 ± 0.7 m/s to 4.9 ± 0.7 m/s, p = .002). There was no statistically significant difference in the mean percentage increase in PWV for either subgroup (8 ± 4% vs. 6 ± 4%, p = .25). Conclusion: These experimental findings showed no statistically significant difference in the percentage increase of aortic PWV after either stent graft generation and confirm that TEVAR increases aortic PWV. As a surrogate for aortic stiffness, this calls for further improvements in future thoracic aortic stent graft designs regarding device compliance.

Antinutritional factors, nutritional improvement, and future food use of common beans: A perspective.

Common bean seeds are an excellent source of protein as well as of carbohydrates, minerals, vitamins, and bioactive compounds reducing, when in the diet, the risks of diseases. The presence of bioactive compounds with antinutritional properties (e.g., phytic acid, lectins, raffinosaccharides, protease inhibitors) limits, however, the bean's nutritional value and its wider use in food preparations. In the last decades, concerted efforts have been, therefore, made to develop new common bean genotypes with reduced antinutritional compounds by exploiting the natural genetic variability of common bean and also applying induced mutagenesis. However, possible negative, or positive, pleiotropic effects due to these modifications, in terms of plant performance in response to stresses or in the resulting technological properties of the developed mutant genotypes, have yet not been thoroughly investigated. The purpose of the perspective paper is to first highlight the current advances, which have been already made in mutant bean characterization. A view will be further provided on future research directions to specifically explore further advantages and disadvantages of these bean mutants, their potential use in innovative foods and representing a valuable genetic reservoir of combinations to assess the true functional role of specific seed bioactive components directly in the food matrix.

Validation and Verification of High-Fidelity Simulations of Thoracic Stent-Graft Implantation.

Thoracic Endovascular Aortic Repair (TEVAR) is the preferred treatment option for thoracic aortic pathologies and consists of inserting a self-expandable stent-graft into the pathological region to restore the lumen. Computational models play a significant role in procedural planning and must be reliable. For this reason, in this work, high-fidelity Finite Element (FE) simulations are developed to model thoracic stent-grafts. Experimental crimp/release tests are performed to calibrate stent-grafts material parameters. Stent pre-stress is included in the stent-graft model. A new methodology for replicating device insertion and deployment with explicit FE simulations is proposed. To validate this simulation, the stent-graft is experimentally released into a 3D rigid aortic phantom with physiological anatomy and inspected in a computed tomography (CT) scan at different time points during deployment with an ad-hoc set-up. A verification analysis of the adopted modeling features compared to the literature is performed. With the proposed methodology the error with respect to the CT is on average 0.92 ± 0.64%, while it is higher when literature models are adopted (on average 4.77 ± 1.83%). The presented FE tool is versatile and customizable for different commercial devices and applicable to patient-specific analyses.

Photocatalyzed Functionalization of Alkenoic Acids in 3D-Printed Reactors.

The valorization of alkenoic acids possibly deriving from biomass (fumaric and citraconic acids) was carried out through conversion in important building blocks, such as γ-keto acids and succinic acid derivatives. The functionalization was carried out by addition onto the C=C double bond of radicals generated under photocatalyzed conditions from suitable hydrogen donors (mainly aldehydes) and by adopting a decatungstate salt as the photocatalyst. Syntheses were performed under batch (in a glass vessel) and flow (by using 3D-printed reactors) conditions. The design of the latter reactors allowed for an improved yield and productivity.

Customized Cochlear Implant Positioning in a Patient With a Low- Grade Glioma: Towards the Best MRI Artifact Management.

OBJECTIVE: To report the personalized decision-making pro- cess adopted for a cochlear implant (CI) candidate requiring magnetic resonance imaging (MRI) brain surveillance. STUDY DESIGN: Clinical capsule report. SETTING: Tertiary academic referral center. PATIENT: A 23-year-old man affected by posttraumatic bilat- eral profound hearing loss, already in radiological follow-up for a suspected small left cuneal low-grade glioma. INTERVENTIONS: A multidisciplinary approach involving preoperative MRI simulations and 3D printed (3DP) models aiming to adapt the CI position to facilitate MRI brain lesion visibility. MAIN OUTCOME MEASURES: MRI visibility and surgical approach. RESULTS: Preoperative MRI scans with the placement of an Ultra 3D CI were performed simulating different implant location to assess the brain lesion visibility in MRI. CI was positioned 9 cm away from the external auditory canal with an angle of 90 degrees. To assess the technical feasibility of the surgical procedure, a patient-specific 3DP head model was produced preoperatively. The postoperative course was uneventful, the patient showed a significant benefit from CI, and the brain lesion was highly visible at the MRI follow-up. CONCLUSIONS: The employment of strategies aimed at improving the MRI quality in CI recipients still represents a topic requiring attention. Thanks to multidisciplinary team collaboration, in our case, the CI position was successfully determined to allow unhindered MRI visibility of a specific intracranial structure.

Communication and Decision Support Tool for an In-Hospital 3D Printing Service.

BACKGROUND: Effective communication is a key factor in healthcare, essential for improving process efficiency and quality of care. This is particularly true in new services, e.g., the 3D printing service inside the hospital. OBJECTIVES: A web platform, called 3DSCT, has been developed to act as an interface between the three categories of operators involved in 3D printing: physicians, radiologists and engineers. METHODS: The 3DSCT platform has been designed using Microsoft Visual Studio Code, enclosing .js scripts and HTML pages with the relative CSS formats. RESULTS: When applied to a real 3D printing service, the 3DSCT platform provided an effective solution that streamlined the process of designing and manufacturing 3D-printed artifacts, from physician's request through development to printing. CONCLUSION: By incorporating the platform into the hospital management system, it will be possible to reduce the overall lead time and decrease the waste of time for the operators involved in 3D printing inside the hospital.

Design and optimization of 3D-bioprinted scaffold framework based on a new natural polymeric bioink.

OBJECTIVES: This aimed at the design and production of engineered 3D scaffold prototypes using a natural polymeric bioink made of chitosan and poly-γ-glutamic acid with a specific focus on 3D-bioprinting process and on 3D framework geometry. METHODS: Prototypes were produced using a 3D bioprinter exploiting layer-by-layer deposition technology. The 3D scaffold prototypes were fully characterized concerning pore size and size distribution, stability in different experimental conditions, swelling capability, and human dermal fibroblasts viability. KEY FINDINGS: Hexagonal framework combined with biopaper allowed stabilizing the 3-layers structure during process manufacturing and during incubation in cell culture conditions. The stability of 3-layers structure was well preserved for 48 h. Crosslinking percentages of 2-layers and 3-layers prototype were 88.2 and 68.39, respectively. The swelling study showed a controlled swelling capability for 2-layers and 3-layers prototype, ∼5%. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay results showed good biocompatibility of 3-layers prototype and their suitability for preserving 48 h cell viability in 3D cultures. Moreover, a significant increment of absorbance value was measured after 48 h, demonstrating cell growth. CONCLUSIONS: Bioink obtained combining chitosan and poly-γ-glutamic acid represents a good option for 3D bioprinting. A stable 3D structure was realized by layer-by-layer deposition technology; compared with other papers, the present study succeeded in using medical healthcare-grade polymers, no-toxic crosslinker, and solvents according to ICH Topic Q3C (R4).

Three-D-printed simulator for kidney transplantation.

BACKGROUND: Three-Dimensional (3D) printing technology can be used to manufacture training platforms for surgeons. Kidney transplantation offers a suitable model, since it mostly entails vascular and ureteric anastomoses. METHODS: A new simulation platform for surgical training in kidney transplantation was realized and validated in this study. A combination of different 3-D printing technology was used to reproduce the key anatomy of lower abdomen, of pelvis, and of a kidney graft, including their mechanical properties. RESULTS: Thirty transplantations were performed by two junior trainees with no previous experience in the area. Analysis of the times required to perform the simulated transplantation showed that proficiency was reached after about ten cases, as indicated by a flattening of the respective curves that corresponded to a shortening of about 40% and 47%, respectively, of the total time initially needed to perform the whole simulated transplantation. Although an objective assessment of the technical quality of the anastomoses failed to show a significant improvement throughout the study, a growth in self-confidence with the procedure was reported by both trainees. CONCLUSION: The quality of the presented simulation platform aimed at reproducing in the highest possible way a realistic model of the operative setting and proved effective in providing an integrated training environment where technical skills are enhanced together with a team-training experience. As a result the trainees' self-confidence with the procedure resulted enforced. Three-D--printed models can also offer pre-operative patient-specific training when anatomical variants are anticipated by medical imaging. An analysis of the costs related to the use of this platform is also provided and discussed.