Managing plastic packaging waste in emerging economies: The case of EPR in India.

India's large population, rapidly growing economy, and the consequent rising plastic waste, has necessitated the need for an efficient and effective plastic waste management (PWM) system for ensuring an environmentally cleaner and sustainable future. Consequently, PWM policy in India has recently undergone a substantial shift from being an informally organized, largely uncoordinated set of programs towards becoming a formal and integrated system based on the extended producer responsibility (EPR) approach. This paper explicates the evolution, development, implementation, and implications of the Indian EPR framework for PWM by developing an integrative mixed-method case study. Using a theory-based stakeholder evaluation model, the study critically analyzes the drivers and constraining factors from a multi-stakeholder perspective and provides prescriptive suggestions on EPR policy formulation and implementation. It highlights three themes i.e., (a) robust regulatory architecture; (b) operational mechanism; and (c) ecosystem catalysts, whose nature, dynamics, and practicality shall determine the future of the Indian EPR framework and those of comparable emerging economies.

Use of Transesophageal Echocardiogram and Interdisciplinary Approach to Intraoperative Management of Renal Cell Carcinoma With Inferior Vena Cava Invasion.

OBJECTIVE: Report experience of patients undergoing surgery for resection of renal cell carcinoma with inferior vena cava invasion and use of transesophageal echocardiogram (TEE). DESIGN: Retrospective and observational study. SETTING: Single large university hospital. PARTICIPANTS: The study comprised 55 consecutive who underwent resection of renal cell carcinoma. INTERVENTIONS: A transesophageal echocardiogram was performed by cardiac anesthesiologists in high grade tumors. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients had tumor thrombi classified as level III, and 6 patients were classified as level IV. There was increased use of TEE for higher level of tumor thrombi. CONCLUSIONS: The surgical management of renal cell carcinoma with inferior vena cava tumor extension is complex. High-grade tumors require individualized treatment. Successful outcomes require collaboration between surgeons and anesthesiologists. Patients with level IIIb to IV tumor invasion benefit from TEE assessment and monitoring, which may be life-saving, and cardiac anesthesia should be involved in those types of cases.

Patient Selection and Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed with Monitored Anesthesia Care Versus General Anesthesia.

OBJECTIVE: The aim of this study was to compare outcomes of monitored anesthesia care (MAC) versus general anesthesia (GA) for transfemoral transcatheter aortic valve replacement (TF-TAVR) and to describe a selection process for the administration of MAC. DESIGN: Retrospective analysis of patients who underwent TF-TAVR under MAC or GA. SETTING: Department of Cardiac Anesthesia, Albany Medical Center, a tertiary university hospital. PARTICIPANTS: Patients selected for TF-TAVR. INTERVENTIONS: Patients were divided into those who underwent MAC and those who underwent GA. MEASUREMENTS AND MAIN RESULTS: The study comprised 104 consecutive patients (55% male, mean age 83 years) who underwent TF-TAVR under MAC (n = 60) or GA (n = 37) from 2014 to 2015. Seven patients were converted from MAC to GA and were omitted from analysis. There was no statistically significant difference between 30-day mortality and complications between the 2 groups. The MAC group had a significantly shorter median intensive care unit length of stay (48 h v 74 h, p = 0.0002). The MAC group also demonstrated reduced procedural time (45.5 min v 62 min, p = 0.003); operating room time (111 min v 153 min, p = <0.001); and fluoroscopy time (650 s v 690 s, p = 0.03). CONCLUSIONS: Patient selection for TF-TAVR with MAC can be formalized and implemented successfully. MAC allows for the minimizing of patient exposure to unnecessary interventions and improving resource utilization in suitable TAVR patients. Selection requires a multidisciplinary clinical decision-making process. MAC demonstrates good outcomes compared with GA, yet it is important to have a cardiac anesthesiologist present in the event of emergency conversion to GA.

Primary cardiac sarcoma presenting with easy bruising: a case report.

Background: Primary cardiac sarcomas are rare, aggressive types of malignancies with poor prognoses and can rarely present with thrombocytopenia. Sarcomas account for 65% of primary malignant cardiac tumours. Clinical symptoms often present with constitutional symptoms such as shortness of breath, weight loss, and fatigue. In addition, the tumour's location determines treatment options and prognosis. Multimodal imaging facilitates the detection and assessment of cardiovascular tumours. This case study presents a rare primary right heart cardiac sarcoma presenting with thrombocytopenia. Case summary: An 80-year-old male presented to the emergency department with complaints of worsening dyspnoea, ease of bruising, and chest pain. An extensive investigation into the cause of thrombocytopenia was performed. A transthoracic echocardiogram, computed tomography scan, and cardiac magnetic resonance (CMR) image revealed a large mass affecting the right atrium and right ventricle. Myocardial biopsy showed high-grade angiosarcoma. Due to his advanced age and intraventricular septal involvement of the mass, the multidisciplinary team decided to proceed with palliative chemotherapy. Discussion: Many cardiac tumours remain asymptomatic, and the diagnosis is made at an advanced stage of the disease. Differential diagnoses of the intramural masses include haemangiomas, lipomas, rhabdomyomas, lymphomas, and sarcomas. Multiple treatment options should be considered to address thrombocytopenia. Tumour diagnosis and identification consist of laboratory tests and multimodal imaging. Complete surgical resection with neoadjuvant and adjuvant purposes is the mainstay of cardiac sarcoma therapy. A multidisciplinary, individualized care approach should be performed.

Cardiac device-induced right to left shunt causing significant hypoxemia: A case report and review of literature.

We describe a patient where a pacemaker lead induced tricuspid valve changes that caused a right to left shunt through a preexisting patent foramen ovale resulting in significant hypoxemia. This event occurred years after the pacemaker had been placed. Surgical closure of the patent foramen ovale resolved the patient's hypoxemia and dyspnea. We also reviewed the previous cases published in the medical literature concerning significant hypoxemia from cardiac device-induced right to left shunts. Three of the four reported cased occurred 4 or more years after device placement. Therefore, late onset hypoxemia in setting of cardiac device placement without an alternative cause should raise the possibility of this complication.

Acute Right Ventricular Failure Postintubation in a Mitral Stenosis Patient.

Mitral stenosis (MS) is prevalent in 0.02-0.2% of the population in developed countries. The pathophysiology of MS results in elevated left atrial pressures and over-time results in pulmonary hypertension (HTN) which ultimately affects the right ventricle. In addition, MS restricts the diastolic filling of the left ventricle. Therefore, during induction patients with MS are limited by their ability to increase cardiac output by increasing stroke volume. Anesthesia goals in severe MS are to avoid sudden changes in heart rate, as well as systemic and pulmonary artery pressures. We report a patient who sustained severe hypotension upon induction and intubation which was resistant to conventional medications. Intraoperative transesophageal echocardiography displayed unique right atrial and right ventricular dilatation. In addition, the leftward inter-ventricular, inter-atrial septal shift and septal bounce were noted as the characteristic findings. Intravenous epinephrine bolus was administered to achieve normo-tension and normal chamber dimensions and interventricular septal position.