Transitioning to sustainable, climate-resilient healthcare: insights from a health service staff survey in Australia.

BACKGROUND: More than 80 countries, including Australia, have made commitments to deliver climate-resilient and low carbon healthcare. Understanding how healthcare workers view their own and their organization's efforts to achieve sustainable and climate-resilient healthcare practice is vital to inform strategies to accelerate that transition. METHODS: We conducted an online staff survey in a large state government hospital-and-health-service organisation in Queensland, Australia, to ascertain attitudes and practices towards environmentally sustainable, climate-resilient healthcare, and views about the organizational support necessary to achieve these goals in their workplace. RESULTS: From 301 participants showed staff strongly support implementing sustainable and climate-resilient healthcare but require significantly more organizational support. Participants identified three categories of organizational support as necessary for the transition to environmentally sustainable and climate-resilient health services and systems: (1) practical support to make sustainability easier in the workplace (e.g. waste, energy, water, procurement, food, transport etc.); (2) training and education to equip them for 21st century planetary health challenges; and (3) embedding sustainability as 'business as usual' in healthcare culture and systems. CONCLUSIONS: The research provides new insight into health workforce views on how organizations should support them to realize climate and sustainability goals. This research has implications for those planning, managing, implementing, and educating for, the transition to environmentally sustainable and climate-resilient health services and systems in Queensland, Australia, and in similar health systems internationally.

Expanding the Geographic Boundaries of Melioidosis in Queensland, Australia.

Melioidosis is an infectious disease caused by the bacterium Burkholderia pseudomallei. Although this environmental organism is endemic in certain regions of Australia, it is not considered endemic in Southern Queensland, where the last case was reported 21 years ago. We report a climate change-associated outbreak of melioidosis occurring during two La Niña events in a region previously considered nonendemic for B. pseudomallei. During a 15-month period, 14 cases of locally acquired melioidosis were identified. Twelve patients were adults (> 50 years), with diabetes mellitus the most common risk factor in 6 of 12 patients (50%). Eleven patients (79%) had direct exposure to floodwaters or the flooded environment. This study suggests an association between climate change and an increased incidence of melioidosis. In addition, this is the first report of environmental sampling and whole-genome analysis to prove endemicity and local acquisition in this region.

The effect of hyperthyroidism at thyroidectomy on complication rates in children with Graves' disease.

BACKGROUND: Graves' disease (GD) is the most common cause of childhood hyperthyroidism. Surgery is often chosen as a treatment modality given the high relapse rates and side effects of antithyroid drugs and has shown to be safe and efficacious. The goal of our study was to evaluate whether hyperthyroidism at time of thyroidectomy is associated with higher intra and postoperative complication rates. METHODS: A retrospective cohort study of children who underwent thyroidectomy for GD by high-volume pediatric otolaryngologists between 2014 and 2021. RESULTS: 64 patients met inclusion criteria. Patients with hyperthyroidism (defined as free T4≥1.63 ng/dL) were more likely to be treated with beta-blocker preoperatively compared to the euthyroid group (20/24 patients (83%) vs 23/40 patients (58%) respectively, p = 0.035). Twenty (83%) patients with hyperthyroidism and 39 euthyroid patients (98%) were treated with methimazole prior to surgery. Intraoperative tachycardia was noted in 5% of euthyroid patients and 20.8% of patients with hyperthyroidism. The mean peak heart rate intra-operatively and the number of patients with heart rate ≥120bmp were significantly higher for patients with hyperthyroidism (96.5 ± 16.2 vs 87.6 ± 22.1bpm, p = 0.02). Two patients required administration of esmolol during surgery for heart rate control, both with hyperthyroidism. Intra-operative peak systolic blood pressure, operative time, estimated blood loss, persistent hypocalcemia, length of admission and recurrent laryngeal nerve paralysis rates were similar among groups. CONCLUSIONS: Hyperthyroidism at surgery is associated with increased heart rate intraoperatively, with no increased risk for other complications. While optimizing thyroid hormone levels before surgery should be pursued in all children, our data suggest that hyperthyroidism should not delay the surgery.

The design of the perfect pediatric supraglottic airway device.

The design evolution of the pediatric supraglottic airway device has experienced a long and productive journey. We have a wealth of clinical studies to support progress and advancements in pediatric clinical practice. While all of the  supraglottic airway devices have been used successfully in millions of children, it is important to be aware of design advantages and disadvantages of the different models of  supraglottic airway devices. Current pediatric supraglottic airway devices may be improved in design to be more ideal. Industry-changing technological advancements are likely to occur in the near future, which may further improve clinical performance of these devices.

Focused review on management of the difficult paediatric airway.

Management of the difficult paediatric airway management may be associated with a high rate of complications. It is important that clinicians understand the patient profiles associated with difficult airway management, and the equipment and techniques available to effectively manage these children. The goal of this focused review is to highlight key airway management concepts when managing the paediatric difficult airway. This includes understanding the advantages and limitations of various airway equipment designed for children and reviewing the difficult airway algorithm with its unique considerations for the paediatric patient. Early recognition of known risk factors and thorough preparation may be helpful in reducing the risk of complications during difficult airway management in children.

Longitudinal wall fractional shortening: an M-mode index based on mitral annular plane systolic excursion (MAPSE) that correlates and predicts left ventricular longitudinal strain (LVLS) in intensive care patients.

BACKGROUND: Left ventricular longitudinal strain (LVLS) is a modern measurement for LV function. However, strain measurement is often difficult in critically ill patients. We sought to show LVLS can be estimated using M-mode-derived longitudinal wall fractional shortening (LWFS), which is less dependent on image quality and is easier to perform in critically ill patients. METHODS: Transthoracic echocardiographic records were retrospectively screened and 80 studies suitable for strain and M-mode measurements in the apical 4-chamber view were selected. Longitudinal wall fractional shortening was derived from conventional M-mode (LWFS) and curved anatomical M-mode (CAMMFS). The relationships between LVLS and mitral annular plane systolic excusion (MAPSE) and M-mode-derived fractional shortening were examined using univariate generalized linear model in a training set (n = 50) and was validated in a separate validation set (n = 30). RESULTS: MAPSE, CAMMFS, and LWFS demonstrated very good correlations with LVLS (r = 0.852, 0.875 and 0.909, respectively). LWFS was the best unbiased predictor for LVLS (LVLS = 1.180 x LWFS - 0.737, P < 0.001). Intra- and inter-rater agreement and reliability for LWFS measurement were good. CONCLUSIONS: LVLS can be estimated by LWFS in the critically ill patients. It provides a fast and accurate prediction of LVLS. LWFS is a reproducible and reliable measurement which can be used as a potential index in place of LVLS in the critically ill population.

Advances in supraglottic airway devices for the management of difficult airways in children.

There are innumerable tools and devices available to facilitate airway management and life-saving gas exchange of the patient's lungs. Over the years, various designs and generations of supraglottic airway devices have proven to be effective in accomplishing this function. Their application has grown beyond the original purpose of controlling the normal pediatric airway without tracheal intubation, and has been incorporated in the difficult airway management algorithms of anesthesia societies around the world based on clear evidence of efficacy. Older supraglottic airway devices since the 1980's have been validated in multiple clinical trials to be safe and effective in the pediatric population, however there is also sufficient evidence that the newer designs have features that help overcome some limitations. These newer designs and features are effective in managing both the normal and difficult pediatric airway, and will be discussed in this comprehensive review.

A randomized comparison between the i-gel™ and the air-Q™ supraglottic airways when used by anesthesiology trainees as conduits for tracheal intubation in children.

PURPOSE: Supraglottic airways are commonly used as conduits for fibreoptic bronchoscopy (FOB)-guided intubation in pediatric patients. We hypothesized that anesthesiology trainees with limited prior experience with FOB-guided intubation through a supraglottic airway in children would intubate the trachea faster through the air-Q™ supraglottic airway than through the i-gel™. METHODS: Ninety-six children aged one month to six years were randomized to receive either the i-gel or air-Q for FOB-guided tracheal intubation by anesthesiology trainees. Time for successful tracheal intubation was the primary endpoint. Secondary endpoints included: time for device insertion, number of attempts for successful device insertion, airway leak pressures, FOB grade of laryngeal view, total number of attempts for tracheal intubation, time for removal of the device after tracheal intubation, and associated complications. RESULTS: The median (interquartile range [IQR]) times to successful tracheal intubation for the air-Q (62.5 [47.9-77] sec) and the i-gel (55.9 [48.5-81.8] sec) were not significantly different (median difference 6.6 sec; 95% confidence interval [CI] -13.3 to 8.7; P = 0.53). The median (IQR) time to insertion for the air-Q (16.7 [14.4-20.0] sec) was shorter than for the i-gel (19.6 [16.7-23.0] sec) (median difference 2.9 sec; 95% CI 0.8 to 4.7; P = 0.005). There were no differences between devices with respect to airway leak pressures, success rates, and time to removal. Compared with the air-Q, the i-gel was associated with more problems during device removal after tracheal intubation, including breakage of the tracheal tube pilot balloon (n = 0 vs n = 13, respectively; P < 0.001), inadvertent extubation (n = 1 vs n = 5, respectively; P < 0.001), and difficulty controlling the tracheal tube (n = 0 vs n = 21, respectively; P < 0.001). CONCLUSIONS: Contrary to our hypothesis, both the air-Q and i-gel supraglottic airways served as effective conduits for FOB-guided tracheal intubation in children when performed by trainees with limited prior experience. The i-gel, however, was associated with more problems during device removal following tracheal intubation. This study was registered at http://clinicaltrials.gov/show/NCT02189590 .

A comparison of myocardial perfusion and rejection in cardiac transplant patients.

INTRODUCTION: Although histological evaluation of the cardiac tissue is the current gold standard for evaluation of rejection, we hypothesized that cardiac perfusion MRI is a safe non-invasive method that correlates tissue blood flow changes with biopsy proven rejection in the cardiac transplant patient. MATERIALS AND METHODS: In a retrospective study from 1984-2001, 83 patients underwent 135 MR Gd-DTPA imaging studies. In 8 patients (9%), biopsies graded 2 or higher (by ISHLT criteria) provided evidence of rejection. Patients were age and sex matched to 11 non-rejected controls for imaging analysis. Time-signal intensity curves generated for a mid-ventricle LV short axis slice during rest and adenosine stress allowed determination of myocardial blood flow (MBF, ml/min/gm). ROC curve analysis by SPSS allowed estimation of sensitivity and specificity. RESULTS: At rest, there was no difference in MBF between patients with prior rejection vs. those without (1.18 +/- 0.26 vs. 1.16 +/- 0.29). At stress there was a decrease in MBF for patients with prior rejection episodes (3.27 +/- 0.74) compared to no rejection (3.60 +/- 0.72), P = 0.067). The area under the ROC curve was 0.82, with specificity and sensitivity of 75% and 81%, respectively. CONCLUSION: This study suggests that perfusion MR imaging can be used in assessing the cardiac transplant patient for rejection related microvascular changes. The high specificity and sensitivity recorded from the ROC curve illustrates the potential utility of this diagnostic test for future studies.