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

Instrumentation and probes for molecular and cellular imaging

Molecular and cellular imaging is a branch of biomedical sciences that combines the use of imaging instrumentation and biotechnology to characterize molecular and cellular processes in living organisms in normal and pathologic conditions. The two merging areas of research behind molecular and cellular imaging are detection technology, i.e. scanners and imaging devices, and development of tracers, contrast agents and reporter probes that make imaging with scanners and devices possible. Several in vivo imaging instruments currently used in human studies, such as computer tomography, ultrasound, magnetic resonance, positron emission tomography and single photon emission computed tomography, have been rescaled for small animal studies, while other methods initially used for in vitro evaluation, such as bioluminescence and fluorescence, have been refined for in vivo imaging. Conventional imaging relies on the use of non specific contrast agents and classical probes; however, newly developed targeted contrast agents and activable ''smart'' imaging probes for so-called ''targeted imaging'' have demonstrated high specificity and high signal to noise ratio in small animal studies. This review focuses on basic recent findings in the technical aspects of molecular and cellular imaging modalities (equipment, targeted probe and contrast agents and applied combinations of instrumentation and probe) with particular attention to the choice of the future: the multimodal imaging approach

Quality control on radiochemical purity in Technetium-99m radiopharmaceuticals labelling: three years of experience on 2280 procedures

Objective: the purpose of this study was to offer an example of evaluations of the ISO9001 certified internal quality assurance (QA) system of99mTc-radiopharmaceutical preparations and quality control in vivo use, using industrial kits and generators in order to identify possible sources of errors in the procedures labeling and quality control procedures. Methods: The study was performed at a single institution over a period of three years (July 1st, 2011 - July 1st, 2014), and included a total of 2280 radiopharmaceutical preparations prepared by four different technologists. All the radiopharmaceutical preparations and quality controls were performed according to each SPC provided by the manufacturer. The radiopharmaceutical preparations were the following (trade names are reported in brackets):99mTc-albumin colloid [Nanocoll] (n=349),99mTc-oxidronate [Technescan\uaehdp] (n=701),99mTc-exametazime [Ceretec] (n=169),99mTc-sestamibi [Cardiolite] (n=92),99mTc-albumin aggregated [Technescan\uaelyomaa] (n=140),99mTc-tetrofosmin [Myoview]) (n=567),99mTc-diethylene triamine pentacetic acid [Technescan\uaedtpa] (n=254), and99mTc-dimercapto succinic acid [Renocis\uae] (n=8). Data were analyzed to determine the number and type of radiopharmaceutical labelling failure and to derive the sources of these failures to define corrective actions and optimize the quality assurance program. Results: A total of 2280 procedures were performed and recorded. Following the quality control procedure six out of the 2280 preparations (0.26%) were non-conforming for clinical use with the RCP limits indicated in the SPC. Five of these were due to gross technical errors in measurements and manual procedures and were immediately repeated, returning within the limits of acceptability. The sixth failure was due to short incubation time, though compliant with the manufacturer\u2019s instructions. Conclusions: We concluded that the quality of the final product depends on a controlled production system based on the implementation of specific standard operating procedures (ISO9001, SOP) for each radiopharmaceutical production, according to strict adherence to the SPC of each radiopharmaceutical. Based on these conclusions, in our opinion every quality control suggesting a possible error in the synthesis procedure recommended in the SPC should be immediately reported to the manufacturer, for a revision of the SPC, as well as to the regulatory agencies for an alert. This strategy may in fact allow the continuous improvement of the labelling procedures and therefore the optimization of the quality control procedures frequency to ensure both patients safety and a more rational management of resources for economic sustainability

Technical and methodological issues in preclinical imaging with PET and SPECT

Small-animal positron emission tomography (PET) and single photon emission tomography (SPECT) are invaluable tools in drug discovery and in assessing novel therapeutic agents. In a typical small-animal PET or SPECT imaging session, a radiopharmaceutical is administered and the kinetics of its distribution tracked. Whereas the PET and SPECT protocols for the radiotraceras used in clinical practice are well established, at least for the radiotracers that are used in clinical practice, the acquisition, reconstruction and data analysis procedures applied in small rodents are heterogeneous among centres, often being determined by the scanner characteristics and by the animal models and anaesthesia procedures used in the laboratory. This review, intended to serve as a guide to preclinical PET and SPECT experiments, aims to familiarise the reader with the aspects of PET and SPECT that pertain to in vivo preclinical acquisitions and, in particular, with the technical and methodological know-how that is needed for better application of radionuclide imaging techniques in preclinical cancer research

Individual cerebral metabolic deficits in Alzheimer's disease and anmestic mild cognitive impairment : an FDG PET study

Purpose The purpose of the study was the identification of group and individual subject patterns of cerebral glucose metabolism (CMRGlu) in patients with Alzheimer’s disease (AD) and with amnestic mild cognitive impairment (aMCI). Methods [18F]fluorodeoxyglucose positron emission tomography (PET) studies and neuropsychological tests were performed in 16 aMCI patients (ten women, age 75 ± 8 years) and in 14 AD patients (ten women, age 75 ± 9 years). Comparisons between patient subgroups and with a control population were performed using Statistical Parametric Mapping. Results Clusters of low CMRGlu were observed bilaterally in the posterior cingulate cortex (PCC), in the precuneus, in the inferior parietal lobule and middle temporal gyrus of AD patients. In aMCI patients, reduced CMRGlu was found only in PCC. Areas of low CMRGlu in PCC were wider in AD compared to aMCI and extended to the precuneus, while low CMRGlu was found in the lateral parietal cortex in AD but not in aMCI patients. Individual subject pattern analysis revealed that 86% of AD patients had low CMRGlu in the PCC (including the precuneus in 71%), 71% in the temporal cortex, 64% in the parietal cortex and 35% in the frontal cortex. Among the aMCI patients, 56% had low CMRGlu in the PCC, 44% in the temporal cortex, 18% in the frontal cortex and none in the parietal cortex. Conclusion This study demonstrates that both AD and aMCI patients have highly heterogeneous metabolic impairment. This potential of individual metabolic PET imaging in patients with AD and aMCI may allow timely identification of brain damage on individual basis and possibly help planning tailored early interventions

Labelled leukocytes for diagnosis of infectious diseases. Our experience in labelling and clinical usefulness

Background: To review our experience in infectious diseases diagnosis, using a simple labelling technique.\ua0Methods: We made 101 scans in 91 patients with suspected infectious diseases confirmed by clinical, histologic or cultural specimens; a clinical or instrumental follow-up was available for every patient. Patients were divided into four subgroups: A: Inflammatory Bowel Diseases; B: Septic Syndromes; C: Bone diseases; D: Others. We used 99mTc-HMPAO in 80 scans and 111In in 21.In 20/80 frozen and stored HMPAO was used. Results: 99mTc-HMPAO frozen and stored labelling yield was: 60%(SD15%), 99mTcHMPAO: 62(12)(p n.s.), 111In 75%(10%), (p<0.05). Frozen-stored HMPAO was sterile and apyrogen. 27 had positive scan without leukocytosis or neutrophilia. No correlation between leukocytosis or neutrophilia and yield was observed. Transit lung times ranged between 14-16 min without differences among three radiopharmaceuticals. In each Group and in the sample as a whole True Positive, False Positive, True Negative, False Negative, Sensitivity, Specificity and Accuracy, were calculated. In Group B and in the sample as a whole Predictive Positive Value and Negative Predictive Value were also evaluated.\ua0 Conclusions: Labelling yields and ''viability'' were good using the three radiopharmaceuticals; labelling procedure was simple and safe. Accuracy PPV, NPV, cost-effectiveness were good; 111In is the choice for diagnosis of bone and joint infections. Frozen-stored HMPAO should be introduced as a cost-saving labelling procedure in practice