Reducing contrast agent residuals in hospital wastewater: the GREENWATER study protocol

Sustainable radiology departments: A European survey to explore radiographers' perceptions of environmental and energy sustainability issues

INTRODUCTION

The environmental impact of radiology and radiotherapy activities is influenced by the energy consumption of equipment, the life cycle of consumables, waste generation, and CO2 emissions caused by staff travel. This study aims to investigate radiographers' perception and knowledge of environmental sustainability issues.

METHODS

An online survey was created and distributed to European radiographers and therapeutic radiographers. The survey questions (n = 43) include demographic data; questions on their perceptions and actions regarding environmental sustainability in healthcare, energy consumption, emissions from staff travel, waste generation from radiological procedures; the role of radiographers in addressing sustainability issues within their departments.

RESULTS

A total of 253 responses were collected from 27 European countries. About their perception on sustainability issues, most participants considered environmental sustainability in healthcare as very important. According to 63.6% (n = 161) of respondents, the energy consumption of radiological equipment is the major source of environmental footprints from radiology activities. Additionally, 44.7% (n = 113) believe that conducting diagnostic examinations remotely could reduce environmental footprints from staff commuting About their actions at workplace, over 70% (n = 192) reported turning off devices after use. Attention to waste recycling is high, but limited to paper, plastic and glass. Contrast agents recycling procedures are implemented by 13% (n = 33). The absence or unawareness of environmental sustainability procedures in the workplace was reported by 66% (n = 167). Radiographers could play an active role in environmental sustainability programs for 243 (96.1%) participants.

CONCLUSION

This study provides a comprehensive overview of European radiographers' knowledge and perceptions concerning environmental sustainability issues. While radiographers recognize the importance of a green radiology department, significant gaps remain in their understanding of eco-friendly initiatives in radiology units' activities.

IMPLICATION FOR PRACTICE

Enhancing radiographers' skills with sustainability expertise could promote a greener culture within radiology departments.

Iodinated contrast media waste management in hospitals in central Norway

INTRODUCTION

The demand for iodine has increased in the last years, among other factors due to increased medical use. There is no consensus regarding iodinated contrast media (ICM)'s damaging impact on the environment and therefore the producers encourage collecting and recycling ICM waste. The aim of the study was to investigate the ICM waste management in hospitals in Central Norway and to explore the radiographers' attitudes regarding ICM recycling and possible causes of suboptimal waste management.

METHODS

The link to the electronic survey was sent to all radiographers working with computed tomography within the Central Norway Regional Health Authority. Descriptive and inferential statistics were performed.

RESULTS

Results reported from 100 radiographers from eight hospitals show that ICM leftovers are recycled or reused in most cases (26% collect them for recycling and 38% use them for oral administration) while 25% send them to the pharmacy together with other pharmaceutical waste and 8% discard them in the sink or the garbage bin. 25% reported that they are not familiar with their department's procedures related to ICM waste. 84% were concerned about the consequences of ICM waste for the environment.

CONCLUSION

There were considerable differences in the management of ICM waste amongst the hospitals and also internally within the hospitals. Improper practices, likely caused by lack of disposal plans and/or suboptimal information flow, were reported to a low extent.

IMPLICATIONS FOR PRACTICE

Local ICM waste management guidelines which are easily available for radiographers may increase both reuse and recycle rates. Including ICM waste management in the educational curriculum for radiographers can provide early understanding of the rationale behind the procedures and their environmental impact.

More sustainable use of iodinated contrast media - Why?

OBJECTIVES

Based on a narrative review of the literature to 1) assess the need for and 2) report methods to help deliver a sustainable approach to iodinated contrast media (ICM) administration.

KEY FINDINGS

Acute ICM shortages have been noted in the literature. As demand for contrast-enhanced imaging continues to increase and access to raw materials becomes more limited, such events may increase. Evidence from the literature has documented a range of iodinated contrast reduction strategies. These include individualised contrast-media dosing, multi-dose bulk ICM vials, switching to alternative modalities or the increased use of non-contrast examinations. The optimisation of imaging parameters, the use of saline chasers, and alternative contrast agents should be further considered. Given the rising concerns regarding the presence and effects of ICMs in waste and drinking water, further consideration of strategies for managing waste and excreted ICMs are starting to emerge.

CONCLUSIONS

Sustainable ICM practices are needed to help avoid supply shortages and to help protect our environment. Such practices must be led and supported locally, nationally, and internationally. Sustainable ICM practices must be reflected within professional Standards of Proficiencies and be adopted by all members of the multidisciplinary team.

IMPLICATIONS FOR PRACTICE

Changes to working practices surrounding the sustainable use of ICMs will likely become commonplace. New methods to ensure optimised ICM dosage with minimal wastage will be more heavily featured in departmental practices. Correct disposal of waste and excreted ICMs will also form part of future changes to practice.

Anthropogenic gadolinium in the Tone River (Japan): an update showing a 7.7-fold increase from 1996 to 2020

BACKGROUND

Anthropogenic gadolinium (Gd), originating from Gd-based contrast agents (GBCAs) used in magnetic resonance imaging (MRI), is widely identified in the aquatic environment with concerns about toxicity and accumulation. We aimed to present new data on anthropogenic Gd in the Tone River, which has the largest drainage area in Japan, and then to compare the current data with those obtained in 1996.

METHODS

The water samples were collected on August 9-10, 2020, at 15 different locations of the Tone River in Japan. The concentrations of the rare earth elements (REEs) were measured by inductively coupled plasma-mass spectrometry and normalized to Post-Archean Australian Shale to construct shale-normalized REE patterns. The degree of Gd-anomaly was defined as the percentage of anthropogenic Gd to the geogenic background and used to compare the water samples from different locations. Pearson's correlation coefficients were calculated.

RESULTS

All the samples displayed positive Gd anomalies. The Gd-anomaly ranged from 121 to 6,545% and displayed a repeating decrease-and-increase trend. The Gd-anomaly showed strong positive correlations to the number of hospitals (r = 0.88; p < 0.001) and their MRI units (r = 0.89; p < 0.001).

CONCLUSIONS

Our study revealed notable anomalies of Gd concentrations in river water in Japan, with strong positive correlations to the number of major hospitals and their MRI units. Compared with the previous report in 2000, the Gd-anomaly in Tone River increased from 851% (sampled in 1996) to 6,545%, i.e., 7.7 times, reflecting the increased use of GBCAs in hospitals.

RELEVANCE STATEMENT

Notable Gd concentration anomalies in river water in Japan were observed. This result underlines the importance of more extensive research on anthropogenic gadolinium, and investigations of risks to human health as well as the development of effective removal technologies may be necessary.

KEY POINTS

• All water samples from Tone River displayed positive Gd anomalies. • The Gd anomalies increased to 7.7 times higher over the past 24 years. • Correlations between Gd values and the number of hospitals and MRI units were observed.

Go Green in Neuroradiology: towards reducing the environmental impact of its practice

Raising public awareness about the relevance of supporting sustainable practices is required owing to the phenomena of global warming caused by the rising production of greenhouse gases. The healthcare sector generates a relevant proportion of the total carbon emissions in developed countries, and radiology is estimated to be a major contributor to this carbon footprint. Neuroradiology markedly contributes to this negative environmental effect, as this radiological subspecialty generates a high proportion of diagnostic and interventional imaging procedures, the majority of them requiring high energy-intensive equipment. Therefore, neuroradiologists and neuroradiological departments are especially responsible for implementing decisions and initiatives able to reduce the unfavourable environmental effects of their activities, by focusing on four strategic pillars-reducing energy, water, and helium use; properly recycling and/or disposing of waste and residues (including contrast media); encouraging environmentally friendly behaviour; and reducing the effects of ionizing radiation on the environment. The purpose of this article is to alert neuroradiologists about their environmental responsibilities and to analyse the most productive strategic axes, goals, and lines of action that contribute to reducing the environmental impact associated with their professional activities.

The environmental impact of energy consumption and carbon emissions in radiology departments: a systematic review

OBJECTIVES

Energy consumption and carbon emissions from medical equipment like CT/MRI scanners and workstations contribute to the environmental impact of healthcare facilities. The aim of this systematic review was to identify all strategies to reduce energy use and carbon emissions in radiology.

METHODS

In June 2023, a systematic review (Medline/Embase/Web of Science) was performed to search original articles on environmental sustainability in radiology. The extracted data include environmental sustainability topics (e.g., energy consumption, carbon footprint) and radiological devices involved. Sustainable actions and environmental impact in radiology settings were analyzed. Study quality was assessed using the QualSyst tool.

RESULTS

From 918 retrieved articles, 16 met the inclusion criteria. Among them, main topics were energy consumption (10/16, 62.5%), life-cycle assessment (4/16, 25.0%), and carbon footprint (2/16, 12.5%). Eleven studies reported that 40-91% of the energy consumed by radiological devices can be defined as "nonproductive" (devices "on" but not working). Turning-off devices during idle periods 9/16 (56.2%) and implementing workflow informatic tools (2/16, 12.5%) were the sustainable actions identified. Energy-saving strategies were reported in 8/16 articles (50%), estimating annual savings of thousand kilowatt-hours (14,180-171,000 kWh). Cost-savings were identified in 7/16 (43.7%) articles, ranging from US $9,225 to 14,328 per device. Study quality was over or equal the 80% of high-quality level in 14/16 (87.5%) articles.

CONCLUSION

Energy consumption and environmental sustainability in radiology received attention in literature. Sustainable actions include turning-off radiological devices during idle periods, favoring the most energy-efficient imaging devices, and educating radiological staff on energy-saving practices, without compromising service quality.

RELEVANCE STATEMENT

A non-negligible number of articles - mainly coming from North America and Europe - highlighted the need for energy-saving strategies, attention to equipment life-cycle assessment, and carbon footprint reduction in radiology, with a potential for cost-saving outcome.

KEY POINTS

• Energy consumption and environmental sustainability in radiology received attention in the literature (16 articles published from 2010 to 2023). • A substantial portion (40-91%) of the energy consumed by radiological devices was classified as "non-productive" (devices "on" but not working). • Sustainable action such as shutting down devices during idle periods was identified, with potential annual energy savings ranging from 14,180 to 171,000 kWh.

Review of strategies to reduce the contamination of the water environment by gadolinium-based contrast agents

Gadolinium-based contrast agents (GBCA) are essential for diagnostic MRI examinations. GBCA are only used in small quantities on a per-patient basis; however, the acquisition of contrast-enhanced MRI examinations worldwide results in the use of many thousands of litres of GBCA per year. Data shows that these GBCA are present in sewage water, surface water, and drinking water in many regions of the world. Therefore, there is growing concern regarding the environmental impact of GBCA because of their ubiquitous presence in the aquatic environment. To address the problem of GBCA in the water system as a whole, collaboration is necessary between all stakeholders, including the producers of GBCA, medical professionals and importantly, the consumers of drinking water, i.e. the patients. This paper aims to make healthcare professionals aware of the opportunity to take the lead in making informed decisions about the use of GBCA and provides an overview of the different options for action.In this paper, we first provide a summary on the metabolism and clinical use of GBCA, then the environmental fate and observations of GBCA, followed by measures to reduce the use of GBCA. The environmental impact of GBCA can be reduced by (1) measures focusing on the application of GBCA by means of weight-based contrast volume reduction, GBCA with higher relaxivity per mmol of Gd, contrast-enhancing sequences, and post-processing; and (2) measures that reduce the waste of GBCA, including the use of bulk packaging and collecting residues of GBCA at the point of application.Critical relevance statement This review aims to make healthcare professionals aware of the environmental impact of GBCA and the opportunity for them to take the lead in making informed decisions about GBCA use and the different options to reduce its environmental burden.Key points• Gadolinium-based contrast agents are found in sources of drinking water and constitute an environmental risk.• Radiologists have a wide spectrum of options to reduce GBCA use without compromising diagnostic quality.• Radiology can become more sustainable by adopting such measures in clinical practice.

Occurrence of iodinated contrast media (ICM) in water environments and their control strategies with a particular focus on iodinated by-products formation: A comprehensive review

Iodinated contrast media (ICM), one of the pharmaceutical and personal care products (PPCPs), are frequently detected in various water bodies due to the strong biochemical stability and recalcitrance to conventional water treatment. Additionally, ICM pose a risk of forming iodinated by-products that can be detrimental to the aquatic ecosystem. Consequently, effectively removing ICM from aqueous environments is a significant concern for environmental researchers. This article provides a comprehensive review of the structural characteristics of ICM, their primary source (e.g., domestic and hospital wastewater), detected concentrations in water environments, and ecological health hazards associated with them. The current wastewater treatment technologies for ICM control are also reviewed in detail with the aim of providing a reference for future research. Prior researches have demonstrated that traditional treatment processes (such as physical adsorption, biochemical method and chemical oxidation method) have inadequate efficiencies in the removal of ICM. Currently, the application of advanced oxidation processes to remove ICM has become extensive, but there are some issues like poor deiodination efficiency and the risk of forming toxic intermediates or iodinated by-products. Conversely, reduction technologies have a high deiodination rate, enabling the targeted removal of ICM. But the subsequent treatment issues related to iodine (such as I- and OI-) are often underestimated, potentially generating iodinated by-products during the subsequent treatment processes. Hence, we proposed using combined reduction-oxidation technologies to remove ICM and achieved synchronous control of iodinated by-products. In the future, it is recommended to study the degradation efficiency of ICM and the control efficiency of iodinated by-products by combining different reduction and oxidation processes.

MRI Gadolinium-Based Contrast Media: Meeting Radiological, Clinical, and Environmental Needs

Gadolinium-based contrast agents (GBCAs) are routinely used in magnetic resonance imaging (MRI). They are essential for choosing the most appropriate medical or surgical strategy for patients with serious pathologies, particularly in oncologic, inflammatory, and cardiovascular diseases. However, GBCAs have been associated with an increased risk of nephrogenic systemic fibrosis in patients with renal failure, as well as the possibility of deposition in the brain, bones, and other organs, even in patients with normal renal function. Research is underway to reduce the quantity of gadolinium injected, without compromising image quality and diagnosis. The next generation of GBCAs will enable a reduction in the gadolinium dose administered. Gadopiclenol is the first of this new generation of GBCAs, with high relaxivity, thus having the potential to reduce the gadolinium dose while maintaining good in vivo stability due to its macrocyclic structure. High-stability and high-relaxivity GBCAs will be one of the solutions for reducing the dose of gadolinium to be administered in clinical practice, while the development of new technologies, including optimization of MRI acquisitions, new contrast mechanisms, and artificial intelligence may help reduce the need for GBCAs. Future solutions may involve a combination of next-generation GBCAs and image-processing techniques to optimize diagnosis and treatment planning while minimizing exposure to gadolinium. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 3.

Considerations for environmental sustainability in clinical radiology and radiotherapy practice: A systematic literature review and recommendations for a greener practice

INTRODUCTION

Environmental sustainability (ES) in healthcare is an important current challenge in the wider context of reducing the environmental impacts of human activity. Identifying key routes to making clinical radiology and radiotherapy (CRR) practice more environmentally sustainable will provide a framework for delivering greener clinical services. This study sought to explore and integrate current evidence regarding ES in CRR departments, to provide a comprehensive guide for greener practice, education, and research.

METHODS

A systematic literature search and review of studies of diverse evidence including qualitative, quantitative, and mixed methods approach was completed across six databases. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and the Quality Assessment Tool for Studies with Diverse Designs (QATSDD) was used to assess the included studies. A result-based convergent data synthesis approach was employed to integrate the study findings.

RESULTS

A total of 162 articles were identified. After applying a predefined exclusion criterion, fourteen articles were eligible. Three themes emerged as potentially important areas of CRR practice that contribute to environmental footprint: energy consumption and data storage practices; usage of clinical consumables and waste management practices; and CRR activities related to staff and patient travel.

CONCLUSIONS

Key components of CRR practice that influence environmental impact were identified, which could serve as a framework for exploring greener practice interventions. Widening the scope of research, education and awareness is imperative to providing a holistic appreciation of the environmental burden of healthcare.

IMPLICATIONS FOR PRACTICE

Encouraging eco-friendly travelling options, leveraging artificial Intelligence (AI) and CRR specific policies to optimise utilisation of resources such as energy and radiopharmaceuticals are recommended for a greener practice.