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Schmid AA, Hungerbühler MN, Lombardo P, Boehm IB. Intradermal testing of iodinated contrast media: Should we test up to pure or with diluted compounds only? Fundam Clin Pharmacol 2024; 38:789-798. [PMID: 38481365 DOI: 10.1111/fcp.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/15/2023] [Accepted: 02/16/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Intradermal testing (IDT) with iodinated contrast media (ICMs) is an established diagnostic tool in patients with ICM hypersensitivity. Currently, it is unclear which test concentration is the more useful one, up to pure or up to 1:10 diluted ICMs. METHODS We searched the literature database PubMed for eligible papers dealing with ICM allergy and their IDT results. We analyzed the data presented by the papers and compared the pooled groups tested with diluted and undiluted ICMs. RESULTS We identified 29 eligible original papers, and extracted data of 1137 patients that formed the study population. Although in the cohort tested with diluted ICMs the number of tested ICMs was greater, the percentage of positive tests was significantly less (9.0% vs. 24.7%; P < 0.0001; OR 0.30 [0.26-0.34]). The frequency of positive tested culprit ICMs was also lesser in the group tested with diluted ICMs (31.0% vs. 72.5%; P < 0.0001; OR 0.17 [0.12-0.23]). The number of drug provocation tests (DPTs) was greater in patients with diluted IDTs (374 vs. 89; P < 0.0001; OR 2.54 [1.93-3.36]). We detected an increased sensitivity in patients with undiluted tests (0.774 vs. 0.282) and a nearly identical specificity in both groups (1 vs. 0.983). CONCLUSIONS For the first time, we show that IDT up to pure ICM concentrations is superior to using diluted ICMs only. Possibly, we can reduce the number of DPTs when performing IDTs with pure ICMs. In the undiluted group, there were no hints for skin irritations or unspecific test reactions.
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Affiliation(s)
- Adrian A Schmid
- Department of Radiology, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Martin N Hungerbühler
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Paolo Lombardo
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Ingrid B Boehm
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
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Copaescu AM, Li L, Blumenthal KG, Trubiano JA. How to Define and Manage Low-Risk Drug Allergy Labels. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1095-1106. [PMID: 38724164 PMCID: PMC11493333 DOI: 10.1016/j.jaip.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/08/2024] [Indexed: 06/06/2024]
Abstract
Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.
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Affiliation(s)
- Ana Maria Copaescu
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Medicine, Austin Health, the University of Melbourne, Heidelberg, VIC, Australia; Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada; The Research Institute of the McGill University Health Centre, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.
| | - Lily Li
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Wash
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia; Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Parkville, VIC, Australia
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Lee SJ, Lee IH, Kim S, Lee JM, Chae YS, Park HK. Effectiveness of Carboplatin-Prescreening Intradermal Skin Tests to Reduce Unanticipated Immediate Hypersensitivity Reactions: A Comparative Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:998-1005.e3. [PMID: 38070772 DOI: 10.1016/j.jaip.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/14/2023] [Accepted: 12/01/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Carboplatin administration poses a risk of immediate hypersensitivity reactions (IHRs) that tend to increase with repeated administration and are mostly IgE-mediated. OBJECTIVE This study evaluated the usefulness of carboplatin-prescreening intradermal skin tests (IDTs). METHODS Carboplatin-prescreening IDTs were routinely conducted in patients with a history of receiving six or more carboplatin cycles beginning in January 2021. The primary objective was to assess disparities in the incidence of unanticipated IHRs to carboplatin administration. We compared patients in the intervention group (from 2021 to 2022) and those who did not undergo prescreening IDTs under the same conditions (preintervention group, from 2019 to 2020). Secondary objectives included evaluating the sensitivity and specificity of the prescreening IDT and the incidence of carboplatin IHR according to the number of infusion cycles. RESULTS The intervention group was composed of 67 patients who were administered 347 carboplatin cycles whereas the preintervention group included 96 patients who were administered 464 carboplatin cycles. The risk of unanticipated carboplatin IHRs decreased by 83.2% in the intervention group compared with results in the preintervention group (preintervention group, 3.45%, n = 16 vs intervention group, 0.58%, n = 2; P = .005). The prescreening IDT showed a sensitivity and specificity of 77.78% and 99.41%, respectively. The risk of newly developed IHRs based on the number of carboplatin cycles was less than 1% (cycles 1-5), 2.11% (cycle 6), 3.90% (cycles 7-12), 2.90% (cycles 13-18), and 0.74% (cycles 19 and greater), respectively. CONCLUSIONS Initiating carboplatin-prescreening IDTs from the seventh cycle on significantly reduced the risk of unanticipated IHRs.
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Affiliation(s)
- Soo Jung Lee
- Department of Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - In Hee Lee
- Department of Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sujeong Kim
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong-Myung Lee
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yee Soo Chae
- Department of Oncology, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Han-Ki Park
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University, Daegu, Korea.
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Lee JH, Yoo Y, Kim SR, Lee JH, Kim SY, An J, Park SY, Park HK, Kim S, Song WJ, Yang MS, Kwon HS, Park HK, Lee J, Hur GY, Ko GJ, Kim SH, Kim SH, Ye YM, Koh YI, Lee BJ, Cho YS, Yong HS, Kim TB. Skin Test-Guided Strategy to Select Alternative Iodinated Contrast Media in Patients With Immediate Hypersensitivity Reaction: A Prospective Confirmative Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3454-3462.e1. [PMID: 37543085 DOI: 10.1016/j.jaip.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 05/30/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Iodinated contrast media (ICM) are a common cause of drug-induced immediate hypersensitivity reaction (IHR). Repeated use of ICM is often necessary; therefore, a standardized protocol to prevent recurrence of IHR is required. OBJECTIVE We aimed to propose an intradermal skin test (IDT)-guided strategy for previous reactors to prevent recurrence of IHR. METHODS We conducted a prospective multicenter study from May 2018 to December 2020 and recruited patients who had experienced IHR to ICM. Once enrolled, the participants underwent IDT with a causative ICM. The alternatives for reexposure were selected using the following protocol: (1) if the IDT with the culprit ICM was positive, further skin tests with other available ICM were conducted to choose IDT-negative agents as alternatives, and (2) if the IDT with the culprit ICM was negative, a randomly changed ICM was used without additional skin tests. The recurrence and severity of hypersensitivity were assessed in subsequent computed tomography examinations. Premedication was administered according to the severity of the index event in all cases. RESULTS A total of 496 participants were enrolled, and 299 were reexposed to ICM. Among 269 participants who followed the protocol, 228 (84.8%) completed computed tomography examinations without adverse reactions, and IHR recurred in 16 of 30 participants (53.3%) who did not follow the protocol (P < .001). In addition, application of the protocol reduced the severity of IHR in recurred cases (P = 0.003). CONCLUSIONS Our IDT-guided strategy not only reduced recurrence of IHR to ICM but also mitigated the severity in recurred cases. This provides evidence for recommending an IDT to diagnose ICM allergy and find safe alternatives.
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Affiliation(s)
- Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngsang Yoo
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Division of Pulmonary and Allergy and Critical Care Medicine, Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Sung-Ryeol Kim
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seo-Young Kim
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin An
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, University of Kyung Hee College of Medicine, Seoul, Korea
| | - So-Young Park
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han-Ki Park
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Sujeong Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, College of Medicine, Pusan National University, Busan, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Gyu-Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gang-Jee Ko
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young-Il Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Ahn JH, Hong SP, Go TH, Kim H. Contrast Agent Selection to Prevent Recurrent Severe Hypersensitivity Reaction to Iodinated Contrast Media Based on Nationwide Database. J Comput Assist Tomogr 2023:00004728-990000000-00158. [PMID: 36944108 DOI: 10.1097/rct.0000000000001462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To investigate the incidence of severe iodinated contrast media (ICM)-related hypersensitivity reaction (HSR) and to find the optimal alternative ICM to reduce the risk of severe HSR recurrence. METHODS We retrospectively reviewed 23,383,183 cases of ICM administration between January 2015 and December 2019 from the nationwide health insurance database. We classified ICMs based on generic profiles and the presence of N-(2,3-dihydroxypropyl) carbamoyl side chains. The incidence of severe and recurrent severe HSRs was calculated, and χ2 tests were performed to compare the prevalence of severe HSR according to ICM groups. In addition, logistic regression analyses were used to assess differences between ICM groups. RESULTS The incidence of severe HSRs was 1.92% (450,067 of 23,282,183). Among 1,875,245 individuals who received ICM twice on different days, severe HSR occurred in 40,850 individuals, and severe HSR recurred in 3319 individuals (8.12%). The risk of recurrence significantly decreased when the ICM changed (9.24% vs 7.08%, P < 0.001), especially when the ICM changed to one with a different side chain (6.74%, P < 0.001). In addition, compared with the reuse of the culprit agent, using combinations of iobitridol/iohexol (odds ratio [OR], 0.696; P = 0.04), iohexol/iopamidol (OR, 0.757; P = 0.007), iopamidol/iohexol (OR, 0.447; P < 0.001), and ioversol/iohexol (OR, 0.683; P = 0.04) reduced the risk of recurrence of severe HSR. CONCLUSIONS Changing the culprit ICM to that with a different side chain can reduce severe HSR recurrence. The optimal choice of an alternative ICM depends on the causative agent.
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Affiliation(s)
| | | | - Tae-Hwa Go
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
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Liu H, Qiu H, Liu J, Wang L, Zhao L, Wang Y, Li X. Stratified assessment and warning regimen for prevention of acute adverse reactions to iodinated contrast media: results of 150,343 cases in a tertiary hospital. Med Biol Eng Comput 2023; 61:709-720. [PMID: 36595153 PMCID: PMC9918562 DOI: 10.1007/s11517-022-02751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 12/24/2022] [Indexed: 01/04/2023]
Abstract
For contrast-enhanced CT examinations, there is a lack of comprehensive optimal management strategies of risk factors to reduce the risk of iodinated contrast media (ICM)-induced acute adverse reactions (AAR). Here, we determine the relationship between the rate of ICM-AAR and a stratified assessment and warning (SAW) regimen, which integrated risk identification, stratification, early warning, and prevention. A total of 120,822 cases in the conventional assessment period (58 years ± 15, 55.25% men) and 150,343 cases (58 years ± 14, 55.83% men) in the SAW period were enrolled. The results showed that the total AAR incidence in the SAW period (414/150,343, 0.28%) was lower than that in the conventional assessment period (506/120,822, 0.42%, P < 0.001), in which the proportion of AAR patients decreased by one-third. It mainly presented as decreases in mild and moderate reactions (P < 0.001), and a decrease in the proportion of moderate AAR patients (P = 0.001). Subgroup analysis showed lower mild and moderate AAR incidence in patients with different risk levels and with different ICM injection parameters following SAW regimen. We concluded that SAW regimen was associated with lower incidence of mild and moderate AAR, and decreased proportion of moderate AAR patients, which held potential for improved ICM safety.
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Affiliation(s)
- Heng Liu
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042 China ,Department of Radiology, PLA Rocket Force Characteristic Medical Center, No. 16 Xinjiekou Outer Street, Beijing, 100088 China
| | - Haiyan Qiu
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042 China
| | - Junling Liu
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042 China
| | - Lingru Wang
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042 China
| | - Li Zhao
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042 China
| | - Yaling Wang
- Department of Nursing, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, China.
| | - Xue Li
- Department of Radiology, Daping Hospital, Army Medical University, No. 10 Changjiang Road, Yuzhong District, Chongqing, 400042, China.
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Chiu TM, Chu SY. Hypersensitivity Reactions to Iodinated Contrast Media. Biomedicines 2022; 10:1036. [PMID: 35625773 PMCID: PMC9138609 DOI: 10.3390/biomedicines10051036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
At present, iodinated contrast media (ICM) are mostly non-ionic, have low osmolality, and are safe. Even if adverse drug reactions (ADRs) occur, most are chemo-toxic symptoms and require only observation or H1 antihistamines. However, rare, unpredictable, and even life-threatening hypersensitivity can still occur. The aim of this review is to summarize the issues that all relevant staff need to know about and be able to respond to. The most significant risk factor for ICM hypersensitivity is a history of ICM hypersensitivity. For high-risk populations, we must cautiously weigh the advantages and disadvantages of premedication and be aware that breakthrough reactions may still occur. The best policy for patients with a history of severe ICM hypersensitivity is to avoid the same ICM. If ICM are inevitable, skin tests, in vitro tests, and drug provocation tests may help to find a feasible alternative that is safer. The severity of the hypersensitivity is correlated with the positivity rate of these tests, so there is no need for further investigations for patients with only mild reactions. We should also keep in mind that even excipients in ICM may induce hypersensitivity. Detailed, standardized documentation is essential for correct diagnosis and the prevention of future occurrence.
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Affiliation(s)
- Tsu-Man Chiu
- Department of Dermatology, Changhua Christian Hospital, Changhua City 50073, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan
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Zou W, Yang S, Chen L, Hu S, Hao G, Hu C. Iodixanol activation of mast cells: Implications in the pathogenesis of iodixanol-induced delayed cutaneous adverse reactions. Toxicology 2022; 465:153034. [PMID: 34774977 DOI: 10.1016/j.tox.2021.153034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 12/20/2022]
Abstract
Iodinated contrast media (ICM) is widely used in radiological examination and interventional therapy. In the commonly used ICM, iodixanol is considered to be the safer one. However, compared with other ICMs, it has a higher incidence of delayed cutaneous adverse reactions. The underlying mechanisms are unclear. In this study, mice with positive allergic reactions were selected based on the mouse clinical allergy symptom score and skin and blood samples taken 1, 6, 24, 48, and 72 h after ICMs (6 g iodine/kg) injection for histological and blood analyses. ICMs-induced pseudo-allergic reactions were investigated through in vivo intravital vascular imaging and passive cutaneous anaphylaxis (PCA) not mediated by IgE and through, calcium imaging degranulation of mast cells (MCs), and western blot assays in vitro. Results shows iodixanol-induced systemic anaphylaxis caused severe extravasation of plasma proteins and degranulation of skin MCs, and increased levels of plasma histamine, cytokines and inflammatory chemokines. Mechanistically, iodixanol increases degranulation of MCs and promotes the synthesis of inflammatory factors by activating PLC-γ and PI3K-related pathways. Trigonelline inhibit iodixanol-induced MC-related pseudo-allergic reactions in vitro and in vivo. These results suggest that mice in the iodixanol group had a higher incidence of delayed cutaneous reactions, characterized by cytokine release over time and delayed cutaneous MC degranulation. Iodixanol's delayed cutaneous adverse reactions may be due to a delayed phase of MC-related pseudo-allergic reactions. Trigonelline revealed anti-allergic activity in iodixanol-induced MC-related pseudo-allergic reactions.
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Affiliation(s)
- Weijie Zou
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China; Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China
| | - Shuang Yang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China; Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China
| | - Li Chen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China
| | - Su Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China; Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China
| | - Guangyu Hao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China; Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China; Institute of Medical Imaging of Soochow University, Suzhou, Jiangsu Province 215006, People's Republic of China.
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Brockow K. Diagnosing and Managing Patients with Reactions to Radiocontrast Media. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00287-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose of the review
Iodinated radio contrast media (RCM) belong to the most common elicitors of drug hypersensitivity reactions (HR). Urticaria or anaphylaxis may occur ≤ 1(−6) hour(s) (immediate HR) and exanthems (non-immediate HR) develop > 6 h after application of RCM. Evidence for an immunologic mechanism of RCM HR against the different RCM benzene ring molecules and the benefit of allergological testing in patients with previous hypersensitivity reactions is progressively increasing.
Recent findings
Positive skin tests can confirm allergy in patients with previous reactions to RCM and help to select alternative better tolerated RCMs. Severe hypersensitivity reactions are mainly caused by an allergic mechanism, whereas the majority of non-severe reactions appear to be non-allergic. Skin testing is highly recommended to help identify allergic hypersensitivity reactions and to select alternatives. Using structurally different RCM is more effective than premedication for the prevention of future reactions. Drug provocation tests to RCM have been increasingly used, but are not yet standardized among different centers.
Summary
In patients with previous severe hypersensitivity reactions to RCM, skin testing is recommended. For future RCM-enhanced examinations in patients with previous reactions, structurally different, skin test-negative preparations should be applied. Drug provocation tests do confirm or exclude RCM hypersensitivity or may demonstrate tolerability of alternative RCMs.
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Sohn KH, Seo JH, Kang DY, Lee SY, Kang HR. Finding the Optimal Alternative for Immediate Hypersensitivity to Low-Osmolar Iodinated Contrast. Invest Radiol 2021; 56:480-485. [PMID: 33587497 DOI: 10.1097/rli.0000000000000765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Avoiding culprit agents is recommended for subjects who have had previous hypersensitivity reaction (HSR) to low-osmolar contrast media (LOCM). However, the guidelines for choosing optimal alternatives have not been determined. We investigated the outcomes of reexposure in patients with previous immediate HSRs to provide a safe option. MATERIALS AND METHODS The outcomes of reexposure were assessed in a cohort with previous LOCM-associated HSR based on skin testing results and the presence of a common N-(2,3-dihydroxypropyl) carbamoyl side chain. RESULTS Among 482 skin tests, 38.7% (31/80), 45.8% (99/216), and 64.0% (119/186) of mild, moderate, and severe index HSRs showed positivity to at least 1 LOCM, of which 62.8% showed positivity to at least 2 different LOCM. The overall recurrent HSRs were reduced from 43.8% upon reexposure to the culprit LOCM to 12.3% upon using nonculprit skin test negative LOCM (P = 0.004); those with severe index HSRs exhibited a significant reduction (11.3% vs 100%), but those with non-severe HSRs to LOCM did not. In subjects with severe index HSRs, the skin test cross-reactivity between LOCM was associated with sharing the common side chain (20.7% vs 11.5%, P = 0.003), and the recurrence rate of HSRs was effectively reduced by avoiding the common side chain (24.0% vs 7.8%, P = 0.039). However, these differences were not observed in those with non-severe index HSRs. CONCLUSIONS In patients who experienced a severe index HSR to LOCM, skin test negative LOCM without a common side chain could be suggested as an option for safe reexposure.
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Affiliation(s)
| | | | - Dong-Yoon Kang
- Drug Safety Center, Seoul National University Hospital, Seoul, South Korea
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Thong BYH, Vultaggio A, Rerkpattanapipat T, Schrijvers R. Prevention of Drug Hypersensitivity Reactions: Prescreening and Premedication. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2958-2966. [PMID: 34366094 DOI: 10.1016/j.jaip.2021.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023]
Abstract
Drug hypersensitivity reactions (DHR) are heterogeneous in their pathomechanisms, clinical presentation, severity, and outcomes. Novel DHR mechanisms, phenotypes, and endotypes have been described. The key to prevention from further exposure to the culprit drugs involves correct identification of the putative drug through a combination of in vitro and/or in vivo tests, accurate drug allergy labeling and reporting, and electronic decision support systems within electronic medical records to prevent future accidental prescribing. Prescreening and premedication, the focus of this review, may be a useful adjunct to preventive measures in certain situations. After an index immediate drug hypersensitivity reaction, prescreening may be useful in perioperative anaphylaxis, and iodinated (ICM) and gadolinium-based contrast media (GCM) where the culprit and potential alternative agents are skin tested. In certain nonimmediate DHR, pharmacogenomic prescreening may be used before prescribing high-risk drugs (eg, carbamazepine and allopurinol) where specific human-leukocyte antigen genotypes are associated with severe cutaneous adverse reactions. Premedication with antihistamine and systemic corticosteroids is another therapeutic strategy to prevent infusion reactions for certain biologicals and chemotherapeutic agents, in cases of perioperative anaphylaxis, ICM and GCM DHR, and clonal mast cell disorders. Rapid drug desensitization may also be used to induce temporary tolerance in situations where there are limited alternative drugs.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
| | - Alessandra Vultaggio
- Immunoallergology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
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Bansie RD, Karim AF, van Maaren MS, Hermans MA, van Daele PLA, Gerth van Wijk R, Rombach SM. Assessment of immediate and non-immediate hypersensitivity contrast reactions by skin tests and provocation tests: A review. Int J Immunopathol Pharmacol 2021; 35:20587384211015061. [PMID: 34053316 PMCID: PMC8170298 DOI: 10.1177/20587384211015061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Allergic and nonallergic hypersensitivity reactions to iodinated contrast media (ICM) and gadolinium-based contrast media are classified as immediate or non-immediate hypersensitivity reactions (IHR and NIHR), respectively. Skin tests and provocation tests are recommended for the evaluation of hypersensitivity reactions to contrast agents; however provocations are not common in clinical practice. METHODS A MEDLINE search was conducted to investigate studies comprising both skin tests and provocation tests that evaluated hypersensitivity reactions to ICM. RESULTS Nineteen studies were identified that reported on skin tests, followed by provocations. In the case of IHR to ICM, 65/69 (94%) patients with a positive skin test for the culprit media tolerated a challenge with a skin-test-negative alternative ICM. In IHR to ICM with a negative skin test for the culprit media, provocations were positive in 3.2%-9.1% patients. In the case of a NIHR to ICM with a positive skin test, provocation with a skin-test-negative agent was tolerated in 75/105 (71%) of cases. In NIHR with a negative skin test for the culprit agent, re-exposure to the culprit or an alternative was positive in 0%-34.6% patients. Provocations with the same ICM in skin test positive patients with IHR or NIHR were positive for a majority of the patients, although such provocation tests were rarely performed. Data on hypersensitivity reactions, skin tests and provocations with gadolinium-based contrast media were limited; however, they exhibited a pattern similar to that observed in ICM. CONCLUSION In both ICM and gadolinium-based contrast media, the risk of an immediate repeat reaction is low when skin tests are negative. In contrast, a provocation with a skin-test-positive contrast medium showed a high risk of an immediate repeat hypersensitivity reaction. Therefore, a thorough medical history is necessary, followed by skin tests. A provocation is recommended, for diagnostic work-up, when the diagnosis is uncertain.
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Affiliation(s)
- Rakesh D Bansie
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands.,Department of Internal Medicine, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - A Faiz Karim
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands.,Department of Internal Medicine, Section Allergy and Clinical Immunology, Gouda Groene Hart Ziekenhuis, Zuid-Holland, the Netherlands
| | - Maurits S van Maaren
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Maud Aw Hermans
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Paul LA van Daele
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Roy Gerth van Wijk
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
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Gamboa P, Sánchez de Vicente J, Galán C, Jáuregui I, Segurola A, García-Lirio E, Seras Y, Martínez-Antón MD, Irazábal B. Tolerance to iopamidol in patients with confirmed allergic immediate hypersensitivity to iomeprol. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2101-2103.e1. [PMID: 33444814 DOI: 10.1016/j.jaip.2020.12.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Pedro Gamboa
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.
| | | | - Cristina Galán
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | - Ignacio Jáuregui
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | - Aritza Segurola
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | | | - Yolanda Seras
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | | | - Begoña Irazábal
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
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Costantino MT, Romanini L, Gaeta F, Stacul F, Valluzzi RL, Passamonti M, Bonadonna P, Cerri G, Pucci S, Ricci P, Savi E, Galluzzo M, Mauro M, Grassedonio E, Yacoub MR, Reginelli A, Testi S, Ridolo E, Nettis E, Di Leo E, Rossi O, Montuschi P, Incorvaia C, Romano A. SIRM-SIAAIC consensus, an Italian document on management of patients at risk of hypersensitivity reactions to contrast media. Clin Mol Allergy 2020; 18:13. [PMID: 32765190 PMCID: PMC7395340 DOI: 10.1186/s12948-020-00128-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity reactions (HRs) to contrast media (CM) can be distinguished in immune-mediated (including allergic reactions) and non-immune-mediated reactions, even if clinical manifestations could be similar. Such manifestations range from mild skin eruptions to severe anaphylaxis, making it important for radiologists to know how to identify and manage them. A panel of experts from the Società Italiana di Radiologia Medica e Interventistica (SIRM) and the Società Italiana di Allergologia, Asma e Immunologia Clinica (SIAAIC) provided a consensus document on the management of patients who must undergo radiological investigations with CM. Consensus topics included: the risk stratification of patients, the identification of the culprit CM and of a safe alternative by an allergy workup, as well as the use of premedication and the correct procedure to safely perform an elective (i.e., scheduled) or urgent examination. The most important recommendations are: (1) in all patients, a thorough medical history must be taken by the prescribing physician and/or the radiologist to identify at-risk patients; (2) in patients with hypersensitivity reactions to CM, the radiologist must consider an alternative, non-contrast imaging study with a comparable diagnostic value, or prescribe a different investigation with another class of CM; (3) if such options are not feasible, the radiologist must address at-risk patients to a reference centre for an allergy evaluation; (4) if timely referral to an allergist is not viable, it is recommended to use a CM other than the responsible one, taking into account cross-reactivity patterns; in the case of patients with histories of severe reactions, the presence of an anesthesiologist is also recommended and a premedication is suggested.
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Affiliation(s)
| | - Laura Romanini
- Radiology, Istituti Ospitalieri di Cremona, ASST Cremona, Cremona, Italy
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Moscati n.30, Rome, Italy
| | - Fulvio Stacul
- Department of Radiology, Ospedale Maggiore, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Rocco Luigi Valluzzi
- Allergy Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Vatican City, Italy
| | | | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Cerri
- Department of Radiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Stefano Pucci
- Allergy Unit. General Hospital, Civitanova Marche, Milan, Italy
| | - Paolo Ricci
- Department of Radiology, Oncologiche ad Anatomopatologiche, Azienda Policlinico Umberto I, Sapienza Università di Roma, Rome, Italy
| | - Eleonora Savi
- Departmental Unit of Allergology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Michele Galluzzo
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Ospedale San Camillo, Rome, Italy
| | | | - Emanuele Grassedonio
- Department of Radiology, Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Mona Rita Yacoub
- Allergy and Immunology Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alfonso Reginelli
- Department of Radiology & Radiotherapy, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Sergio Testi
- Allergy and Clinical Immunology Unit, San Giovanni di Dio’s Hospital, Florence, Italy
| | - Erminia Ridolo
- Department of Medicine and Surgery Clinical, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Eustacchio Nettis
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology, Unit of Internal Medicine, “F. Miulli” Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Oliviero Rossi
- Allergy Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Paolo Montuschi
- Pharmacology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
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Robinson K, Platt S, Bibi K, Banovic F, Barber R, Howerth EW, Madsen G. A Pilot Study on the Safety of a Novel Antioxidant Nanoparticle Delivery System and Its Indirect Effects on Cytokine Levels in Four Dogs. Front Vet Sci 2020; 7:447. [PMID: 32851027 PMCID: PMC7406565 DOI: 10.3389/fvets.2020.00447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/19/2020] [Indexed: 12/31/2022] Open
Abstract
Acute spinal cord injury consists of a primary, traumatic event followed by a cascade of secondary events resulting in ongoing cell damage and death. There is great interest in prevention of these secondary effects to reduce permanent long-term neurologic deficits. One such target includes reactive oxygen species released following injury, which can be enzymatically converted into less harmful molecules by superoxide dismutase and catalase. Canine intervertebral disc herniation has been suggested as a naturally occurring model for acute spinal cord injury and its secondary effects in people. The aims of this study were to test the safety of a novel antioxidant delivery system in four healthy dogs and to indirectly test effect of delivery via cytokine measurement. All dogs experienced adverse events to some degree, with two experiencing adverse events considered to be severe. The clinical signs, including combinations of bradycardia, hypotension, hypersalivation, pale gums, and involuntary urination, were consistent with complement activation-related pseudoallergy (CARPA). CARPA is a well-known phenomenon that has been reported to occur with nanoparticle-based drug delivery, among other documented causes. Two dogs also had mild to moderate changes in their blood cell count and chemistry, including elevated alanine transferase, and thrombocytopenia, which both returned to normal by day 7 post-administration. Cytokine levels trended downwards over the first 3 days, but many were elevated at measurement on day 7. Intradermal testing suggested catalase as a potential cause for reactions. No long-term clinical signs were observed, and necropsy results revealed no concerning pathology. Additional evaluation of this product, including further characterization of reactions to catalase containing components, dose-escalation, and desensitization should be performed before evaluation in clinically affected dogs.
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Affiliation(s)
- Kelsey Robinson
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Simon Platt
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Katherine Bibi
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Frane Banovic
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Renee Barber
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Elizabeth W Howerth
- Department of Pathology, College of Veterinary Medicine, University of Georgia, Athens, GA, United States
| | - Gary Madsen
- ProTransit Nanotherapy, LLC, Omaha, NE, United States
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Hsu Blatman KS, Sánchez-Borges M, Greenberger PA. Anaphylaxis in the Radiology Suite. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1203-1209. [DOI: 10.1016/j.jaip.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 11/24/2022]
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18
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Kim TB. Prescreening skin test effectiveness in predicting hypersensitivity to iodinated contrast media. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.3.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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