X-ray contrast media--an overview

Impact of the reductive deiodination on the sorption of iodinated X-ray contrast media to filter sand and activated carbon

Iodinated X-ray contrast media (ICM) and their aerobic transformation products (TPs) are widespread in the aquatic environment due to their persistent and mobile character. In a previous lab study, we have shown that the reductive (partial) deiodination of selected triiodobenzene derivatives increases the sorption to aquifer sand and loam soil, since iodine affects the compounds by steric hindrance, repulsive forces, resonance and inductive effects. These results suggest that the (partial) deiodination generally occurring to ICM and aerobic ICM TPs during anoxic/anaerobic bank filtration has a potential to increase their removal by sorption to natural sorbents. To basically assess the sorption potential to technically applied materials for drinking water treatment subsequent to bank filtration, we investigated the sorption of iopromide, diatrizoate and 5-amino-2,4,6-triiodoisophtalic acid and their di, mono and deiodinated structures to used filter sand from a waterworks and different fresh powdered activated carbons in batch tests using Berlin drinking water. The filter material, coated by iron and manganese oxides as well as organic material (including biofilm), preferentially removed monoiodinated derivatives, but diffusion through the organic layer heavily slowed the sorption. Therefore, the removal potential by sorption in rapid sand filters of waterworks for (partially) deiodinated benzene derivatives is suggested to be low. The deiodination of iopromide and diatrizoate significantly increased the sorption affinity to activated carbon and the competitiveness with regard to drinking water DOC. Despite the large atom radius of iodine, no clear correlation was found between the pore characteristics of the activated carbons and the molecular size of the compounds. This study emphasises the importance of anoxic/anaerobic conditions for the removal of persistent and mobile ICM and ICM TPs during drinking water treatment.

Contrast Reactions and Approaches to Staffing the Contrast Reaction Management Team

RATIONALE AND OBJECTIVES

Managing contrast reactions is critical as contrast reactions can be life-threatening and unpredictable. Institutions need an effective system to handle these events. Currently, there is no standard practice for assigning trainees, radiologists, non-radiologist physicians, or other non-physician providers for management of contrast reaction.

MATERIALS AND METHODS

The Association of Academic Radiologists (AAR) created a task force to address this gap. The AAR task force reviewed existing practices, studied available literature, and consulted experts related to contrast reaction management. The Society of Chairs of Academic Radiology Departments (SCARD) members were surveyed using a questionnaire focused on staffing strategies for contrast reaction management.

RESULTS

The task force found disparities in contrast reactions management across institutions and healthcare providers. There is a lack of standardized protocols for assigning personnel for contrast reaction management.

CONCLUSION

The AAR task force suggests developing standardized protocols for contrast reaction management. The protocols should outline clear roles for different healthcare providers involved in these events.

Image quality of abdominal photon-counting CT with reduced contrast media dose: Evaluation of reduced contrast media protocols during the COVID19 pandemic supply shortage

Rationale and objectives

Aim of this study was to assess the impact of contrast media dose (CMD) reduction on diagnostic quality of photon-counting detector CT (PCD-CT) and energy-integrating detector CT (EID-CT).

Methods

CT scans of the abdominal region with differing CMD acquired in portal venous phase on a PCD-CT were included and compared to EID-CT scans. Diagnostic quality and contrast intensity were rated. Additionally, readers had to assign the scans to reduced or regular CMD. Regions-of-interest (ROIs) were placed in defined segments of portal vein, inferior vena cava, liver, spleen, kidneys, abdominal aorta and muscular tissue. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated.

Results

Overall 158 CT scans performed on a PCD-CT and 68 examinations on an EID-CT were analyzed. Overall diagnostic quality showed no significant differences for PCD-CT with standard CMD which scored a median 5 (IQR:5-5) and PCD-CT with 70% CMD scoring 5 (4-5). (For PCD-CT, 71.69% of the examinations with reduced CMD were assigned to regular CMD by the readers, for EID-CT 9.09%. Averaged for all measurements SNR for 50% CMD was reduced by 19% in PCD-CT (EID-CT 34%) and CNR by 48% (EID-CT 56%). Virtual monoenergetic images (VMI)50keV for PCD-CT images acquired with 50% CMD showed an increase in SNR by 72% and CNR by 153%.

Conclusions

Diagnostic interpretability of PCD-CT examinations with reduction of up to 50% CMD is maintained. PCD-CT deducted scans especially with 70% CMD were often not recognized as CMD reduced scans. Compared to EID-CT less decline in SNR and CNR is observed for CMD reduced PCD-CT images. Employing VMI50keV for CMD-reduced PCD-CT images compensated for the effects.

Differences in radiopacity among CT contrast agents and concentrations: A quantitative study

BACKGROUND AND PURPOSE

Several studies in the literature have attempted to subjectively assess the degree of visualization of different neurovascular structures using different contrast agents and concentrations. Given the recent contrast shortages, we aim to objectively compare the radiopacity achieved with four angiographic contrast agents used in clinical practice.

METHODS

Isovue 370, Visipaque 320, Omnipaque 300, and Isovue 300 were each drawn up at 25%, 50%, 75%, and 100% concentrations and compared against normal saline and air syringes. CT scans were obtained, and regions of interest were analyzed for radiopacity using Hounsfield unit (HU) measurements. An aneurysm model with different contrast concentrations was also scanned and dimensions compared. Two-tailed t-tests and Cohen's d coefficients were applied to assess for differences in mean HU measurements.

RESULTS

Isovue 370 and Isovue 300 had the highest and lowest mean HU, respectively (p < .001). Visipaque 320 at 25% concentration had the lowest mean HU at -.76. Statistically similar agents (p < .05) were Visipaque 320 and Omnipaque 300 at a 100% concentration (p = .30), and Omnipaque 300 and Isovue 300 at a 25% concentration (p = .73). Aneurysm dimensions among Isovue 370, Visipaque 320, and Omnipaque 300 were all similar, whereas with Isovue 300, the dimensions were significantly smaller (p < .05).

CONCLUSION

Isovue 370 provides the highest HU radiopacity and the most accurate aneurysm measurements. Angiographic measurements obtained with Isovue 300 may underestimate the actual aneurysmal dimensions. Visipaque 320 and Omnipaque 300 at 100% concentration have similar mean HUs and are beneficial for patients with chronic kidney or cardiac disease.

Intravenous versus oral hydration to reduce the risk of postcontrast acute kidney injury after intravenous contrast-enhanced CT in patients with severe chronic kidney disease (ENRICH): a study protocol for a single-centre, parallel-group, open-labelled non-inferiority randomised controlled trial in Denmark

INTRODUCTION

Contrast-enhanced CT (CECT) is widely used for diagnostic purposes. The use of contrast medium carries a risk for postcontrast acute kidney injury (PC-AKI), especially in patients with AKI or chronic kidney disease (CKD). Current guidelines recommend prophylactic intravenous hydration to prevent PC-AKI in high-risk patients. Oral hydration is non-inferior to intravenous hydration in patients with moderate CKD, but it has not been evaluated in high-risk patients.

METHODS AND ANALYSIS

The ENRICH trial will enrol 254 patients with estimated glomerular filtration rate ≤30 mL/min/1.73 m2 undergoing intravenous CECT, who are block randomised (2-4-2) with stratification for CKD stage, diabetes status, and indication for referral to prophylactic treatment with oral or intravenous hydration. PC-AKI is defined as an absolute increase in SCr of >0.3 mg/dL or >1.5 from baseline at 2-5 days. Renal function will also be evaluated <90 days, <7 days and 1-3 days before intravenous CECT, and 25-40 days after intravenous CECT. Secondary outcomes include dialysis, renal adverse events, hospitalisation due to hydration-related or contrast-related sequelae, and all-cause mortality ≤30 days postcontrast. Pre- and postcontrast plasma and urinary biomarkers will be evaluated for diagnostic and prognostic accuracy of the primary and secondary outcomes.

ETHICS AND DISSEMINATION

Oral hydration is patient-friendly and less costly compared with intravenous hydration. If oral hydration is non-inferior to intravenous hydration in high-risk patients, it could be implemented as new hydration strategy, which will facilitate the clinical diagnosing of elective patients with severe CKD without unnecessary resource utilisation. The protocol is approved by the Regional Scientific Ethical Committee for Southern Denmark (S-20210126), and the Data Protection Agency (21/66779). The study is conducted in accordance with the Declaration of Helsinki. Positive as well as negative findings will be reported in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05283512.

Two-photon excited luminescence of structural light enhancement in subwavelength SiO2 coating europium ion-doped paramagnetic gadolinium oxide nanoparticle and application for magnetic resonance imaging

BACKGROUND

Oxides of lanthanide rare-earth elements show great potential in the fields of imaging and therapeutics due to their unique electrical, optical and magnetic properties. Oxides of lanthanide-based nanoparticles enable high-resolution imaging of biological tissues by magnetic resonance imaging (MRI), computed tomography (CT) imaging, and fluorescence imaging. In addition, they can be used to detect, treat, and regulate diseases by fine-tuning their structure and function. It remains challenging to achieve safer, efficient, and more sensitive nanoparticles for clinical applications through the structural design of functional and nanostructured rare-earth materials.

RESULT

In this study, we designed a mesoporous silica-coated core-shell structure of europium oxide ions to obtain near-infrared two-photon excitation fluorescence while maintaining high contrast and resolution in MRI. We designed enhanced 800 nm photoexcitation nanostructures, which were simulated by the finite-difference method (FDM) and finite-difference time-domain method (FDTD). The nanoparticle structure, two-photon absorption, up-conversion fluorescence, magnetic properties, cytotoxicity, and MRI were investigated in vivo and in vitro. The nanoparticle has an extremely strong optical fluorescence response and multiple excitation peaks in the visible light band under the 405 nm continuous-wave laser excitation. The nanoparticle was found to possess typical optical nonlinearity induced by two-photon absorption by ultrafast laser Z-scan technique. Two-photon excited fluorescence of visible red light at wavelengths of 615 nm and 701 nm, respectively, under excitation of the more biocompatible near-infrared (pulsed laser at 800 nm). In an in vitro MRI study, a T1 relaxation rate of 6.24 mM^-1 s^-1 was observed. MRI in vivo showed that the nanoparticles could significantly enhance the signal intensity in liver tissue.

CONCLUSIONS

These results suggest that this sample has applied potential in visible light fluorescence imaging and MRI.

Can reductive deiodination improve the sorption of iodinated X-ray contrast media to aquifer material during bank filtration?

Iodinated X-ray contrast media (ICM) as well as their aerobic transformation products (TPs), are highly polar triiodobenzoic acid derivatives, ubiquitously found in the urban water cycle. Based on their polarity, their sorption affinity to sediment and soil is negligible. However, we hypothesize that the iodine atoms bound to the benzene ring play a decisive role for sorption, due to their large atom radius, high electron number and symmetrical positioning within the aromatic system. The aim of this study is to investigate, if the (partial) deiodination, occurring during anoxic/anaerobic bank filtration, improves the sorption to aquifer material. Tri, di, mono and deiodinated structures of two ICMs (iopromide and diatrizoate) and one precursor/TP of ICM (5-amino-2,4,6-triiodoisophtalic acid) were tested in batch experiments, using two aquifer sands and a loam soil with and without organic matter. The di, mono and deiodinated structures were produced by (partial) deiodination of the triiodinated initial compounds. The results demonstrated that the (partial) deiodination increases the sorption to all tested sorbents, even though the theoretical polarity increases with decreasing number of iodine atoms. Whereas lignite particles positively affected the sorption, mineral components decreased it. Kinetics tests show biphasic sorption for the deiodinated derivatives. We have concluded that iodine affects the sorption by sterical hindrance, repulsive forces, resonance and inductive effects, depending on the number and position of iodine, side chain characteristics and composition of the sorbent material. Our study has revealed an increased sorption potential of ICMs and their iodinated TPs to aquifer material during anoxic/anaerobic bank filtration as a result of (partial) deiodination, whereby a complete deiodination is not necessary for efficient removal by sorption. Furthermore, it suggests that the combination of an initial aerobic (side chain transformations) and a subsequent anoxic/anaerobic (deiodination) redox milieu supports the sorption potential.

Occurrence and risk of iodinated X-ray contrast media in source and tap water from Jiangsu province, China

Microcontaminants in the water environment have received increasing attention due to their adverse effects on human health and wildlife. However, iodinated X-ray contrast media (ICM), a type of microcontaminants, have not yet been systematically documented in source and tap water. This study investigated ICM in water samples via a sampling activity from 25 drinking water sources and their corresponding 30 household taps in south-central Jiangsu Province, China. The total concentrations of ICM ranged from 14.2 to 138.5 ng/L in source water and 3.7 to 101.3 ng/L in tap water, respectively. The calculated average water treatment efficiency to remove ICM is 38.3% with large variation under different processes (ranging from 7.3% to 75.7%), which implied that ICM could not be effectively removed using current treatment technologies. By integrating other ICM into the predominant compound iohexol with relative potency factors, the health risks of total ICM through water consumption were assessed using the Monte Carlo simulation. The results concluded that the risk of ingesting ICM through tap water was not a major health concern for adults, teens, or children in the study area. Nevertheless, due to the lack of long-term toxicity data relevant for humans for ICM, this risk may be underestimated, which requires further research.

Bridging the gap between bench and clinic: the importance of understanding the mechanism of iodinated contrast media hypersensitivity

Since the advent of CT, iodinated contract media (ICM) has become one of the most regularly administered intravenous medications in clinical settings. Although considered generally safe, ICM is one of the most common causes of adverse drug reactions in clinical practice, accounting for more than 2 million adverse reactions worldwide. Currently, there are few useful tools to diagnose patient hypersensitivity, with the major limitation being the lack of consensus regarding the mechanisms of hypersensitivity to ICM. While there is an overwhelming abundance of literature pertaining to clinical features including incidence, symptomatology, and risk, few studies have further investigated the underlying mechanisms behind their clinical observations. Of the available literature discussing pathophysiology, most primary studies were completed over 20 years ago, since which the molecular characteristics of ICM have changed. Furthermore, many reviews mentioning pathophysiology fail to adequately emphasize the clinical importance of understanding the molecular pathways involved in hypersensitivity. In this review, we aim to emphasize the clinical relevance of pathophysiology as it relates to the prediction and diagnosis of hypersensitivity reactions to ICM. To this end, we will first briefly characterize hypersensitivity reactions to ICM with respect to epidemiology and clinical presentation. We will then present the existing evidence supporting various proposed mechanisms of hypersensitivity, highlighting the gaps that remain in the mechanistic delineation of both immediate and delayed reactions. Finally, we discuss the possibility of in vitro testing as a way to predict and diagnose hypersensitivity reactions, pending a more complete elucidation of mechanisms.

Evaluation of the accumulation of the iodinated contrast agents diatrizoic acid and iohexol in Dreissena polymorpha mollusks

Mollusks are very sensitive to aquatic environmental alterations and then, are important bio-indicators for monitoring the contamination of water bodies. Iodinated X-ray contrast media (ICMs) are ubiquitously present in the aquatic environment, primarily due to their high consumption for diagnosis purposes, high injection levels, low biodegradability, and low removal rates by wastewater treatment plants. Although these compounds are assumed to be of low toxicity, aquatic organisms are continuously exposed to these agents, which may result in adverse effects as ICMs can act as iodine source and disrupt the endocrine system. Thus, the evaluation of their environmental risk, especially on aquatic fauna is of great interest. To this end, we first compared the accumulation behavior, based on iodine analysis, of two ICM exhibiting different osmolality, diatrizoic acid and iohexol in Dreissena polymorpha bivalves exposed under laboratory conditions at concentrations of 0, 100, and 1000 μg/L during 4 and 7 days. This study was the first to provide information on iodine concentration in whole soft tissues and several organs in control zebra mussels. Moreover, it showed, after exposure, an increase of iodine content mainly in the digestive glands, followed by gills and gonads, highlighting that ICMs actually enter the organisms. Thus, bioaccumulation of ICMs studies were then performed, by liquid chromatography coupled to tandem mass spectrometry, on entire mollusks and digestive glands of organisms exposed at 0, 10, 100, and 1000 μg/L of both ICMs during 21 days, followed by 4 days of depuration. These first data on ICMs concentrations in zebra mussels, showed a clear accumulation of ICMs in mussels as a function of relative exposure level, as well as a rapid depuration. Osmolality did not seem to have a significant impact on the accumulation level, but a slight difference was observed on the accumulation pattern between both ICMs.

Successful Desensitization to the Radiocontrast Material Iohexol (Omnipaque™)

Adverse reactions to radiocontrast media (RCM) are rare and occur predominantly in association with intravenous administration but may also occur with intra-arterial and nonvascular injections (e.g., retrograde pyelography, intra-articular injections) of RCM. This article reports the case of a 52-year-old lady who was known to have amyloidosis secondary to rheumatoid arthritis and was on regular renal replacement therapy. She was under follow-up for regular angioplasties to manage the central vein stenosis that was affecting her right brachiocephalic arteriovenous fistula (AVF) and was referred to our Immunology service when she developed an allergic reaction after her AVF angioplasty (central venoplasty). Despite being dialysed immediately post-angioplasty, she complained of skin rash and itching with hoarseness of voice that developed almost six to eight hours post-angioplasty. We decided to arrange the iodinated non-ionic iso-osmolar contrast agent iodixanol (Visipaque™) for her instead, as it is known to be better tolerated in patients with reactions to Omnipaque™ due to its lower osmolarity as compared to Omnipaque™. However, since it was the first time to request this contrast in our hospital, it was not possible due to logistical reasons. It was necessary that our patient continued to undergo angioplasty every three months, however, she was developing more severe and earlier symptoms with each subsequent exposure to the radiocontrast medium. After her latest reaction of generalized itching and angioedema with shortness of breath during the procedure despite premedication, it was decided for her to undergo desensitization to Omnipaque™. In the absence of a published protocol for this, we used a protocol used for desensitization to Visipaque™. She showed an excellent response and completed her remaining angioplasties until Visipaque™ became available. Hence, desensitization to Omnipaque™ using the published protocol to Visipaque™ is likely to help patients allergic to Omnipaque™ or where Visipaque™ is not available or non-affordable in low/middle-income countries.

Evaluating the Image Quality of Neck Structures Scanned on Chest CT with Low-Concentration-Iodine Contrast Media

BACKGROUND

The purpose of this study was to investigate and compare the image quality of low-concentration-iodine (240 mgI/mL) contrast media (CM) and high-concentration-iodine (320 mgI/mL) CM according to the radiation dose.

METHODS

A total of 366 CT examinations were examined. Based on an assessment of quantitative and qualitative parameters by two radiologists, the quality was compared between Group A (low-concentration-iodine CM) and Group B (high-concentration-iodine CM) images of thyroid gland, sternocleidomastoid muscle (SCM), internal jugular vein (IJV), and common carotid artery (CCA). Another subgroup analysis compared Group a, (using ≤90 kVp in Group A), and Group b, (using ≥100 kVp in Group B) for finding the difference in image quality when the tube voltage is lowered.

RESULTS

Image quality did not differ between Groups A and B or between Groups a and b. The signal-to-noise ratio and contrast-to-noise ratio were significantly higher for Group B than Group A for the thyroid gland, IJV, and CCA. No statistical differences were found in the comparison of all structures between Groups a and b.

CONCLUSION

There was no significant difference in image quality based on CM concentration with variable radiation doses. Therefore, if an appropriate CT protocol is applied, clinically feasible neck CT images can be obtained even using low-concentration-iodine CM.

Differences in the Recurrence Rate of Immediate Adverse Drug Reactions According to the Components of Alternative Contrast Media: Analysis of Repetitive Computed Tomography Cases in a Single Tertiary Hospital

INTRODUCTION

The recurrence rates of immediate adverse drug reactions (ADRs) to the alternative radiocontrast media (RCM) are not well known. Previous studies suggest selection of alternative RCM considering carbamoyl side chains; however, its usefulness for preventing the recurrence of ADRs has not been clearly verified.

OBJECTIVE

The aim of this study was to verify the recurrence rate of immediate ADRs according to the alternative RCM.

METHOD

This retrospective study analyzed 6420 contrast-enhanced computed tomography (CT) cases of 2009 patients registered in the ADR system from 861,664 CT cases in a single tertiary hospital between 2015 and 2020. Iohexol, iopromide, iobitridol, and iopamidol were used for CT. According to the carbamoyl side chains present, iohexol belongs to group 1, iopromide belongs to groups 1 and 2, iobitridol belongs to group 2, and iopamidol belongs to group 3.

RESULTS

Replacing iobitridol with iopamidol (odds ratio [OR] 2.595, 95% confidence interval [CI] 1.48-4.550) or iopromide (OR 3.354, 95% CI 1.420-7.926) as the subsequent RCM was associated with increased recurrence, while replacing iopamidol with iobitridol (OR 0.506, 95% CI 0.282-0.908) and iopromide with iohexol (OR 0.355, 95% CI 0.177-0.711) was associated with decreased recurrence. Other changes did not influence the recurrence of ADRs.

CONCLUSIONS

The recurrence of immediate ADRs increased in certain RCM combinations of preceding and subsequent CT scans, and the RCMs did not show cross-reactivity. Therefore, the clinical benefit of the alternative RCM considering cross-reactivity is limited. This result suggests that the side chains of RCM do not have an important role in the recurrence of immediate ADRs.

Mas-Related G Protein–Coupled Receptor-X2 and Its Role in Non-immunoglobulin E–Mediated Drug Hypersensitivity

A diverse group of Food and Drug Administration-approved cationic drugs including antibiotics, neuromuscular blocking drugs, opioids, antidepressants, and radiocontrast media activate mast cells and cause hypersensitivity reactions by both an immunoglobulin E IgE-dependent and independent manner. The recent discovery that these drugs activate mast cells via the G protein-coupled receptor known as Mas-related GPCR-X2 (MRGPRX2) has represented a paradigm shift of how drug hypersensitivity reactions are viewed. This article provides an overview of the current status of the role of MRGPRX2 on non-IgE-mediated drug hypersensitivity. Potential risk factors and evaluation for suspected MRGPRX2-mediated drug reactions are also discussed.

Anemia is associated with increased risk of contrast‑induced acute kidney injury: A Systematic Review and Meta-analysis

Previous studies have identified numerous risk factors of contrast-induced acute kidney injury (CI-AKI) in patients undergoing coronary angiography. However, the association between anemia and CI-AKI remains conflicting. Thus, we conducted a meta-analysis to further clarify the relationship between anemia and CI-AKI. PubMed, EMBASE and Web of Science were systematically searched from inception to June 2020 to identify eligible studies. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were used to estimate the correlation between anemia and CI-AKI. The potential publication bias was estimated using funnel plot and Begg's test. A total of 13 studies (five case-control studies and eight cohort studies) comprising 27,135 patients were included. The pooled results showed that anemia was a significant risk factor of CI-AKI (OR, 1.82; 95% CI, 1.27-2.61). Moreover, the results of subgroup analyses and sensitivity analyses were basically consistent with the overall pooled result. Funnel plot and Begg's test indicated that there existed potential publication bias, but the result of trim and filled analysis showed that the pooled results kept stable after adding 'missing' studies. This meta-analysis suggested that anemia may be correlated with an increased incidence of CI-AKI in patients undergoing coronary angiography. However, our conclusions should be interpreted with caution due to some limitations. Therefore, further high-quality trials should be conducted to confirm our findings.

Diagnosing and Managing Patients with Reactions to Radiocontrast Media

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.

Reversible contrast-induced encephalopathy after coil embolization of epistaxis

A 37-year-old woman (35 weeks pregnant) was admitted to a local hospital due to severe epistaxis resulting in shock and the need for emergency cesarean section. After failure to tamponade the bleeding, angiographic treatment was provided. After the procedure, she was admitted to the neurocritical intensive care unit and was confused and agitated, requiring sedation and endotracheal intubation. In the intensive care unit, diagnostic investigations included brain magnetic resonance imaging, lumbar puncture with viral panel, electroencephalogram, tests for autoimmunity, and hydroelectrolytic and metabolic evaluations. Magnetic resonance imaging showed a puntiform restricted diffusion area on the left corona radiata on diffusion weighted imaging and mild cortical posterior edema (without restricted diffusion), and an electroencephalogram showed moderate diffuse slow activity and fronto-temporal slow activity of the left hemisphere with associated scarce paroxysmal components. The other exams did not show any relevant alterations. Due to the temporal relationship, the clinical history and the magnetic resonance imaging results, a diagnosis of contrast-induced encephalopathy was made. After 2 days in the intensive care unit, sedation was withdrawn, the patient was extubated, and total neurological recovery was verified within the next 24 hours.

Pharmacological prevention of delayed hypersensitivity reactions caused by iodinated contrast media

Background

Delayed hypersensitivity reactions (DHRs) to radiocontrast media (RCM) occur in approximately 0.5–23.0% of patients and are thought to be caused by T cell-mediated mechanisms. However, an optimal pharmacological preventive strategy is not yet established in patients with histories of delayed reactions to RCM.

Objective

We aimed to evaluate the efficacy of pharmacological prevention in patients with histories of delayed reactions to non-ionic low-osmolar RCM when re-exposed to RCM.

Methods

A retrospective review of electronic medical records of 117 patients with previous histories of DHRs to RCM who visited an allergy clinic for the prevention of reactions after the re-exposure to RCM was conducted. The effects of pharmacological prevention were compared according to the symptom scores of previous reactions based on their intensities and durations with electronic medical records (EMRs).

Results

Of the 117 patients who experienced DHRs after RCM injection, we confirmed the outcomes of RCM re-exposure in 101 patients. For pharmacological prevention, 92 patients (91.1%) received steroids before RCM injection and among them, 50 patients (49.5%) received additional steroids after RCM injection. With this pharmacological prevention, patients of symptoms improved or no recurrence, recurrence of similar previous symptoms, and recurrence of worse symptoms were 98 (97.0%), 2 (2.0%), and 1 (1.0%), respectively. The proportions of no recurrence after pharmacological prevention were lower in patients with severe reactions and higher symptom scores.

Conclusion

Pharmacological prevention showed a beneficial effect in most patients with delayed hypersensitivity to RCM. Further investigations are needed to establish an effective protocol for the prevention of delayed reactions to RCM.

Unexpected degradation and deiodination of diatrizoate by the Cu(II)/S(IV) system under anaerobic conditions

Transition metal catalyzed sulfite auto-oxidation is a promising technology used in water and wastewater treatment for the elimination of contaminants. In the literature, this process has been reported to be efficient only in the presence of oxygen. However, in this study, we unexpectedly found that the degradation of diatrizoate (DTZ) by a system based on the combination of copper ion and sulfite (Cu(II)/S(IV)) reached over 95% under anaerobic conditions, but was considerably retarded under aerobic conditions at pH 7. Furthermore, it was found that Cu(I), generated from the cleavage of the CuSO₃ complex, was the main reactive species responsible for the degradation of DTZ by the Cu(II)/S(IV) system under anaerobic conditions. In fact, the absence of oxygen promoted the accumulation of Cu(I). The concomitant release of the iodide ion with the degradation of DTZ indicated that the anaerobic degradation of DTZ by the Cu(II)/S(IV) system mainly proceeded through the deiodination pathway, which was also confirmed by the detection of deiodinated products. The anaerobic degradation of DTZ was favored at higher initial concentrations of Cu(II) or sulfite in this system. Since the CuSO₃ complex, the precursor of Cu(I), was formed mainly at pH 7, the highest anaerobic degradation of DTZ was achieved at pH 7. An increase in reaction temperature considerably enhanced the degradation of DTZ by the Cu(II)/S(IV) system with an apparent activation energy of 119.4 kJ/mol. The presence of chloride, bicarbonate and humic acid slightly influenced the anaerobic degradation of DTZ. The experiments with real water samples also demonstrated the effectiveness of the degradation of DTZ by the Cu(II)/S(IV) system under anaerobic conditions.

Outcomes in patients with known contrast allergy undergoing contrast-enhanced endourological procedures: a retrospective cohort study

BACKGROUND

Intravenous administration of iodinated contrast agents carries the risk of allergic reaction, yet this risk is unclear with administration into the urinary tract. We sought to evaluate patients with known contrast, iodine, or shellfish allergies for allergic response when undergoing urologic imaging requiring intraluminal, urinary tract contrast administration.

MATERIALS AND METHODS

We retrospectively reviewed consecutive patients undergoing endourologic procedures from 2010 to 2015 at our institution. Clinical records were reviewed for demographics, medical history, allergies, procedure details, fluids administered, anesthetic and pharmacologic agents administered, and continuous monitoring parameters. Patients with known allergies to iodine, shellfish, and/or contrast were identified and evaluated for clinical or hemodynamic signs of allergy. A convenience sample of 50 patients without allergy history was used as a comparison group.

RESULTS

We identified 1,405 procedures involving 1,000 consecutive patients. Procedures included retrograde pyelograms and antegrade nephrostograms. Eighty-six cases involving 58 patients with contrast, iodine, or shellfish allergies were identified. Of those with contrast allergy history, 18 (20.1%) cases involved patients with a history of anaphylactic reaction. Of these, 11 (61%) received steroid prophylaxis. No patients in either group (Allergy, No Allergy) were identified as having an allergic reaction during the procedure. There were no statistically significant differences in intraoperative intravenous fluids (p=0.931), procedure duration (p=0.747), or vasopressor use (p=0.973) between groups. Due to the zero event rate of contrast allergy, we used the Hanley and Lippman-Hand method, which places true population risk (95% confidence interval) of a significant event at less than 3.5%.

CONCLUSIONS

In 86 cases involving patients with a history of contrast allergy, we found no evidence of clinically significant allergic reaction to intraluminal endourologic contrast administration under continuous anesthesia monitoring. The risk of significant reactions to contrast administered within the urinary tract appears to be low in these patients, regardless of prophylaxis.

Associations between HLA-A, -B, and -C alleles and iodinated contrast media-induced hypersensitivity in Koreans

A common cause of drug hypersensitivity reactions is iodinated contrast media (ICM). ICM-induced hypersensitivity had been considered to be a non-immunological reaction, but evidence for an immunological mechanism has increased recently. Thus, we evaluated whether HLA-A, -B, and -C alleles were associated with ICM-induced hypersensitivity. In total, 126 patients who underwent contrast-enhanced computed tomography studies through outpatient clinics at a tertiary referral hospital between 2008 and 2012 were assessed. Sixty-one patients experienced ICM-induced hypersensitivity and the remainder, 65, were ICM-tolerant patients (control). ICM-induced hypersensitivity patients showed 51 with immediate, 7 with non-immediate, 3 with both or mixed type. HLA-A, -B, and -C genotyping was performed using a PCR sequence-based typing method. Four kinds of ICM were used: iopromide, iohexol, iobitridol, and iodixanol. The most used ICM among the hypersensitivity patients was iopromide. Significant difference in the frequency of HLA-B*58:01 (odds ratios [OR], 3.90; p = 0.0200, 95% confidence interval [CI], 1.16-13.07) was observed between ICM-induced immediate hypersensitivity and control. There were statistically significant differences in the frequencies of the HLA-B*38:02 (OR, 10.24; p = 0.0145; 95% CI, 1.09-96.14) and HLA-B*58:01 (OR, 3.98; p = 0.0348; 95% CI, 1.03-15.39) between iopromide-induced immediate hypersensitivity and control. The mechanism of ICM-induced hypersensitivity remains unknown, but this study showed associations, although weak, with HLA-B*58:01 alleles for ICM-induced immediate hypersensitivity and HLA-B*38:02 and HLA-B*58:01 for iopromide-induced immediate hypersensitivity as risk predictors. Further studies are needed to validate the associations in larger samples and to identify the functional mechanism behind these results.

Iodinated trihalomethanes formation in iopamidol-contained water during ferrate/chlor(am)ination treatment

Iopamidol is a commonly used iodinated X-ray contrast media in medical field, and its residue in water can react with disinfectants to form highly toxic iodinated disinfection by-products (I-DBPs). This study investigated the degradation of iopamidol and formation of DBPs, especially iodinated trihalomethanes (I-THMs), during ferrate (Fe(VI)) pre-oxidation and subsequent chlor(am)ination under raw water background. It was found that iopamidol degradation efficiency in raw water by Fe(VI) at pH 9 could reach about 80%, which was much higher than that at pH 5 and pH 7 (both about 25%). With Fe(VI) dose increasing, iopamidol removal efficiency increased obviously. During the iopamidol degradation by Fe(VI), IO₃^- was the dominant product among all the iodine species. After pre-treated by Fe(VI), yields of THM4 and I-THMs can be reduced in subsequent chlor(am)ination. Besides, pH was a crucial factor for Fe(VI) pre-oxidition controlling DBPs. With the pH increasing from 5 to 9, the yield of THM4 kept increasing in subsequent chlorination but showed the highest amount at pH 6 in subsequent chloramination. The yield of I-THMs increased first and then decreased with the increase of pH in both subsequent chlorination and chloramination. I-THM concentrations in chlorinated samples were lower than chloraminated ones under acidic conditions but became higher under neutral and alkaline conditions. The total CTI of THMs during Fe(VI)-chloramination was higher than that during Fe(VI)-chlorination under neutral condition, but sharply decreased under alkaline conditions. In summary, Fe(VI)-chloramination subsequent treatment under alkaline conditions should be an effective method for iopamidol removal and DBP control.

Assessment of immediate and non-immediate hypersensitivity contrast reactions by skin tests and provocation tests: A review

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.

Comprehensive review on iodinated X-ray contrast media: Complete fate, occurrence, and formation of disinfection byproducts

Iodinated contrast media (ICM) are drugs which are used in medical examinations for organ imaging purposes. Wastewater treatment plants (WWTPs) have shown incapability to remove ICM, and as a consequence, ICM and their transformation products (TPs) have been detected in environmental waters. ICM show limited biotransformation and low sorption potential. ICM can act as iodine source and can react with commonly used disinfectants such as chlorine in presence of organic matter to yield iodinated disinfection byproducts (IDBPs) which are more cytotoxic and genotoxic than conventionally known disinfection byproducts (DBPs). Even highly efficient advanced treatment systems have failed to completely mineralize ICM, and TPs that are more toxic than parent ICM are produced. This raises issues regarding the efficacy of existing treatment technologies and serious concern over disinfection of ICM containing waters. Realizing this, the current review aims to capture the attention of scientific community on areas of less focus. The review features in depth knowledge regarding complete environmental fate of ICM along with their existing treatment options.

HLA-DRB1*15: 02 Is Associated With Iodinated Contrast Media-Related Anaphylaxis

BACKGROUND

The incidence of severe reaction induced by iodinated contrast media (ICM) has increased over the years with an increasing use of imaging modalities. Although ICM anaphylaxis is rare, it can be life-threatening, but currently, there is no biomarker that can identify individuals at risk of ICM anaphylaxis.

OBJECTIVE

The aim of this study is to investigate the genetic susceptibility of ICM anaphylaxis.

METHODS

Patients who had ICM anaphylaxis were enrolled in the study, and their blood samples were collected for genotyping of human leukocyte antigen (HLA)-A, -B, -C, and -DR. The results were compared with those of healthy Korean general population. MRGPRX2 gene in ICM anaphylaxis group was also sequenced and compared with the Korean standard database of genetic polymorphism.

RESULTS

The frequencies of 3 HLA alleles (B*52:01, C*12:02, and DRB1*15:02) were significantly higher in 47 patients with ICM anaphylaxis. In particular, HLA-DRB1*15:02 was 5 times more frequent in the ICM anaphylaxis group than the Korean general population (34.0% vs 6.6%; odds ratio, 7.306; 95% confidence interval, 3.622-14.740), and this difference was most pronounced in subjects with iohexol-induced anaphylaxis (odds ratio, 16.516; 95% CI, 5.241-52.047; P < 0.0001). Eight single nucleotide polymorphisms were identified in MRGPRX2 gene, but their frequencies were not different in those with ICM anaphylaxis compared with the general Korean population.

CONCLUSIONS

HLA-DRB1*15:02 is associated with ICM anaphylaxis in the Korean population.

Novel biomarkers for post-contrast acute kidney injury identified from long non-coding RNA expression profiles

Background: Post-contrast acute kidney injury (PC-AKI) is a severe complication of cardiac catheterization. Emerging evidence indicated that long non-coding RNAs (lncRNAs) could serve as biomarkers for various diseases. However, the lncRNA expression profile and potential biomarkers in PC-AKI remain unclear. This study aimed to investigate novel lncRNA biomarkers for the early detection of PC-AKI. Methods: lncRNA profile in the kidney tissues of PC-AKI rats was evaluated through RNA sequencing. Potential lncRNA biomarkers were identified through human-rat homology analysis, kidney and blood filtering in rats and verified in 112 clinical samples. The expression patterns of the candidate lncRNAs were detected in HK-2 cells and rat models to evaluate their potential for early detection. Results: In total, 357 lncRNAs were found to be differentially expressed in PC-AKI. We identified lnc-HILPDA and lnc-PRND were conservative and remarkably upregulated in both kidneys and blood from rats and the blood of PC-AKI patients; these lncRNAs can precisely distinguish PC-AKI patients (area under the curve (AUC) values of 0.885 and 0.875, respectively). The combination of these two lncRNAs exhibited improved accuracy for predicting PC-AKI, with 100% sensitivity and 83.93% specificity. Time-course experiments showed that the significant difference was first noted in the blood of PC-AKI rats at 12 h for lnc-HILPDA and 24 h for lnc-PRND. Conclusion: Our study revealed that lnc-HILPDA and lnc-PRND may serve as the novel biomarkers for early detection and profoundly affect the clinical stratification and strategy guidance of PC-AKI.

Intrathecal iodinated contrast-induced transient spinal shock

Transient spinal shock is a previously unreported complication of intrathecal contrast. A 63-year-old man presented with the chief complaint of worsening back pain. Computed topography of lumbar spine without contrast showed a lytic lesion. After international normalized ratio (INR) correction, patient was sent for CT myelogram. After intrathecal contrast injection, the patient dropped his blood pressure profoundly and developed clinical manifestations of spinal shock. Emergent intravenous bolus fluids were initiated resulting in improvement in blood pressure. Patient's spinal shock resolved within hours. CT myelogram was normal except previously known lytic lesion. It was concluded that the transient shock was most likely due to contrast injection. We believe that this is the first reported case of transient spinal shock following CT myelogram using water-soluble iodinated non-ionic contrast agent administered intrathecally.

Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update

BACKGROUND

 Despite tremendous improvement in molecular properties over the last century, intravascular injection of iodinated contrast material may still have systemic and hemodynamic consequences. Patients with pre-existing renal insufficiency may be at risk for acute kidney injury, which may be associated with an increased risk of the need for dialysis and mortality in the long term. Many questions as to the physiological pathways, optimal definition, and incidence of contrast-induced acute kidney injury remain open. These uncertainties are reflected in the changing landscape of this field in terms of nomenclature, research, and clinical practice.

METHODS

 Clinical practice guidelines for the prevention of post-contrast acute kidney injury all recommend giving prophylaxis in the form of intravenous hydration to high-risk patients. Solid evidence for this strategy is lacking. This article gives an overview of the changing landscape of post-contrast acute kidney injury and prophylactic intravenous hydration, with the aim of supporting informed decision-making in clinical practice.

RESULTS

 Recent data have caused a shift in guideline recommendations: 90 % of patients formerly considered high-risk for contrast-induced acute kidney injury no longer qualify for prophylaxis. The remaining high-risk patients, with severe chronic kidney disease, represent a vulnerable population for whom intravenous hydration may provide some benefits but also carries risk.

CONCLUSION

 Intravenous hydration may benefit 'new' high-risk patients. However, it also confers risk. A dual approach to screening patients will help avoid this risk in clinical practice.

KEY POINTS

  · Intravenous hydration is the cornerstone for preventing contrast-induced acute kidney injury. · Solid evidence is lacking; recent data caused a shift in guideline recommendations. · Intravenous hydration may benefit 'new' high-risk patients with severe chronic kidney disease; however, it also confers risk. · A dual approach to screening patients will help avoid this risk in clinical practice.

CITATION FORMAT

· Nijssen E, Rennenberg R, Nelemans P et al. Post-Contrast Acute Kidney Injury and Intravenous Prophylactic Hydration: An Update. Fortschr Röntgenstr 2021; 193: 151 - 159.

Facile Hydrothermal Synthesis of an Iodine-Doped Computed Tomography Contrast Agent Using Insoluble Triiodobenzene

Carbonized iodine-doped particles (CIPs) were developed to overcome the disadvantages of computed tomography (CT) contrast agents, such as high osmolality and the radiodensity dilution of monomolecular contrast agents and low solubility and high toxicity of polymeric contrast agents. The CIPs were synthesized via a hydrothermal synthesis for 8 h using ATIPA (5-amino-2,4,6-triiodoisophthalic acid), glycerol, and tromethamine in the presence of D.W. (deionized water)-insoluble ATIPA converted into CIPs through a hydrothermal synthesis, showing high solubility and low osmotic pressure. The in vitro contrast effect determined for the resulting CIPs demonstrated a 57.6% enhancement compared to iohexol, and the osmotic pressure of the resulting CIPs was lower than that of iohexol. In addition, the CIPs demonstrated no dilution-induced contrast decrease in plasma and, therefore, demonstrated high contrast strength in vivo. Cytotoxicity tests, hemolysis assays, and histological analyses were conducted to verify the biocompatibility of the CIP product; however, no toxicity was observed. Furthermore, the CIP demonstrated a much higher contrast effect than iohexol at low concentrations. These results indicate that the CIP we have produced may be used as an effective blood pool agent for CT imaging.

Imaging characteristics of intravascular spherical contrast agents for grating-based x-ray dark-field imaging – effects of concentrations, spherical sizes and applied voltage

This study investigates the x-ray scattering characteristics of microsphere particles in x-ray-grating-based interferometric imaging at different concentrations, bubble sizes and tube voltages (kV). Attenuation (ATI), dark-field (DFI) and phase-contrast (PCI) images were acquired. Signal-to-noise (SNR) and contrast-to-noise ratios with water (CNRw) and air as reference (CNRa) were determined. In all modalities, a linear relationship between SNR and microbubbles concentration, respectively, microsphere size was found. A significant gain of SNR was found when varying kV. SNR was significantly higher in DFI and PCI than ATI. The highest gain of SNR was shown at 60 kV for all media in ATI and DFI, at 80 kV for PCI. SNR for all media was significantly higher compared to air and was slightly lower compared to water. A linear relationship was found between CNRa, CNRw, concentration and size. With increasing concentration and decreasing size, CNRa and CNRw increased in DFI, but decreased in PCI. Best CNRa and CNRw was found at specific combination of kV and concentration/size. Highest average CNRa and CNRw was found for microspheres in ATI and PCI, for microbubbles in DFI. Microspheres are a promising contrast-media for grating-based-interferometry, if kV, microsphere size and concentration are appropriately combined.

Oral premedication in patients with a history suggesting hypersensitivity to iodinated contrast media

Introduction

Iodinated contrast media (ICM) are pharmaceuticals widely used in diagnostic procedures. Adverse effects associated with their administration are quite frequent and mostly mild. However, they raise concerns in patients and doctors in the context of their future use.

Aim

To determine efficacy of premedication before medical procedures with the use of iodinated contrast media in patients with a history suggesting a hypersensitivity reaction after their past use.

Material and methods

Out of 152 patients consulted due to adverse reactions after ICM (85 women and 67 men, aged 43–90), 101 were selected with the history suggesting a mild hypersensitivity reaction (urticaria, itching, skin redness, malaise etc.). All the patients had health problems requiring a procedure with ICMadministration in the near future. The premedication was given with cetirizine (10 mg) and prednisone (20 mg or 50 mg, randomly assigned) 13, 7 and 1 h before the ICM administration. Presence of adverse events was compared between the subgroups with χ² test and efficacy of premedication – with Wilcoxon test.

Results

Seventy-six patients underwent the radiologic procedure with premedication with antihistamine and a lower (40 patients) or higher dose (36 patients) of prednisone. Four of them reported a cutaneous hypersensitivity reaction (urticaria, itching, redness) and one – dyspnoea. There was no statistically significant difference in relation to the premedication protocol (p = 0.1306).

Conclusions

Premedication with cetirizine and prednisone before radiologic procedures proved to be efficient in patients with a history suggesting hypersensitivity to iodinated contrast media. There was no significant difference in efficacy related to the dose of prednisone (20 mg vs. 50 mg).

Highly efficient degradation of iohexol on a heterostructured graphene-analogue boron nitride coupled Bi2MoO6 photocatalyst under simulated sunlight

Iohexol (IOH), as a typical iodinated X-ray contrast media (ICMs) with potential threat to human health, is difficult to be removed with the conventional wastewater treatment methods. In this work, new boron nitride coupled Bi₂MoO₆ layered microspheres (BN/Bi₂MoO₆) composites were applied to remove IOH from water via photocatalytic degradation. The degradation constant k_app of IOH over 3.5 wt% BN/Bi₂MoO₆ was 0.016 min^-1, which was 3.2 times that of Bi₂MoO₆ (0.005 min^-1). The degradation rate of IOH on 3.5 wt% BN/Bi₂MoO₆ reached 92% in 150 min. The enhanced photocatalytic activity of BN/Bi₂MoO₆ can be attributed to the heterojunction between BN and Bi₂MoO₆. The matched type-I band alignment heterojunction of two semiconductors prominently improved the charge separation. Based on the trapping experiments, holes and superoxide radicals were proved to be the main active species for photocatalytic IOH degradation. Besides, the degradation products of IOH were analyzed by LC-HRMS and the possible degradation mechanism of IOH was also proposed in this work.

Synthesis and in vivo evaluation of PEG-BP-BaYbF5 nanoparticles for computed tomography imaging and their toxicity

Computed tomography (CT) is one of the most widespread imaging techniques in clinical use worldwide. CT contrast agents are administered to improve soft tissue contrast and highlight blood vessels. However, the range of CT contrast agents available in the clinic is limited and they suffer from short-circulation times and low k-edge values that result in the need for high doses for in vivo applications. Nanomaterials containing a mixture of electron-dense elements, such as BaYbF₅ nanoparticles, have shown promise as more efficient CT contrast agents, but they require biocompatible coatings for biomedical applications. Here, we explore the use of a bifunctional PEG polymer (5 kDa) containing a terminal bisphosphonate (BP) anchor for efficient binding to the surface of BaYbF₅ nanomaterials. The resulting PEG(5)-BP-BaYbF₅ nanoparticles were synthesized and characterized using TEM, DLS, TGA, XRD and Z-potential measurements. Their in vitro stability was verified and their ability to produce CT contrast in a wide range of X-ray energies, covering preclinical and clinical scanners, was demonstrated. In vitro toxicity studies with PEG(5)-BP-BaYbF₅ in the phagocytic pro-monocytic human cell line U937 did not identify toxic effects, even at high concentrations (30 mM). In vivo, PEG(5)-BP-BaYbF₅ exhibited efficient CT contrast for angiography imaging, highlighting blood vessels and vascular organs, and long circulation times as expected from the PEG coating. However, at late time points (48 h), in vivo toxicity was observed. While the causes could not be completely elucidated, in vitro studies suggest that decomposition and release of Yb³⁺ and/or Ba²⁺ metal ions after decomposition of PEG(5)-BP-BaYbF₅ may play a role. Overall, despite the promising CT contrast properties, our results suggest that BaYbF₅ nanomaterials may suffer from significant long-term toxicities.

Contrast-enhanced micro-computed tomography of articular cartilage morphology with ioversol and iomeprol

Non-ionic, low-osmolar contrast agents (CAs) used for computed tomography, such as Optiray (ioversol) and Iomeron (iomeprol), are associated with the reduced risk of adverse reactions and toxicity in comparison with ionic CAs, such as Hexabrix. Hexabrix has previously been used for imaging articular cartilage but has been commercially discontinued. This study aimed to evaluate the efficacy of Optiray and Iomeron as alternatives for visualisation of articular cartilage in small animal joints using contrast-enhanced micro-computed tomography (CECT). For this purpose, mouse femora were immersed in different concentrations (20%-50%) of Optiray 350 or Iomeron 350 for periods of time starting at five minutes. The femoral condyles were scanned ex vivo using CECT, and regions of articular cartilage manually contoured to calculate mean attenuation at each time point and concentration. For both CAs, a 30% CA concentration produced a mean cartilage attenuation optimally distinct from both bone and background signal, whilst 5-min immersion times were sufficient for equilibration of CA absorption. Additionally, plugs of bovine articular cartilage were digested by chondroitinase ABC to produce a spectrum of glycosaminoglycan (GAG) content. These samples were immersed in CA and assessed for any correlation between mean attenuation and GAG content. No significant correlation was found between attenuation and cartilage GAG content for either CAs. In conclusion, Optiray and Iomeron enable high-resolution morphological assessment of articular cartilage in small animals using CECT; however, they are not indicative of GAG content.

Biomarkers in the prediction of contrast media induced nephropathy - the BITCOIN study

Background

Subjects with chronic kidney disease are at increased risk for contrast-induced acute kidney injury (CI-AKI). Risk stratification is traditionally based on glomerular filtration rate (GFR) and proteinuria. The present trial examines, whether tubular and inflammatory biomarkers are able to identify subjects at increased risk as well.

Methods

We performed a prospective study in 490 patients undergoing coronary angiography. An increase of serum creatinine concentration ≥ 0.3 mg/dl from baseline to day 2–3 was defined as primary endpoint (CI-AKI). Urinary neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and calprotectin were assessed < 24h before coronary angiography. Prognostic accuracy was assessed by receiver operating characteristics (ROC) calculations.

Results

30 (6.1%) patients suffered from CI-AKI (27 AKIN stage I, 3 AKIN stage II, 0 AKIN stage III). Those subjects who developed CI-AKI had 3.1 fold higher baseline urinary NGAL/creatinine ratios than those without CI-AKI (60.8 [IQR 18.7–93.1] μg/mg vs. 19.9 [IQR 12.3–38.9] μg/mg, p = 0.001). In those subjects without clinically overt CKD (eGFR > 60 ml/min, urinary albumin creatinine ratio <30 mg/g), the NGAL/creatinine ratio was 2.6 higher in CI-AKI vs. no CI-AKI (47.8 [IQR 11.8–75.3] vs. 18.6 [IQR 11.7–36.3] μg/mg). No significant differences were obtained for KIM-1 and calprotectin (p>0.05 each). ROC analyses revealed an area under the curve (AUC) of 0.68 (95% CI 0.60–0.81) for NGAL/creatinine. An NGAL/creatinine ratio < 56.4 μg/mg has a negative predictive value of 96.5%.

Conclusions

The present study is the largest investigation on the use of urinary biomarkers for CI-AKI risk stratification so far. It shows that NGAL provides prognostic information beyond the glomerular biomarkers eGFR and proteinuria.

Random forest for prediction of contrast-induced nephropathy following coronary angiography

The majority of prediction models for contrast-induced nephropathy (CIN) have moderate performance. Therefore, we aimed to develop a better pre-procedural prediction tool for CIN following contemporary percutaneous coronary intervention (PCI) or coronary angiography (CAG). A total of 3469 patients undergoing PCI/CAG between January 2010 and December 2013 were randomly divided into a training (n = 2428, 70%) and validation data-sets (n = 1041, 30%). Random forest full models were developed using 40 pre-procedural variables, of which 13 variables were selected for a reduced CIN model. CIN developed in 78 (3.21%) and 37 of patients (3.54%) in the training and validation datasets, respectively. In the validation dataset, the full and reduced models demonstrated improved discrimination over classic Mehran, ACEF CIN risk scores (AUC 0.842 and 0.825 over 0.762 and 0.701, respectively, all P < 0.05) and common estimated glomerular filtration rate. Compared to that for the Mehran risk score model, the full and reduced models had significantly improved fit based on the net reclassification improvement (all P < 0.001) and integrated discrimination improvement (P = 0.001, 0.028, respectively). Using the above models, 2462 (66.7%), 661, and 346 patients were categorized into low (< 1%), moderate (1% to 7%), and high (> 7%) risk groups, respectively. Our pre-procedural CIN risk prediction algorithm (http://cincalc.com) demonstrated good discriminative ability and was well calibrated when validated. Two-thirds of the patients were at low CIN risk, probably needing less peri-procedural preventive strategy; however, the discriminative ability of CIN risk requires further external validation. TRIAL REGISTRATION: ClinicalTrials.gov NCT01400295.

Effect of Different Iodine Concentrations on Patient-Reported Discomfort in Contrast-Enhanced Computed Tomography: A Prospective Comparative Trial

PURPOSE

 Reducing contrast media injection speed while maintaining iodine flux is a promising workaround to lower or avoid contrast media-related discomfort during CT examinations. This approach demands contrast media with a higher concentration to guarantee excellent image quality. It remains unclear whether these concentration changes affect the patient's experience. Thus, the aim of this study was to evaluate the influence of different concentrations of intravenous iodinated contrast media on patient discomfort during and after contrast media delivery.

MATERIALS AND METHODS

 Patients were randomized to receive either Iomeprol 400 mg/ml (group A) or 300 mg/ml (group B) during routinely scheduled CT examinations at our department. The iodine delivery rate and injection time were kept constant in both groups. After examination, study subjects completed a digital questionnaire on different CM-related sensation items using digital visual analogue scales.

RESULTS

 253 consecutive patients were enrolled in a 6-month period. Most of the patients reported heat sensation in both groups (mean VAS: 5.3 mm in group A vs. 5.0 mm in group B, p = 0.5). Taste sensation also did not differ significantly between both groups (2.4 mm vs. 2.0 mm, p = 0.08). Pain sensation was reported to be significantly lower in group B patients (1.3 mm vs. 1.0 mm, p = 0.005), even though pain sensation in general was reported on a very low level. Other injection-related sensations were rarely reported.

CONCLUSION

 Patient-reported discomfort during intravenous injection of high-concentration contrast media (400 mg/ml) was low and only marginally different when compared to the injection of contrast media with a lower concentration. The injection of highly concentrated contrast media showed comparable overall patient acceptance, allowing a reduction of the injection speed and volume during examinations.

KEY POINTS

  · Patient-reported, contrast-related discomfort was very low in this study.. · High-concentration contrast media (HCCM) showed comparable overall patient acceptance.. · HCCM allow a reduction of injection speeds while keeping iodine flux constant..

CITATION FORMAT

· Vahldiek JL, Schaafs LA, Niehues BK et al. Effect of Different Iodine Concentrations on Patient-Reported Discomfort in Contrast-Enhanced Computed Tomography: A Prospective Comparative Trial. Fortschr Röntgenstr 2020; 192: 945 - 951.

Disinfection byproducts and halogen-specific total organic halogen speciation in chlorinated source waters - The impact of iopamidol and bromide

This study investigated the speciation of halogen-specific total organic halogen and disinfection byproducts (DBPs) upon chlorination of natural organic matter (NOM) in the presence of iopamidol and bromide (Br^-). Experiments were conducted with low bromide source waters with different NOM characteristics from Northeast Ohio, USA and varied spiked levels of bromide (2-30 μmol/L) and iopamidol (1-5 μmol/L). Iopamidol was found to be a direct precursor to trihalomethane (THM) and haloacetic acid formation, and in the presence of Br^- favored brominated analogs. The concentration and speciation of DBPs formed were impacted by iopamidol and bromide concentrations, as well as the presence of NOM. As iopamidol increased the concentration of iodinated DBPs (iodo-DBPs) and THMs increased. However, as Br^- concentrations increased, the concentrations of non-brominated iodo- and chloro-DBPs decreased while brominated-DBPs increased. Regardless of the concentration of either iopamidol or bromide, bromochloroiodomethane (CHBrClI) was the most predominant iodo-DBP formed except at the lowest bromide concentration studied. At relevant concentrations of iopamidol (1 μmol/L) and bromide (2 μmol/L), significant quantities of highly toxic iodinated and brominated DBPs were formed. However, the rapid oxidation and incorporation of bromide appear to inhibit iodo-DBP formation under conditions relevant to drinking water treatment.

Impact on clinical practice of updated guidelines on iodinated contrast material: CINART

Objective

Guidelines on safe use of iodinated contrast material recommend intravenous prophylactic hydration to prevent post-contrast adverse (renal) effects. Recently, guidelines have been updated and standard prophylaxis is no longer recommended for the majority of patients. The current study aims to evaluate the consequences for clinical practice of the updated guidelines in terms of complications, hospitalisations, and costs.

Methods

The Contrast-Induced Nephropathy After Reduction of the prophylaxis Threshold (CINART) project is a retrospective observational study. All elective procedures with intravascular iodinated contrast administration at Maastricht University Medical Centre (UMC+) in patients aged > 18 years, formerly eligible for prophylaxis (eGFR 30–44 ml/min/1.73 m² or eGFR 45–59 ml/min/1.73 m² in combination with diabetes or > 1 predefined risk factor), and currently eligible for prophylaxis (eGFR < 30 ml/min/1.73 m²) were included. Data were used to calculate relative reductions in complications, hospitalisations, and costs associated with standard prophylactic intravenous hydration. CINART is registered with Clinicaltrials.gov: NCT03227835.

Results

Between July 1, 2017, and July 1, 2018, 1992 elective procedures with intravascular iodinated contrast in patients formerly and currently eligible for prophylaxis were identified: 1808 in patients formerly eligible for prophylaxis and 184 in patients currently eligible for prophylaxis. At Maastricht UMC+, guideline updates led to large relative reductions in numbers of complications of prophylaxis (e.g. symptomatic heart failure; − 89%), extra hospitalisations (− 93%), and costs (− 91%).

Conclusion

Guideline updates have had a demonstrable impact on daily clinical practice benefiting patient, hospital, and health care budgets. Clinical practice varies between institutions and countries; therefore, a local estimation model is provided with which local impact on costs, hospitalisations, and complications can be calculated.

Key Points

• Clinical practice guidelines recommend prophylactic intravenous hydration to prevent post-contrast adverse outcomes such as contrast-induced acute kidney injury.

• Clinical practice guidelines have recently been updated, and standard prophylaxis is no longer recommended for the majority of patients.

• The guideline updates have a large impact on daily clinical practice: relative reductions at Maastricht UMC+ were − 89% prophylaxis complications, − 93% hospitalisations, and − 91% costs, and similar reductions are expected for Dutch and adherent European medical centres.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06719-7) contains supplementary material, which is available to authorized users.

Resolving the kinetic and intrinsic constraints of heat-activated peroxydisulfate oxidation of iopromide in aqueous solution

Iopromide (IOP) has been identified as one of the most persistent pharmaceuticals in wastewater treatment processes, however, kinetic and intrinsic factors constraining its fast removal in advanced oxidation processes (AOPs) are yet to be resolved. Here oxidation of IOP by heat-activated peroxydisulfate (PDS) was investigated both experimentally and theoretically. Rates of IOP degradation were enhanced by elevating solution temperature and acidity. An apparent kinetic rate equation was developed, based on the pseudo-first-order reaction model and assumption of steady state of SO₄^-. The common water constituents showed inhibitory effects on IOP decomposition to various extent. An insufficient supply of SO₄^- was considered as the major kinetic constraint. Eight byproducts were identified and most of which had intact triiodinated benzene ring. O-demethylation, oxidation of amino moiety and oxidation/elimination of alcohol groups are proposed as the primary degradation pathways, in accordance with the incomplete mineralization and non-detectable release of inorganic iodine. Quantum chemical calculations predict that oxidation of alkyl chains of IOP preferentially occurs and IOP byproducts with shorter side chains and intact triiodinated ring are more reactive than IOP. By virtue of the identified kinetic and intrinsic constraints, strategies to maximize degradation efficiency of IOP are proposed.

Validation of pre-operative risk scores of contrast-induced acute kidney injury in a Chinese cohort

Background

Pre-operative risk scores are more valuable than post-procedure risk scores because of lacking effective treatment for contrast-induced acute kidney injury (CI-AKI). A number of pre-operative risk scores have been developed, but due to lack of effective external validation, most of them are also difficult to apply accurately in clinical practice. It is necessary to review and validate the published pre-operative risk scores for CI-AKI.

Materials and methods

We systematically searched PubMed and EMBASE databases for studies of CI-AKI pre-operative risk scores and assessed their calibration and discriminatory in a cohort of 2669 patients undergoing coronary angiography or percutaneous coronary intervention (PCI) from September 2007 to July 2017. The definitions of CI-AKI may affect the validation results, so three definition were included in this study, CI-AKI broad1 was defined as an increase in serum creatinine (Scr) of 44.2 μmol/L or 25%; CI-AKI broad2, an increase in Scr of 44.2 μmol/L or 50%; and CI-AKI-narrow, an increase in Scr of 44.2 μmol/L. The calibration of the model was assessed with the Hosmer-Lemeshow test and the discriminatory capacity was identified by C-statistic.

Results

Of the 8 pre-operative risk scores for CI-AKI identified, 7 were single-center study and only 1 was based on multi-center study. In addition, 7 of the scores were just validated internally and only Chen score was externally validated. In the validation cohort of 2669 patients, the incidence of CI-AKI ranged from 3.0%(Liu) to 16.4%(Chen) for these scores. Furthermore, the incidence of CI-AKI was 6.59% (178) for CI-AKI broad1, 1.44% (39) for CI-AKI broad2, and 0.67% (18) for CI-AKI-narrow. For CI-AKI broads, C-statistics varied from 0.44 to 0.57. For CI-AKI-narrow, the Maioli score had the best discrimination and calibration, what’s more, the C-statistics of Maioli, Chen, Liu and Ghani was ≥0.7.

Conclusion

Most pre-operative risk scores were established based on single-center studies and most of them lacked external validation. For CI-AKI broads, the prediction accuracy of all risk scores was low. The Maioli score had the best discrimination and calibration, when using the CI-AKI-narrow definition.