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Okubo Y, Miyamoto S, Okamura S, Tokuyama T, Nakano Y. Retrograde carbon dioxide coronary sinus venography. Pacing Clin Electrophysiol 2023; 46:31-33. [PMID: 35859525 DOI: 10.1111/pace.14570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 01/20/2023]
Abstract
It is potentially harmful to perform coronary sinus (CS) angiography in patients with severe contrast allergy or severe renal dysfunction due to the risk of contrast-induced nephropathy (CIN). However, angiography is a well-established method to guide LV-lead position during cardiac resynchronization therapy-implantation. These two case reports describe the first successful applications of carbon dioxide CS angiography in patients requiring cardiac resynchronization therapy.
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Affiliation(s)
- Yousaku Okubo
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shogo Miyamoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Sho Okamura
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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2
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Li L, Foer D, Hallisey RK, Hanson C, McKee AE, Zuccotti G, Mort EA, Sequist TD, Kaufman NE, Seguin CM, Kachalia A, Blumenthal KG, Wickner PG. Improving Allergy Documentation: A Retrospective Electronic Health Record System-Wide Patient Safety Initiative. J Patient Saf 2022; 18:e108-e114. [PMID: 32487880 PMCID: PMC7704710 DOI: 10.1097/pts.0000000000000711] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Documentation of allergies in a coded, non-free-text format in the electronic health record (EHR) triggers clinical decision support to prevent adverse events. Health system-wide patient safety initiatives to improve EHR allergy documentation by specifically decreasing free-text allergy entries have not been reported. The goal of this initiative was to systematically reduce free-text allergen entries in the EHR allergy module. METHODS We assessed free-text allergy entries in a commercial EHR used at a multihospital integrated health care system in the greater Boston area. Using both manual and automated methods, a multidisciplinary consensus group prioritized high-risk and frequently used free-text allergens for conversion to coded entries, added new allergen entries, and deleted duplicate allergen entries. Environmental allergies were moved to the patient problem list. RESULTS We identified 242,330 free-text entries, which included a variety of environmental allergies (42%), food allergies (18%), contrast media allergies (13%), "no known allergy" (12%), drug allergies (2%), and "no contrast allergy" (2%). Most free-text entries were entered by medical assistants in ambulatory settings (34%) and registered nurses in perioperative settings (20%). We remediated a total of 52,206 free-text entries with automated methods and 79,578 free-text entries with manual methods. CONCLUSIONS Through this multidisciplinary intervention, we identified and remediated 131,784 free-text entries in our EHR to improve clinical decision support and patient safety. Additional strategies are required to completely eliminate free-text allergy entry, and establish systematic, consistent, and safe guidelines for documenting allergies.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | | | | | | | | | | | | | | | | | - Allen Kachalia
- Division of General Medicine, Department of Medicine and Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine Baltimore, MD
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston MA
| | - Paige G. Wickner
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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3
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Prins MLM, Ballieux BEPB, Meijer OC, Pereira AM, Nijhoff MF. Adrenal Vein Sampling in a Patient With Primary Hyperaldosteronism and Severe Contrast Allergy. J Endocr Soc 2021; 5:bvab122. [PMID: 34350369 PMCID: PMC8328093 DOI: 10.1210/jendso/bvab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
We report on a case of a 50-year-old female patient with primary hyperaldosteronism, in whom adrenal venous sampling was required to differentiate between unilateral and bilateral disease. Because of a history of severe allergy to iodinated contrast media, premedication with glucocorticoids was indicated. Exogenous glucocorticoids, however, can affect measurements of serum cortisol. To avoid this potential confounding effects on the cortisol assay, we decided to use dexamethasone instead of prednisolone or hydrocortisone. A high-dose adrenocorticotropin (ACTH) stimulation test with the simultaneous use of dexamethasone revealed an adequate adrenal cortisol response. ACTH-stimulated adrenal venous sampling showed reliable results, which provided a solid basis for further clinical decision-making.
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Affiliation(s)
- Margaretha L M Prins
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Bartholomeus E P B Ballieux
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michiel F Nijhoff
- Department of Medicine, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Medicine, Division of Endocrinology, Leiden University Medical Centre, Leiden, The Netherlands
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Ananthakrishnan L, Parrott DT, Mielke N, Xi Y, Davenport MS. Fidelity of Electronic Documentation for Reactions Prompting Premedication to Iodinated Contrast Media. J Am Coll Radiol 2021; 18:982-989. [PMID: 33571478 DOI: 10.1016/j.jacr.2021.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE The aims of this study were to assess the fidelity of electronic health record documentation prompting premedication to iodinated contrast media and to determine the appropriateness of administered premedication on the basis of that documentation. METHODS In this retrospective quality assurance cohort study, medication adverse events recorded in electronic health records between January 1, 2018, and August 31, 2019, to "iodine," "iodine-containing products," and "iodinated contrast media" were identified (N = 4,309); entries missing documentation (n = 1,651) and breakthrough reactions (n = 22) were excluded. Reaction description, severity, and free-text comments were used to categorize each entry as concordant (documentation matches recorded severity per the ACR Manual on Contrast Media version 10.3), discordant (description-severity mismatch, agent unrelated to iodinated contrast media, not a hypersensitivity reaction), or unclear. A subset of patients undergoing premedication was identified, and premedication was categorized as appropriate, inappropriate, or unsure on the basis of the index reaction using the aforementioned framework. Descriptive statistics were calculated. RESULTS There were 2,636 adverse event entries in 2,441 patients: 59.9% (1,578 of 2,636) were classified as concordant, 30.2% (797 of 2,636) as discordant (n = 377 not a hypersensitivity reaction, n = 317 description-severity mismatch, and n = 103 unrelated agent), and 9.9% (n = 261) as unclear documentation. For the premedicated subset, concordance classification was feasible for 202 unique patients premedicated 335 times. Premedication was appropriate in 72% (240 of 335) and inappropriate in 22% (73 of 335); 17% of premedication events (56 of 335) were inappropriately administered for a prior physiologic reaction. CONCLUSIONS Premedication prompts in the electronic health record are often erroneous because of inaccurate coding, incomplete data, and reaction misclassification. These errors result in inappropriate premedication for a substantial minority of patients.
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Affiliation(s)
- Lakshmi Ananthakrishnan
- Director of Computed Tomography, Assistant Professor, Abdominal Imaging Division, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Daniel T Parrott
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nathan Mielke
- Baylor Scott and White Health System, Round Rock, Texas
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew S Davenport
- Associate Chair of Operations, Service Chief of Adult Radiology, Departments of Radiology and Urology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Abstract
Intravascular ultrasound allows for detailed imaging of the dialysis access anatomy. Accurate visualization and precise measurements of the anatomy can be obtained using intravascular ultrasound, while limiting contrast usage and radiation exposure. Intravascular ultrasound allows for a true appreciation of stenosis morphology and can further guide endovascular management decisions, with a particular benefit in management of central venous lesions. Here, we describe a series of cases that together highlight the advantages of using intravascular ultrasound in the evaluation and management of dialysis access care.
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Affiliation(s)
- Daniel Patel
- Volusia Flagler Vascular Center, Daytona Beach, FL, USA
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Maus TP, Schueler BA, Magnuson DJ, Magnuson D. Relative Conspicuity of Gadolinium-Based Contrast Agents in Interventional Pain Procedures. Pain Med 2017; 18:651-654. [PMID: 28586445 DOI: 10.1093/pm/pnw312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective To assess the relative radiographic conspicuity of gadolinium-based contrast agents (GBCAs) that may be used in spinal injection procedures when iodine-based contrast agents are contraindicated. Methods Eight GBCAs and three iodinated agents of varying iodine concentrations were radiographed under conditions representative of lumbar spinal injections at four kilovoltage peak (kVp) values. Radiographic contrast of each agent was measured as the percent pixel value difference with respect to background. Results Gadobutrol (Gadovist, 1 mM/mL) had the highest radiographic contrast among the gadolinium agents tested. Measured radiographic contrast correlated with the molar concentration of gadolinium. Gadobutrol radiographic contrast lies between the contrast of iohexol concentrations of 240 and 140 mgI/mL. All agents have decreasing contrast as kVp increases, but GBCAs decrease less than iodine-based agents. Conclusions Gadobutrol is the GBCA with the greatest conspicuity for use in spinal injection procedures. It also has the highest molar concentration of gadolinium, and potential neural toxicity from intrathecal delivery must be considered.
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Affiliation(s)
- Timothy P Maus
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Beth A Schueler
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Dayne Magnuson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
The use of iodinated contrast agents for angiography dates back to the 1920s. With over 75 million contrast-requiring procedures performed annually worldwide, it is important to understand the risk factors, pathogenesis, diagnosis, prevention, and treatment of adverse reactions caused by iodinated contrast media (ICM). As contrast media have evolved from ionic, high-osmolality to nonionic, low-osmolality formulations the risk of reactions has decreased over time; however, no pretreatment protocol has been shown to eliminate all repeat reactions. Clinical alertness and early recognition of adverse reactions is of paramount importance and key for appropriate management of these patients. In this article, we review the most recent literature regarding adverse reactions to ICM and provide an insight into the pathogenesis, clinical presentation, pretreatment, and management of contrast-related reactions.
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Affiliation(s)
- Wendy Bottinor
- Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Pritam Polkampally
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Ion Jovin
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia ; Department of Medicine/Cardiac Catheterization Laboratory, McGuire Veterans Affairs Medical Center, Richmond, Virginia
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Morito H, Hoshina K, Hosaka A, Okamoto H, Shigematsu K, Miyata T. Endovascular surgery for inflammatory abdominal aortic aneurysm with contrast allergy-usefulness of carbon dioxide angiography and intravascular ultrasound: a case report. Ann Vasc Dis 2012; 5:104-8. [PMID: 23555498 DOI: 10.3400/avd.cr.11.00087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Accepted: 12/25/2011] [Indexed: 11/13/2022] Open
Abstract
We report a patient with inflammatory abdominal aortic aneurysm who underwent endovascular aneurysm repair, despite his having an allergy to iodinated contrast medium and anatomy unsuitable for the procedure. Intravascular ultrasound-guided and CO2-assisted aortic stent graft placement was performed, and the procedures resulted in the successful exclusion of the aneurysm with regression of the mantle sign and resolution of hydronephrosis.
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Affiliation(s)
- Haruna Morito
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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