X-ray contrast media--an overview

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.

Kidney Biomarkers of Injury and Repair as Predictors of Contrast-Associated AKI: A Substudy of the PRESERVE Trial

RATIONALE & OBJECTIVE

The PRESERVE trial used a 2 × 2 factorial design to compare intravenous saline solution with intravenous sodium bicarbonate solution and oral N-acetylcysteine with placebo for the prevention of 90-day major adverse kidney events and death (MAKE-D) and contrast-associated acute kidney injury (CA-AKI) among patients with chronic kidney disease undergoing angiography. In this ancillary study, we evaluated the predictive capacities of preangiography injury and repair proteins in urine and plasma for MAKE-D, CA-AKI, and their impact on trial design.

STUDY DESIGN

Longitudinal analysis.

SETTING & PARTICIPANTS

A subset of participants from the PRESERVE trial.

EXPOSURES

Injury (KIM-1, NGAL, and IL-18) and repair (MCP-1, UMOD, and YKL-40) proteins in urine and plasma 1 to 2 hours preangiography.

OUTCOMES

MAKE-D and CA-AKI.

ANALYTICAL APPROACH

We analyzed the associations of preangiography biomarkers with MAKE-D and with CA-AKI. We evaluated whether the biomarker levels could enrich the MAKE-D event rate and improve future clinical trial efficiency through an online biomarker prognostic enrichment tool available at prognosticenrichment.com.

RESULTS

We measured plasma biomarkers in 916 participants and urine biomarkers in 797 participants. After adjusting for urinary albumin-creatinine ratio and baseline estimated glomerular filtration rate, preangiography levels of 4 plasma (KIM-1, NGAL, UMOD, and YKL-40) and 3 urine (NGAL, IL-18, and YKL-40) biomarkers were associated with MAKE-D. Only plasma KIM-1 level was significantly associated with CA-AKI after adjustment. Biomarker levels provided modest discriminatory capacity for MAKE-D. Screening patients using the 50th percentile of preangiography plasma KIM-1 or YKL-40 levels would have reduced the required sample size by 30% (∼2,000 participants).

LIMITATIONS

Evaluation of prognostic enrichment does not account for changing trial costs, time needed to screen patients, or loss to follow-up. Most participants were male, limiting the generalizability of our findings.

CONCLUSIONS

Preangiography levels of injury and repair biomarkers modestly predict the development of MAKE-D and can be used to improve the efficiency of future CA-AKI trials.

The Role of Hospital Transfer in Reexamination Computed Tomography Scans: A Nationwide Cohort Study of Gastric Cancer Patients Undergoing Surgery

Because the high-cost of medical imaging can cause a tremendous economic burden across the health care system, we investigated factors associated with taking additional computed tomography (CT) scans. Data of gastric cancer patients were eligible for analysis if the patient underwent a gastrectomy during the study period (2002–2013). We defined initial CT scans as those taken within 90 days from the surgery date. If there was an additional CT scan between the date of an initial CT scan and the surgery date, we regarded it as a reexamination. We used multivariate logistic regression analysis for reexamination CT scans. Among 3342 gastrectomy patients, 1165 participants underwent second CT scans. Transfer experience (adjusted odds ratio (OR) = 23.87, 95% confidence interval (CI) = 18.15–31.39) was associated with higher OR for reexamination. Among transferred patients, an increased number per 100 beds at the initial CT hospital was associated with a decreased OR for reexamination (OR = 0.88, 95% CI = 0.83–0.94), but increased beds in surgery hospitals was related to an increased OR for reexamination (OR = 1.29, 95% CI = 1.20–1.36). In our study, transfer experience, initial CT scan in a low-volume hospital, and surgical treatment in a high-volume hospital were associated with reexamination CT scans.

Adverse reactions during procedures: Hypersensitivity to contrast agents and dyes

OBJECTIVE

This review provides an overview of the literature on hypersensitivity reactions during procedures to commonly used contrast agents and dyes. A synthesis of current knowledge on clinical symptoms, epidemiology and risk factors, pathomechanism, and management of hypersensitivity reactions to these substances is presented.

DATA SOURCES

A literature search was conducted through Medline. Included were peer-reviewed articles written in English between 2000 and 2019.

STUDY SELECTIONS

Relevant clinical studies, experimental studies, and review articles have been selected. Additionally, case reports have been included if they carried significant information about rare clinical forms of hypersensitivity reactions, disease mechanisms, or therapy.

RESULTS

An allergological workup is only indicated for patients with a history of immediate (IHR) and nonimmediate hypersensitivity reactions (NIHR) but not for toxic or unrelated adverse events. Skin tests with or without experimental cellular laboratory tests in patients with previous reactions can provide evidence for an allergic mechanism. Positive skin tests indicating allergy are more common in severe reactions. If the adverse event was allergic, skin testing of alternatives is helpful for the selection of other contrast agents for future procedures. Premedication alone may be insufficient in these cases, and breakthrough reactions occur. For nonallergic reactions, change of contrast agent and premedication is often but not always sufficient to suppress reactions.

CONCLUSION

Patients with previous NIHR or IHR, especially moderate and severe IHR, needing potential re-administration of contrast agents should be skin tested to identify an allergic mechanism as well as alternative agents to be used for future procedures.

Cost-effective reduction of micro pollutants in the water cycle - Case study on iodinated contrast media

Surface waters, especially in densely populated areas, are facing multiple anthropogenic pressures. Micro pollutants are of growing concern. Improved analytical methods are used to focus on substances like ICM with a (high) potential of hazardous effects against water organisms or the water quality in general ICM are essential for instance in computer tomographic examinations in medical facilities. Discharge of ICM to the sewer system occurs via human urine excretions. Common waste water treatment plants do not eliminate these substances completely. Therefore, increasing concentrations are found in the rivers worldwide. The project MERK'MAL explored a potentially cost-effective measure to reduce ICM in the River Ruhr, located in Germany, North Rhine-Westphalia. The results from this pilot study show that urine bags are an effective measure to reduce ICM concentrations. During the urine collection with bags measurements of ICM concentrations have shown a reduction, compared to the baseline concentration that was measured at the same sampling point in the effluent of the corresponding waste water treatment plant. The ICM reduction ranged between 20 and 34% for the mean values and between 7 and 33% for the median value. Additional payment equivalent costs per examination with ICM are approx. 3.36 €, full costs including imputed costs are expected in a cost range of 5.38 € to 6.09 € per examination. The extension of the study is envisioned, helping to sustainably enhance water quality in the River Ruhr in terms of ICM concentrations.

Intradermal Testing With Radiocontrast Media to Prevent Recurrent Adverse Reactions

OBJECTIVE. Adverse drug reactions (ADRs) to radiocontrast media are a significant social and economic burden and are difficult to predict. Because some ADRs to radiocontrast media may be immunologically induced, a skin test with diluted 1:10 radiocontrast media has been used to predict ADRs. However, using this test in clinical practice is difficult because of its low sensitivity. SUBJECTS AND METHODS. This study enrolled 36 patients with a history of immediate ADR to radiocontrast media who visited the Allergy and Asthma Clinic of Severance Hospital from 2017 to 2018. Patients underwent intradermal testing (IDT) with five types of diluted (1:10) and undiluted radiocontrast media (iohexol, iobitridol, iopamidol, iopromide, and iodixanol). The IDT result was regarded as positive if at least one radiocontrast medium elicited a positive reaction. Positivity of IDT and sensitivity to the culprit radiocontrast medium were calculated and compared. For subsequent CT examinations with a radiocontrast medium, the contrast agent eliciting a negative skin reaction in IDT was selected, excluding the previous culprit radiocontrast medium. RESULTS. IDT positivity and sensitivity for the culprit radiocontrast medium at 1:10 dilution were 47.2% and 47.2%, respectively, whereas the positivity and sensitivity for the undiluted radiocontrast medium were 86.1% and 75.0%, respectively. The positivity and sensitivity were higher with frequent radiocontrast medium use or with severe reaction. Of 22 patients who underwent another CT examination with the contrast medium selected on the basis of IDT results, 21 (95.5%) did not experience an ADR. CONCLUSION. IDT to prevent ADR should be performed with undiluted radiocontrast medium. Selecting an alternative radiocontrast agent on the basis of IDT results can be clinically useful to prevent recurrent ADRs to radiocontrast media.

Kinetics and model development of iohexol degradation during UV/H2O2 and UV/S2O82- oxidation

The degradation rates and kinetics of one commonly used iodinated contrast medium, iohexol, were investigated and compared during ultraviolet (UV) photolysis, UV/H₂O₂ and UV/S₂O₈^2- advanced oxidation processes (AOPs). Results indicate that the iohexol degradation rate increased in the order of UV/H₂O₂ < UV irradiation < UV/S₂O₈^2- and followed pseudo-first-order kinetics. Increasing persulfate concentration significantly increased iohexol degradation rate, whereas increasing H₂O₂ concentration caused reverse effect. Radical scavenging test results show that UV photolysis, OH and radicals all contributed to iohexol degradation during UV/S₂O₈^2-, but OH was the main contributor during UV/H₂O₂ and was consumed by excess H₂O₂. The kinetic models of iohexol degradation by both AOPs were developed, and the reaction rate constants with OH and were calculated as 5.73 (±0.02) × 10⁸ and 3.91 (±0.01) × 10¹⁰ M^-1 s^-1, respectively. Iohexol degradation rate remained stable at pH 5-9 during UV irradiation and UV/H₂O₂, but gradually decreased at pH 5-7 and remained stable at pH 7-9 during UV/S₂O₈^2-. The presence of anions displayed inhibitory effects on iohexol degradation during UV/S₂O₈^2- in the order of Cl^- >HCO₃^- ≫ SO₄^2-. UV/S₂O₈^2- AOP exhibited high degradation efficiency and stability on the basis of UV irradiation, which can be applied as a promising degradation method for iohexol. UV/S₂O₈^2- AOP can effectively mineralize iohexol to CO₂ but promoted the generation of toxic iodoform (CHI₃), and the subsequent chlorination had the potential to reduce the content of disinfection by-products; therefore, further evaluation of possible environmental hazards is warranted.

Microbubbles as a contrast agent in grating interferometry mammography: an ex vivo proof-of-mechanism study

Grating interferometry mammography (GIM) is an experimental breast imaging method at the edge of being clinically implemented. Besides attenuation, GIM can measure the refraction and scattering of x-rays resulting in differential phase contrast (DPC) and dark-field (DF) images. In this exploratory study, we assessed the feasibility of using microbubbles as a contrast agent in GIM. Two millilitres of microbubbles and iodine were respectively injected into ex vivo breast phantoms, consisting of fresh chicken breasts. Native and postcontrast images were acquired with a clinically compatible GIM setup, operated at 38 kVp, 14-s acquisition time, and with a dose of 1.3 mGy. The visibility of the contrast agents was analysed in a side-by-side comparison by three radiologists. The contrast-to-noise-ratio (CNR) was calculated for each contrast agent. We found that both contrast agents were judged to be visible by the readers. The mean CNR was 3.1 ± 1.9 for microbubbles in DF and 24.2 ± 6.5 for iodine in attenuation. In conclusion, this is a first proof-of-mechanism study that microbubbles could be used as a contrast agent in clinically compatible GIM, due to their scattering properties, which implies the potential use of a contrast agent with a high safety profile in x-ray-based breast imaging.

Adverse Drug Reactions to Radiographic Contrast Media in a Teaching Hospital in North India: An Observational Study

BACKGROUND

Radiocontrast media are used extensively nowadays to visualize internal organs. Currently, non-ionic iodinated contrast media are used which are generally considered to be safe but some adverse reactions have been reported. Thus, the present study was carried out to analyze the nature and incidence of adverse drug reactions (ADRs) to radiographic contrast media in a teaching hospital.

METHODS

An observational study carried out for a period of six months in a teaching hospital. Contrast media induced adverse reactions were analyzed in terms of affected organs, rate, causality assessment, severity and preventability. The treatment and outcomes of adverse events were also recorded. Naranjo Probability Scale was used to evaluate the relationship between the contrast agent used and the suspected ADR. The severity of the suspected ADRs was determined using Hartwig Scale and preventability was assessed using modified Schumock and Thornton criterion.

RESULTS

A total of 15 suspected ADRs occurred in 11 patients with an incidence of 1.4%. It included 5 (45.4%) males and 6 (54.5%) females (p < 05). The highest percentage (72.7 %) of ADRs was seen in adult patients, the mean age being 40.8 years. Vomiting (33.3%) was the most common ADR noted followed by severe nausea and rashes. 64.7 % of ADRs were categorized as probable and 35.3 % were possible. Adverse reactions required treatment in 46.6% patients. There was no fatality reported.

CONCLUSION

The reactions observed were mild to moderate in severity and occurred within 30 minutes of the administration of the contrast.

Preparation and characterization of multimodal hybrid organic and inorganic nanocrystals of camptothecin and gold

We demonstrate a novel inorganic-organic crystalline nanoconstruct, where gold atoms were imbedded in the crystal lattices as defects of camptothecin nanocrystals, suggesting its potential use as simultaneous agents for cancer therapy and bioimaging. The incorporation of gold, a potential computed tomography (CT) contrast agent, in the nanocrystals of camptothecin was detected by transmission electron microscope (TEM) and further quantified by energy dispersive X-ray spectrometry (EDS) and inductively coupled plasma-optical emission spectrometers (ICP-OES). Due to gold's high attenuation coefficient, only a relatively small amount needs to be present in order to create a good noise-to-contrast ratio in CT imaging. The imbedded gold atoms and clusters are expected to share the same biological fate as the camptothecin nanocrystals, reaching and accumulating in tumor site due to the enhanced permeation and retention (EPR) effect.

In Vivo Examination of Folic Acid-Conjugated Gold-Silica Nanohybrids as Contrast Agents for Localized Tumor Diagnosis and Biodistribution

Enhanced biocompatibility of nanosized contrast agent with high radiodensity and specific biodistribution is an important parameter for localized tumor imaging and organ safety. Various nanoparticles, especially gold nanorods (GNRs), have been applied for tumor diagnosis. However, their toxicity, nonspecific biodistribution, and easy aggregation are critical issues in cancer medicine. To avoid these issues, encapsulation of the GNRs in the core of nanoscopic mesoporous silica (MS) under ambient conditions, yielding multifunctional nanomaterials for cancer nanomedicine, is a recent and active development. Interestingly, GNR embedded MS nanohybrid (GNR-MS), though a promising material in nanomedicine, is rarely examined for tumor diagnosis, in vivo toxicity, organ safety, contrast ability, and excretion. Herein, we report a systematic in vivo examination of folic acid functionalized GNR-MS (GNR-MS-FA) for localized 4T1 breast tumor diagnosis, organ safety, and excretion using a one-time dose administration. The nanomaterials show good aqueous dispersibility, biocompatibility, high radiodensity, and tumor specific targeting ability ( in vitro as well as in vivo). The in vivo tumor diagnosis and specific biodistribution of injected nanomaterials clearly demonstrates their potential for the visualization of tumors deep in the body of mice. In addition, all organs including the healthy glomerulus of the kidney are observed to be free of tissue injuries thereby indicating the superior biocompatibility of the nanomaterials.

Prophylactic Intravenous Hydration to Protect Renal Function From Intravascular Iodinated Contrast Material (AMACING): Long-term Results of a Prospective, Randomised, Controlled Trial

BACKGROUND

The aim of A MAastricht Contrast-Induced Nephropathy Guideline (AMACING) trial was to evaluate non-inferiority of no prophylaxis compared to guideline-recommended prophylaxis in preventing contrast induced nephropathy (CIN), and to explore the effect on long-term post-contrast adverse outcomes. The current paper presents the long-term results.

METHODS

AMACING is a single-centre, randomised, parallel-group, open-label, phase 3, non-inferiority trial in patients with estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m2 combined with risk factors, undergoing elective procedures requiring intravenous or intra-arterial iodinated contrast material. Exclusion criteria were eGFR < 30 mL/min/1.73 m2, dialysis, no referral for prophylaxis. The outcomes dialysis, mortality, and change in renal function at 1 year post-contrast were secondary outcomes of the trial. Subgroup analyses were performed based on pre-defined stratification risk factors. AMACING is registered with ClinicalTrials.gov: NCT02106234.

FINDINGS

From 28,803 referrals, 1120 at-risk patients were identified. 660 consecutive patients agreed to participate and were randomly assigned (1:1) to no prophylaxis (n = 332) or standard prophylactic intravenous hydration (n = 328). Dialysis and mortality data were available for all patients. At 365 days post-contrast dialysis was recorded in two no prophylaxis (2/332, 0.60%), and two prophylaxis patients (2/328, 0.61%; p = 0.9909); mortality was recorded for 36/332 (10.84%) no prophylaxis, and 32/328 (9.76%) prophylaxis patients (p = 0.6490). The hazard ratio was 1.118 (no prophylaxis vs prophylaxis) for one-year risk of death (95% CI: 0.695 to 1.801, p = 0.6449). The differences in long-term changes in serum creatinine were small between groups, and gave no indication of a disadvantage for the no-prophylaxis group.

INTERPRETATION

Assuming optimal contrast administration, not giving prophylaxis to elective patients with eGFR 30-59 mL/min/1.73 m2 is safe, even in the long-term.

FUNDING

Stichting de Weijerhorst.

A rapid and easy method based on hydrophilic interaction chromatography coupled with tandem mass spectrometry (HILIC-MS/MS/MS) to quantify iodinated X-ray contrast in wastewaters

This work proposes the first method based on hydrophilic interaction liquid chromatography coupled to multiple reaction monitoring with triple stage fragmentation (HILIC-MRM³) to quantify polar organic micropollutants in complex sewage waters. A fast HILIC-MRM³ analytical method, without sample preparation except a dilution step, was developed and validated to quantify seven iodinated contrast media (ICMs) in sewage waters, namely iohexol, iomeprol, ioversol, iopamidol, diatrizoic acid, iopromide and iopentol. Several chromatographic columns and mobile phase conditions were investigated and a good separation of the ICMs was obtained with a mixed-mode column (Acclaim Mixed-mode WAX) used in HILIC conditions. The validation was performed using a synthetic matrix: the limits of quantification (LOQ) were inferior to 1 µg/L and the linearity of each compound was comprised within the [0.5-50] µg/L range. The applicability of the HILIC-MRM³ method was assessed by the analysis of several raw waters. The results highlighted the presence of ICMs in most samples, at concentrations up to several mg/L in hospital sewage waters.

Formation of DBPs and halogen-specific TOX in the presence of iopamidol and chlorinated oxidants

Iopamidol is a known direct precursor to iodinated and chlorinated DBP formation; however, the influence of iopamidol on both iodo/chloro-DBP formation has yet to be fully investigated. This study investigated the effect of iopamidol on the formation and speciation of halogen-specific total organic halogen (TOX), as well as iodo/chloro-DBPs, in the presence of 3 source waters (SWs) from Northeast Ohio and chlorinated oxidants. Chlorination and chloramination of SWs were carried out at pH 6.5-9.0 and, different iopamidol and dissolved organic carbon (DOC) concentrations. Total organic iodine (TOI) loss was approximately equal (22-35%) regardless of SW. Total organic chlorine (TOCl) increased in all SWs and was substantially higher in the higher SUVA₂₅₄ SWs. Iopamidol was a direct precursor to chloroform (CHCl₃), trichloroacetic acid (TCAA), and dichloroiodomethane (CHCl₂I) formation. While CHCl₃ and TCAA exhibited different formation trends with varying iopamidol concentrations, CHCl₂I increased with increasing iopamidol and DOC concentrations. Low concentrations of iodo-acids were detected without discernible trends. Total trihalomethanes (THMs), total haloacetic acids (HAAs), TOCl, and unknown TOCl (UTOCl) were correlated with fluorescence regional volumes and SUVA₂₅₄. The yields of all these species showed a strong positive correlation with fulvic, humic, and combined humic and fulvic regions, as well as SUVA₂₅₄. Iopamidol was then compared to the 3 SWs with respect to DBP yield. Although the SUVA₂₅₄ of iopamidol was relatively high, it did not produce high yields of THMs and HAAs compared to the 3 SWs. However, chlorination of iopamidol did result in high yields of TOCl and UTOCl.

Radiopaque nano and polymeric materials for atherosclerosis imaging, embolization and other catheterization procedures

A review of radiopaque nano and polymeric materials for atherosclerosis imaging and catheterization procedures is presented in this paper. Cardiovascular diseases (CVDs) are the leading cause of death in the US with atherosclerosis as a significant contributor for mortality and morbidity. In this review paper, we discussed the physics of radiopacity and X-ray/CT, clinically used contrast agents, and the recent progress in the development of radiopaque imaging agents and devices for the diagnosis and treatment of CVDs. We focused on radiopaque imaging agents for atherosclerosis, radiopaque embolic agents and drug eluting beads, and other radiopaque medical devices related to catheterization procedures to treat CVDs. Common strategies of introducing radiopacity in the polymers, together with examples of their applications in imaging and medical devices, are also presented.

Cytotoxicity of radiocontrast dyes in human umbilical cord mesenchymal stem cells

Radiocontrast dyes are used for a wide range of diagnostic procedures for enhancing the image of anatomical structures, pain targets, and vascular uptake. While some of these dyes show toxicity to primary cells, their effect on stem cells, particularly mesenchymal stem cells (MSCs), is unknown. This study investigates the cytotoxic effects of two clinically used radiocontrast dyes, iohexol and iopamidol, on bone marrow and human umbilical cord MSCs. Exposure to these dyes significantly affected morphology of MSCs from both sources, as treated cells appeared transparent and no longer fibroblastoid. Cell viability decreased as determined by trypan blue and Annexin-V/PI staining, in a dose dependent manner with simultaneous loss of CD90 and CD105 concurrent with spontaneous differentiation in MSCs treated with iohexol and iopamidol. In addition, significantly higher cell death was observed in MSCs exposed to iopamidol than iohexol. At a concentration of 1:1, iohexol and iopamidol induced apoptosis in 19% and 92% (<.01) of MSCs, respectively. Global transcriptome analysis of treated MSCs revealed 139 and 384 differentially expressed genes in iohexol vs control and iopamidol vs control at p ≤ .01 and 1.5-fold, respectively. This suggested that iopamidol had more significant effect on the transcription of MSCs. Based on these results a molecular mechanism of radiocontast dye induced cell death via intrinsic apoptosis pathway mediated by p53 was proposed. Since iopamidol was significantly more toxic than iohexol in human MSCs, a more careful examination of safety of radiocontrast dyes for clinical use is warranted.

Oxidation of iopamidol with ferrate (Fe(VI)): Kinetics and formation of toxic iodinated disinfection by-products

Presence of iodinated X-ray contrast media (ICMs) in source water is of high concern, because of their potential to form highly toxic iodinated disinfection by-products (I-DBPs). This study investigated kinetics, mechanisms and products for oxidation of one ICMs, iopamidol (IPM) by ferrate (Fe(VI)). The obtained apparent second-order rate constants for oxidation of IPM by Fe(VI) ranged from 0.7 M^-1 s^-1 to 74.6 M^-1 s^-1 at pH 6.0-10.0, which were highly dependent on pH. It was found that the oxidation of IPM by Fe(VI) led to the formation of highly toxic I-DBPs. Iodoform (IF), iodoacetic acid and triiodoacetic acid formations were observed during the oxidation and IF dominated the formed I-DBPs. The formation of I-DBPs was also governed by pH and the maximum formation of I-DBPs occurred at pH 9.0. Transformation pathways of IPM by Fe(VI) oxidation were speculated to proceed through deiodination, amide hydrolysis and oxidation of amine reactions. The deiodination reaction during the oxidation of IPM by Fe(VI) contributed to the formation of I-DBPs. The formation of I-DBPs during the oxidation of IPM by Fe(VI) was significantly higher than those of iohexol, diatrizoate and iopromide, which was consistent with the lowest molecular orbital energy gap of IPM. Although Fe(VI) is considered as a green oxidant, the formation of highly toxic I-DBPs during the oxidation of IPM should receive great attention.

Formation of iodinated THMs during chlorination of water and wastewater in the presence of different iodine sources

The formation potential of iodinated trihalomethanes (I-THMs) during chlorination of different organic precursors in the presence of various iodine sources was studied. Organic precursors included humic acid, natural organic matter from river water and wastewater effluent organic matter. Inorganic iodide and two iodinated X-ray contrast media compounds (iopamidol and diatrizoate) were used as iodine sources. The formation potential of I-THMs under different experimental conditions (chlorination contact time, iodide and bromide concentrations) was investigated. The formation of I-THM species upon chlorination of river water and humic acids rapidly increased up to 24h and then a decreasing trend was observed. Wastewater, showed a rapid formation of I-THMs within the first 6h, followed by a lower rate with extended time. Formation of I-THMs in the presence of iopamidol was more favorable regarding the other two iodine sources. CHBrClI was the dominant specie followed by CHCl₂I and CHBr₂I. Increasing iodide concentrations result in higher I-THMs formation. The presence of bromide enhanced the I-THMs yields and shifted towards bromine-containing species (CHBrClI and CHBr₂I).

In vivotumor active cancer targeting and CT-fluorescence dual-modal imaging with nanoprobe based on gold nanorods and InP/ZnS quantum dots

Gold nanorod, InP/ZnS QD and c(RGDfC) based multifunctional nanoprobe for dual-modal imaging of active targeting of tumorsin vivo.

Safety of Iohexol Administration to Measure Glomerular Filtration Rate in Different Patient Populations: A 25-Year Experience

<b><i>Background/Aim:</i></b> In clinical research setting, accurate and precise measurement of glomerular filtration rate (GFR) is essential to overcome the limitations of GFR estimation with equations, which are often unreliable. In recent decades, a method for measuring GFR by plasma clearance of iohexol, a non-ionic radiocontrast agent, was developed. To evaluate the safety of the procedure, we aimed to review all immediate adverse reactions that could be related to iohexol administration in our group’s 25 years worth of experience. <b><i>Methods:</i></b> We retrospectively reviewed all GFR investigations in 2,891 patients, between 1992 and 2016, as part of 37 clinical trials coordinated by our group. Subjects with disparate renal diseases, kidney transplant recipients, and living donors – all with different renal function categories – were included in the surveyed clinical trials. <b><i>Results:</i></b> During 15,147 GFR measurements, only one treatment-related event of moderate intensity was identified. Flushing, urticaria, and itching were observed in a diabetic patient a few minutes after iohexol administration during the first GFR measurement. The event recovered without sequelae after intravenous injection of methylprednisolone sodium succinate. The patient was not hospitalized and the event was categorized as non-serious. Eight additional non-serious events observed closely following iohexol injection were considered as not related to treatment. Thus, independent of disease conditions and GFR categories, the overall rate of treatment-related events was 0.0066%. <b><i>Conclusion:</i></b> Iohexol administration for GFR measurement is a safe procedure, even in repeated investigations in the same subject, that should be adopted in clinical research and, when needed, also in clinical practice.

A novel method for photo-oxidative degradation of diatrizoate in water via electromagnetic induction electrodeless lamp

In this study, an electromagnetic induction electrodeless lamp (EIEL) was first introduced into UV advanced oxidation processes (AOPs) for photodegradation of Diatrizoate (DTZ), which was the most persistent iodinated X-ray contrast medium (ICM), and traditional Hg lamps were taken as references. Direct photolysis rate of DTZ under EIEL irradiation was 1.34 times as that under Hg irradiation, but the electric energy consumption was 0.87 times. In this sense, the combination of EIEL and oxidants (O₂, H₂O₂ and S₂O₈^2-(PS)) was further investigated. The remarkably increased photodegradation rates were observed in UV/PS system due to primary contribution rate of SO₄^- (62.5%) based on the results of radical concentrations and second-order rate constants of DTZ with SO₄^- and OH. Inorganic ions influencing the photodegradation process were investigated. The effect of natural organic materials (NOMs) in UV/PS system was studied based on contribution ratios of light screening effect and quenching. Transformation mechanisms of DTZ in UV/PS system included deiodination, intramolecular cyclization, decarboxylation, deacetylation and deamination, which were further confirmed by frontier electron density calculations. The study indicated that UV/PS with EIEL irradiation has the potential to remove pharmaceuticals in contaminated aquatic environments.

Synthesis and Preclinical Characterization of a Cationic Iodinated Imaging Contrast Agent (CA4+) and Its Use for Quantitative Computed Tomography of Ex Vivo Human Hip Cartilage

Contrast agents that go beyond qualitative visualization and enable quantitative assessments of functional tissue performance represent the next generation of clinically useful imaging tools. An optimized and efficient large-scale synthesis of a cationic iodinated contrast agent (CA4+) is described for imaging articular cartilage. Contrast-enhanced CT (CECT) using CA4+ reveals significantly greater agent uptake of CA4+ in articular cartilage compared to that of similar anionic or nonionic agents, and CA4+ uptake follows Donnan equilibrium theory. The CA4+ CECT attenuation obtained from imaging ex vivo human hip cartilage correlates with the glycosaminoglycan content, equilibrium modulus, and coefficient of friction, which are key indicators of cartilage functional performance and osteoarthritis stage. Finally, preliminary toxicity studies in a rat model show no adverse events, and a pharmacokinetics study documents a peak plasma concentration 30 min after dosing, with the agent no longer present in vivo at 96 h via excretion in the urine.

Cancer-Associated, Stimuli-Driven, Turn on Theranostics for Multimodality Imaging and Therapy

Advances in bioinformatics, genomics, proteomics, and metabolomics have facilitated the development of novel anticancer agents that have decreased side effects and increased safety. Theranostics, systems that have combined therapeutic effects and diagnostic capabilities, have garnered increasing attention recently because of their potential use in personalized medicine, including cancer-targeting treatments for patients. One interesting approach to achieving this potential involves the development of cancer-associated, stimuli-driven, turn on theranostics. Multicomponent constructs of this type would have the capability of selectively delivering therapeutic reagents into cancer cells or tumor tissues while simultaneously generating unique signals that can be readily monitored under both in vitro and in vivo conditions. Specifically, their combined anticancer activities and selective visual signal respond to cancer-associated stimuli, would make these theranostic agents more highly efficient and specific for cancer treatment and diagnosis. This article focuses on the progress of stimuli-responsive turn on theranostics that activate diagnostic signals and release therapeutic reagents in response to the cancer-associated stimuli. The present article not only provides the fundamental backgrounds of diagnostic and therapeutic tools that have been widely utilized for developing theranostic agents, but also discusses the current approaches for developing stimuli-responsive turn on theranostics.

The Application of Contrast Media for In Vivo Feature Enhancement in X-Ray Computed Tomography of Soil-Grown Plant Roots

The use of in vivo X-ray microcomputed tomography (μCT) to study plant root systems has become routine, but is often hampered by poor contrast between roots, soil, soil water, and soil organic matter. In clinical radiology, imaging of poorly contrasting regions is frequently aided by the use of radio-opaque contrast media. In this study, we present evidence for the utility of iodinated contrast media (ICM) in the study of plant root systems using μCT. Different dilutions of an ionic and nonionic ICM (Gastrografin 370 and Niopam 300) were perfused into the aerial vasculature of juvenile pea plants via a leaf flap (Pisum sativum). The root systems were imaged via μCT, and a variety of image-processing approaches used to quantify and compare the magnitude of the contrast enhancement between different regions. Though the treatment did not appear to significantly aid extraction of full root system architectures from the surrounding soil, it did allow the xylem and phloem units of seminal roots and the vascular morphology within rhizobial nodules to be clearly visualized. The nonionic, low-osmolality contrast agent Niopam appeared to be well tolerated by the plant, whereas Gastrografin showed evidence of toxicity. In summary, the use of iodine-based contrast media allows usually poorly contrasting root structures to be visualized nondestructively using X-ray μCT. In particular, the vascular structures of roots and rhizobial nodules can be clearly visualized in situ.

Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial

BACKGROUND

Intravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. However, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. This was the aim of the AMACING trial.

METHODS

AMACING is a prospective, randomised, phase 3, parallel-group, open-label, non-inferiority trial of patients at risk of contrast-induced nephropathy according to current guidelines. High-risk patients (with an estimated glomerular filtration rate [eGFR] of 30-59 mL per min/1·73 m²) aged 18 years and older, undergoing an elective procedure requiring iodinated contrast material administration at Maastricht University Medical Centre, the Netherlands, were randomly assigned (1:1) to receive intravenous 0·9% NaCl or no prophylaxis. We excluded patients with eGFR lower than 30 mL per min/1·73 m², previous dialysis, or no referral for intravenous hydration. Randomisation was stratified by predefined risk factors. The primary outcome was incidence of contrast-induced nephropathy, defined as an increase in serum creatinine from baseline of more than 25% or 44 μmol/L within 2-6 days of contrast exposure, and cost-effectiveness of no prophylaxis compared with intravenous hydration in the prevention of contrast-induced nephropathy. We measured serum creatinine immediately before, 2-6 days, and 26-35 days after contrast-material exposure. Laboratory personnel were masked to treatment allocation. Adverse events and use of resources were systematically recorded. The non-inferiority margin was set at 2·1%. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT02106234.

FINDINGS

Between June 17, 2014, and July 17, 2016, 660 consecutive patients were randomly assigned to receive no prophylaxis (n=332) or intravenous hydration (n=328). 2-6 day serum creatinine was available for 307 (92%) of 332 patients in the no prophylaxis group and 296 (90%) of 328 patients in the intravenous hydration group. Contrast-induced nephropathy was recorded in eight (2·6%) of 307 non-hydrated patients and in eight (2·7%) of 296 hydrated patients. The absolute difference (no hydration vs hydration) was -0·10% (one-sided 95% CI -2·25 to 2·06; one-tailed p=0·4710). No hydration was cost-saving relative to hydration. No haemodialysis or related deaths occurred within 35 days. 18 (5·5%) of 328 patients had complications associated with intravenous hydration.

INTERPRETATION

We found no prophylaxis to be non-inferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration according to current clinical practice guidelines.

FUNDING

Stichting de Weijerhorst.

Cardiac CT Imaging of Plaque Vulnerability: Hype or Hope?

Advances in cardiovascular computed tomography (CT) have resulted in an excellent ability to exclude coronary heart disease (CHD). Anatomical information, functional information, and spectral information can already be obtained with current CT technologies. Moreover, novel developments such as targeted nanoparticle contrast agents, photon-counting CT, and phase contrast CT will further enhance the diagnostic value of cardiovascular CT. This review provides an overview of current state of the art and future cardiovascular CT imaging.

Immediate hypersensitivity to iodinated contrast media: diagnostic accuracy of skin tests and intravenous provocation test with low dose

BACKGROUND

The diagnosis of HSR to iodinated contrast media (ICM) is challenging based on clinical history and skin tests.

OBJECTIVE

This study evaluates the negative predictive value (NPV) of skin tests and intravenous provocation test (IPT) with low-dose ICM in patients with suspected immediate hypersensitivity reaction (HSR) to ICM.

METHODS

Thirty-seven patients with suspected immediate hypersensitivity reaction to ICM were included retrospectively. Skin tests and a single-blind placebo-controlled intravenous provocation test (IPT) with low-dose iodinated contrast media (ICM) were performed.

RESULTS

Skin tests with ICM were positive in five cases (one skin prick test and five intradermal test). Thirty-six patients were challenged successfully by IPT, and only one patient had a positive challenge result, with a grade I reaction by the Ring and Messmer classification. Ten of 23 patients followed up by telephone were re-exposed to a negative tested ICM during radiologic examination; two experienced a grade I immediate reaction.

CONCLUSIONS & CLINICAL RELEVANCE

For immediate hypersensitivity reaction to ICM, the NPV for skin tests and IPT with low dose was 80% (95% CI 44-97%).

Clinical observation of adverse drug reactions to non-ionic iodinated contrast media in population with underlying diseases and risk factors

OBJECTIVE

To determine the adverse drug reaction (ADR) profile of non-ionic iodinated contrast media in populations with underlying diseases and risk factors and to provide guidance for more safe and rational use of iodinated contrast media (ICMs) in the clinic.

METHODS

Data from 120,822 cases who underwent enhanced CT examination in our hospital from January 2014 to March 2016 were collected. A standardized case report form was used for data collection and analysis.

RESULTS

The incidence of ADRs was 0.4% and 0.44% in patients with and without underlying diseases, respectively (p = 0.378). Risk factor analysis revealed that patients with asthma had the highest incidence of ADRs, followed by patients with cardiac insufficiency and patients who were aged had the lowest incidence. There was a low incidence of ADRs in patients under metformin (0.36%) and β-adrenaline receptor antagonist (0.20%) medication. The incidence was the highest in patients with previous ADRs to ICMs (7.17%) and the lowest in those with a history of ICM usage but no previous reactions (0.32%). ADRs were more common in patients at high risk at a higher injection dose (≥100 ml; p < 0.01) and speed (≥5 ml s^-1; p < 0.01).

CONCLUSION

The incidence of ADRs was extremely low in patients regardless of underlying diseases. Some high-risk factors have certain correlations with the occurrence of ADRs. Particular attention should be given to patients at high risk when performing enhanced CT examination. Advances in knowledge: The correlation between various risk factors and underlying diseases and ADRs was comprehensively analyzed in a large-scale population.

Photodecomposition of iodinated contrast media and subsequent formation of toxic iodinated moieties during final disinfection with chlorinated oxidants

Large amount of iodinated contrast media (ICM) are found in natural waters (up to μg.L(-)(1) levels) due to their worldwide use in medical imaging and their poor removal by conventional wastewater treatment. Synthetic water samples containing different ICM and natural organic matter (NOM) extracts were subjected to UV254 irradiation followed by the addition of chlorine (HOCl) or chloramine (NH2Cl) to simulate final disinfection. In this study, two new quantum yields were determined for diatrizoic acid (0.071 mol.Einstein(-1)) and iotalamic acid (0.038 mol.Einstein(-1)) while values for iopromide (IOP) (0.039 mol.Einstein(-1)), iopamidol (0.034 mol.Einstein(-1)) and iohexol (0.041 mol.Einstein(-1)) were consistent with published data. The photodegradation of IOP led to an increasing release of iodide with increasing UV doses. Iodide is oxidized to hypoiodous acid (HOI) either by HOCl or NH2Cl. In presence of NOM, the addition of oxidant increased the formation of iodinated disinfection by-products (I-DBPs). On one hand, when the concentration of HOCl was increased, the formation of I-DBPs decreased since HOI was converted to iodate. On the other hand, when NH2Cl was used the formation of I-DBPs was constant for all concentration since HOI reacted only with NOM to form I-DBPs. Increasing the NOM concentration has two effects, it decreased the photodegradation of IOP by screening effect but it increased the number of reactive sites available for reaction with HOI. For experiments carried out with HOCl, increasing the NOM concentration led to a lower formation of I-DBPs since less IOP are photodegraded and iodate are formed. For NH2Cl the lower photodegradation of IOP is compensated by the higher amount of NOM reactive sites, therefore, I-DBPs concentrations were constant for all NOM concentrations. 7 different NOM extracts were tested and almost no differences in IOP degradation and I-DBPs formation was observed. Similar behaviour was observed for the 5 ICM tested. Both oxidant poorly degraded the ICM and a higher formation of I-DBPs was observed for the chloramination experiments compared to the chlorination experiment. Results from toxicity testing showed that the photodegradation products of IOP are toxic and confirmed that the formation of I-DBPs leads to higher toxicity. Therefore, for the experiment with HOCl where iodate are formed the toxicity was lower than for the experiments with NH2Cl where a high formation of I-DBPs was observed.

Clinical characteristics of adverse reactions to nonionic low osmolality contrast media in patients transferred from the CT room to the emergency room

Nonionic low osmolality contrast media (LOCMs) are used universally in computed tomography (CT) imaging. Although adverse reactions due to nonionic LOCMs are a common cause of emergency room (ER) admissions, few studies have investigated these adverse reactions. In the present study, we evaluated the characteristics of patients who were transferred from the CT room to the ER due to adverse reactions to contrast media, and we determined the risk factors for severe adverse reactions. A single-center retrospective study was conducted over a 41-month period. Baseline and clinical characteristics were evaluated and analyzed according to moderate and severe severity. In particular, risk factors of severe reactions were determined using logistic regression analysis. In total, 70 patients were admitted to the ER with adverse reactions due to nonionic LOCMs. Of these, 33 developed a moderate reaction, and 37 developed a severe reaction. Compared with the moderate reaction group, the severe reaction group was older, had higher blood pressures, showed more symptoms indicating the cardiovascular and central nervous system, and developed faster reactions to LOCMs. According to the multivariate logistic regression analysis, the age of the patient and time to onset of reaction demonstrated a statistical relationship with severe adverse reactions. In the receiver operating characteristic analysis, the optimal cutoff values for age and time to onset were 60 years and 5 min. In conclusion, clinicians should be attentive to anaphylaxis due to nonionic LOCM, in particular, for elderly patients aged older than 60 years and a time to reaction onset of less than 5 min.

Thyroid Dysfunction in Children Exposed to Iodinated Contrast Media

CONTEXT

Iodinated contrast media (ICM) is routinely used in imaging studies and contains several 100-fold the recommended daily allowance of iodine.

OBJECTIVE

To determine whether children exposed to ICM have a higher risk of iodine-induced thyroid dysfunction.

DESIGN

This was a single-institution case-control study, examining patients with incident thyroid dysfunction aged less than 18 years from 2001 to 2015. Cases were matched 1:1 to euthyroid controls by age, sex, and race.

SETTING

This was a single-institution case-control study occurring at tertiary care center.

PARTICIPANTS

Cases were defined as those with thyroid dysfunction (by International Classification of Diseases, Ninth Revision diagnosis codes and/or 2 consecutive abnormal serum TSH values <6 mo apart). We analyzed 870 cases matched to 870 controls (64% female, 51% White).

MAIN OUTCOMES MEASURES

Using conditional logistic regression, the association between ICM exposure and the primary outcome, thyroid dysfunction, occurring within 2 years of exposure was assessed.

RESULTS

Sixty-nine patients received ICM, including 53 (6%) among cases and 16 (2%) among controls. The risk of incident hypothyroidism was significantly higher after ICM exposure (odds ratio 2.60; 95% confidence interval, 1.43-4.72; P < .01). The median interval between exposure and onset of hypothyroidism was 10.8 months (interquartile range, 6.6-17.9). In hypothyroid cases, the median serum TSH concentration was 6.5 mIU/L (interquartile range, 5.8-9.6).

CONCLUSIONS

ICM exposure increases the risk of incident hypothyroidism in pediatric patients. Children receiving ICM should be monitored for iodine-induced thyroid dysfunction, particularly during the first year after exposure.

Use of orbitrap-MS/MS and QSAR analyses to estimate mutagenic transformation products of iopamidol generated during ozonation and chlorination

The effects of two water purification processes (ozonation, and chlorination after ozonation) on the mutagenicity of a solution containing iopamidol (X-ray contrast medium) were investigated by using the Ames assay. No mutagenicity was observed during ozonation. In contrast, mutagenicity was induced by the ozone-treated iopamidol-containing solution after subsequent chlorination, indicating that mutagenic transformation-products (TPs) were generated. Ten of 70 peaks detected on the LC/MS total ion chromatogram (TIC) of the ozone-treated iopamidol-containing solution after chlorination had a positive correlation (r(2) > 0.6) between their peak areas and the observed mutagenicity, suggesting that TPs detected as these peaks may induce mutagenicity. To narrow down the possible contributors to the observed mutagenicity, we compared the areas of the peaks on the TIC-charts with and without chlorination. Of the ten peaks, six were also detected in the ozone-treated iopamidol-containing solution without chlorination, which did not induce mutagenicity, indicating that these peaks were not related to the observed mutagenicity. Accurate m/z values and MS/MS analysis with an orbitrap MS of the remaining four peaks revealed that two of them represented the same TP in the negative and positive ion modes. The three remaining TPs were assessed in four quantitative structure-activity relationship models for predicting Ames mutagenicity. At least one model predicted that two of the three TPs were mutagenic, whereas none of the models predicted that the other TP was a mutagen, suggesting that the former TPs, estimated as N1-acetyl-5-amino-6-chloro-2-iodobenzene-1,3-dicarboxamide and 3-hydroxy-2-{3-[(2-hydroxyethoxy)carbonyl]-2,4,6-triiodo-5-nitrobenzoyl}amino)propanoic acid, could be the candidate compounds that contributed to the observed mutagenicity.

Neurosonology and noninvasive imaging of the carotid arteries

In this chapter, we review imaging of the extracranial carotid arteries and the indications for noninvasive carotid artery evaluation, measuring the degree of arterial stenosis and plaque morphology. We also analyze the types of noninvasive imaging, including carotid duplex ultrasound, transcranial Doppler, magnetic resonance angiography, and computer tomography angiography. We look at each of these modalities, briefly discussing techniques, benefits, limitations, and sources of error. Furthermore, we discuss the apparent accuracy and the need for multimodality imaging. Finally, an imaging algorithm for the evaluation of the extracranial carotid arteries is proposed, which is in routine use at our hospital.