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Zhao Y, Wang H, Wu Z, Zhu Y, Wang J. Case Report: A Rare Case of Iodixanol-Induced Anaphylactic Shock in Cerebral Angiography. J Asthma Allergy 2024; 17:361-367. [PMID: 38623449 PMCID: PMC11018123 DOI: 10.2147/jaa.s460263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/01/2024] [Indexed: 04/17/2024] Open
Abstract
Background Adverse reactions induced by isoosmolar contrast medium (iodixanol) are mostly mild, with rashes and headaches being the most common. Although anaphylactic shock has been reported, no related incidents have been documented on cerebral angiography. Objective This article reports a serious case of anaphylactic shock possibly induced by iodixanol and provides an overview of the case report. Case Summary A 65-year-old female with persistent headaches for nearly six months and CTA examination revealed multiple intracranial aneurysms. After two treatments, she returned to the hospital for aneurysm of reexamination a month ago. Following a preoperative assessment, cerebral angiography was performed. Three minutes after the procedure, the patient experienced dizziness, increased heart rate, followed by hypotension (BP 90/43 mm Hg), a sudden drop-in heart rate (HR 68 bpm), and a drop in SpO2 to 92%. Intravenous dexamethasone for anti-allergic were administered immediately, along with therapy through oxygen-inhalation. However, the patient then developed limb convulsions, unresponsiveness, and was urgently given diazepam for sedation and sputum aspiration to maintain airway patency. Blood pressure decrease to 53/29 mm Hg, and SpO2 readings were unavailable. Intravenous dopamine to elevates blood pressure, and assists breathing by intubating in the endotracheal. After 3 minutes, as the blood pressure remained undetectable, intermittent intravenous epinephrine 1mg was administered to raise the blood pressure, gradually restoring it to 126/90 mm Hg, and SpO2 increased to 95%. The patient was diagnosed with iodixanol-induced anaphylactic shock and urgently transferred to the NICU for monitoring and treatment. The patient died despite immediate treatment. Conclusion A 65-year-old female developed serious anaphylactic shock during cerebral angiography after receiving iodixanol. Although iodixanol is considered one of the safest iodinated contrast mediums (ICM), clinicians should be aware of its the potential for serious hypersensitivity reactions that can lead to fatal and life-threatening events.
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Affiliation(s)
- Yang Zhao
- Department of Pharmacy, Guangyuan Central Hospital, Guangyuan, Sichuan, People’s Republic of China
| | - Hua Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Zhengjun Wu
- Department of Pharmacy, Guangyuan Central Hospital, Guangyuan, Sichuan, People’s Republic of China
| | - Yunxiang Zhu
- Department of Pharmacy, Guangyuan Central Hospital, Guangyuan, Sichuan, People’s Republic of China
| | - Jingsong Wang
- Department of Pharmacy, Guangyuan Central Hospital, Guangyuan, Sichuan, People’s Republic of China
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Huang L, Luo Y, Chen ZL, Yang ZY, Wu Y. Thyroid dysfunction associated with iodine-contrast media: A real-world pharmacovigilance study based on the FDA adverse event reporting system. Heliyon 2023; 9:e21694. [PMID: 37954365 PMCID: PMC10638017 DOI: 10.1016/j.heliyon.2023.e21694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/09/2023] [Accepted: 10/25/2023] [Indexed: 11/14/2023] Open
Abstract
Objective To comprehensively analyze characteristics of thyroid dysfunction associated with iodine contrast media (ICM) based on data from the FDA adverse event reporting system (FAERS). Methods Disproportionate analysis was employed to identify signals of thyroid dysfunction caused by ICM, and descriptive analysis was performed to examine the clinical characteristics of reported cases involving ICM-related thyroid dysfunctions. Results A total of 83 adverse event reports were identified, documenting thyroid dysfunctions associated with ICM agents. Treatment with ICM was significantly associated with higher reporting of hypothyroidism ([ROR] = 2.21, 95 % CI: 1.59-3.08; IC025 = 0.58) and hyperthyroidism (ROR = 3.49, 95 % CI: 2.37-5.13; IC025 = 1.14). Among the six ICM agents investigated, iodixanol demonstrated the highest signal strength in both hypothyroidism (ROR = 9.47) and hyperthyroidism (ROR = 5.44). Hypothyroidism and hyperthyroidism almost occurred in the first 30 days after ICM administration (76.9 % and 70 % of patients, respectively). Furthermore, the proportion of severe outcomes in hyperthyroidism was significantly higher than that in hypothyroidism (12/26 vs. 2/35, P = 0.009). Conclusion The present study highlights the varying risks of thyroid dysfunction associated with different ICM agents, with iodixanol exhibiting the highest signal intensity. Hypothyroidism and hyperthyroidism associated with ICM generally manifest within the first month following administration. Consequently, monitoring of thyroid function during this period is strongly recommended for ICM agents presenting higher risk profiles.
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Affiliation(s)
- Lu Huang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, People's Hospital of Fushun County, Fushun, China
| | - Yan Luo
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Pharmacy, Chengdu Seventh People's Hospital, Chengdu, China
| | - Zhen-Lin Chen
- Department of Pharmacy, People's Hospital of Fushun County, Fushun, China
| | - Zhi-Yun Yang
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Institute for Rational and Safe Medication Practices, Central South University, Changsha, China
| | - Yue Wu
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Jiang H, Li Y, Wu X, Yu H, Zhang X, Ge W, Yan S. Pharmacist-led iodinated contrast media infusion risk assessment service. Front Pharmacol 2023; 14:1161621. [PMID: 37229268 PMCID: PMC10203501 DOI: 10.3389/fphar.2023.1161621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Background: With the increasing development of medical imaging, the use of iodinated contrast media has become more widespread. Adverse reactions caused by iodinated contrast media have drawn much attention. Despite this, there is still a lack of unified standards for the safe infusion process of iodinated contrast media in clinical practice both domestically and internationally. Objectives: Establishing a risk management service system to better predict the risks associated with iodinated contrast media infusion, reduce the incidence of adverse reactions and minimize patient harm. Method: A prospective interventional study was carried out from April 2021 to December 2021 at Nanjing Drum Tower Hospital in China. During this study, a service system was established to manage the risks associated with the infusion of iodinated contrast media. Personalized risk identification and assessment were performed by a pharmacist-led multidisciplinary team before iodinated contrast media infusion. Early warning, prevention, and adverse reaction management were performed according to different risk levels during and after infusion. Results: A multidisciplinary team led by pharmacists was established to evaluate the risks associated with infusion of iodinated contrast media. A total of 157 patients with risk factors related to the iodinated contrast media were screened out, which prevented 22 serious adverse events and enhanced the quality of medical care. All participants expressed high satisfaction with the service. Conclusion: Through practical exploration, the pharmacist-led multidisciplinary team can provide advance warning and effectively limit the risks of adverse reactions caused by iodinated contrast media to a preventable and controllable level. This approach serves as a valuable reference for developing strategies and schemes to reduce the incidence of such reactions. Therefore, we encourage the implementation of this intervention in other areas of China.
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Affiliation(s)
- Huiyan Jiang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yuan Li
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Xiaoyan Wu
- Department of Radiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Hongming Yu
- Department of Radiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Xin Zhang
- Department of Radiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Simin Yan
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
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van der Molen AJ, Dekkers IA, Bedioune I, Darmon-Kern E. A systematic review of the incidence of hypersensitivity reactions and post-contrast acute kidney injury after ioversol in more than 57,000 patients: part 1-intravenous administration. Eur Radiol 2022; 32:5532-5545. [PMID: 35312790 PMCID: PMC9279198 DOI: 10.1007/s00330-022-08636-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/20/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the incidence of adverse drug reactions (ADRs), including hypersensitivity reactions (HSRs) and post-contrast acute kidney injury (PC-AKI), after intravenous (IV) administration of ioversol. MATERIALS AND METHODS A systematic literature search (1980-2021) of studies documenting IV use of ioversol and presence or absence of ADRs, HSRs, or PC-AKI was performed. Key information including patients' characteristics, indication and dose of ioversol, safety outcome incidence, intensity and seriousness were extracted. RESULTS Thirty-one studies (> 57,000 patients) were selected, including 4 pediatric studies. The incidence of ADRs in adults was reported in 12 studies from ioversol clinical development with a median (range) of 1.65% (0-33.3%), and 3 other studies with an incidence between 0.13 and 0.28%. The incidence of HSRs (reported in 2 studies) ranged from 0.20 to 0.66%, and acute events (4 studies) from 0.23 to 1.80%. Severe reactions were rare with a median (range) of 0 (0-4%), and none were reported among pediatric patients. The incidence of ADRs and HSRs with ioversol, especially those of severe intensity, was among the lowest in studies comparing different iodinated contrast media (ICM) of the same class. PC-AKI incidence was variable (1-42% in 5 studies); however, ioversol exposure per se did not increase the incidence. CONCLUSIONS When administered by the IV route, ioversol has a good safety profile comparable to that of other ICM within the same class, with a low incidence of severe/serious ADRs overall, and particularly HSRs. PC-AKI incidence does not seem to be increased compared to patients who did not receive ioversol. Further well-designed studies are warranted to confirm these results. KEY POINTS • Ioversol has a good safety profile in adult and pediatric patients when IV administered. • ADR and HSR incidence with ioversol, especially those of severe intensity, was among the lowest compared to other ICM. • IV administration of ioversol per se did not increase PC-AKI incidence.
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Affiliation(s)
- Aart J. van der Molen
- Contrast Media Safety Research Group, Department of Radiology C-2S, Leiden University Medical Center, Albinusdreef 2, NL-2333 ZA Leiden, The Netherlands
| | - Ilona A. Dekkers
- Contrast Media Safety Research Group, Department of Radiology C-2S, Leiden University Medical Center, Albinusdreef 2, NL-2333 ZA Leiden, The Netherlands
| | - Ibrahim Bedioune
- Clinical Development Department, Guerbet, Roissy CDG Cedex, France
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Talmon A, Tal Y, Moss J, Hershkowitz I, Shaham D, Sosna J, Hershko AY. Clinical impact of allergy and pre-medication in CT studies with low-osmolality intravenous iodinated contrast media. Clin Radiol 2021; 77:210-215. [PMID: 34973806 DOI: 10.1016/j.crad.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022]
Abstract
AIM To evaluate the occurrence and severity of allergic reactions to iodinated contrast media (ICM), including associated risk factors and the impact of pre-medication. MATERIALS AND METHODS Data on patients who had experienced allergic reactions during outpatient computed tomography (CT) examinations between January 2014 and September 2018 were analysed retrospectively. Response severity was assessed according to validated criteria. A control group was selected among individuals who underwent CT during the study period and did not experience allergic reactions. RESULTS Screening of 36,920 CT studies revealed 74 (0.2%) individuals with systemic reactions to ICM. No significant differences in patient characteristics were found among patients who experienced mild (n=54), moderate (n=17), or severe (n=4) reactions. Previous ICM allergy was reported in 10 patients (13.3%). Patients with a history of ICM allergy had mild (9/10) or moderate (1/10) reactions, with one individual showing decreased intensity of the allergic response compared to a previous event. Within the control group, four patients (4%) had previous ICM allergy. In these individuals, lack of allergic reactions could not be attributed to pre-medication. All patients with severe reactions did not have a prior history of ICM allergy. CONCLUSION Severe allergic reactions to ICM are rare, lack significant risk factors, and do not appear to be impacted by pre-medication. The findings presented herein highlight the need for prospective work that will re-evaluate the yield of pre-medication protocols.
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Affiliation(s)
- A Talmon
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Y Tal
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - J Moss
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - I Hershkowitz
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - D Shaham
- Department of Radiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - J Sosna
- Department of Radiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - A Y Hershko
- Allergy and Clinical Immunology Unit, Department of Medicine, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Israel.
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Chen B, Yu F, Chen W, Wang Y, Hao F. Acute Urticaria in Inpatients Undergoing Non-emergent Coronary Angiography With Corticosteroid Prophylaxis: A Retrospective Study. Front Med (Lausanne) 2021; 8:616015. [PMID: 34179031 PMCID: PMC8222595 DOI: 10.3389/fmed.2021.616015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Acute urticaria (AU) is the most frequently reported immediate hypersensitivity reaction in skin by administration of iodinated contrast media (ICM). We aimed to establish the pattern and identify the risk factors of AU among inpatients undergoing non-emergent coronary angiography (CAG) with prophylactic corticosteroids in China. Methods: Medical records of 19,326 adult inpatients undergoing non-emergent CAG with prophylactic methylprednisolone in 2013–2019 were retrospectively investigated. AU was identified within 1 h post-ICM administration, and diffuse involvement was defined when wheals occur in two or more body parts, including the back, abdomen, chest, and extremities. Age- and sex-matched inpatients (1:4) without AU were randomly selected for assessment of risk factors. Results: Approximately 0.8% of CAG inpatients had AU, including 101 diffuse and 64 limited form. The diffuse AU was more common in settings of non-diagnostic CAG, iohexol used, average ICM injection≥3 ml/min, recurrent CAG, and past history of immediate hypersensitivity to ICM. Inpatients with preexisting allergies, decreased evaluated glomerular filtration rate, and increased high sensitivity C reactive protein or neutrophil-to-lymphocyte ratio prior to CAG had a higher probability of AU (odds ratio >1, P < 0.05 for all variables). All AU inpatients complained of pruritus, and mild itching predominated. AU dissipated in several days under treatment of ebastine or levocetirizine 10 mg/daily, but ebastine showed superiority. Conclusions: ICM-induced AU is not uncommon in non-emergent CAG inpatients with prophylactic methylprednisolone. Preexisting allergies, renal dysfunction, and mild inflammation are high-risk factors, and antihistamine monotherapy is a favorable candidate for ICM-related AU.
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Affiliation(s)
- Bangtao Chen
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fubing Yu
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, China
| | - Fei Hao
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Aydin OC, Aydin S, Guney HZ. Pharmacovigilance and radiologists: How well do they get along? Br J Radiol 2020; 93:20200596. [PMID: 32903029 DOI: 10.1259/bjr.20200596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Considering the growing use of imaging modalities and contrast agents, radiologists are prone to encounter adverse drug reactions (ADR). In the current study, we mainly aim to evaluate the knowledge of radiologists regarding pharmacovigilance (PV). Also, we intend to gather information about their previous ADR experiences. Secondarily, we hope to increase the awareness about contrast-medium-related ADRs and attract attention to the importance of properly reporting these ADRs. METHODS A survey was generated by using an online survey webpage, and the relevant link was e-mailed to radiologists and radiology residents. The survey begins with a short explanation about the study. The second section contains questions about PV knowledge level, and the final section aims to gather information about the experienced ADRs. RESULTS The survey was completed by 202 participants. 65.3% stated that they were aware of PV. 24.8% of the participants said that they know the national PV program. 97% told that they knew the term ADR. 66.3% of the participants encountered an ADR. 53.7% of them reported these ADRs. 70.8% of them reported these ADRs to a clinician. CONCLUSIONS Radiologists encounter ADRs almost as frequently as the other doctors. Their awareness about PV is similar with other healthcare professionals. They have fewer information about TUFAM and PvCPs. Radiologists generally prefer to communicate with a clinician about an ADR. Overall condition of radiologists about PV is quite similar with other healthcare professionals and education can improve it, as for the others. ADVANCES IN KNOWLEDGE Radiologists encounters ADRs almost as frequently as the other doctors. Overall condition of radiologists about PV is quite similar with other healthcare professionals and education can improve it, as for the others.
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Affiliation(s)
- Ozlem Celik Aydin
- Department of Medical Pharmacology, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Sonay Aydin
- Department of Radiology, Dr. Sami Ulus Training and Research Hospital, Ankara, Turkey
| | - Hakki Zafer Guney
- Department of Medical Pharmacology, Gazi University, Faculty of Medicine, Ankara, Turkey
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Gracia‐Bara MT, Moreno E, Laffond E, Muñoz‐Bellido F, Lázaro M, Macías E, de Arriba S, Campanón V, Sobrino M, Dávila I. Tolerability of iobitridol in patients with non-immediate hypersensitivity reactions to iodinated contrast media. Allergy 2019; 74:195-197. [PMID: 30225896 DOI: 10.1111/all.13603] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Maria Teresa Gracia‐Bara
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
| | - Esther Moreno
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
- Department of Biomedical and Diagnostic Sciences Salamanca Medical School University of Salamanca Salamanca Spain
| | - Elena Laffond
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
- Department of Biomedical and Diagnostic Sciences Salamanca Medical School University of Salamanca Salamanca Spain
| | - Francisco Muñoz‐Bellido
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
- Department of Biomedical and Diagnostic Sciences Salamanca Medical School University of Salamanca Salamanca Spain
| | - Milagros Lázaro
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
| | - Eva Macías
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
| | - Sonia de Arriba
- Allergy Service University Hospital of Salamanca Salamanca Spain
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
- Department of Biomedical and Diagnostic Sciences Salamanca Medical School University of Salamanca Salamanca Spain
| | - Valle Campanón
- Allergy Service University Hospital of Salamanca Salamanca Spain
| | - Miriam Sobrino
- Allergy Service University Hospital of Salamanca Salamanca Spain
| | - Ignacio Dávila
- IBSAL (Institute for Biomedial Research of Salamanca) SalamancaSpain
- Department of Biomedical and Diagnostic Sciences Salamanca Medical School University of Salamanca Salamanca Spain
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Moreno E, Gracia-Bara MT, Mayorga C, Lázaro M, Campanón MV, Dávila I. Hypersensitivity Reactions to Iodinated Contrast Media: Is it a True Allergy? CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0154-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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