Correction to: SIRM‑SIAAIC consensus, an Italian document on management of patients at risk of hypersensitivity reactions to contrast media

Special Issue on suspected perioperative allergic reactions

The purpose of this work was to gain clinical experience with and to identify the optimal conditions for the use of recombinant human TSH (rhTSH, commercially available as Thyrogen) in the management of patients with differentiated thyroid cancer (DTC). The study involved 22 patients for a total of 27 administration cycles of rhTSH, for either diagnostic (in 19 instances) and/or therapeutic purposes (in 8 instances). There were 19 patients with papillary cancer (follicular variant in 4, columnar variant in 1) and 3 patients with follicular cancer (1 Hurtle cell variant). All patients had previously undergone total thyroidectomy and 1-5 cycles of 131I-therapy. Thyrogen was administered i.m. according to the suggested protocol: 0.9 mg i.m. on days 1 and 2, radioiodine on day 3. Peak serum TSH levels between 68-237 microIU/mL were observed after rhTSH administration; these were on average 65% higher, on a patient-by-patient basis, than peak serum TSH observed after conventional withdrawal of thyroxine treatment in 19 patients, while in 3 patients they were 28% lower, but still in the potent stimulation range (86-94 microIU/mL). There was general agreement between imaging results obtained under rhTSH stimulation and those obtained on prior occasions during thyroxine withdrawal, although radioiodine uptake was interpreted as less intense following Thyrogen administration. Of 18 patients undergoing rhTSH administration for diagnostic purposes, 11 patients had a negative radioiodine whole-body scan (WBS) and 7 had a positive WBS. Three of the WBS-negative patients were shown to be actually affected by tumor recurrence, respectively by PET with [18F]FDG (in 2 cases) and by post-131I therapy scan. Serum thyroglobulin (hTg) increased to abnormal levels following rhTSH stimulation in 3/7 of the WBS-positive patients as well as in 1/11 WBS-negative patients. In 3/7 WBS-positive as well as in 3/11 WBS-negative patients, serum hTg progressively rose under rhTSH stimulation, yet still remaining below 3 ng/mL. Post-131I therapy scans following Thyrogen administration showed good radioiodine uptake in 7/8 patients, the single unsuccessful case being most likely due to expansion of the iodine pool because of recent use of an iodinated contrast medium. The overall results show the feasibility and practical advantages of employing rhTSH stimulation in the general clinical setting rather than thyroxine withdrawal in the management of DTC patients. Caution should be raised on the interpretation of the serum hTg response to such potent but short-lived TSH stimulation.

Hypersensitivity reactions (HRs) to contrast media (CM) can be distinguished in immune-mediated (including allergic reactions) and non-immune-mediated reactions, even if clinical manifestations could be similar. Such manifestations range from mild skin eruptions to severe anaphylaxis, making it important for radiologists to know how to identify and manage them. A panel of experts from the Società Italiana di Radiologia Medica e Interventistica (SIRM) and the Società Italiana di Allergologia, Asma e Immunologia Clinica (SIAAIC) provided a consensus document on the management of patients who must undergo radiological investigations with CM. Consensus topics included: the risk stratification of patients, the identification of the culprit CM and of a safe alternative by an allergy workup, as well as the use of premedication and the correct procedure to safely perform an elective (i.e., scheduled) or urgent examination. The most important recommendations are: (1) in all patients, a thorough medical history must be taken by the prescribing physician and/or the radiologist to identify at-risk patients; (2) in patients with hypersensitivity reactions to CM, the radiologist must consider an alternative, non-contrast imaging study with a comparable diagnostic value, or prescribe a different investigation with another class of CM; (3) if such options are not feasible, the radiologist must address at-risk patients to a reference centre for an allergy evaluation; (4) if timely referral to an allergist is not viable, it is recommended to use a CM other than the responsible one, taking into account cross-reactivity patterns; in the case of patients with histories of severe reactions, the presence of an anesthesiologist is also recommended and a premedication is suggested.

There is a relationship between patients with chronic kidney disease and coronary artery disease. These two entities share both common etiologies and risk factors. Management of different patients with coronary artery disease in the aspect of renal insufficiency and certain medications such as contrast media is thus of high importance. Treatment nihilism is a major problem though and healthcare providers must make efforts to maintain a stable kidney function in all coronary artery disease patients.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5430077/Activity.aspx

Correspondence: Jon S. Thompson, MD, Department of Surgery, University of Nebraska, 92 3280 Nebraska Medical Center, Omaha, Nebraska 68198-3280.

Acute hypersensitivity reactions to contrast media(AHRC) are infrequent, usually mild but potentially fatal. Although there are recommendations from Radiology, Intensive Care and Allergology fields regarding its management, a clinical multidisciplinary protocol that integrates these complementary approaches is missing. We aimed to elaborate a protocol that includes adverse reactions definition and classification; identification of risk factors and management of patients with AHRC. A non systematic revision of national and international guidelines was made regarding the management of hypersensitivity reactions, in order to elaborate a clinical consensus protocol to be used in different medical fields (Radiology, Allergology and Intensive Care). Non-renal adverse contrast reactions can be classified in chemotoxic (related to contrast chemical properties) and hypersensitivity reactions (with involvement of immunological mediators IgE and non IgE mediated); and in mild, moderate and severe (regarding severity), with different therapeutic approaches. Identified risk factors are previous contrast media reaction and asthma. Pre-medication decreases the probability of symptoms but does not exclude the possibility of a severe reaction. Patients suspected of AHRC should be observed in an allergy clinic to confirm the diagnosis and find an alternative contrast media. Clinical alert record as well as the notification of reaction to surveillance system of adverse drug reactions should be performed. This clinical expert’s protocol consensus based on national and international guidelines aims to be a valuable practical tool in the management of patients that need contrast media during a radiologic exam.

Allergic diseases are quite prevalent worldwide, and the incidence of allergy is increasing everywhere [1-7]. Because allergic and immunologic processes overlap all organ systems, allergy is not always taught in medical schools as a separate subject. Indeed, lack of recognition of the specialty and of the need to teach about allergic and immunologic diseases results in allergy not being included at all in some medical school curricula [8]. With an estimated 22% of the global population experiencing allergic and immunologic diseases, it is time to recognize and strengthen education in allergy and immunology [8]. The World Allergy Organization (WAO), an alliance of 74 national and regional allergy societies, created this consensus document to establish educational guidelines for worldwide application to help identify and correct allergy education and training deficiencies and to define appropriate competencies. In creating this consensus, it is recognized that each country has its own principles and goals in medical education at the undergraduate and postgraduate levels. This document defines what WAO considers medical practitioners should know to care appropriately for allergic patients.

Taxanes (a class of chemotherapeutic agents) are an important cause of hypersensitivity reactions (HSRs) in cancer patients. During the last decade, the development of rapid drug desensitization has been key to allow patients with HSRs to taxanes to be safely re-treated although the mechanisms of these HSRs are not fully understood. Earlier studies suggested that solvents, such as Cremophor EL used to solubilize paclitaxel, were responsible for HSRs through complement activation, but recent findings have raised the possibility that some of these HSRs are IgE-mediated. Taxane skin testing, which identifies patients with an IgE-mediated sensitivity, appears as a promising diagnostic and risk stratification tool in the management of patients with HSRs to taxanes. The management of patients following a HSR involves risk stratification and re-exposure could be performed either through rapid drug desensitization or graded challenge based on the severity of the initial HSR and the skin test result. Rapid drug desensitization has been shown to be an effective and safe method to re-introduce taxanes in hundreds of patients, including those with life-threatening HSRs. Patients with non-severe delayed skin HSRs may benefit from rapid drug desensitization since they may be at increased risk for an immediate HSR upon re-exposure. This review focuses on the clinical presentation, diagnosis, and novel mechanisms of immediate HSRs to taxanes. A new management strategy for HSRs to taxanes based on skin testing and rapid drug desensitization is proposed.

IntroductionIn order to minimise adverse effects or patient injuries related to the effect of iodinated contrast media (ICM) on the thyroid, international guidelines and research recommend developing routines for identification and management of patients at risk of developing a thyroid dysfunction. This study aimed to investigate thyroid‐related ICM administration practices among diagnostic imaging departments in Norway.MethodsThe cross‐sectional survey included 24 hospitals and 75 respondents with a 69% response rate. The survey covered practices for assessment and management of at‐risk patients and the participants’ perceived rationale for the routines.ResultsThe use of written checklists as recommended by international guidelines was quite modest (15%) and the respondents preferred various methods to identify risk and contraindications. Only 20% reported checking for any scheduled thyroid‐scintigraphy and/or radioactive‐iodine therapy. 42% indicated that they did not have thyroid‐related ICM routines, and the main perceived reason was lack of knowledge on the topic. Radiographers and radiologists expressed uncertainty about each other’s roles and routines.ConclusionThis study revealed the need of optimisation of routines regarding ICM administration to patients at risk for thyroid dysfunction.

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Nutritional Therapy of Renal Failure

Lidocaine is the most commonly used local anesthetic (LA) agent in various dental as well as oral and maxillofacial procedures. Although rare, adverse effects and allergic reactions to lidocaine have been reported. In patients with suspected allergy to LA or a history of such reaction, careful history-taking and allergy testing should be performed to choose an alternative LA agent to avoid any adverse effects. Here, we present two cases of delayed hypersensitivity reaction to lidocaine, wherein the patients presented with erythema, edema, and itching. Intradermal testing confirmed allergic reaction to lidocaine, and the patients underwent successful dental treatment using an alternative LA agent. This report highlights the importance of allergy testing prior to LA use considering the serious consequences of allergy to these agents and describes the management of such patients using an alternative LA agent.

Nephrogenic Systemic Fibrosis and Management of High-risk Patients

Intraoperative Assessment of Circumflex Artery Occlusion During Mitral Valve Operation

Background: Recognition of anaphylaxis and differentiation from other infusion reactions in an oncology setting is imperative; epinephrine is the recommended treatment for anaphylaxis and should be administered immediately to patients in whom anaphylaxis is suspected. Trastuzumab has a potentially tremendous oncological benefit, and when hypersensitivity reactions occur, rechallenge with desensitization protocols has become more common. Oncology presents a unique situation in which repeat drug exposure after a serious adverse reaction is often warranted due to the mortality risk of untreated cancer—allergists can assist with both symptom assessment and risk mitigation. Case presentation: This case showcases successful desensitization in a 43-year-old female with locally advanced HER2-positive breast cancer following a severe anaphylactic reaction to trastuzumab, in which epinephrine was not administered. We report the establishment of the Medical Oncology and Allergy Clinic: Canada’s first multidisciplinary clinic aimed at expediting the assessment and management of oncology patients with adverse drug reactions (including chemotherapy, contrast media, antimicrobials) and those with primary and acquired immunodeficiency. Conclusions: We propose this multidisciplinary clinic model as a treatment framework moving forward, with the goal of continuing first-line therapies in cancer patients who develop drug-hypersensitivity (i.e., through desensitization). This case highlights the unmet need for a multidisciplinary approach to the management of oncology patients who experience hypersensitivity reactions.