International Iohexol Shortage: Alternative Contrast Agents and Imaging Procedures for the Urologist.

INTRODUCTION: In April 2022, GE Healthcare announced a COVID-19-related interruption in iohexol manufacturing, leading to an international iodinated contrast shortage. The shortage greatly impacted urological practice, highlighting the value of alternative contrast agents and imaging/procedure alternatives. These alternatives are reviewed in this work. METHODS: A review of existing literature describing the use of alternative contrast agents, alternative imaging procedures, and contrast conservation strategies in urological care was performed using the PubMed database. The review was not performed systematically. RESULTS: Older iodinated contrast agents such as ioxaglate and diatrizoate can replace iohexol for intravascular imaging in patients without renal impairment. These agents, along with gadolinium-based agents such as Gadavist, have been used intraluminally for urological procedures and diagnostic imaging. Several lesser-known imaging and procedure alternatives are described and include air contrast pyelography, contrast-enhanced ultrasound, voiding urosonography, and low tube voltage CT urography. Conservation strategies include contrast dose reductions and use of contrast management devices for contrast vial splitting. CONCLUSIONS: The COVID-19-related iohexol shortage caused significant hardship for urological care internationally, leading to delayed contrasted imaging studies and urological procedures. Alternative contrast agents, imaging/procedure alternatives, and conservation strategies are reviewed in this work with the goal of equipping the urologist to mitigate the current iodinated contrast shortage and to prepare in the event of a future shortage.

CT Transit Time And Its Correlation To Cardiac Output Derived From Mr

Introduction: Pulmonary transit time (PTT), the time taken for contrast to travel from the left to right ventricle, can be used as a surrogate marker for cardiac output. There have been previous studies evaluating the prognostic significance of Magnetic Resonance (MR) and Computed Tomography (CT) PTT in heart failure patients. This study used dynamic CT images to determine the PTT and study its correlation with left and right ventricular ejection fraction and left and right cardiac output in COVID patients, with a known range of cardiac outputs. Method(s): 123 COVID-19 patients were retrospectively studied. A single contrast bolus timing scan was acquired with a 320-detector CT (Acquilion ONE, Canon). A single 2 mm slice was placed axially where left and right ventricle and descending aorta were visualised. Contrast administration and scan acquisition began at the same with 20 ml of Omnipaque with 40 ml saline flush at 5 ml/s. One image was acquired every second and the total scan time was 26 seconds. A circular ROI was placed in the centre left and right ventricle, the signal intensity was plotted over time for each of these regions. Matlab software was used to extract the peak contrast time between the right and left ventricles. MR cardiac images were acquired on a 3 T Prisma, which determined MR PTT, left and right ejection fraction (LVEF, RVEF) and left and right ventricle cardiac output (LVCO, RVCO). These values were already computed from a previous study where this data was taken from. Correlations were studied using the Pearson correlation method using Minitab software. Result(s): There was correlation between MR PTT and LVEF and RVEF, r = - 0.433 p<0.05 and r=-0.358 p<0.05 respectively. A correlation was also seen with CT PTT and LVEF (figure 1) and RVEF, r=-0.-345 p<0.05 and r=-0.2 p=0.029 respectively. A correlation was seen for MR PTT and LVCO and RVCO, r=-0.322 p<0.05 and r=-0.295 p<0.05 but not for CT PTT and LVCO and RVCO, r=-0.1 p=0.297 and r=-0.04 p=0.668 respectively. Conclusion(s): A correlation was seen between MR PTT and CT PTT for both LVEF and RVEF, but this was not seen for CT PTT and LVCO and RVCO. Further work is required to understand the limitations of the CT PTT and why it fails to correlate with these parameters. Limitations may include dynamic CT temporal resolution or due to poor image quality due to motion from breathing. Compared to previous studies there is agreement between the MR PTT and MR cardiac parameters. At this stage there is an indication that CT PTT could be a potential tool to estimate LVEF and RVEF. [Formula presented]Copyright © 2023

Metrics-driven successful strategy by emergency and radiology driven task force to mitigate global CT contrast media shortage in a safety net hospital.

Iodinated contrast media (ICM) shortages and secondary supply chain problems due to Coronavirus Disease lockdowns in China significantly impacted radiology operations nationwide. The lack of ICM necessitated operational workflow changes designed to ration contrast use, particularly in the hospital setting. In this manuscript, we share our strategic methods with advanced process/outcome metrics to monitor the effectiveness of our strategy under a coordinated multidisciplinary team effort. Alternate studies such as substituting magnetic resonance angiography for computed tomographic angiography for emergency department patients were studied to measure the suitability of these examinations for specific diagnoses. This article presents readers with a comprehensive crisis management strategy deployed at our institution, emphasizing various options with a limited ICM supply, and minimizing the impact on clinical care.

Mesenchymal Stem/Stromal Cells: INTERIM REPORT FROM THE NEPHSTROM MULTI-CENTRE, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED PHASE-1B CLINICAL TRIAL OF A NOVEL MESENCHYMAL STROMAL CELL THERAPY IN PROGRESSIVE DIABETIC KIDNEY DISEASE

Background & Aim: Funded in 2015, the NEPHSTROM EU-H2020 consortium aimed to translate pre-clinical evidence of efficacy of “off-the-shelf” intravenous (i.v.) allogeneic mesenchymal stromal cells (allo-MSC) in diabetic nephropathy to early-phase clinical investigation in patients with progressive diabetic kidney disease (DKD). Methods, Results & Conclusion: Methods: The trial IMP, NEPHSTROM ORBCEL-M, consists of cryopreserved, CD362-selected bone marrow allo-MSCs or matching placebo (cryopreservation fluid). The protocol for a multi-site, randomised, placebo-controlled, double- blind, dose-escalation phase-1b clinical trial in adults with DKD due to type 2 diabetes was designed collaboratively by a group of academic nephrologists and cell therapy specialists from Italy, the UK, Ireland and the Netherlands. Inclusion criteria included age 40-85 yrs and type 2 diabetes with evidence of progressive DKD [eGFR 25- 55mL/min/1.73m2, urine albumin creatinine ratio >88mg/g and rapid eGFR decline or ≥15% risk of ESRD within 5 years]. Three dose cohorts were planned, each with n=12 NEPHSTROM ORBCEL-M recipients + n=4 Placebo recipients and 18 months follow-up. Results: Following regulatory approval of the trial dossier through the EMA’s Voluntary Harmonisation Procedure and ethical approvals at the Sponsor site (Bergamo, Italy) and three other sites (Galway, Ireland;Birmingham and Belfast, UK), the NEPHSTROM trial (NCT02585622) opened March 2018. To date, 27 patients have been treated and 14 have completed the trial protocol. We report here our (as-yet blinded) experiences with the first fixed-dose cohort (80x10e6 cells/placebo i.v.), consisting of 16 subjects enrolled at 3 sites and followed for 18 months. The trial intervention proved safe, with one quickly-resolved infusion reaction and no subsequent SAEs ascribed to the IMP. Two patients died of unrelated causes between 12 and 18 months. Serial serum assays for anti-HLA antibodies indicated no persistent allo-immune sensitisation. NEPHSTROM ORBCEL-M effects on trends in eGFR, true GFR (iohexol clearance), albuminuria, serum/plasma inflammatory biomarkers and immune cell profiles will be analysed after unblinding. Following DSMB approval and COVID-19-related trial pauses, 11 second dose cohort subjects (160x10e6 cells/placebo i.v.) have been treated and are undergoing follow-up with no IMP-related adverse events to date. Conclusion: A novel, off-the-shelf, i.v. allo-MSC IMP has thus far proven safe and feasible in adults with progressive DKD.