Radiologic Contrast Media Desensitization for Delayed Cardiac Catheterization

This protocol for rapid desensitization to intravenous radiographic contrast material (RCM) improves the strategy first reported by Uppal et al. Desensitization is a validated preventative measure for medical emergencies, such as cardiac catheterization, when patients present with histories of anaphylactoid reactions to the allergen of concern. The patient required another catheterization that was modified to repeat the final dosage of 320 mg/mL of Visipaque®, accommodating cardiac catheterization postponement, contrary to readministration of doses 4 (0.625 mg/mL) and 8 (10 mg/mL) as reported in Uppal et al. Our risk score calculations suggested that the patient was at low risk of contrast-induced nephropathy (CIN) that did not necessitate reduced dosage. No complications were reported following catheterization. We propose repetition of the final RCM dosage as a more effective and efficient desensitization strategy, as long as the scoring system does not indicate high risk for CIN.

Palpation Versus Ultrasound-Guided Acromioclavicular Joint Intra-articular Corticosteroid Injections: A Retrospective Comparative Clinical Study

Background: Primary osteoarthritis (OA) is the most common cause of pain arising from the acromioclavicular (AC) joint. The true incidence is unknown because of differences in the criteria used to define arthritis in various studies. The proper diagnosis of AC joint OA requires a thorough physical examination, radiographic findings, and a diagnostic local anesthetic injection. Objective: The goal of this study was to assess the effects and safety of ultrasound (US) versus palpation-guided acromioclavicular (AC) joint intra-articular (IA) corticosteroid injection for patients with osteoarthritis (OA) of the AC joint. Study Design: Retrospective, compared clinical study. Setting: University hospital outpatient pain clinic. Method: We retrospectively reviewed the charts of patients with AC joint degenerative OA who had undergone US or palpation-guided AC joint IA corticosteroid injection between January 2012 and December 2013 at our outpatient clinic. One hundred consecutive patients identified from chart review met inclusion criteria. Patients (N = 50) in US guide AC joint IA steroid injection group were administered a mixture of 0.5% lidocaine (1 mL) with triamcinolone (20 mg/mL; 0.5 mL) and radiographic contrast material (0.5 mL) and patients (N = 50) in palpation-guided AC joint IA steroid injection group were administered a mixture of 0.5% lidocaine (1 mL) with triamcinolone (20 mg/mL; 0.5 mL) and 0.5 mL of radiographic contrast material. Results were measured using the Shoulder Pain and Disability Index (SPADI), Verbal Numeric pain Scale (VNS) at rest (VNSar), under local pressure (VNSlp) ,and the arm adduction test (VNSaat) at the joint space area before injections and at one, 3, and 6 months after the injections. Successful treatment occurred when patients obtained significant pain relief (as measured by > 50% improvement in the VNS score and 20 point improvement in the SPADI) at one, 3, and 6 months after the injections. Univariable analysis was performed to evaluate the relationship between possible outcome predictors and therapeutic effect by using a chi-square test. Logistic regression analysis was performed to assess whether injection method, injection accuracy, patients’ age, gender, and duration of the disease were independent predictors of successful outcome. Results: SPADI, VNSaat, VNSlp, and VNSar improved at one, 3, and 6 months after the injections in both groups. There was a statistically significantly greater improvement in the VNSlp score and SPDAI at 6 months and in the VNSaat score at 3 months and 6 months for US-guided group as compared with the palpation group. Successful treatment is defined as significant differences found between the groups or from the 3-month to 6-month outcomes. Multiple logistic regression and univariable analysis showed that the significant outcome predictors at 6-month follow-up was the injection accuracy. Limitations: Limitations include the retrospective nature of the study, lack of evaluation of longterm effects , most of the injections were performed in patients with a BMI of less than 30 kg/m2, and the treatment procedures were conducted by the same physician. Conclusion: US-guided AC joint IA injection for the treatment of symptomatic AC joint OA resulted in better pain and functional status improvement than palpation-guided IA injection at the 6-month follow-up. Key Words: Ultrasound, injection, acromioclavicular joint, steroid

Accuracy of Acromioclavicular Joint Injections

Background: Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic. Purpose: The purpose of this study was to evaluate the accuracy of in vivo AC joint injections. Study Design: Case series; Level of evidence, 4. Methods: Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular. Results: Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint. Conclusion: This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.