Certolizumab

Certolizumab is a Fab fragment of a humanized monoclonal antibody against tumor necrosis factor-alpha (TNF-alpha). Differing from the other TNF-alpha inhibitors due to the absence of Fc fragment and pegylation, it binds to both the soluble and transmembrane forms of TNF-alpha, creating a strong TNF-alpha blockage. Previously approved for psoriatic arthritis, certolizumab received another approval from FDA in 2018 for the treatment of moderate to severe chronic plaque psoriasis that does not respond to conventional systemic treatments or for which these treatments are contraindicated. Administered via subcutaneous injections, certolizumab also has a low-dose option for patients weighing less than 90 kg. Certolizumab is considered a safe biological drug that can be preferred during pregnancy and lactation.Copyright © 2022 by Turkish Society of Dermatology and Venereology.

Case Report of Succesful Multidisiplinary Treatment for Patient with Metastatic Lung Cancer and Relapsed/Refractory Chronic Lymphatic Leukemia/Small Lymphocytic Lymphoma

Introduction: Croatian National Cancer Registry of Croatian Institute for Public Health reported that in year 2020 lung cancer was the second most common cancer site diagnosed in men with 16% and the third most common in women with 10% incidence among all cancer sites. Unfortunatelly lung cancer has the highest mortality in both men and women. Haematological malignancies had 7% share in all malignancies in both male and female cances cases. In 2020 190 newly diagnosed cases of lymphatic leukemia in men and 128 cases in women were reporeted, meaning 1.5 and 1.2% of all malignancies, respectively. Chronic lymphatic leukemia (CLL) is an advanced age disease and incidence increases with age. Impaired immunity, T and B cell dysfunction in CLL, chromosomal aberations, long-term immunosuppressive therapy and genetic factors can all cause secondary malignancies. Co- occurence of solid tumors and CLL is very rare. Although patiens with CLL have an increased risk of developing second primary malignancies including lung carcinoma, the data about their clinical outcomes are lacking. Parekh et al. retrospectively analyzed patients with simultaneous CLL and lung carcinoma over a 20-year period, and they found that ~2% of patients with CLL actually developed lung carcinoma. The authors claimed that up to 38% of patients will also develop a third neoplasm more likely of the skin (melanoma and basal cell carcinoma), larynx (laryngeal carcinoma) or colon. Currently there are no specific guidelines for concurrent CLL and non-small cell lung carcinoma (NSCLC) treatment. Usually, when the tumors are diagnosed simultaneously, treatment is based to target the most aggressive malignancy, as the clinical outcomes depend on the response of the tumor with the poorest prognosis. For this reason, a multidisciplinary approach is mandatory. Case report: A patient with history of coronary heart disease, myocardial infarction and paroxysmal atrial fibrillation was diagnosed in 2019 (at the age of 71) with B chronic lymphocytic leukemia with bulky tumor (inguinal lymph nodes 8x5 cm), stage B according to Binet, intermediate risk. He was treated with 6 cycles of chemoimmunotherapy (rituximab/cyclofosfamid/fludarabine). In 10/2019 remission was confirmed, but MSCT described tumor in the posterior segment of upper right lung lobe measuring 20x17 mm and bilateral metastases up to 11 mm. Bronchoscopy and biopsy were performed, and EGFR neg, ALK neg, ROS 1 neg, PD-L1>50% adenocarcinoma was confirmed. He was referred to Clinical Hospital Center Osijek where monotherapy with pembrolizumab in a standard dose of 200 mg intravenously was started in 01/2020. Partial remission was confirmed in October 2020. Immunotherapy was discontinued due to development of pneumonitis, dysphagia and severe weight loss (20kg), but without radiologically confirmed disease progression. At that time he was referred to our hospital for further treatment. Gastroscopy has shown erosive gastritis with active duodenal ulcus, Forrest III. Supportive therapy and proton pump inhibitor were introduced. After complete regression of pneumonitis, improvement of general condition and resolution of dysphagia, no signs of lung cancer progression were found and pembrolizumab was reintroduced in 12/2021. Hypothyroidism was diagnosed in 01/2021 and levothyroxine replacement ther apy was started. In 03/2021 he underwent surgical removal of basal cell carcinoma of skin on the right temporal region with lobe reconstruction. From 02/2021, when pembrolizumab was reintroduced, regression in tumor size was continously confirmed with complete recovery of general condition. He was hospitalized for COVID 19 infection in 09/2021, and due to complications pembrolizumab was discontinued till 11/2021. Lung cancer immunotherapy proceeded till 11/2022, when Multidisciplinary team decided to finish pembrolizumab because of CLL relapse. CLL was in remission till August 2022 when due to B symptoms, lymphcytosis, anemia and generalized lymphadenopathy, hematological workup including biopsy of cervical lymph node was performed and CLL/SLL relapse was confirmed. Initially chlorambucil was introduced, but disease was refractory. Based on cytogenetic test results (IGHV unmutated, negative TP53) and due to cardiovascular comorbidity (contraindication for BTK inhibitors) venetoclax and rituximab were started in 01/2023. After just 1 cycle of treatment normal blood count as well as regression of B symptoms and peripheral lymphadenopathy occured, indicating the probability of complete disease remission. In our patient with metastatic lung adenocarcinoma excellent disease control is achieved during 41 month of treatment in first line setting. Furthermore, relapsed/refractory CLL/SLL is currently in confirmed remission. Conclusion(s): Successful treatment of patients with multiple primary malignancies is based on multidisciplinarity, early recognition and management of side effects, treatment of comorbidities with the aim of prolonging life, controlling symptoms of disease and preserving quality of life.

Evaluating Efficacy Of Functional Luminal Imaging Probe In Preoperative Evaluation For Antireflux Procedures

Introduction: The COVID-19 pandemic caused significant decreases in outpatient procedures, many of which are required before to antireflux operation (ARS). The purpose of this study was to add functional luminal imaging probe (FLIP) to esophagogastroduodenoscopy (EGD) and esophageal pH monitoring to assess its utility in decreasing the need for follow up studies in patients being evaluated for ARS. Method(s): Retrospective observational study was performed on 81 patients being evaluated for GERD who underwent EGD, pH monitoring, and FLIP. Data collected included average distensibility index (DI) at 60 mL, presence of repetitive anterograde or retrograde contractions, hiatal hernia dimensions, pathology results, pH data, and need for follow-up testing. Result(s): Based on FLIP results, HRM was recommended in 35 patients (43.2%). This included 14 patients with DI suggestive of significant esophagogastric junction outflow obstruction, eight of whom completed HRM with four confirmed as achalasia. FLIP results were suspicious for eosinophilic esophagitis (EoE) in four patients of which one was confirmed as EoE on biopsy. Gastric emptying study was felt to be necessary for 11 patients before to ARS. Conclusion(s): FLIP identified patients with possible alternative pathologies including achalasia and EoE that would otherwise be a contraindication to ARS. FLIP at the time of EGD and pH monitoring is useful as it guides the clinical decision on need for additional outpatient procedures, which may be difficult to obtain in pandemic conditions. FLIP was effective at reducing the requirements for further follow-up testing in the majority of patients being evaluated for potential ARS.

Outcomes of a Pilot Contribution Database for the ICU Pharmacy Team at the University Hospitals of Leicester NHS Trust

Introduction It has long been felt that many contributions made by the ICU Pharmacy team, are not well showcased by the yearly regional network multi-speciality contributions audit. Themes specific to ICU are diluted amongst Trust and region wide data, and valuable learning for the multi-disciplinary team (MDT) is subsequently overlooked. Objective(s): The aims of this project were to: * Develop and pilot a MicrosoftTM Access © database for the ICU pharmacy team to record significant contributions. * Enable the production of reports to the ICU Quality & Safety board, to raise awareness, disseminate concerns, and influence future quality improvement projects. * Provide examples to contribute to the training of the whole MDT. * Generate evidence of team effectiveness and encourage further investment. * Provide team members with a means to recall contributions, for revalidation, appraisal, prescribing re-affirmation and framework mapping. Method(s): * A database was built with a user-friendly data-entry form to prevent overwriting. Fields were agreed with peers who would be using the database. * The team were invited to voluntarily enter their contributions which they thought added value and provided useful learning. * The pilot phase ceased with the emergence of the Omicron SARS-CoV-2 variant, due to staffing pressures and surge planning. Result(s): * Between 12/07/2021 and 25/11/2021, a total of 211 contributions were recorded. * Pharmacists entered 88.6% and a single technician entered 11.4% of these. * Independent Prescribing was utilised in 52.13% of contributions, and deprescribing in 25.12%. * Figure 1 demonstrates the contributions by drug group * The top 5 drugs associated with contributions were: ? Dalteparin ? Vancomycin ? Voriconazole ? Meropenem ? Co-trimoxazole * Treatment optimisation was an outcome for 76.3% of all contributions. Figure 2 stratifies these by type. Contributions. * Drug suitability was a cause for intervention in 12.8% of all contributions, encompassing allergies, contraindications, cautions and interactions and routes. * Medicines reconciliation accounted for 17.54% of all contributions, which almost half were Technician led. Admission was the most common stage to intervene (81.08%), followed by transcription. * Of all contributions, 37.91% were classified as patient safety incidents. Reassuringly 76.25% of these were prevented by the Pharmacy team. Themes have been extracted from these incidents and are presented in Table 1. Conclusion(s): PROTECTED-UK1 demonstrated the value pharmacists contribute to the quality and safety of patient care on ICU. Studies of similar quality and scale including Pharmacy Technicians are lacking, but even in this pilot study, it is evident how important their input is. Independent prescribing is a fundamental and well utilised part of our ICU Pharmacist skillset, supporting the GPICS2 recommendation that ICU pharmacists should be encouraged to become prescribers. Compiling a team interventions database is a useful tool to highlight local priority areas for guideline development;training;and ensuring that appropriate decision support is built into electronic prescribing systems. To improve the usefulness of the data, further stratification of contributions according to the Eadon Criteria3 may be worthwhile, to expand its use as a medication safety thermometer for ICU.

Post-COVID Challenges in Occupational Medicine as a Branch of Clinical and Educational Medicine

BACKGROUND: The COVID-19 pandemic has exhausted the employees of hospital center and had a negative impact on medical students. AIM: The aims are to show the efforts of Occupational Medicine to provide support for healthcare workers and to increase student's interest in O.M. MATERIALS AND METHODS: Out of the total number of employees of the Clinical Hospital Center Rijeka, which is 3500, 275 of them claim for recognition of COVID-19 occupational diseases in 2022. The 6th-year medical students of the Rijeka Faculty of Medicine, 130 in total and 22 sanitary engineers were surveyed by the quality service regarding their satisfaction with the Occupational Medicine classes. Statsoft Statistica 10 was used to calculate the results. RESULT(S): All HCW are recognized as having COVID-19 as a professional disease. Older age correlated with greater absenteeism. Hospital employees are dissatisfied, tired, they demand work benefits, contraindications for shift work, night work, work in COVID centers, and requesting maternity leave. Many also quit their jobs the hospital management is looking for and hiring new employees, who quickly leave due to difficult working conditions and low incomes. Occupational medicine also has a problem with students. During the pandemic, classes were held online. Interest in classes declined, a small number of students joined the lectures, but all responded to the survey. The answers showed a lack of interest in the Occupational Medicine course. With subsiding of the pandemic, it would be obligatory to continue "live" classes, take students on a tour of industrial facilities, and cancel the failed evaluation of teachers. CONCLUSION(S): Easing of working conditions for HCW and changes in teaching is necessary.Copyright © 2023, Scientific Foundation SPIROSKI. All rights reserved.

Experience of Baricitinib in a Real-World Population with Efficacy and Side Effects: A South London Regional Analysis

Background/Aims Baricitinib is the most common Janus Kinase inhibitor (JAKi) used in the treatment of rheumatological conditions. Whilst randomised controlled trials have demonstrated the efficacy and safety profile of baricitinib, real-world data on the experience of JAKi use in clinical practice is lacking. The aim of this analysis was to evaluate baricitinib use in a real-world patient population in South London. Methods We looked at two rheumatology departments in South London (St George's Hospital;a tertiary teaching centre and Kingston Hospital;a district general hospital). All patients prescribed baricitinib between January 2017 to June 2022 were included. A retrospective assessment of electronic patient notes was performed to evaluate disease activity (determined by DAS-28 scores at baseline, 3-6 months and presently);adverse effects including side effects, rates of and reasons for discontinuation;and prescribing practice, including previous use of other biological disease modifying anti-rheumatic drugs (bDMARDs). Baseline data including age, gender, co-morbidities and rheumatological diagnoses were also included. Results 233 patients were included in this evaluation, with seropositive rheumatoid arthritis being the most common diagnosis (58%) and with a significant female population (87%). Baricitinib improved average DAS-28 scores from 5.75 (range 3.57-8.3) at baseline to 3.23 (range 0.28-7.49) at 3-6 months post-baricitinib, with the most recent DAS-28 score of 2.90 (range 0.56-6.77). Rates of adverse effects were low as shown in Table 1. Baricitinib was discontinued in 60/233 patients, with average duration to discontinuation of 9.5 months. The most common reasons for discontinuation were: ineffective disease control (28/60), recurrent bacterial infection (5/60), deranged liver function (3/60) and venous thromboembolism (2/60). Eight patients died whilst taking baricitinib. Where documented, the causes of death were Covid-19 (4/8) and malignancy (1/8). 110 out of 233 patients had received other bDMARDs before starting baricitinib. Documented reasons for baricitinib choice over tumour necrosis factor inhibitors (TNFi) included: previous lack of response to TNFi (89/233), contra-indication to TNFi (11/233) and preference of oral route (10/ 233). Conclusion Our real-world study of JAKi use shows that baricitinib is efficacious in the treatment of rheumatological conditions. Moreover, baricitinib is well tolerated, with low rates of adverse effects and subsequent discontinuation. (Table Presented).

The Complexities of Managing Hypertriglyceridemia-Induced Pancreatitis in a Critically-Ill COVID-19 Patient

Introduction: Hypertriglyceridemia-induced pancreatitis (HTP) is a variant of pancreatitis requiring unique management. The complications of COVID-19 and its treatments can make HTP therapy more nuanced. This case describes a patient who presented in diabetic ketoacidosis (DKA) with HTP, and COVID-19. The patient developed renal and respiratory failure, necessitating hemodialysis (HD) and extracorporeal membrane oxygenation (ECMO), complicating an otherwise straightforward medical management plan. Case Description: A morbidly obese (BMI 38.9 kg/m2) 43-year-old male presented to an outside hospital with abdominal pain, and vomiting, and was found to have HTP with triglycerides (TG) >2000 mg/dL (<149 mg/dL) and presumed new-onset type 2 Diabetes (HbA1c 10.9%) with DKA. Treatment with fluids, intravenous (IV) insulin infusion and plasmapheresis were initiated. He developed hypoxia after receiving over 17 liters of fluids and was intubated, subsequently developing renal failure and was transferred to our tertiary center for HD and ECMO. On admission, he tested positive for COVID-19, rhabdomyolysis [creatinine kinase 5600 U/L (30-200 U/L)], HTP [TG 783 mg/dL (<149 mg/dL), lipase 461 U/l (7-60 U/L)], glucose 269 mg/dL (not in DKA), transaminitis [AST 184 U/L (4-40 U/L), ALT 61 U/L (4-41 U/L)] and renal failure (GFR 10 ml/min/1.73m2). IV insulin infusion was initiated for hyperglycemia worsened by COVID-19 dexamethasone treatment. Plasmapheresis was performed twice with minimal effect at maintaining a low TG. Fenofibrate was not initiated due to renal failure;Lovaza could not be given via oral gastric tube;Atorvastatin was attempted once rhabdomyolysis resolved, with subsequent worsening of liver function tests. Heparin infusion was initiated for deep vein thrombosis treatment and HTP but was stopped after development of heparin induced thrombocytopenia. The patient developed worsening hypoglycemia requiring cessation of IV insulin, hypotension requiring maximum pressor support, and worsening sepsis leading to his death. Discussion(s): This case illustrates the challenges of managing a patient with HTP and COVID-19. It demonstrates how a normally straightforward treatment algorithm can become increasingly complex when factoring the patient's comorbid conditions. The case highlights the importance of knowing both treatment indications and contraindications for HTP. In this case, HTP may have been the initial diagnosis, straightforward for most endocrinologists, but its treatments and comorbid conditions ultimately made the landscape more challenging, limiting effective management and ultimately leading to this patient's demise.Copyright © 2023

Treating Lymphoma in the Pandemic Era: What We Learned from Our Experience at Fondazione Irccs Istituto Nazionale Dei Tumori

From March 2020 to May 2022, when SARS-CoV2 pandemic started spreading in Italy, 15 consecutive patients with non-Hodgkin Lymphoma (NHL) have been treated at the Pediatric Unit of Fondazione IRCCS Istituto Nazionale dei Tumori. Three of 15 patients developed COVID19 while on treatment [1 Burkitt lymphoma (BL), 1 anaplastic large cell lymphoma, 1 lymphoblastic T-cell lymphoma (T-LL)] and one patient at diagnosis [gray zone lymphoma (GZL), previously misdiagnosed as Hodgkin lymphoma]. Median age at diagnosis was 12 years;3 were male. Median positivity time of the nasal swab was 58 days (range 9-107 days). All patients remained asymptomatic or paucisymptomatic (flu-like symptoms) while positive. The first positive patient with T-LL, was in the induction phase of the Euro-LB-02 protocol guidelines: he succeeded in completing the whole treatment during the 107 days of swab positivity, experiencing mild toxicities (grade 2 transaminases and grade 3 lipase increase, both reversible) without significant delays. For this reason, we reduced the total dose of the first HD-MTX (protocol M) and administer the subsequent doses in 6 hours infusion instead of 24 with no further toxicities. After this first experience, all the subsequent patients have been treated accordingly, without major deviations from the established protocols. Minor precautions: the patient with refractory GZL received IEP course instead of IGEV as second-line treatment to avoid severe subsequent immunosuppression;the patient with BL omitted the fourth course of Rituximab during the period of swab positivity. Overall, we did not observe outstanding toxicities except for a toxic MTX level with subsequent reversible acute renal failure. Main teaching from these pilot experiences, which may translate into guidelines: 1) SARS-CoV2 infection is not an absolute contraindication to the oncological treatments. This is of main importance for the patients affected by lymphoma whose dose-intensity has a prognostic value. 2)We need to pay caution during HD-MTX treatment;indeed, we observed unexpected similar toxicities in other patients treated with HD-MTX for other solid malignancies. 3) The clearance of SARS-CoV2 might be exceptionally prolonged with persistent positivity of the nasal swabs for a longer time than the matched healthy population due to the immunosuppression characterizing lymphoma patients. For this reason and given the importance of maintaining the dose-intensity, specific treatments aiming at speeding up the clearing process are warmly suggested. (Figure Presented) Figure 1: (: 091) ITHACA study design and blood sampling time points. (OHT = Orthotopic Heart Transplant).Copyright © 2022 Elsevier Ltd. All rights reserved.

METFORMIN REDUCED SARS-CoV-2 VIRAL LOAD IN A PHASE 3 RANDOMIZED CLINICAL TRIAL

Background: Metformin has in vitro activity against SARS-CoV-2. In a published phase 3, quadruple-blinded, placebo-controlled randomized trial of outpatient COVID-19 therapy, metformin resulted in a 42% reduction in ER visits/hospitalizations/deaths by day 14, 58% reduction in hospitalizations/ death by day 28, and 42% reduction in Long Covid through 10 months. This analysis presents the results of viral load sampling performed during that clinical trial. Method(s): Covid-Out trial (NCT04510194) enrolled adults aged 30 to 85 within 3 days of a documented SARS-CoV-2 infection and < 7 days after symptom onset. The trial randomized 1323 participants to metformin (1000mg/day days 2-5;1500mg/day days 6 to 14), ivermectin, fluvoxamine, and/or exact-matching placebo in a 2x3 factorial trial design. Nasal swabs for viral load were an optional component, self-collected from the anterior nares on day 1, 5, and 10. Viral loads were measured via RT-qPCR using N1 and N2 targets in the SARSCoV- 2 nucleocapsid protein, with relative Ct values converted to absolute copy number via calibration to droplet digital PCR. A linear Tobit regression model was used to assess change over time while accounting for left censoring due to the viral load limit of detection. Results were adjusted for other treatment allocations within the factorial design, vaccination status, and baseline viral load. Repeated measures were accounted for using clustered standard errors within participants. Result(s): Samples were available from n = 945, 871, and 775 participants on days 1, 5, and 10, respectively. The mean change from baseline to followup was -0.64 log10 copies/mL (95%CI, -1.16 to -0.13) for metformin versus placebo, which equates to a 4.4-fold greater decrease. The mean change in SARS-CoV-2 from baseline to day 5 was -0.48 log10 copies/mL, and was -0.81 log10 copies/mL from baseline to day 10. The anti-viral effect increased with increased metformin dosing days 6-14. The antiviral effect was larger in those unvaccinated (mean -0.95 log copies/mL) than vaccinated (mean -0.39 log copies/mL). There was no change in viral load vs. placebo for ivermectin or fluvoxamine. Conclusion(s): Metformin lowered SARS-CoV-2 viral load in this quadrupleblinded, randomized clinical trial. The temporal relationship to dose titration suggests a dose-dependent effect. The magnitude of antiviral effect was similar to nirmatrelvir at day 5, greater than nirmatrelvir at day 10. Metformin is safe, widely available, and has few contraindications.

Coronavirus disease 2019 vaccination in patients with chronic kidney diseases.

Patients with chronic kidney disease (CKD) are at high risk for coronavirus disease 2019 (COVID-19). Government agencies or learned societies in many countries recommend prioritizing patients with CKD for COVID-19 vaccines. The immune response rate to the COVID-19 vaccines is lower in hemodialysis patients and kidney transplant recipients compared with that in healthy individuals, and increasing the number of vaccinations each member of these population may improve their immune response rate. There was no significant difference in the incidence of adverse reactions after vaccination between patients with CKD and healthy controls. Patients with stable CKD should be vaccinated against COVID-19 unless there were contraindications to vaccination. The mRNA vaccines, inactivated vaccines, and recombinant protein subunit vaccines are all safe for patients with CKD. Patients with CKD treated with rituximab or high-dose glucocorticoid need to weigh the benefits and risks before vaccination, and COVID-19 vaccines can be given when rituximab treatment ends for more than 6 months or after glucocorticoid reduction.Copyright © 2021 by the Chinese Medical Association.

Online medical consultations and Covid-19 Vaccines in allergic patients

Background: Anaphylaxis reports after Covid-19 vaccination caused concerns regarding adverse effects. Many allergic patients demanded assurances by their allergists. Online Medical Consultations (OMC) are a communication tool between Primary Care and Allergy Department in Navarre. We assessed the impact of allergists' advice regarding Covid-19 vaccination in allergic patients, defined by vaccination status after OMC, and compared reported allergy severity between vaccinated and non-vaccinated. Method(s): Retrospective review of Allergy OMC and vaccination records of patients attended between 2020th September and 2021th August. We screened Covid-19 related OMC and selected those related with possible contraindications/specific recommendations before vaccination (BV).We analysed demographics, vaccination status, allergic diseases (green: non-anaphylactic allergy;yellow: anaphylaxis/ severe drug allergy;red: severe allergy to Covid-19 vaccine or related drug/excipients;blue: non-immunologic symptoms) and OMC replies (contraindication or other recommendations) Results: We received 1438 OMC, 422 due to Covid-19 vaccine and analysed 302 (71.6%), concerning BV. Demographics: Age (median, P25-P75) 61 (46.7-72.25) years. Sex: Female 221 (73.2%);Male 81 (26.8%). Vaccination: 275 (91.1%) completed vaccination (CV) (2 doses), 11 (3.6%) received 1 (IC) and 16 patients (5.3%) none (NC). Specific preparations were contraindicated in 28 (9.4%) (Pfizer-Biontech : 17, Astra-Zeneca 3 and Moderna: 8 cases). Recommendations: 30-minute observation 18.2%;45-minute observation 14.6%;antihistamines 2.6%;time interval with other injectables 1%;alternative vaccine 2.3%;other modifications 1%;premedication and observation period (2.3%). Ten patients (3.3%) required another OMC after adverse events during vaccination. Allergy severity was different according to sex (Male: green 59.2%, yellow 38.2%, red 0%;blue 2.46%;Female: green: 60.2%, yellow 31.8%, red 9.9%, blue: 4.5% (p = 0.025)). Comparison of allergies between groups: CV (Green: 60.7%, yellow: 33.4%, red: 2.9%, blue: 1%);IC (Green: 27%;yellow: 63.6% red: 0%, blue: 9%);NC (Green: 68.75%, yellow: 12.5%, red: 0%, blue: 18.75% (p = 0.03)) Conclusion(s): Adherence to OMC recommendations has been excellent in these patients. Differences in the number of OMC according to sex appear related to previous allergy diagnosis. Observed differences in past allergic diseases according to vaccination status are not related to real contraindications.

Practices of French and Francophones allergists in the management of allergic risks and complications of anti-SARS- COV- 2 vaccination

Background: The SARS-COV- 2 vaccination campaign has massively mobilized the allergists' community to screen patients deemed at risk for the SARS-COV- 2 vaccines. To describe data regarding the management of medical calls regarding the allergic risk for the SARS-COV- 2 vaccination, amongst French allergists. Method(s): A questionnaire-based survey was launched on the AdviceMedica platform (a platform of medical advice exchange between peers) between July and October 2021 (including two reminders). Result(s): Fifty-four allergists answered the survey. Three quarters of the responders were full-time allergists. Overall, 42% and 35% had an exclusive hospital or private practice, respectively. Allergists were mostly contacted by telephone (96.3%) and e-mail (79.6%), by general practitioners (92.6%) or physicians practicing in vaccination centers (88.8%) (median of vaccine related medical calls: 10 per week (Q25-Q75: 7-20, range (2-300). Allergists favored in-person visits rather than teleconsultations (85.2% vs. 61.1%). Allergy testing was prescribed for suspicions of allergy to polyethylene glycol (84.4%) or other vaccines and non-identified drugs (64.4%). Half of the responders (29, 53.7%) could perform vaccination and four (13.7%) declared reactions during vaccination. The responders used several tools in taking their clinical decision: exchanges with peers from the AdviceMedica platform (40.4%), advice from tertiary university hospital allergy units (25%), recommendations of the French Society of Allergy (17.3%). The three most frequent drawbacks that the allergists encountered were: having a hard time adding supplementary patient visits within optimal delays (three quarters of the responders), the reluctance expressed by the physicians requiring the advice and by the patients (two thirds) and the fact that the learnt society recommendations were deemed not to cover many on-field situations (one third). The major benefits from screening were estimated to be the lack of allergy contraindication to vaccination (88.7%) and the increased visibility of the allergist's role (69.8%). Conclusion(s): This survey put numbers on the management of screening patients deemed at risk for the SARS-COV- 2 vaccination amongst French allergists. Peer exchange was the most frequent tool in taking a clinical decision.

Desensitization protocol for anti-SARS- CoV- 2 vaccines in allergic patients: A case series

Background: Vaccination has proven to be the best viable tool for preventing the spread of SarsCov2 infection. The fear of adverse events represents one of the limits of this vaccination campaign. As Allergists, we had a fundamental role evaluating the allergological risks and performing specific tests. The only absolute contraindication to SARS-CoV- 2 vaccination is hypersensitivity to its components. When an individual is allergic to an indispensable medication, it is possible to resort to desensitization. Given the lack of a standardized scheme, the aim of our study is to propose a desensitization protocol for anti-SARS- CoV- 2 vaccines. Method(s): The desensitization protocol we developed consists in the fractioned administration of the entire vaccine dose into 5 separate injections of increasing quantity, through a 2-hour period. Premedication with antihistamines and chromones was administrated. Between January 2021 and January 2022, 23 patients referred to our Unit were deemed with a high risk of hypersensitivity reactions to the vaccines and underwent the desensitization protocol. We here describe 23 consecutive cases of patients who underwent desensitization to anti-SARS- CoV- 2 vaccine. Result(s): 4/23 had positive allergy skin test to Polysorbate and underwent desensitization for their entire vaccination cycle. 19/23 had a previous hypersensitivity reaction to an anti-SARS- CoV- 2 vaccine (18 after the first dose and 1 after the second one). Among 4 patients with sensitization to Polysorbate none developed hypersensitivity reactions after fractionated administration of BNT162b2 vaccine. Among 19 patients that underwent desensitization because of hypersensitivity reactions after I or II dose of vaccine, 15 experienced a reaction following vaccination with BNT162b2, 4 with mRNA-1273 and 4 with ChAdOx1-S recombinant. Furthermore, we categorized their reactions according to WAO score per systemic reactions: 15/19 (79%) grade1, 2/19 (10.5%) grade2, 2/19 (10.5%) grade3. No severe late hypersensitivity reactions were observed. All but one of this 19 patients had no hypersensitivity reactions after vaccination through the desensitization protocol. 1 patient experienced anaphylaxis during desensitization with BNT162b2 vaccine (WAO grade4). No late hypersensitivity reactions were observed. Overall, 22/23 (95.6%) patients that underwent anti-SARS- CoV- 2 vaccination through the desensitization protocol did not experience hypersensitivity reactions. Conclusion(s): Our results suggest that desensitization can be implemented to extend the vaccination to currently ineligible individuals. Larger studies are needed to prove the safety and efficacy of this approach.

Vaccines for the prevention of infections in adults with haematological malignancies

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the benefits and adverse effects of vaccines for the prevention of infections in adults with haematological malignancies.Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Allergist coorporation, the COVID-19 vaccination's keystone

Background: The French vaccination campaign against COVID-19 was accompanied by an overwhelming increase in allergists work load highlighting our key role in the stratification of the allergy risk prior to vaccination. Method(s): In order to describe our triage and testing experience for the COVID-19 vaccination all requests were analysed in a standardized way prospectively. Our final goal was to filter the requests and avoid any delay in the vaccination process. We first set up and validated locally a questionnaire (completed by the requesting practitioner) allowing to evaluate the risk of allergy to the vaccine, based on the clinical history of the patient. Questionnaire-based allergy advices were delivered (regular vaccination or allergy testing prior to vaccination). Result(s): From January 2021 to January 2022, we addressed 1047 requests. Forty-one patients (4%) were tested. 96% had allergies to other compounds, not increasing the risk of reacting to the covid vaccines and were vaccinated safely. Half of the tested patients experienced an immediate reaction to the vaccine and the other half had a history of allergy to the vaccine's components. We identified 3 groups of patients: -Suspicions of polyethylene glycol (PEG) containing laxative allergy comprised 8 patients (26%), including 2 cases with proven IgE-mediated allergy to PEG. They were 63% (5) women, 63% (5) atopic (average age of 49 +/-10 yrs). Two thirds (63%, 5 patients) had an immediate reaction to PEG, including 3 and 2 patients with anaphylaxis with and without shock, respectively. The two allergic patients refused vaccination and received a certificate of contraindication to PEG-containing vaccines (as per French law). -Reactions to the covid vaccine comprised 21 patients: most were women (86%, 18 patients) and 29% (6) were atopic (average age was 51 +/-19 yrs). Three quarters (76%, 16 patients) presented a reaction within 1 hour after the vaccination, considered as potential anaphylaxis in 12 patients (8 patients with and 5 without shock). 100% (21 patients) were tested negative. Twenty patients (95%) were further vaccinated without reaction. One required H1 antihistamine. -Suspicions of allergy to PEG or polysorbate as excipients included 12 patients (29%). Most clinical histories were anaphylactic (42% without and 33% with shock). Following negative excipient skin testing, regular vaccination was authorized. Conclusion(s): Overall, only 4% of the initial requests were deemed eligible for allergy testing. We did not diagnose any allergy in patients who reacted to the vaccines and we delivered two certificates of contraindication to mRNA COVID-19 PEG-containing vaccines in two cases of confirmed IgE-mediated allergy to PEG.

A Rare Case Of Peripartum Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. Case presentation: A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Conclusion(s): Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain;however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.Copyright © 2022

Vaccination against COVID-19 in patients with allergic diseases

Background: In the context of the COVID-19 pandemic it is very important to achieve collective immunity. Allergic reactions to vaccines are rare -up to 30 per 100 000, but 4-8 may have anaphylaxis. The aim of this study was to develop safe COVID-19 vaccination algorithm for patients with allergic diseases (AD). Method(s): Patients with the history of AD were invited for vacination to the Regional Allergy Center in Dnipro (Ukraine). Before vaccination all patients underwent: serum tryptase, whole blood count (WBC), D-dimer, blood biochemistry, electrocardiogram (ECG) and spirometry (for patients with asthma (A) only). 126 patients with AD 19-85 (53.2+/-1.5) years old (50, 39.68% men) were included into the study. 25.39% of them had seasonal allergic rhinitis (SAR);15.07% -A;10.32% -A+ SAR;35.71% -urticaria;11.11% -drug allergy;2.38% -history of anaphylaxis. Result(s): There were not any clinically significant changes found in WBC, blood biochemistry and ECG. At the same time in 4 patients (3.2%) high tryptase level was detected. Mastocytosis was diagnosed by sternal puncture in 3 of them. During 12 weeks they were treated by monoclonal antibodies and after that vaccinated with two doses of mRNA vaccine without adverse reactions. For 1 patient with high tryptase level and a history of 3 anaphylaxis with hospitalization vacination was postponed. 1 patient had elevated D-dimer (PTA was diagnosed by CT) -vaccination was temporarily delayed. In 10 patients uncontrolled A with FEV1 below 70% (36-65%) was found. After the correction of basic therapy, within 2 weeks vaccination was carried out. All patients were given a 4-fold dose of desloratadine 30 minutes before vaccination. Conclusion(s): 1. AD are not a contraindication for vacciantion against COVID-19. 2. Before vacciantion all patients with a history of AD should be examined by an allergist. 3. For patients with severe AD level of serum tryptase should be detected before vacciantion. 4. Patients with AD should be vaccinated in an allergy center with premedication of H1-blocker in a 4-fold dose.

VACCINATION against NEW CORONAVIRUS INFECTION in PATIENTS with CARDIOVASCULAR and AUTOIMMUNE DISEASES.

The review article is devoted to a discussion of the issues of vaccination against a new coronavirus infection in patients with cardiovascular and autoimmune diseases. Presented at the time of this writing are data on domestic vaccines safety in the Russian Federation: combined vector vaccines "Gam-COVID-Vac" and "Gam-COVID-Vac-Lyo", peptide-based vaccine "EpiVacCorona", concentrated, purified and inactivated whole-virion "KoviVac" vaccine, and a standalone vaccine/booster shot "Sputnik Light". The analysis of the main contraindication applicable to the vaccines in different categories of patients has been carried out. A number of consensus documents published by Russian and foreign professional medical associations and communities on the issues of vaccination of patients with cardiovascular and autoimmune diseases are considered in detail.Copyright © 2021 Infectious Diseases: News, Opinions, Training. All rights reserved.

Management of COVID-19 very Elderly Patients in Nursing Homes and Long-Term Care Facilities: Description of a New Model and Experience in a Medicalized Nursing Home

Introduction: COVID-19 has been a challenge for healthcare, mainly in elderly patients in Nursing Homes (NHs) and Long-Term Care Facilities (LTCFs). We present a pioneering novel experience in addressing healthcare of elderly patients with COVID-19 in these facilities by a re-conversion of a NH in a medicalized NH. Method(s): All patients admitted to the center were included, recording clinical and epidemiological variables. We conducted a descriptive analysis and a multivariate analysis to identify variables linked to mortality and persistence of positive PCR test. Result(s): 84 patients were included (40% men), women presented more symptomatology. We found a positive correlation between the duration of symptoms and the days required to obtain a negative PCR test (r=0.512, P<0.001). We also found an independent and significant association between as-thenia (OR=2.58;IC95% 1.22-5.46) and mutism (OR=5.21;IC95% 1.58-17.15) and a longer time to achieve a negative PCR test. All patients, except contraindication, were treated with hydrox-ychloroquine and azithromycin, which was the recommended treatment during the period of the study. The early start of corticoid treatment (within the first 72 hours since the start of symptoms) was linked to a lower mortality in patients with moderate-severe symptoms. Mortality was lower than expected (which was higher than 20% in that period and group of age), reaching 14%, the main factors linked to mortality were the presence of mutism (OR=19;IC95% 3.4-108;P=0.001) and dyspnea (OR=12;IC95% 1.3-111;P=0.029). Conclusion(s): An alternative system was presented for the care of these patients through the recon-version of a basic NH in a medicalized one, which showed a significant reduction in the expected mortality.Copyright © 2021 Bentham Science Publishers.