Allergic Reactions to Current Available COVID-19 Vaccinations: Pathophysiology, Causality, and Therapeutic Considerations.

Vaccines constitute the most effective medications in public health as they control and prevent the spread of infectious diseases and reduce mortality. Similar to other medications, allergic reactions can occur during vaccination. While most reactions are neither frequent nor serious, anaphylactic reactions are potentially life-threatening allergic reactions that are encountered rarely, but can cause serious complications. The allergic responses caused by vaccines can stem from activation of mast cells via Fcε receptor-1 type I reaction, mediated by the interaction between immunoglobulin E (IgE) antibodies against a particular vaccine, and occur within minutes or up to four hours. The type IV allergic reactions initiate 48 h after vaccination and demonstrate their peak between 72 and 96 h. Non-IgE-mediated mast cell degranulation via activation of the complement system and via activation of the Mas-related G protein-coupled receptor X2 can also induce allergic reactions. Reactions are more often caused by inert substances, called excipients, which are added to vaccines to improve stability and absorption, increase solubility, influence palatability, or create a distinctive appearance, and not by the active vaccine itself. Polyethylene glycol, also known as macrogol, in the currently available Pfizer-BioNTech and Moderna COVID-19 mRNA vaccines, and polysorbate 80, also known as Tween 80, in AstraZeneca and Johnson & Johnson COVID-19 vaccines, are excipients mostly incriminated for allergic reactions. This review will summarize the current state of knowledge of immediate and delayed allergic reactions in the currently available vaccines against COVID-19, together with the general and specific therapeutic considerations. These considerations include: The incidence of allergic reactions and deaths under investigation with the available vaccines, application of vaccination in patients with mast cell disease, patients who developed an allergy during the first dose, vasovagal symptoms masquerading as allergic reactions, the COVID-19 vaccination in pregnancy, deaths associated with COVID-19 vaccination, and questions arising in managing of this current ordeal. Careful vaccine-safety surveillance over time, in conjunction with the elucidation of mechanisms of adverse events across different COVID-19 vaccine platforms, will contribute to the development of a safe vaccine strategy. Allergists' expertise in proper diagnosis and treatment of allergic reactions is vital for the screening of high-risk individuals.

Radiotherapy and Renal Cell Carcinoma: A Continuing Saga.

Renal cell carcinoma (RCC) is one of the most aggressive malignancies of the genito-urinary tract, having a poor prognosis especially in patients with metastasis. Surgical resection remains the gold standard for localized renal cancer disease, with radiotherapy (RT) receiving much skepticism during the last decades. However, many studies have evaluated the role of RT, and although renal cancer is traditionally considered radio-resistant, technological advances in the RT field with regards to modern linear accelerators, as well as advanced RT techniques have resulted in breakthrough therapeutic outcomes. Additionally, the combination of RT with immune checkpoint inhibitors and targeted agents may maximize the clinical benefit. This review article focuses on the role of RT in the therapeutic management of renal cell carcinoma.

Sepsis and the muscle tissue. A narrative review.

Sepsis and septic shock are considered major factors in the development of myopathy in critically ill patients, which is correlated with increased morbidity rates and ICU length of stay. The underlying pathophysiology is complex, involving mitochondrial dysfunction, increased protein breakdown and muscle inexcitability. Sepsis induced myopathy is characterized by several electrophysiological and histopathological abnormalities of the muscle, also has clinical consequences such as flaccid weakness and failure to wean from ventilator. In order to reach definite diagnosis, clinical assessment, electrophysiological studies and muscle biopsy must be performed, which can be challenging in daily practice. Ultrasonography as a screening tool can be a promising alternative, especially in the ICU setting. Sepsis and mechanical ventilation have additive effects leading to diaphragm dysfunction thus complicating the patient's clinical course and recovery. Here, we summarize the effects of the septic syndrome on the muscle tissue based on the existing literature.

Retrosternal goitre: the role of the thoracic surgeon.

Purpose of this Mini-Review is to evaluate the role of a thoracic surgeon in the surgical management of retrosternal goitre. A cervical approach is sufficient in the majority of the cases. On the other hand, there are cases where a cervical approach is combined with sternotomy or thoracotomy, depending on the position of the goitre, in the anterior or posterior mediastinum. On top of that, different minimally invasive approaches including video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery (RATS) have been introduced, providing faster recovery, superior manoeuvrability and better aesthetic results.

Non-cirrhotic intrahepatic portal hypertension: associated gut diseases and prognostic factors.

BACKGROUND/AIMS: Non-cirrhotic intrahepatic portal hypertension (NCIPH) is generally regarded to have a benign prognosis. We have studied a cohort followed-up at a tertiary referral center and postulate that gut-derived prothrombotic factors may contribute to the pathogenesis and prognosis of NCIPH. METHODS: We retrospectively analyzed prognostic indicators in 34 NCIPH patients. We also searched for associated gut diseases. RESULTS: Transplant-free survival in NCIPH patients from first presentation with NCIPH at 1, 5, and 10 years was 94% (SE: 4.2%), 84% (6.6%), and 69% (9.8%), respectively. Decompensated liver disease occurred in 53% of patients. Three (9%) patients had ulcerative colitis while five of 31 (16%) tested had celiac disease and on Kaplan-Meier analysis, celiac disease predicted reduced transplant-free survival (p=0.018). On multivariable Cox regression analysis, independent predictors of reduced transplant-free survival were older age at first presentation with NCIPH, hepatic encephalopathy, and portal vein thrombosis. Prevalence of elevated initial serum IgA anticardiolipin antibody (CLPA) was significantly higher in NCIPH (36% of patients tested), compared to Budd-Chiari syndrome (6%) (p=0.032, Fisher's exact test) and celiac disease without concomitant liver disease (0%) (p=0.007). CONCLUSIONS: We have identified prognostic factors and report progression to liver failure in 53% of NCIPH patients followed-up at our center. Our data supports a role for intestinal disease in the pathogenesis of intrahepatic portal vein occlusion leading to NCIPH.

Multimarker strategy for the prediction of 31 days cardiac death in patients with acutely decompensated chronic heart failure.

BACKGROUND: To investigate the combined prognostic value of admission serum levels of B-type natriuretic peptide (BNP), cardiac troponin I (cTnI) and high sensitivity C-reactive protein (hs-CRP), in patients hospitalized because of acutely decompensated severe (New York Heart Association class III/IV) low-output chronic heart failure (CHF). METHODS: A total of 577 consecutive patients recruited in the 5 participating centers, were studied. Cardiac mortality by 31 days was the prespecified primary study end point. RESULTS: A total of 102 (17.7%) patients died by 31 days. When the study patients were divided according to the number of elevated study biomarkers, there was a significant gradual increased risk of 31-day cardiac death with increasing in the number of elevated biomarkers (p<0.001). The value of the discriminant C statistic for the Cox regression analysis, increased significantly when each of the study biomarkers was incorporated with the other risk predictors into a Cox regression model, with the highest C statistic value for the Cox regression model that included all the study biomarkers (p<0.001). By multivariate Cox regression analysis, elevated serum levels of BNP (p=0.002), cTnI (p<0.001) and hs-CRP (p=0.02) were independent predictors of the study end point. CONCLUSIONS: In conclusion, in patients hospitalized for acute decompensation of severe (NYHA III/IV) low-output CHF, BNP, cTnI and hs-CRP upon admission offers enhanced early risk stratification. With increasing number of elevated biomarkers, the risk of 31-day cardiac death increases gradually that implies treatment intensification, and closer follow-up.

Spinal Subdural Staphylococcus Aureus Abscess: case report and review of the literature.

BACKGROUND: Only 65 cases (including our case) of spinal subdural abscesses have been reported to the literature, mostly to the lumbar spine. Staphylococcus aureus is the most common bacterial. The symptoms are not caracteristic and contrast - enhanced magnetic resonance imaging scan (MRI) is the imaging method of choice. The early diagnosis is crucial for the prognosis of the patient. CASE PRESENTATION: We present a patient 75 years old who had a history of diabetes and suffered acute low back pain in the region of the lumbar spine for the last 4 days before his admission to the hospital. He also experienced lower leg weakness, fever and neck stiffness. After having a brain CT scan and a lumbar puncture the patient hospitalized with the diagnosis of meningitis. Five days after his admission the diagnosis of subdural abscess secured with contrast - enhanced MRI but meanwhile the condition of the patient impaired with respiratory failure and quadriplegia and he was admitted to the ICU. A laminectomy was performed eight days after his admission into the hospital but unfortunately the patient died. CONCLUSION: Early diagnosis and treatment are very important for the good outcome in patients with subdural abscess. Although morbidity and mortality are very high, surgical and antibiotic treatment should be established as soon as possible after the diagnosis has secured.

Sleep disorders and brain MRI as early indicators of subclinical hepatic encephalopathy.

BACKGROUND/AIMS: Cirrhotic patients with hepatic encephalopathy have significant impairment of their daily activities. Sleep disturbances and increased signal on T1-weighted brain Magnetic Resonance Imaging (MRI) are commonly encountered in this clinical entity. The prevalence of these abnormalities in patients with subclinical encephalopathy is unknown. METHODOLOGY: Sleep history and brain MRI were evaluated in 26 cirrhotic individuals with no evidence of encephalopathy. Thirteen patients without liver dysfunction or signs of neurological impairment served as a control group. RESULTS: Sleep disturbances were found in 24 of 26 cirrhotic patients (92.3%), whereas 18 of them (69.2%) had brain MRI abnormalities (p<0.05 by McNemar's test). Among the control group, 1 of 13 patients had sleep disorders, whereas none exhibited abnormal MRI (both p<0.001 by chi2 compared to study group). Increased bilirubin and globulin levels, and decreased albumin levels were found to have a significant correlation to brain MRI abnormalities among cirrhotic patients. CONCLUSIONS: Sleep disturbances are emerging as a sensitive sign of subclinical encephalopathy in cirrhotic patients. A major role of brain MRI is also recognized, as abnormal images are highly prevalent in this clinical entity. Furthermore, the level of MRI abnormalities appears to be in concordance with the abnormal liver function tests.