Showing posts with label patient. Show all posts
Showing posts with label patient. Show all posts

Sunday, July 4, 2021

COVID and cancer

 

COVID-19 vaccination in cancer patients: 

What are the vaccines being developed and nearing approval?

The World Health Organization (WHO) currently counts more than two hundred research projects for the development of a vaccine conferring protective immunity against the SARS-CoV-2 virus, among which more than fifty are in clinical development. New technologies, previous experience with vaccine projects against related viruses and the presence of a pandemic health hazard accelerated the usual development cycle from years to months. Presentation of SARS-CoV-2 antigens to the host, in the context of vaccine development, relied on technologies based on messenger RNA (mRNA), inactivated/attenuated or genetically modified viruses, synthetic long viral peptides and plasmid DNA vaccines. Four vaccines have been authorised until April 2021 for use in the European Union (Comirnaty Pfizer/BioNTech, COVID-19 Vaccine Moderna, Vaxzevria AstraZeneca, COVID-19 Vaccine Janssen) while three more are under rolling review by the European Medicines Agency (EMA; CVnCoV, NVX-CoV2373, Sputnik V). More vaccines are under clinical development and are being assessed for efficacy and safety.

Overall mRNA-based vaccines have shown >90% protection from COVID-19 disease with good tolerance, whereas non-replicating adenoviral vector-based vaccines have shown protection rates of 62%-90% conferred by different dosing regimens. Storage requirements and number of doses differ between vaccines and operational practicalities related to transport, administration, recording and follow-up of vaccinated people, and pharmacovigilance are pivotal for the successful roll-out of vaccination programmes and their optimal impact on public health. Despite some preclinical data of reduced neutralising potential of generated antibodies against new, mutated forms of the virus, available clinical evidence suggests that approved vaccines confer protective immunity against new mutational variants of SARS-CoV-2. Moreover, a rational strategy for minimising the risk of emergence of additional virus variants is based on effective mass vaccination programmes for establishment of vaccine-induced immunity in order to prevent new infections and, thus, mutations. Additional questions exist that necessitate generation of data, including long-term safety, duration of immunity, protective immunity against mild as opposed to severe cases of infection as well as immunity in the elderly, vaccine impact on contagious potential of vaccinated people and repeat vaccination intervals.  A combination of severe thrombosis and thrombocytopaenia, of possible immune pathogenesis similar to that seen in heparin-induced thrombocytopaenia, has been observed very rarely following vaccination, mostly with adenoviral vector-based vaccines (Vaxzevria, COVID-19 Vaccine Janssen), occurring during the first few weeks after inoculation. Healthcare professionals and patients should be alert to the signs and symptoms of thromboembolism and/or thrombocytopaenia, and if present, seek specialist medical treatment promptly. In view of the rarity of the side-effect and the risk from COVID-19, the risk/benefit profile of the vaccines is considered favourable by the EMA. The use of all approved COVID-19 vaccines should be in accordance with official national recommendations.

Specifically, for patients with cancer or a history of cancer, strategies of continued generation of data within trials as well in real world settings will provide more insights on vaccine activity, optimal dose and frequency, safety, potential for interaction with malignant disease, antineoplastic therapies or other comorbidities. Consequently, prospective observational studies focusing on patients with active cancer receiving chemotherapy, targeted therapy or immunotherapy, as well as in patients in the chronic phase of disease or in the survivorship phase are warranted and may lead to interventional clinical trials, if needed.

A large array of other vaccine candidates against SARS-CoV-2 are currently under investigation applying various techniques such as mRNA-, protein subunit-, viral vector- or inactivated virus vaccines.

These recommendations should be used as guidance for prioritising the various aspects of cancer care in order to mitigate the negative effects of the COVID-19 pandemic on the management of cancer patients. The situation is evolving, and pragmatic actions may be required to deal with the challenges of treating patients, while ensuring their rights, safety and wellbeing.

Statements:

  • Effective and safe vaccines against COVID-19, authorised after thorough, independent and robust scientific review by regulatory authorities, should be administered in the context of operationally sound vaccination programmes [V]. A pharmacovigilance plan is mandatory in the context of the vaccination programme.
  • Effective mass vaccination programmes coupled to robust pharmacovigilance are key for preventing infections and emergence of viral mutations, while safeguarding favourable vaccine risk/benefit profiles [V].
  • Ongoing scientific assessment by medical and regulatory authorities underpins the safe and effective use of COVID-19 vaccines. Use of the vaccine during vaccination campaigns take into account the pandemic situation and vaccine availability at national level.
  • Continued research in the context of clinical trials and registries as well as in-trial and post-trial follow-up is advised in order to generate more data on vaccine efficacy and safety in the general population as well as in special populations, including patients with active cancer or history of cancer [V].
  • Patients with cancer as a group have been shown to be at higher risk of severe COVID-19 [1]. Among patients with cancer, it seems that haematological and lung malignancies and the presence of metastatic disease are associated with a persistently increased risk. Patients with solid tumours appear to suffer an increased risk, particularly in the first year after diagnosis which drops to baseline if diagnosis is >5 years ago [2]. For any malignancy, active disease confers a significantly increased risk of severe COVID-19 [IV] [3, 4]. However, the higher incidence and severity of COVID-19 in patients with cancer, as opposed to those without cancer, are observations based on non-comparative retrospective studies. Data on the true incidence and direct comparisons remain elusive. Most studies do not have the full denominator to calculate the true incidence [IV].

    Severity and mortality rates from the COVID-19 and Cancer Consortium (CCC19) registry and other cohorts have ranged from 5% to 61% (meta-analysis showed 26%) which is much higher than in the overall population (~2%-3%), but this is with caveats of unadjusted rates, while the cancer population is an older population with more comorbidities, poorer performance status, and many unmeasured confounding and selection biases [IV].

    SARS-Cov-2 infection may also result in significant and devastating delays in screening, diagnosis, treatment and monitoring/surveillance strategies in patients with cancer which can ultimately cause an increased risk of cancer-related morbidity and mortality, as well as major economic burden and high patient volumes needing care in the healthcare systems. Moreover, the impact on clinical trials accrual appears to be very significant and detrimental, although it is hard to measure.

  • Although evidence regarding vaccination in patients with cancer is limited, there is enough evidence to support anti-infective vaccination in general (excluding live-attenuated vaccines and replication-competent vector vaccines) even in patients with cancer undergoing immunosuppressive therapy [5-7]. Reduced protective effects may occur in patients treated with B cell-depleting agents (anti-CD19, anti-CD20, anti-CD10 monoclonal antibodies and CD19 CAR-T cells) in view of suboptimal immune response [8-12]. The level of efficacy may be expected to be generally reduced in certain populations of cancer patients with intense immunosuppression, such as recipients of haematopoietic stem cell transplantation [V] [5-7]. However, based on data extrapolation from other vaccines and the mechanism of action of the COVID-19 vaccines (not live), it is conceivable that the efficacy and safety of vaccination against COVID-19 may be estimated to be similar to that of patients without cancer, although data from clinical trials are lacking [V]. Beyond stem cell transplantation, the efficacy of COVID-19 vaccines can also vary in patients with distinct contexts of malignant disease (tumour type, disease extent, intrinsic or therapy-induced immunosuppression); however, the benefits of vaccination seem to significantly and substantially outweigh the risks [V].

    The timing of vaccination depends on individual therapy scenarios and may ideally occur before systemic therapy starts; however, if the patient has already started systemic therapy, it is reasonable to vaccinate during therapy [V].

  • Vaccinating healthcare staff against influenza has been shown to reduce nosocomial transmission of the infection in cancer care [13]. Furthermore, certain immunocompromised cancer patients might not achieve a sufficient immune response to vaccination. This provides a rationale for vaccinating healthcare staff who work in a high-risk setting against COVID-19 as well [Evidence III for influenza]

    Statements:

    • Patients with cancer have an increased risk of severe COVID-19 (i.e. haematological malignancy requiring chemotherapy or active, advanced solid tumour or history of solid tumour <5 years ago) and should be vaccinated against SARS-CoV-2 regardless of any other indications (i.e. age) and positioned at high prioritisation [V]. Patients who have received B cell depletion in the past 6 months may derive reduced protection. The time-point for vaccination after allogeneic stem cell transplantation should follow general recommendations – usually, in the absence of graft-versus-host disease (GvHD), the vaccine can be applied 6 months post stem cell transplantation [V]. Patients in clinical trials, e.g. immunotherapy, should not be deprived of COVID-19 vaccination; therefore, efforts should be made for clinical trial protocols to allow concurrent COvID-19 vaccines.
    • Healthcare workers caring for patients with cancer with increased risk should be prioritised in receiving vaccination to minimise nosocomial transmission.
    • The efficacy and duration of immunity in patients with cancer are still unknown and unexplored. Given the often-immune compromised status and the frailty of these patients, we suggest monitoring in the context of registries and dedicated clinical trials.
    • Close surveillance and monitoring of patients with cancer is required after COVID-19 vaccination to assess potential adverse events and measure clinical outcomes, e.g. infection, severity and mortality from COVID-19, complications from cancer, etc.
    • Physical distancing measures, masks, face shields, sanitizers and other hygiene measures are still required during the pandemic, including for patients with cancer, and should certainly accompany the vaccination strategies.
Source: https://www.esmo.org/

Friday, March 15, 2013

Ischemic heart disease

Ischemic heart disease arises when a patient has an obstruction in the arteries feeding their heart (coronary artery disease).  The older you become and if you smoke, have high blood pressure, diabetes or high cholesterol, your risk of IHD increases.  Ischemic heart disease is the leading killer among adults in the United States.

Ischemic heart disease can cause angina (chest pain during exercise) and can bring on a myocardial infarction, otherwise known as a heart attack.  Ischemia may be caused by a high fat diets and little or no exercise, which may also lead to angina.

Angina

The major indication of Angina is pain over the mid chest that sometimes radiates down the left arm, to the jaw or back.  The existence of episodes of angina is in essence diagnostic of Ischemic Heart Disease.  The symptoms of angina pectoris can commonly be controlled by beta-blockers, nitrates and calcium-channel blockers.  Beta blockers have also proven to decrease the risk of troubling cardiac events in patients with angina.



Heart Attack

Most heart attacks are caused by Coronary Artery Disease (CAD), a plaque that has built up on the walls inside your coronary arteries.  These are the arteries that oxygen and blood to your heart.  This plaque can break off and cause a blood clot which can block your artery to which no blood or oxygen can flow, thus causing a Heart Attack or Myocardial Infarction.



So, please be sure to take care of your self by eating healthy and exercising frequently.  Get regular checkups and if you have any question that you may be having angina or a heart attack please seek medical attention right away.


Tuesday, March 12, 2013

Congestive heart failure diet

Congestive heart failure diet should be focused on avoiding salt, lipids (especially animal fats) and alcohol. Enjoying the food we eat is very important, but in time, patients with congestive heart failure will learn to like foods with lower amounts of salt. Salt is one of the most feared “enemies” for patients with heart disease, because it favors water retention and increases heart labor, edema (water retention in the tissues) and worsens heart failure symptoms.

Why is it so important to know and respect  the congestive heart failure diet?

Congestive heart failure diet is important to be respected in order to increase quality of life and slow down the disease evolution. Everyone who reads the sentence above may wonder how can congestive heart failure diet increase the quality of life, when we suppose to give up on so many daily “pleasures”. It is hard to imagine that after a so called “normal” life, when we could eat everything we wanted, one day we have to change our life and eating style completely with a congestive heart failure diet plan . Many patients are tempted to skip these rules, thinking that their physician wouldn’t notice or that a few exceptions from time to time wouldn’t harm anyone.
A congestive heart failure diet that includes avoiding lipids is a fact well known by everyone, but also by few respected. We read in many articles that there are good and bad fats and that fats will increase body weight, however, many patients with heart disease don’t respect congestive heart failure diet and gain weight even after their physician recommended they should lose weight. Once the patients become overweight, the risk of developing diabetes, atherosclerosis and therefore hypertension, coronary disease (which determines chest pain, a very often symptom among patients with coronary disease), heart attacks or strokes increases. Good fats are a source of omega-3 fatty acids, found mostly in cold-water fish, nuts, oils and seeds, and also in dark leafy greens, flaxseed oils and some vegetable oils. Omega-3 fatty acid is an “essential fatty acid,” which cannot be synthesized by our bodies, the only source for this is food. Congestive heart failure diet should contain Omega-3 fatty acids, because these essential acids can lower blood pressure, combat LDL (bad) cholesterol, also it is thought to play a role in brain protection.
Congestive heart failure diet should definitely exclude alcohol, although this is not a type of food it is often used for different, most of them groundless reasons, like routine, entourage acceptance, digestion, pain relieve. Chronic alcohol consumption can determine a type of dilated cardiomyopathy which in time will lead to congestive heart failure. However, small amounts of wine it is considered to have a favorable impact, due to its antioxidant features.
A correct congestive heart failure diet should also contain limited amounts of foods rich in sugar or carbohydrates (the main source of energy for the body, transformed into blood sugar, mostly glucose, the body’s basic fuel and also the main source of calories) like: cookies, chocolate, candies, biscuits, sweet fruits like banana, pears, strawberries, sugar as such, honey, milk, popcorn, green peas, sweet potatoes etc.

Please consult your medic about a congestive heart failure diet, and don’t eat random.

Thursday, February 21, 2013

Heart murmurs in adults

What are heart murmurs in adults?

We all read or heard talking about heart murmurs in adults, and many of us are curious to find out if  they have this dysfunction. A few know the true meaning of this condition, that’s why when our physician tells us we have  heart murmurs either we think we suffer from a devastating disease, either we ignore it, but none of this reaction is normal.  Next we will clarify the meaning and the cause for heart murmurs, in order to prepare people that might be diagnosed with this disorder to understand and deal their condition properly.
Heart murmurs in adults refer to the abnormal sounds heard by doctors when they listen to the heartbeats with a stethoscope. In medical practice, hearing  heart murmurs in adults raises the suspicion of heart valve pathology, but sometimes these abnormal heart sounds can occur in other conditions like a defect in the heart wall, anemia, fever etc. When there is no heart modification that can explain the murmurs, they are called functional. Because this condition can occur in other pathologies beside hear disorder, everytime we suspect a heart murmurs in adults we should check its presence with an echocardiography examination.
Heart murmurs affect both children and adults and are recognized as the “noise” heard between the two normal heart sounds. If the murmur occurs after the first heart sound is called systolic, which means it occurs during heart contraction, and if it occurs after the second heart sound is called diastolic and this means it occurs while heart is in its relaxation period. The classification into systolic and diastolic is important because it indicates whether we are facing a valve stenosis (narrowing of the heart valve) or insufficiency (the valves fail to close properly, letting blood to flow back into the heart chambers). There are other classifications for heart murmurs in adults, but those medical terms are more important for the specialists.

 Why do heart murmurs in adults occur and how we deal with them?

 As we explained above, in most of the cases heart murmurs in adults occur when there is a heart pathology:
  • heart valve narrowing or closure impairment, in this case the blood flow becomes turbulent and makes a noise that we call it murmur,
  • a defect in heart wall-a congenital defect that occurs in children, allowing blood to flow from one side of the heart to the other, determining blood with oxygen and blood with carbone dioxide to mix. Sometimes this condition can remain undiagnosed until late adulthood, because it is a small defect and doesn’t cause symptoms, but in many cases is diagnosed soon after birth, being recognized as a prolonged murmur (noise) heard during heart auscultation and needs surgical correction. Another type of heart murmur heard in children is the one determined by the ductus arteriosus persistence (a connection between aorta and pulmonary artery in the uterine life).
  • other condition like anemia or fever can determine heart murmurs in adults, because they determine turbulent blood flow, but this murmur disappears once the condition is treated.
How do we  with deal heart murmurs in adults ? In patients suffering from valve pathology periodically monitoring is important because in time they can lead to heart failure, in order to prevent this, surgical replacement of the valves can be performed. Heart wall defect can also be repaired providing a normal life for these patients, while the causes for functional heart murmurs in adults once treated determine these abnormal heart sounds to disappear.

Heart murmurs in adults are a serious medical condition,  if you think you have it call your doctor.

Friday, August 24, 2012

Heart palpitations after eating

Heart palpitations after eating are one of the causes of heart palpitations seen in patients. This may be normal under certain conditions, but if it is associated with other symptoms can be a problem for the patients.
After you read this article you know which are the mechanisms, symptoms, causes, treatments and preventions of heart palpitations after eating.
Heart palpitations after eating are fast heart beats that occurs after eating and may or may not feel the patient. Heart palpitations may be due to cardiac or extracardiac. Very important is the severity of the heart palpitations after eating. They can be without hemodynamic significance (just heart palpitations and anxiety)  or hemodynamically significant, considered severe (with low blood sugar, syncope, chest pain and difficulty of breathing).

Mechanism of heart palpitations after eating  

After eating a meal, need for blood in the stomach and surrounding organs increases and thus aids digestion. In this process of digestion and absorption of food, increased heart rate may be undetectable or may be felt as palpitations. If you want to see if you have heart palpitations    you have to measure your pulse rate. This can be done at any hand with the index and the middle finger of the wrist from the other hand. If the pulse rate is over 90 -100 beats and it is maintained over this values,  the patient should consult a doctor.

Other symptoms that accompany heart palpitations after eating

This are nausea, dizziness, fatigue, asthenia, chest pain, shortness of breath  and discomfort in abdominal region felt as feeling bloated. After dinner heart palpitations after eating can may the patient inability to sleep in peace at night and this may be a very important problem for the patient.

Causes of heart palpitations after eating

There are many causes for this condition. One of this is hiatal hernia, which is a condition that upper part of the stomach enters into the thorax. For this, patients with hiatal hernia should avoid lying position for at least two hours after a meal.
Today an important cause for heart palpitations after eating is obesity. More persons are obese due to environmental factors (a sedentary lifestyle, a diet high in sugar, fast food). In this persons suffering from obesity, the heart must work harder to pump the blood to the stomach. Severe anemia is another cause for heart palpitations after eating. In this patients hemoglobin value are very low and may be accompanied by low serum ferritin values. This palpitations are often accompanied with fatigue, asthenia and adinamie.
There are also hormonal imbalances that cause heart palpitations after eating. Patients with hyperthyroidism (disease of the thyroid gland with overproduction of thyroid hormones).

Treatment of heart palpitations after eating

There is no specific treatment for patients with heart palpitations after eating. They must have a lifestyle adapted for prevent heart palpitations. For example:
  • Have frequent meals and few quantitative
  • Not have a sedentary lifestyle
  • Not have a diet high in sugar and caffeine
  • To conduct periodic reviews to prevent severe anemia or hyperthyroidism

If heart palpitations after eating continue after prevention methods the patients should consult a doctor.

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