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Iba T, Connors JM, Levy JH. What Role Does Microthrombosis Play in Long COVID? Semin Thromb Hemost 2024; 50:527-536. [PMID: 37748518 DOI: 10.1055/s-0043-1774795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Soon after the outbreak of coronavirus disease 2019 (COVID-19), unexplained sustained fatigue, cognitive disturbance, and muscle ache/weakness were reported in patients who had recovered from acute COVID-19 infection. This abnormal condition has been recognized as "long COVID (postacute sequelae of COVID-19 [PASC])" with a prevalence estimated to be from 10 to 20% of convalescent patients. Although the pathophysiology of PASC has been studied, the exact mechanism remains obscure. Microclots in circulation can represent one of the possible causes of PASC. Although hypercoagulability and thrombosis are critical mechanisms of acute COVID-19, recent studies have reported that thromboinflammation continues in some patients, even after the virus has cleared. Viral spike proteins and RNA can be detected months after patients have recovered, findings that may be responsible for persistent thromboinflammation and the development of microclots. Despite this theory, long-term results of anticoagulation, antiplatelet therapy, and vascular endothelial protection are inconsistent, and could not always show beneficial treatment effects. In summary, PASC reflects a heterogeneous condition, and microclots cannot explain all the presenting symptoms. After clarification of the pathomechanisms of each symptom, a symptom- or biomarker-based stratified approach should be considered for future studies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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2
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Riou M, Coste F, Meyer A, Enache I, Talha S, Charloux A, Reboul C, Geny B. Mechanisms of Pulmonary Vasculopathy in Acute and Long-Term COVID-19: A Review. Int J Mol Sci 2024; 25:4941. [PMID: 38732160 PMCID: PMC11084496 DOI: 10.3390/ijms25094941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite the end of the pandemic, coronavirus disease 2019 (COVID-19) remains a major public health concern. The first waves of the virus led to a better understanding of its pathogenesis, highlighting the fact that there is a specific pulmonary vascular disorder. Indeed, COVID-19 may predispose patients to thrombotic disease in both venous and arterial circulation, and many cases of severe acute pulmonary embolism have been reported. The demonstrated presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the endothelial cells suggests that direct viral effects, in addition to indirect effects of perivascular inflammation and coagulopathy, may contribute to pulmonary vasculopathy in COVID-19. In this review, we discuss the pathological mechanisms leading to pulmonary vascular damage during acute infection, which appear to be mainly related to thromboembolic events, an impaired coagulation cascade, micro- and macrovascular thrombosis, endotheliitis and hypoxic pulmonary vasoconstriction. As many patients develop post-COVID symptoms, including dyspnea, we also discuss the hypothesis of pulmonary vascular damage and pulmonary hypertension as a sequela of the infection, which may be involved in the pathophysiology of long COVID.
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Affiliation(s)
- Marianne Riou
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
| | - Florence Coste
- EA4278, Laboratoire de Pharm-Ecologie Cardiovasculaire, UFR Sciences Technologies Santé, Pôle Sport et Recherche, 74 rue Louis Pasteur, 84000 Avignon, France; (F.C.); (C.R.)
| | - Alain Meyer
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
| | - Irina Enache
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
| | - Samy Talha
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
| | - Anne Charloux
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
| | - Cyril Reboul
- EA4278, Laboratoire de Pharm-Ecologie Cardiovasculaire, UFR Sciences Technologies Santé, Pôle Sport et Recherche, 74 rue Louis Pasteur, 84000 Avignon, France; (F.C.); (C.R.)
| | - Bernard Geny
- Translational Medicine Federation of Strasbourg (FMTS), University of Strasbourg, CRBS, Team 3072 “Mitochondria, Oxidative Stress and Muscle Protection”, 1 rue Eugène Boeckel, CS 60026, 67084 Strasbourg, France; (M.R.); (A.M.); (I.E.); (S.T.); (A.C.)
- Physiology and Functional Exploration Service, University Hospital of Strasbourg, 1 Place de l’hôpital, 67091 Strasbourg, France
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Gómez-Moyano E, Pavón-Morón J, Rodríguez-Capitán J, Bardán-Rebollar D, Ramos-Carrera T, Villalobos-Sánchez A, Pérez de Pedro I, Ruiz-García FJ, Mora-Robles J, López-Sampalo A, Pérez-Velasco MA, Bernal-López MR, Gómez-Huelgas R, Jiménez-Navarro M, Romero-Cuevas M, Costa F, Trenas A, Pérez-Belmonte LM. The Role of Heparin in Postural Orthostatic Tachycardia Syndrome and Other Post-Acute Sequelae of COVID-19. J Clin Med 2024; 13:2405. [PMID: 38673677 PMCID: PMC11050777 DOI: 10.3390/jcm13082405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/11/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
The therapeutic management and short-term consequences of the coronavirus disease 2019 (COVID-19) are well known. However, COVID-19 post-acute sequelae are less known and represent a public health problem worldwide. Patients with COVID-19 who present post-acute sequelae may display immune dysregulation, a procoagulant state, and persistent microvascular endotheliopathy that could trigger microvascular thrombosis. These elements have also been implicated in the physiopathology of postural orthostatic tachycardia syndrome, a frequent sequela in post-COVID-19 patients. These mechanisms, directly associated with post-acute sequelae, might determine the thrombotic consequences of COVID-19 and the need for early anticoagulation therapy. In this context, heparin has several potential benefits, including immunomodulatory, anticoagulant, antiviral, pro-endothelial, and vascular effects, that could be helpful in the treatment of COVID-19 post-acute sequelae. In this article, we review the evidence surrounding the post-acute sequelae of COVID-19 and the potential benefits of the use of heparin, with a special focus on the treatment of postural orthostatic tachycardia syndrome.
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Affiliation(s)
- Elisabeth Gómez-Moyano
- Servicio de Dermatología, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain;
| | - Javier Pavón-Morón
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (J.P.-M.); (M.J.-N.); (M.R.-C.)
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain;
| | - Jorge Rodríguez-Capitán
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (J.P.-M.); (M.J.-N.); (M.R.-C.)
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain;
| | | | | | - Aurora Villalobos-Sánchez
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
| | - Iván Pérez de Pedro
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
| | | | - Javier Mora-Robles
- Servicio de Cardiología, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain
| | - Almudena López-Sampalo
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
| | - Miguel A. Pérez-Velasco
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
| | - Maria-Rosa Bernal-López
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
- Centro de Investigación en Red Fisiopatología de la Obesidad y la Nutrtición (CIBERObn), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain
| | - Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
- Centro de Investigación en Red Fisiopatología de la Obesidad y la Nutrtición (CIBERObn), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain
| | - Manuel Jiménez-Navarro
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (J.P.-M.); (M.J.-N.); (M.R.-C.)
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain;
| | - Miguel Romero-Cuevas
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain; (J.P.-M.); (M.J.-N.); (M.R.-C.)
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain;
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic ‘G. Martino’, Via C. Valeria 1, 98165 Messina, Italy;
| | - Alicia Trenas
- Servicio de Medicina Interna, Área Sanitaria Norte de Málaga, Hospital de Antequera, 29200 Antequera, Spain;
| | - Luis M. Pérez-Belmonte
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA-Plataforma BIONAND, Universidad de Málaga (UMA), 29010 Málaga, Spain;
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, 29010 Málaga, Spain (I.P.d.P.); (A.L.-S.); (M.-R.B.-L.); (R.G.-H.)
- Servicio de Medicina Interna, Hospital Helicópteros Sanitarios, 29660 Marbella, Spain
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Diar Bakerly N, Smith N, Darbyshire JL, Kwon J, Bullock E, Baley S, Sivan M, Delaney B. Pathophysiological Mechanisms in Long COVID: A Mixed Method Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:473. [PMID: 38673384 PMCID: PMC11050596 DOI: 10.3390/ijerph21040473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Long COVID (LC) is a global public health crisis affecting more than 70 million people. There is emerging evidence of different pathophysiological mechanisms driving the wide array of symptoms in LC. Understanding the relationships between mechanisms and symptoms helps in guiding clinical management and identifying potential treatment targets. METHODS This was a mixed-methods systematic review with two stages: Stage one (Review 1) included only existing systematic reviews (meta-review) and Stage two (Review 2) was a review of all primary studies. The search strategy involved Medline, Embase, Emcare, and CINAHL databases to identify studies that described symptoms and pathophysiological mechanisms with statistical analysis and/or discussion of plausible causal relationships between mechanisms and symptoms. Only studies that included a control arm for comparison were included. Studies were assessed for quality using the National Heart, Lung, and Blood Institute quality assessment tools. RESULTS 19 systematic reviews were included in Review 1 and 46 primary studies in Review 2. Overall, the quality of reporting across the studies included in this second review was moderate to poor. The pathophysiological mechanisms with strong evidence were immune system dysregulation, cerebral hypoperfusion, and impaired gas transfer in the lungs. Other mechanisms with moderate to weak evidence were endothelial damage and hypercoagulation, mast cell activation, and auto-immunity to vascular receptors. CONCLUSIONS LC is a complex condition affecting multiple organs with diverse clinical presentations (or traits) underpinned by multiple pathophysiological mechanisms. A 'treatable trait' approach may help identify certain groups and target specific interventions. Future research must include understanding the response to intervention based on these mechanism-based traits.
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Affiliation(s)
- Nawar Diar Bakerly
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M15 6BH, UK
- Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK;
| | - Nikki Smith
- Locomotion Study Patient Advisory Group, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Level D, Martin Wing, Leeds General Infirmary, Leeds LS1 3EX, UK;
| | - Julie L. Darbyshire
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (J.L.D.); (J.K.)
| | - Joseph Kwon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK; (J.L.D.); (J.K.)
| | - Emily Bullock
- Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK;
| | - Sareeta Baley
- Birmingham Community Healthcare NHS Trust, Birmingham B7 4BN, UK;
| | - Manoj Sivan
- Rehabilitation Medicine, University of Leeds, Leeds Teaching Hospitals and Leeds Community Healthcare NHS Trusts, Leeds LS11 0DL, UK;
| | - Brendan Delaney
- Medical Informatics and Decision Making, Imperial College, London SW7 2AZ, UK;
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Greenstein YY, Hubel K, Froess J, Wisniewski SR, Venugopal V, Lai YH, Berger JS, Chang SY, Colovos C, Shah F, Kornblith LZ, Lawler PR, Gaddh M, Guerrero RM, Nkemdirim W, Lopes RD, Reynolds HR, Amigo JS, Wahid L, Zahra A, Goligher EC, Zarychanski R, Leifer E, Huang DT, Neal MD, Hochman JS, Cushman M, Gong MN. Symptoms and Impaired Quality of Life After COVID-19 Hospitalization: Effect of Therapeutic Heparin in Non-ICU Patients in the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 Acute Trial: Effect on 3-Month Symptoms and Quality of Life. Chest 2024; 165:785-799. [PMID: 37979717 PMCID: PMC11026170 DOI: 10.1016/j.chest.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/06/2023] [Accepted: 11/11/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND Therapeutic-dose heparin decreased days requiring organ support in noncritically ill patients hospitalized for COVID-19, but its impact on persistent symptoms or quality of life (QOL) is unclear. RESEARCH QUESTION In the Accelerating COVID-19 Therapeutic Interventions and Vaccines 4 ACUTE (ACTIV-4a) trial, was randomization of patients hospitalized for COVID-19 illness to therapeutic-dose vs prophylactic heparin associated with fewer symptoms and better QOL at 90 days? STUDY DESIGN AND METHODS This was an open-label randomized controlled trial at 34 hospitals in the United States and Spain. A total of 727 noncritically ill patients hospitalized for COVID-19 from September 2020 to June 2021 were randomized to therapeutic-dose vs prophylactic heparin. Only patients with 90-day data on symptoms and QOL were analyzed. We ascertained symptoms and QOL by the EQ-5D-5L at 90-day follow-up in a preplanned analysis for the ACTIV-4a trial. Individual domains assessed by the EQ-5D-5L included mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Univariate and multivariate analyses were performed. RESULTS Among 571 patients, 288 (50.4%) reported at least one symptom. Among 410 patients, 148 (36.1%) reported moderate to severe impairment in one or more domains of the EQ-5D-5L. The presence of 90-day symptoms was associated with moderate-severe impairment in the EQ-5D-5L domains of mobility (adjusted OR [aOR], 2.37; 95% CI, 1.22-4.59), usual activities (aOR, 3.66; 95% CI, 1.75-7.65), pain (aOR, 2.43; 95% CI, 1.43-4.12), and anxiety (aOR, 4.32; 95% CI, 2.06-9.02), compared with patients reporting no symptoms There were no differences in symptoms or in the overall EQ-5D-5L index score between treatment groups. Therapeutic-dose heparin was associated with less moderate-severe impairment in all physical functioning domains (mobility, self-care, usual activities) but was independently significant only in the self-care domain (aOR, 0.32; 95% CI, 0.11-0.96). INTERPRETATION In a randomized controlled trial of hospitalized noncritically ill patients with COVID-19, therapeutic-dose heparin was associated with less severe impairment in the self-care domain of EQ-5D-5L. However, this type of impairment was uncommon, affecting 23 individuals. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04505774; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
| | | | - Joshua Froess
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | | | - Vidya Venugopal
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Yu-Hsuan Lai
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | | | - Steven Y Chang
- David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christos Colovos
- University of Vermont Larner College of Medicine, Burlington, VT
| | - Faraaz Shah
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, ON, Canada; McGill University Health Centre, Montreal, QC, Canada
| | - Manila Gaddh
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | | | | | - Lana Wahid
- Duke University School of Medicine, Durham, NC
| | | | | | | | - Eric Leifer
- National Heart, Lung, and Blood Institute, Bethesda, MD
| | - David T Huang
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Matthew D Neal
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Mary Cushman
- University of Vermont Larner College of Medicine, Burlington, VT
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Violi F, Harenberg J, Pignatelli P, Cammisotto V. COVID-19 and Long-COVID Thrombosis: From Clinical and Basic Science to Therapeutics. Thromb Haemost 2024; 124:286-296. [PMID: 37967846 DOI: 10.1055/s-0043-1776713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Coronavirus infectious disease-19 (COVID-19) is a pandemic characterized by serious lung disease and thrombotic events in the venous and circulation trees, which represent a harmful clinical sign of poor outcome. Thrombotic events are more frequent in patients with severe disease requiring intensive care units and are associated with platelet and clotting activation. However, after resolution of acute infection, patients may still have clinical sequelae, the so-called long-COVID-19, including thrombotic events again in the venous and arterial circulation. The mechanisms accounting for thrombosis in acute and long COVID-19 have not been fully clarified; interactions of COVID-19 with angiotensin converting enzyme 2 or toll-like receptor family or infection-induced cytokine storm have been suggested to be implicated in endothelial cells, leucocytes, and platelets to elicit clotting activation in acute as well in chronic phase of the disease. In acute COVID-19, prophylactic or full doses of anticoagulants exert beneficial effects even if the dosage choice is still under investigation; however, a residual risk still remains suggesting a need for a more appropriate therapeutic approach. In long COVID-19 preliminary data provided useful information in terms of antiplatelet treatment but definition of candidates for thrombotic prophylaxis is still undefined.
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Affiliation(s)
- Francesco Violi
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Via Orazio, Naples, Italy
| | - Job Harenberg
- Medical Faculty Mannheim, Ruprecht-karls University Heidelberg, Heidelberg, Germany
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
- Mediterranea Cardiocentro, Via Orazio, Naples, Italy
| | - Vittoria Cammisotto
- Department of Clinical Internal, Anaesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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7
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Boyarchuk O, Perestiuk V, Kosovska T, Volianska L. Coagulation profile in hospitalized children with COVID-19: pediatric age dependency and its impact on long COVID development. Front Immunol 2024; 15:1363410. [PMID: 38510249 PMCID: PMC10950941 DOI: 10.3389/fimmu.2024.1363410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/23/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction Pulmonary endotheliopathy and microvascular immunothrombosis play a key role in acute COVID-19. Moreover, persistent endotheliopathy and heightened coagulability frequently occur in individuals recovering from COVID-19, suggesting the intriguing possibility of their role in the development of long COVID. The aim of our study was to investigate the coagulation profile in patients with COVID-19 based on age and their role in the development of long COVID. Methods We conducted a prospective single-center cohort study from September 2022 to August 2023. The study involved 190 patients younger than 18 years who were hospitalized at the Ternopil City Children's Hospital, Ukraine due to COVID-19. Patients underwent determination of coagulation profile in addition to the general clinical examination. After discharge from the hospital, patients were monitored for the presence of long COVID symptoms. Among the 157 participants who consented for follow-up, 62 patients (39.5%) had long COVID symptoms according to the WHO definition, while the rest (95 patients) did not have symptoms of long COVID (fully recovered). Results The study revealed the normal count of platelets in the majority of patients (86.8%), whereas abnormalities in the coagulation profile were revealed in 94.5% of children with COVID-19, and these changes were age-dependent. The patients were mostly presented with increased activated partial thromboplastin time (69.1%), prothrombin time (PT) (39.8%) and D-dimer (45.0%). There was no significant difference between the median of platelet levels and coagulation profile indicators between the groups with long COVID and recovered. Among children who developed persistent long COVID symptoms there was a statistically higher percentage of abnormal PT values (53% versus 36.1%, p=0.0432), with no significant differences in other coagulation profile indicators. Abnormal PT along with female gender, comorbidities, especially allergic pathology, nutritional disorder, including obesity, were determined as potential risk factors of the long COVID development (Odds ratio - 2.0611; 95% 1.0179-4.1737, p=0.0445). Conclusions The study highlights the need for more extensive research into the coagulation profiles of pediatric populations, considering age-specific factors. This could enhance our understanding of thromboinflammation in COVID-19 and its potential contribution to the development of persistent symptoms.
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Yada N, Zhang Q, Bignotti A, Ye Z, Zheng XL. ADAMTS13 or Caplacizumab Reduces the Accumulation of Neutrophil Extracellular Traps and Thrombus in Whole Blood of COVID-19 Patients under Flow. Thromb Haemost 2024. [PMID: 38272066 DOI: 10.1055/a-2253-9359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
BACKGROUND Neutrophil NETosis and neutrophil extracellular traps (NETs) play a critical role in pathogenesis of coronavirus disease 2019 (COVID-19)-associated thrombosis. However, the extents and reserve of NETosis, and potential of thrombus formation under shear in whole blood of patients with COVID-19 are not fully elucidated. Neither has the role of recombinant ADAMTS13 or caplacizumab on the accumulation of NETs and thrombus in COVID-19 patients' whole blood under shear been investigated. METHODS Flow cytometry and microfluidic assay, as well as immunoassays, were employed for the study. RESULTS We demonstrated that the percentage of H3Cit + MPO+ neutrophils, indicative of NETosis, was dramatically increased in patients with severe but not critical COVID-19 compared with that in asymptomatic or mild disease controls. Upon stimulation with poly [I:C], a double strain DNA mimicking viral infection, or bacterial shigatoxin-2, the percentage of H3Cit + MPO+ neutrophils was not significantly increased in the whole blood of severe and critical COVID-19 patients compared with that of asymptomatic controls, suggesting the reduction in NETosis reserve in these patients. Microfluidic assay demonstrated that the accumulation of NETs and thrombus was significantly enhanced in the whole blood of severe/critical COVID-19 patients compared with that of asymptomatic controls. Like DNase I, recombinant ADAMTS13 or caplacizumab dramatically reduced the NETs accumulation and thrombus formation under arterial shear. CONCLUSION Significantly increased neutrophil NETosis, reduced NETosis reserve, and enhanced thrombus formation under arterial shear may play a crucial role in the pathogenesis of COVID-19-associated coagulopathy. Recombinant ADAMTS13 or caplacizumab may be explored for the treatment of COVID-19-associated thrombosis.
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Affiliation(s)
- Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kanas City, Kansas, United States
| | - Quan Zhang
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kanas City, Kansas, United States
| | - Antonia Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kanas City, Kansas, United States
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kanas City, Kansas, United States
| | - X Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kanas City, Kansas, United States
- Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kanas City, Kansas, United States
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Gheorghita R, Soldanescu I, Lobiuc A, Caliman Sturdza OA, Filip R, Constantinescu – Bercu A, Dimian M, Mangul S, Covasa M. The knowns and unknowns of long COVID-19: from mechanisms to therapeutical approaches. Front Immunol 2024; 15:1344086. [PMID: 38500880 PMCID: PMC10944866 DOI: 10.3389/fimmu.2024.1344086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/14/2024] [Indexed: 03/20/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by SARS-CoV-2 has been defined as the greatest global health and socioeconomic crisis of modern times. While most people recover after being infected with the virus, a significant proportion of them continue to experience health issues weeks, months and even years after acute infection with SARS-CoV-2. This persistence of clinical symptoms in infected individuals for at least three months after the onset of the disease or the emergence of new symptoms lasting more than two months, without any other explanation and alternative diagnosis have been named long COVID, long-haul COVID, post-COVID-19 conditions, chronic COVID, or post-acute sequelae of SARS-CoV-2 (PASC). Long COVID has been characterized as a constellation of symptoms and disorders that vary widely in their manifestations. Further, the mechanisms underlying long COVID are not fully understood, which hamper efficient treatment options. This review describes predictors and the most common symptoms related to long COVID's effects on the central and peripheral nervous system and other organs and tissues. Furthermore, the transcriptional markers, molecular signaling pathways and risk factors for long COVID, such as sex, age, pre-existing condition, hospitalization during acute phase of COVID-19, vaccination, and lifestyle are presented. Finally, recommendations for patient rehabilitation and disease management, as well as alternative therapeutical approaches to long COVID sequelae are discussed. Understanding the complexity of this disease, its symptoms across multiple organ systems and overlapping pathologies and its possible mechanisms are paramount in developing diagnostic tools and treatments.
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Affiliation(s)
- Roxana Gheorghita
- Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
| | - Iuliana Soldanescu
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), University of Suceava, Suceava, Romania
| | - Andrei Lobiuc
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
| | - Olga Adriana Caliman Sturdza
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Suceava Emergency Clinical County Hospital, Suceava, Romania
| | - Roxana Filip
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Suceava Emergency Clinical County Hospital, Suceava, Romania
| | - Adela Constantinescu – Bercu
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Institute of Cardiovascular Science, Hemostasis Research Unit, University College London (UCL), London, United Kingdom
| | - Mihai Dimian
- Integrated Center for Research, Development and Innovation for Advanced Materials, Nanotechnologies, Manufacturing and Control Distributed Systems (MANSiD), University of Suceava, Suceava, Romania
- Department of Computer, Electronics and Automation, University of Suceava, Suceava, Romania
| | - Serghei Mangul
- Department of Clinical Pharmacy, USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, United States
- Department of Quantitative and Computational Biology, USC Dornsife College of Letters, Arts and Sciences, University of Southern California (USC), Los Angeles, CA, United States
| | - Mihai Covasa
- Department of Biomedical Sciences, College of Medicine and Biological Science, University of Suceava, Suceava, Romania
- Department of Basic Medical Sciences, Western University of Health Sciences, College of Osteopathic Medicine, Pomona, CA, United States
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10
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Rittmannsberger H, Barth M, Lamprecht B, Malik P, Yazdi-Zorn K. [Interaction of somatic findings and psychiatric symptoms in COVID-19. A scoping review]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT OSTERREICHISCHER NERVENARZTE UND PSYCHIATER 2024; 38:1-23. [PMID: 38055146 DOI: 10.1007/s40211-023-00487-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/24/2023] [Indexed: 12/07/2023]
Abstract
An infection with SARS-CoV‑2 can affect the central nervous system, leading to neurological as well as psychiatric symptoms. In this respect, mechanisms of inflammation seem to be of much greater importance than the virus itself. This paper deals with the possible contributions of organic changes to psychiatric symptomatology and deals especially with delirium, cognitive symptoms, depression, anxiety, posttraumatic stress disorder and psychosis. Processes of neuroinflammation with infection of capillary endothelial cells and activation of microglia and astrocytes releasing high amounts of cytokines seem to be of key importance in all kinds of disturbances. They can lead to damage in grey and white matter, impairment of cerebral metabolism and loss of connectivity. Such neuroimmunological processes have been described as a organic basis for many psychiatric disorders, as affective disorders, psychoses and dementia. As the activation of the glia cells can persist for a long time after the offending agent has been cleared, this can contribute to long term sequalae of the infection.
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Affiliation(s)
- Hans Rittmannsberger
- Abteilung Psychiatrie und psychotherapeutische Medizin, Pyhrn-Eisenwurzen Klinikum Steyr, Steyr, Österreich.
| | - Martin Barth
- Abteilung Psychiatrie und psychotherapeutische Medizin, Pyhrn-Eisenwurzen Klinikum Steyr, Steyr, Österreich
| | - Bernd Lamprecht
- Med Campus III, Universitätsklinik für Innere Medizin mit Schwerpunkt Pneumologie, Kepler Universitätsklinikum GmbH, Linz, Österreich
- Medizinische Fakultät, Johannes Kepler Universität Linz, Linz, Österreich
| | - Peter Malik
- Abteilung Psychiatrie und psychotherapeutische Medizin, Pyhrn-Eisenwurzen Klinikum Steyr, Steyr, Österreich
| | - Kurosch Yazdi-Zorn
- Neuromed Campus, Klinik für Psychiatrie mit Schwerpunkt Suchtmedizin, Kepler Universitätsklinikum GmbH, Linz, Österreich
- Medizinische Fakultät, Johannes Kepler Universität Linz, Linz, Österreich
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11
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Romero-Molina AO, Ramirez-Garcia G, Chirino-Perez A, Fuentes-Zavaleta DA, Hernandez-Castillo CR, Marrufo-Melendez O, Lopez-Gonzalez D, Rodriguez-Rodriguez M, Castorena-Maldonado A, Rodriguez-Agudelo Y, Paz-Rodriguez F, Chavez-Oliveros M, Lozano-Tovar S, Gutierrez-Romero A, Arauz-Gongora A, Garcia-Santos RA, Fernandez-Ruiz J. SARS-CoV-2's brain impact: revealing cortical and cerebellar differences via cluster analysis in COVID-19 recovered patients. Neurol Sci 2024; 45:837-848. [PMID: 38172414 DOI: 10.1007/s10072-023-07266-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND COVID-19 is a disease known for its neurological involvement. SARS-CoV-2 infection triggers neuroinflammation, which could significantly contribute to the development of long-term neurological symptoms and structural alterations in the gray matter. However, the existence of a consistent pattern of cerebral atrophy remains uncertain. OBJECTIVE Our study aimed to identify patterns of brain involvement in recovered COVID-19 patients and explore potential relationships with clinical variables during hospitalization. METHODOLOGY In this study, we included 39 recovered patients and 39 controls from a pre-pandemic database to ensure their non-exposure to the virus. We obtained clinical data of the patients during hospitalization, and 3 months later; in addition we obtained T1-weighted magnetic resonance images and performed standard screening cognitive tests. RESULTS We identified two groups of recovered patients based on a cluster analysis of the significant cortical thickness differences between patients and controls. Group 1 displayed significant cortical thickness differences in specific cerebral regions, while Group 2 exhibited significant differences in the cerebellum, though neither group showed cognitive deterioration at the group level. Notably, Group 1 showed a tendency of higher D-dimer values during hospitalization compared to Group 2, prior to p-value correction. CONCLUSION This data-driven division into two groups based on the brain structural differences, and the possible link to D-dimer values may provide insights into the underlying mechanisms of SARS-COV-2 neurological disruption and its impact on the brain during and after recovery from the disease.
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Affiliation(s)
- Angel Omar Romero-Molina
- Instituto de Neuroetologia, Universidad Veracruzana, Xalapa, Veracruz, Mexico
- Laboratorio de Neuropsicologia, Facultad de Medicina, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Gabriel Ramirez-Garcia
- Laboratorio de Neuropsicologia, Facultad de Medicina, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Amanda Chirino-Perez
- Laboratorio de Neuropsicologia, Facultad de Medicina, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Juan Fernandez-Ruiz
- Instituto de Neuroetologia, Universidad Veracruzana, Xalapa, Veracruz, Mexico.
- Laboratorio de Neuropsicologia, Facultad de Medicina, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico.
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12
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Zhang J, Kuang T, Liu X. Advances in researches on long coronavirus disease in children: a narrative review. Transl Pediatr 2024; 13:318-328. [PMID: 38455739 PMCID: PMC10915432 DOI: 10.21037/tp-23-472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/31/2023] [Indexed: 03/09/2024] Open
Abstract
Background and Objective In the context of the global pandemic of coronavirus disease 2019 (COVID-19), more than 700 million infections and millions of deaths have occurred in countries around the world. Currently, two main sequelae of this disease are considered to occur in children, namely, multi-system inflammatory syndrome in children and long COVID. Among these two, the incidence of long COVID is higher and its impact on the population is more extensive, which is the focus of us. However, due to the lack of relevant studies and the limitations of most studies, the studies on sequelae of COVID-19 infection lag behind those of adults, but they have begun to attract the attention of some clinicians and researchers. We aim to summarize the current knowledge of long COVID in children, helping pediatricians and researchers to better understand this disease and providing guidance on research and clinical treatment of it. Methods We reviewed all the studies on "long COVID", pediatric, children, adolescent, post-COVID syndrome in PubMed published after 2019. Key Content and Findings This review summarizes the latest researches on epidemiology, pathogenesis, clinical manifestations, prevention and treatment of long COVID in children. Based on the existing research data, we summarized and analyzed the characteristics of long COVID in children, discovering the means to decipher the diagnosis of COVID-19 in children and some potential therapeutic treatments. Conclusions We aim to summarize existing research on long COVID in children and help pediatricians and government agencies quickly understand the disease so that it can be used for clinical diagnosis, treatment and prevention in the population. In addition, providing a research basis for further researches on the cellular and even molecular level to explain the occurrence and development of diseases, and has a guiding role for future research direction.
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13
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Poyatos P, Luque N, Sabater G, Eizaguirre S, Bonnin M, Orriols R, Tura-Ceide O. Endothelial dysfunction and cardiovascular risk in post-COVID-19 patients after 6- and 12-months SARS-CoV-2 infection. Infection 2024:10.1007/s15010-024-02173-5. [PMID: 38324145 DOI: 10.1007/s15010-024-02173-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/01/2024] [Indexed: 02/08/2024]
Abstract
INTRODUCTION SARS-CoV-2 infection causes severe endothelial damage, an essential step for cardiovascular complications. Endothelial-colony forming cells (ECFCs) act as a biomarker of vascular damage but their role in SARS-CoV-2 remain unclear. The aim of this study was to assess whether the number of ECFCs and angiogenic biomarkers remained altered after 6 and 12-months post-infection and whether this imbalance correlated with the presence of long-COVID syndrome and other biological parameters measured. METHODS Seventy-two patients were recruited at different time-points after overcoming COVID-19 and thirty-one healthy controls. All subjects were matched for age, gender, BMI, and comorbidities. ECFCs were obtained from peripheral blood and cultured with specific conditions. RESULTS The results confirm the presence of a long-term sequela in post-COVID-19 patients, with an abnormal increase in ECFC production compared to controls (82.8% vs. 48.4%, P < 0.01) that is maintained up to 6-months (87.0% vs. 48.4%, P < 0.01) and 12-months post-infection (85.0% vs. 48.4%, P < 0.01). Interestingly, post-COVID-19 patients showed a significant downregulation of angiogenesis-related proteins compared to controls indicating a clear endothelial injury. Troponin, NT-proBNP and ferritin levels, markers of cardiovascular risk and inflammation, remained elevated up to 12-months post-infection. Patients with lower numbers of ECFC exhibited higher levels of inflammatory markers, such as ferritin, suggesting that ECFCs may play a protective role. Additionally, long-COVID syndrome was associated with higher ferritin levels and with female gender. CONCLUSIONS These findings highlight the presence of vascular sequela that last up to 6- and 12-months post-infection and point out the need for preventive measures and patient follow-up.
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Affiliation(s)
- Paula Poyatos
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain
| | - Neus Luque
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain
| | - Gladis Sabater
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain
| | - Saioa Eizaguirre
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain
| | - Marc Bonnin
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain
| | - Ramon Orriols
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain.
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain.
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain.
| | - Olga Tura-Ceide
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institute (IDIBGI), 17190, Girona, Spain.
- Department of Medical Sciences, Faculty of Medicine, University of Girona, Girona, Spain.
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain.
- Department of Pulmonary Medicine, Servei de Pneumologia, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel, 170, 08036, Barcelona, Spain.
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14
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Philippe A, Günther S, Rancic J, Cavagna P, Renaud B, Gendron N, Mousseaux E, Hua-Huy T, Reverdito G, Planquette B, Sanchez O, Gaussem P, Salmon D, Diehl JL, Smadja DM. VEGF-A plasma levels are associated with impaired DLCO and radiological sequelae in long COVID patients. Angiogenesis 2024; 27:51-66. [PMID: 37526809 DOI: 10.1007/s10456-023-09890-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Long COVID, also known as post-acute sequelae of COVID-19 (PASC), is characterized by persistent clinical symptoms following COVID-19. OBJECTIVE To correlate biomarkers of endothelial dysfunction with persistent clinical symptoms and pulmonary function defects at distance from COVID-19. METHODS Consecutive patients with long COVID-19 suspicion were enrolled. A panel of endothelial biomarkers was measured in each patient during clinical evaluation and pulmonary function test (PFT). RESULTS The study included 137 PASC patients, mostly male (68%), with a median age of 55 years. A total of 194 PFTs were performed between months 3 and 24 after an episode of SARS-CoV-2 infection. We compared biomarkers evaluated in PASC patients with 20 healthy volunteers (HVs) and acute hospitalized COVID-19 patients (n = 88). The study found that angiogenesis-related biomarkers and von Willebrand factor (VWF) levels were increased in PASC patients compared to HVs without increased inflammatory or platelet activation markers. Moreover, VEGF-A and VWF were associated with persistent lung CT scan lesions and impaired diffusing capacity of the lungs for carbon monoxide (DLCO) measurement. By employing a Cox proportional hazards model adjusted for age, sex, and body mass index, we further confirmed the accuracy of VEGF-A and VWF. Following adjustment, VEGF-A emerged as the most significant predictive factor associated with persistent lung CT scan lesions and impaired DLCO measurement. CONCLUSION VEGF-A is a relevant predictive factor for DLCO impairment and radiological sequelae in PASC. Beyond being a biomarker, we hypothesize that the persistence of angiogenic disorders may contribute to long COVID symptoms.
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Affiliation(s)
- Aurélien Philippe
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Sven Günther
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Jeanne Rancic
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
| | - Pauline Cavagna
- Pharmacy Department, Pitié-Salpêtrière Hospital, AP-HP Sorbonne University, Paris, France
- Université Paris Cité, INSERM, PARCC, 75015, Paris, France
| | - Bertrand Renaud
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Elie Mousseaux
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France
- Department of Radiology, Georges Pompidou European Hospital, 75015, Paris, France
| | - Thông Hua-Huy
- Unité d'Explorations Fonctionnelles Respiratoires et du Sommeil, AP-HP, Georges Pompidou European Hospital, 75015, Paris, France
| | - Guillaume Reverdito
- Paris-Cardiovascular Research Center INSERM 970, Université de Paris, Paris, France
- Department of Radiology, Georges Pompidou European Hospital, 75015, Paris, France
| | - Benjamin Planquette
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Respiratory Diseases Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Olivier Sanchez
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Respiratory Diseases Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Pascale Gaussem
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - Dominique Salmon
- Infectious Diseases and Immunology Department, AP-HP. Centre, Université Paris Cité, Hôtel-Dieu Hospital, 75004, Paris, France
| | - Jean-Luc Diehl
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France
- Intensive Care Unit, AP-HP. Centre Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France
| | - David M Smadja
- University Paris Cité, Innovative Therapies in Hemostasis, INSERM, 75006, Paris, France.
- Hematology Department, AP-HP.Centre, Université Paris Cité, Georges Pompidou European Hospital, 75015, Paris, France.
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Wu X, Xiang M, Jing H, Wang C, Novakovic VA, Shi J. Damage to endothelial barriers and its contribution to long COVID. Angiogenesis 2024; 27:5-22. [PMID: 37103631 PMCID: PMC10134732 DOI: 10.1007/s10456-023-09878-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
The world continues to contend with COVID-19, fueled by the emergence of viral variants. At the same time, a subset of convalescent individuals continues to experience persistent and prolonged sequelae, known as long COVID. Clinical, autopsy, animal and in vitro studies all reveal endothelial injury in acute COVID-19 and convalescent patients. Endothelial dysfunction is now recognized as a central factor in COVID-19 progression and long COVID development. Different organs contain different types of endothelia, each with specific features, forming different endothelial barriers and executing different physiological functions. Endothelial injury results in contraction of cell margins (increased permeability), shedding of glycocalyx, extension of phosphatidylserine-rich filopods, and barrier damage. During acute SARS-CoV-2 infection, damaged endothelial cells promote diffuse microthrombi and destroy the endothelial (including blood-air, blood-brain, glomerular filtration and intestinal-blood) barriers, leading to multiple organ dysfunction. During the convalescence period, a subset of patients is unable to fully recover due to persistent endothelial dysfunction, contributing to long COVID. There is still an important knowledge gap between endothelial barrier damage in different organs and COVID-19 sequelae. In this article, we mainly focus on these endothelial barriers and their contribution to long COVID.
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Affiliation(s)
- Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical University, 150001, Harbin, China
| | - Mengqi Xiang
- Department of Hematology, The First Hospital, Harbin Medical University, 150001, Harbin, China
| | - Haijiao Jing
- Department of Hematology, The First Hospital, Harbin Medical University, 150001, Harbin, China
| | - Chengyue Wang
- Department of Hematology, The First Hospital, Harbin Medical University, 150001, Harbin, China
| | - Valerie A Novakovic
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, 150001, Harbin, China.
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA.
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, MA, Boston, USA.
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16
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Nara N, Shimizu M, Yamamoto M, Nakamizo T, Hayakawa A, Johkura K. Prolonged platelet hyperactivity after COVID-19 infection. Br J Haematol 2024; 204:492-496. [PMID: 37822090 DOI: 10.1111/bjh.19125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/20/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023]
Abstract
Platelet hyperactivity often occurs in patients with coronavirus disease 2019 (COVID-19). However, it remains unclear how long platelet hyperactivity lasts after the acute phase, owing to a lack of follow-up studies. To elucidate the course of platelet hyperactivity, we serially measured platelet activity in patients with COVID-19 up to 40 days after hospital admission using an easily assessable haematology analyser that semi-quantitates platelet clumps on a scattergram. Our results showed that platelet hyperactivity persisted for at least 40 days even after acute inflammation subsided in most patients with COVID-19, regardless of disease severity. Persistent platelet hyperactivity may contribute to thromboembolic complications in post-COVID-19 patients.
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Affiliation(s)
- Noriko Nara
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Mie Shimizu
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Masahiro Yamamoto
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Tomoki Nakamizo
- Department of Clinical Studies, Radiation Effects Research Foundation, Nagasaki, Japan
| | - Azusa Hayakawa
- Department of Cardiology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Ken Johkura
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
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17
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Negrut N, Menegas G, Kampioti S, Bourelou M, Kopanyi F, Hassan FD, Asowed A, Taleouine FZ, Ferician A, Marian P. The Multisystem Impact of Long COVID: A Comprehensive Review. Diagnostics (Basel) 2024; 14:244. [PMID: 38337760 PMCID: PMC10855167 DOI: 10.3390/diagnostics14030244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: COVID-19 was responsible for the latest pandemic, shaking and reshaping healthcare systems worldwide. Its late clinical manifestations make it linger in medical memory as a debilitating illness over extended periods. (2) Methods: the recent literature was systematically analyzed to categorize and examine the symptomatology and pathophysiology of Long COVID across various bodily systems, including pulmonary, cardiovascular, gastrointestinal, neuropsychiatric, dermatological, renal, hematological, and endocrinological aspects. (3) Results: The review outlines the diverse clinical manifestations of Long COVID across multiple systems, emphasizing its complexity and challenges in diagnosis and treatment. Factors such as pre-existing conditions, initial COVID-19 severity, vaccination status, gender, and age were identified as influential in the manifestation and persistence of Long COVID symptoms. This condition is highlighted as a debilitating disease capable of enduring over an extended period and presenting new symptoms over time. (4) Conclusions: Long COVID emerges as a condition with intricate multi-systemic involvement, complicating its diagnosis and treatment. The findings underscore the necessity for a nuanced understanding of its diverse manifestations to effectively manage and address the evolving nature of this condition over time.
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Affiliation(s)
- Nicoleta Negrut
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Georgios Menegas
- Department of Orthopaedics, Achillopouleio General Hospital of Volos, Polymeri 134, 38222 Volos, Greece;
| | - Sofia Kampioti
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Maria Bourelou
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Francesca Kopanyi
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Faiso Dahir Hassan
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Anamaria Asowed
- Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania (M.B.); (F.D.H.)
| | - Fatima Zohra Taleouine
- University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK;
| | - Anca Ferician
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (A.F.)
| | - Paula Marian
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (A.F.)
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18
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S B MJ, Chacko B, Selvarajan S, Peter JV, Geevar T, Dave RG, Georgy JT, Zachariah A, George T, Sathyendra S, Hansdak SG, Krishnaswami RK, Thangakunam B, Gupta R, Karuppusami R, Nair SC, Srivastava A. Biomarkers of coagulation, endothelial, platelet function, and fibrinolysis in patients with COVID-19: a prospective study. Sci Rep 2024; 14:2011. [PMID: 38263377 PMCID: PMC10805716 DOI: 10.1038/s41598-024-51908-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024] Open
Abstract
Prospective and sequential evaluation of homeostatic changes leading to thrombosis across COVID 19 disease severity spectrum are limited. In this prospective observational study, haemostasis was evaluated in patients with mild, moderate-severe, and critical COVID-19 infection. Markers of endothelial activation [Soluble thrombomodulin (sTM), von Willebrand Factor (VWF)], platelet activation [Soluble P-selectin, beta-thromboglobulin (BTG)] and global haemostasis [Rotational thromboelastometry (ROTEM)] were evaluated on days 1 and 5 after admission. The study cohort comprised of 100 adult patients (mild = 20, moderate-severe = 22, critical = 58). Sixty-five patients received anticoagulation for 10 (7-14) days. Thrombotic events were seen in 9 patients. In-hospital mortality was 21%. Endothelial activation markers were elevated at baseline in all subgroups, with levels in moderate-severe (sTM = 4.92 ng/ml, VWF = 295 U/dl) [reference-ranges: sTM = 2.26-4.55 ng/ml; Soluble P-selectin = 13.5-31.5 ng/ml; BTG = 0.034-1.99 ng/ml] and critical patients (sTM = 6.07 ng/ml, VWF = 294 U/dl) being significantly higher than in the mild group (sTM = 4.18 ng/ml, VWF = 206 U/dl). In contrast, platelet activation markers were elevated only in critically ill patients at baseline (Soluble P-selectin = 37.3 ng/ml, BTG = 2.51 ng/ml). The critical group had significantly lower fibrinolysis on days 1 and 5 when compared with the moderate-severe arm. COVID-19 infection was associated with graded endothelial activation and lower fibrinolysis that correlated with illness severity.
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Affiliation(s)
- Manoj Job S B
- Department of Critical Care, Christian Medical College, Vellore, 632004, India.
| | - Binila Chacko
- Department of Critical Care, Christian Medical College, Vellore, 632004, India
| | - Sushil Selvarajan
- Department of Clinical Hematology, Christian Medical College, Vellore, India
| | - John Victor Peter
- Department of Critical Care, Christian Medical College, Vellore, 632004, India
| | - Tulasi Geevar
- Department of Transfusion Medicine, Christian Medical College, Vellore, India
| | - Rutvi Gautam Dave
- Department of Transfusion Medicine, Christian Medical College, Vellore, India
| | - Josh Thomas Georgy
- Department of General Medicine, Christian Medical College, Vellore, India
| | - Anand Zachariah
- Department of General Medicine, Christian Medical College, Vellore, India
| | - Tina George
- Department of General Medicine, Christian Medical College, Vellore, India
| | - Sowmya Sathyendra
- Department of General Medicine, Christian Medical College, Vellore, India
| | | | | | | | - Richa Gupta
- Department of Respiratory Medicine, Christian Medical College, Vellore, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, India
| | | | - Alok Srivastava
- Department of Clinical Hematology, Christian Medical College, Vellore, India
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19
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Zaidi AK, Singh RB, A A Rizvi S, Dehgani-Mobaraki P, Palladino N. COVID-19 pathogenesis. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2024; 202:67-112. [PMID: 38237991 DOI: 10.1016/bs.pmbts.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The pathogenesis of COVID-19 involves a complex interplay between host factors and the SARS-CoV-2 virus, leading to a multitude of clinical manifestations beyond the respiratory system. This chapter provides an overview of the risk factors, genetic predisposition, and multisystem manifestations of COVID-19, shedding light on the underlying mechanisms that contribute to extrapulmonary manifestations. The chapter discusses the direct invasion of SARS-CoV-2 into various organs as well as the indirect mechanisms such as dysregulation of the renin-angiotensin-aldosterone system (RAAS), immune response dysfunctions within the innate and adaptive immune systems, endothelial damage, and immunothrombosis. Furthermore, the multisystem manifestations of COVID-19 across different organ systems, including the cardiovascular, renal, gastrointestinal, hepatobiliary, nervous, endocrine and metabolic, ophthalmic, ear-nose-throat, reproductive, hematopoietic, and immune systems are discussed in detail. Each system exhibits unique manifestations that contribute to the complexity of the disease.
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Affiliation(s)
| | - Rohan Bir Singh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States; Department of Population, Policy and Practice, Greater Ormond Street Institute of Child Health, University College London, United Kingdom; Discipline of Ophthalmology and Visual Sciences, Adelaide Medical School, University of Adelaide, Australia
| | - Syed A A Rizvi
- College of Biomedical Sciences, Larkin University, Miami, Florida, United States.
| | - Puya Dehgani-Mobaraki
- Founder and President, Associazione Naso Sano, Ringgold Institution ID 567754, San Mariano, Italy.
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20
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Yin H, Li Y, Qian J, Lu L. Bier spots associated with long COVID. Int J Rheum Dis 2024; 27:e15042. [PMID: 38287540 DOI: 10.1111/1756-185x.15042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/03/2024] [Indexed: 01/31/2024]
Affiliation(s)
- Hanlin Yin
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan Li
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinjing Qian
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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21
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Kerzhner O, Berla E, Har-Even M, Ratmansky M, Goor-Aryeh I. Consistency of inconsistency in long-COVID-19 pain symptoms persistency: A systematic review and meta-analysis. Pain Pract 2024; 24:120-159. [PMID: 37475709 DOI: 10.1111/papr.13277] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/29/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Individuals recovering from acute COVID-19 episodes may continue to suffer from various ongoing symptoms, collectively referred to as Long-COVID. Long-term pain symptoms are amongst the most common and clinically significant symptoms to be reported for this post-COVID-19 syndrome. OBJECTIVES This systematic review and meta-analysis aimed to evaluate the proportions of persisting pain symptoms experienced by individuals past the acute phase of COVID-19 and to identify their associated functional consequences and inflammatory correlates. METHODS Two online databases were systematically searched from their inception until 31 March 2022. We searched primary research articles in English, which evaluated individuals after laboratory-confirmed COVID-19 acute phase resolution and specifically reported on pain symptoms and their inflammatory and/or functional outcomes. RESULTS Of the 611 identified articles, 26 were included, used for data extraction, and assessed for their methodological quality and risk of bias by two independent reviewers. Pain symptoms were grouped under one of six major pain domains, serving as our primary co-outcomes. Proportional meta-analyses of pooled logit-transformed values of single proportions were performed using the random-effects-restricted maximum-likelihood model. An estimated 8%, 6%, 18%, 18%, 17%, and 12% of individuals continued to report the persistence of chest, gastrointestinal, musculoskeletal joint, musculoskeletal muscle, general body, and nervous system-related pain symptoms, respectively, for up to one year after acute phase resolution of COVID-19. Considerable levels of heterogeneity were demonstrated across all results. Functional and quality-of-life impairments and some inflammatory biomarker elevations were associated with the persistence of long-COVID pain symptoms. CONCLUSION This study's findings suggest that although not well characterized, long-COVID pain symptoms are being experienced by non-negligible proportions of those recovering from acute COVID-19 episodes, thus highlighting the importance of future research efforts to focus on this aspect.
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Affiliation(s)
- Oleg Kerzhner
- Loewenstein Rehabilitation Medical Center, Ra'anana, Israel
| | - Einat Berla
- Israel Defense Forces Medical Corps, Ramat Gan, Israel
| | - Meirav Har-Even
- Department of Anatomy and Anthropology, School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Motti Ratmansky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pain Clinic, Sheba Medical Center, Ramat Gan, Israel
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22
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Motes A, Nugent K. Periodic generalized edema following COVID-19 infection. Am J Med Sci 2024; 367:61-66. [PMID: 37816456 DOI: 10.1016/j.amjms.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/12/2023]
Abstract
The unprecedented impact and sequelae of COVID-19 infection are not yet fully understood, and better understanding of the pathophysiology of these infections is needed. Endothelial dysfunction might be common sequelae associated with COVID-19, and increased inflammatory responses, oxidative stress, proinflammatory cytokines, and impaired mitochondrial function also contribute to the pathophysiology of post COVID-19 medical disorders. Systemic capillary leak syndrome following COVID-19 infection, both new onset and exacerbation of a prior disorder, has been reported. The pathophysiology of SCLS is uncertain; it likely develops during transient vascular endothelial dysfunction or endotheliopathy and inflammation resulting from circulating humoral factors. Here, we report a case of adult patient with 2 episodes of systemic capillary leak syndrome following prior COVID-19 infection. This patient had a transient response to intravenous IgG.
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Affiliation(s)
- Arunee Motes
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX United States
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX United States.
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23
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Mroueh A, Fakih W, Carmona A, Trimaille A, Matsushita K, Marchandot B, Qureshi AW, Gong DS, Auger C, Sattler L, Reydel A, Hess S, Oulehri W, Vollmer O, Lessinger JM, Meyer N, Pieper MP, Jesel L, Bäck M, Schini-Kerth V, Morel O. COVID-19 promotes endothelial dysfunction and thrombogenicity: role of proinflammatory cytokines/SGLT2 prooxidant pathway. J Thromb Haemost 2024; 22:286-299. [PMID: 37797691 DOI: 10.1016/j.jtha.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND COVID-19 is associated with an increased risk of cardiovascular complications. Although cytokines have a predominant role in endothelium damage, the precise molecular mechanisms are far from being elucidated. OBJECTIVES The present study hypothesized that inflammation in patients with COVID-19 contributes to endothelial dysfunction through redox-sensitive SGLT2 overexpression and investigated the protective effect of SGLT2 inhibition by empagliflozin. METHODS Human plasma samples were collected from patients with acute, subacute, and long COVID-19 (n = 100), patients with non-COVID-19 and cardiovascular risk factors (n = 50), and healthy volunteers (n = 25). Porcine coronary artery endothelial cells (ECs) were incubated with plasma (10%). Protein expression levels were determined using Western blot analyses and immunofluorescence staining, mRNA expression by quantitative reverse transcription-polymerase chain reaction, and the level of oxidative stress by dihydroethidium staining. Platelet adhesion, aggregation, and thrombin generation were determined. RESULTS Increased plasma levels of interleukin (IL)-1β, IL-6, tumor necrosis factor-α, monocyte chemoattractant protein-1, and soluble intercellular adhesion molecule-1 were observed in patients with COVID-19. Exposure of ECs to COVID-19 plasma with high cytokines levels induced redox-sensitive upregulation of SGLT2 expression via proinflammatory cytokines IL-1β, IL-6, and tumor necrosis factor-α which, in turn, fueled endothelial dysfunction, senescence, NF-κB activation, inflammation, platelet adhesion and aggregation, von Willebrand factor secretion, and thrombin generation. The stimulatory effect of COVID-19 plasma was blunted by neutralizing antibodies against proinflammatory cytokines and empagliflozin. CONCLUSION In patients with COVID-19, proinflammatory cytokines induced a redox-sensitive upregulation of SGLT2 expression in ECs, which in turn promoted endothelial injury, senescence, platelet adhesion, aggregation, and thrombin generation. SGLT2 inhibition with empagliflozin appeared as an attractive strategy to restore vascular homeostasis in COVID-19.
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Affiliation(s)
- Ali Mroueh
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Walaa Fakih
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Adrien Carmona
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Antonin Trimaille
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France; Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France. https://twitter.com/A_Trimaille
| | - Kensuke Matsushita
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France; Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Benjamin Marchandot
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Abdul Wahid Qureshi
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Dal-Seong Gong
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Cyril Auger
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France
| | - Laurent Sattler
- Department Laboratory Haematology, Centre for Thrombosis and Haemostasis, Strasbourg University Hospital, Strasbourg, France
| | - Antje Reydel
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Sébastien Hess
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Walid Oulehri
- Department of Critical Care, Strasbourg University Hospital, Strasbourg, France
| | - Olivier Vollmer
- Department of Immunology and Internal Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Jean-Marc Lessinger
- Biochemistry and Molecular Biology Laboratory, Strasbourg University Hospital, Strasbourg, France
| | - Nicolas Meyer
- Department of Biostatistics, Strasbourg University Hospital, Strasbourg, France
| | | | - Laurence Jesel
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France; Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France
| | - Magnus Bäck
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Section of Translational Cardiology, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Institut National de la Sante et de la Recherche Medicale U1116, Université de Lorraine, Nancy, France
| | - Valérie Schini-Kerth
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France.
| | - Olivier Morel
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine, FMTS, Strasbourg, France; Division of Cardiovascular Medicine, Strasbourg University Hospital, Strasbourg, France; Department Laboratory Haematology, Centre for Thrombosis and Haemostasis, Strasbourg University Hospital, Strasbourg, France; Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam.
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24
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Cojocaru DC, Mitu F, Leon MM, Dima-Cozma LC, Adam CA, Cumpăt CM, Negru RD, Maștaleru A, Onofrei V. Beyond the Acute Phase: Long-Term Impact of COVID-19 on Functional Capacity and Prothrombotic Risk-A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:51. [PMID: 38256314 PMCID: PMC10819578 DOI: 10.3390/medicina60010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Assessment of the prothrombotic, proinflammatory, and functional status of a cohort of COVID-19 patients at least two years after the acute infection to identify parameters with potential therapeutic and prognostic value. Materials and Methods: We conducted a retrospective, descriptive study that included 117 consecutive patients admitted to Iasi Pulmonary Rehabilitation Clinic for reassessment and a rehabilitation program at least two years after a COVID-19 infection. The cohort was divided into two groups based on the presence (n = 49) or absence (n = 68) of pulmonary fibrosis, documented through high-resolution computer tomography. Results: The cohort comprises 117 patients, 69.23% females, with a mean age of 65.74 ± 10.19 years and abnormal body mass index (31.42 ± 5.71 kg/m2). Patients with pulmonary fibrosis have significantly higher levels of C-reactive protein (CRP) (p < 0.05), WBC (7.45 ± 7.86/mm3 vs. 9.18 ± 17.24/mm3, p = 0.053), neutrophils (4.68 ± 7.88/mm3 vs. 9.07 ± 17.44/mm3, p < 0.05), mean platelet volume (MPV) (7.22 ± 0.93 vs. 10.25 ± 0.86 fL, p < 0.05), lactate dehydrogenase (p < 0.05), and D-dimers (p < 0.05), but not ferritin (p = 0.470), reflecting the chronic proinflammatory and prothrombotic status. Additionally, patients with associated pulmonary fibrosis had a higher mean heart rate (p < 0.05) and corrected QT interval (p < 0.05). D-dimers were strongly and negatively correlated with diffusion capacity corrected for hemoglobin (DLCO corr), and ROC analysis showed that the persistence of high D-dimers values is a predictor for low DLCO values (ROC analysis: area under the curve of 0.772, p < 0.001). The results of pulmonary function tests (spirometry, body plethysmography) and the 6-minute walk test demonstrated no significant difference between groups, without notable impairment within either group. Conclusions: Patients with COVID-19-related pulmonary fibrosis have a persistent long-term proinflammatory, prothrombotic status, despite the functional recovery. The persistence of elevated D-dimer levels could emerge as a predictive factor associated with impaired DLCO.
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Affiliation(s)
- Doina-Clementina Cojocaru
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Florin Mitu
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
- Academy of Medical Sciences, 030167 Bucharest, Romania
- Academy of Romanian Scientists, 700050 Iasi, Romania
| | - Maria-Magdalena Leon
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Lucia Corina Dima-Cozma
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Cristina Andreea Adam
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Carmen Marinela Cumpăt
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Robert D. Negru
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Alexandra Maștaleru
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- Clinical Rehabilitation Hospital, Cardiovascular and Respiratory Rehabilitation Clinic, Pantelimon Halipa Street No. 14, 700661 Iasi, Romania
| | - Viviana Onofrei
- Department of Medical Specialties I and III, “Grigore T. Popa” University of Medicine and Pharmacy, University Street No. 16, 700115 Iasi, Romania
- “St. Spiridon” Clinical Emergency Hospital, Cardiology Department Independence Boulevard No. 1, 700111 Iasi, Romania
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25
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Rajewska-Tabor J, Sosińska-Zawierucha P, Pyda M, Lesiak M, Bręborowicz A. Protective role of N-acetylcysteine and Sulodexide on endothelial cells exposed on patients' serum after SARS-CoV-2 infection. Front Cell Infect Microbiol 2023; 13:1268016. [PMID: 38188630 PMCID: PMC10768024 DOI: 10.3389/fcimb.2023.1268016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/09/2023] [Indexed: 01/09/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 causes hyperinflammation and activation of coagulation cascade and, as a result, aggravates endothelial cell dysfunction. N-acetylcysteine and Sulodexide have been found to mitigate endothelial damage. The influence on coronary artery endothelial cells of serum collected after 4 ± 1 months from coronavirus infection was studied. The concentrations of serum samples of interleukin 6, von Willebrand Factor, tissue Plasminogen Activator, and Plasminogen Activator Inhibitor-1 were studied. The cultures with serum of patients after coronavirus infection were incubated with N-acetylcysteine and Sulodexide to estimate their potential protective role. The blood inflammatory parameters were increased in the group of cultures incubated with serum from patients after coronavirus infection. Supplementation of the serum from patients after coronavirus infection with N-acetylcysteine or Sulodexide reduced the synthesis of interleukin 6 and von Willebrand Factor. No changes in the synthesis of tissue Plasminogen Activator were observed. N-acetylcysteine reduced the synthesis of Plasminogen Activator Inhibitor-1. N-acetylcysteine and Sulodexide increased the tPA/PAI-1 ratio. N-acetylcysteine may have a role in reducing the myocardial injury occurring in the post-COVID-19 syndrome. Sulodexide can also play a protective role in post-COVID-19 patients.
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Affiliation(s)
- Justyna Rajewska-Tabor
- I Clinic of Cardiology, Unit of Magnetic Resonance, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Malgorzata Pyda
- I Clinic of Cardiology, Unit of Magnetic Resonance, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Lesiak
- I Clinic of Cardiology, Unit of Magnetic Resonance, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Bręborowicz
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
- Collegium Medicum, Zielona Góra, Poland
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26
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Kuchler T, Hausinger R, Braunisch MC, Günthner R, Wicklein R, Knier B, Bleidißel N, Maier M, Ribero A, Lech M, Adorjan K, Stubbe H, Kotilar K, Heemann U, Schmaderer C. All eyes on PCS: analysis of the retinal microvasculature in patients with post-COVID syndrome-study protocol of a 1 year prospective case-control study. Eur Arch Psychiatry Clin Neurosci 2023:10.1007/s00406-023-01724-5. [PMID: 38041762 DOI: 10.1007/s00406-023-01724-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 11/04/2023] [Indexed: 12/03/2023]
Abstract
Since widespread vaccination against COVID-19, the development of effective antiviral drugs, and the decreasing number of patients with COVID-19 in intensive care, the risk from SARS-CoV-2 infection appears less threatening. However, studies show that a significant number of patients suffer from long-term sequelae, even months after SARS-CoV-2 infection. The so-called post-COVID syndrome (PCS) often presents a diagnostic and treatment challenge for physicians. This study protocol describes the "All Eyes on PCS" study, which aims to investigate the retinal microvasculature in PCS patients and COVID-19-recovered patients to provide new insights into the pathophysiology of PCS. "All Eyes on PCS" is a prospective, case-control study with the primary objective of detecting endothelial dysfunction (ED) in patients with PCS. Therefore, we intend to recruit patients with PCS, fully SARS-CoV-2-infection-recovered (CR) participants, and SARS-CoV-2-infection-naïve (CN) participants. Baseline measurements will include: (1) patient-specific characteristics, (2) biochemistry, (3) retinal vessel analysis (RVA), (4) survey questionnaires as patient-reported outcomes measurements (PROMs), (5) optical coherence tomography (OCT), OCT angiography (OCTA), and adaptive optics (AO), (6) blood pressure recordings, (7) handgrip strength test. After 6 months, baseline measurements will be repeated in the PCS cohort, and after 1 year, a telephone query will be conducted to assess residual symptoms and treatment needs. The aim of this study is to gain insight into the pathophysiology of PCS and to provide an objective biomarker for diagnosis and treatment, while also creating a comprehensive clinical database of PCS patients.ClinicalTrials.gov Identifier: NCT05635552; Date: 2.12.2022.
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Affiliation(s)
- Timon Kuchler
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Renate Hausinger
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Roman Günthner
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Rebecca Wicklein
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Benjamin Knier
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Nathalie Bleidißel
- Department of Ophthalmology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias Maier
- Department of Ophthalmology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Andrea Ribero
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- Medizinische Klinik und Poliklinik IV, LMU University Hospital Munich, Ziemssenstraße 5, 80336, Munich, Germany
| | - Maciej Lech
- Medizinische Klinik und Poliklinik IV, LMU University Hospital Munich, Ziemssenstraße 5, 80336, Munich, Germany
| | - Kristina Adorjan
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Nußbaumstraße 7, 80336, Munich, Germany
| | - Hans Stubbe
- Medizinische Klinik und Poliklinik II, LMU University Hospital Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Konstantin Kotilar
- Aachen University of Applied Sciences, Heinrich-Mussmann-Str. 1, 52428, Jülich, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Pan JQ, Tian ZM, Xue LB. Hyperbaric Oxygen Treatment for Long COVID: From Molecular Mechanism to Clinical Practice. Curr Med Sci 2023; 43:1061-1065. [PMID: 37924387 DOI: 10.1007/s11596-023-2799-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/20/2023] [Indexed: 11/06/2023]
Abstract
Long COVID symptoms typically occur within 3 months of an initial COVID-19 infection, last for more than 2 months, and cannot be explained by other diagnoses. The most common symptoms include fatigue, dyspnea, coughing, and cognitive impairment. The mechanisms of long COVID are not fully understood, but several hypotheses have been put forth. These include coagulation and fibrosis pathway activation, inflammatory and autoimmune manifestations, persistent virus presence, and Epstein-Barr virus reactivation. Hyperbaric oxygen therapy (HBOT) is a therapeutic method in which a person inhales 100% oxygen under pressure greater than that of the atmosphere. HBOT has some therapeutic effects, including improvement of microcirculation, inhibition of cytokine release leading to a reduction in inflammatory responses, inhibition of autoimmune responses, and promotion of neurological repair. Several clinical trials have been carried out using HBOT to treat long COVID. The results suggest that HBOT helps to improve symptom severity, reduce symptom duration, and enhance patients' quality of life. It is believed that HBOT is an effective option for patients with long COVID, which is worth actively promoting.
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Affiliation(s)
- Jian-Qing Pan
- Department of Hyperbaric Oxygen, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China.
| | | | - Lian-Bi Xue
- Department of Hyperbaric Oxygen, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China
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Zhang Q, Bignotti A, Yada N, Ye Z, Liu S, Han Z, Zheng XL. Dynamic Assessment of Plasma von Willebrand Factor and ADAMTS13 Predicts Mortality in Hospitalized Patients with SARS-CoV-2 Infection. J Clin Med 2023; 12:7174. [PMID: 38002786 PMCID: PMC10672082 DOI: 10.3390/jcm12227174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Plasma levels of von Willebrand factor (VWF) are significantly elevated in patients with coronavirus disease 2019 (COVID-19). However, dynamic changes and prognostic value of this biomarker in hospitalized patients with COVID-19 have not been determined. METHODS A total of 124 patients infected with SARS-CoV-2 were prospectively recruited for the study. Serial blood samples were obtained at the time of admission (D1), 3-4 days following standard-care treatments (D2), and 1-2 days prior to discharge or any time collected prior to death (D3). Plasma VWF antigen, ADAMTS13 antigen, and ADAMTS13 proteolytic activity, as well as the ratio of VWF/ADAMTS13 were determined, followed by various statistical analyses. RESULTS On admission, plasma levels of VWF in COVID-19 patients were significantly elevated compared with those in the healthy controls, but no statistical significance was detected among patients with different disease severity. Plasma ADAMTS13 activity but not its antigen levels were significantly lower in patients with severe or critical COVID-19 compared with that in other patient groups. Interestingly, the ratios of plasma VWF antigen to ADAMTS13 antigen were significantly higher in patients with severe or critical COVID-19 than in those with mild to moderate disease. More importantly, plasma levels of VWF and the ratios of VWF/ADAMTS13 were persistently elevated in patients with COVID-19 throughout hospitalization. Kaplan-Meier and Cox proportional hazard regression analyses demonstrated that an increased plasma level of VWF or ratio of VWF/ADAMTS13 at D2 and D3 was associated with an increased mortality rate. CONCLUSIONS Persistent endotheliopathy, marked by the elevated levels of plasma VWF or VWF/ADAMTS13 ratio, is present in all hospitalized patients following SARS-CoV-2 infection, which is strongly associated with mortality.
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Affiliation(s)
- Quan Zhang
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
- Department of Pulmonary and Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Antonia Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Zhan Ye
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Szumam Liu
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Zhe Han
- Center for Precision Disease Modeling, Department of Medicine, University of Maryland School of Medicine, 670 West Baltimore Street, Baltimore, MD 21201, USA
| | - X. Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, KS 66160, USA
- Institute of Reproductive and Developmental Sciences, The University of Kansas Medical Center, Kansas City, KS 66160, USA
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29
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Luchian ML, Higny J, Benoit M, Robaye B, Berners Y, Henry JP, Colle B, Xhaët O, Blommaert D, Droogmans S, Motoc AI, Cosyns B, Gabriel L, Guedes A, Demeure F. Unmasking Pandemic Echoes: An In-Depth Review of Long COVID's Unabated Cardiovascular Consequences beyond 2020. Diagnostics (Basel) 2023; 13:3368. [PMID: 37958264 PMCID: PMC10647305 DOI: 10.3390/diagnostics13213368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
At the beginning of 2020, coronavirus disease 2019 (COVID-19) emerged as a new pandemic, leading to a worldwide health crisis and overwhelming healthcare systems due to high numbers of hospital admissions, insufficient resources, and a lack of standardized therapeutic protocols. Multiple genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been detected since its first public declaration in 2020, some of them being considered variants of concern (VOCs) corresponding to several pandemic waves. Nevertheless, a growing number of COVID-19 patients are continuously discharged from hospitals, remaining symptomatic even months after their first episode of COVID-19 infection. Long COVID-19 or 'post-acute COVID-19 syndrome' emerged as the new pandemic, being characterized by a high variability of clinical manifestations ranging from cardiorespiratory and neurological symptoms such as chest pain, exertional dyspnoea or cognitive disturbance to psychological disturbances, e.g., depression, anxiety or sleep disturbance with a crucial impact on patients' quality of life. Moreover, Long COVID is viewed as a new cardiovascular risk factor capable of modifying the trajectory of current and future cardiovascular diseases, altering the patients' prognosis. Therefore, in this review we address the current definitions of Long COVID and its pathophysiology, with a focus on cardiovascular manifestations. Furthermore, we aim to review the mechanisms of acute and chronic cardiac injury and the variety of cardiovascular sequelae observed in recovered COVID-19 patients, in addition to the potential role of Long COVID clinics in the medical management of this new condition. We will further address the role of future research for a better understanding of the actual impact of Long COVID and future therapeutic directions.
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Affiliation(s)
- Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Yannick Berners
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Jean-Philippe Henry
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Benjamin Colle
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Steven Droogmans
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Andreea Iulia Motoc
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart-en Vaatziekten, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur Site Godinne, Av. Dr. G. Thérasse, 1, 5530 Yvoir, Belgium (A.G.); (F.D.)
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30
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Li J, Zhou Y, Ma J, Zhang Q, Shao J, Liang S, Yu Y, Li W, Wang C. The long-term health outcomes, pathophysiological mechanisms and multidisciplinary management of long COVID. Signal Transduct Target Ther 2023; 8:416. [PMID: 37907497 PMCID: PMC10618229 DOI: 10.1038/s41392-023-01640-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/04/2023] [Accepted: 09/04/2023] [Indexed: 11/02/2023] Open
Abstract
There have been hundreds of millions of cases of coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). With the growing population of recovered patients, it is crucial to understand the long-term consequences of the disease and management strategies. Although COVID-19 was initially considered an acute respiratory illness, recent evidence suggests that manifestations including but not limited to those of the cardiovascular, respiratory, neuropsychiatric, gastrointestinal, reproductive, and musculoskeletal systems may persist long after the acute phase. These persistent manifestations, also referred to as long COVID, could impact all patients with COVID-19 across the full spectrum of illness severity. Herein, we comprehensively review the current literature on long COVID, highlighting its epidemiological understanding, the impact of vaccinations, organ-specific sequelae, pathophysiological mechanisms, and multidisciplinary management strategies. In addition, the impact of psychological and psychosomatic factors is also underscored. Despite these crucial findings on long COVID, the current diagnostic and therapeutic strategies based on previous experience and pilot studies remain inadequate, and well-designed clinical trials should be prioritized to validate existing hypotheses. Thus, we propose the primary challenges concerning biological knowledge gaps and efficient remedies as well as discuss the corresponding recommendations.
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Affiliation(s)
- Jingwei Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yun Zhou
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Jiechao Ma
- AI Lab, Deepwise Healthcare, Beijing, China
| | - Qin Zhang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- Department of Postgraduate Student, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Jun Shao
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Shufan Liang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Yizhou Yu
- Department of Computer Science, The University of Hong Kong, Hong Kong, China.
| | - Weimin Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China.
| | - Chengdi Wang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, Med-X Center for Manufacturing, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China.
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Raman B, McCracken C, Cassar MP, Moss AJ, Finnigan L, Samat AHA, Ogbole G, Tunnicliffe EM, Alfaro-Almagro F, Menke R, Xie C, Gleeson F, Lukaschuk E, Lamlum H, McGlynn K, Popescu IA, Sanders ZB, Saunders LC, Piechnik SK, Ferreira VM, Nikolaidou C, Rahman NM, Ho LP, Harris VC, Shikotra A, Singapuri A, Pfeffer P, Manisty C, Kon OM, Beggs M, O'Regan DP, Fuld J, Weir-McCall JR, Parekh D, Steeds R, Poinasamy K, Cuthbertson DJ, Kemp GJ, Semple MG, Horsley A, Miller CA, O'Brien C, Shah AM, Chiribiri A, Leavy OC, Richardson M, Elneima O, McAuley HJC, Sereno M, Saunders RM, Houchen-Wolloff L, Greening NJ, Bolton CE, Brown JS, Choudhury G, Diar Bakerly N, Easom N, Echevarria C, Marks M, Hurst JR, Jones MG, Wootton DG, Chalder T, Davies MJ, De Soyza A, Geddes JR, Greenhalf W, Howard LS, Jacob J, Man WDC, Openshaw PJM, Porter JC, Rowland MJ, Scott JT, Singh SJ, Thomas DC, Toshner M, Lewis KE, Heaney LG, Harrison EM, Kerr S, Docherty AB, Lone NI, Quint J, Sheikh A, Zheng B, Jenkins RG, Cox E, Francis S, Halling-Brown M, Chalmers JD, Greenwood JP, Plein S, Hughes PJC, Thompson AAR, Rowland-Jones SL, Wild JM, Kelly M, Treibel TA, Bandula S, Aul R, Miller K, Jezzard P, Smith S, Nichols TE, McCann GP, Evans RA, Wain LV, Brightling CE, Neubauer S, Baillie JK, Shaw A, Hairsine B, Kurasz C, Henson H, Armstrong L, Shenton L, Dobson H, Dell A, Lucey A, Price A, Storrie A, Pennington C, Price C, Mallison G, Willis G, Nassa H, Haworth J, Hoare M, Hawkings N, Fairbairn S, Young S, Walker S, Jarrold I, Sanderson A, David C, Chong-James K, Zongo O, James WY, Martineau A, King B, Armour C, McAulay D, Major E, McGinness J, McGarvey L, Magee N, Stone R, Drain S, Craig T, Bolger A, Haggar A, Lloyd A, Subbe C, Menzies D, Southern D, McIvor E, Roberts K, Manley R, Whitehead V, Saxon W, Bularga A, Mills NL, El-Taweel H, Dawson J, Robinson L, Saralaya D, Regan K, Storton K, Brear L, Amoils S, Bermperi A, Elmer A, Ribeiro C, Cruz I, Taylor J, Worsley J, Dempsey K, Watson L, Jose S, Marciniak S, Parkes M, McQueen A, Oliver C, Williams J, Paradowski K, Broad L, Knibbs L, Haynes M, Sabit R, Milligan L, Sampson C, Hancock A, Evenden C, Lynch C, Hancock K, Roche L, Rees M, Stroud N, Thomas-Woods T, Heller S, Robertson E, Young B, Wassall H, Babores M, Holland M, Keenan N, Shashaa S, Price C, Beranova E, Ramos H, Weston H, Deery J, Austin L, Solly R, Turney S, Cosier T, Hazelton T, Ralser M, Wilson A, Pearce L, Pugmire S, Stoker W, McCormick W, Dewar A, Arbane G, Kaltsakas G, Kerslake H, Rossdale J, Bisnauthsing K, Aguilar Jimenez LA, Martinez LM, Ostermann M, Magtoto MM, Hart N, Marino P, Betts S, Solano TS, Arias AM, Prabhu A, Reed A, Wrey Brown C, Griffin D, Bevan E, Martin J, Owen J, Alvarez Corral M, Williams N, Payne S, Storrar W, Layton A, Lawson C, Mills C, Featherstone J, Stephenson L, Burdett T, Ellis Y, Richards A, Wright C, Sykes DL, Brindle K, Drury K, Holdsworth L, Crooks MG, Atkin P, Flockton R, Thackray-Nocera S, Mohamed A, Taylor A, Perkins E, Ross G, McGuinness H, Tench H, Phipps J, Loosley R, Wolf-Roberts R, Coetzee S, Omar Z, Ross A, Card B, Carr C, King C, Wood C, Copeland D, Calvelo E, Chilvers ER, Russell E, Gordon H, Nunag JL, Schronce J, March K, Samuel K, Burden L, Evison L, McLeavey L, Orriss-Dib L, Tarusan L, Mariveles M, Roy M, Mohamed N, Simpson N, Yasmin N, Cullinan P, Daly P, Haq S, Moriera S, Fayzan T, Munawar U, Nwanguma U, Lingford-Hughes A, Altmann D, Johnston D, Mitchell J, Valabhji J, Price L, Molyneaux PL, Thwaites RS, Walsh S, Frankel A, Lightstone L, Wilkins M, Willicombe M, McAdoo S, Touyz R, Guerdette AM, Warwick K, Hewitt M, Reddy R, White S, McMahon A, Hoare A, Knighton A, Ramos A, Te A, Jolley CJ, Speranza F, Assefa-Kebede H, Peralta I, Breeze J, Shevket K, Powell N, Adeyemi O, Dulawan P, Adrego R, Byrne S, Patale S, Hayday A, Malim M, Pariante C, Sharpe C, Whitney J, Bramham K, Ismail K, Wessely S, Nicholson T, Ashworth A, Humphries A, Tan AL, Whittam B, Coupland C, Favager C, Peckham D, Wade E, Saalmink G, Clarke J, Glossop J, Murira J, Rangeley J, Woods J, Hall L, Dalton M, Window N, Beirne P, Hardy T, Coakley G, Turtle L, Berridge A, Cross A, Key AL, Rowe A, Allt AM, Mears C, Malein F, Madzamba G, Hardwick HE, Earley J, Hawkes J, Pratt J, Wyles J, Tripp KA, Hainey K, Allerton L, Lavelle-Langham L, Melling L, Wajero LO, Poll L, Noonan MJ, French N, Lewis-Burke N, Williams-Howard SA, Cooper S, Kaprowska S, Dobson SL, Marsh S, Highett V, Shaw V, Beadsworth M, Defres S, Watson E, Tiongson GF, Papineni P, Gurram S, Diwanji SN, Quaid S, Briggs A, Hastie C, Rogers N, Stensel D, Bishop L, McIvor K, Rivera-Ortega P, Al-Sheklly B, Avram C, Faluyi D, Blaikely J, Piper Hanley K, Radhakrishnan K, Buch M, Hanley NA, Odell N, Osbourne R, Stockdale S, Felton T, Gorsuch T, Hussell T, Kausar Z, Kabir T, McAllister-Williams H, Paddick S, Burn D, Ayoub A, Greenhalgh A, Sayer A, Young A, Price D, Burns G, MacGowan G, Fisher H, Tedd H, Simpson J, Jiwa K, Witham M, Hogarth P, West S, Wright S, McMahon MJ, Neill P, Dougherty A, Morrow A, Anderson D, Grieve D, Bayes H, Fallon K, Mangion K, Gilmour L, Basu N, Sykes R, Berry C, McInnes IB, Donaldson A, Sage EK, Barrett F, Welsh B, Bell M, Quigley J, Leitch K, Macliver L, Patel M, Hamil R, Deans A, Furniss J, Clohisey S, Elliott A, Solstice AR, Deas C, Tee C, Connell D, Sutherland D, George J, Mohammed S, Bunker J, Holmes K, Dipper A, Morley A, Arnold D, Adamali H, Welch H, Morrison L, Stadon L, Maskell N, Barratt S, Dunn S, Waterson S, Jayaraman B, Light T, Selby N, Hosseini A, Shaw K, Almeida P, Needham R, Thomas AK, Matthews L, Gupta A, Nikolaidis A, Dupont C, Bonnington J, Chrystal M, Greenhaff PL, Linford S, Prosper S, Jang W, Alamoudi A, Bloss A, Megson C, Nicoll D, Fraser E, Pacpaco E, Conneh F, Ogg G, McShane H, Koychev I, Chen J, Pimm J, Ainsworth M, Pavlides M, Sharpe M, Havinden-Williams M, Petousi N, Talbot N, Carter P, Kurupati P, Dong T, Peng Y, Burns A, Kanellakis N, Korszun A, Connolly B, Busby J, Peto T, Patel B, Nolan CM, Cristiano D, Walsh JA, Liyanage K, Gummadi M, Dormand N, Polgar O, George P, Barker RE, Patel S, Price L, Gibbons M, Matila D, Jarvis H, Lim L, Olaosebikan O, Ahmad S, Brill S, Mandal S, Laing C, Michael A, Reddy A, Johnson C, Baxendale H, Parfrey H, Mackie J, Newman J, Pack J, Parmar J, Paques K, Garner L, Harvey A, Summersgill C, Holgate D, Hardy E, Oxton J, Pendlebury J, McMorrow L, Mairs N, Majeed N, Dark P, Ugwuoke R, Knight S, Whittaker S, Strong-Sheldrake S, Matimba-Mupaya W, Chowienczyk P, Pattenadk D, Hurditch E, Chan F, Carborn H, Foot H, Bagshaw J, Hockridge J, Sidebottom J, Lee JH, Birchall K, Turner K, Haslam L, Holt L, Milner L, Begum M, Marshall M, Steele N, Tinker N, Ravencroft P, Butcher R, Misra S, Walker S, Coburn Z, Fairman A, Ford A, Holbourn A, Howell A, Lawrie A, Lye A, Mbuyisa A, Zawia A, Holroyd-Hind B, Thamu B, Clark C, Jarman C, Norman C, Roddis C, Foote D, Lee E, Ilyas F, Stephens G, Newell H, Turton H, Macharia I, Wilson I, Cole J, McNeill J, Meiring J, Rodger J, Watson J, Chapman K, Harrington K, Chetham L, Hesselden L, Nwafor L, Dixon M, Plowright M, Wade P, Gregory R, Lenagh R, Stimpson R, Megson S, Newman T, Cheng Y, Goodwin C, Heeley C, Sissons D, Sowter D, Gregory H, Wynter I, Hutchinson J, Kirk J, Bennett K, Slack K, Allsop L, Holloway L, Flynn M, Gill M, Greatorex M, Holmes M, Buckley P, Shelton S, Turner S, Sewell TA, Whitworth V, Lovegrove W, Tomlinson J, Warburton L, Painter S, Vickers C, Redwood D, Tilley J, Palmer S, Wainwright T, Breen G, Hotopf M, Dunleavy A, Teixeira J, Ali M, Mencias M, Msimanga N, Siddique S, Samakomva T, Tavoukjian V, Forton D, Ahmed R, Cook A, Thaivalappil F, Connor L, Rees T, McNarry M, Williams N, McCormick J, McIntosh J, Vere J, Coulding M, Kilroy S, Turner V, Butt AT, Savill H, Fraile E, Ugoji J, Landers G, Lota H, Portukhay S, Nasseri M, Daniels A, Hormis A, Ingham J, Zeidan L, Osborne L, Chablani M, Banerjee A, David A, Pakzad A, Rangelov B, Williams B, Denneny E, Willoughby J, Xu M, Mehta P, Batterham R, Bell R, Aslani S, Lilaonitkul W, Checkley A, Bang D, Basire D, Lomas D, Wall E, Plant H, Roy K, Heightman M, Lipman M, Merida Morillas M, Ahwireng N, Chambers RC, Jastrub R, Logan S, Hillman T, Botkai A, Casey A, Neal A, Newton-Cox A, Cooper B, Atkin C, McGee C, Welch C, Wilson D, Sapey E, Qureshi H, Hazeldine J, Lord JM, Nyaboko J, Short J, Stockley J, Dasgin J, Draxlbauer K, Isaacs K, Mcgee K, Yip KP, Ratcliffe L, Bates M, Ventura M, Ahmad Haider N, Gautam N, Baggott R, Holden S, Madathil S, Walder S, Yasmin S, Hiwot T, Jackson T, Soulsby T, Kamwa V, Peterkin Z, Suleiman Z, Chaudhuri N, Wheeler H, Djukanovic R, Samuel R, Sass T, Wallis T, Marshall B, Childs C, Marouzet E, Harvey M, Fletcher S, Dickens C, Beckett P, Nanda U, Daynes E, Charalambou A, Yousuf AJ, Lea A, Prickett A, Gooptu B, Hargadon B, Bourne C, Christie C, Edwardson C, Lee D, Baldry E, Stringer E, Woodhead F, Mills G, Arnold H, Aung H, Qureshi IN, Finch J, Skeemer J, Hadley K, Khunti K, Carr L, Ingram L, Aljaroof M, Bakali M, Bakau M, Baldwin M, Bourne M, Pareek M, Soares M, Tobin M, Armstrong N, Brunskill N, Goodman N, Cairns P, Haldar P, McCourt P, Dowling R, Russell R, Diver S, Edwards S, Glover S, Parker S, Siddiqui S, Ward TJC, Mcnally T, Thornton T, Yates T, Ibrahim W, Monteiro W, Thickett D, Wilkinson D, Broome M, McArdle P, Upthegrove R, Wraith D, Langenberg C, Summers C, Bullmore E, Heeney JL, Schwaeble W, Sudlow CL, Adeloye D, Newby DE, Rudan I, Shankar-Hari M, Thorpe M, Pius R, Walmsley S, McGovern A, Ballard C, Allan L, Dennis J, Cavanagh J, Petrie J, O'Donnell K, Spears M, Sattar N, MacDonald S, Guthrie E, Henderson M, Guillen Guio B, Zhao B, Lawson C, Overton C, Taylor C, Tong C, Mukaetova-Ladinska E, Turner E, Pearl JE, Sargant J, Wormleighton J, Bingham M, Sharma M, Steiner M, Samani N, Novotny P, Free R, Allen RJ, Finney S, Terry S, Brugha T, Plekhanova T, McArdle A, Vinson B, Spencer LG, Reynolds W, Ashworth M, Deakin B, Chinoy H, Abel K, Harvie M, Stanel S, Rostron A, Coleman C, Baguley D, Hufton E, Khan F, Hall I, Stewart I, Fabbri L, Wright L, Kitterick P, Morriss R, Johnson S, Bates A, Antoniades C, Clark D, Bhui K, Channon KM, Motohashi K, Sigfrid L, Husain M, Webster M, Fu X, Li X, Kingham L, Klenerman P, Miiler K, Carson G, Simons G, Huneke N, Calder PC, Baldwin D, Bain S, Lasserson D, Daines L, Bright E, Stern M, Crisp P, Dharmagunawardena R, Reddington A, Wight A, Bailey L, Ashish A, Robinson E, Cooper J, Broadley A, Turnbull A, Brookes C, Sarginson C, Ionita D, Redfearn H, Elliott K, Barman L, Griffiths L, Guy Z, Gill R, Nathu R, Harris E, Moss P, Finnigan J, Saunders K, Saunders P, Kon S, Kon SS, O'Brien L, Shah K, Shah P, Richardson E, Brown V, Brown M, Brown J, Brown J, Brown A, Brown A, Brown M, Choudhury N, Jones S, Jones H, Jones L, Jones I, Jones G, Jones H, Jones D, Davies F, Davies E, Davies K, Davies G, Davies GA, Howard K, Porter J, Rowland J, Rowland A, Scott K, Singh S, Singh C, Thomas S, Thomas C, Lewis V, Lewis J, Lewis D, Harrison P, Francis C, Francis R, Hughes RA, Hughes J, Hughes AD, Thompson T, Kelly S, Smith D, Smith N, Smith A, Smith J, Smith L, Smith S, Evans T, Evans RI, Evans D, Evans R, Evans H, Evans J. Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1003-1019. [PMID: 37748493 PMCID: PMC7615263 DOI: 10.1016/s2213-2600(23)00262-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/16/2023] [Accepted: 06/30/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures. METHODS In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025. FINDINGS Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation. INTERPRETATION After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification. FUNDING UK Research and Innovation and National Institute for Health Research.
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Vonu P, Safeek R, Dadireddy K, Zumberg M, Spiguel L, Sorice-Virk S. COVID-19 Associated Micro-Anastomotic Thrombosis After Abdominal Free Tissue Transfer: A Case Report and Literature Review. Plast Surg (Oakv) 2023; 31:408-412. [PMID: 37908324 PMCID: PMC10015279 DOI: 10.1177/22925503231161081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/29/2023] [Accepted: 01/31/2023] [Indexed: 11/02/2023] Open
Abstract
The hypercoagulable state of COVID-19 infection presents a challenge to microsurgeons. While the American Society of Anesthesiologists recommends deferring surgery for 4-10 weeks for COVID-19-infected patients, little else is known regarding how to mitigate thrombotic complications for patients undergoing free tissue transfer. Here, we present a presumed COVID-19-induced hypercoagulable state in a patient undergoing abdominally based free tissue transfer for breast reconstruction as a brief review of the literature to guide clinical decision making.
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Affiliation(s)
- Peter Vonu
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Rachel Safeek
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Kalyan Dadireddy
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Marc Zumberg
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Lisa Spiguel
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Sarah Sorice-Virk
- Division of Plastic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
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Noor M, McGrath O, Drira I, Aslam T. Retinal Microvasculature Image Analysis Using Optical Coherence Tomography Angiography in Patients with Post-COVID-19 Syndrome. J Imaging 2023; 9:234. [PMID: 37998081 PMCID: PMC10672226 DOI: 10.3390/jimaging9110234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/14/2023] [Accepted: 10/17/2023] [Indexed: 11/25/2023] Open
Abstract
Several optical coherence tomography angiography (OCT-A) studies have demonstrated retinal microvascular changes in patients post-SARS-CoV-2 infection, reflecting retinal-systemic microvasculature homology. Post-COVID-19 syndrome (PCS) entails persistent symptoms following SARS-CoV-2 infection. In this study, we investigated the retinal microvasculature in PCS patients using OCT-angiography and analysed the macular retinal nerve fibre layer (RNFL) and ganglion cell layer (GCL) thickness via spectral domain-OCT (SD-OCT). Conducted at the Manchester Royal Eye Hospital, UK, this cross-sectional study compared 40 PCS participants with 40 healthy controls, who underwent ophthalmic assessments, SD-OCT, and OCT-A imaging. OCT-A images from the superficial capillary plexus (SCP) were analysed using an in-house specialised software, OCT-A vascular image analysis (OCTAVIA), measuring the mean large vessel and capillary intensity, vessel density, ischaemia areas, and foveal avascular zone (FAZ) area and circularity. RNFL and GCL thickness was measured using the OCT machine's software. Retinal evaluations occurred at an average of 15.2 ± 6.9 months post SARS-CoV-2 infection in PCS participants. Our findings revealed no significant differences between the PCS and control groups in the OCT-A parameters or RNFL and GCL thicknesses, indicating that no long-term damage ensued in the vascular bed or retinal layers within our cohort, providing a degree of reassurance for PCS patients.
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Affiliation(s)
- Maha Noor
- Department of Eye Research, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Orlaith McGrath
- Department of Eye Research, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
| | - Ines Drira
- Department of Eye Research, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Ophtalmologie Département, Centre Hospitalier Universitaire de Toulouse, 31300 Toulouse, France
| | - Tariq Aslam
- Department of Eye Research, Manchester Royal Eye Hospital, Manchester University NHS Foundation Trust, Oxford Road, Manchester M13 9WL, UK
- Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester M13 9PL, UK
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Abdullah M, Ali A, Usman M, Naz A, Qureshi JA, Bajaber MA, Zhang X. Post COVID-19 complications and follow up biomarkers. NANOSCALE ADVANCES 2023; 5:5705-5716. [PMID: 37881715 PMCID: PMC10597564 DOI: 10.1039/d3na00342f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/11/2023] [Indexed: 10/27/2023]
Abstract
Millions of people were infected by the coronavirus disease (COVID-19) epidemic, which left a huge burden on the care of post COVID-19 survivors around the globe. The self-reported COVID-19 symptoms were experienced by an estimated 1.3 million people in the United Kingdom (2% of the population), and these symptoms persisted for about 4 weeks from the beginning of the infection. The symptoms most frequently reported were exhaustion, shortness of breath, muscular discomfort, joint pain, headache, cough, chest pain, cognitive impairment, memory loss, anxiety, sleep difficulties, diarrhea, and a decreased sense of smell and taste in post-COVID-19 affected people. The post COVID-19 complications were frequently related to the respiratory, cardiac, nervous, psychological and musculoskeletal systems. The lungs, liver, kidneys, heart, brain and other organs had been impaired by hypoxia and inflammation in post COVID-19 individuals. The upregulation of substance "P" (SP) and various cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin 6 (IL-6), interleukin 10 (IL-10), interleukin 1 beta (IL-1β), angiotensin-converting enzyme 2 (ACE2) and chemokine C-C motif ligand 3 (CCL3) has muddled respiratory, cardiac, neuropsychiatric, dermatological, endocrine, musculoskeletal, gastrointestinal, renal and genitourinary complications in post COVID-19 people. To prevent these complications from worsening, it was therefore important to study how these biomarkers were upregulated and block their receptors.
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Affiliation(s)
- Muhammad Abdullah
- Institute of Molecular Biology and Biotechnology, University of Lahore Pakistan
| | - Amjed Ali
- University Institute of Physical Therapy, University of Lahore Pakistan
| | - Muhammad Usman
- Department of Bioinformatics, School of Medical Informatics and Engineering, Xuzhou Medical University Xuzhou China
| | - Anam Naz
- Institute of Molecular Biology and Biotechnology, University of Lahore Pakistan
| | - Javed Anver Qureshi
- Institute of Molecular Biology and Biotechnology, University of Lahore Pakistan
| | - Majed A Bajaber
- Department of Chemistry, Faculty of Science, King Khalid University P.O. Box 9004 Abha 61413 Saudi Arabia
| | - Xiao Zhang
- Department of Bioinformatics, School of Medical Informatics and Engineering, Xuzhou Medical University Xuzhou China
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Altmann DM, Whettlock EM, Liu S, Arachchillage DJ, Boyton RJ. The immunology of long COVID. Nat Rev Immunol 2023; 23:618-634. [PMID: 37433988 DOI: 10.1038/s41577-023-00904-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/13/2023]
Abstract
Long COVID is the patient-coined term for the disease entity whereby persistent symptoms ensue in a significant proportion of those who have had COVID-19, whether asymptomatic, mild or severe. Estimated numbers vary but the assumption is that, of all those who had COVID-19 globally, at least 10% have long COVID. The disease burden spans from mild symptoms to profound disability, the scale making this a huge, new health-care challenge. Long COVID will likely be stratified into several more or less discrete entities with potentially distinct pathogenic pathways. The evolving symptom list is extensive, multi-organ, multisystem and relapsing-remitting, including fatigue, breathlessness, neurocognitive effects and dysautonomia. A range of radiological abnormalities in the olfactory bulb, brain, heart, lung and other sites have been observed in individuals with long COVID. Some body sites indicate the presence of microclots; these and other blood markers of hypercoagulation implicate a likely role of endothelial activation and clotting abnormalities. Diverse auto-antibody (AAB) specificities have been found, as yet without a clear consensus or correlation with symptom clusters. There is support for a role of persistent SARS-CoV-2 reservoirs and/or an effect of Epstein-Barr virus reactivation, and evidence from immune subset changes for broad immune perturbation. Thus, the current picture is one of convergence towards a map of an immunopathogenic aetiology of long COVID, though as yet with insufficient data for a mechanistic synthesis or to fully inform therapeutic pathways.
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Affiliation(s)
- Daniel M Altmann
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK.
| | - Emily M Whettlock
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
| | - Siyi Liu
- Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
| | - Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, Hammersmith Hospital, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Rosemary J Boyton
- Department of Infectious Disease, Imperial College London, Hammersmith Hospital, London, UK
- Lung Division, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Greistorfer T, Jud P. Pathophysiological Aspects of COVID-19-Associated Vasculopathic Diseases. Thromb Haemost 2023; 123:931-944. [PMID: 37172941 DOI: 10.1055/s-0043-1768969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Since the beginning of coronavirus disease 2019 (COVID-19) pandemic, numerous data reported potential effects on the cardiovascular system due to infection by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which may lead to COVID-19-associated vasculopathies during the acute phase and measurable vascular changes in the convalescent phase. Infection by SARS-CoV-2 seems to have specific direct and indirect effects on the endothelium, immune and coagulation systems thus promoting endothelial dysfunction, immunothrombosis, and formation of neutrophil extracellular traps although the exact mechanisms still need to be elucidated. This review represents a recent update of pathophysiological pathways of the respective three major mechanisms contributing to COVID-19 vasculopathies and vascular changes and includes clinical implications and significance of outcome data.
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Affiliation(s)
- Thiemo Greistorfer
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Tziolos NR, Ioannou P, Baliou S, Kofteridis DP. Long COVID-19 Pathophysiology: What Do We Know So Far? Microorganisms 2023; 11:2458. [PMID: 37894116 PMCID: PMC10609046 DOI: 10.3390/microorganisms11102458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/17/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023] Open
Abstract
Long COVID-19 is a recognized entity that affects millions of people worldwide. Its broad clinical symptoms include thrombotic events, brain fog, myocarditis, shortness of breath, fatigue, muscle pains, and others. Due to the binding of the virus with ACE-2 receptors, expressed in many organs, it can potentially affect any system; however, it most often affects the cardiovascular, central nervous, respiratory, and immune systems. Age, high body mass index, female sex, previous hospitalization, and smoking are some of its risk factors. Despite great efforts to define its pathophysiology, gaps remain to be explained. The main mechanisms described in the literature involve viral persistence, hypercoagulopathy, immune dysregulation, autoimmunity, hyperinflammation, or a combination of these. The exact mechanisms may differ from system to system, but some share the same pathways. This review aims to describe the most prevalent pathophysiological pathways explaining this syndrome.
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Affiliation(s)
- Nikolaos-Renatos Tziolos
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, 71110 Heraklion, Greece (D.P.K.)
| | - Petros Ioannou
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, 71110 Heraklion, Greece (D.P.K.)
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Stella Baliou
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Diamantis P. Kofteridis
- Department of Internal Medicine & Infectious Diseases, University Hospital of Heraklion, 71110 Heraklion, Greece (D.P.K.)
- School of Medicine, University of Crete, 71003 Heraklion, Greece
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Gómez-Sánchez L, Tamayo-Morales O, Suárez-Moreno N, Bermejo-Martín JF, Domínguez-Martín A, Martín-Oterino JA, Martín-González JI, González-Calle D, García-García Á, Lugones-Sánchez C, González-Sánchez S, Jiménez-Gómez R, García-Ortiz L, Gómez-Marcos MA, Navarro-Matías E. Relationship between the structure, function and endothelial damage, and vascular ageing and the biopsychological situation in adults diagnosed with persistent COVID (BioICOPER study). A research protocol of a cross-sectional study. Front Physiol 2023; 14:1236430. [PMID: 37772064 PMCID: PMC10523018 DOI: 10.3389/fphys.2023.1236430] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/17/2023] [Indexed: 09/30/2023] Open
Abstract
Background: SARS-CoV-2 infection affects the vascular endothelium, which mediates the inflammatory and thrombotic cascade. Moreover, alterations in the endothelium are related to arterial stiffness, which has been established as a marker of cardiovascular disease. The objective of this study is to analyse how the structure, vascular function, vascular ageing and endothelial damage are related to the biopsychological situation in adults diagnosed with persistent COVID and the differences by gender. Methods: This cross-sectional, descriptive, observational study will be carried out in the Primary Care Research Unit of Salamanca (APISAL) and in the BioSepsis laboratory of the University of Salamanca. The sample will be selected from the persistent COVID monographic office at the Internal Medicine Service of the University Hospital of Salamanca, and from the population of subjects diagnosed with persistent COVID in the clinical history of Primary Care. Through consecutive sampling, the study will include 300 individuals diagnosed with persistent COVID who meet the diagnosis criteria established by the WHO, after they sign the informed consent. Endothelial damage biomarkers will be measured using ELLA-SimplePlexTM technology (Biotechne). Their vascular structure and function will be analysed by measuring the carotid intima-media thickness (Sonosite Micromax); the pulse wave and carotid-femoral pulse wave velocity (cfPWV) will be recorded with Sphygmocor System®. Cardio Ankle Vascular Index (CAVI), brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index will be analysed with Vasera VS-2000®. The integral assessment of the subjects with persistent COVID will be conducted with different scales that evaluate fatigue, sleep, dyspnea, quality of life, attention, nutrition state, and fragility. We will also evaluate their lifestyles (diet, physical activity, smoking habits and alcohol consumption), psychological factors, and cognitive deterioration, which will be gathered through validated questionnaires; moreover, physical activity will be objectively measured using a pedometer for 7 days. Body composition will be measured through impedance using an Inbody 230. Vascular ageing will be calculated with 10 and 90 percentiles of cfPWV and baPWV. Furthermore, we will analyse the presence of vascular injury in the retina, heart, kidneys and brain, as well as cardiovascular risk. Demographic and analytical variables will also be gathered. Discussion: Arterial stiffness reflects the mechanic and functional properties of the arterial wall, showing the changes in arterial pressure, blood flow, and vascular diameter that occur with each heartbeat. SARS-CoV-2 affects the endothelial cells that are infected with this virus, increasing the production of pro-inflammatory cytokines and pro-thrombotic factors, which can cause early vascular ageing and an increase of arterial stiffness. Persistent COVID is a complex heterogeneous disorder that affects the lives of millions of people worldwide. The identifications of potential risk factors to better understand who is at risk of developing persistent COVID is important, since this would enable early and appropriate clinical support. It is unknown whether vascular alterations caused by COVID-19 resolve after acute infection or remain over time, favouring the increase of arterial stiffness and early vascular ageing. Therefore, it is necessary to propose studies that analyse the evolution of persistent COVID in this group of patients, as well as the possible variables that influence it. Clinical Trial registration: ClinicalTrials.gov, identifier NCT05819840.
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Affiliation(s)
- Leticia Gómez-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Hospital de la Paz de Madrid, Servicio de Urgencias, Madrid, Spain
| | - Olaya Tamayo-Morales
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Salamanca, Spain
| | - Nuria Suárez-Moreno
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
| | - Jesus F. Bermejo-Martín
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Andrea Domínguez-Martín
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
| | - José A. Martín-Oterino
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Hospital Universitario de Salamanca, Internal Medicine Department, Salamanca, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - José I. Martín-González
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Hospital Universitario de Salamanca, Internal Medicine Department, Salamanca, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - David González-Calle
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
- Hospital Universitario de Salamanca, Cardiology Department, Salamanca, Spain
| | - Ángel García-García
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
- Hospital Universitario de Salamanca, Emergency Department, Salamanca, Spain
| | - Cristina Lugones-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Salamanca, Spain
| | - Susana González-Sánchez
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Salamanca, Spain
| | - Raquel Jiménez-Gómez
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
| | - Luis García-Ortiz
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - Manuel A. Gómez-Marcos
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Research Network on Chronicity, Primary Care and Health Promotion (RICAPPS), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
- Department of Medicine, University of Salamanca, Salamanca, Spain
| | - Elena Navarro-Matías
- Primary Care Research Unit of Salamanca (APISAL), Salamanca Primary Care Management, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Castilla and León Health Service–SACYL, Gerencia Regional de Salud, Valladolid, Spain
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Rojas M, Herrán M, Ramírez-Santana C, Leung PSC, Anaya JM, Ridgway WM, Gershwin ME. Molecular mimicry and autoimmunity in the time of COVID-19. J Autoimmun 2023; 139:103070. [PMID: 37390745 PMCID: PMC10258587 DOI: 10.1016/j.jaut.2023.103070] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 07/02/2023]
Abstract
Infectious diseases are commonly implicated as potential initiators of autoimmune diseases (ADs) and represent the most commonly known factor in the development of autoimmunity in susceptible individuals. Epidemiological data and animal studies on multiple ADs suggest that molecular mimicry is one of the likely mechanisms for the loss of peripheral tolerance and the development of clinical disease. Besides molecular mimicry, other mechanisms such as defects in central tolerance, nonspecific bystander activation, epitope-determinant spreading, and/or constant antigenic stimuli, may also contribute for breach of tolerance and to the development of ADs. Linear peptide homology is not the only mechanism by which molecular mimicry is established. Peptide modeling (i.e., 3D structure), molecular docking analyses, and affinity estimation for HLAs are emerging as critical strategies when studying the links of molecular mimicry in the development of autoimmunity. In the current pandemic, several reports have confirmed an influence of SARS-CoV-2 on subsequent autoimmunity. Bioinformatic and experimental evidence support the potential role of molecular mimicry. Peptide dimensional analysis requires more research and will be increasingly important for designing and distributing vaccines and better understanding the role of environmental factors related to autoimmunity.
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Affiliation(s)
- Manuel Rojas
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA; Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia.
| | - María Herrán
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Carolina Ramírez-Santana
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Patrick S C Leung
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA
| | - Juan-Manuel Anaya
- Health Research and Innovation Center at Coosalud, Cartagena, 130001, Colombia
| | - William M Ridgway
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, 95616, USA
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40
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Kondo R, Iwakiri Y, Kage M, Yano H. Endotheliopathy of liver sinusoidal endothelial cells in liver disease. Pathol Int 2023; 73:381-393. [PMID: 37589433 DOI: 10.1111/pin.13361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 07/27/2023] [Indexed: 08/18/2023]
Abstract
Liver is the largest solid organ in the abdominal cavity, with sinusoid occupying about half of its volume. Under liver disease, hemodynamics in the liver tissue dynamically change, resulting in injury to liver sinusoidal endothelial cells (LSECs). We discuss the injury of LSECs in liver diseases in this article. Generally, in noninflamed tissues, vascular endothelial cells maintain quiescence of circulating leukocytes, and unnecessary blood clotting is inhibited by multiple antithrombotic factors produced by the endothelial cells. In the setting of inflammation, injured endothelial cells lose these functions, defined as inflammatory endotheliopathy. In chronic hepatitis C, inflammatory endotheliopathy in LSECs contributes to platelet accumulation in the liver tissue, and the improvement of thrombocytopenia by splenectomy is attenuated in cases with severe hepatic inflammation. In COVID-19, LSEC endotheliopathy induced by interleukin (IL)-6 trans-signaling promotes neutrophil accumulation and platelet microthrombosis in the liver sinusoids, resulting in liver injury. IL-6 trans-signaling promotes the expression of intercellular adhesion molecule-1, chemokine (C-X-C motif) ligand (CXCL1), and CXCL2, which are the neutrophil chemotactic mediators, and P-selectin, E-selectin, and von Willebrand factor, which are involved in platelet adhesion to endothelial cells, in LSECs. Restoring LSECs function is important for ameliorating liver injury. Prevention of endotheliopathy is a potential therapeutic strategy in liver disease.
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Affiliation(s)
- Reiichiro Kondo
- Department of Pathology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yasuko Iwakiri
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Masayoshi Kage
- Department of Medical Engineering, Junshin Gakuen University, Fukuoka, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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41
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Krinsky N, Sizikov S, Nissim S, Dror A, Sas A, Prinz H, Pri-Or E, Perek S, Raz-Pasteur A, Lejbkowicz I, Cohen-Matsliah SI, Almog R, Chen N, Kurd R, Jarjou'i A, Rokach A, Ben-Chetrit E, Schroeder A, Caulin AF, Yost CC, Schiffman JD, Goldfeder M, Martinod K. NETosis induction reflects COVID-19 severity and long COVID: insights from a 2-center patient cohort study in Israel. J Thromb Haemost 2023; 21:2569-2584. [PMID: 37054916 PMCID: PMC10088279 DOI: 10.1016/j.jtha.2023.02.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/29/2023] [Accepted: 02/12/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND COVID-19 severity and its late complications continue to be poorly understood. Neutrophil extracellular traps (NETs) form in acute COVID-19, likely contributing to morbidity and mortality. OBJECTIVES This study evaluated immunothrombosis markers in a comprehensive cohort of acute and recovered COVID-19 patients, including the association of NETs with long COVID. METHODS One-hundred-seventy-seven patients were recruited from clinical cohorts at 2 Israeli centers: acute COVID-19 (mild/moderate, severe/critical), convalescent COVID-19 (recovered and long COVID), along with 54 non-COVID controls. Plasma was examined for markers of platelet activation, coagulation, and NETs. Ex vivo NETosis induction capability was evaluated after neutrophil incubation with patient plasma. RESULTS Soluble P-selectin, factor VIII, von Willebrand factor, and platelet factor 4 were significantly elevated in patients with COVID-19 versus controls. Myeloperoxidase (MPO)-DNA complex levels were increased only in severe COVID-19 and did not differentiate between COVID-19 severities or correlate with thrombotic markers. NETosis induction levels strongly correlated with illness severity/duration, platelet activation markers, and coagulation factors, and were significantly reduced upon dexamethasone treatment and recovery. Patients with long COVID maintained higher NETosis induction, but not NET fragments, compared to recovered convalescent patients. CONCLUSIONS Increased NETosis induction can be detected in patients with long COVID. NETosis induction appears to be a more sensitive NET measurement than MPO-DNA levels in COVID-19, differentiating between disease severity and patients with long COVID. Ongoing NETosis induction capability in long COVID may provide insights into pathogenesis and serve as a surrogate marker for persistent pathology. This study emphasizes the need to explore neutrophil-targeted therapies in acute and chronic COVID-19.
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Affiliation(s)
| | | | | | - Adi Dror
- Peel Therapeutics Israel, Ltd, Nesher, Israel
| | - Anna Sas
- Peel Therapeutics Israel, Ltd, Nesher, Israel
| | | | | | - Shay Perek
- Department of Internal Medicine A, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ayelet Raz-Pasteur
- Department of Internal Medicine A, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Izabella Lejbkowicz
- Epidemiology Department and Biobank, Rambam Health Care Campus, Haifa, Israel
| | | | - Ronit Almog
- Epidemiology Department and Biobank, Rambam Health Care Campus, Haifa, Israel
| | - Nikanor Chen
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ramzi Kurd
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Jarjou'i
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Rokach
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eli Ben-Chetrit
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avi Schroeder
- Laboratory for Targeted Drug Delivery and Personalized Medicine Technologies, Department of Chemical Engineering, Technion - Israel Institute of Technology, Haifa 32000, Israel
| | | | - Christian Con Yost
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA; Molecular Medicine Program, University of Utah, Salt Lake City, Utah, USA
| | - Joshua D Schiffman
- Peel Therapeutics, Inc, Salt Lake City, Utah, USA; Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
| | | | - Kimberly Martinod
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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Turner S, Laubscher GJ, Khan MA, Kell DB, Pretorius E. Accelerating discovery: A novel flow cytometric method for detecting fibrin(ogen) amyloid microclots using long COVID as a model. Heliyon 2023; 9:e19605. [PMID: 37809592 PMCID: PMC10558872 DOI: 10.1016/j.heliyon.2023.e19605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/24/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023] Open
Abstract
Long COVID has become a significant global health and economic burden, yet there are currently no established methods or diagnostic tools to identify which patients might benefit from specific treatments. One of the major pathophysiological factors contributing to Long COVID is the presence of hypercoagulability; this results in insoluble amyloid microclots that are resistant to fibrinolysis. Our previous research using fluorescence microscopy has demonstrated a significant amyloid microclot load in Long COVID patients. However, this approach lacked the elements of statistical robustness, objectivity, and rapid throughput. In the current study, we have used imaging flow cytometry for the first time to show a significantly increased concentration and size of these microclots. We identified notable variations in size and fluorescence between microclots in Long COVID and those of controls even using a 20× objective. By combining cell imaging and the high-event-rate and full-sample analysis nature of a conventional flow cytometer, imaging flow cytometry can eliminate erroneous results and increase accuracy in gating and analysis beyond what pure quantitative measurements from conventional flow cytometry can provide. Although imaging flow cytometry was used in our study, our results suggest that the signals indicating the presence of microclots should be easily detectable using a conventional flow cytometer. Flow cytometry is a more widely available technique than fluorescence microscopy and has been used in pathology laboratories for decades, rendering it a potentially more suitable and accessible method for detecting microclots in individuals suffering from Long COVID or conditions with similar pathology, such as myalgic encephalomyelitis.
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Affiliation(s)
- Simone Turner
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland, 7602, South Africa
| | | | - M Asad Khan
- Respiratory Medicine, Manchester University Hospitals, Wythenshawe Hospital, Manchester, M23 9LT, United Kingdom
| | - Douglas B. Kell
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland, 7602, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, L69 7ZB, UK
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kemitorvet 200, 2800, Kgs Lyngby, Denmark
| | - Etheresia Pretorius
- Department of Physiological Sciences, Faculty of Science, Stellenbosch University, Stellenbosch, Private Bag X1, Matieland, 7602, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, L69 7ZB, UK
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Lemhöfer C, Sturm C, Loudovici-Krug D, Guntenbrunner C, Bülow M, Reuken P, Quickert S, Best N. Quality of life and ability to work of patients with Post-COVID syndrome in relation to the number of existing symptoms and the duration since infection up to 12 months: a cross-sectional study. Qual Life Res 2023; 32:1991-2002. [PMID: 36869248 PMCID: PMC9984128 DOI: 10.1007/s11136-023-03369-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE Following SARS-CoV-2 virus infection, patients may suffer from long-lasting symptoms regardless of disease severity. Preliminary results show limitations in health-related quality of life (HRQoL). The aim of this study is to show a possible change depending on the duration since infection and the accumulation of symptoms. Additionally, other possible influencing factors will be analyzed. METHODS The study population consisted of patients (18-65 years) presenting to the Post-COVID outpatient clinic of the University Hospital Jena, Germany, between March and October 2021. The HRQoL was assessed by the use of the RehabNeQ and the SF-36. Data analysis was descriptive with frequencies, means, and/or percentages. In addition, a univariate analysis of variance was performed to show the dependence of physical and psychological HRQoL on specific factors. This was finally tested for significance at an alpha level of 5%. RESULTS Data from 318 patients were analyzed, most of whom had 3-6 months of infection (56%) and 5-10 symptoms persisted (60.4%). Both mental (MCS) and physical sum score (PCS) of HRQoL were significantly lower than those of the German normal population (p < .001). The number of remaining symptoms (MCS p = .0034, PCS p = .000) as well as the perceived ability to work (MCS p = .007, PCS p = .000) influenced the HRQoL. CONCLUSION The HRQoL of patients with Post-COVID-syndrome is still reduced months after infection and so is their occupational performance. In particular, the number of symptoms could have an influence on this deficit, which would need to be further investigated. Further research is needed to detect other factors influencing HRQoL and to implement appropriate therapeutic interventions.
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Affiliation(s)
- Christina Lemhöfer
- Institute of Physical and Rehabilitation Medicine, University Hospital Jena, Am Klinikum 1, 07743, Jena, Germany.
| | - Christian Sturm
- Hannover Medical School, Clinic for Rehabilitation Medicine, Hannover, Germany
| | - Dana Loudovici-Krug
- Institute of Physical and Rehabilitation Medicine, University Hospital Jena, Am Klinikum 1, 07743, Jena, Germany
| | | | - Marcus Bülow
- Institute of Physical and Rehabilitation Medicine, University Hospital Jena, Am Klinikum 1, 07743, Jena, Germany
| | - Philipp Reuken
- Clinic for Internal Medicine IV (Gastroenterology, Hepatology, Infectiology), University Hospital Jena, Jena, Germany
| | - Stefanie Quickert
- Clinic for Internal Medicine IV (Gastroenterology, Hepatology, Infectiology), University Hospital Jena, Jena, Germany
| | - Norman Best
- Institute of Physical and Rehabilitation Medicine, University Hospital Jena, Am Klinikum 1, 07743, Jena, Germany
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Boccatonda A, Campello E, Simion C, Simioni P. Long-term hypercoagulability, endotheliopathy and inflammation following acute SARS-CoV-2 infection. Expert Rev Hematol 2023; 16:1035-1048. [PMID: 38018136 DOI: 10.1080/17474086.2023.2288154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION both symptomatic and asymptomatic SARS-CoV-2 infections - coined Coronavirus disease 2019 (COVID-19) - have been linked to a higher risk of cardiovascular events after recovery. AREAS COVERED our review aims to summarize the latest evidence on the increased thrombotic and cardiovascular risk in recovered COVID-19 patients and to examine the pathophysiological mechanisms underlying the interplay among endothelial dysfunction, inflammatory response and coagulation in long-COVID. We performed a systematic search of studies on hypercoagulability, endothelial dysfunction and inflammation after SARS-CoV-2 infection. EXPERT OPINION endothelial dysfunction is a major pathophysiological mechanism responsible for most clinical manifestations in COVID-19. The pathological activation of endothelial cells by a virus infection results in a pro-adhesive and chemokine-secreting phenotype, which in turn promotes the recruitment of circulating leukocytes. Cardiovascular events after COVID-19 appear to be related to persistent immune dysregulation. Patients with long-lasting symptoms display higher amounts of proinflammatory molecules such as tumor necrosis factor-α, interferon γ and interleukins 2 and 6. Immune dysregulation can trigger the activation of the coagulation pathway. The formation of extensive microclots in vivo, both during acute COVID-19 and in long-COVID-19, appears to be a relevant mechanism responsible for persistent symptoms and cardiovascular events.
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Affiliation(s)
- Andrea Boccatonda
- Internal Medicine, Bentivoglio Hospital, AUSL Bologna, Bentivoglio, Italy
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Chiara Simion
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
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Tsilingiris D, Vallianou NG, Karampela I, Christodoulatos GS, Papavasileiou G, Petropoulou D, Magkos F, Dalamaga M. Laboratory Findings and Biomarkers in Long COVID: What Do We Know So Far? Insights into Epidemiology, Pathogenesis, Therapeutic Perspectives and Challenges. Int J Mol Sci 2023; 24:10458. [PMID: 37445634 PMCID: PMC10341908 DOI: 10.3390/ijms241310458] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Long COVID (LC) encompasses a constellation of long-term symptoms experienced by at least 10% of people after the initial SARS-CoV-2 infection, and so far it has affected about 65 million people. The etiology of LC remains unclear; however, many pathophysiological pathways may be involved, including viral persistence; a chronic, low-grade inflammatory response; immune dysregulation and a defective immune response; the reactivation of latent viruses; autoimmunity; persistent endothelial dysfunction and coagulopathy; gut dysbiosis; hormonal and metabolic dysregulation; mitochondrial dysfunction; and autonomic nervous system dysfunction. There are no specific tests for the diagnosis of LC, and clinical features including laboratory findings and biomarkers may not specifically relate to LC. Therefore, it is of paramount importance to develop and validate biomarkers that can be employed for the prediction, diagnosis and prognosis of LC and its therapeutic response, although this effort may be hampered by challenges pertaining to the non-specific nature of the majority of clinical manifestations in the LC spectrum, small sample sizes of relevant studies and other methodological issues. Promising candidate biomarkers that are found in some patients are markers of systemic inflammation, including acute phase proteins, cytokines and chemokines; biomarkers reflecting SARS-CoV-2 persistence, the reactivation of herpesviruses and immune dysregulation; biomarkers of endotheliopathy, coagulation and fibrinolysis; microbiota alterations; diverse proteins and metabolites; hormonal and metabolic biomarkers; and cerebrospinal fluid biomarkers. At present, there are only two reviews summarizing relevant biomarkers; however, they do not cover the entire umbrella of current biomarkers, their link to etiopathogenetic mechanisms or the diagnostic work-up in a comprehensive manner. Herein, we aim to appraise and synopsize the available evidence on the typical laboratory manifestations and candidate biomarkers of LC, their classification based on pathogenetic mechanisms and the main LC symptomatology in the frame of the epidemiological and clinical aspects of the syndrome and furthermore assess limitations and challenges as well as potential implications in candidate therapeutic interventions.
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Affiliation(s)
- Dimitrios Tsilingiris
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Dragana, 68100 Alexandroupolis, Greece;
| | - Natalia G. Vallianou
- Department of Internal Medicine, Evangelismos General Hospital, 45-47 Ipsilantou Street, 10676 Athens, Greece;
| | - Irene Karampela
- 2nd Department of Critical Care, Medical School, University of Athens, Attikon General University Hospital, 1 Rimini Street, 12462 Athens, Greece;
| | | | - Georgios Papavasileiou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527 Athens, Greece; (G.P.); (D.P.)
| | - Dimitra Petropoulou
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527 Athens, Greece; (G.P.); (D.P.)
| | - Faidon Magkos
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, DK-2200 Frederiksberg, Denmark;
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527 Athens, Greece; (G.P.); (D.P.)
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Paniskaki K, Konik MJ, Anft M, Heidecke H, Meister TL, Pfaender S, Krawczyk A, Zettler M, Jäger J, Gaeckler A, Dolff S, Westhoff TH, Rohn H, Stervbo U, Scheibenbogen C, Witzke O, Babel N. Low avidity circulating SARS-CoV-2 reactive CD8+ T cells with proinflammatory TEMRA phenotype are associated with post-acute sequelae of COVID-19. Front Microbiol 2023; 14:1196721. [PMID: 37333646 PMCID: PMC10272838 DOI: 10.3389/fmicb.2023.1196721] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
The role of adaptive SARS-CoV-2 specific immunity in post-acute sequelae of COVID-19 (PASC) is not well explored, although a growing population of convalescent COVID-19 patients with manifestation of PASC is observed. We analyzed the SARS-CoV-2-specific immune response, via pseudovirus neutralizing assay and multiparametric flow cytometry in 40 post-acute sequelae of COVID-19 patients with non-specific PASC manifestation and 15 COVID-19 convalescent healthy donors. Although frequencies of SARS-CoV-2-reactive CD4+ T cells were similar between the studied cohorts, a stronger SARS-CoV-2 reactive CD8+ T cell response, characterized by IFNγ production and predominant TEMRA phenotype but low functional TCR avidity was detected in PASC patients compared to controls. Of interest, high avidity SARS-CoV-2-reactive CD4+ and CD8+ T cells were comparable between the groups demonstrating sufficient cellular antiviral response in PASC. In line with the cellular immunity, neutralizing capacity in PASC patients was not inferior compared to controls. In conclusion, our data suggest that PASC may be driven by an inflammatory response triggered by an expanded population of low avidity SARS-CoV-2 reactive pro-inflammatory CD8+ T cells. These pro-inflammatory T cells with TEMRA phenotype are known to be activated by a low or even without TCR stimulation and lead to a tissue damage. Further studies including animal models are required for a better understanding of underlying immunopathogensis. Summary: A CD8+ driven persistent inflammatory response triggered by SARS-CoV-2 may be responsible for the observed sequelae in PASC patients.
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Affiliation(s)
- Krystallenia Paniskaki
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Margarethe J. Konik
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Moritz Anft
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | | | - Toni L. Meister
- Department of Molecular and Medical Virology, Ruhr-University Bochum, Bochum, Germany
| | - Stephanie Pfaender
- Department of Molecular and Medical Virology, Ruhr-University Bochum, Bochum, Germany
| | - Adalbert Krawczyk
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Markus Zettler
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jasmin Jäger
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Anja Gaeckler
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Timm H. Westhoff
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
| | - Hana Rohn
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ulrik Stervbo
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | - Carmen Scheibenbogen
- Institute for Medical Immunology, Charité-Universitätsmedizin Berlin, Campus Virchow, Berlin, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nina Babel
- Center for Translational Medicine and Immune Diagnostics Laboratory, Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Bochum, Germany
- Berlin Institute of Health at Charité – University Clinic Berlin, BIH Center for Regenerative Therapies (BCRT) Berlin, Berlin, Germany
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47
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Komaroff AL, Lipkin WI. ME/CFS and Long COVID share similar symptoms and biological abnormalities: road map to the literature. Front Med (Lausanne) 2023; 10:1187163. [PMID: 37342500 PMCID: PMC10278546 DOI: 10.3389/fmed.2023.1187163] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
Some patients remain unwell for months after "recovering" from acute COVID-19. They develop persistent fatigue, cognitive problems, headaches, disrupted sleep, myalgias and arthralgias, post-exertional malaise, orthostatic intolerance and other symptoms that greatly interfere with their ability to function and that can leave some people housebound and disabled. The illness (Long COVID) is similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as well as to persisting illnesses that can follow a wide variety of other infectious agents and following major traumatic injury. Together, these illnesses are projected to cost the U.S. trillions of dollars. In this review, we first compare the symptoms of ME/CFS and Long COVID, noting the considerable similarities and the few differences. We then compare in extensive detail the underlying pathophysiology of these two conditions, focusing on abnormalities of the central and autonomic nervous system, lungs, heart, vasculature, immune system, gut microbiome, energy metabolism and redox balance. This comparison highlights how strong the evidence is for each abnormality, in each illness, and helps to set priorities for future investigation. The review provides a current road map to the extensive literature on the underlying biology of both illnesses.
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Affiliation(s)
- Anthony L. Komaroff
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - W. Ian Lipkin
- Center for Infection and Immunity, Mailman School of Public Health, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, United States
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48
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Sykes RA, Neves KB, Alves-Lopes R, Caputo I, Fallon K, Jamieson NB, Kamdar A, Legrini A, Leslie H, McIntosh A, McConnachie A, Morrow A, McFarlane RW, Mangion K, McAbney J, Montezano AC, Touyz RM, Wood C, Berry C. Vascular mechanisms of post-COVID-19 conditions: Rho-kinase is a novel target for therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:371-386. [PMID: 37019821 PMCID: PMC10236521 DOI: 10.1093/ehjcvp/pvad025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/24/2023] [Accepted: 04/04/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND In post-coronavirus disease-19 (post-COVID-19) conditions (long COVID), systemic vascular dysfunction is implicated, but the mechanisms are uncertain, and the treatment is imprecise. METHODS AND RESULTS Patients convalescing after hospitalization for COVID-19 and risk factor matched controls underwent multisystem phenotyping using blood biomarkers, cardiorenal and pulmonary imaging, and gluteal subcutaneous biopsy (NCT04403607). Small resistance arteries were isolated and examined using wire myography, histopathology, immunohistochemistry, and spatial transcriptomics. Endothelium-independent (sodium nitroprusside) and -dependent (acetylcholine) vasorelaxation and vasoconstriction to the thromboxane A2 receptor agonist, U46619, and endothelin-1 (ET-1) in the presence or absence of a RhoA/Rho-kinase inhibitor (fasudil), were investigated. Thirty-seven patients, including 27 (mean age 57 years, 48% women, 41% cardiovascular disease) 3 months post-COVID-19 and 10 controls (mean age 57 years, 20% women, 30% cardiovascular disease), were included. Compared with control responses, U46619-induced constriction was increased (P = 0.002) and endothelium-independent vasorelaxation was reduced in arteries from COVID-19 patients (P < 0.001). This difference was abolished by fasudil. Histopathology revealed greater collagen abundance in COVID-19 arteries {Masson's trichrome (MT) 69.7% [95% confidence interval (CI): 67.8-71.7]; picrosirius red 68.6% [95% CI: 64.4-72.8]} vs. controls [MT 64.9% (95% CI: 59.4-70.3) (P = 0.028); picrosirius red 60.1% (95% CI: 55.4-64.8), (P = 0.029)]. Greater phosphorylated myosin light chain antibody-positive staining in vascular smooth muscle cells was observed in COVID-19 arteries (40.1%; 95% CI: 30.9-49.3) vs. controls (10.0%; 95% CI: 4.4-15.6) (P < 0.001). In proof-of-concept studies, gene pathways associated with extracellular matrix alteration, proteoglycan synthesis, and viral mRNA replication appeared to be upregulated. CONCLUSION Patients with post-COVID-19 conditions have enhanced vascular fibrosis and myosin light change phosphorylation. Rho-kinase activation represents a novel therapeutic target for clinical trials.
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Affiliation(s)
- Robert A Sykes
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Karla B Neves
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Rhéure Alves-Lopes
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
| | - Ilaria Caputo
- Università degli Studi di Padova, 35122 Padova, Italy
| | - Kirsty Fallon
- Clinical Research Facility, Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde Health Board, Glasgow, UK
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Anna Kamdar
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
| | - Assya Legrini
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Holly Leslie
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Alasdair McIntosh
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Andrew Morrow
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Kenneth Mangion
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
| | - John McAbney
- Institute of Biomedical and Life Sciences (FBLS), University of Glasgow, Glasgow G12 8QQ, UK
| | - Augusto C Montezano
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, QC H4A 3J1, Canada
| | - Rhian M Touyz
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, QC H4A 3J1, Canada
| | - Colin Wood
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Colin Berry
- School of Cardiovascular and Metabolic Health, University of Glasgow, UK
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, UK
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde Health Board, Glasgow, UK
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49
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Wieder R. Awakening of Dormant Breast Cancer Cells in the Bone Marrow. Cancers (Basel) 2023; 15:cancers15113021. [PMID: 37296983 DOI: 10.3390/cancers15113021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
Up to 40% of patients with breast cancer (BC) have metastatic cells in the bone marrow (BM) at the initial diagnosis of localized disease. Despite definitive systemic adjuvant therapy, these cells survive in the BM microenvironment, enter a dormant state and recur stochastically for more than 20 years. Once they begin to proliferate, recurrent macrometastases are not curable, and patients generally succumb to their disease. Many potential mechanisms for initiating recurrence have been proposed, but no definitive predictive data have been generated. This manuscript reviews the proposed mechanisms that maintain BC cell dormancy in the BM microenvironment and discusses the data supporting specific mechanisms for recurrence. It addresses the well-described mechanisms of secretory senescence, inflammation, aging, adipogenic BM conversion, autophagy, systemic effects of trauma and surgery, sympathetic signaling, transient angiogenic bursts, hypercoagulable states, osteoclast activation, and epigenetic modifications of dormant cells. This review addresses proposed approaches for either eliminating micrometastases or maintaining a dormant state.
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Affiliation(s)
- Robert Wieder
- Rutgers New Jersey Medical School and the Cancer Institute of New Jersey, 185 South Orange Avenue, MSB F671, Newark, NJ 07103, USA
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50
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Englert H, Göbel J, Khong D, Omidi M, Wolska N, Konrath S, Frye M, Mailer RK, Beerens M, Gerwers JC, Preston RJS, Odeberg J, Butler LM, Maas C, Stavrou EX, Fuchs TA, Renné T. Targeting NETs using dual-active DNase1 variants. Front Immunol 2023; 14:1181761. [PMID: 37287977 PMCID: PMC10242134 DOI: 10.3389/fimmu.2023.1181761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Abstract
Background Neutrophil Extracellular Traps (NETs) are key mediators of immunothrombotic mechanisms and defective clearance of NETs from the circulation underlies an array of thrombotic, inflammatory, infectious, and autoimmune diseases. Efficient NET degradation depends on the combined activity of two distinct DNases, DNase1 and DNase1-like 3 (DNase1L3) that preferentially digest double-stranded DNA (dsDNA) and chromatin, respectively. Methods Here, we engineered a dual-active DNase with combined DNase1 and DNase1L3 activities and characterized the enzyme for its NET degrading potential in vitro. Furthermore, we produced a mouse model with transgenic expression of the dual-active DNase and analyzed body fluids of these animals for DNase1 and DNase 1L3 activities. We systematically substituted 20 amino acid stretches in DNase1 that were not conserved among DNase1 and DNase1L3 with homologous DNase1L3 sequences. Results We found that the ability of DNase1L3 to degrade chromatin is embedded into three discrete areas of the enzyme's core body, not the C-terminal domain as suggested by the state-of-the-art. Further, combined transfer of the aforementioned areas of DNase1L3 to DNase1 generated a dual-active DNase1 enzyme with additional chromatin degrading activity. The dual-active DNase1 mutant was superior to native DNase1 and DNase1L3 in degrading dsDNA and chromatin, respectively. Transgenic expression of the dual-active DNase1 mutant in hepatocytes of mice lacking endogenous DNases revealed that the engineered enzyme was stable in the circulation, released into serum and filtered to the bile but not into the urine. Conclusion Therefore, the dual-active DNase1 mutant is a promising tool for neutralization of DNA and NETs with potential therapeutic applications for interference with thromboinflammatory disease states.
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Affiliation(s)
- Hanna Englert
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josephine Göbel
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Danika Khong
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maryam Omidi
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Wolska
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Konrath
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maike Frye
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reiner K. Mailer
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manu Beerens
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian C. Gerwers
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roger J. S. Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jacob Odeberg
- Department of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
- Science for Life Laboratory, Department of Protein Science, CBH, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Lynn M. Butler
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
- Science for Life Laboratory, Department of Protein Science, CBH, KTH Royal Institute of Technology, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Coen Maas
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Evi X. Stavrou
- Medicine Service, Section of Hematology-Oncology, Louis Stokes Veterans Administration Medical Center, Cleveland, OH, United States
- Department of Medicine, Hematology and Oncology Division, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Tobias A. Fuchs
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Neutrolis, Inc., Cambridge, MA, United States
| | - Thomas Renné
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Medical Center, Mainz, Germany
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