Immunogenicity profile after COVID-19 vaccination in patients with onco-hematological diseases

OBJECTIVE

To evaluate the influence of onco-hematological pathologies on seroconversion to COVID-19 vaccines, in addition to the effects of chemotherapy treatment on this response.

METHODS

The present study evaluated the immunogenic response of 76 patients with onco-hematological diseases to multiple vaccine platforms compared to 25 control individuals.

RESULTS

Our results showed positive response rates of 74.02% in patients with onco-hematological diseases and 100% in controls. When analyzed according to etiological group, patients with lymphoproliferative disorders achieved a positive vaccine response rate of 58.7%, whereas those with myeloproliferative diseases achieved a 100% response rate. We also observed that patients previously exposed to COVID-19 presented a 75% increase in their antibody values after vaccination, and these values were 37% higher than those of patients who did not have such exposure. We found that patients who underwent B-lymphocyte-depleting therapy in the last 2 years before vaccination had a worse response rate of 18.75%.

CONCLUSION

Despite the immunosuppression of patients with onco-hematological diseases, caused by the biology of their diseases and treatment, benefit and safety in vaccinating these patients are observed, in view of the important recall immune response and incidence of adverse effects similar to those of the healthy population.

SÃO AS RELAÇÕES PLAQUETAS/LINFÓCITOS E NEUTRÓFILOS/LINFÓCITOS PREDITORAS DE DESFECHO DESFAVORÁVEL NA COVID-19?

Introdução

COVID-19 é o conjunto de sintomas causados pelo SARS-CoV-2, variando de quadros leves a formas graves. Pacientes com COVID-19 grave frequentemente apresentam marcadores laboratoriais anormais que refletem resposta inflamatória sistêmica. Alguns deles, estão ligados a desfechos clínicos desfavoráveis e estão emergindo como parâmetros prognósticos confiáveis. Alterações hematológicas fazem parte destes parâmetros.

Objetivo

Avaliar hemograma de pacientes internados e correlacionar com o desfecho da infecção pelo COVID-19. Material e Método: De março de 2020 a julho de 2021 ocorreram 15013 internações nas instalações do HSPE, 4638 casos tiveram RT-PCR positivo para COVID-19. Avaliamos dados preliminares dos pacientes que tiveram PCR + durante sua internação no período de 07/2020 a 04/2021 que totalizaram 828 pacientes. Foram excluídas internações por outro motivo e PCR+ durante a internação e PCR+ executados para internação eletiva e assintomáticos. Para efeito da análise os pacientes foram divididos em 2 grupos: os que evoluíram a óbito e os que receberam alta hospitalar.

Resultados

O hemograma de entrada dos pacientes que receberam alta hospitalar revelou valores médios de hemoglobina (Hb) 12,84 g/dL (± 2,10); leucócitos (LCT)  8433/mm³ (± 4.363,45), variando de 990 a 45.106/mm³; Neutrófilos (NEUT) 6.457,71/mm³ (± 3.692,15) de 567 a 28240/mm³; linfócitos (LINF) 1.246,25/mm³ (± 776,79) de 200 a 7190/mm³; plaquetas (PLT) 233630/mm³ (± 91.079,10) de 36.000 a 759.000/mm³. O grupo dos óbitos apresentou Hb média 12,39 g/dL (± 2,41), variando de 6,10 a 19,10 g/dL;  NEUT 7621/mm³ (± 5.444); LINF 1070/mm³ (± 955); PLT 192.000/mm³ (± 102.229) 10.600 a 684000/mm³. Quando avaliamos a relação plaquetas/linfócitos (RPL): 145 pacientes com RPL ≥ a 180 evoluíram a óbito enquanto 291 obtiveram receberam alta. Dos pacientes com RLP < 180, 98 evoluíram para óbito, enquanto 216 obtiveram desfecho favorável (p= 0,5803). A relação neutrófilo/linfócitos (RNL) à entrada demonstrou que 37 pacientes com RNL < 3,3 evoluíram para óbito enquanto 154 obtiveram desfecho favorável (p = 0,0001). Das RNL por ocasião dos desfechos < 3,3, 10 evoluíram a óbito e 237 tiveram desfecho favorável e 215 com RNL ≥ 3,3 evoluíram para óbito e 251 para alta hospitalar (p = 0,0001).

Discussão

Elevada RPL (> 180) como fator prognóstico na COVID-19 foi recentemente descrita, com especificidade e sensibilidade de 0,44 e 0,77, respectivamente. Entretanto, a RPL não foi medida em um ponto específico no curso da doença. Recente metanálise evidenciou RPL elevada em doença grave comparando com não grave. Elevada RNL foi identificada como marcador para mortalidade hospitalar e COVID-19 grave. Os neutrófilos são importantes nas respostas imunes inatas, enquanto os linfócitos nas respostas inflamatórias. Assim, aumento da RNL reflete desequilíbrio da resposta inflamatória e pode ser considerado indicador de gravidade.  Estudo prévio introduziu RNL como um preditor independente de desfechos clínicos na COVID-19.

Conclusão

A RNL ao diagnóstico ≥ 3,3 revela-se como marcador prognóstico tanto em análise feita com dados à entrada quanto por ocasião do desfecho. Análise em curso com maior número de casos pretende verificar a estratificação de valores desta relação, no sentido de prever com maior rigor o seu impacto. A RPL não demonstrou diferença entre os grupos. Entretanto, melhor padronização quanto ao momento em que esta avaliação deva ser realizada se faz necessária.

Cancer Incidence in Turin: The Effect of Migration

Aims and Background

Studies on migrant populations have been of great value in clarifying the role of environmental factors in cancer occurrence. Most of them consider migrants from other countries or continents. Turin, the target territory of this study, was an important area of Internal migration initially from the East, and more recently from southern Italy.

Methods

The study compared incidence rates (age-standardized) of the native population, of the migrants and incidence rates of the Cancer Registries located in the four main areas of origin.

Results

Overall incidence rates in migrants from southern Italy were intermediate compared with those of the stable populations of the South and the North. The same effect was not true for people from the North-East, who migrated in earlier decades. In this population, migration towards lower-incidence areas did not reduce cancer incidence. Migrants from the South showed a significant increase in intestinal, breast, and tobacco-related tumors compared to the stable southern population. No effect of migration was found for cancer of the mouth, pharynx, esophagus, stomach or corpus uteri. Incidence of liver cancer in migrant southern males was significantly different from the stable and the native north-western population.

Conclusions

The results, based on incidence data, validated previous findings based on mortality data on the effect of Italian Internal migrations and showed that migrants underwent changes in some environmental exposures. In particular, migrants from the South to the North of Italy came into contact with new risk factors, with an increase in occurrence of cancer.

Posterior Circulation Evaluation in Patients with Sickle Cell Anemia

BACKGROUND

The role of transcranial Doppler (TCD) ultrasonography in identifying children with sickle cell anemia (SCA) at risk for stroke is well known; however, the major studies that evaluated TCD velocities in children with SCA did not report posterior circulation evaluation data. The objective of our study was to describe the pattern of blood flow velocities in the posterior circulation of patients with SCA and to examine their relationship with findings on magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA).

METHODS

All adult patients with SCA followed in the outpatient clinic of our hospital were evaluated with TCD and MRI/MRA. The highest velocities of the middle cerebral arteries or internal carotid arteries were taken as the time-averaged maximum mean (TAMM) velocity for each patient and the maximum mean flow velocities in the posterior circulation (TAMMpost) were recorded.

RESULTS

Fifty-six patients with SCA and 56 healthy nonanemic volunteers were evaluated. The mean TAMMpost in the basilar, vertebral, and posterior cerebral arteries (PCAs) were significantly higher among cases than controls (P < .01). In patients with SCA, the TAMMpost in all posterior circulation arteries had a positive correlation with TAMM. Only 1 patient with stenosis in the posterior circulation (right PCA) was identified.

CONCLUSION

We found a low frequency of stenosis but high blood flow velocities in the posterior circulation in patients with SCA. The role of increased TCD velocities in the posterior circulation upon stroke risk in patients with SCA should be further examined.

Interleukin-1β and interleukin-6 gene polymorphisms are associated with manifestations of sickle cell anemia

Sickle cell anemia (SCA), a disorder characterized by both acute and chronic inflammation, exhibits substantial phenotypic variability. Interleukin-1 beta (IL-1β) and IL-6 are important in acute and chronic diseases, and their single nucleotide polymorphisms (SNPs) have been considered as predictors of prognosis in several inflammatory conditions. This study aims at exploring possible association of IL-1β and IL-6 SNPs as potential genetic modifiers and or predictors of SCA clinical and laboratory phenotypes. This cross-sectional study involved 107 SCA patients and 110 age, sex and ethnicity-matched healthy individuals. The SNPs were identified by PCR-RFLP for IL-1β (-511C>T and +3954C>T) and IL-6 (-597G>A and -174G>C) genes. Associations between these SNPs and the clinical and laboratory profiles of patients with SCA were then determined. Allelic and genotypic frequencies of IL-1β and IL-6 SNPs between patients with SCA and controls were similar and followed HWE. IL-1β +3954C>T SNP was associated with increased risk of osteonecrosis, elevated pulmonary arterial pressure and lower absolute reticulocyte count, while IL-6 -597G>A was associated with higher likelihood of retinopathy and leg ulcer. These data indicate that IL-1β and IL-6 gene SNPs are associated with SCA complications among Brazilian patients and may act as genetic predictors of SCA clinical heterogeneity.

Exercise-Induced Abnormal Increase of Systolic Pulmonary Artery Pressure in Adult Patients With Sickle Cell Anemia: An Exercise Stress Echocardiography Study

BACKGROUND

Pulmonary hypertension (PH) at rest is a risk factor for death in patients with sickle cell anemia (SCA). Exercise echocardiography (EE) can detect latent PH. We sought to investigate the occurrence of exercise-induced abnormal response of systolic pulmonary artery pressure (SPAP) in adult patients with SCA and normal SPAP at rest, and to identify the independent predictors of this abnormal response.

METHODS AND RESULTS

Forty-four adult patients with SCA and normal SPAP at rest (tricuspid regurgitant jet flow velocity [TRV] <2.5 m/sec) were studied and divided into 2 groups: exhibiting normal SPAP after treadmill EE (TRV ≤ 2.7 m/sec) (G1), and exhibiting abnormal exercise-induced increase of SPAP (TRV > 2.7 m/sec) (G2). TRV cutoff points at rest and during EE were based on data from healthy-matched control subjects. Abnormal response of SPAP with exercise occurred in 57% of the sample (G2), with mean TRV level of 3.39 ± 0.41 m/sec (range 2.8-4.5 m/sec), significantly higher than those of G1 (2.29 ± 0.25 m/sec, range 2.0-2.7 m/sec; P < 0.001). Multivariate analysis identified TRV value in resting conditions ≥2.25 m/sec (P < 0.05), left atrial volume index ≥41 mL/m² (P < 0.05), and a E/e'-waves ratio ≥6.3 (P < 0.05) as independent predictors of exercise-induced increase of SPAP.

CONCLUSION

We concluded that adult patients with SCA and normal SPAP at rest may exhibit abnormal exercise-induced increase in SPAP, which was independently related to resting TRV levels, and indices of diastolic impairment and left ventricular filling pressure.

Priapism is associated with sleep hypoxemia in sickle cell disease

PURPOSE

We assessed penile rigidity during sleep and the relationship of sleep abnormalities with priapism in adults with sickle cell disease.

MATERIALS AND METHODS

This was a case-control study of 18 patients with sickle cell disease and a history of priapism during the previous year, and 16 controls with sickle cell disease. Participants underwent overnight polysomnography and RigiScan® Plus recording to detect penile rigidity oscillations.

RESULTS

The priapism group (cases) showed a higher apnea-hypopnea index and oxyhemoglobin desaturation parameters than controls. A lower positive correlation between the apnea-hypopnea index and oxyhemoglobin desaturation time was observed in cases than in controls (Spearman coefficient ρ = 0.49, p = 0.05 vs ρ = 0.76, p <0.01), suggesting that desaturation events occurred independently of apnea. Two controls and 14 cases had a total sleep time that was greater than 10% with oxyhemoglobin saturation less than 90% but without CO(2) retention. Penile rigidity events were observed during rapid eye movement sleep and during stage 2 of nonrapid eye movement sleep, particularly in cases. The duration of penile rigidity events concomitant to respiratory events was higher in cases than in controls. Regression analysis revealed that the periodic limb movement and desaturation indexes were associated with priapism after adjusting for rapid eye movement sleep and lung involvement. Finally, oxyhemoglobin saturation less than 90% was associated with priapism after adjusting for lung involvement, hyperhemolysis and the apnea-hypopnea index.

CONCLUSIONS

Oxyhemoglobin desaturation during sleep was associated with priapism history. It may underlie the distribution pattern of penile rigidity events during sleep in these patients.

Bone marrow and peripheral white blood cells number is affected by sleep deprivation in a murine experimental model

Sleep deficit and related disorders are becoming increasingly prevalent in modern life and an extensive literature has documented that acute or chronic sleep deprivation can lead to several physiological consequences. Here, we evaluated the effects of sleep deprivation on hematopoietic composition of either bone marrow or peripheral blood. Mice were subjected to paradoxical sleep deprivation (PSD) for 72 h by modified multiple platform method, with or without an additional sleep recovery (SR) period of 10 days. PSD decreased total cellularity of the bone marrow and peripheral blood concomitantly. Subsequent analysis of cell composition showed that absolute number of hematopoietic stem/progenitor cells and colony-forming units was decreased. Moreover, the absolute number of granulocytes and monocytes in bone marrow was reduced in PSD group. These alterations were paralleled by an accumulation of neutrophils and monocytes in peripheral blood. PSD also induced lymphopenia in the circulation. To the best of our knowledge, this is the first study that demonstrates the importance of sleep on the hematopoietic microenvironment and provides new insights into the relationship between sleep and the immune system.

Molecular analysis of β-thalassemia patients: first identification of mutations HBB:c.93-2A>G and HBB:c.114G>A in Brazil

The various clinical phenotypes in β-thalassemias have stimulated the study of genetic factors that could modify the manifestations of these diseases. We examined 21 patients with β-thalassemia (β-thal) in order to identify some genetic modifying factors: β-thalassemia mutations, HBG2:g.-158C>T polymorphism, α-globin gene deletions and (AT)xNz(AT)y motif within the hypersensitive site 2-locus control region (HS2-LCR). In the 42 alleles analyzed, the most frequent mutations observed were HBB:c.92+6T>C (30.9%), HBB:c.118C>T (16.7%), HBB:c.93-21G>A (11.9%) and HBB:c.92+1G>A (4.8%); this finding is in accordance with previous data of the Brazilian population. The other genetic factors analyzed showed no relation with the severity of the disease. For the first time in Brazil, we report HBB:c.93-2A>G and HBB:c.114G>A mutations on the β-globin gene, both in a heterozygous state. This is also the first study to analyze the HS2-LCR in β-thalassemic individuals in the Brazilian population.

Absence of association between TNF-α polymorphism and cerebral large-vessel abnormalities in adults with sickle cell anemia

Stroke is a serious complication of sickle cell anemia (SCA) affecting children and adults. Recent reports suggested that tumor necrosis factor-α (TNF-α) (-308) polymorphism is an important risk factor for stroke in children with SCA. The role of TNF-α polymorphism in the frequency of brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) abnormalities in adults with SCA is still uncertain. Our objective was to evaluate the frequency of TNF-α polymorphism in adults with SCA and to correlate it to brain MRI and MRA findings. TNF-α (-308) polymorphism was determined in 49 adults with SCA. All subjects were evaluated with brain MRI/MRA to establish the presence of intracranial abnormalities. Thirty-three (67.3%) had abnormal brain MRA scans, 8 (16.3%) had intracranial stenosis and 29 (59.2%) showed arterial tortuosity. Forty-one (83.7%) had the GG genotype and 8 had the GA genotype. There was no correlation between homozygosity for G allele and MRA or MRI abnormalities. Although TNF-α (-308) polymorphism is a potential predictor of the genetic risk for stroke in children, we found no association between the polymorphism and large vessel abnormalities in adults with SCA.

Brain magnetic resonance imaging abnormalities in adult patients with sickle cell disease: correlation with transcranial Doppler findings

BACKGROUND AND PURPOSE

Brain imaging abnormalities were reported in up to 44% of children with sickle cell disease (SCD). The prevalence of neuroimaging abnormalities in adult patients with SCD and their relationship to transcranial Doppler is still unclear. Our objectives were to study the frequency of MRI and MR angiography abnormalities in adults with SCD and to define what transcranial Doppler velocities are associated with intracranial stenoses detected by MR angiography.

METHODS

We examined all adult patients (>16 years) with SCD followed in the hematology outpatient clinic at our university hospital with MRI, MR angiography, and transcranial Doppler.

RESULTS

We evaluated 50 patients. The overall prevalence of MRI abnormalities was 60%. Abnormal MRI findings were more frequent when vessel tortuosity or stenoses were present on MR angiography (P<0.01). Patients with intracranial stenoses had significantly higher time-averaged maximum mean velocities (P=0.01). A time-averaged maximum mean velocity of 123.5 cm/s allowed the diagnosis of middle cerebral artery or internal carotid artery intracranial stenosis with sensitivity of 100% and specificity of 73% with an area under the receiver operator characteristic curve of 0.91 (CI, 0.79 to 1.00).

CONCLUSIONS

The frequency of brain imaging abnormalities detected by MRI/MR angiography in adults with SCD was higher than that described for children. Transcranial Doppler velocities in adult patients with intracranial stenoses were lower than those described for the pediatric population with SCD.

Multiple primary choledocholithiasis in sickle cell disease

Choledocholithiasis can be caused by either primary or secondary bile duct stones. Although patients with sickle cell disease (SCD) are at high risk of development of pigmented gallstones due to chronic hemolysis, primary choledocholithiasis in SCD is very uncommon. The delay in the diagnosis of biliary tract pathology can occur in patients who had a prior cholecystectomy. There is a possible relationship between prior cholecystectomy and the subsequent occurrence of primary common bile duct stones, due to the higher probability of infection of the biliary system. Here, we report an unusual and severe case of multiple primary choledocholithiasis, associated with pancreatitis, in a patient with SCD, fourteen years after cholecystectomy.

Transcranial Doppler ultrasonography in adults with sickle cell disease

BACKGROUND

Transcranial Doppler (TCD) is used to select children with sickle cell disease (SCD) for primary stroke prevention using regular blood transfusion. Whether it can also identify high stroke risk in adults with SCD is not known.

METHODS

The authors examined 112 adult patients from two convenience population samples with SCD and 53 healthy control subjects to compare velocities in adults to those reported in children with SCD and to evaluate the influence of age and hematocrit on TCD.

RESULTS

Adults with SCD had a higher mean time-averaged maximum mean velocity (110.9 +/- 25.7 cm/s) compared with healthy controls (71.1 +/- 12.0 cm/s), and the difference is approximately proportional to their anemia. No cases with velocities >/=200 cm/s (the threshold used in children for prophylactic treatment) were found in this sample.

CONCLUSIONS

Transcranial Doppler velocities in adults with sickle cell disease (SCD) are lower than those in children with SCD. Velocity criteria used in children cannot be used to stratify risk of stroke in adults.

Migraine-mimicking headache and sickle cell disease: a transcranial Doppler study

Headache occurs in sickle cell disease (SCD), but its characteristics and frequency have not previously been studied. Our aim was to study patterns of headache in adults with SCD and to correlate its presence with blood flow velocities measured by transcranial Doppler (TCD) and with brain magnetic resonance imaging (MRI) abnormalities. We studied 56 adults with SCD. Twenty-eight patients (50%) had severe and frequent headaches. In 20 patients (35.7%) the headache met the International Headache Society criteria for migraine without aura. Patients with frequent and severe headache presented TCD velocities significantly higher than those without headache, or with milder headache. No correlation was found between headache and abnormalities in brain MRI. A migraine-mimicking headache occurs in SCD but we should not understand it as a primary headache because the blood flow abnormalities secondary to SCD detected by TCD seem to play an important role in these patients.

XmnI polymorphism is associated with fetal hemoglobin levels in hypoplastic syndromes

CONTEXT AND OBJECTIVE

Acquired fetal hemoglobin (HbF) elevation has been implicated as a prognostic factor in dyserythropoietic disorders. Our objectives were to examine acquired HbF increases in aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) patients, and to evaluate whether there is an association between the presence of XmnI and 5' hypersensitive site locus control region (LCR-HS2) polymorphisms and the HbF levels.

DESIGN AND SETTING

Cross-sectional study at the Hematology and Blood Transfusion Service of Universidade Federal de São Paulo - Escola Paulista de Medicina.

METHODS

We studied a group of 37 patients with AA and/or PNH. Polymerase chain reaction (PCR) and enzymatic digestion were utilized to analyze XmnI polymorphisms; and PCR, cloning and automated sequencing for the HS2 polymorphisms.

RESULTS

The mean HbF level was 2.32%, but there was no significant difference in HbF level between the AA and PNH groups (p = 0.46). HbF levels of less than 1.0% showed a significant correlation with absence of the XmnI (+) polymorphism (p = 0.02). The presence of the XmnI allele was greater in the AA group (p = 0.007).

CONCLUSIONS

XmnI polymorphism absence reduction is associated with acquired HbF elevation. Further studies are required to confirm these observations and make treatment, prognosis and survival comparisons.

Transcranial Doppler in Adult Patients with Sickle Cell Disease

BACKGROUND

Transcranial Doppler (TCD) is the key test in determining the need for prophylactic blood transfusion to prevent stroke in children with sickle cell disease (SCD). The role of TCD in assessing stroke risk in adults with SCD as well as the pattern of TCD velocities in these patients are still undetermined.

METHODS

The authors compared TCD velocities in SCD adults (n=56) with those of healthy controls (n=56).

RESULTS

Velocities in SCD adults were lower than those found in children and higher than in controls and negatively correlated to hematocrit in both groups.

CONCLUSION

The pattern of TCD velocities in adults with SCD is different from that described in children. Age-specific TCD criteria may assist the detection of stroke risk in these patients.