Persistent hypofibrinolysis in severe COVID-19 associated with elevated fibrinolysis inhibitors activity

Hypercoagulability and reduced fibrinolysis are well-established complications associated with COVID-19. However, the timelines for the onset and resolution of these complications remain unclear. The aim of this study was to evaluate, in a cohort of COVID-19 patients, changes in coagulation and fibrinolytic activity through ROTEM assay at different time points during the initial 30 days following the onset of symptoms in both mild and severe cases. Blood samples were collected at five intervals after symptoms onset: 6-10 days, 11-15 days, 16-20 days, 21-25 days, and 26-30 days. In addition, fibrinogen, plasminogen, PAI-1, and alpha 2-antiplasmin activities were determined. Out of 85 participants, 71% had mild COVID-19. Twenty uninfected individuals were evaluated as controls. ROTEM parameters showed a hypercoagulable state among mild COVID-19 patients beginning in the second week of symptoms onset, with a trend towards reversal after the third week of symptoms. In severe COVID-19 cases, hypercoagulability was observed since the first few days of symptoms, with a tendency towards reversal after the fourth week of symptoms onset. A hypofibrinolytic state was identified in severe COVID-19 patients from early stages and persisted even after 30 days of symptoms. Elevated activity of PAI-1 and alpha 2-antiplasmin was also detected in severe COVID-19 patients. In conclusion, both mild and severe cases of COVID-19 exhibited transient hypercoagulability, reverted by the end of the first month. However, severe COVID-19 cases sustain hypofibrinolysis throughout the course of the disease, which is associated with elevated activity of fibrinolysis inhibitors. Persistent hypofibrinolysis could contribute to long COVID-19 manifestations.

Extracellular vesicles are a late marker of inflammation, hypercoagulability and COVID-19 severity

Exacerbated inflammation and coagulation are a hallmark of COVID-19 severity. Extracellular vesicles (EVs) are intercellular transmitters involved in inflammatory conditions, which are capable of triggering prothrombotic mechanisms. Since the release of EVs is potentially associated with COVID-19-induced coagulopathy, the aim of this study was to evaluate changes in inflammation- and hypercoagulability-related EVs during the first month after symptom onset and to determine whether they are associated with disease severity. Blood samples of patients with mild or severe forms of the disease were collected on three occasions: in the second, third and fourth weeks after symptom onset for the quantification by flow cytometry of CD41A (platelet glycoprotein IIb/IIIa), CD162 (PSGL-1), CD31 (PECAM-1) and CD142 cells (tissue factor). Analysis of variance (ANOVA) with repeated measures, Kruskal-Wallis and correlation tests were used. Eighty-five patients were enrolled, 71% of whom had mild disease. Seventeen uninfected individuals served as controls. Compared to controls, both mild and severe COVID-19 were associated with higher EV-CD31+, EV-CD41+ and EV-CD142+ levels. All EV levels were higher in severe than in mild COVID-19 only after the third week from symptom onset, as opposed to C-reactive protein and D-dimer levels, which were higher in severe than in mild COVID-19 earlier during disease progression. EV levels were also associated with C-reactive protein and D-dimer levels only after the third week of symptoms. In conclusion, EVs expressing CD41A, CD31, TF, and CD162 appear as late markers of COVID-19 severity. This finding may contribute to the understanding of the pathogenesis of acute and possibly long COVID-19.

Data-driven, cross-disciplinary collaboration: lessons learned at the largest academic health center in Latin America during the COVID-19 pandemic

Introduction

The COVID-19 pandemic has prompted global research efforts to reduce infection impact, highlighting the potential of cross-disciplinary collaboration to enhance research quality and efficiency.

Methods

At the FMUSP-HC academic health system, we implemented innovative flow management routines for collecting, organizing and analyzing demographic data, COVID-related data and biological materials from over 4,500 patients with confirmed SARS-CoV-2 infection hospitalized from 2020 to 2022. This strategy was mainly planned in three areas: organizing a database with data from the hospitalizations; setting-up a multidisciplinary taskforce to conduct follow-up assessments after discharge; and organizing a biobank. Additionally, a COVID-19 curated collection was created within the institutional digital library of academic papers to map the research output.

Results

Over the course of the experience, the possible benefits and challenges of this type of research support approach were identified and discussed, leading to a set of recommended strategies to enhance collaboration within the research institution. Demographic and clinical data from COVID-19 hospitalizations were compiled in a database including adults and a minority of children and adolescents with laboratory confirmed COVID-19, covering 2020-2022, with approximately 350 fields per patient. To date, this database has been used in 16 published studies. Additionally, we assessed 700 adults 6 to 11 months after hospitalization through comprehensive, multidisciplinary in-person evaluations; this database, comprising around 2000 fields per subject, was used in 15 publications. Furthermore, thousands of blood samples collected during the acute phase and follow-up assessments remain stored for future investigations. To date, more than 3,700 aliquots have been used in ongoing research investigating various aspects of COVID-19. Lastly, the mapping of the overall research output revealed that between 2020 and 2022 our academic system produced 1,394 scientific articles on COVID-19.

Discussion

Research is a crucial component of an effective epidemic response, and the preparation process should include a well-defined plan for organizing and sharing resources. The initiatives described in the present paper were successful in our aim to foster large-scale research in our institution. Although a single model may not be appropriate for all contexts, cross-disciplinary collaboration and open data sharing should make health research systems more efficient to generate the best evidence.

High-dose chemotherapy with autologous stem cell transplant (HDCT) for patients (pts) with advanced germ-cell tumors (aGCT): Real-world evidence from a tertiary cancer center in Brazil

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Background: HDCT is a potentially curative treatment for pts with aGCT after conventional-dose chemotherapy (CDC). There is scarce evidence of outcomes from aGCT pts treated with HDCT in low and middle-income countries. Methods: We reviewed our institutional database to identify pts with progressive aGCT referred for HDCT following tumor boards. Medical charts were analyzed to extract clinical data. Log-rank was used to compare survival estimates and Cox proportional hazard to determine effects on overall survival (OS). Exploratory correlation and survival trend analysis used synthetic minority oversampling and Spearman’s rho estimated correlations. Results: From 1/2013 to 8/2022, 35 aGCT pts were referred for HDCT. Median age was 28 years (IQR 25-30). Most pts had testicular primary (84%), non-seminoma histology (87%), 1 prior treatment line (62%), poor-risk by IGCCCG (78%), and intermediate to very high-risk by IPFSG (45%). Of these, 32 pts were deemed eligible after initial evaluation, 25 had mobilization chemotherapy, and 21 received ≥1 cycle of HDCT. Reasons for treatment non-fulfillment included progressive disease and/or performance deterioration due to toxicity. HDCT regimen varied, with most pts receiving TI-CE (62%). Most pts had delays ≥1 month (85%) and ≥2 months (52%) in the scheduled treatment. The 1-year and 2-year OS rates were 42% and 38% in the eligible population, while 70% and 62% among those who had ≥ 1 cycle HDCT. No risk factors correlated with OS in the univariate analysis (Table). Exploratory analysis of oversampled pts treated with ≥1 cycle of HDCT showed correlation of poor IGCCCG (p<0.01) and IPFSG (p=0.03) with OS. Time to mobilization (TTM) was larger in poor-risk IGCCCG pts (0.4 vs. 1.7 months, p<0.01). Four deaths were attributed to HDCT. Conclusions: HDCT was feasible at our tertiary center in Brazil, despite some treatment-related deaths. For pts who had at least 1 HDCT cycle, survival outcomes were similar to the established literature. Significant delays in protocol were noted and correlated with prognostic group risk. [Table: see text]

First report of PhALLCON: A phase 3 study comparing ponatinib (pon) vs imatinib (im) in newly diagnosed patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL)

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Background: The standard of care in patients (pts) with newly diagnosed (dx) Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) is BCR::ABL1 tyrosine kinase inhibitors (TKIs) in combination with chemotherapy (chemo) or steroids. Treated with 1st- or 2nd-generation TKIs, pts eventually progress due to emergence of resistance. Multiple studies have reported promising minimal residual disease (MRD) negativity (neg) rates and survival outcomes with pon in combination with chemo or chemo-free regimens. PhALLCON (NCT03589326), the first randomized study comparing TKIs in pts with Ph+ALL, evaluates pon vs im in combination with reduced-intensity chemo. Methods: This phase 3 open-label trial randomized adult newly dx Ph+ALL pts 2:1 to receive pon (30 mg once daily [QD]) or im (600 mg QD) with reduced-intensity chemo through end of induction (EOI; Cycles 1–3), consolidation (Cycles 4–9), and post-consolidation (Cycles 10–20). After Cycle 20, pts received single-agent pon or im until disease progression or unacceptable toxicity. The composite primary endpoint was MRD-neg ( BCR:: ABL1 ≤0.01% ) complete remission (CR) for 4 weeks at EOI. Event-free survival (EFS: any cause death, failure to achieve CR by EOI, relapse from CR) was a key secondary endpoint. Results: 245 pts were randomized to pon (n=164) or im (n=81); median age was 54 y (37% ≥60 y). At data cutoff (Aug 2022), 78 pts (pon vs im: 42% vs 12%) were on study treatment; the top 3 reasons for discontinuation were hematopoietic stem cell transplantation (31% vs 37%), adverse events (12% vs 12%), and lack of efficacy (7% vs 26%). Median follow-up was 20 mo vs 18 mo (pon vs im). The primary endpoint was met (Table) by significantly higher MRD-neg CR rate for pon vs im (34.4% vs 16.7%; p=0.0021). Survival data were not mature; however, the median EFS was reached in im and not in pon, with a trend toward improvement (HR=0.652, 95% CI 0.385–1.104). Time to treatment failure reported an improvement as well (HR=0.455). The treatment-emergent adverse event (TEAE) rates (any grade [Gr] and Gr3/4/5) were comparable between treatment arms. Arterial occlusive events (AOEs) were infrequent and similar between the arms (Table). Conclusions: Pon was superior to im in combination with reduced-intensity chemo in pts with newly dx Ph+ALL, with a significantly higher MRD-neg CR rate at the EOI. Pon was associated with deeper and more durable responses, with a trend toward improved EFS and comparable safety vs im. Clinical trial information: NCT03589326 . [Table: see text]

Measles, mumps and rubella vaccine 12 months after hematopoietic stem cell transplantation

The measles, mumps and rubella (MMR) vaccine is usually recommended from 24 months after a hematopoietic stem cell transplant (HSCT). Some authors have demonstrated that the MMR vaccination can be safe from 12 months post-HSCT in non-immunosuppressed patients, as recommended by the Brazilian National Immunization Program/Ministry of Health, since 2006. The objectives of this study were to evaluate when patients received MMR vaccine after an HSCT in our care service and if there were reports of any side effects. We retrospectively reviewed the records of HSCT recipients who received at least one MMR dose in our care service, a quaternary teaching hospital in Sao Paulo city, Brazil, from 2017 to 2021. We identified 82 patients: 75.6% (90.1% in the autologous group and 45.1% in the allogeneic group) were vaccinated before 23 months post-transplantation. None reported side effects following the vaccination. Our data support that the MMR vaccination is safe from 12 to 23 months after HSCT.

EXTRACELLULAR VESICLES AS MARKERS OF INFLAMMATION AND HYPERCOAGULABILITY DURING THE FIRST MONTH OF SARS-COV-2 INFECTION IN OUTPATIENTS AND HOSPITALIZED PATIENTS

Introduction

During SARS-CoV-2 infection, a severe hypercoagulability state is observed due to the stimulus of multiple mechanisms of hemostasis, such as coagulation, activation of platelets, endothelial cells, monocytes and neutrophils and impaired fibrinolysis. As a consequence, thrombotic complications are common in the course of COVID-19. Microvesicles (MVs) are intracellular transmitters that participate in pathological conditions, such as inflammatory and infectious processes, and are capable of triggering prothrombotic mechanisms. Since MVs release is potentially associated with COVID-19-induced coagulopathy, our aim was to identify during the course of the disease when the stimulus for MVs release occurs and whether this was associated with adverse outcomes.

Objective

We evaluated changes in the levels of MVs markers during the first month of SARS-CoV-2 infection in patients (pts) with severe disease (hospitalized in an Intensive Care Unit ‒ ICU) as compared to outpatients. We also evaluated the association between MVs markers with: inflammatory biomarkers (C-reactive protein, CRP), hypercoagulability (D-dimer) and death.

Methods

Blood samples were collected on three occasions: before the 10^th day of symptoms, in the 3^rd week of symptoms and in the 4^th week of symptoms for the quantification of the following MVs markers by flow cytometry: CD41A (platelet activation), CD162 (PSGL-1; leukocyte-platelet interaction), CD31 (endothelium-platelet interaction) and CD142 (tissue factor). Statistical tests of ANOVA with repeated measures, Mann-Whitney and regression methods were used.

Results

The population studied was 85 pts, being 25 from ICU. Mostly were men (51%), with a median age of 41 years. The concentration of MVs expressing CD31+, CD41+, CD162+ and CD142+ were persistently elevated in pts who required ICU compared to outpatients at the 3 moments studied, except for the levels of MVs-CD31+ and MVs-CD142+ that were similar between ICU and outpatients in the 4^th week of symptoms. However, despite the differences between the groups, there were no significant changes in the levels of MVs during the course of the disease within the groups. In subgroup analysis, we observed that increases in the levels of MVs-CD162+ and MVs-CD142+ in the 3^rd week of symptoms were associated with the risk of death (p=0.02 and p=0.06, respectively). We also observed that during the course of the disease an association between MVs, coagulability and inflammation was evident. In the 3rd week of symptoms, D-dimer levels were correlated with MV-CD31+ (r=0.52, p<0.0001), MV-CD162+ (r=0.35, p=0.001), MV-CD41A+ (r=0.44, p<0.0001) and MV-CD142+ (r=0.47, p<0.0001) and CRP values were correlated with MV-CD31+ (r=0.56, p=<0.0001), MV-CD162+ (r=0.48, p<0.0001), MV-CD41A+ (r= 0.41, p=0.0001), and MV-CD142+ (r=0.56, p<0.0001). By the 4^th week of symptoms, both D-dimers and CRP correlations with the above MVs remained unchanged.

Conclusion

To conclude, MVs that express antigens related to platelet activation, leukocyte-platelet interaction and endothelium-platelet interaction, as well as those related to tissue factor are released during the course of COVID-19 in pts with severe disease. After the 4^th week of symptoms, the release of these MVs was associated with signs of inflammation and hypercoagulability. Additionally, MVs that express tissue factor and leukocyte-platelet interaction antigens were particularly high among non-survivors, suggesting that these MVs may serve as markers of the risk of death. Finally, these findings suggest the participation of innate immunity and tissue factor pathways in the prognosis of COVID-19, and point towards a possible role of MVs as biomarkers of disease prognosis.

Post-acute sequelae of SARS-CoV-2 infection: relationship of central nervous system manifestations with physical disability and systemic inflammation

BACKGROUND

Despite the multitude of clinical manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC), studies applying statistical methods to directly investigate patterns of symptom co-occurrence and their biological correlates are scarce.

METHODS

We assessed 30 symptoms pertaining to different organ systems in 749 adults (age = 55 ± 14 years; 47% female) during in-person visits conducted at 6-11 months after hospitalization due to coronavirus disease 2019 (COVID-19), including six psychiatric and cognitive manifestations. Symptom co-occurrence was initially investigated using exploratory factor analysis (EFA), and latent variable modeling was then conducted using Item Response Theory (IRT). We investigated associations of latent variable severity with objective indices of persistent physical disability, pulmonary and kidney dysfunction, and C-reactive protein and D-dimer blood levels, measured at the same follow-up assessment.

RESULTS

The EFA extracted one factor, explaining 64.8% of variance; loadings were positive for all symptoms, and above 0.35 for 16 of them. The latent trait generated using IRT placed fatigue, psychiatric, and cognitive manifestations as the most discriminative symptoms (coefficients > 1.5, p < 0.001). Latent trait severity was associated with decreased body weight and poorer physical performance (coefficients > 0.240; p ⩽ 0.003), and elevated blood levels of C-reactive protein (coefficient = 0.378; 95% CI 0.215-0.541; p < 0.001) and D-dimer (coefficient = 0.412; 95% CI 0.123-0.702; p = 0.005). Results were similar after excluding subjects with pro-inflammatory comorbidities.

CONCLUSIONS

Different symptoms that persist for several months after moderate or severe COVID-19 may unite within one latent trait of PASC. This trait is dominated by fatigue and psychiatric symptoms, and is associated with objective signs of physical disability and persistent systemic inflammation.

Post-acute sequelae of SARS-CoV-2 infection (PASC): a protocol for a multidisciplinary prospective observational evaluation of a cohort of patients surviving hospitalisation in Sao Paulo, Brazil

INTRODUCTION

COVID-19 may lead to persistent and potentially incapacitating clinical manifestations (post-acute sequelae of SARS-CoV-2 infection (PASC)). Using easy-to-apply questionnaires and scales (often by telephone interviewing), several studies evaluated samples of COVID-19 inpatients from 4 weeks to several months after discharge. However, studies conducting systematic multidisciplinary assessments of PASC manifestations are scarce, with thorough in-person objective evaluations restricted to modestly sized subsamples presenting greatest disease severity.

METHODS AND ANALYSES

We will conduct a prospective observational study of surviving individuals (above 18 years of age) from a cohort of over 3000 subjects with laboratory-confirmed COVID-19 who were treated as inpatients at the largest academic health centre in Sao Paulo, Brazil (Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo). All eligible subjects will be consecutively invited to undergo a 1-2-day series of multidisciplinary assessments at 2 time-points, respectively, at 6-9 months and 12-15 months after discharge. Assessment schedules will include detailed multidomain questionnaires applied by medical research staff, self-report scales, objective evaluations of cardiopulmonary functioning, physical functionality and olfactory status, standardised neurological, psychiatric and cognitive examinations, as well as diagnostic laboratory, muscle ultrasound and chest imaging exams. Remaining material from blood tests will be incorporated by a local biobank for use in future investigations on inflammatory markers, genomics, transcriptomics, peptidomics and metabolomics.

ETHICS AND DISSEMINATION

All components of this programme have been approved by local research ethics committees. We aim to provide insights into the frequency and severity of chronic/post-COVID multiorgan symptoms, as well as their interrelationships and associations with acute disease features, sociodemographic variables and environmental exposures. Findings will be disseminated in peer-reviewed journals and at scientific meetings. Additionally, we aim to provide a data repository to allow future pathophysiological investigations relating clinical PASC features to biomarker data extracted from blood samples.

TRIAL REGISTRATION NUMBER

RBR-8z7v5wc; Pre-results.

Autologous hematopoietic stem cell transplant in a patient with leprosy: Is it safe?

A patient with non-Hodgkin lymphoma, preparing for an autologous hematopoietic stem cell transplant (HSCT), developed leprosy. The patient was successfully treated with rifampicin, ofloxacin, and doxycycline, and the HSCT was performed without complications, being the first report, to our knowledge, of leprosy in an autologous HSCT patient.

Oxaliplatin-related thrombocytopenia

Oxaliplatin is a third generation platinum compound that inhibits DNA synthesis, mainly through intrastrandal cross-links in DNA. Most of the experience with the clinical use of this drug is derived from colorectal cancer but it is also used in other tumor types such as ovary, breast, liver and non-Hodgkin's lymphoma. Thrombocytopenia is a frequent toxicity seen during oxaliplatin treatment, occurring at any grade in up to 70% of patients and leading to delays or even discontinuation of the chemotherapy. Although myelossupression is recognized as the main cause of oxaliplatin-related thrombocytopenia, new mechanisms for this side-effect have emerged, including splenic sequestration of platelets related to oxaliplatin-induced liver damage and immune thrombocytopenia. These new pathophysiology pathways have different clinical presentations and evolution and may need specific therapeutic maneuvers. This article attempts to review this topic and provides useful clinical information for the management of oxaliplatin-related thrombocytopenia.

Presence of human immunodeficiency virus (HIV) and T-lymphotropic virus type I and II (HTLV-I/II) in a haemophiliac population in Belo Horizonte, Brazil, and correlation with additional serological results

The aim of this study was to determine the prevalence of human immunodeficiency virus type 1 (HIV-1) and human T lymphotropic virus types I and II (HTLV-I/II) infections in 226 haemophiliac patients treated at Fundação Hemominas in Belo Horizonte, Minas Gerais State, Brazil, and to verify association with other serological results. Patients positive for HTLV-I/II had also a neurological, haematological and ophthalmological evaluation. Fundação Hemominas offers comprehensive care for all haemophiliac patients in Minas Gerais. Thirty-six (15.9%) of the 226 patients showed reactive results to HIV-1 [ELISA, Abbott, USA, confirmed by Western blot (WB), Cambridge Biotech, USA, and/or immunofluorescence, Fiocruz, Brazil] and 16 (7.1%) had reactive sera to HTLV-I/II (ELISA, Ortho). Eleven of these 16 (4.9%) were positive, 3/16 (1.3%) were indeterminate and 2/16 (0.9%) were negative in the HTLV WB (Cambridge Biotech). Neurological, haematological and ophthalmological examination of 9/16 patients revealed no abnormality suggestive of HTLV disease. Of the 16 patients reactive to HTLV-I/II ELISA test, six (37.5%) were also positive to HIV-1 (chi 2 = 5.92; P = 0.01). Seropositivity for HTLV-I/II and HIV-1 was associated with advancing age and positive results for hepatitis C virus (HCV), Chagas' disease (T. cruzi infection) and syphilis. No association between the presence of HTLV with type and severity of haemophilia and hepatitis B results was detected. The prevalence of antibodies against HIV-1 is approximately three times that of HTLV-I/II and a patient positive for HTLV-I/II had a significantly increased risk of being positive for HIV-1, HCV and T. cruzi.