Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy

ABSTRACT Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.

Prevalence of the MTHFR C677T Mutation in Fertile and Infertile Women / Prevalência da mutação MTHFR C677T em mulheres férteis e inférteis

Abstract Introduction The importance of the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in infertile women remains controversial. Objective To evaluate if the MTHFR C677T mutations are more frequent in infertile women, and if they can be associated with the occurrence of infertility in the Brazilian population. Methods This case-control study included 130 infertile women consulting at a private clinic betweenMarch 2003 andMarch 2005 (data previously published), and 260 fertile women attending the family planning outpatient clinic of our institution between April 2012 and March 2013. Data analysis The Chi-squared and Fisher Exact tests were used to evaluate the association between the presence of the MTHFR C677T mutation and a history of infertility. Results The frequency of the mutation was of 58.5% for the case group (n = 76) and of 49.2% for the fertile controls (n = 128). The mutation was homozygous in 13 women in the case group (10%) and in 23 of the fertile women in the control group (8.8%). These differences were not statistically significant. Conclusions These results suggest that the presence of the MTHFR C677T mutation does not constitute a risk factor for infertility, even when themutation is homozygous. Further studies are needed to confirm whether research on this mutation should be considered unnecessary in women with infertility.

Resumo Introdução A importância da mutação C677T no gene da metilenotetrahidrofolato redutase (MTHFR) em mulheres com infertilidade permanece controversa. Objetivo Avaliar se a mutação MTHFR C677Témais frequente em mulheres inférteis, e se pode ser associada com a ocorrência de infertilidade na população brasileira. Métodos Estudo de caso-controle, com avaliação de 130 mulheres com infertilidade atendidas em clínica privada no período de março de 2003 a março de 2005 (dados previamente publicados) e 260 mulheres férteis atendidas no ambulatório de planejamento familiar de nossa instituição no período de abril de 2012 a março de 2013. Análise dos dados Foram utilizados os testes de Qui-quadrado e Exato de Fisher para o estudo da associação entre a presença damutação MTHFR C677T e o antecedente de infertilidade. Resultados A frequência da mutação foi de 58,5% nos casos (n = 76) e de 49,2% nos controles (n = 128). Dentre os casos, 13 apresentavam esta mutação em homozigose (10%). Nos controles, a homozigose foi encontrada em 23 mulheres férteis (8,8%). Estas diferenças não foram estatisticamente significativas. Conclusões Este estudo sugere que a presença da mutação MTHFR C677T não constitui fator de risco para infertilidade, mesmo em casos de homozigose. Estudos complementares são necessários para ratificar se a investigação desta mutação deve ser considerada desnecessária em mulheres com infertilidade.

CD144, CD146 and VEGFR-2 properly identify circulating endothelial cell

Studies evaluating circulating endothelial cells by flow cytometry are faced by a lack of con- sensus about the best combination of monoclonal antibodies to be used. The rarity of these cells in peripheral blood, which represent 0.01% of mononuclear cells, drastically increases this challenge. Objective: The aim of this study is to suggest some combinations of markers that would safely and properly identify these cells. Methods: Flow cytometry analysis of circulating endothelial cells was performed applying three different panels composed of different combinations of the CD144, CD146, CD31, CD133, CD45 and anti-Vascular endothelial growth factor receptor-2 antibodies. Results: In spite of the rarity of the events, they were detectable and presented similar interperson numbers of circulating endothelial cells. Conclusion: The combination of markers successfully identified the circulating endothelial cells in healthy individuals, with the use of three different panels confirming the obtained data as reliable.

Prevalência dos fatores trombofílicos em mulheres com infertilidade / Prevalence of thrombophilic factors in infertile women

OBJETIVO: determinar a prevalência dos fatores trombofílicos em mulheres inférteis. MÉTODOS: estudo de corte transversal, no qual foram admitidas mulheres inférteis atendidas em clínica privada e submetidas à investigação de trombofilia, conforme protocolo da referida clínica, no período de março de 2003 a março de 2005, após aprovação do Comitê de Ética e Pesquisa da Universidade Estadual de Campinas (UNICAMP). Foram incluídas mulheres com história de infertilidade, definida como um ano de coito desprotegido sem concepção. Foram excluídas mulheres com hepatopatia e dados incompletos em prontuário, obtendo-se uma amostra de 144 mulheres. Os fatores trombofílicos avaliados foram: o anticorpo anticardiolipina (ACL), o anticoagulante lúpico (ACGL), a deficiência de proteína C (DPC), a deficiência de proteína S (DPS), a deficiência de antitrombina III (DAT), a presença do fator V de Leiden, uma mutação no gene da protrombina e a mutação do metileno tetrahidrofolato redutase (MTHFR). Resultados: os valores de prevalência obtidos para ACL e ACGL foram de 2 por cento. A prevalência dos fatores trombofílicos hereditários foram: DPC=4 por cento, DPS=6 por cento, DAT=5 por cento, fator V de Leiden=3 por cento, mutação da protrombina=3 por cento e mutação MTHFR=57 por cento. CONCLUSÕES: das 144 pacientes selecionadas, 105 mulheres, ou seja, 72,9 por cento apresentavam pelo menos um fator trombofílico presente. Isto reforça a importância e justifica a necessidade da investigação destes fatores neste grupo de mulheres.

PURPOSE: to establish the prevalence of thrombophilic factors in infertile women. METHODS: a cross-sectional study was performed, in which infertile women, seen in a private clinic with investigation for thrombophilia were included, according to the protocol of the clinic, between March 2003 and March 2005, after the approval of the Research Ethics Committee of the Universidade Estadual de Campinas (UNICAMP). One hundred and forty-four infertile women without any liver disease were evaluated. Infertility is defined as one year of unprotected sexual intercourse without conception. The acquired and/or inherited thrombophilic factors investigated were: anticardiolipin antibody (aCL), lupus anticoagulant (LA), protein C deficiency (PCD), protein S deficiency (PSD), antithrombin III deficiency (ATD), presence of the factor V Leiden, mutation G20 210A in the prothrombin gene, and C677T mutation of methylene tetrahydrofolate reductase (MTHFR). RESULTS: the prevalence values obtained for aCL and LA were 2 percent. The prevalence of the hereditary thrombophilic factors were: PCD=4 percent, PSD=6 percent, ATD=5 percent, factor V Leiden=3 percent, prothrombin mutation=3 percent, MTHFR mutation=57 percent. Conclusions: of the 144 patients selected, 105 women (72.9 percent) presented at least one thrombophilic factor. This reinforces the importance and justifies the need of investigation in this group.

Methylene tetrahydrofolate reductase gene mutation together with anticardiolipin antibody during pregnancy: a case report

CONTEXT: High plasmatic homocysteine levels have been associated with arterial and venous thrombosis. The C677T methylene tetrahydrofolate reductase (MTHFR) gene mutation is one of the known causes for high homocysteine levels in plasma. Anticardiolipin antibody (ACA) is also associated with thrombosis and, along with other clinical complications such as recurrent abortion and stillbirth, is part of the antiphospholipid syndrome. DESIGN: Case report. CASE REPORT: A 19-year-old woman with two gestations and one parity (G2P1) had exhibited deep venous thrombosis in her previous puerperal period. Investigation of thrombophilic factors revealed ACA-IgM and heterozygous C677T mutation in the MTHFR gene. Lupus anticoagulant, protein C, protein S and antithrombin III deficiencies, and Leiden factor V and the G20210A mutation in the prothrombin gene, were not detected. The patient received 55,000 IU of subcutaneous heparin daily, from the 15th to the 36th week of pregnancy, when vaginal delivery took place. There were no clinical complications during the puerperal period and she was discharged three days after delivery, while still using oral anticoagulants

A rapid detection method for PAI-1 promoter insertion/deletion polymorphism (4G/5G)

O inibidor do ativador do plasminogênio-1 (PAI-1) é o inibidor principal da fibrinólise. Estudos populacionais prospectivos e retrospectivos demonstraram que níveis plasmáticos elevados de atividade do PAI-1 säo um fator de risco para doença coronariana isquêmica. Recentemente descreveu-se um polimorfismo de inserçäo/deleçäo (4G/5G), localizado na regiäo promotora do gene PAI-1, relacionado aos níveis plasmáticos do PAI-1. A presença do alelo 4G está associada a níveis elevados de atividade do PAI-1. A metodologia comumente empregada para a determinaçäo desse polimorfismo é a amplificaçäo do DNA pela PCR, utilizando-se oligonucleotídeos alelo-específicos. Esta técnica demanda tempo e em análises populacionais, que geralmente avaliam um elevado número de amostras, técnicas otimizadas seriam de grande interesse. Neste artigo descrevemos a determinaçäo deste polimorfismo pela técnica de PCR e SSCP, utilizando o aparelho PhastSystem. Este método mostrou-se uma alternativa ao método anterior, de fácil realizaçäo e com resultados reprodutíveis.

Use of autologous fibrin glue in dermatologic surgery: application of skin graft and second intention healing

Objective: To evaluate the efficiency of biological sealant, an autologous fibrin glue, in dermatological surgery. Design: Randomized clinical trial Setting: The Dermatology Service of Hospital das Clinicas, Universidade de Campinas (UNICAMP), referral center. Patients: 14 patients with malign epithelial cutaneoos tumors participated in the evaluation, each having two tumors, generally facial and symmetrical, in order to perform a comparative evaluation on the same individual. Procedures: The glue was prepared beforehand with a sample of autologous blood. Surgical extirpation of the tumor was followed by grafts or second intention healing. Outcomes: The efficiency of the sealant was then evaluated in relation to hemostasis, adhesion, surgical time and evolution of the granulation tissue, clinically and histologically. Results: Immediate hemostasis and graft adhesion, with a significant reduction of surgical time, and in the open wounds there was immediate hemostasis and a clinical increase in granulation tissue, but with no histological differences among the groups on the 7th day. Conclusion: It is an adjuvant resource in skin cancer surgery.

Fatores de risco relacionados à hemostasia - aterosclerose e infarto do miocárdio / Hemostatic risk factors and myocardial infarction

O infarto agudo do miocárdio é uma das causas mais importantes de morte no Brasil. A oclusäo arterial raramente ocorre devido a progressäo de estreitamento, mas geralmente é causada pela formaçäo de trombo sobre uma placa aterosclerótica. O vaso aterosclerótico também apresenta alteraçöes funcionais, que predispöem a trombose ou vasoconstriçäo excessiva. Alteraçöes dos fatores de coagulaçäo, que säo considerados fatores de risco para doença coronária isquêmica, têm sido descritas tanto em trabalhos de corte como em estudos epidemiológicos prospectivos. O fibrinogênio é considerado fator de risco independente para o infarto agudo do miocárdio. O fator VII, o fator VIII, o fator de von Willebrand, o t-PA e o PAI-1 também parecem estar associados ao risco de doença coronária isquêmica. O grande questionamento é se a alteraçäo desses componentes da hemostasia é causa ou consequência do processo aterosclerótico. Discute-se o papel da hemostasia na aterosclerose e no infarto agudo do miocárdio, assim como os estudos mais relevantes que avaliaram os fatores de coagulaçäo envolvidos no risco dessa doença.