HIGH RNAemia ASSOCIATES WITH SKEWED T-CELL RESPONSE IN PLWH HOSPITALIZED FOR COVID-19

Background: Severe COVID-19 outcomes have been reported in people living with HIV (PLWH). High SARS-CoV-2 RNAemia has emerged as a hallmark of severe COVID-19, yet its pathogenic role in the context of COVID-19 in PLWH is currently unknown. We hereby measured SARS-CoV-2 RNAemia and explored its association with T-cell/humoral responses and clinical severity in PLWH. Method(s): Unvaccinated PLWH and age/sex-matched people living without HIV (PLWOH) hospitalized for radiologically-confirmed COVID-19 pneumonia were consecutively enrolled (March 2020-January 2021). We measured: SARS-CoV-2 RNAemia (RT-qPCR);T-cell activation (HLA-DR+CD-38+), cytotoxic T-cells [granzyme-B(GRZB)+perforin(PRF)+], GRZB/PRF production (MFI) by cytotoxic T-cells (flow cytometry);SARS-CoV-2-specific cytokines (IFN-gamma/ TNF-alpha/IL-2/IL-4/IL-17A)-producing T-cells, after SARS-CoV-2 spike peptides challenge (flow cytometry);anti-RBD antibodies (ELISA), Spike-ACE2 binding inhibition (receptor binding inhibition assay). Statistics: Mann-Whitney test and Spearman's correlation. Result(s): 18 PLWH (16 on cART;median CD4 361.5/mL;HIV-RNA< 50 cp/ mL in 15/18) and 18 PLWOH were included at a median of 10 days from symptoms onset (Fig.1A). PLWH had lower PaO2/FiO2 [140 (122-151.5) vs. 207 (156.3-309.3);P=0.0005] and higher SARS-CoV-2 RNAemia (Fig.1B). While humoral responses were comparable between groups ( Fig.1C-D), as was T-cell activation, PLWH showed skewed T-cell responses: higher perforin production by cytotoxic T-cells (Fig.1E);fewer SARS-CoV-2-specific IFN-gamma+ and IL-4+ CD4 T-cells (Fig.1F);lower Th1 tri-functional (IFN-gamma+TNF-alpha+IL-2+) and bi-functional (IFN-gamma+TNF-alpha+) CD4 T-cells (Fig.1G);reduced TNF-alpha+ CD8 T-cells (Fig.1H). Interestingly, SARS-CoV-2 RNAemia correlated negatively with PaO2/FiO2 nadir and SARS-CoV-2-specific T-cells, yet positively with perforin production by cytotoxic T-cells (Fig.1I-M). No correlations between RNAemia and humoral responses were found. Conclusion(s): As compared to HIV-uninfected patients, PLWH hospitalized for COVID-19 pneumonia feature high SARS-CoV-2 RNAemia which is linked to respiratory failure and skewed T-cell responses, with higher perforin production by cytotoxic T-cells, and yet fewer polyfunctional SARS-CoV-2-specific T-cells. Our data suggest a link between HIV-related T-cell dysfunction and poor control over circulating SARS-CoV-2 that may in turn influence COVID-19 severity in PLWH. (Figure Presented).

Adaptive Immunity Dysregulation Is Associated to the Development of Long Covid

Background: The pathogenetic mechanisms behind the development of long- COVID (LC) are largely unknown. Because both plasma SARS-CoV-2 RNAemia and dysregulated immunity have been correlated with COVID-19 severity, we evaluated whether they are associated with LC. Method(s): We consecutively enrolled unvaccinated hospitalized COVID-19 patients during acute-COVID-19 (T0) in March-October 2020 who either developed LC at a follow-up visit 2-3 months from virologic clearance (T1) or did not. LC was defined as persistence >=2 months after recovery of >=1 symptom: anosmia, dysgeusia, fever, gastrointestinal symptoms, dyspnoea, fatigue, musculoskeletal pain, muscle weakness, brain fog. We measured: SARS-CoV-2 RNAemia (RT-qPCR, log10(copies/mL)), magnitude (ELISA, AUC) and functionality (pseudovirus neutralization, ID50;Fc-mediated functions, %ADCC) of SARS-CoV-2-specific antibodies, SARS-CoV-2-specific B and CD4-T-cells (Immunophenotype, AIM and ICS assays). Result(s): We enrolled 48 COVID-19 individuals, 38/48 (79.2%) developed LC (LC+) and 10 did not (LC-). LC+ and LC- had similar co-morbidities and symptoms in the acute phase (Fig.1A), and the majority showed a radiologically documented SARS-CoV-2 pneumonia. The SARS-CoV-2 RNAemia did not differ between groups at both time points. The levels of RBD-specific Abs, as well as their functionality, appeared to increase over time in the LC- group but not in the LC+ (Fig.1B-D). Similarly, a trend towards increased RBD-specific B-cells was observed over time in the LC- group but not in LC+ (Fig.1E). B-cell immunophenotyping showed a significant increase over time of classical memory B cells (MBCs) at the expenses of activated MBCs (Fig.1F-G) as well as an IgA class-switching in the LC- group compared to LC+ (Fig.1H-I). Furthermore, LC+ showed a faster decline of SARS-CoV-2-specific (CD69+CD137+) CD4- TEMRA and CD4-TEM (Fig.1L-M). Finally, IFN-gamma-producing TREG of LC- individuals increased over time (Fig.1N). Conclusion(s): Acutely ill, hospitalized COVID-19 patients developing LC feature a dysregulated SARS-CoV-2-specific humoral as well as B- and T-cell response, in both magnitude and functionality, suggesting a link between dysregulated SARS-CoV-2-specific adaptive immunity and LC development. The fine understanding of the factors contributing to such dysregulation in LC patients is strongly needed, that might further inform targeted therapeutic interventions. (Figure Presented).

Hypofractionated Postmastectomy Radiotherapy (HF-PMRT): What did We Learn from COVID-19 Era?

Objectives: In breast cancer (BC) patients receiving mastectomy, postmastectomy radiotherapy (PMRT) improves long-term outcomes by decreasing local failure and cancer mortality. However, the optimal PMRT schedule is still under investigation. The present review aims to discuss the evidence regarding hypofractionated (HF) PMRT in BC patients in order to identify the optimal treatment approach. Additional purpose is to highlight what we have learned from COVID-19 era regarding HF schedules for PMRT in BC patients. Mechanism: Between February and November 2021, literature and database research were conducted. Key references were detected from a PubMed query. Range of publication date was between 2000 and 2021. Selection criteria included English language publications in humans. Hand searching included meeting proceedings of the European Society for Radiotherapy and Oncology (ESTRO), European Society of Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and American Society for Radiation Oncology (ASTRO). The website clinicaltrials.gov was also searched. Randomized controlled trials evaluating HF-PMRT were included. Findings in brief: Our research returned 87 published papers. Fourteen trials were included in our final analysis. The comparisons of several different schedules of HF-PMRT with conventional fractionated PMRT provided similar results in terms of locoregional disease control without increasing toxicity. Particularly, an acute skin toxicity incidence grade 2 or higher ranged between 10 and 25% among the studies we analyzed. Conclusion(s): The present paper suggests that safety and efficacy of HF-PMRT is comparable with conventional schedules and standard practice guidelines are already available. COVID-19 pandemic has emphasised the need for increasingly tailored treatment protocols. Modern HF regimens should continue to be the standard of treatment in BC patients who receive PMRT also in the post-COVID-19 era.Copyright © 2023 The Author(s).

Heterologous Vaccine Schedule Against Sars-CoV-2 with 2 Doses of Inactivated Virus and a Booster of mRNA BNT162b2 in Kidney Transplant Recipients

Purpose: Emerging evidence suggests that 3 doses of SARS-CoV-2 mRNA vaccine enhance immunity in kidney transplant (KT) patients. However, few studies have focused on humoral response after inactivated virus-based vaccines. Here we report the results of humoral response in KT recipients in comparison with healthy control group after homologous and heterologous regimens with inactivated virus (Coronavac) and mRNA vaccine BNT162b2. Method(s): A multicenter prospective study was conducted. KT recipients received heterologous vaccine schedule (2 doses of Coronavac and a booster of mRNA BNT162b2, n= 136) or homologous (3 doses of BNT162b2 n=19). Healthy control group received 2 doses or Coronavac (n=67) or BNT162b2 (n=15). Serum IgG antibodies against Receptor Binding Domain of SARS-CoV-2 Spike protein were determined 30 and 40 days after last dose. Result(s): Seroconversion was 52.2% and 57,9% with heterologous and homologous vaccination schedules in KT, p=0.789, figure 1. Among KT patients with seroconversion, antibody levels against RBD of SARS-CoV-2 were [1012 (183-3111) and 603 (41-1255) BAU/mL, with heterologous and homologous schedule, respectively. Levels were higher in KT compared to heathy control with 2 doses of inactivated virus 308 (209-335), p=0.03 and lower than heathy control with 2 doses of BNT162b2: 2638 (2608-3808) BAU/mL, p=0.001]. Conclusion(s): Seroconversion improves after a third dose with homologous or heterologous vaccine schedules. Among patients with seroconversion antibody levels were higher than in heathy control with two doses of inactivated virus. Measurement of antibody levels could help to improve vaccination policies.

SARS-CoV-2 PLASMA VIREMIA and DYSREGULATED IMMUNITY in SEVERE COVID-19

Background: Critical COVID-19 occurs ca. 7d from symptoms onset, and is associated to immune dysregulation as well as SARS-CoV-2 detection in plasma (i.e. viremia). We hereby sought to detail the association between SARS-CoV-2 viremia measured at the end of the first week of disease and immune phenotypes/function in COVID-19 patients. Methods: We consecutively enrolled patients hospitalized in the acute phase of ascertained SARS-CoV-2 pneumonia. In this disease stage, we studied SARS-CoV-2 viremia (RT-PCR) and cytokines (MACSPlex), HLA-DR+CD38+ activated, GRZB+PRF+ pro-cytolitic T-cells, intracellular cytokine production (IL-2, IFNγ, TNFα, IL-4, IL-17A) after SARS-CoV-2 challenge (S-N-M-peptide pool). Simultaneous Th1-cytokines production (polyfunctionality) and amount (iMFI) was assessed. Humoral response: anti-S1/S2 IgG, anti-RBD total-Ig, IgM, IgA, IgG1 and IgG3 (ELISA), pseudoviruses neutralization (ID50) and Fc-mediated functions (%ADCC). Results: Out of 54 patients, 27 had detectable viremia (V+). Albeit comparable age and co-morbidities, V+ patients more frequently required non-invasive/invasive ventilatory support (p=0.035), with a trend to higher death (p=0.099) vs patients with undetectable viremia (V-)(Fig.1A). V+ displayed higher circulating IFN-α (p=0.002) and IL-6 (0.003), lower activated HLA-DR+CD38+CD4 (p=0.01) and CD8 (p=0.02), with no differences in GRZB+PRF+ T-cells. V+ featured reduced SARS-CoV-2-specific cytokine-producing T-cells, reaching significance for IFNγ+CD4 (p=0.02), TNFα+CD8, IL-4+CD8 (p=0.04) (Fig.1B-C), with lower bi-and tri-functional SARS-CoV-2-specific CD4 Th1, reaching significance for IL-2+TNFα+CD4 (p=0.03) (Fig.1D). A trend towards lower cytokines iMFI in bi-and tri-functional SARS-CoV-2-specific CD4 Th1 was observed in V+, reaching significance for IL-2+TNFα+CD4, p=0.004. V+ displayed lower anti-S IgG, anti-RBD total-Ig, IgM, IgG1 and IgG3 (Fig.1E), with lower ID50 and %ADCC vs V-(Fig.1F-G). Conclusion: Hospitalized COVID-19 patients with detectable plasma SARS-CoV-2 RNA in the acute phase of disease present worse outcome, higher inflammatory cytokines, fewer activated and SARS-CoV-2-specific polyfunctional T-cells, suggesting a link between SARS-CoV-2 viremia at the end of the first stage of disease and immune dysregulation. Whether high ab initium viral burden and/or intrinsic host factors contribute to a delayed and/or exhausted immune response in severe COVID-19 remains to be elucidated, to further inform strategies of targeted therapeutic interventions.

Intrafraction error analysis of homemade mouth-bite masks in linac-based SRS for brain metastasis

Purpose or Objective To assess the intrafraction accuracy of a frameless stereotactic linac-based radiosurgery (SRS) for brain metastases (BM) using a homemade mouth-bite thermoplastic mask in combination with cone-beam computed tomography (CBCT) and six-degrees of freedom (6-DOF) couchtop. Materials and Methods Covid-19 restrictions resulted in significant delays in the supply of the dedicated devices for BM SRS. A frameless approach using a homemade mouth-bite thermoplastic mask was implemented to offer BM SRS in a period of limited mobility (figure 1). All patients were immobilized and treated at the same institution with 6 MV FFF VMAT radiosurgery, with a 2 mm isotropic expansion from the GTV to the PTV. Before treatment delivery, patients underwent a low-dose CBCT to check position accuracy. Through image co-registration, translational (x, y, z) and rotational errors (roll, pitch, and yaw) were determined. The 6-DOF couchtop was used to automatically relocate the patient with sub-millimetric precision. Immediately after irradiation, patients underwent a second CBCT to verify any translational or rotational errors occurring during therapy (intrafraction motion). $Φg Results From February 2020 to January 2021 sixteen patients (29 lesions) received BM SRS (14-21 Gy). The whole procedure, from the first CBCT scan to the end of irradiation and subsequent CBCT, required a median time of 9 minutes [6-13]. Mean translational error was 0.0 ± 0.3 mm [-0.7;0.9] in lateral direction, and -0.1 ± 0.5 mm [-1.4;1.0] in longitudinal direction. A 2.2 mm maximum shift was recorded on the vertical axis, nevertheless the mean translation error was 0.1 ± 0.6 mm. Roll, pitch and yaw registered a mean value of -0.1 ± 0.3° [-0.8;0.2], 0.0 ± 0.2° [-0.8;0.2], and -0.1 ± 0.3° [-0.8;0.4], respectively. The results are summarized in figure 2. Conclusion This study demonstrated that homemade mouth-bite thermoplastic masks combined with CBCT, 6-DOF couchtop, and fast FFF treatment delivery allow minimal intra-fraction uncertainties in BM SRS, confirming the accuracy of PTV margin definition. The results are comparable to the declared specifics of SRS dedicated commercial frameless mask, while improving patient's comfort compared to the invasive fixed frame. However, the moulding procedure requires improved RTT skills and expertise. Our findings show that SRS can be safely delivered in radiotherapy units without dedicated expensive installations, such as CyberKnife and Gamma Knife, thus reducing patient mobility according to Covid-19 restrictions.

Suicidality and COVID-19: Data from an Emergency Setting in Italy

BACKGROUND: Suicidality is a widespread phenomenon with a dramatic burden worldwide. The Coronavirus disease 2019 (Covid-19) pandemic determined a relevant impact on mental health, due to the infection itself and its socio-economic consequences. The present study is aimed at analyzing the prevalence of suicidality during the Covid-19 pandemic among subjects requiring a psychiatric consultation in an emergency setting. SUBJECTS AND METHODS: Socio-demographic and clinical information was collected at the emergency department of the General Hospital of Perugia from June 1st, 2020 to January 31st, 2021. Data was entered into an electronic datasheet and retrospectively analysed. Pearson's bivariate correlation was performed in order to assess significant associations between suicide-related variables and specific socio-demographic and clinical features (p<0.05). RESULTS: Among 447 subjects included in the analysis, 109 (24.4%) showed suicidality-related phenomena, particularly suicide attempts (SA) (n=44, 9.8%), suicidal ideation (SI) (n=41, 9.2%), non suicidal self-injury (NSSI) (n=31, 6.9%), that in some cases co-occurred. A statistically significant association was detected between NSSI and living with marital family (p=0.024) and between suicidality-related phenomena and adjustment disorders (p=0.018). None of the examined subjects reported a previous positivity for Covid-19 and neither did their relatives. CONCLUSIONS: The present study confirms the impact of the Covid-19 pandemic on suicide-related phenomena. Consultation psychiatry fulfills a key role in the early detection and clinical management of these conditions, that require targeted intervention strategies.

Dental Education Challenges during the COVID-19 Pandemic Period in Italy: Undergraduate Student Feedback, Future Perspectives, and the Needs of Teaching Strategies for Professional Development

The COVID-19 pandemic literally stopped most human movement and activities as it initially spread, which included dental practices and dental education. This defined the need for significative changes in teaching and learning with the use of "e-learning" methods, also for traineeships. This study was designed to determine the undergraduate student perception of these new methods as part of their education. This involved 353 students attending the Dental School of the G. D'Annunzio University of Chieti-Pescara, from the first to the sixth years. A questionnaire in Italian and was set-up using "Google Forms" and sent by email to the students. The questionnaire was divided into three parts: the first part included questions for general information, including age, sex and year of course;the second part had multiple choice questions related to their evaluation of the e-learning teaching, using a scale of opinion in the replies to each question (e.g., "scarce", "fair", "satisfying", "very good" and "excellent");and the third part included two open questions to indicate the strengths and limitations of these new teaching and learning approaches. The categorical variables in the first and second parts of the questionnaire were evaluated using Chi squared tests, setting significance at p < 0.05, while the comments were evaluated qualitatively. The student feedback showed significant appreciation (p < 0.05) of the new methods and the efforts that the lecturers put in to provide lectures of as high a quality as possible. However, a lack of practical training was significantly perceived as an important problem in the structure of their new curriculum (p < 0.05). COVID-19 has been an epic tragedy that has hit the human population not only in terms of health and healthcare, but also quality of life. This includes the quality of dental education within universities. However, the pandemic can be seen to also represent motivation to invest in the necessary technological innovation to deliver the best possible education to our future dentists.

Fractal analysis of market (in)efficiency during the COVID-19

Using the multifractional Brownian motion as a model of the price dynamics, we analyze the impact of the COVID-19 pandemic on the efficiency of fifteen financial markets from Europe, US and Asia. We find that Asian markets (Hang Seng, Nikkei 225, Kospi) have recovered full efficiency, while European and US markets after an initial rebound have not yet returned to the pre-crisis level of efficiency. The inefficiency that currently characterizes US and European markets originates moderately high levels of volatility.

S75 Hyperpolarised 129-xenon MRI in differentiating between fibrotic and inflammatory interstitial lung disease and assessing longitudinal change

S75 Figure 1Difference between the fibrotic and inflammatory groups in mean 129Xe ADC (a) and LmD (b) at baseline study visit[Figure omitted. See PDF]Conclusions129Xe DW-MRI could have a role in differentiating changes in the airway microstructure between fibrotic and inflammatory ILD. 129Xe RBC:TP has sensitivity to longitudinal change with a decline in gas exchange observed in the fibrotic group but not in the inflammatory group.

Accurate triage may be efficacious in selecting patients who could safely continue anticancer therapy during SARS-CoV-2 pandemic

Background: During the SARS-COV-2 pandemic, cancer patients (pts) who are infected may develop severe disease if their systemic treatment is not temporarily stopped. Nasopharyngeal swab was not extensively available to screen cancer pts for SARS-COV-2 infection in northern Italy, the most area in the country most affected by the pandemic. From the beginning of the outbreak onwards, all pts admitted to the Medical Oncology Unit at Spedali Civili Hospital, Brescia, underwent a triage investigating the presence of symptoms and signs suggestive of SARS-COV-2 infection. Triage results were used to decide which pts should continue antineoplastic treatments. Methods: All consecutive cancer pts being admitted for systemic treatment from February 24th to April 21st 2020 were considered. Triage, performed by a trained nurse, consisted of questions regarding the presence of fever, cough, dyspnea, anosmia, dysgeusia, headache, nasal congestion, conjunctival congestion, sore throat, diarrhoea, nausea and vomiting, measurement of body temperature and pulse oximetry. All enrolled pts were followed-up for overt SARS-COV-2 development until May 18th. Results: Overall, 1180 pts were included, 54% female and median age 65 years. Most represented primary malignancies were breast (32%), gastroenteric (18%) and lung (16.5%). Thirty-one (2.5%) presented with clinically evident SARS-COV-2 disease and infection was proven by positive nasopharyngeal swab and/or radiological imaging. The triage identified 69 (6%) “grey zone” pts, with suspicious symptoms (i.e. fever 41%, cough 30%, dyspnea 19%). The nasopharyngeal swab was negative in 48% of them and was not performed in the remaining 52% of pts, as well as in all pts who were triage negative. Both SARS-COV-2 positive and “grey zone” pts did not receive treatment and were addressed to hospitalisation or home quarantine. All the 1080 pts (91.5%) who resulted negative at triage continued their antineoplastic therapy as scheduled, none of them presenting symptoms of SARS-COV-2 infection during the follow-up. Conclusions: Accurate triage allowed safe continuation of anticancer treatment in 91.5% of pts during the SARS-COV-2 outbreak. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Vaginal delivery in SARS-CoV-2-infected pregnant women in Northern Italy: a retrospective analysis.

OBJECTIVE: To report mode of delivery and immediate neonatal outcome in women infected with COVID-19. DESIGN: Retrospective study. SETTING: Twelve hospitals in northern Italy. PARTICIPANTS: Pregnant women with COVID-19-confirmed infection who delivered. EXPOSURE: COVID 19 infection in pregnancy. METHODS: SARS-CoV-2-infected women who were admitted and delivered from 1 to 20 March 2020 were eligible. Data were collected from the clinical records using a standardised questionnaire on maternal general characteristics, any medical or obstetric co-morbidity, course of pregnancy, clinical signs and symptoms, treatment of COVID 19 infection, mode of delivery, neonatal data and breastfeeding. MAIN OUTCOME AND MEASURES: Data on mode of delivery and neonatal outcome. RESULTS: In all, 42 women with COVID-19 delivered at the participating centres; 24 (57.1%, 95% CI 41.0-72.3) delivered vaginally. An elective caesarean section was performed in 18/42 (42.9%, 95% CI 27.7-59.0) cases: in eight cases the indication was unrelated to COVID-19 infection. Pneumonia was diagnosed in 19/42 (45.2%, 95% CI 29.8-61.3) cases: of these, 7/19 (36.8%, 95% CI 16.3-61.6) required oxygen support and 4/19 (21.1%, 95% CI 6.1-45.6) were admitted to a critical care unit. Two women with COVID-19 breastfed without a mask because infection was diagnosed in the postpartum period: their newborns tested positive for SARS-Cov-2 infection. In one case, a newborn had a positive test after a vaginal operative delivery. CONCLUSIONS: Although postpartum infection cannot be excluded with 100% certainty, these findings suggest that vaginal delivery is associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn. TWEETABLE ABSTRACT: This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS-Cov-2 transmission to the newborn.