Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

An epidemiological investigation of circulating arboviruses in the Brazilian state of Amapá during the outbreaks of 2013-2016

Introdução: As arboviroses causam graves problemas de saúde pública no Brasil e em muitos dos países da América Latina. A epidemiologia molecular é um instrumento valioso na compreensão da dispersão, persistência e diversidade desses patógenos virais. Objetivos: Neste projeto, buscamos investigar a dinâmica epidemiológica molecular dos arbovíroses (com especial enfoque aos vírus da dengue-DENV, chikungunya - CHIKV e zika -ZIKV) que circularam no estado do Amapá entre os anos de 2013 e 2016. Métodos: 824 amostras de plasma humano foram coletadas pelos laboratórios de Saúde Publica (LACEN) no estado do Amapá entre os anos de 2013 e 2016; essas amostras foram obtidas de pacientes que apresentavam sintomas consistentes com uma das arboviroses. O material genético viral presente nestas amostras foi extraído e os ensaios de qPCR foram realizados. Todas as amostras foram submetidas inicialmente a um ensaio triplex (ZIKV/DENV/CHIKV), as amostras negativas foram posteriormente submetidas a um ensaio de pan-flavivírus. As amostras positivas para um dos ensaios foram submetidas a NGS (sequenciamento de nova geração). Resultados: Das 824 amostras testadas, 36 foram positivas para DENV, ZIKV ou CHIKV; desses 36 positivos, 24 foram para DENV, 11 para CHIKV e 1 para ZIKV. Foram obtidos 27 genomas completos: 16 de DENV (15 DENV1, genótipo V e 1 DENV2, genótipo III) e 11 de CHIKV (genótipo asiático / caribenho). Das 788 amostras testadas com o ensaio de pan-flavivírus, 22 amostras foram positivas; porem apenas uma amostra produziu genoma completo pela técnica de NGS. Este genoma foi relacionado com um flavivírus com semelhante em 76,81% com o vírus Long Pine Key - LPKV, que anteriormente só tinha sido descrito em mosquitos. Árvores de Maximum likelihood e Maximum clade credibility foram construídas utilizando os genomas do DENV1 obtidos neste estudo. Essas árvores exibiam duas linhagens distintas de DENV1, genótipo V presentes na América Latina. Uma destas linhagens tem um padrão de circulação que inclui países do Caribe, América Central e América do Sul (incluindo Brasil); a outra linhagem distinta circula dentro das fronteiras do Brasil. As árvores também indicam que o DENV1 presente no estado do Amapá é da linhagem que tem o padrão de circulação que inclui o Caribe e as Américas Central e do Sul e que essa linhagem surgiu no Amapá entre 2005 e 2010. Conclusão: Este estudo fornece dados importantes sobre as arboviroses no Amapá e os dados genômicos mais recentes disponíveis para a região, bem como o contexto brasileiro e latino-americano para esses dados. Dados dessa natureza são inestimáveis nos esforços das autoridades de saúde pública para a prevenção e controle de epidemias por estes agentes.Introduction: Arboviral febrile illnesses plague the nation of Brazil and many of its surrounding Latin America countries. Molecular epidemiology is a growing and increasingly invaluable tool in the field of public health for understanding the dispersal, persistence, and diversity of these impactful viral pathogens. Objectives: In this project, the identities and molecular epidemiological dynamics of arboviruses circulating in the Brazilian state of Amapá between the years 2013 and 2016, with special focus on DENV, CHIKV and ZIKV, were investigated and given Brazilian and Latin American geographical and temporal context via molecular epidemiological analyses. Methods: 824 human blood plasma samples were collected from LACEN laboratories in the state of Amapá between the years 2013 and 2016; these samples originated from patients showing symptoms consistent with any of the common arboviral febrile illnesses. The viral genetic material present in these samples was extracted and qPCR diagnostics assays were performed; all samples first underwent a triplex assay (ZIKV/DENV/CHIKV - ZDC), then the samples yielding negative results for the triplex assay underwent a pan-flavivirus assay. The samples yielding positive results for either assay were submitted for NGS and all whole viral genomes subsequently obtained underwent phylogenetic molecular epidemiological analyses. Results: Of the 824 samples tested, 36 tested positive for the ZDC assay; of those positives, 24 tested positive for DENV, 11 for CHIKV, and 1 for ZIKV. 27 full genomes were obtained from these ZDC positives: 16 of DENV (15 DENV1, genotype V and 1 DENV2, genotype III) and 11 of CHIKV (Asian and Caribbean genotype). Of the 788 samples tested with the pan-flavivirus assay, 22 samples yielded positive results, from only one of which a genome was obtainable. This genome was found to be closely related to a flavivirus previously only found in mosquitoes (76.8% identity with Long Pine Key Virus - LPKV). Maximum likelihood and maximum clade credibility trees were constructed using the DENV1 genomes obtained from this study. These trees displayed two distinct lineages of DENV1, genotype V present in Latin America, one of which has a circulation pattern spanning widely across the Caribbean and Central and South America (including Brazil), while the other circulates within Brazilian borders. The trees also indicate that the DENV1 present in the state of Amapá is of the lineage having the wider circulation pattern and that this lineage emerged in Amapá between 2005 and 2010. Conclusion: This study provides important data concerning the range of the arboviral landscape in Amapá and the most recent genomic data available for the region as well as Brazilian and Latin American context to that data. Data of this nature are invaluable in the efforts of public health officials for the prevention and control of epidemics of these impactful arboviral pathogens

Wuhan large pig roundworm virus identified in human feces in Brazil

We report here the complete genome sequence of a bipartite virus, herein denoted WLPRV/human/BRA/TO-34/201, from a sample collected in 2015 from a two-year-old child in Brazil presenting acute gastroenteritis. The virus has 98-99% identity (segments 2 and 1, respectively) with the Wuhan large pig roundworm virus (unclassified RNA virus) that was recently discovered in the stomachs of pigs from China. This is the first report of a Wuhan large pig roundworm virus detected in human specimens, and the second genome described worldwide. However, the generation of more sequence data and further functional studies are required to fully understand the ecology, epidemiology, and evolution of this new unclassified virus.FAPESPCNPqAdolfo Lutz Inst, Virol Ctr, Enter Dis Lab, Av Dr Arnaldo 355, BR-01246902 Sao Paulo, SP, BrazilFed Univ Para, Inst Biol Sci, Belem, Para, BrazilFac Med ABC, Postgrad Program Hlth Sci, Santo Andre, BrazilUniv Fed Sao Paulo, Retrovirol Lab, Sao Paulo, SP, BrazilUniv Sao Paulo, Fac Med, LIM 46, Sao Paulo, BrazilFed Univ Tocantins, Palmas, Tocantins, BrazilPubl Hlth Lab Tocantins State LACEN TO, Palmas, BrazilUniv Sao Paulo, Inst Trop Med, Av Dr Eneas de Carvalho Aguiar 470, BR-05403000 Sao Paulo, SP, BrazilBlood Syst Res Inst, San Francisco, CA USAUniv Calif San Francisco, Dept Lab Med, San Francisco, CA 94143 USAUniv Fed Sao Paulo, Retrovirol Lab, Sao Paulo, SP, BrazilFAPESP: 2015/12944-9FAPESP: 2017/00021-9FAPESP: 2016/01735-2CNPq: 400354/2016-0Web of Scienc

Plasma virome of 781 Brazilians with unexplained symptoms of arbovirus infection include a novel parvovirus and densovirus.

Plasma from patients with dengue-like symptoms was collected in 2013 to 2016 from the Brazilian states of Tocantins and Amapa. 781 samples testing negative for IgM against Dengue, Zika, and Chikungunya viruses and for flaviviruses, alphaviruses and enteroviruses RNA using RT-PCRs were analyzed using viral metagenomics. Viral particles-associated nucleic acids were enriched, randomly amplified, and deep sequenced in 102 mini-pools generating over 2 billion reads. Sequence data was analyzed for the presence of known and novel eukaryotic viral reads. Anelloviruses were detected in 80%, human pegivirus 1 in 19%, and parvovirus B19 in 17% of plasma pools. HIV and enteroviruses were detected in two pools each. Previously uncharacterized viral genomes were also identified, and their presence in single plasma samples confirmed by PCR. Chapparvovirus and ambidensovirus genomes, both in the Parvoviridae family, were partially characterized showing 33% and 34% identity in their NS1 sequences to their closest relative. Molecular surveillance using pre-existing plasma from febrile patients provides a readily scalable approach for the detection of novel, potentially emerging, viruses

Adaptive Evolution of New Variants of Dengue Virus Serotype 1 Genotype V Circulating in the Brazilian Amazon

Dengue virus (DENV) is a mosquito-borne viral pathogen that plagues many tropical-climate nations around the world, including Brazil. Molecular epidemiology is a growing and increasingly invaluable tool for understanding the dispersal, persistence, and diversity of this impactful virus. In this study, plasma samples (n = 824) from individuals with symptoms consistent with an arboviral febrile illness were analyzed to identity the molecular epidemiological dynamics of DENV circulating in the Brazilian state of Amapá. Twelve DENV type 1 (DENV-1) genomes were identified, which were phylogenetically related to the BR4 lineage of genotype V. Phylodynamics analysis suggested that DENV-1 BR-4 was introduced into Amapá around early 2010, possibly from other states in northern Brazil. We also found unique amino acids substitutions in the DENV-1 envelope and NS5 protein sequences in the Amapá isolates. Characterization of the DENV-1 BR-4 sequences highlights the potential of this new lineage to drive outbreaks of dengue in the Amazon region

Chikungunya Virus Asian Lineage Infection in the Amazon Region Is Maintained by Asiatic and Caribbean-Introduced Variants

The simultaneous transmission of two lineages of the chikungunya virus (CHIKV) was discovered after the pathogen’s initial arrival in Brazil. In Oiapoque (Amapá state, north Brazil), the Asian lineage (CHIKV-Asian) was discovered, while in Bahia state, the East-Central-South-African lineage (CHIKV-ECSA) was discovered (northeast Brazil). Since then, the CHIKV-Asian lineage has been restricted to the Amazon region (mostly in the state of Amapá), whereas the ECSA lineage has expanded across the country. Despite the fact that the Asian lineage was already present in the Amazon region, the ECSA lineage brought from the northeast caused a large outbreak in the Amazonian state of Roraima (north Brazil) in 2017. Here, CHIKV spread in the Amazon region was studied by a Zika–Dengue–Chikungunya PCR assay in 824 serum samples collected between 2013 and 2016 from individuals with symptoms of viral infection in the Amapá state. We found 11 samples positive for CHIKV-Asian, and, from these samples, we were able to retrieve 10 full-length viral genomes. A comprehensive phylogenetic study revealed that nine CHIKV sequences came from a local transmission cluster related to Caribbean strains, whereas one sequence was related to sequences from the Philippines. These findings imply that CHIKV spread in different ways in Roraima and Amapá, despite the fact that both states had similar climatic circumstances and mosquito vector frequencies

Recombination Located over 2A-2B Junction Ribosome Frameshifting Region of Saffold Cardiovirus

Here we report the nearly full-length genome of a recombinant Saffold virus strain (SAFV-BR-193) isolated from a child with acute gastroenteritis. Evolutionary analysis performed using all available near-full length Saffold picornavirus genomes showed that the breakpoint found in the Brazilian strain (SAFV-BR-193) is indeed a recombination hotspot. Notably, this hotspot is located just one nucleotide after the ribosomal frameshift GGUUUUU motif in the SAFV genome. Empirical studies will be necessary to determine if this motif also affects the binding affinity of RNA-dependent RNA-polymerase (RdRp) and therefore increases the changes of RdRp swap between molecules during the synthesis of viral genomes

Recombinant Strains of Human Parechovirus in Rural Areas in the North of Brazil

We characterized the 24 nearly full-length genomes of human parechoviruses (PeV) from children in the north of Brazil. The initial phylogenetic analysis indicated that 17 strains belonged to genotype 1, 5 to genotype 4, and 1 to genotype 17. A more detailed analysis revealed a high frequency of recombinant strains (58%): A total of 14 of our PeV-As were chimeric, with four distinct recombination patterns identified. Five strains were composed of genotypes 1 and 5 (Rec1/5); five strains shared a complex mosaic pattern formed by genotypes 4, 5, and 17 (Rec4/17/5); two strains were composed of genotypes 1 and 17 (Rec1/17); and two strains were composed of genotype 1 and an undetermined strain (Rec1/und). Coalescent analysis based on the Vp1 gene, which is free of recombination, indicated that the recombinant strains most likely arose in this region approximately 30 years ago. They are present in high frequencies and are circulating in different small and isolated cities in the state of Tocantins. Further studies will be needed to establish whether the detected recombinant strains have been replacing parental strains or if they are co-circulating in distinct frequencies in Tocantins

Recombinant Strains of Human Parechovirus in Rural Areas in the North of Brazil.

We characterized the 24 nearly full-length genomes of human parechoviruses (PeV) from children in the north of Brazil. The initial phylogenetic analysis indicated that 17 strains belonged to genotype 1, 5 to genotype 4, and 1 to genotype 17. A more detailed analysis revealed a high frequency of recombinant strains (58%): A total of 14 of our PeV-As were chimeric, with four distinct recombination patterns identified. Five strains were composed of genotypes 1 and 5 (Rec1/5); five strains shared a complex mosaic pattern formed by genotypes 4, 5, and 17 (Rec4/17/5); two strains were composed of genotypes 1 and 17 (Rec1/17); and two strains were composed of genotype 1 and an undetermined strain (Rec1/und). Coalescent analysis based on the Vp1 gene, which is free of recombination, indicated that the recombinant strains most likely arose in this region approximately 30 years ago. They are present in high frequencies and are circulating in different small and isolated cities in the state of Tocantins. Further studies will be needed to establish whether the detected recombinant strains have been replacing parental strains or if they are co-circulating in distinct frequencies in Tocantins

Detection and Characterization of Enterovirus B73 from a Child in Brazil

Enterovirus B73 is a new member of the Enterovirus B species. First detected in the USA, it has been subsequently identified in China, India, Oman, and the Netherlands. In this study, we characterize the first B73 strain (named TO-127) to be detected in South America. TO-127 was obtained from a child with acute gastroenteritis living in a rural area in Northern Brazil. The subject was not infected with any known enteric pathogens such as norovirus, rotavirus, helminths, or enteric bacteria. Analysis of the nearly full-length TO-127 genome (6993 nt) indicated a 74–75% nucleotide similarity with EV-B73 strains from other countries. Evolutionary analysis suggests that B73 is endemic and widespread