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COVID-19 has a broad spectrum of clinical manifestations, from asymptomatic or mild/moderate symptoms to severe symptoms and death. The mechanisms underlying its clinical evolution are still unclear. Upon SARS-CoV-2 infection, host factors, such as the inflammasome system, are activated by the presence of the virus inside host cells. The search for COVID-19 risk factors is of relevance for clinical management. In this study, we investigated the impact of inflammasome single-nucleotide polymorphisms (SNPs) in SARS-CoV-2-infected individuals with distinct severity profiles at clinical presentation. Patients were divided into two groups according to disease severity at clinical presentation based on the WHO Clinical Progression Scale. Group 1 included patients with mild/moderate disease ( WHO < 6 ; n = 76 ), and group 2 included patients with severe/critical COVID-19 ( WHO ≥ 6 ; n = 357 ). Inpatients with moderate to severe/critical profiles were recruited and followed-up at Hospital Center for COVID-19 Pandemic – National Institute of Infectology (INI)/FIOCRUZ, RJ, Brazil, from June 2020 to March 2021. Patients with mild disease were recruited at Oswaldo Cruz Institute (IOC)/FIOCRUZ, RJ, Brazil, in August 2020. Genotyping of 11 inflammasome SNPs was determined by real-time PCR. Protection and risk estimation were performed using unconditional logistic regression models. Significant differences in NLRP3 rs1539019 and CARD8 rs2043211 were observed between the two groups. Protection against disease severity was associated with the A/A genotype ( OR adj = 0.36 ; P = 0.032 ), allele A ( OR adj = 0.93 ; P = 0.010 ), or carrier-A ( OR adj = 0.45 ; P = 0.027 ) in the NLRP3 rs1539019 polymorphism; A/T genotype ( OR adj = 0.5 ; P = 0.045 ), allele T ( OR adj = 0.93 ; P = 0.018 ), or carrier-T ( OR adj = 0.48 ; P = 0.029 ) in the CARD8 rs2043211 polymorphism; and the A-C-G-C-C ( OR adj = 0.11 ; P = 0.018 ), A-C-G-C-G ( OR adj = 0.23 ; P = 0.003 ), C-C-G-C-C ( OR adj = 0.37 ; P = 0.021 ), and C-T-G-A-C ( OR adj = 0.04 ; P = 0.0473 ) in NLRP3 genetic haplotype variants. No significant associations were observed for the other polymorphisms. To the best of our knowledge, this is the first study demonstrating an association between CARD8 and NLRP3 inflammasome genetic variants and protection against COVID-19 severity, contributing to the discussion of the impact of inflammasomes on COVID-19 outcomes.

Background COVID-19 has a broad spectrum of clinical manifestations, from asymptomatic to mild or moderate symptoms, reaching the most severe forms and death. The mechanisms underlying the SARS-CoV-2 infection and its clinical evolution are still unclear. Once SARS-CoV-2 infects individuals, host factors are activated by the presence of the virus inside the cells, such as the inflammasome system. The search of risk factors for COVID-19 is of relevance for clinical management. In this study, we investigated the impact of 11 single-base polymorphisms (SNPs) in the NLRP3, CARD8, AIM2, CASP-1, IFI16, and IL-1β inflammasome genes in SARS-CoV-2 infected individuals with distinct disease outcomes. Methods Patients were divided into two groups: (1) inpatients, with severe/critical disease (Hospitalized group, n=451), and (2) convalescent volunteers with prior SARS-CoV-2 infection and a history of asymptomatic to mild symptoms (Mild group, n=43). Patients hospitalized were followed up at a Hospital Center for COVID-19 Pandemic – National Institute of Infectology (INI)/FIOCRUZ, Rio de Janeiro, Brazil, from June 2020 to March 2021. The Mild group was recruited at Oswaldo Cruz Institute (IOC)/FIOCRUZ, Rio de Janeiro, Brazil, in 2020. Genotyping of the SNPs was determined by Real-Time PCR. Protection and risk estimations were performed by unconditional logistic regression models. Results Among the genotyped SNPs, significant differences in the NLRP3 rs1539019 and rs10754558 frequencies were observed between the groups. The C/C genotype (ORadj=6.31; Padj=0.026) or allele C (ORadj=1.05; Padj=0.002) in rs1539019 polymorphism were associated with the risk for hospitalization, while the C/G genotype (ORadj=0.16; Padj=0.016) or carrier-G (ORadj=0.2; Padj=0.028) in rs10754558 polymorphism were associated with protection for hospitalization. Regarding the NLRP3 genetic variants, the A-C-G-C-G haplotype (ORadj=0.14; Padj= 0.030) was associated with protection for hospitalization. No significant association was observed for the other polymorphisms. Conclusions As of our knowledge, this is the first study demonstrating the association of inflammasome NLRP3 variants with risk and/or protection for hospitalization in COVID-19. Studies linking the NLRP3 inflammasome and SARS-CoV-2 infection are still scarce due to the recent emergence of this pathogen. Our results contribute to the discussion of the impact of inflammasomes in the clinical evolution of COVID-19.

Resumo: Realizou-se um estudo etnográfico entre estudantes de Medicina no momento de seu primeiro contato com pacientes numa escola pública do Rio de Janeiro ao longo do seu aprendizado de Semiologia. Este artigo apresenta resultados parciais, obtidos em entrevistas em que os estudantes responderam questões sobre a relação médico-paciente e suas impressões sobre a Semiologia. Não houve recusas, e os estudos responderam às questões escrevendo suas opiniões e impressões. Os resultados mostraram algumas diferenças de gênero. Estudantes de sexo feminino frequentemente expressaram seus sentimentos sobre professores e pacientes, e os do sexo masculino comentaram principalmente sobre o nível cientifico e questões pedagógicas concernentes aos conteúdo da disciplina. Ambos os grupos referiam a presença de fortes laços relacionais com o professor. Bons relacionamentos foram apresentados como fonte importante de motivação para estudo e esforço de desenvolver habilidades junto ao paciente. O professor é encarado como um “pai”. Por outro lado, relações conflituosas são relatadas como fonte de depressão e desestímulo tanto para estudar como para estabelecer boas relações com pacientes. Algumas respostas apontaram procedimentos desrespeitosos para com o paciente da parte de alunos e professores, deplorando estes eventos como um antiexemplo para a formação médica. O pouco tempo destinado ao retorno de pacientes já examinados foi criticado, por cerca de 50% dos estudantes, como negativo para o aprendizado de como seguir pacientes e se relacionar com eles de modo mais humanizado. Conclui-se que, embora 50% dos estudantes não apresentam problemas com o ambiente de relações no hospital, é necessário estar atento às críticas do corpo discente a fim de incrementar o conteúdo ético do aprendizado clínico. Abstract: An ethnographic study was conducted among medical students during their first contact with inpatients in a public medical school in Rio de Janeiro as part of their course on Basic Clinical Skills (BCS). This article presented the interim results from interviews in which the students responded to questions on the physician-patient relationship and their impressions on BCS. There were no refusals to participate, and students answered the questions by writing their feelings about teachers and patients, while men focused mainly on scientific and pedagogical issues involving the course contents. Nevertheless, both groups reported a Strong bond with the professor. Good relationships were reported as a powerful source of motivation for studying and improving professional skills, where the professor serves as a father figure. Meanwhile, difficulties in relations with professors were reported as a source of depression and discouragement both for studying and establishing good relationships with patients. Some answers revealed disrespectful procedures towards patients by instructors and students, identifying these events as bad examples in medical education. The limited time devoted to return examinations with the same patients in the wards was criticized as a negative factor in the process of learning how to accompany patients and provide more human care. These critical comments came from approximately 50% of the interviewees. The study concludes that even if 50% of students report no problems in the teaching hospital´s relational environment, attention should be given to students’ criticism in order to improve ethical procedures during their training.

Background: Since the beginning of the COVID-19 pandemic, no direct antiviral treatment is effective as post-exposure prophylaxis (PEP). Lopinavir/ritonavir (LPV/r) was repurposed as a potential PEP agent against COVID-19. Methods: We conducted a pragmatic open-label, parallel, cluster-randomized superiority trial in four sites in Switzerland and Brazil. Clusters were randomized to receive LPV/r PEP (400/100 mg) twice daily for 5 days or no PEP (surveillance). The primary outcome is the occurrence of COVID-19 within 21 days post-enrollment. Findings: Of 318 participants, 157 (49.4%) were women, median age was 39 (interquartile range, 28-50) years. A total of 209 (179 clusters) participants were randomized to LPV/r PEP and 109 (95 clusters) to surveillance. Baseline characteristics were similar, with the exception of baseline SARS-CoV-2 PCR positivity, which was 3-fold more frequent in the LPV/r arm (34/209 [16.3%] vs 6/109 [5.5%], respectively). During 21-day follow-up, 48/318 (15.1%) participants developed COVID-19: 35/209 (16.7%) in the LPV/r group and 13/109 (11.9%) in the surveillance group (unadjusted hazard ratio 1.44; 95% CI, 0.76 to 2.73). In the primary endpoint analysis adjusted for propensity score to receive LPV/r, the hazard ratio for developing COVID-19 in the LPV/r group vs surveillance was 0.53 (95% CI, 0.23 to 1.23, respectively; P =.14). Interpretation: LPV/r role as PEP for COVID-19 remains unanswered. In this trial, LPV/r over 5 days did not significantly reduce incidence of COVID-19 in exposed individuals. We observed a change in directionality of the effect in favor of LPV/r after adjusting for baseline SARS-CoV-2 PCR results, indicating a potential role of antivirals in COVID-19 prevention. Clinical Trial Registration Details: ClinicalTrials.gov (Identifier: NCT04364022); Swiss National Clinical Trial Portal: SNCTP 000003732. Funding Information: Fondation privee des HUG and Swiss National Fund (project number: 33IC30_166819). Declaration of Interests: None reported. Ethics Approval Statement: The protocol and amendments were approved by Swissmedic and local ethics committees in Switzerland and Brazil. Participants provided written informed consent before study entry.