Forecasting daily confirmed COVID-19 cases in Algeria using ARIMA models

BACKGROUND

COVID-19 has become a threat worldwide, affecting every country.

AIMS

This study aimed to identify COVID-19 cases in Algeria using times series models for forecasting the disease.

METHODS

Confirmed COVID-19 daily cases data were obtained from 21 March 2020 to 26 November 2020 from the Algerian Ministry of Health. Forecasting was done using the Autoregressive Integrated Moving Average (ARIMA) models (0,1,1) with Minitab 17 software.

RESULTS

Observed cases during the forecast period were accurately predicted and placed within prediction intervals generated by ARIMA. Forecasted values of COVID-19 positive cases, recoveries and deaths showed an accurate trend, which corresponded to actual cases reported during 252, 253 and 254 days. Results were strengthened by variations of less than 5% between forecast and observed cases in 100% of forecasted data.

CONCLUSION

ARIMA models with optimally selected covariates are useful tools for predicting COVID-19 cases in Algeria.

427 The Effect of Malnutrition on Early Outcomes after Cancer Surgery: An International Prospective Cohort Study in 82 Countries

Background

Malnutrition is a state linked to worse postoperative outcomes, and cancer patients are particularly vulnerable due to cachexia. We aimed to explore the effect of malnutrition on 30-day mortality following gastric and colorectal cancer surgery.

Method

GlobalSurg3 was multicentre international cohort study which collected data from consecutive patients undergoing emergency or elective surgery for gastric and colorectal cancer. Malnutrition was defined using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multilevel variable regression approaches determined the relationship between malnutrition and early postoperative outcomes.

Results

6438 patients were included in the final analysis (1184 gastric cancer; 5254 colorectal cancer). Severe malnutrition was common across all income-strata, affecting 1 in 4 patients overall, with a higher burden in low and lower-middle income countries (64%). In patients undergoing elective surgery (n = 5709), severe malnutrition was independently associated with increased mortality (aOR = 1.62 (1.07-2.48, P = 0.024) after accounting for patient factors, disease stage and country effects.

Conclusions

Severe malnutrition represents a high global burden in cancer surgery, particularly within lower income settings. Malnutrition is an independent risk-factor for 30-day mortality following elective surgery for gastric and colorectal cancer, suggesting perioperative nutritional interventions may improve outcomes after cancer surgery.

5952The involvement and interplay of HMGB1 with soluble MD-2 in dilated cardiomyopathy and its impact in immune cell recruitment

Objective

Dilated cardiomyopathy (DCM) is characterized by systolic dysfunction and simultaneous dilatation of the left or both ventricles. Besides other causes, the innate immune system plays a major role in the development and progression of the disease. To uncover links between molecular mechanisms and disease progression our group has focused on the toll like receptor 4 / myeloid differentiation factor-2 (MD-2) system.

Purpose

We already reported that soluble MD-2 (sMD-2) is a risk factor for survival in patients with DCM. High mobility group box protein 1 (HMGB1) is a potent intrinsic interaction partner of MD-2. In the current study, we quantified HMGB-1 in plasma from patients with DCM at baseline, upon first hospital admission. Furthermore, we studied the impact of different HMGB-1 isoforms on monocyte adhesion in vitro.

Methods

We included 77 DCM patients divided by median time point of death after first hospital admission into “early death”, “late death” and “alive” group. MD-2 was quantified by means of ELISA. MD-2 and HMGB1 was quantified by means of ELISA. Statistical analysis was performed using a linear regression model.

Human umbilical vein endothelial cells (HUVEC; n=6) were treated for 48h with two isoforms of HMGB1 (disulfide (ds) and fully reduced (fr)) alone and in combination with MD-2. Subsequently, those activated HUVEC were incubated with fresh isolated peripheral blood mononuclear cells (PBMCs) for 20 min. Finally, monocyte adhesion was quantified using multicolour FACS.

Results

At baseline, we found significantly increased sMD-2 level in the “early death” group (591.3±75.5 ng/ml) compared to the “later death” group (369.2±46.5 ng/ml; p=0.015) and the “alive” group (303.2±18.1 ng/ml; p<0.001). Likewise, we could demonstrate significantly increased levels of HMGB1 in the “early death” group (0.93±0.14 ng/ml) compared to the “later death” (0.57±0.17 ng/ml; p=0.04) and the “alive” group (0.49±0.06 ng/ml; p<0.001). In all patients who died during the observation period, sMD-2 and HMGB1 plasma levels showed a positive correlation.

In vitro, we could demonstrate a significantly increased monocyte adhesion on HUVECs in the dsHMGB1 and the frHMGB1 group compared to controls (p=0.001; p=0.004). In contrast, the dsHMGB1 MD-2 group showed a significantly decreased monocyte adhesion on HUVECs compared to dsHMGB1 treatment alone (p=0.049). In the frHMGB1 MD-2 group, however, the reduction of the monocyte adhesion was less pronounced and did not reach significance (Fig. 1).

Conclusion

Our findings give a first hint that the interplay between HMGB1 and MD-2 is particularly involved in the development and progression of DCM. Furthermore, the data suggest that soluble MD-2 is capable of reducing the pro-inflammatory effects of dsHMGB1 but not of frHMGB1

5946The immune protein MD-2 is associated with early death in dilated cardiomyopathy and increases M1 macrophage polarization and recruitment in vitro

Objective

Dilated cardiomyopathy (DCM) is characterized by systolic dysfunction and dilatation of ventricles. Myocardial inflammation and leukocyte activation and recruitment play a major role in the development and progression of disease. Myeloid differentiation factor-2 (MD-2) is the TLR (toll like receptor)-4 co-receptor and has been shown to be an important risk predictor for mortality of DCM patients. It is expressed in various cell types and mediates TLR-4 dependent inflammation/activation processes.

Purpose

We examined the impact of MD-2 on mortality of DCM patients and on polarization and recruitment of monocytes in vitro.

Methods

In 77 DCM patients, divided by median time point of death after first hospital admission into early and late death and alive group, MD-2 was quantified by means of ELISA. In THP-1 monocytes, cytokine secretion was quantified by ELISA after 72h treatment with MD-2 (5μg/mL). Bone marrow derived macrophages (BMDM) were generated from MD-2 KO and WT mice. NFkB phosphorylation (10min) and changes in gene expression (4h) of different adhesion molecules was quantified after treatment with 1 or 10ng/mL LPS. In human umbilical vein endothelial cells (HUVEC), protein kinase B (PKB) phosphorylation was quantified after 15min of treatment with 10ng/mL LPS or 5μg/mL MD-2. CCL2 gene expression in lysed cells (4h) and CCL2 secretion in supernatants (48h) were quantified to. Adhesion of monocytes on treated HUVEC was determined by FACS (Fig.1a). Initial HUVEC treatment with MD-2 (5μg/mL) or LPS (10 or 100ng/mL) took place for 48h.

Results

We found significant increased MD-2 in early (591.3ng/mL; N=18) vs late death (p=0.015) (369.2ng/mL; N=17) and alive (p≤0.0001) (303.2ng/mL; N=42) patients. Treatment of THP-1 cells (N=5) with MD-2 lead to a significantly increased secretion of inflammatory cytokines IL-8 (p=0.012), IP-10 (p=0.029), and MCP-1 (p=0.032) but not of anti-inflammatory cytokines IL-4, IL-10 and IL-13. Treatment of BMDM obtained from MD-2 KO and WT mice with 10ng/mL LPS lead to a increased phosphorylation of NFkB (N=4; p=0.022) and increased gene expression (N=6) of adhesion molecules VLA-4 (p=0.006) and ICAM-1 (p=0.049) in WT mice but not in KO mice. In HUVEC, LPS (p=0.008) and MD-2 induced a comparable increased phosphorylation of PKB (p=0.008) as well as an increase of CCL2 gene expression (p=0.029) and protein amount (p=0.039). Furthermore, treatment of HUVEC with both MD-2 (p=0.015) and LPS (p=0.0001) lead to a significant increase in monocyte adhesion (Fig.1).

Conclusion

The impact of MD-2 on cardiac inflammation and macrophage recruitment has not been described yet. In this study, we showed that, in DCM, elevated levels of sMD-2 are associated with early death. Furthermore, we could demonstrate that MD-2 enhances the process of HUVEC based monocyte recruitment. Finally, we could show that MD-2 induces inflammatory monocyte activity and triggers polarization of macrophages towards an inflammatory phenotype.

Acute disseminated encephalomyelitis complicating dengue infection with neuroimaging mimicking multiple sclerosis: A report of two cases

Acute disseminated encephalomyelitis (ADEM) complicating dengue infection is still exceedingly rare even in endemic countries such as Malaysia. Here we report two such cases, the first in an elderly female patient and the second in a young man. Both presented with encephalopathy, brainstem involvement and worsening upper and lower limb weakness. Initial magnetic resonance imaging (MRI) of the brain was normal in the first case. Serum for dengue Ig M and NS-1 was positive in both cases. Cerebrospinal fluid (CSF) showed pleocytosis in both with Dengue IgM and NS-1 positive in the second case but not done in the first. MRI brain showed changes of perpendicular subcortical palisading white matter, callosal and brainstem disease mimicking multiple sclerosis (MS) in both patients though in the former case there was a lag between the onset of clinical symptoms and MRI changes which was only clarified on reimaging. The temporal evolution and duration of the clinical symptoms, CSF changes and neuroimaging were more suggestive of Dengue ADEM rather than an encephalitis though initially the first case began as dengue encephalitis. Furthermore in dengue encephalitis neuroimaging is usually normal or rarely edema, haemorrhage, brainstem, thalamic or focal lesions are seen. Therefore, early recognition of ADEM as a sequelae of dengue infection with neuroimaging mimicking MS and repeat imaging helped in identifying these two cases. Treatment with intravenous steroids followed by maintenance oral steroids produced good outcome in both patients.

ECG-gated coronary angiography enables submillisievert imaging in invasive cardiology

BACKGROUND

The median dose area products (DAP) and effective doses (ED) of patients arising from coronary angiography (CA) are considerable: According the 2013 National German Registry, they amount to 19.8 Gy × cm(2) and 4.0 mSv, respectively.

METHODS

We investigated the feasibility of prospective electrocardiogram (ECG)-gated coronary angiography (CA)-a novel technique in invasive cardiology-with respect to possible reduction in irradiation effects. Instead of universally fix-rated radiographic acquisition within 7.5-15 frames/s, one single frame/heartbeat was triggered toward the diastolic moment immediately before atrial contraction (77 % of ECG-RR interval) most likely to provide motion-free and hence optimized resolution of the coronary tree. For 200 patients (body mass index 27.8 kg/m(2), age 67.5 years, male 55 %, 68 bpm) undergoing ECG-gated CA, we measured various median (interquartile range) parameters for radiation exposure.

RESULTS

The total DAP was 0.64 (0.46-1.00), radiographic fraction was 0.30 (0.19-0.43), and fluoroscopic fraction was 0.35 (0.21-0.57) Gy × cm(2). Radiographic imaging occurred within 21.7 s (17.1-26.3), with 25 frames (20-30) over the course of 7 runs (6-8). Fluoroscopy time was 119 s (94-141). Radiographic DAP was 12.6 mGy × cm(2)/frame and 13.8 mGy × cm(2)/s. Fluoroscopic DAP was 0.8 mGy × cm(2)/pulse and 3.1 mGy × cm(2)/s. Patient reference point air kerma was 17.0 mGy (11.1-28.1) and contrast volume was 70 ml (60-85).

CONCLUSION

In conclusion, invasive ECG-gated coronary imaging is feasible in clinical routine and enables patient EDs of approx. 3 % of typical values in invasive cardiology: 0.13 mSv (0.09-0.20).

Initial white blood cell count is an independent risk factor for survival in patients with dilated cardiomyopathy

BACKGROUND

The impact of white blood cell count (WBCc) on the outcome of patients with non-ischemic left ventricular (LV) dysfunction is unknown. In the present study we investigated the influence of WBCc on mortality and cardiac inflammation in patients with reduced LV systolic function in the absence of ischemic or valvular etiology.

METHODS AND RESULTS

We included 381 patients with reduced left ventricular (LV) ejection fraction (LVEF ≤ 45%) quantified by two-dimensional echocardiography. Coronary artery disease and valvular diseases were excluded by angiography and echo, respectively, in all patients. WBCc was quantified routinely upon first hospital admission. In 291 patients, endomyocardial biopsies from the right ventricle were performed upon first hospital admission for assessment of cardiac inflammation. Follow-up was up to 5.5 years (median 2.93 [1.7;4.0]). Information on vital status of patients was obtained from official resident data files. WBCc >11 Gpt/l was associated with significantly increased mortality in patients with severe LV dilation (end-diastolic diameter (LVEDD) >70 mm quantified by echocardiography) in comparison to patients showing WBCc ≤ 11 Gpt/l (41.7% vs 13.6%, p=0.02). Multivariable Cox regression analysis showed that WBCc predicts mortality independently of other cardiovascular risk factors and LVEF (hazard ratio 1.14; p=0.04). Doses of heart failure medication did not differ significantly in patients with LVEDD >70 mm and WBCc >11 Gpt/l when compared to LVEDD >70 mm and WBCc ≤ 11 Gpt/l (percent of maximum doses: ß-blockers p=0.51, ACE inhibitors p=0.56, AT1 antagonists p=0.77, aldosterone antagonists p=0.35). WBCc including its subpopulations (monocytes, lymphocytes and granulocytes) did not show a significant correlation with cardiac amounts of CD3(+)-lymphocytes (r=0.02, p=0.78) or CD68(+)-macrophages (r=1.0, p=0.09) (n=291).

CONCLUSION

WBCc at first hospital admission predicts long term-mortality in patients with dilated cardiomyopathy independently of cardiovascular risk factors.

Enhancement of endothelial nitric oxide synthase production reverses vascular dysfunction and inflammation in the hindlimbs of a rat model of diabetes

AIMS/HYPOTHESIS

Reduced bioavailability of nitric oxide (NO) is a hallmark of diabetes mellitus-induced vascular complications. In the present study we investigated whether a pharmacological increase of endothelial NO synthase (eNOS) production can restore the impaired hindlimb flow in a rat model of severe diabetes.

METHODS

A model of diabetes mellitus was induced in male Sprague-Dawley rats by a single injection of streptozotozin. Rats were treated chronically with the eNOS transcription enhancer AVE3085 (10 mg [kg body weight](-1) day(-1); p.o.) or vehicle for 48 days and compared with controls. Endothelial function and arterial BP were investigated in vivo using an autoperfused hindlimb model and TIP-catheter measurement, respectively. Protein production of eNOS, total and phosphorylated vasodilator-stimulated phosphoprotein (VASP) were assessed in their quadriceps muscle tissue, whereas cyclic GMP (cGMP) concentrations were assessed in blood plasma. RNA levels of intracellular and vascular cell adhesion molecules (ICAM-1 and VCAM-1) were measured by real-time PCR.

RESULTS

Untreated diabetic rats showed significantly reduced quadriceps muscle contents of eNOS (-64%) and phosphorylated VASP (-26%) protein associated with impaired vascular function (maximum vasodilatation: -30%, p < 0.05) and enhanced production of ICAM-1 (+121%) and VCAM-1 (+156%). Chronic treatment with AVE3085 did not alter arterial BP or severe hyperglycaemia, but did lead to significantly increased production of eNOS (+95%), cGMP (+128%) and VASP phosphorylation (+65%) as well as to improved vascular function (+36%) associated with reduced production of ICAM-1 (-36%) and VCAM-1 (-58%).

CONCLUSIONS/INTERPRETATION

In a rat model of severe diabetes, pharmacological enhancement of impaired eNOS production and NO-cGMP signalling by AVE3085 restores altered hindlimb blood flow and prevents vascular inflammation.

Anti-inflammatory effects of atorvastatin improve left ventricular function in experimental diabetic cardiomyopathy

AIMS/HYPOTHESIS

Emerging evidence suggests that statins exert beneficial effects beyond those predicted by their cholesterol-lowering actions. We investigated whether atorvastatin influences the development of left ventricular (LV) dysfunction, independently of cholesterol-lowering, in an experimental model of type 1 diabetes mellitus cardiomyopathy.

METHODS

Streptozotocin-induced diabetic rats were treated with atorvastatin (50 mg/kg daily, orally) or with vehicle for 6 weeks. LV function was analysed using tip-catheter measurements. Cardiac stainings of TNF-alpha, IL-1beta, intercellular adhesion molecule-1, vascular cellular adhesion molecule-1, CD11a/lymphocyte-associated antigen-1, CD11b/macrophage antigen alpha, CD18/beta2-integrin, ED1/CD68, collagen I and III, and Sirius Red were assessed by digital image analysis. Ras-related C3 botulinum toxin substrate (RAC1) and ras homologue gene family, member A (RHOA) activities were determined by RAC1 glutathione-S-transferase-p21-activated kinase and rhotekin pull-down assays, respectively. Cardiac lipid peroxides were measured by a colorimetric assay. The phosphorylation state of p38 mitogen-activated protein kinase (MAPK) and endothelial nitric oxide synthase (eNOS) protein production were analysed by western blot.

RESULTS

Diabetes was associated with induced cardiac stainings of TNF-alpha, IL-1beta, cellular adhesion molecules, increased leucocyte infiltration, macrophage residence and cardiac collagen content. In contrast, atorvastatin reduced both intramyocardial inflammation and myocardial fibrosis, resulting in improved LV function. This effect was paralleled with a normalisation of diabetes-induced RAC1 and RHOA activity, in the absence of LDL-cholesterol lowering. In addition, atorvastatin decreased diabetes-induced cardiac lipid peroxide levels and p38 MAPK phosphorylation by 1.3-fold (p < 0.05) and 3.2-fold (p < 0.0005), respectively, and normalised the reduced eNOS production caused by diabetes.

CONCLUSIONS/INTERPRETATION

These data indicate that atorvastatin, independently of its LDL-cholesterol-lowering capacity, reduces intramyocardial inflammation and myocardial fibrosis, resulting in improved LV function in an experimental model of diabetic cardiomyopathy.

Inhibition of p38 mitogen-activated protein kinase attenuates left ventricular dysfunction by mediating pro-inflammatory cardiac cytokine levels in a mouse model of diabetes mellitus

AIMS/HYPOTHESIS

We investigated the effect of SB 203580, a pharmacological inhibitor of p38 mitogen-activated protein kinase (MAPK), on cardiac inflammation, cardiac fibrosis, and left ventricular function using an animal model of diabetic cardiomyopathy.

MATERIALS AND METHODS

Diabetes mellitus was induced by streptozotocin (50 mg/kg i.p. for 5 days) in 20 C57/BL6J mice. Diabetic mice were treated daily with the p38 MAPK inhibitor SB 203580 (1 mg/kg daily, n=10) or with placebo (n=10) and were compared to non-diabetic controls. Left ventricular function was measured by pressure-volume loops after 8 weeks of diabetes mellitus. The parameters for systolic function were the end systolic pressure-volume relationship (ESPVR) and the left ventricular end systolic pressure. The parameters for diastolic function were the left ventricular end diastolic pressure and the end diastolic pressure-volume relationship (EDPVR). Cardiac tissue was analysed by ELISA for the protein content of the cytokines TNF-alpha, IL6, IL1-beta, and TGF-beta1. Phosphorylation of MAPK p38 was analysed by western blot, and the total cardiac collagen content was analysed by Sirius red staining.

RESULTS

Left ventricular dysfunction was documented by impaired ESPVR and EDPVR. Cardiac cytokine levels and cardiac fibrosis were increased in diabetic animals compared to controls. Treatment with the p38 inhibitor normalised cardiac cytokine levels and improved systolic function, but did not change cardiac fibrosis and diastolic dysfunction compared to placebo.

CONCLUSIONS/INTERPRETATION

Pharmacological inhibition of p38 MAPK prevents cardiac inflammation and attenuates left ventricular dysfunction in diabetic cardiomyopathy.

What constitutes general surgical training? Evidence from the log books of trainees in one district general hospital

It is accepted wisdom that surgical expertise in the UK is achieved by virtue of long service, and perhaps not enough genuine training. The average age at appointment to consultant posts in general surgery has risen from 37.0 years in 1978 to 38.0 in 1992. This message has reached the politicians who run the Health Service: at the Association of Surgeons in Training Annual General Meeting in September 1991 Mrs Virginia Bottomley said 'A complaint often made to me is that trainees, particularly surgical trainees, in the UK are over-experienced but under-trained'. Training posts acquire a reputation (good or bad) based on word of mouth, pass rate in examinations, and success in placing trainees into higher grades. Little is known about the relationship between training and operative experience. Log books have been introduced as a compulsory requirement for the Clinical Surgery in General and Intercollegiate Specialty Examinations. This report aims to define the operative experience of trainees at a District General Hospital by analysis of data obtained from their log books. This information has been used to calculate trainee workload in terms of intermediate equivalents (IE) and service equivalent value (SEV).