Electric and viscoelastic parameters of erythrocytes were determined by dielectrophoresis using an electric optical system of cell detection. Results: the progression of rheological disturbances in the patients with type 2 DM was accompanied by significant decreases in deformation amplitude; dipole moment; polarizability; and membrane capacity; and increases in conductivity, viscosity, rigidity, hemolysis, and formation of aggregates (p < 0.05). Combined use of the parameters increased sensitivity (97.8%) and specificity (86.7%) for diagnosis of rheological disturbances in type 2 DM. Conclusion: the proposed experimental approach possesses low invasiveness, high productivity, shorter duration, vividness of the results. The method allows to evaluate not only local  but also systemic status of microcirculation using more than 20 parameters of erythrocytes.Hemorheological disorders in structural and functional parameters of erythrocytes are involved in the pathological process in type 2 diabetes mellitus (DM). Aim: to investigate the feasibility of differential diagnosis of the degrees of rheological disturbances in patients with type 2 DM by dielectrophoresis of erythrocytes. Methods: 62 subjects (58.7 ± 1.6 years) with type 2 DM diagnosed according to the criteria of the ADA were subdivided into two groups: medium ( Among patients with diabetes mellitus (DM), early disability and mortality, which are mostly caused by diabetic angiopathies, are the most important socioclinical problem of modern diabetology . Timely At present, in clinical practice, physicians use a variety of methods for the detection of microcirculatory disturbances in DM.There are methods for the detection of diabetic microangiopathy that are designed strictly for local vascular analysis . To detect diabetic retinopathy, clinicians utilize several methods: slit-lamp examination of the conjunctiva, fundoscopy, retinal fluorescent angiography, quantitative perimetry, autocampigraphy, and examination of darkness adaptation. These methods allow visual evaluation of the state of retinal vessels and extrapolation of the obtained results to the vascular system as a whole. Nonetheless, these methods require specially trained personnel and ophthalmological equipment. The shortcomings of direct ophthalmoscopy are a small examined area, the absence of stereoscopy, close contact with a patient, and the inability to examine the extreme periphery of the fundus. In clinical practice, this approach is convenient as a screening method of medical examination. Contact binocular ophthalmoscopy by means of a slit lamp and contact lenses is the golden standard of diagnosis of fundus pathologies. Nevertheless, this method has limitations related to inflammatory processes on the eye surface, well-pronounced opacification or degenerative alterations of the cornea, and health state of the patient  . A microCurrently, the methods of capillaroscopy and capillarography and determination of vascular permeability allow us to answer the question about the systemic status of capillaries. Furthermore, capillaroscopy together with biochemical indicators is a cornerstone for diagnosing the preclinical stage of diabetic microangiopathy. In case of a combinatorial approach to the assessment of the microcirculatory bed, clinicians perform capillaroscopy in a resting state with subsequent evaluation of structural changes in capillary status. Additionally, they perform capillaroscopy and oxyhemometric analysis with four functional trials and the action of physical stimuli on the extremity being analyzed: cuff occlusion, assessment of cold exposure, assessment of heat exposure, and testing of raising the extremity. This technique ensures the most accurate diagnosis of microangiopathies in this group of patients because of comprehensive evaluation of the microcirculatory bed at early stages of a disorder on the basis of measuring the reserve properties of capillaries . It shouAbroad, in patients with DM, clinicians employ the method of microangiopathy diagnosis ,8 that cHistochemical and electron-microscopic analyses of blood vessels in skin biopsies enable the detection of characteristic-for-DM alterations in vessel walls in the form of basal-membrane thickening, proliferation of the endothelium, and increased deposition of PAS-positive substances. A biopsy can be taken from any site of the skin by means of a special dermatome, from an ear lobe, or from the mucous membrane of the mouth or rectum. Nonetheless, because of the complexity and certain traumaticity of the method, it is used not so much for diagnosis but rather for studying the pathogenesis and prevalence of diabetic microangiopathies .Various types of proteomics have been employed for pathoanatomical research on diabetic microangiopathy. Common proteomic techniques, including gel-based ones, possess limited sensitivity and reproducibility and are usually used to detect biomarkers of high or medium prevalence. Clinical samples from patients with diabetic microangiopathy, e.g., biopsy samples, are rather small. Therefore, the technologies of sample preparation, quantitative labeling, and mass spectrometry should be optimized for detecting a protein at a low concentration, for processing of multiple samples, and for accurate quantitation. Besides, signal transduction pathways are difficult to study because they contain many low-abundance proteins. At present, there are no biomarkers identifiable by proteomic methods that can be applied to the diagnosis of diabetic microangiopathy. It is noteworthy that the high cost of proteomic methods is another obstacle to their widespread use in clinical settings .Shortcomings and limitations of the methods described above necessitate the development of new approaches to the detection of microcirculatory disturbances in DM.The pathogenesis of microvascular complications in type 2 DM is linked with the pathological involvement of erythrocytes , which not only perform the oxygen transport function in the blood–tissue system but also participate in the regulation of rheological properties of the blood and in interactions with endothelial cells .At the capillary level, the state of RBCs is a determinant of microcirculation. Moreover, many changes in blood fluidity, for instance, deformability and aggregation of RBCs, are detectable much earlier than the obvious systemic symptoms .Microrheological properties of RBCs, such as deformability, the aggregation ability, and production of vasoreactive factors, are determined by specific features of the molecular organization of the erythrocytic membrane and of the peri-membrane cytoplasmic matrix ,14.5 and 5 × 104 Hz) and cytoplasm (high frequencies: 106 and 5 × 105 Hz). A brief dielectrophoretic assay (1–2 min.) helps to determine many parameters (>20) reflecting structural and functional status of RBCs . The above characteristics of RBCs are tightly associated with a pathological process, as revealed by us previously in patients with a diffuse pathology of the liver [The dielectrophoresis method proposed by us for studying the electric and viscoelastic properties of RBCs is based on changes in cell parameters under the action of a nonuniform alternating electric field (NUAEF). The use of different frequencies of the electric field helps to assay the state of both RBC membranes . On the other hand, the velocity of cell motion toward electrodes, dipole moment, and cellular capacity denote blood serum biochemical shifts associated with DM . Polarizability of cells and levels of hemolysis and aggregation are related to altered conditions of RBC maturation processes and indicate their lowered resistance to various factors; this drawback will later affect their interaction with the cells of a changed endothelium.The RBC parameters in patients with type 2 DM were studied here for the first time by dielectrophoresis. This approach has several substantial advantages over the existing assays of microcirculation: low invasiveness ; the ability to evaluate the microcirculation state in the body as a whole rather than at a few sites; the use of high technologies; vivid results ; low cost without the need for expensive reagents and equipment; high reproducibility of the results; and possible the diagnostics as well as personalization of the therapeutic regimen for a patient.Therefore, electric and viscoelastic parameters of RBCs, as measured by dielectrophoresis, help to obtain valuable information that is directly related to the development of rheological disturbances in DM.The objective of this work was to test the feasibility of differential diagnosis of degrees of rheological disturbances in patients with type 2 DM by means of RBC dielectrophoresis.In the clinical diagnostic department of the Institute of Internal and Preventive Medicine during 2016, we recruited patients with type 2 DM in accordance with the criteria of the American Diabetes Association (2016) . Our incSixty-two patients with type 2 DM at age 58.7 ± 1.6 years (mean ± SEM) were analyzed; 43 (69.4%) of them were females and 19 (30.6%) were males. The healthy control group consisted of 38 subjects at age 48.5 ± 2.2 years (24 (63.2%) females and 14 (36.8%) males) without DM, and without any other detectable pathology of internal organs, who visited our clinical diagnostic department for preventive purposes (Group 1). The subjects in the control group led a healthy lifestyle, did not smoke, and did not drink alcohol more often than once or twice a month, and the alcohol doses did not exceed 40 g for males and 20 g for females in terms of pure ethanol. In this group, the electric and viscoelastic parameters of RBCs were within the reference range appropriate for respective age.Glycosylated hemoglobin (HbA1c): <7% for the medium risk and >7% for the high risk;blood pressure: <140/85 mm Hg for the medium risk and >140/85 mm Hg for the high risk;High-density lipoprotein (HDL) cholesterol: >40 mg/dL for the medium risk and <40 mg/dL for the high risk;Low-density lipoprotein (LDL) cholesterol: <100 mg/dL for the medium risk and >100 mg/dL for the high risk.Patients with type 2 DM were subdivided into two groups: medium risk (Group 2) and high risk of microcirculatory disturbances (Group 3) according to various indicators in keeping with recommendations of the European Association for the Study of Diabetes (EASD) 2013)  and reco13  and rThe Biomedical Ethics Committee of the federal publicly funded institution Institute of Internal and Preventive Medicine (session of 18 December 2015) approved the study protocol.The patients underwent comprehensive clinical examination and instrumental analyses, including electrocardiography ; ultrasonography of abdominal-cavity organs, kidneys, heart, and vessels ; fundoscopy ; an assay of glycated hemoglobin ; and determination of the albumin/creatinine ratio in spot urine .At admission of in-patients, fasting collection of venous blood from the cubital vein was conducted in the amount of 8 mL into two vacutainers : the first one  for biochemical assays, and the second vacutainer  for determining the electric and viscoelastic parameters of RBCs by dielectrophoresis.Biochemical indicators  were determined using KONELAB PRIME 30i . RBC parameters , mean corpuscular hemoglobin (MCH), mean cell hemoglobin concentration (MCHC), red cell distribution width (RDW-CV) in %, and red cell distribution width (RDW-SD) in femtoliters) and leukocyte counts were determined on an automatic hematology analyzer, HT Micro CC-20 Plus . The RBC sedimentation rate was measured by Panchenkov’s micromethod.Blood fibrinogen was quantified by the Clauss method with reagents from Renam . Immunoenzyme assays based on standard ELISA kits were carried out to quantitate serum C-reactive protein (Biomerica kit) on an immunoenzyme assay analyzer, Multiscan EX (Finland) .Electric and viscoelastic parameters of RBCs were measured by dielectrophoresis by means of an electric optical system of cell detection . The pro11 V/m2; and frequency range, 5 × 104 to 1 × 106 Hz. We analyzed cell polarizability, membrane capacity, electric conductivity, a position of crossover frequency, indices of aggregation and destruction of RBCs, velocity of cell motion toward electrodes, induced dipole moment, deformation amplitude of RBCs at a frequency of 106 Hz, the deformation degree of the cells at a frequency of 5 × 105 Hz, and summarized viscosity and summarized rigidity of RBCs. The data were processed using an original software suite, CELLFIND . Intertest repeatability of the method was 7–12%.The measurements were conducted immediately after the resuspension of RBCs. In a measurement cell, the RBCs were exposed to an NUAEF at the following settings: electric intensity, 105 V/m; electric intensity gradient, 10www.ibm.com/spss). The Kolmogorov–Smirnov test was employed to characterize the distribution of numerical variables. In case of a normal distribution, the average (mean) and standard error of the mean (SEM) were calculated (presented as mean ± SEM). In the case of the normal distribution, the significance of differences (or correlations) of parameters was assessed by Student’s t test or Pearson’s correlation analysis. If a distribution was not normal, then nonparametric tests were performed . In all the statistical analyses, the threshold of null hypothesis probability (p) was assumed to be 0.05. To evaluate the utility of RBC parameters for the stratification of severity of rheological disturbances in type 2 DM, receiver operating characteristic (ROC) analysis was carried out.Statistical analysis of the data was performed in the SPSS software, v. 22 (n = 47), and high risk of microcirculatory disturbances . The clinical parameters of the patients from these groups were found to be within the range corresponding to the risk of damage to large and small vessels.On the basis of the above-mentioned criteria, our patients with DM were distributed into two groups: a medium risk of damage to small vessels, i.e., medium severity of rheological and microcirculatory disturbances  were higher in Group 3 than in Group 2. All patients with DM received sugar-lowering therapy  and hypertension medication.There were no significant differences in age, sex, alcohol consumption style, and cigarette smoking between the groups of patients with DM. By contrast, in the group with the high severity of rheological disturbances (Group 3), DM duration and arterial-hypertension duration were significantly greater and there was greater prevalence of (1) a family history of early cardiovascular diseases and (2) a history of ischemic heart disease with myocardial infarctions. Systolic and diastolic blood pressure and the prevalence of cardiac rhythm and conduction aberrations (p = 0.018), glycated hemoglobin, albumin/creatinine ratio in spot urine, stronger manifestations of hyperlipidemia (mostly type 2B hyperlipidemia), and disturbances of purine metabolism, liver function, and the excretory function of kidneys.The patients with high severity of rheological disturbances showed worse manifestations of DM and its complications: this group featured higher levels of fasting glycemia .It is worth mentioning that the patients with well-pronounced rheological disturbances (Group (3) had a higher body mass index, severer diabetic neuropathy and retinopathy , angiopathy .The analysis of RBC parameters did not reveal significant differences among the groups in the RBC count, a color parameter, and hemoglobin. Nonetheless, it was found that patients with DM had higher hematocrit and greater RBC distribution width, whereas the average corpuscular volume and average hemoglobin content of RBCs turned out to be lower than those in the healthy controls (5 and 1 × 106 Hz (4 and 1 × 105 Hz), we noted repulsion of the cells from the electrodes (negative dielectrophoresis) with hemolysis of some RBCs under the influence of the electric field.In the assay involving the NUAEF, RBCs of healthy controls (group 1) showed a high velocity of motion toward electrodes and high elasticity at frequencies of 5 × 10× 106 Hz a. At low5 and 1 × 106 Hz), deformability of the cells (m) and translational motion velocity of the cells (μm/s) toward the electrodes were found to be significantly lower , with ~25% of the discocytes becoming spikelike. It is known that the membrane integrity and biconcave shape of RBCs are mostly ensured by the energy of high-energy compounds [There were differences in RBC characteristics associated with the severity of rheological disturbances in DM. In a solution of a dielectric, most RBCs from the patients with medium severity of rheological disturbances (Group 2) had a discocyte shape, and 24% ± 6% of the cells became spherocytes or assumed a shape of a “deflated ball.” In patients with severe microcirculatory disturbances (Group 3), we detected an increase in the proportion of nondiscocyte shapes up to 48% ± 6%  but directly correlated with summarized viscosity  and summarized rigidity of RBCs .With the increasing severity of rheological disturbances (from Group 2 to Group 3 of patients with DM), there were increases in electric conductivity, indices of aggregation and destruction, summarized viscosity, and summarized rigidity. At the same time, deformation amplitude of RBCs, polarizability at 10It is reported that the deformability of RBCs is determined by their viscoelastic characteristics . AccordiAs a consequence of cholesterol exchange between RBCs and the lipoproteins adsorbed on their surface, cholesterol is incorporated into the RBC membrane. During this process, RBC size increases, and these cells change shape, with a substantial decrease in their filtration ability ,28.Such alterations cause microcirculatory disturbances and increase the risk of ischemic states including the diabetic foot. The decrease in cell elasticity under the influence of the NUAEF and progressive worsening of rheological disturbances in DM can be regarded as a “model” of RBC behavior at the level of capillaries, whose size is >2.5-fold less than the diameter of these cells . On the On the other hand, extensive regions of the capillary bed get “excluded” from the bloodstream and oxygen exchange because the aggregates and the rigid cells are unable to enter the zone of smallest vessels. The “rarefaction” of the capillary bed further aggravates hypoxia and ischemia at the periphery .r = −0.60, p = 0.02; r = −0.53, p = 0.04, respectively). Given that polarizability reflects biological activity of cells, its progressive decreases with increasing DM severity is possibly associated with activation of accelerated low-efficiency erythropoiesis in this disease. Activation of the renal juxtaglomerular apparatus, in conjunction with progressive narrowing of renal arteries, leads to increased production of erythropoietin, which is a stimulator of accelerated formation of RBCs [The propensity of RBCs for excessive disintegration and aggregation in patients with DM were found to correlate with low polarizability of the cells , with glycated hemoglobin , the urine ratio of albumin to creatinine . It is known that higher excretion of albumin with urine develops as a consequence of damage to (and dysfunction of) the renal vascular endothelium, increased pressure in the capillary network of glomeruli (glomerular hypertension), disruption of structural integrity of the glomerular basal membrane, and dysfunction of the canalicular epithelium [We revealed correlations of RBC characteristics with several clinical and biochemical parameters and some parameters of RBCs. It should be noted that most parameters of RBCs were found to correlate with the fasting glycemia level .Because the last two parameters reflect the compensation degree of carbohydrate metabolism, their relation with electric and viscoelastic characteristics of RBCs is not surprising. Glycated hemoglobin noticeably raises internal viscosity of RBCs (by forming cross-links with the cell membranes) and summarized rigidity too ,35. Thesr = 0.33, p = 0.013) and with summarized viscosity ; for triglycerides: with deformation amplitude , with summarized viscosity , with summarized rigidity , and with cell polarizability at 106 Hz ) and with results of liver assays ; for the total bilirubin level: with deformation amplitude , with summarized viscosity , and with summarized rigidity ; for the albumin level: cell polarizability at 106 Hz ) confirms interactions of RBCs with serum components. The most revealing are the correlations of RBC characteristics with the severity of diabetic retino- and angiopathy , with the deformation degree at 5 × 105 Hz , with summarized viscosity , with summarized rigidity , with the average diameter of RBCs , and with dipole moment . Probably, the shifts in the structural and functional properties of RBCs contribute to the progression of DM complications, in agreement with data from other investigators [The observed correlations indicate the involvement of RBCs in the pathogenesis of diabetic complications. The observed associations with lipid profile parameters ; this phenomenon influences the surface charge of the membranes. The reason for the tight link between electric parameters of RBCs and the albumin/creatinine ratio is obvious; this ratio is being evaluated as an indicator of the initial stages of endothelial dysfunction, which is one of the major components of DM pathogenesis ,11.5 Hz; p < 0.01; It was found here that in patients with DM, there is a shift of crossover frequency to a high-frequency range (>5 × 10p < 0.0001), and this effect may indirectly indicate membrane thickening. This phenomenon is probably related to several factors, for instance, the enhancement of mutual exchange of lipids with blood serum, as confirmed by correlations of RBC membrane capacity with the levels of total cholesterol  and triglycerides . Another possible contributor is adsorption of high-molecular-weight proteins on the surface of membranes  in conjunction with the well-pronounced inflammation in patients with DM. This notion is supported by the higher levels of some inflammation markers observed in the present study . This effect is a sign of a decreased electric charge of RBCs. On the one hand, a possible reason is the alteration of average RBC corpuscular volume in patients with DM ; this chThus, it was demonstrated here that DM progression is accompanied by a process of RBC depolarization. Meanwhile, amplitude and frequency parameters of RBCs in the NUAEF were found to be accurate indicators of physicochemical properties of the membrane and cytoplasm of these cells as well as markers of their biological activity.To assess the usefulness of RBC parameters for the stratification of severity of microcirculatory disturbances in patients with DM, ROC analysis was performed (construction of ROC curves) for the various characteristics of RBCs.6 Hz, the deformation degree of the cells at the frequency of 5 × 105 Hz, dipole moment, and electric conductivity of the cells. Less accurate discrimination was manifested by the polarizability of RBCs at the frequency of 106 Hz, morphology, structure of the RBC surface, and the velocity of RBC motion toward the electrodes . Inclusion of such a group of patients with DM may increase the practical utility of this research because the rheological disturbances are reversible at the early stages.A possible limitation of the proposed method of assaying RBC parameters is the necessity of taking into account various factors  that can affect these RBC characteristics.The advantage of the proposed method over existing ones is that this diagnostic technique for rheological disturbances and diabetic microangiopathy allows to both identify this complication (regardless of the affected site) and determine its severity. The degree of changes in RBC parameters has the diagnostic value. Our method is barely invasive (involves only blood collection), thereby preventing serious complications in the patients and not requiring hospitalization. In relation to the physical and psychological state of a patient, there are no restrictions on our method. The evaluation of measured RBC parameters is objective and not affected by the qualifications and experience of the test operator. The dielectrophoresis assay requires only inexpensive widely available reagents thus increasing the accessibility of this method for a mass diagnostic program, including the one intended for screening. The proposed method is not labor-intensive and not costly. The high sensitivity, specificity, and clear-cut criteria for the evaluation of rheological-disturbance severity and diabetic microangiopathy are expected to facilitate diagnostics at an early stage of the disease.-6 Hz, and membrane capacity and corresponds to increases in electric conductivity, summarized viscosity, summarized rigidity, and propensity for hemolysis and aggregation;worsening of rheological disturbances in patients with DM is accompanied by significant decreases in RBC deformation amplitude, dipole moment, polarizability at the frequency of 10-6 Hz, the cell deformation degree at the frequency of 5 × 105 Hz, dipole moment, and electric conductivity of the cells (area under the ROC curve: 0.713–0.982);we identified the most useful parameters of RBCs for the stratification of severity of rheological disturbances in type 2 DM: summarized viscosity and summarized rigidity of RBCs, deformation amplitude of the cells at the frequency of 10-the proposed panel of electric and viscoelastic parameters of RBCs has the following analytical characteristics: diagnostic sensitivity 97.8%; diagnostic specificity 86.7%; positive predictive value 95.8%, negative predictive value 92.8%, and accuracy index 95.2% when used as a diagnostic test, in comparison with the EASD risk assessment criteria for vascular complications in patients with DM.Thus, our results on rheological disturbances in patients with type 2 DM lead to the following conclusions:The application of dielectrophoresis to the diagnosis and severity assessment of rheological disturbances and diabetic microangiopathy will enable rapid detection  of the DM complications that determine the prognosis, risk of disability, and life expectancy of the patients. This feature denotes unquestionable economic efficiency of the proposed diagnostic method.


Primary care is the major point of access in most health systems in developed countries and therefore for the detection of coronavirus disease 2019 (COVID-19) cases. The quality of its IT systems, together with access to the results of mass screening with Polymerase chain reaction (PCR) tests, makes it possible to analyse the impact of various concurrent factors on the likelihood of contracting the disease.Through data mining techniques with the sociodemographic and clinical variables recorded in patient’s medical histories, a decision tree-based logistic regression model has been proposed which analyses the significance of demographic and clinical variables in the probability of having a positive PCR in a sample of 7,314 individuals treated in the Primary Care service of the public health system of Catalonia. The statistical approach to decision tree modelling allows 66.2% of diagnoses of infection by COVID-19 to be classified with a sensitivity of 64.3% and a specificity of 62.5%, with prior contact with a positive case being the primary predictor variable.The use of a classification tree model may be useful in screening for COVID-19 infection. Contact detection is the most reliable variable for detecting Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases. The model would support that, beyond a symptomatic diagnosis, the best way to detect cases would be to engage in contact tracing. On 31 December 2019, the authorities of the People’s Republic of China reported numerous cases of pneumonia of unknown etiology in Wuhan (China) to the WHO. A week later they confirmed that it was a new coronavirus outbreak that has been called SARS-CoV-2 .In Catalonia, the spread of the pandemic has put a severe strain on the health system, which has had to adapt. This impact has been especially important in primary care centres, which are the main point of access for COVID-19 cases . One of the strengths of the primary care system in Catalonia is the existence of a computerized medical history which covers 95% of a population of approximately seven and a half million people .Clinical decision support systems (CDSS) play an important role in medicine, especially in medical diagnostic processes, and these are becoming increasingly important in medical decision making, particularly in those situations in which decisions must be made effectively and reliably . Binary In this context, the aim of this study is to evaluate the application of a decision tree to the diagnosis of COVID-19 based on clinical and sociodemographic information registered in the medical history collected by the primary care system in Catalonia.Primary care professionals have been using a COVID-specific data collection sheet since 26 March 2020, as part of the computerized medical history used by the primary care system, which is intended to identify patients who present with symptoms compatible with a coronavirus infection. This sheet was set up to conduct face-to-face or telephone triage of patients, electronically document related clinical information, manage and communicate the results of pandemic-related tests, and oversee the safe handling of such cases. It automatically accesses the demographic data in the patient’s medical history  in order that the healthcare professionals treating the patient need only record the possible presence of contact with infected individuals and associated symptoms such as fever, cough, shortness of breath, a general feeling of being unwell, an altered mental state, gastrointestinal symptoms (including vomiting and diarrhoea), anosmia / ageusia,  and other symptoms and signs.This study includes a retrospective cohort of individuals assigned to one of the 311 Primary Care Teams (PCT) run by the Catalan Institute of Health , with aThe main variable of interest is the result (positive or negative) of the Reverse transcription-PCR test among the members of the cohort studied. From the samples collected with a nasal and throat swab with Virus Transport Medium (VTM) refrigerated at 4° C for a maximum of 48 hours, the Cobas © SARS-CoV-2 technique was performed, which has sensitivity and specificity close to 100% .For the descriptive analysis, the variables recorded at the time of the visit and those which are automatically collected from the patient’s medical history such as age, sex, the presence of comorbidities and other important underlying conditions such as rurality, socioeconomic level and morbidity clusters . To asseA multinomial logit model was used for a full factorial model through the SPSS Statistics Standard Edition program. The estimation of the parameters was carried out through an iterative maximum likelihood algorithm. Although the ratio of the advantages of any pair of categories was assumed to be independent of the other response categories, an adjustment was made for the variables age and sex. To find out if there is a relationship between different categorical variables collected and the fact of presenting a positive PCR test (dependent variable), the independent variables that were shown to be related to the response variable in the descriptive analysis were used as possible predictors and that therefore could be good predictors. In particular, the variables that were studied as possible predictors were age, gender, rurality, socioeconomic level, the presence of chronic diseases and symptoms, according to type and number. The adequacy of the model was based on its ability to show an improvement with respect to the null model (model without predictors). From the 3 statistical tests that quantify this improvement  we choose the likelihood ratio.Prediction results were obtained using the QUEST classification type of tree. This method is fast and avoids other methods’ bias in favor of predictors with many categories as in the study. This kind of decision tree can be specified only if the dependent variable is nominal (as PCR result). The predictor variables proposed for the logistic model were the same as those used to make the decision tree model.To check the degree of success of the two classification methods (regression model and tree model), we used the ROC curves functions from the R package pROC, for statistics. An estimate of the area under the curve was made using a binegative exponential model, and the ROC curve was obtained, with its confidence interval and coordinate points. The quantitative contrast variables were obtained from the probabilities resulting from the regression analysis and the tree model. To avoid introducing a bias in test using train-data, we performed a train-test split before data preparation steps. To simulate a train and test set we split randomly the data set into 80% train and 20% test.The study was approved by the Ethics Committee for Clinical Research (ECCR) of the Jordi Gol University Institute for Primary Care Research (IDIAP) in Barcelona (Code 20/088-PCV) and was carried out in accordance with the general ethical principles for observational studies . The ethThe continuous variables are presented as mean and standard deviations. The categorical variables are presented as counts and percentages and the comparison between groups was done using the Chi-square independence test with the Yates continuity correction or the Fisher exact test, as appropriate. The logistic regression model is adjusted for assessing the association of the different values/variables with the probability of having a positive test of SARS-CoV-2, after adjusting for age, sex and other symptoms. The results of the regression are calculated as odds ratios (OR) and the corresponding confidence intervals (CI) of 95%. The Hosmer-Lemeshow test was also used with 10 groups as a fit-test of the model. The QUEST algorithm was used to grow the classification tree. The predictive accuracy of each model was evaluated by calculating the area under the curve (AUC).The level of statistical significance was considered to be p <0.05 . The IBM SPSS Statistics for Windows package (version 24) and the R package with RStudio (version 4.2.1) were used for the analysis.The mean age of the participants in the study was 51.5 ± 19.1 years, with the participants who had a positive PCR (p <0.001) being significantly older. 42.79%  had positive PCR. The proportion of men with positive tests was significantly higher than women (52.0% vs. 49.5%) (p = 0.041). Regarding the social variables, although no association is observed between the socioeconomic level of those evaluated and the results of the PCR, the rurality variable did have an association, with a lower number of positives (24.1% vs. 27.8%) in rural areas (p <0.001). Those who tested positive for SARS-CoV-2 do not show a higher number of chronic diseases, but do show symptoms with a significantly higher frequency than those with negative tests: fever (33.5% vs. 23.6%), cough (37.7% vs. 34.5%), diarrhoea (19.0% vs. 17.0%), slurred speech (3.9% vs. 2.1%), a general feeling of being unwell (49.3% vs. 39.2%), an altered mental state (2.6% vs. 1.8%) and anosmia / ageusia (27.4% vs. 13.2%) . Most part of participants with a valid PCR (71.8%) had symptoms  and 53.7% of them had a positive PCR (p < 0.001), a greater number of symptoms was associated with a positive PCR  (p < 0.001). 67.8%  of the subjects who reported having been in contact with a confirmed case of COVID-19 tested positive for SARS-CoV-2 (p < 0.001) .The diagram obtained by applying a decision tree is a graphical representation of the model and each possible Boolean alternative corresponding to a decision to be made is represented by a decision node (DN). Each DN contains a table showing the number of cases (frequency and percentage) of the values that the dependent variable under study can take .Contact variable, indicating that this is the main predictive variable. The second DN has a higher Chi-square than the first DN (71.81 vs. 61.06) and shows that of the 57.9% cases that are contacts, 58.7% have a positive PCR. The second DN branches back into DN 5 and 6, depending on the presence of taste dysfunction. We observe (DN 5) that cases with taste dysfunction are more likely to have a positive PCR, with a 71.3% compared to 55.9% of DN 6, which is the absence of taste dysfunction. DN 6 branches into DN 11 and 12, depending on the presence of fever. It is observed that a 66.6% of patients with fever have a positive PCR. DN 11 branches into 15 and 16, which correspond to an individual aged over 45. DN 16, which are cases > 45 years of age, has a positive PCR of 75.6%. This DN 16 branches into DN 19 and 20 depending on whether the participant’s gender is male or female. DN 19, which corresponds to males, has a higher percentage of positive PCRs (82.4%). Finally, DN 19 branches between 21 and 22, which defines the presence of a general feeling of being unwell. DN 21, which corresponds to a feeling of being unwell, carries a probability of having a positive PCR higher than the other node (87.7%). The sequence of DNs that best define cases with a positive PCR (variables which influence having a positive PCR) are: DN 0, DN 2, DN 6, DN 11, DN 16, DN 19, DN 21. This is, they influence, in order of importance, the following variables: Contact, Taste dysfunction, Fever, Age > 45, Sex and General feeling of being unwell.The dependent variable (positive PCR) branches into two DN (1 and 2), according to the The graphical representation of the area under the curve (AUC) of the multivariable regression model and tree classification , show a This study contributes to improving the detection and classification systems of suspected cases of COVID-19 infection through case-specific demographic and clinical characteristics. The absence of thorough studies , 9–11 anIn order to obtain the objective, we have applied logistic regression and decision tree classification methods , which sThe results obtained with the tree diagram technique or logistic regression are very similar. In both methods the variable with the highest gain and proportion of gain is the same, thus with both approaches the root node or main variable is the fact of having documented contact with a confirmed case of COVID-19. Among the variables which refer to the symptoms associated with the presence of COVID-19 infection, both models consider the presence of taste/smell dysfunction, the presence of fever and a general feeling of being unwell as key predictor variables.Pre-symptomatic and asymptomatic transmission play a key role in the transmission of diseases between communities, especially due to the hidden nature of the spread. If we add to this the fact that the main predictor variable is the contact with a suspected case, the model would guarantee that, apart from a symptomatic diagnosis, the best way to detect a case would be to study contacts. Transmission through contacts and case detections through confirmed case tracking is well documented –23. In aThis study has several limitations which may affect the interpretation and generalization of the findings. The first is the assumption that the PCR (reference test) presents, in real conditions, a sensitivity and specificity of 100%. Although there is still no consensus, various authors are providing data which could indicate that the sensitivity of the PCR test may not reach 100% in real conditions –27. We mA second limitation is the study population which had a PCR. A large number of individuals whose data were recorded on the screening sheet were excluded from the sample because no confirmatory PCR was performed and this was because during the peak of the pandemic (study period) the PCR performance criteria were limited to a specific sector of the population   and thisOn the other hand, if we analyze the results of the AUC, in terms of the probability of having a positive test in a suspected patient, we observe that in both models there is a low capacity (66 and 68%) to discriminate between classes and a low sensitivity and specificity.The recent emergence of this virus means that many data mining and artificial intelligence projects are currently underway, and although previous studies exist , 11, 29,The use of a tree classification model may be useful in screening for the presence of a case of COVID-19 infection. The main variable associated with the risk of developing COVID-19 is the contact with a previously infected person. Early detection and isolation of contacts seems to be the best tool to detect and reduce the extent of SARS-CoV-2.S1 File(R)Click here for additional data file.


In acute peritonitis, any surgical intervention leads to impaired immune protection with the development of postoperative purulent-septic complications, which increases several times the likelihood of death, especially in people with secondary immunodeficiency as a consequence diabetes mellitus.We aimed to study the dynamics of pro- and anti-inflammatory cytokine content in rat serum under experimental acute generalized peritonitis on the background of diabetes mellitus.Fifty-six white rats were used for the study. The determination of the serum cytokine profile was performed by enzyme-linked immunosorbent assay.When comparing the levels of interleukins between the study groups, a statistically significant increase in the level of proinflammatory cytokines was found in the group of diabetic animals during all experimental periods. In particular, the concentration of interleukin – 1β increased significantly by 94% on day 1 of observation, by 115% on day 3, and by 121% on day 7 compared to the control group. Similarly, a significant increase in TNF-α levels was observed in animals with diabetes. In this group, the most significant increase in the level of TNF-α was recorded on the seventh day of the experiment, and it increased by 3.4 times.Animals with acute peritonitis on the background of diabetes had a significantly increased concentration of anti-inflammatory cytokines in the serum of all study groups, which confirms their involvement in the pathogenesis of the disease under study. Acute generalized peritonitis (AGP) is increasingly associated with concomitant diabetes mellitus (DM), resulting in changes in its mechanisms of development and worsening of the effects of treatment. However, any surgery leads to impaired immune protection with the development of postoperative purulent-septic complications -2, whichCurrently, peritonitis is considered in the inflammatory process dynamics, which is characterized by the release of pro- and anti-inflammatory cytokines -4. The mThus, cytokines can play a significant role in the pathogenesis of AGP on the background of DM, but the specific mechanism of their action is not yet well understood. Therefore, the aim of our work was to study the content of pro- and anti-inflammatory cytokines in the serum of rats under the conditions of experimental AGP on the background of DM.The experiment involved 56 white rats, which were divided into three groups: the main group – 24 animals with simulated AGP on the background of DM; comparison group – 24 animals with simulated AGP; the control group – 8 intact animals, which were kept under standard vivarium conditions. All groups of animals compared were representative in terms of weight, sex, and age.The experimental DM was reproduced by intraperitoneal administration of streptozotocin on an empty stomach at a dose of 60 mg/kg , which was dissolved in sodium citrate buffer, pH 4.5) . StudiesAfter two weeks from the use of streptozotocin in rats, the glucose content from the venous blood, which was obtained from the tail vein, was determined. In subsequent studies, only those rats in which the glucose content was greater than 300 mg/L were further examined. Animals of the control group were administered subcutaneously sterile sodium chloride solution 0.9%.The influence of AGP on the course of DM was studied on the model proposed by Lazarenko et al. . This moThe observation dates were 1, 3, and 7 days. This experimental study was conducted in accordance with the general rules and regulations of the European Convention on the Protection of Vertebrate Animals, which are used for research and other scientific purposes .Determination of cytokine profile in serum (interleukin-1β (IL-1β), interleukin-10 (IL-10) and tumor necrosis factor-α (TNF-α)) was determined by enzyme-linked immunosorbent assay using an “ELISA Kit for Rats”, Uscn Life Science Inc. according to the manufacturer’s instructions .Currently, there is no doubt that in AGP against the background of DM, the activation of specific and nonspecific immune responses is associated with the effect on various homeostatic systems of a variety of universal mediators, among which cytokines are essential. They are often called cellular hormones because they interact with specific cellular receptors, exerting autocrine, paracrine, and endocrine regulation. Cytokines act primarily not only at the level of the inflammation site and the territory of the responding lymphoid organs, but also at the level of the whole organism, so there is a need to study the interleukins in the blood plasma to study the systemic nature of inflammation in AGP against the background of DM.Our study showed that on the first day after the modeling of AGP (comparative group), the level of IL-1β in serum increased statistically significantly by 86%. In contrast, on the third day, there was a significant increase of 104% relative to intact animals and 107% compared to the control group on day 7 of the experiment . In animIn the analysis of the anti-inflammatory IL-10 level on days 1, 3 and 7, it was noted that in the serum of experimental animals with AGP, there was a statistically insignificant decrease of this cytokine by 11%, 13% and 16%, respectively. The study showed that the level of IL-10 in the serum of animals with AGP on the background of DM significantly decreased by 14% in the first day, by 17% on the third day, by 15% on the seventh day compared to intact animals . In our study, the level of TNF-α in the serum of a group of animals with simulated AGP for the first, third and seventh days of the experiment increased statistically significantly by 3.2, 3.3 and 3.4 times, respectively. Similarly, the indicator of growth was observed in the animals of the main group. The most significant increase in TNF-α level in animals of the AGP group against the background of DM was recorded on the seventh day of the experiment – it increased by 3.4 times.Analyzing these results, we can conclude that modeling of AGP against the background of DM leads to impaired immunological and nonspecific reactivity of the organism.Analyzing these results, we can conclude that modeling of AGP against the background of DM leads to impaired immunological and nonspecific reactivity of the organism. It is known that the microbial factor in peritonitis is the trigger mechanism of subsequent pathophysiological disorders . Under tThe initiation and major stages of the development of an inflammatory response are controlled mainly by proinflammatory cytokines produced by macrophages, neutrophils, and T-cells in response to stimulation by bacterial agents. Naturally, gram-negative endotoxin stimulates macrophages and neutrophils to produce TNF- α, IL-1, IL-12, IL-8, and IL-6. Exotoxins, superantigens of gram-positive bacteria activate T-cells and monocytes to produce IL-2, IL-1, TNF-α. At the same time, proinflammatory cytokines play a protective role because they provide infections with effector cells , stimulate their phagocytic, bactericidal activity, and induce the initiation of an antigen-specific immune response, which together promotes pathogen elimination .Due to the massive contamination of the abdominal cavity and the formation of a large number of toxins and biologically active substances that interact with the highly reactive and highly resorptive peritoneum, the mechanisms of limiting the local inflammatory process in conditions of peritonitis are widespread. As a result of increasing the permeability of the endothelium, cytokines enter the systemic bloodstream, where they activate leukocytes and platelets and cause the release of adhesion molecules from the endothelium. Initially, under the action of a small number of proinflammatory cytokines , an initial acute-phase reaction occurs, aimed at mobilizing the body’s defenses at the systemic level . This prIt is also known that DM is characterized by a progressive deterioration of pancreatic function , resultiThus, interleukin-1 β may be one of the factors that differentially affect the nature of pancreatic β-cell function - from stimulation to inactivation, which is characteristic of the dynamics of DM development. At the same time, the metabolic shifts that accompany this disease, in particular hyperglycemia , are theThe data obtained indicate the activation of macrophages and the possibility of inhibition of β-cell functional capacity. IL-1β activates T and B lymphocytes, enhances their cytotoxic properties, and initiates TNF-α synthesis.As a typical anti-inflammatory cytokine, which plays a key role in the regulation of the intensity of inflammation and the effectiveness of immune defense, TNF-α refers to markers of nonspecific generalized inflammation. It has numerous immunomodulatory effects that are fundamental in the pathogenesis of autoimmune inflammation. Currently, there is evidence that TNF-α has the ability to stimulate the proliferation of autoreactive lymphocytes of different classes, to cause aberrant expression of adhesion molecules and antigens of histocompatibility class II on the surface of pancreatic cells, which can lead to the disruption of the process of antigen recognition . In addiChanges in the TNF-α system in diabetes can be explained from two points. First, they can be a consequence of metabolic disorders  . TherefoIn animals with AGP on the background of DM, the concentration of anti-inflammatory cytokines in the serum of animals of all study groups was significantly increased, which confirms their involvement in the pathogenesis of the investigated pathology. In particular, the concentration of interleukin – 1β increased significantly by 94% on the first day of observation, by 115% on the third day, and by 121 on the seventh day compared to the control group. Similarly, a significant increase in TNF-α levels was observed in animals with diabetes. The most significant increase in the level of this indicator in this group of animals was recorded on the seventh day of the experiment – by 3.4 times.Under these conditions, a new level of regulatory interconnection is emerging, where changes in the cytokine system of macrophage origin play an important role. This suggests that the development of complications in this comorbid pathology is associated with a violation of nonspecific immunity.The work is a fragment of the planned research work – Development of new open (miniaccess) and laparoscopic surgical interventions in the treatment of diseases of the abdominal cavity on the principles of the multimodal program “fast track surgery” (State registration number 0119U002805). The authors declare that there is no conflict of interest.


Positive single-strand ribonucleic acid [(+)ssRNA] viruses can cause multiple outbreaks, for which comprehensive tailored therapeutic strategies are still missing. Virus and host cell dynamics are tightly connected, generating a complex dynamics that conveys in virion assembly to ensure virus spread in the body. Starting from the knowledge of relevant processes in (+ss)RNA virus replication, transcription, translation, virions budding and shedding, and their respective energy costs, we built up a systems thinking (ST)–based diagram of the virus–host interaction, comprehensive of stocks, flows, and processes as well-described in literature. In ST approach, stocks and flows are expressed by a proxy of the energy embedded and transmitted, respectively, whereas processes are referred to the energy required for the system functioning. In this perspective, healthiness is just a particular configuration, in which stocks relevant for the system  are constant, and the system behavior is stationary. At time of infection, the presence of additional stocks  confers a complex network of feedbacks leading to new configurations, which can evolve to maximize the virions stock, thus changing the system structure, output, and purpose. The dynamic trajectories will evolve to achieve a new stationary status, a phenomenon described in microbiology as integration and symbiosis when the system is resilient enough to the changes, or the system may stop functioning and die. Application of external driving forces, acting on processes, can affect the dynamic trajectories adding a further degree of complexity, which can be captured by ST approach, used to address these new configurations. Investigation of system configurations in response to external driving forces acting is developed by computational analysis based on ST diagrams, with the aim at designing novel therapeutic approaches. Positive single-stranded ribonucleic acid [(+)ssRNA] viruses, including picornaviruses, flaviviruses, Togaviridae, and human coronaviruses (CoVs) , cause mRecent studies confirmed the complexity of viral dynamics, whose fitness is improved by the complex interactions with the host proteins , as prevIn ST, the behavior of a dynamic system can be described and predicted by the temporal evolution of its configurations, given by hierarchical feedback loops and self-organization. The configuration evolution then can be analytically computed by proper simulators  to furthSystem dynamics (SD) approach is mostly used for strategic modeling, typically for ecological and socioeconomic systems, to understand the supply chain performance. In particular, results of SD modeling provide a set of alternative evolutive patterns in form of graphs, capturing the internal dynamics of a system even in lack of some experimental data to fit. These can provide alternative scenarios that, when fitting experimental evidences, indicate the most effective leverage points to control the system evolution.systemic intervention strategies.In this article, we show that, by approaching the host–virus interaction as a dynamic systemic problem , it is pQi, i = 1, 2,…, n, relevant to the study at issue, that constitute an n-ple of numbers , which at any time represents the state of the system. A stock may change its value only upon its inflows and/or its outflows, represented by arrows entering or exiting the stock. Processes are any occurrence capable to alter—either quantitatively or qualitatively—a flow, by the action of one or more of the system elements. In a stationary state of the system, stock values are either constant or regularly oscillating. Processes, which cause the stationarity or perturbation of a system, must be activated by a driver, acting on the flows where the process is located. The pattern of the feedbacks acting in the system configurations is the feature that ultimately defines the systems dynamics. Each flow depends on the state variables Qi by relationships of the kind dQi/dt = kf(Qj), i, j = 1,…, n, where n is the number of stocks in the system.The basic SD element is the stock and flow diagram. Stocks are countable extensive variables The stocks and flows inventory reported in 1, which uses approximation techniques to evaluate stocks.After setting the initial conditions at time 0 for the stocks, system solutions were obtained using recursive computation for a relative short period of time , in order to appreciate the model dynamic behavior. The computational model based on a set of differential equations that describe the rates of change of all stocks in the ST diagram  was devek associated to flows, the set of interconnected equations was treated by a standard finite-different method, taking care of choosing a time step short enough to evidence the dynamics of any of the studied processes. The coefficients ki were calculated, on the basis of literature data, considering the dynamics of each single stock, by quantifying flows and stocks during the time interval set as simulation step, as shown in ki coefficients), describing the reaction of each system component to a change in any other one, were derived from the stocks turnover times  and a set of phenomenological coefficients er times . TherefoThe reliability of both available data and modeling was tested by evaluating the effect of the variation of each of the most relevant input data (stocks and processes) on the system trajectories. Unfortunately, here is not a single comprehensive procedure suitable for the validation of all dynamic models, being dependent on their usefulness, in turn referred to the very purpose of the model itself . We chosFirst, we identified the important structures in the system and then used to build up the stock-flow diagram of the virus–host interaction system. In Q1 depended on the cell bioenergetics, e.g., the number of mitochondria, OX-PHOS activity levels, and cell cycle phase  to stocks Q2A and Q2B to produce, respectively, short- and long-half-life proteins, which could, in turn, be recruited by VR machinery. J20A and J20B, grouped into the flow J20, represented the outflow of folded, fully functional proteins addressed to secretion or surface exposure. Based on basal proteostasis of host cell, recovery of energetic sources from proteins not addressed to leave the system could be possible via several complex processes , identified by flows of materials J21A and J21B, respectively, from Q2A and Q2B back to Q1.The dynamics of energy allocation for protein synthesis contained in the stock le phase . In the Q3 , Q4 , and Q5 (full assembled virions to shed virus outside), diverted, at the time of infection, resources directly from Q1  and Q2B . Virions shedding was represented by the flows J7 and J50 through the contribution of the host flows J17 and J27. The output flows J4 and J5 were set to be effective only if the value of the respective stock Q3 and Q5 was higher than a threshold, as represented by the two switch symbols in the diagram.The viral load in the system, expressed by the stocks Q2A stock on the energy supply process ; (ii) the positive control of Q3 stock on the VR process ; (iii) the positive control of Q4 stock on the processes of synthesis and maturation of host proteins ; (iv) the positive control of Q5 stock on the VR process .We identified four feedback loops , and the values of stocks Q1, Q2A, and Q2B are constant; thus, the system behavior is stationary . We found a non-linear evolution of the system output (the Q5 stock) depending on the initial conditions: for Q3 stock in the range , the Q5 was linear, whereas for higher initial viral load, the growth of Q5 was linear in the first day and non-linear in the further timeframe, associated to a progressive, unpredictable reduction of Q3–Q4 stocks, reflecting in biological terms the turnover of viral proteins required for virions budding.The behavior of stock values Q4 stock on processes of the host cell, forcing host proteins Q2B to favor the production of virions  through the increased J23, J25, and J27 flows. In biological terms, the progressive Q1 reduction reflects the metabolic rewiring of infected host cells (The non-linear behavior of the (+)ssRNA virus–host interaction was due to the control of st cells , with prst cells . The desst cells . Resultsst cells , b, whenQ1 following different initial values of Q3 could explain both the variable incubation time in each individual subject and why infections due to (+)ssRNA viruses can occur asymptomatically in most cases. The resilience of virus–host system for a specific range of Q3 amount could, in turn, depend on intrinsic and extrinsic factors. Indeed, in response to manipulation of stocks and flows, and based on timeframe of observation, the system could evolve along different, non-linear trajectories, requiring early intervention upon infection to make the system resilient to growth of viral stocks.The behavior of in vitro studies, with a detail level established on the basis of the purpose of the study design. To this end, we applied the search of systemic leverage points by simulating the dynamics of multiple scenarios, upon the action of a generic external driving force (D), assuming that the minimization of the value of Q5 stock over time should limit the propagation of virions outside the cells.Currently, the search for a therapeutic strategy is based on single target-related parameters, while we propose to identify systemic targets  to improve host response to host–virus interaction. Starting from the pharmacodynamics of compounds currently under investigation for a typical (+)ssRNA virus , we coulQ5 virions stock, via manipulation of J7 and/or J50. However, minimization of J7 was counter-effective, due to the increase of Q5 as consequence of the feedback action in the VR process (data not shown). The effects of full (100%) or partial (50%) reduction of J50 (flow of energy required for virions budding) could prevent the outflow from Q5 without stopping its growth, diverting resources from Q1 and Q2B to Q5, so further supporting viral hijacking of cellular metabolism and impairing host cell homeostasis. As shown in J50 was different based on application time, Day 0 , or J4 , or J5 (flow of energy required for virions assembly), which are involved in virions assembly and are typically dependent on intrinsic viral biological properties.Second, we explored the systemic response to full (100%) or partial (50%) reduction of either J5 at Day 0 could recover the systems dynamics in a stationary status, in all scenarios of initial viral load tested ssRNA virus–host interaction has been indirectly confirmed by the data recently published by Gordon et al., who cloned, tagged, and expressed 26 of 29 severe acute respiratory syndrome (SARS)–CoV-2 proteins individually in HEK293T cells and used mass spectrometry to measure protein–protein interactions  at Day 0 did not affect the dynamics of the system  or partial (50%) reduction of e system . In parte system , the Q5  and K2A .J3 (flow of energy required for RNA replication) at Day 0 did not affect the dynamics of the system  or partial (50%) reduction of e system , but—difSeveral strategies can be used to reduce selectively virus RNA, including nucleoside analogs, which are metabolized intracellularly into their active ribonucleoside 5′-triphosphate forms and incorporated into the nascent viral RNA by error-prone viral RNA-dependent RNA polymerase (RdRps), to disrupt RNA synthesis directly via chain termination, or accumulation of deleterious mutations in the viral genome. The response to nucleoside analogs could be better tested by our computational model, adding the mutations rate and the DNA/RNA metabolism of host cell, not included in the diagram for lack of experimental data about the turnover of RNA stock, specific for each host cell type of interest.Q1, Q3, and Q5 arising from targeting J5 was mitigated by the combination with reduction of J50 or J21, since the combination targeting J5 and J21 , whose impact on the human body energy dynamics is already understood. The use of a multiscale hierarchical perspective is in principle already possible, as discussed in previous works adopting the same sort of system representation  in the present study. On the other hand, the interaction between different cell populations in the host could be also developed, to represent the interaction between healthy and infected cells, and the contribution of immune system  or the rentation .Q3) or the replication process (J3), our results suggest that the virus growth is more vulnerable if the process of virion growth before expulsion  is targeted.This work highlights the advantages of applying an ST-based approach to the study of virus–host interaction, being reflected in the possibility of extracting systemic dynamic features that would be otherwise counterintuitive. While a traditional single-target approach would address strategies targeting the viral RNA (The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.AR designed the study and collected medical knowledge. FG built up the diagram. MC built up the simulator. All authors performed simulation, analyzed data, prepared the figures, and wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The tandem gold(I)-catalyzed rearrangement/Nazarov reaction of enynyl acetates in which the double bond is embedded in a piperidine ring was computationally and experimentally studied. The theoretical calculations predict that the position of the propargylic acetate substituent has a great impact on the reactivity. In contrast to our previous successful cyclization of the 2-substituted substrates, where the nitrogen favors the formation of the cyclized final product, the substitution at position 3 was computed to have a deleterious effect on the electronic properties of the molecules, increasing the activation barriers of the Nazarov reaction. The sluggish reactivity of 3-substituted piperidines predicted by the calculations was further confirmed by the results obtained with some designed substrates. In the development of new and effective catalysts, step economy is surely one of the major goals. A reduction of the number of steps in the synthesis of complex compounds can be attained by cascade reactions, which allow for structural modifications on the organic compounds by forming several chemical bonds in one pot. To this end, gold catalysis –7 has be1 because of the accelerating effect of the nitrogen atom that stabilizes the oxyallyl cation intermediate 4 formed upon the ring closure. This was in analogy to that found for the classical Brønsted or Lewis acid-catalyzed Nazarov reaction involving N-heterocycles -rearrangement/Nazarov cyclization were studied computationally . To this process . The strocess -rearrangement/Nazarov reaction of l⋅mol−1) . To homovative 1 , confirm5 as a substrate seems to be related to the higher stability of the intermediate III, which could be attributed to the π-donating ability of the nitrogen atom to stabilize the positive charge -rearrangement/Nazarov cyclization that we used for enynyl acetates of the type 1  16] to  to 1  were modified by using different precatalysts (I and V.In order to increase the reaction rate and decrease the amount of side products, the best reaction conditions (with AgSbFatalysts , entry 5atalysts , entry 61, prompting us to prepare enynyl acetate 20 as reported in 8 to 10 failed with the seven-membered ring. Thus, the enesulfonamide 18 was prepared via the palladium-catalyzed reduction of the corresponding phosphate 17 -rearrangement/Nazarov cyclization of 2,3-dehydropiperidines substituted with a propargyl acetate group in the 3-position, demonstrating the significance of the correct positioning of the nitrogen atom relative to the forming cycle. The comparison of the reactivity of the substrate having the piperidine ring substituted at the 2- vs the 3-position was very instructive about the optimal electronic features of the reactive species. In this regard, the initial rearrangement of the propargyl acetate induces the formation of a divinyl cationic intermediate, which is differently stabilized by conjugation with the nitrogen atom depending on the relative position of nitrogen. For the 3-substitution, the π-donor ability of the nitrogen atom strongly stabilizes the intermediate, reducing the reactivity. NBO calculations have also been used to confirm this hypothesis. We present some experimental data corroborating the sluggish reactivity of the 3-substituted substrates, in comparison to the 2-substituted analogues that we have previously described.File 1Computational section, experimental section, and NMR spectra.


Accidents and injuries are one of the most important causes of disability and death in developed and developing countries. Awareness of the dimensions and causes of accidents and injuries can be beneficial for health policymakers. Therefore, this study was conducted to aim of estimation the incidence rate and evaluation of epidemiological pattern of accidents and incidents in the Khomein City.This descriptive-analytical study from cross-sectional type was carried out using data from the national program of accidents and injuries registry in the Khomein Province in 2017. The study population is injured by accidents referring to the hospital. To calculate the age-standardized incidence rate (ASR) was used from the world standard population. Data analysis was performed using SPSS software version 20 and at an error level of 5%.The mean and standard deviation of age the injured was 32.9±18.8. The annually Incidence Rate (IR) of accidents and injuries was 939.1 cases per 100,000 people, while the age-standardized incidence rate (ASR) were estimated to be 917 per 100,000 people. In total, the sex ratio  in all accidents is 2.46, that this proportion in the age group of 20-29 years was maximum. The most incidents occurred in both sexes were reported motor vehicle (car) accident (32.2%), motorcycle accident (31.7%), pedestrian accident (16.2%) and poisoning (6.2%), respectively. Between gender variable and type of incident was observed significant difference (P<0.001). Cases of suicide attempt in the female group were 6.5 times higher than the men group.The incidence rate of traffic crashes in the city of Khomein is several times the provincial and national levels, for this reason, this city is considered as a high-risk and at-risk regions for traffic accidents in the country. Therefore, should be In addition to the optimizing the roads and removing the Accident-prone spots, The Naja Rahvar Police with by imposing strict and accurate traffic rules and more control of the drivers behavior, are attempting to reduce the occurrence of accidents. The high occurrence of poisonings and suicide attempt several times in the women s group is warning danger for the authorities to take preventive policies and applying cultural mechanisms to reduce this ratio to be stepped up.Epidemiologic, Accidents and Injuries, IR, ASR, Suicide, Khomein


As the virtual mirror of complex real-time business processes of organisations’ underlying information systems, the workflow management system (WfMS) has emerged in recent decades as a new self-autonomous paradigm in the open, dynamic, distributed computing environment. In order to construct a trustworthy workflow management system (TWfMS), the design of a software behaviour trustworthiness measurement algorithm is an urgent task for researchers. Accompanying the trustworthiness mechanism, the measurement algorithm, with uncertain software behaviour trustworthiness information of the WfMS, should be resolved as an infrastructure. Based on the framework presented in our research prior to this paper, we firstly introduce a formal model for the WfMS trustworthiness measurement, with the main property reasoning based on calculus operators. Secondly, this paper proposes a novel measurement algorithm from the software behaviour entropy of calculus operators through the principle of maximum entropy (POME) and the data mining method. Thirdly, the trustworthiness measurement algorithm for incomplete software behaviour tests and runtime information is discussed and compared by means of a detailed explanation. Finally, we provide conclusions and discuss certain future research areas of the TWfMS. The workflow management system (WfMS) is considered a multidisciplinary system-of-systems (SoS)-oriented software under the modern IT background of cloud computing, internet of things (IoT), big data, and advanced technologies for the future. When a WfMS encounters unexpected accidents, human intervention or offline adjustment is insufficient to be appropriated for its complex undertaken commissions and high availability requirements. Similar to real-time systems, a WfMS requires online adjustment to accommodate random changes occurring in its surroundings or software architecture under human control strategies, which may affect its functionalities or non-functionalities and transaction data consistence—and even its trustworthiness level. For example, addressing course timetabling problems  from theSoftware trustworthiness  is consiFrom an overview of the above related works, we can draw the conclusion that BPM measurement can be transformed from socialised human production to mechanised computing by means of electronic equipment. Therefore, there is a need for a comprehensive approach to connect the macroscopic and microscopic measurements systematically, thereby reflecting the user’s subjective experience of the trustworthiness of BPM according to the objective evidence of trustworthiness of the WfMS. However, in the dynamic and open WfMS runtime environment, the goal of comprehensively interpreting and obtaining the WfMS software behaviour is almost impossible to achieve. Generally, we can only obtain partial software behaviour, which represents incomplete trustworthiness of the entire service QoS without sufficient preciseness when the parameters regarding other software behaviour are uncertain . AccordiIn line with the related works discussed above, as a special type of QMS for workflow quality management, WfMSs experience multiple loops consisting of re-engineering and/or reorganisations. This process improves the WfMS into a high-level order—with relatively low entropy of information systems—from low-level disorder—with high entropy of information systems in the long term— along with consistently maintaining its trustworthiness as defined by users. This cycle, which covers the entire life of the WfMS, is also known as the resilience engineering (RE)  model an(1)Interface no.0 is linked to the core work engine(s) component of the WfMS and the additional self-configuration-parameter system for the WfMS (SCP4WMS) RE tool in the process execution service module; that is, we consider the SCP4WMS tools an extension of and supplementary to the process execution service module.(2)Interfaces no.6 and no.7 are linked to the self-optimization framework system for the WfMS (SOF4WMS) and self-healing model system for WfMS (SHM4WMS) RE tools, respectively, with the management and monitoring tool, which constructs the TWfMS mechanism with the SCP4WMS tool; that is, we consider the SOF4WMS and SHM4WMS tools extensions of and supplementary to the management and monitoring tool.(3)Interface no.8 is linked to the tools for communication on called application of typical web services with an additional tool, the auto construction method for the WfMS (ACM4WMS), based on services combination; that is, we consider the ACM4WMS tool an extension of and supplementary to the standard tools linked to the process execution service module via interface no.3.(4)Interface no.9 is linked to the requirement auto-analysis tool with the process definition tool, where the former consists of four components known as acquisition, decomposition, combination, and verification based on a Petri net (ADCV-PN); that is, we consider the ADCV-PN tools extensions of and supplementary to the process definition tool.(5)Interface no.10 is connected to the management and monitoring tool with the ACM4WMS tool when the WfMS encounters “local break points”, whereby the WfMS trustworthiness can no longer be maintained by the management and monitoring tool, even with the assistance of the tool sets of SCP4WMS, SOF4WMS, and SHM4WMS. In the context of the scenario described above, via interface no.10, the management and monitoring tool transfers the exceptional event unsolved by the SCP4WMS, SOF4WMS, and SHM4WMS tool sets sequentially to the ACM4WMS tool, in order to reconstruct the WfMS by searching for resources in the cloud. At such a time, we consider the WfMS as beginning local resilience engineering (LRE).(6)Interface no.11 is connected to the management and monitoring tool with the ADCV-PN tools when the WfMS encounters “global break points”, whereby the WfMS trustworthiness can no longer be sufficiently accurate by means of the ACM4WMS tool, even if all of the resources in the cloud are traversed by means of the ACM4WMS tool. In the context of the scenario described above, via interface no.11, the management and monitoring tool finally transfers the exceptional event unsolved by the ACM4WMS tool to the ADCV-PN tools, in order to remodel the WfMS under user validation. At such a time, we consider the WfMS as beginning global resilience engineering (GRE).As SoS-oriented, complex system software, a formal representation of the mechanisms and methods revealing the internal principles of WfMS trustworthiness is imperative for the design, development, and maintenance tasks covering the entire WfMS lifecycle. In our prior research, we presented a reference model for the TWfMS ,19, as i1.1.If the parameters of the operating environment variables of workflow engines have changed and will cause WfMS failure and improper operation, SCP4WMS will modify the parameters of the WfMS itself according to predefined rules and return the new parameters of the WfMS itself to the TDC in order to be adaptable to the new environment variables of the workflow engines.1.2.SCP4WMS should transmit the remaining parameters to SOF4WMS to deal with other WfMS mechanisms.1.3.SCP4WMS should compute the WfMS behaviour trustworthiness according to the algorithm illustrated in 1.4.When SCP4WMS receives the new parameters of the WfMS itself, modified by SOF4WMS, it should return these to the TDC in order to be optimised with the new operating condition variables of the workflow engines.1.5.When SCP4WMS receives the new parameters of the WfMS itself, modified by SHM4WMS, it should return these to the TDC in order to be recovered with the new transaction consistence variables of the workflow engines.SCP4WMS means self-configuration-parameter system for the WfMS. It has the function of analysing the parameters transferred from the trustworthiness data collection (TDC) component, which gathers real-time data from the WfMS at the multilevel of components, component combinations, and application software. According to the analysis, SCP4WMS carries out the following procedures.2.1.If the parameters of the operating condition variables of the workflow engines have changed and will lead to worse or better WfMS performance, SOF4WMS will modify the parameters of the WfMS itself, according to predefined ECA rules, and return the new parameters of the WfMS itself to SCP4WMS to be optimised with the new operating condition variables of the workflow engines.2.2.SOF4WMS should transmit the remaining parameters to SHM4WMS in order to deal with other WfMS mechanisms.2.3.SOF4WMS should verify the WfMS behaviour trustworthiness according to the algorithm for software/service behaviour trustworthiness validation and transform it into the subsequent mechanism SHM4WMS.2.4.When SOF4WMS receives the new parameters of the WfMS itself, modified by SHM4WMS, it should return these to SCP4WMS to be recovered with the new transaction consistence variables of the workflow engines.SOF4WMS means self-optimisation framework system for the WfMS, and one of its functions is analysing the parameters transferred from the SCP4WMS component. According to the analysis, SOF4WMS carries out the following procedures.3.1.If the parameters of the transaction consistence variables of the workflow engines have changed and will cause an inconsistent transaction record in the WfMS, SHM4WMS will modify the parameters of the WfMS itself, according to predefined ECA rules, and return the new parameters to SOF4WMS to be recovered with the new transaction consistence variables of the workflow engines.3.2.3.2.1.If the WfMS NF is higher than or equal to the requirement NF of users when the ACM4WMS constructs the WfMS at the initial time, jump to step (3.3) directly.3.2.2.Otherwise, SHM4WMS will transfer it to the TWfMS method, which means that SHM4WMS will suggest the management and monitoring tool to transfer it to ACM4WMS through the local RE path (3.2.3). The management and monitoring tool transfers the NF that is lower than that of the initial WfMS to ACM4WMS through the local RE path.SHM4WMS should compute the WfMS behaviour trustworthiness according to the NF algorithm (NF paradigms):3.3.If ACM4WMS can reconstruct a WfMS with a new NF that is higher than or equal to the requirement NF of users from the source service in the cloud successfully, then jump to step (3.3) directly.3.4.Otherwise, the management and monitoring tool sends the NF that is lower than that of the initial WfMS to the ADCV-PN tools through the global RE path .3.5.Register the new WfMS NF into the SHM4WMS database and return to step (1).SHM4WMS means self-healing-model system for the WfMS, and one of its functions is analysing the parameters transferred from the SOF4WMS component. According to the analysis, SHM4WMS carries out the following procedures.Based on the above model, from the implementation view of software architecture, we propose the core components of the methods and mechanisms ,19 as ilIn this section, we introduce the general recursive measurement algorithm for the TWfMS based on the priority according to calculus. We provide the application server (AS) of the WfMS, consisting of the components and operations organised as a tree.Firstly, the initial trustworthiness of AS is set to the value of 0.5, which means that we cannot judge whether or not it is more trustworthy than the initial value of 0.5 for proper trustworthiness when the ACM4WMS tool constructs the WfMS at the initial time, as illustrated in the following Equation (1): Secondly, we add the start and end components as the first and last activities of the original process with an absolute trustworthiness value of 1, which means they are coded with a simple but stable start or stop program with our absolute trust. Furthermore, we set the other components as the remaining immediate activities with an initial trustworthiness value of 0.5 for the same reason as that mentioned above. The initial trustworthiness of components is expressed by the following Equation (2): Thirdly, we classify the operations among these components into three types of calculus. That is, for the operated component A, which is operated with the operating component B via dependency calculus C.strong dependency calculus.If, following the operation, the trustworthiness of A is replaced with the minimum trustworthiness of components A and B, we name C indirect dependency calculus.If, following the operation, the trustworthiness of A is replaced with the multiplication value of the trustworthiness of components A and B, we name C weak dependency calculus.If, following the operation, the trustworthiness of A is replaced with the average value of the trustworthiness of components A and B, we name C The operations can be illustrated as the following Equations: (3) with classes or (4) with a sequence order perspective from start, immediate, and end activities.Algorithm 1: General_Recursive_Measure . It is well known that any STDE partition can be uniquely associated with an equivalence relation on the STDE. Therefore, we define the STDE as the static trustworthiness data to reflect the In contrast, all dynamic software attributes can only be reflected by software executed data entropy (SEDE). Thus, we define SEDE as dynamic trustworthiness data for reflecting the Definition 6.Assume that Therefore, we denote In contrast, we denote Definition 7.Taking the equivalence relation where H means the trustworthiness of the owning trustee. The rule can be explained as follows: given that R occurred with a probability of CF(R), the trustee is the software itself, and the trustworthiness of the rule is  with probability CF. Thus, the trustworthiness of the software is H with probability CF(H).CF(H) by means of criteria 1 to 3.We can calculate Criterion 1.According to the definitions above, CF(H) can be calculated as follows:Criterion 2.Given an equivalence relation R on Criterion 3.According to the definitions above, given an equivalence relation R on where the uncertainty regarding CF(R) consisting of where where Above, we have introduced the definitions of STDE and SEDE associated with the P stands for the equivalence relation on the software test data entropy (STDE) or software executed data entropy (SEDE)) indicating the degree of congruence or similarity between It is critical to obtain a mapping congruence: Here, we calculate the congruence between We now suggest a general congruence measure between partitions of In the section above, we have introduced a general measure of similarity or congruence between two partitions on STDE and SEDE using the underlying equivalence relations. Equation (19) implies that we should traverse all of the equivalence relations from the STDE and SEDE circularly. Thus, the largest complexity of Equation (19) is We now consider the perspective of the partitions themselves. Taking into account Equations (11) and (12), without loss of generality, we can assume that We now use this to obtain the congruence: Then, we can calculate Through analysis, the complexity of Equation (22) is determined as Therefore, can we conclude that the performance of Equation (22) is far superior to that of Equation (19) simply by their differing complexities? Indeed, with the trends of infrastructure-as-a-service (IaaS), platform-as-a-service (PaaS), and software-as-a-service (SaaS) in the cloud, increasing software components encapsulated as services are emanating from third parties so that there no longer exists a steady and closed STDE. For this reason, the precondition of Equation (11) that clusters STDE into the test space In order to address the measurement problem of WfMS trustworthiness, based on prior research ,19,20,21In summary, our study is closely related to former works, but it differs from these in terms of two aspects on which we place emphasis simultaneously: self-autonomic computing and trust computing, including the evaluation method , which irnetware , and allIn future work, we plan to conduct simulations or practical industry experiments to verify and evaluate our measurement algorithm for the WfMS mechanism. It is our hope that future works will be completed in the context of the reduction process of WfMS behaviour entropy, given the unavoidable nature of WfMS behaviour entropy increasing.


The microstructure, precipitates, and austenite grain in high-strength low-alloy steel were characterized by optical microscope, transmission electron microscope, and laser scanning confocal microscopy to investigate the effect of Mo on the toughness of steel. The microstructure was refined and the toughness was enhanced after the addition of 0.07% Mo in steel. The addition of Mo can suppress the Widmanstätten ferrite (WF) formation and promote the transformation of acicular ferrite (AF), leading to the fine transformed products in the heat-affected zone (HAZ). The chemical composition of precipitates changed from Nb to  because of the addition of Mo. The calculated lattice misfit between Nb and ferrite was approximately 11.39%, while it was reduced to 5.40% for , which significantly affected the size and number density of precipitates. A detailed analysis of the precipitates focusing on the chemical composition, size, and number density has been undertaken to understand the contribution of Mo on the improvement of steel toughness. Owing to the superior comprehensive properties, including excellent low-temperature impact toughness, high tensile strength, and good weldability, high-strength low-alloy (HSLA) steels have been widely applied in various fields, such as ship construction, offshore engineering, navy vessels, and even nuclear fission power plant components ,6,7,8,9.The refinement of grains by the pinning effect of fine precipitates has been acknowledged as an effective way to improve the toughness and strength of steel ,14,15. TIn this study, four kinds of steel with different Mo content were designed to systematically investigate the effect of Mo on the toughness of steel. The microstructural evolution of cast ingots, hot-rolled steel sheets, and CGHAZ was analyzed by optical microscope (OM). The macroscopic and microscopic characteristics of fracture were examined to further analyze the toughness of steel. The changes in chemical composition, size, and number density of precipitates and their contribution to the refinement of austenite size and improvement of toughness were elaborated in detail.3. The samples were subjected to impact tests at the distance of 2 mm from the fusion line at −20 °C by a drop-weight impact tester (JB-W300A series). The four kinds of studied steels containing no Mo (N1), 0.04% Mo (N2), 0.06% Mo (N3), and 0.07% Mo (N4) were smelted in a 100 kg vacuum induction furnace and cast into ingots. The chemical compositions of four kinds of steel were determined using optical emission spectroscopy  and given in 3 + 97 mL C2H5OH) for 25 s after mechanical polishing. The observation of microstructure in steel was performed by Leica OM. FEI scanning electron microscope  and Leica stereomicroscope were conducted to analyze the morphological characteristics of macroscopic and microscopic fracture. The four kinds of steel sheets were machined into cylindrical samples with a diameter of 7 mm and a height of 3 mm, which were austenitized at 1100 °C for 300 s and cooled to room temperature at a cooling rate of 7 °C/s by laser scanning confocal microscopy  to in situ record and observe the grain growth of austenite. A JEOL JEM-2800 transmission electron microscope  equipped with energy-dispersive X-ray spectroscopy (EDS) detection system was employed to determine the sizes and chemical compositions of precipitates. The samples for TEM observation were prepared by the carbon extraction replica technique. To prepare carbon extraction replicas, the polished samples were etched with 2% nitric acid solution (2 mL HNO3 + 98 mL C2H5OH), followed by evaporation of carbon evaporated onto the etched surface. Finally, the surface was scored to ≈ 3 mm squares and the sample etched first with 10% nitric acid solution (10 mL HNO3 + 90 mL C2H5OH) and then soaked with alcohol. Subsequently, the extracted replicas were rinsed with distilled water, placed on the copper grid and dried. A substantial number of measurements were conducted to determine the average size of the precipitates. To investigate the characteristics of precipitates in steel, scanning transmission electron microscope (STEM) bright-field (BF)/dark-field (DF) images, EDS mappings of precipitates in steel were acquired by using TEM equipped with an EDS detection system operated at a voltage of 200 kV.The samples were chemically etched in a 3% nitric acid solution m= . TherefoIt has been demonstrated that a relatively small change in the number density and size distribution of the precipitates can strongly influence the size of ferrite and prior austenite grain . The effequation :(4)f=πNdIn summary, the effect of Mo on the microstructure, precipitates, and impact toughness in HAZ were investigated in this study. For the range of 0–0.07%, the addition of Mo gave a reduction in the size of grains. Meanwhile, the addition of Mo retarded the transformation of WF in CGHAZ and promoted AF formation. With the enhancement of the impact toughness in HAZ, the area of fibrous crack zone increased gradually, and the area of the stretch zone was correspondingly reduced. Due to the addition of Mo, the precipitates were changed from Nb to . Furthermore, the addition of Mo not only increased the number density of precipitates but also diminished the size, which in turn promoted the refinement of the grain size and the enhancement of the steel toughness. The decrease of lattice misfit resulted from the partial replacement of Nb by Mo was responsible for the increase in the number density of precipitates. A refinement in the size of precipitates was attributed to the reduction of the interface energy between the precipitates and ferrite.