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Wyse CA, Rudderham LM, Nordon EA, Ince LM, Coogan AN, Lopez LM. Circadian Variation in the Response to Vaccination: A Systematic Review and Evidence Appraisal. J Biol Rhythms 2024; 39:219-236. [PMID: 38459699 PMCID: PMC11141079 DOI: 10.1177/07487304241232447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
Molecular timing mechanisms known as circadian clocks drive endogenous 24-h rhythmicity in most physiological functions, including innate and adaptive immunity. Consequently, the response to immune challenge such as vaccination might depend on the time of day of exposure. This study assessed whether the time of day of vaccination (TODV) is associated with the subsequent immune and clinical response by conducting a systematic review of previous studies. The Cochrane Library, PubMed, Google, Medline, and Embase were searched for studies that reported TODV and immune and clinical outcomes, yielding 3114 studies, 23 of which met the inclusion criteria. The global severe acute respiratory syndrome coronavirus 2 vaccination program facilitated investigation of TODV and almost half of the studies included reported data collected during the COVID-19 pandemic. There was considerable heterogeneity in the demography of participants and type of vaccine, and most studies were biased by failure to account for immune status prior to vaccination, self-selection of vaccination time, or confounding factors such as sleep, chronotype, and shiftwork. The optimum TODV was concluded to be afternoon (5 studies), morning (5 studies), morning and afternoon (1 study), midday (1 study), and morning or late afternoon (1 study), with the remaining 10 studies reporting no effect. Further research is required to understand the relationship between TODV and subsequent immune outcome and whether any clinical benefit outweighs the potential effect of this intervention on vaccine uptake.
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Affiliation(s)
- Cathy A. Wyse
- Kathleen Lonsdale Institute for Human Health Research and Department of Biology, Maynooth University, Maynooth, Ireland
| | - Laura M. Rudderham
- Kathleen Lonsdale Institute for Human Health Research and Department of Biology, Maynooth University, Maynooth, Ireland
| | - Enya A. Nordon
- Kathleen Lonsdale Institute for Human Health Research and Department of Biology, Maynooth University, Maynooth, Ireland
| | - Louise M. Ince
- Division of Pharmacology and Toxicology, College of Pharmacy, The University of Texas at Austin, Austin, Texas, USA
| | - Andrew N. Coogan
- Kathleen Lonsdale Institute for Human Health Research and Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Lorna M. Lopez
- Kathleen Lonsdale Institute for Human Health Research and Department of Biology, Maynooth University, Maynooth, Ireland
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2
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Hiemstra FW, Stenvers DJ, Kalsbeek A, de Jonge E, van Westerloo DJ, Kervezee L. Daily variation in blood glucose levels during continuous enteral nutrition in patients on the intensive care unit: a retrospective observational study. EBioMedicine 2024; 104:105169. [PMID: 38821022 PMCID: PMC11177052 DOI: 10.1016/j.ebiom.2024.105169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND The circadian timing system coordinates daily cycles in physiological functions, including glucose metabolism and insulin sensitivity. Here, the aim was to characterise the 24-h variation in glucose levels in critically ill patients during continuous enteral nutrition after controlling for potential sources of bias. METHODS Time-stamped clinical data from adult patients who stayed in the Intensive Care Unit (ICU) for at least 4 days and received enteral nutrition were extracted from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Linear mixed-effects and XGBoost modelling were used to determine the effect of time of day on blood glucose values. FINDINGS In total, 207,647 glucose measurements collected during enteral nutrition were available from 6,929 ICU patients (3,948 males and 2,981 females). Using linear mixed-effects modelling, time of day had a significant effect on blood glucose levels (p < 0.001), with a peak of 9.6 [9.5-9.6; estimated marginal means, 95% CI] mmol/L at 10:00 in the morning and a trough of 8.6 [8.5-8.6] mmol/L at 02:00 at night. A similar impact of time of day on glucose levels was found with the XGBoost regression model. INTERPRETATION These results revealed marked 24-h variation in glucose levels in ICU patients even during continuous enteral nutrition. This 24-h pattern persists after adjustment for potential sources of bias, suggesting it may be the result of endogenous biological rhythmicity. FUNDING This work was supported by a VENI grant from the Netherlands Organisation for Health Research and Development (ZonMw), an institutional project grant, and by the Dutch Research Council (NWO).
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Affiliation(s)
- Floor W Hiemstra
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands; Group of Circadian Medicine, Department of Cell and Chemical Biology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Dirk Jan Stenvers
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Department of Endocrinology and Metabolism, Amsterdam UMC Location Vrije Universiteit, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Andries Kalsbeek
- Department of Endocrinology and Metabolism, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands; Netherlands Institute for Neuroscience (NIN), Royal Dutch Academy of Arts and Sciences (KNAW), Meibergdreef 47, Amsterdam 1105 BA, the Netherlands; Laboratory of Endocrinology, Department of Laboratory Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, the Netherlands
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - David J van Westerloo
- Department of Intensive Care, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Laura Kervezee
- Group of Circadian Medicine, Department of Cell and Chemical Biology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands.
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Islam MN, Islam MS, Shourav NH, Rahman I, Faisal FA, Islam MM, Sarker IH. Exploring post-COVID-19 health effects and features with advanced machine learning techniques. Sci Rep 2024; 14:9884. [PMID: 38688931 DOI: 10.1038/s41598-024-60504-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 04/23/2024] [Indexed: 05/02/2024] Open
Abstract
COVID-19 is an infectious respiratory disease that has had a significant impact, resulting in a range of outcomes including recovery, continued health issues, and the loss of life. Among those who have recovered, many experience negative health effects, particularly influenced by demographic factors such as gender and age, as well as physiological and neurological factors like sleep patterns, emotional states, anxiety, and memory. This research aims to explore various health factors affecting different demographic profiles and establish significant correlations among physiological and neurological factors in the post-COVID-19 state. To achieve these objectives, we have identified the post-COVID-19 health factors and based on these factors survey data were collected from COVID-recovered patients in Bangladesh. Employing diverse machine learning algorithms, we utilised the best prediction model for post-COVID-19 factors. Initial findings from statistical analysis were further validated using Chi-square to demonstrate significant relationships among these elements. Additionally, Pearson's coefficient was utilized to indicate positive or negative associations among various physiological and neurological factors in the post-COVID-19 state. Finally, we determined the most effective machine learning model and identified key features using analytical methods such as the Gini Index, Feature Coefficients, Information Gain, and SHAP Value Assessment. And found that the Decision Tree model excelled in identifying crucial features while predicting the extent of post-COVID-19 impact.
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Affiliation(s)
- Muhammad Nazrul Islam
- Department of Computer Science and Engineering, Military Institute of Science and Technology, Mirpur Cantonment, Dhaka, 1216, Bangladesh.
| | - Md Shofiqul Islam
- Department of Computer Science and Engineering, Military Institute of Science and Technology, Mirpur Cantonment, Dhaka, 1216, Bangladesh
| | - Nahid Hasan Shourav
- Department of Computer Science and Engineering, Military Institute of Science and Technology, Mirpur Cantonment, Dhaka, 1216, Bangladesh
| | - Iftiaqur Rahman
- Department of Computer Science and Engineering, Military Institute of Science and Technology, Mirpur Cantonment, Dhaka, 1216, Bangladesh
| | - Faiz Al Faisal
- Department of Computer Science and Engineering, Green University of Bangladesh, Dhaka, Bangladesh
| | - Md Motaharul Islam
- Department of Computer Science and Engineering, United International University, Dhaka, 1212, Bangladesh
| | - Iqbal H Sarker
- School of Science, Edith Cowan University, Perth, WA, 6027, Australia
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4
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Zemelka-Wiacek M, Agache I, Akdis CA, Akdis M, Casale TB, Dramburg S, Jahnz-Różyk K, Kosowska A, Matricardi PM, Pfaar O, Shamji MH, Jutel M. Hot topics in allergen immunotherapy, 2023: Current status and future perspective. Allergy 2024; 79:823-842. [PMID: 37984449 DOI: 10.1111/all.15945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 11/22/2023]
Abstract
The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.
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Affiliation(s)
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Cezmi A Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Mübeccel Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Thomas B Casale
- Departments of Medicine and Pediatrics and Division of Allergy and Immunology, Joy McCann Culverhouse Clinical Research Center, University of South Florida, Tampa, Florida, USA
| | - Stephanie Dramburg
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Karina Jahnz-Różyk
- Department of Internal Diseases, Pneumonology, Allergology and Clinical Immunology, Military Institute of Medicine-National Research Institute, Warsaw, Poland
| | - Anna Kosowska
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
| | - Paolo M Matricardi
- Department of Pediatric Respiratory Care, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
| | - Mohamed H Shamji
- Allergy and Clinical Immunology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wroclaw, Poland
- ALL-MED Medical Research Institute, Wroclaw, Poland
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Serbanescu-Kele Apor de Zalán C, Bouwman M, van Osch F, Damoiseaux J, Funnekotter-van der Snoek MA, Verduyn Lunel F, Van Hunsel F, de Vries J. Changes in Local and Systemic Adverse Effects following Primary and Booster Immunisation against COVID-19 in an Observational Cohort of Dutch Healthcare Workers Vaccinated with BNT162b2 (Comirnaty ®). Vaccines (Basel) 2023; 12:39. [PMID: 38250852 PMCID: PMC10821042 DOI: 10.3390/vaccines12010039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
In healthcare workers (HCWs) and in the general population, fear of adverse effects is among the main reasons behind COVID-19 vaccine hesitancy. We present data on self-reported adverse effects from a large cohort of HCWs who underwent primary (N = 470) and booster (N = 990) mRNA vaccination against SARS-CoV-2. We described general patterns in, and predictors of self-reported adverse effect profiles. Adverse effects following immunisation (AEFI) were reported more often after the second dose of primary immunisation than after the first dose, but there was no further increase in adverse effects following the booster round. Self-reported severity of systemic adverse effects was less following booster immunisation. Prior infection with SARS-CoV-2 was found to be a significant predictor of AEFI following primary immunisation, but was no longer a predictor after booster vaccination. Compared to other studies reporting specifically on adverse effects of SARS-CoV-2 vaccination in healthcare workers, we have a relatively large cohort size, and are the first to compare adverse effects between different rounds of vaccination. Compared to studies in the general population, we have a considerably homogenous population. Insights in AEFI following primary and booster vaccinations may help in addressing vaccine hesitancy, both in HCWs and in the general population.
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Affiliation(s)
- Christiaan Serbanescu-Kele Apor de Zalán
- Department of Intensive Care, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands
- Department of Internal Medicine, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands
| | - Maud Bouwman
- Department of Medical Microbiology, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands; (M.B.); (J.D.); (J.d.V.)
| | - Frits van Osch
- Department of Clinical Epidemiology, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands;
- Department of Epidemiology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Jan Damoiseaux
- Department of Medical Microbiology, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands; (M.B.); (J.D.); (J.d.V.)
- Central Diagnostic Laboratory, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | | | - Frans Verduyn Lunel
- Department of Medical Microbiology, Utrecht University Medical Centre, 3584 CX Utrecht, The Netherlands;
| | - Florence Van Hunsel
- Department of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands;
- Netherlands Pharmacovigilance Centre (Lareb), 5237 MH Hertogenbosch, The Netherlands
| | - Janneke de Vries
- Department of Medical Microbiology, VieCuri Medical Centre, 5912 BL Venlo, The Netherlands; (M.B.); (J.D.); (J.d.V.)
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6
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MacMath D, Chen M, Khoury P. Artificial Intelligence: Exploring the Future of Innovation in Allergy Immunology. Curr Allergy Asthma Rep 2023:10.1007/s11882-023-01084-z. [PMID: 37160554 PMCID: PMC10169188 DOI: 10.1007/s11882-023-01084-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE OF REVIEW Artificial intelligence (AI) has increasingly been used in healthcare. Given the capacity of AI to handle large data and complex relationships between variables, AI is well suited for applications in healthcare. Recently, AI has been applied to allergy research. RECENT FINDINGS In this article, we review how AI technologies have been utilized in basic science and clinical allergy research for asthma, atopic dermatitis, rhinology, adverse reactions to drugs and vaccines, food allergy, anaphylaxis, urticaria, and eosinophilic gastrointestinal disorders. We discuss barriers for AI adoption to improve the care of patients with atopic diseases. These studies demonstrate the utility of applying AI to the field of allergy to help investigators expand their understanding of disease pathogenesis, improve diagnostic accuracy, enable prediction for treatments and outcomes, and for drug discovery.
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Affiliation(s)
- Derek MacMath
- Department of Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Meng Chen
- Division of Pulmonary, Allergy & Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paneez Khoury
- National Institutes of Allergic and Infectious Diseases, National Institutes of Health, 9000 Rockville Pike, Bethesda, MD, USA.
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7
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Sarmiento Varón L, González-Puelma J, Medina-Ortiz D, Aldridge J, Alvarez-Saravia D, Uribe-Paredes R, Navarrete MA. The role of machine learning in health policies during the COVID-19 pandemic and in long COVID management. Front Public Health 2023; 11:1140353. [PMID: 37113165 PMCID: PMC10126380 DOI: 10.3389/fpubh.2023.1140353] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
The ongoing COVID-19 pandemic is arguably one of the most challenging health crises in modern times. The development of effective strategies to control the spread of SARS-CoV-2 were major goals for governments and policy makers. Mathematical modeling and machine learning emerged as potent tools to guide and optimize the different control measures. This review briefly summarizes the SARS-CoV-2 pandemic evolution during the first 3 years. It details the main public health challenges focusing on the contribution of mathematical modeling to design and guide government action plans and spread mitigation interventions of SARS-CoV-2. Next describes the application of machine learning methods in a series of study cases, including COVID-19 clinical diagnosis, the analysis of epidemiological variables, and drug discovery by protein engineering techniques. Lastly, it explores the use of machine learning tools for investigating long COVID, by identifying patterns and relationships of symptoms, predicting risk indicators, and enabling early evaluation of COVID-19 sequelae.
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Affiliation(s)
| | - Jorge González-Puelma
- Centro Asistencial Docente y de Investigación, Universidad de Magallanes, Punta Arenas, Chile
- Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
| | - David Medina-Ortiz
- Departamento de Ingeniería en Computación, Facultad de Ingeniería, Universidad de Magallanes, Punta Arenas, Chile
| | - Jacqueline Aldridge
- Departamento de Ingeniería en Computación, Facultad de Ingeniería, Universidad de Magallanes, Punta Arenas, Chile
| | - Diego Alvarez-Saravia
- Centro Asistencial Docente y de Investigación, Universidad de Magallanes, Punta Arenas, Chile
- Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
| | - Roberto Uribe-Paredes
- Departamento de Ingeniería en Computación, Facultad de Ingeniería, Universidad de Magallanes, Punta Arenas, Chile
| | - Marcelo A. Navarrete
- Centro Asistencial Docente y de Investigación, Universidad de Magallanes, Punta Arenas, Chile
- Escuela de Medicina, Universidad de Magallanes, Punta Arenas, Chile
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8
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Ye J, Shao X, Yang Y, Zhu F. Predicting the negative conversion time of nonsevere COVID-19 patients using machine learning methods. J Med Virol 2023; 95:e28747. [PMID: 37185847 DOI: 10.1002/jmv.28747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/10/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
Based on the patient's clinical characteristics and laboratory indicators, different machine-learning methods were used to develop models for predicting the negative conversion time of nonsevere coronavirus disease 2019 (COVID-19) patients. A retrospective analysis was performed on 376 nonsevere COVID-19 patients admitted to Wuxi Fifth People's Hospital from May 2, 2022, to May 14, 2022. The patients were divided into training set (n = 309) and test set (n = 67). The clinical features and laboratory parameters of the patients were collected. In the training set, the least absolute shrinkage and selection operator (LASSO) was used to select predictive features and train six machine learning models: multiple linear regression (MLR), K-Nearest Neighbors Regression (KNNR), random forest regression (RFR), support vector machine regression (SVR), XGBoost regression (XGBR), and multilayer perceptron regression (MLPR). Seven best predictive features selected by LASSO included: age, gender, vaccination status, IgG, lymphocyte ratio, monocyte ratio, and lymphocyte count. The predictive performance of the models in the test set was MLPR > SVR > MLR > KNNR > XGBR > RFR, and MLPR had the strongest generalization performance, which is significantly better than SVR and MLR. In the MLPR model, vaccination status, IgG, lymphocyte count, and lymphocyte ratio were protective factors for negative conversion time; male gender, age, and monocyte ratio were risk factors. The top three features with the highest weights were vaccination status, gender, and IgG. Machine learning methods (especially MLPR) can effectively predict the negative conversion time of non-severe COVID-19 patients. It can help to rationally allocate limited medical resources and prevent disease transmission, especially during the Omicron pandemic.
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Affiliation(s)
- Jiru Ye
- Department of Respiratory and Critical Care Medicine, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaonan Shao
- Department of Nuclear Medicine, The Third Affiliated Hospital of Soochow University, Institute of Clinical Translation of Nuclear Medicine and Molecular Imaging of Soochow University, Changzhou Clinical Medical Center, Changzhou, China
| | - Yong Yang
- Department of Pediatrics, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Feng Zhu
- Department of Respiratory and Critical Care Medicine, Affiliated Wuxi Fifth Hospital of Jiangnan University, Wuxi Fifth People's Hospital, Wuxi, China
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