As the distribution uniformity of nanoparticles in functional nanofibers has a great impact on their performance, an electrospinning device with multiple air inlets, which has a copper porous spinneret, is proposed to obtain functional nanofibers with higher yield and more uniform distribution of nanoparticles. The mechanism of batch preparation of functional nanofibers containing ZnO nanoparticles by the device was studied through experiments and theoretical analysis. The experimental data are in good agreement with the theoretical analysis results, which showed that under the appropriate voltage (50 kV) and air flow (50 m In recent years, due to the characteristics of high specific surface area, good electrical conductivity, stable physical and chemical properties, as well as fast charge and discharge, the application of electrospun nanofiber-based materials in supercapacitor electrode materials has attracted great attention –2. AlthoWith the expanding application field of electrospun nanofibers and the change of human needs, various functional nanofibers have emerged as promising materials, such as conductive fibers , phase cIn our previous works, some self-made free surface electrospinning (FSE) devices were proposed for high-throughput fabrication of nanofibers . EspeciaN,N-Dimethylformamide (DMF) was purchased from Shanghai Lingfeng Chemical Reagent Co., LTD. All materials are analytical grade and can be used without purification.Polyacrylonitrile  and zinc oxide nanoparticles  were supplied by Shanghai Sinopharm Chemical Reagent Co., LTD. Firstly, 4.5 g PAN and 44 g DMF solution were weighed separately by an electronic balance , mixed and placed on an unheated magnetic stirrer  for stirring for 24 h. Then 1.5 g ZnO nanoparticles were added into PAN solution, where the mass ratio of PAN to ZnO was 3:1, and the mixture was stirred for 4 h to obtain the homogeneous ZnO/PAN spinning solution. The mass fraction of PAN to spinning solution was 9 wt %, and that of ZnO to spinning solution was 3 wt %.3/h, and the spinning voltages were 40, 50, and 60 kV.All EMAI experiments were performed at 25 °C and 60% relative humidity. The following MEAI parameters were used. The receiving distance was 18 cm, the speed of the receiving drum was 300 r/min, the air flow rates were 0, 50, 100, and 150 mThe spinning solution viscosity was measured by a viscosity instrument . The spinning solution conductivity was tested by a conductivity tester . The yield of nanofibers fabricated by EMAI was determined using an electronic balance . The nanofiber morphology was investigated by a scanning electron microscopy , and Image J software  was used to characterize the fiber diameter distribution by random selection of 100 nanofibers from ten SEM images of each sample. Simultaneously, the element distribution on the sample surface was characterized by a desktop SEM .11 µS/cm, the viscosity of the spinning solution was 377 mPa·s, and the conductivity of the spinning solution was 797 µS/cm [Maxwell 3D was used to simulate the electric field distribution of EMAI under different voltages . A simplified 3D model of the porous copper spinneret with a diameter of 70 mm and a height of 45 mm is shown in 97 µS/cm .3/h (3/h (3/h (3/h)  , the num3/h were studied. It was found that, when the applied voltage was 40 kV  caused by the fluctuation height of spinning solution, surface tension (Ps) of the spinning solution, and electric field force (PE) produced by the applied voltage. These forces determine whether a jet could be formed at point A. The polymer fluid surface tension would make the liquid surface shrink and bend as much as possible, and the change of external electric field would interact with the accumulated charges on the polymer fluid surface, making the charge density on the charged fluid surface uneven. Accordingly, the formulas to calculate these three forces are as follows:3), g is the gravitational acceleration (m/s2), h is the fluctuation height of the polymer spinning solution (m), γ is the surface tension coefficient of the spinning solution (N/m), ε0 is vacuum dielectric constant, E0 is the edge electric field intensity (V/m), Ep is the electric field intensity of the thin liquid surface (V/m), εα is the dielectric constant of the polymer, and k is the amount of radial fluctuations on the spinning solution surface.where ρ is the density of spinning solution , which could weaken the instability of the jets. The resultant vertical upward force F2 generated by the applied electric field force FE and the vertical component of viscous force would push the jets upward. The formulas of the resultant forces (F1 and F2) could be written as follows [In addition, the centripetal force  follows :EB is the electric field intensity at point B, and qB is the charge determined by the spinning solution properties at point B, which is generally an integer multiple of the primary charge (1.60 × 10−19 C).where α is the angle between the viscous force and the vertical direction, On the basis of the spinning effects under different voltages –g and fo3/h  acting on the spinning solution surface was greater than the solution surface tension (Ps), unstable fluctuation on the free surface of solution easily occurs, thus significantly increasing the probability of multijet formation [ormation –26.In order to study further the electric field forces on the spinning solution surface under different voltages, the electric field intensity distributions on the surface were analyzed, as shown in 3/h, only few microbubbles were generated, thus yielding ZnO/PAN nanofibers with uniform ZnO nanoparticle distribution.An electrospinning device with multiple air inlets (EMAI) was used to prepare ZnO/PAN nanofibers in batches. It was found that the distribution of ZnO nanoparticles in the composite nanofibers obtained by EMAI was more uniform than that by SSFSE. This was because the air flow through multiple pores enabled the ZnO nanoparticles in the spinning solution to maintain uniform dispersion in the EMAI spinning process and reduced the agglomeration of nanoparticles. The influence of air flow rate on the spinning effect was investigated through experiments, which showed that too large or too small air flow rate was not conducive to obtaining high-quality functional nanofibers. When the air flow rate was 50 mIn addition, the influence of the spinning voltage on the EMAI processes as well as the quality and yield of ZnO/PAN nanofibers were investigated experimentally and theoretically. The theoretical and experimental results were consistent and showed that as the spinning voltage increased, the number of jets generated on the spinning solution surface increased. However, an excessive spinning voltage (60 kV) would make the jets unstable and the spinning speed too fast, resulting in thicker fibers and fiber bundles. When the voltage was 50 kV, the spinning process was stable, and the quality and yield of ZnO/PAN nanofibers were high. This provides a convenient and effective method for batch preparation of functional nanofibers uniformly loaded with nanoparticles, thus expanding the practical application of functional nanofibers in the future.


Antimicrobial resistance (AMR) was regarded as one of the top ten global public health problems by the World Health Organization (WHO). While the complexity of AMR poses threats to humans, animals, and the environment, to combat AMR necessitates a multi-sector approach. In March 2022, world leaders and experts called on all countries to reduce antimicrobial pollution to protect the environment, and WHO published the strategic framework for collaboration on AMR in May, emphasizing significant global threat of AMR and calling for multisectoral coordination based on One Health approach , 2.In 2013, China proposed the construction of the Silk Road Economic Belt and the 21st Century Maritime Silk Road . As of July 2022, 149 countries and 32 international organizations participated in the Belt and Road Initiative (BRI) .With the GOHI-AMR platform, which is the first One Health-based systemic tool to conduct a global assessment of AMR, we would be able to assess the AMR status and provide specific recommendations for the B&R’s continued health implementation strategies or plans.There were 149 countries in B&R, of which 113 countries were included in the GOHI-AMR database including China . They wei.Increasing One Health-based funds and talent: This may necessitate a greater emphasis on the cultivation and exchange plans of talent in One Health-related fields by subsidizing education funds and the recruitment of more pharmaceutical companies to increase capital investment.ii.Establishing a monitoring network of antimicrobial consumption: Linking countries to build a surveillance platform of antimicrobial consumption and use, especially on antimicrobial abuse, comprehensively monitoring and regularly reporting the overall consumption of humans, animals and pesticides, urging high-consuming countries to rationally optimize the management of antibiotic usage.iii.Establishing collaborative laboratories to monitor AMR: Utilizing the joint laboratory platform, standardize AMR surveillance plan, facilitate reciprocal exchanges on AMR management, organize regular professional technical training, invite countries with relatively complete AMR management to share their experiences, and improve the national action plan for AMR surveillance.iv.Establishing a cross-border AMR surveillance online database in B&R: It is essential to establish online AMR surveillance data based on the joint laboratory. Thus, nations can stay aware of the emerging AMR trends and bridge the gap between them.v.Strengthening ecological governance continuously: Combined with the Belt and Road Ecological and Environmental Cooperation Plan, adhering to the concept of One Health, promote implementation of the 2030 Agenda for Sustainable Development, which must prioritize monitoring AMR in the environment and in animals. Continually boost investment in AMR-related ecological prevention research, including vaccine, probiotics, lactic acid bacteria, and enzybiotics (Additional file Given the large AMR discrepancies between B&R countries indicated by GOHI-AMR data, the future health cooperation plan in B&R should prioritize the most critical AMR concerns. Due to the close relationship between AMR and the human living environment, we focused on the One Health approach and propose the following recommendations for the current primary situation:AMR has remained a global public health concern, and its effects vary considerably in B&R countries. Countries should adopt the One Health strategy, pay great attention to AMR issues, provide financial and human resource assistance, utilize joint laboratories and a cross-border AMR monitoring database to promote health cooperation, and prioritize ecological governance in accordance with other B&R cooperation plans. This report's suggestions serve as a guide for future B&R public health cooperation and policy development.Additional file 1. Fig.S1.Additional file 2. Fig.S2.


This editorial of the Special Issue “Personal Therapy for Blood disorders” aims to draw more attention to blood cancer heterogeneity and personalized strategies for diagnosis, prognosis and therapeutic treatment. Personalized approaches can provide more accurate diagnosis and therapies than standard procedures established from large population studies or by cohort-based decisions. This Special Issue invites research groups to share their most recent findings, especially from molecular profiles obtained using the different omics technologies, toward approaches for individualized treatments. The debate on the implementation of personalized molecular approaches in the clinical setting and how patients could be integrated in the decision-making process is especially welcome.Recognition of the molecular heterogeneity as the cornerstone of efficient anti-leukemia therapies. Acute lymphoblastic leukemia is the most common childhood cancer and it arises in hematopoietic stem cells, which change into malignant white blood cells through the accumulation of genetic mutations [utations . No cellutations . It is futations . Therefoutations . RegardeAll-patients omics versus stratified omics analyses. Liquid chromatography-mass spectrometry (LC-MS) analysis of proteomes and metabolomes provides global or targeted identifications and quantitative values of the proteins and metabolites of the study subjects [subjects ,6. In thsubjects . Lately,subjects . This stsubjects . Considering everything, the leukemia heterogeneity does not allow for categorizing all the patients based on their cytogenetics and genomic profiles. Therefore, omics strategies that aim to "molecularly" describe patients at different levels should be utilized to decide the best therapeutical approach. Implementation of the omics technologies in clinical settings. The above reflections along with the current original research and literature reviews highlight the need to investigate individual molecular profiles to benefit from targeted therapies and decrease the deleterious effects of untargeted strategies [rategies . This Sp


Breast cancer is the second cause of cancer death in women worldwide. The search for therapeutic and preventive alternatives has increased in recent years. One synthetic drug for patients with hormone receptor-positive tumours is tamoxifen citrate (TMX). Curcumin (Cur) is a natural compound that is being tested. Both were coupled with nanoscale-controlled and sustained release systems to increase the effectiveness of the treatment and reduce adverse effects. We produced a controlled release system based on uniaxial and coaxial polymeric nanofibers of polycaprolactone (PCL), alginate (Alg) and gelatine (Gel) for the transport and release of TMX and Cur, as a new alternative to breast cancer treatment. Nanofibers combining PCL–Alg and PCL–Gel were fabricated by the electrospinning technique and physicochemically characterised by thermal analysis, absorption spectroscopy in the infrared region and X-ray diffraction. Morphology and size were studied by scanning electron microscopy. Additionally, the release profile of TMX and Cur was obtained by UV-Vis spectroscopy. Additionally, the cytotoxic effect on breast cancer cell line MCF7 and peripheral-blood mononuclear cells (PBMCs) from a healthy donor were evaluated by a Resazurin reduction assay. These assays showed that PCL–TMX nanofiber was highly toxic to both cell types, while PCL–Cur was less toxic. Cancer is a group of multifactorial diseases, caused by the accumulation of mutations in DNA, which leads cells to express a genetic program that establishes internal and external communication networks promoting proliferation, invasion of other tissues and establishment of new growth foci . The susIt has a protective effect against cancers of the skin , oral caNanofibers are a versatile tool because their composition, size and shape can be controlled, as well as making surface modifications, in order to minimise toxic potential and improve the distribution in the body, ensuring a safe and effective delivery vehicle. They are biocompatible, biodegradable and excellent support matrices. Prior to clinical use, the release and degradation time, as well as their biological activity, can be known. The drug is encapsulated and isolated from the external environment by a physical barrier that, by enzymatic or non-enzymatic mechanisms, dissolves and disintegrates when in contact with biological fluids, favouring the release of the active agent that it transports ,38. FurtIn this study, nanofibers were manufactured by electrospinning uniaxial and coaxial PCL with two hydrosoluble polymers in order to evaluate the effect of the coating on the release of curcumin, as well as evaluating nanofibers loaded with tamoxifen as a control compound for assessing substance release systems and an anticancer effect. They were characterized by SEM, FTIR, XRD and the thermogravimetric method; on the other hand, the cytotoxicity was evaluated in a MCF7 breast cancer cell line and PBMCs by a Resazurin reduction assay.wM = 43,000–50,000 g/mol) and tamoxifen citrate were purchased from Polysciences, Inc.  and Drogaria Araujo S.A. , respectively. Gelatine (bovine skin type B), sodium alginate, curcumin, glacial acetic acid (99.9%) and ethyl acetate  were obtained from Sigma-Aldrich . Dichloromethane (DCM) and methanol (MET) were purchased from Vetec . All other materials used were analytical grade.PCL , alginate (Alg) and gelatine (Gel) were prepared at the following concentrations: PCL at 10% w/v PCL solution with 2 mL of a 0.1% w/v Alg solution in a mixture of glacial acetic acid, ethyl acetate and water in a 3:2:1 ratio, before adding the curcumin and stirring for 12 h at room temperature. The PCL–Alg (PCL–Alg–Cur2) and PCL–Gel (PCL–Gel–Cur) combinations, both loaded with curcumin, were used to make coaxial fibres. The nanofiber core was also produced with 10% w/v PCL solution loaded with curcumin and coated with a 0.1% w/v Alg or 8% w/v Gel solution. The solutions were taken to a Harvard Apparatus pHD 2000 injection pump connected to a Gamma High Voltage Research ES40 voltage generator. The pump used a metal needle with an internal diameter of 1 mm, with a distance of 20 cm between the tip of the injection needle and the collection plate.To understand the effect of the addition of hydrophilic polymers, uniaxial fibres were prepared using a PCL–Alg mixture loaded with Cur (PCL–Alg–Cur1). These nanofibers were prepared by mixing 8 mL of a 10% −1 region. The crystallographic profile of both raw materials and fibres was obtained by X-ray diffraction. The X-ray diffraction pattern of the nanofibers was analysed using a Shimadzu XRD-700-X-Ray diffractometer, equipped with a copper tube and CuKα (λ = 1.5405 Å) radiation. Data were processed in the 2θ angles ranging from 4 to 60° and the scanning rate was 4θ min−1. Thermogravimetric (TG) profiling was performed using a TA Instruments SDT Q600 analyser, in N2 atmosphere with a constant flow rate of 50 mL.min−1, in the temperature range of 25–800 °C using a heating rate of 10 °C min−1. The morphology and diameter of the fibres were studied by scanning electron microscopy: portions of the fibres were deposited directly on copper sample holders inside the electrospinning equipment. The micrographs were taken with a FEG Quanta 2000 electron microscope using an acceleration voltage of 10 kV under reduced pressure.The starting materials and nanofibers were characterised using the following physicochemical techniques: absorption spectroscopy in the infrared region, X-ray diffraction and thermal analysis. In the infrared analysis, a Perkin Elmer spectrum GX spectrophotometer was used; the samples were prepared with KBr and readings were made in the 4000–400 cm2 fragments of each fibre in 2 mL of phosphate-buffered saline  with 0.01% sodium dodecyl sulphate (SDS) in a shaker thermostatted at 37 °C. The medium was replaced with the same amount of fresh medium after 1, 2, 4, 10, 24 and up to 300 h for quantification analysis. The amount of Cur released was quantified by UV-Vis spectroscopy at a wavelength of 427 nm, and the same was carried out for TMX at 365 nm.The electrospinning technique enables the uniform incorporation of bio-active molecules and nanoparticles in the nanofibrous polymeric matrix. The release profiles of uniaxial and coaxial nanofibers loaded with Cur and TMX were measured by incubating 1 cmThe encapsulation efficiency of the nanofibers was determined indirectly, taking into account the percentage of release and taking into account the amount of curcumin (100 mg) or tamoxifen (15 mg) incorporated during the electrospinning process. The concentration of released curcumin and tamoxifen from nanofibers was calculated based on a curcumin and tamoxifen standard curve, respectively. The released drug (%) was estimated as the given equation:v/v) antibiotic and antifungal solution  supplemented with 10% foetal bovine serum (FBS) in 75 cm2 plastic bottles at 37 °C in a humidified atmosphere with 95% humidity and 5% CO2. Normal cells were isolated from 10 mL of peripheral blood from a healthy volunteer who had given informed consent. The blood was collected in tubes with heparin, and mononuclear cells (PBMCs) were obtained by Ficoll gradient. The tubes were centrifuged at 2.000 rpm for 5 min and then the buffy coat was removed with a sterile 2 mL pipette. This was gently added to a 15 mL tube with 2 mL of Ficoll Histopaque-1077, then centrifuged without brake for 20 min at 2.000 rpm. The white layer was recovered with a sterile 2 mL pipette and poured into a fresh tube containing 5 mL of 1 × PBS, then centrifuged at 2.500 rpm for 5 min. Then, 5 mL of PBS was added to the pellet, and it was centrifuged again. Immediately the new cell pellet was gently resuspended in a fresh 15 mL tube containing 5 mL of PB-MAX karyotyping medium with 100 µL of phytohemagglutinin (PHA M) and antibiotic and antifungal solution. The tube was stored at 37 °C and 5% CO2 for 24 h before treatment with the nanofibers. Then, PBMCs and MCF7 cells were seeded in duplicate in a 96-well culture plate at a density of 15,000/200 µL for 24 h. After, a 7 mm diameter circle of each of the nanofibers was added to a well and left for 1 to 6 days.For in vitro cytotoxicity analysis, an MCF-7 breast cancer cell line was obtained from frozen laboratory stock vials obtained from ATCC . Those cells were cultured in a DMEM medium prepared with 1%  without treatment to all when each treatment was applied. All the treatments showed statistically significant differences, but this test does not discriminate between groups. In addition, the Bonferroni test was used to compare each treatment with cells not exposed to nanofibers.The morphological characterization and geometrical evaluation of the fibres (size distribution by diameter and orientation) were studied by scanning electron microscopy (SEM). In general, the morphology and size of the fibres are influenced by different factors such as viscosity, polymer concentration and solvent type, and operational factors such as the distance between the needle and the collection plate, the current applied and the leakage flow of the polymer solution. The micrographs and diameter distribution diagrams show the effect of both the polymer and drug on the morphology of the nanofibers. The uniaxial PCL–Cur nanofibers had a size distribution between 600 nm–1.2 µm and an average diameter of 1.03 µm with a uniform appearance, while the TMX-loaded fibres had an average diameter of 400 nm, also with a uniform morphology and no imperfections. This increase in the size of the curcumin-loaded nanofibers can be explained by several factors, one of them being the injection rate of the polymeric mixture used (3 mL/h), as different authors report that higher injection rates (above 0.5 mL/h) encourage the formation of larger drops at the point of the needle, which consequently lead to a larger diameter in the fibres formed. Another factor was the presence of a molecule with non-polar characteristics such as curcumin and the type of solvent used in the preparation of the polymeric mixture (methanol and dichloromethane), as this mixture has high relative permittivity values, which is a determining factor in the fibre formation process ,51.Uniaxial nanofibers with the presence of alginate (PCL–Alg–Cur1) showed a smaller size distribution pattern in the range of 150–550 nm, with an average size of 290 nm and a morphology with the formation of beads distributed throughout the nanofiber structure. This drastic decrease in particle size compared to the nanofibers that had only PCL may be due to the low injection rate of the polymeric mixture (1.5 mL/h) and the type of solvents used in the preparation of the solution, since the mixture of acetic acid and ethyl acetate allowed us to increase its polarity, and consequently, the charge density, improving the electrical conductivity of the droplet surface, thereby promoting the decrease in the diameter of the fibres formed . Unlike For their part, the PCL–Gel–Cur coaxial fibres had a size distribution with diameters in the range of 100–500 nm and an average diameter of 215 nm c. The miIt is known that the major disadvantage of synthetic polymers such as PCL is the lack of cell recognition signals. However, there are strategies to modify the surface characteristics of synthetic polymers to improve cell adhesion, proliferation, migration and differentiation, including blending these polymers with substances with hydrophilic characteristics and preferably with other polymers of natural origins . Therefo−1 due to the O-H functional group of the alcohol and phenolic groups, a characteristic C=O band at 1627 cm−1, an N-H band at 1575 cm−1, the C=C stretching band (reflecting ring vibrations) at 1453 cm−1, the C-N amino stretching bands at 1227 cm−1 and the C-O phenolic stretching band at 1174 cm−1. For Cur  decreased viability similarly to PCL–Cur nanofibers, although after 6 days of exposure, the cells recovered their metabolic activity and showed viability above 100%  incubation, day 4 (24 h Rsz), day 5 (6 h Rsz) and day 6 (24 h Rsz), with values of ove 100% . All datThe PCL–Cur nanofibers reduced the viability more than the other nanofibers with curcumin until day four of incubation, but an increase was observed particularly on day six, when the values were similar to those of the untreated cells .Free curcumin at the highest concentration (150 µM) drastically reduced MCF-7 viability during the first six hours of exposure, although all concentrations used were cytotoxic after two days of treatment. Meanwhile, free TMX severely reduced viability at the highest concentration from the third day of treatment. This showed that the action of free TMX on viability decrease was faster when it was released by the nanofiber. Contrary to what happens with free curcumin, whose action is more severe from the second day of exposure while encapsulated in the nanofibers, a moderate decrease was observed from the third day.PBMCs cannot be kept in culture for a long time as they are normal cells, so they were incubated for one day with the nanofibers, and fluorescence was measured between 4 and 48 h after adding resazurin. It was observed that PCL and PCL–Cur strongly stimulated the viability of these cells, while PCL–Gel–Cur decreased viability at 4 and 6 h, but after 24 h–36 h, the cells were able to recover and the effect was slight. PCL–Alg–Cur2 did not affect cell viability .MCF-7 cells were cultivated with free concentrations of curcumin of 0–150 µM, and tamoxifen of 0–100 nM; a similar effect was observed in the viability .It is well known that nanometric-scale biomaterials, especially natural or synthetic polymer nanofibers, are used in current research for the prevention, treatment, and diagnosis of diseases such as cancer, and local delivery systems for drugs or active substances.In addition to presenting characteristics of biocompatibility and biodegradability, these systems must allow the controlled release of active agents and be similar to the native extracellular matrix of human tissues and cells ,81,82.Thus, local delivery systems have the advantage over systemic therapy of being able to provide continuous delivery of drugs at higher concentrations and directly to the target site. Benefits of these systems include improved patient compliance, reduced toxic effects and systemic complications . TherefoTo the best of our knowledge, no comparative studies have reported on uniaxial and coaxial nanofibers containing the combination of PCL with alginate and/or gelatine, and the effect on cell viability of the MCF7 cell line and low toxicity in PBMCs cells.Nanofibers with TMX and curcumin were effectively produced by electrospinning and showed a high release rate in the first 24 h after coming into contact with a suitable medium.Both chemicals reduced cell viability—TMX reduced cell viability more rapidly and severely when it was released from the nanofibers than when it was free, while free curcumin at high concentrations acted faster and more severely than when released by nanofibers.PCL–Alg–Cur2 did not affect the cell viability of PBCMs cells, so this may be the best vehicle to transport curcumin. TMX-free was shown to severely affect the viability of PBMCs.Different studies have evidenced that core–shell curcumin nanofibers have antibacterial properties. However, few studies have showed the advantages of adding hydrophilic polymers to PCL structure and the modulate release effect on toxicity in MCF7 cancer cells. Likewise, no studies related to nanofibers determine the effect of these biomaterials on PBMC cells, since most of them refer to fibroblast cell lines .On the other hand, the studies related to the antiproliferative activity of curcumin have not compared its effects with tamoxifen (as a reference molecule); the present work showed that despite the high effectiveness of tamoxifen nanofibers on the MCF7 cell line, there is high PBMC cell toxicity. In this sense, the PCL–Alg–Cur and PCL–Gel–Cur nanofibers become an effective, non-toxic, antiproliferative local alternative for breast cancer treatment.


The change of magnetization of about 6% is shown as a result of applying an electric field (21 kV cm−1) to the composite made of the aforementioned molecular crystals at room temperature. In the ferromagnetic resonance measurement (FMR) under the effect of an applied electric field, a shift of the resonance magnetic field is also observed in the nanocomposites. This work provides a pathway towards molecular multiferroic nanocomposites with magnetoelectric coupling interactions at room temperature.Incorporation of magnetic and electric orders in a form of multiferroics is an interesting topic in materials science. Making a molecular heterogeneous composite by incorporating the molecular magnet vanadium–chromium Prussian blue analogue (V–Cr PBA) and a molecular ferroelectric imidazolium chloride C 4 introduces a room temperature multiferroic composite.Incorporation of molecular magnetic and ferroelectric V–Cr PBA and ImClO However, in the realm of molecular chemistry and physics, there is an equal interest in exploring molecular structures that can be tuned or respond to external stimuli manipulations. In that respect, multiferroic materials that simultaneously exhibit both electrical and magnetic properties are an active field of research.A(MB(CN)6)b. nH2O .12 In this context, vanadium–chromium PBA (V–Cr PBA) molecular ferrimagnets show room temperature magnetic ordering transition.6,13,14 In Prussian blue analogues V–Cr PBA, the water molecules coordinate with vanadium cations to compensate the vacancies in the PBA lattice. This create zeolitic water molecules existing in the PB lattice,15 leading to the formation of hydrogen bonding networks that are capable to take part in a charge transfer mechanism of proton transfer.16 On the other hand, the water molecules are also connected with some of the vanadium atoms which by themselves are responsible for the magnetic properties of PBA. There are two promising strategies to change the magnetic properties of a molecular magnet material: the pressure and electric field stimuli.10,17 In some PBA, the pressure up to 0.8 GPa can shift magnetization up to 10%, at temperatures well below the transition temperature.17 In both scenarios, the stretching in the MAII PBM data was replaced with SVG by xgml2pxml:<glyph-data id="z.dbd" format="PBM" resolution="300" x-size="8" y-size="10" xml:space="preserve">00000000000000000000000000000000111111110000000011111111000000000000000000000000</glyph-data><svg xmlns="http://www.w3.org/2000/svg" version="1.0" width="13.200000pt" height="16.000000pt" viewBox="0 0 13.200000 16.000000" preserveAspectRatio="xMidYMid meet"><metadata>Created by potrace 1.16, written by Peter Selinger 2001-2019</metadata><g transform="translate scale" fill="currentColor" stroke="none"><path d="M0 440 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z M0 280 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z"/></g></svg>C PBM data was replaced with SVG by xgml2pxml:<glyph-data id="z.tbd" format="PBM" resolution="300" x-size="17" y-size="11" xml:space="preserve">0000000000000000000000000000000000000000000000000000111111111111111000000000000000000011111111111111100000000000000000001111111111111110000000000000000000000000000000000000000000000000000</glyph-data><svg xmlns="http://www.w3.org/2000/svg" version="1.0" width="23.636364pt" height="16.000000pt" viewBox="0 0 23.636364 16.000000" preserveAspectRatio="xMidYMid meet"><metadata>Created by potrace 1.16, written by Peter Selinger 2001-2019</metadata><g transform="translate scale" fill="currentColor" stroke="none"><path d="M80 600 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z M80 440 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z M80 280 l0 -40 600 0 600 0 0 40 0 40 -600 0 -600 0 0 -40z"/></g></svg>NMBIII structure is the responsible for the change of symmetry and the modification of the magnetic property consequently.One of the challenges in the path of achieving molecular multiferroic is incorporating suitable ferromagnetic and ferroelectric materials together in such a way that both phases exist simultaneously under the specific temperature, particularly room-temperature multiferroic orders. One of the promising molecular ferrimagnet families are Prussian blue analogues (PBA) with general formula M418 is selected with V–Cr PBA magnet for the preparation of heterogeneous composites.In this work, room temperature molecular ferroelectric crystal ImClO4 phase exhibits high polarization of 8 μC cm−1.19,20At room temperature, ImClO4 and V–Cr PBA, we demonstrate a noticeable response at room temperature with six percent of magnetization tunability when the bias electric field is in the order of 20 kV cm−1.In the 1 : 1 ratio between ImClO4 crystal structure are displayed in 4 exhibits a hexagonal symmetry in contrast to the five-member ring symmetry of its molecular structure.18,21Magnetic V–Cr PBA and ferroelectric ImClOiii) and vanadium(ii) chloride are mixed with 3 : 2 weight ratio in water and is left in a centrifuge tube for one day to react completely. The product is washed for a few times and then centrifuged to remove the unreacted agents. The achieved substance with a dark blue color is dried for one day in a vacuum chamber at room temperature.7,22 The product is a dark blue powder of PB nanocrystals. Since the PB powder is sensitive to oxidation, it is necessary to be kept in the glove box. To synthesize ImClO4, equal molar amounts of imidazolium (C3N2H4) with perchloric acid (HClO4) are mixed. The solvent is dried slowly in several days to achieve a white transparent powder crystal.18 Different ratios of the synthesized crystals (PB and ImClO4) were ground together and then pressed to have round palettes with 6 mm diameter and about 1 mm thickness. To contact a thin copper wire to the top and bottom of the composite palette sample, silver epoxy was used , was used for the previous part.To prepare PB powder crystals, the power of potassium hexacyanochromate in the composite, we measured the Fourier-Transform infrared (FTIR) spectra of each of the constituents before mixing and the as-produced composite.In order to confirm the presence of both materials –NC–Cr(iii) and, VIVO–NC–Cr(iii) respectively.6,12 The presence of VIVO with the assigned peak at 981 cm−1 is due to being exposed to air for a short time during the synthesis process.6 The ratio of V(iii) to V(ii) can have a slight shift in TC ranges between 296 to 310 ± 8 K. This will not be very significant change for the suggested properties here. The Agilent Cary 630 FTIR spectrometer which is suitable for dry-powder samples was used for the previous part.In 4 show the splitting of the saturation part of magnetization hysteresis curves. In the −1). The Microsense EZ7-380V vibrational sample magnetometer (VSM) was used to measure room-temperature magnetization as well as magnetization versus temperature. The composition ratio between PBA and ImClO4 plays an important role in the magnitude of the magnetization change. In H = 100 and 200 Oe changes 0.011 and 0.017 respectively under the on/off cycle of electric field bias E = 6 kV cm−1. It is observed that 2 : 1 in contrast to 1 : 1 and 1 : 2 ratios, exhibit an opposite magnetic behavior under the electric field biases .Prussian blue analogues are molecular ferrimagnetic insulator with a bandgap 3 eV and conductivity of 10A. Jalouli conducted the project and wrote the manuscript. Dr S. Ren designed the project.There are no conflicts to declare.RA-012-D2RA04060C-s001


In the mediation models, the relationship between the adherence to the sleep–wake routines and aggressive behaviors was significant. The models showed the hypothesized mediated relationships among the adherence to the sleep–wake routines, negative emotional states, and aggressive behaviors  = 10.478, p < 0.001; Model 2: F = 9.826, p = 0.003). The findings confirmed the potential protective role of the adherence to the sleep–wake routines for the emotional and behavioral adjustment of adults with autism. Theoretical and practical contributions of the study were discussed; indeed, our results may inform parent-coaching as well as intervention programs for individuals with ASD given that adequate sleep hygiene may contribute to improvements in internalizing/externalizing behaviors.Disruption in routine may be related to experiencing negative emotional states and to aggressive behaviors in individuals with Autism Spectrum Disorder (ASD). The lockdown because of COVID-19 contributed to the disruption of individuals’ routines, including the sleep–wake cycle. The current study tested a relationship between the adherence to the sleep–wake routine and aggressive behaviors via the mediation role of negative emotional states . Forty-three parents of adults with ASD completed a web-based questionnaire about their life condition during the first lockdown (April–May 2020). Preliminary analyses showed a worsening in the adults’ aggressive behaviors during the lockdown in comparison to before it (Z = −3.130;  Since the COVID-19 pandemic was declared in January 2020 ,4. MoreoAccording to the DSM-5 , one of Among the routines adhered to by individuals with ASD, the sleep–wake one is pivotal for daily functioning in terms of cognitive and social functioning and attention ,13,14. DIndividuals with ASD are at high risk of presenting aggressive behaviors ,27,28. AHypothesis 1 (H1).We expected to find a negatively increased aggressive behavior in individuals with low adherence to sleep–wake routines. In other words, a lower adherence to the sleep–wake routines would be rated to higher levels of aggressive behaviors (HP1).In addition, disturbed sleep–wake routines have been related to individuals’ negative emotional states . In partHypothesis 2 (H2).We expected to find a negative impact of the lack of adherence to the sleep–wake routines on the emotional states of adults with ASD. In other words, a lower adherence to the sleep–wake routines would be related to higher levels of anxiety and anger (HP2).Both these two negative emotional states were found ,37,38 toHypothesis 3 (H3).We expected to find a positive relationship between negative emotional states (anxiety and anger) and aggressive behaviors in adults with ASD. In other words, higher negative emotional states lead to higher levels of aggressive behaviors (HP3).Although the abovementioned studies are valuable, they considered only children or adolescents with ASD, and they did not analyze the interplay between the considered variables. Therefore, the present research intended to address this gap in the literature testing the mediation effect of the emotional states on the relationship between sleep–wake routines and aggressive behaviors.Data were collected during the first mandatory lockdown due to COVID-19 in Italy (April–May 2020). An online survey was implemented using Qualtrics XM software and disseminated via the main social media platforms  via the snowball method. The predefined inclusion criteria were: (1) having a son/daughter with an ASD diagnosis aged over 18 years and (2) the parental ability to read and understand the Italian language. The exclusion criterion was the presence of any preexisting medical condition for the parents who completed the survey. The questions were previously tested on the general population ,6 and onForty-three parents [M(sd) = 54.8(10.2) years] of an adult son/daughter with ASD [M(sd) = 24.8(6) years] completed the online survey. Adherence to the sleep–wake routines. Two items [Did your son/daughter adhere to sleep routines during the lockdown?”) and wake- (“Did your son/daughter adhere to wake routines during the lockdown?”) related routines. Response options ranged from 1  to 5 (“very much”), with high scores indicating higher adherence. An aggregate total score  was calculated as the average of the two items with higher scores indicating higher adherence.wo items ,6,39 askNegative emotional states. Two questions [During the lockdown, how much do you think your son/daughter was anxious?”) and angry  during the previous week corresponding to the lockdown period. Response options ranged from 1  to 5 (“very much”), with high scores indicating higher levels of anxiety and anger/irritability.uestions ,6,39 askAggressive behaviors. Two questions [Was your son/daughter aggressive towards him/herself during the lockdown?”) and others (“Was your son/daughter aggressive towards others during the lockdown?”). Response options ranged from 0  to 7 (“very much”), with high scores indicating higher aggressive problems. An aggregate total score  was calculated as the average of the two items.uestions  asked paBehavioral problems. In order to explore behavioral problems in adults with ASD before and during the lockdown, a total of 12 ad hoc questions were formulated. Specifically, six questions asked parents how often—before the lockdown—their adult son/daughter showed a set of behavioral problems, such as: “How often did your son/daughter show stereotyped behaviors before the lockdown?”, “How often did your son/daughter show aggressive behaviors towards him/herself before the lockdown?”, “How often did your son/daughter show aggressive behaviors towards others before the lockdown?”, “How often did your child show repetitive behaviors before the lockdown?”, “How often did your child have difficulties in managing the transition from one activity to another before the lockdown?”, “How often did your child show hyper- or hyporeactivity to light/movement activity/touch material before the lockdown?”). A set of six similar questions were formulated to asked parents how often their son/daughter showed these behavioral problems during the lockdown. Response options ranged from 0  to 7 (“very much”), with higher scores indicating greater behavioral problems.https://www.processmacro.org/index.html, accessed on 10 June 2021), applying Model 4 and 5000 bootstraps inference for model coefficients. In the mediation models, the predictor variable (x) was the adherence to the sleep–wake routines, the outcome (y) was the aggressive behaviors, and the mediators (M) were the anxious (Model 1) and angry (Model 2) emotional states.The statistical analyses were performed using SPSS version 25  . In ordeRegarding behavioral problems, the results of the comparison between before and during the lockdown are summarized in p < 0.001) and their negative emotional states . Furthermore, the adults’ anxiety and anger correlated with aggressive behaviors .Spearman’s rho correlations showed that adherence to the sleep–wake routines was significantly and negatively related both to the adults’ aggressive behaviors  = 10.478, p < 0.001; Model 2: F = 9.826, p = 0.003). In both models, the two total effects were significant. The two mediation models were both significant  = 16.124, p < 0.001; Model 4: F = 37.800, p < 0.001) and in both models, the two total effects were significant. Since the design of the present study is cross-sectional, two alternative reverse models were carried out (Model 3 and 4), in which anxiety and anger were considered as independent variables, the aggressive behaviors as the mediator, and the adherence to the sleep–wake routines as the dependent variable. The two mediation models were both significant , and aggressive behaviors in adults. Our work tested two mediation models (Model 1 and 2) and two alternative reverse models (Model 3 and 4). The findings regarding Model 1 and 2 showed that poor adherence to the sleep–wake routines was associated with more aggressive behaviors toward self and others, as well as with more anxiety and anger. Furthermore, experiencing negative emotional states was positively associated with externalizing aggressive behaviors. Regarding the reverse models (Model 3 and 4), when the aggressive behavior was used as mediator on the relationship between emotional states and adherence to the sleep–wake routines, the results showed significant indirect effects.Specifically, regarding the relationships between the adherence to the sleep–wake routines and aggressive behaviors (HP1), our results corroborated the hypothesized associations as theorized in terms of the causal bidirectional link by Hollway and Aman . RegardiRegarding Model 3 and 4, in HP1 as well as in HP3 the reverse relationships were significant. Specifically, the results showed that the aggressive behaviors externalized by the adults with ASD predicted a disruption in the adherence to the sleep–wake routines (HP1 reverse); furthermore, the negative emotional states experienced by the participants predicted the aggressive behaviors (HP3 reverse). Finally, in HP2, the reverse models were not significant. This means that the establishing and/or the maintenance of the adherence to the sleep–wake routines lead the individuals with ASD to experience low levels of anxiety and anger and to externalize less aggressive behaviors. It would be interesting to further explore this reverse relationship in future research.In sum, the disruption of the adherence to the sleep–wake routines because of the COVID-19 lockdowns could reflect psychological distress experienced by adults with ASD and their parents . This diThe present study had several limitations. The research had a cross-sectional design; therefore, any conclusion regarding causality cannot be considered. Based on this issue, two models based on the associations found in the literature, and two alternative reverse models were tested. All four models tested demonstrated the hypothesized relationships among variables. Future research with a longitudinal design should disentangle the causal link among the variables. The sample size was small and nonrandom, due to the clinical population recruited during COVID-19 outbreak, and the data were parent-reported. Although the sample size was consistent with other research including ASD individuals , and theThe impact of the lockdowns on the routines of individuals with ASD has been inevitable. Our study demonstrated that the behavioral problems of adults with ASD worsened during the mandatory lockdown due to COVID-19. Moreover, the mediation models demonstrated the hypothesized relationships between the adherence to the adherence to the sleep–wake routines, negative emotional states, and aggressive behaviors. The more the lockdown resulted in a disruption of the routines, the more adults with ASD expressed negative emotions and behavioral problems. The reverse models also demonstrated that the higher the levels of anger and anxiety, the worse the behavioral problems and the disruption of the routines.This indicates there is a need to further evaluate this topic to define parent-coaching programs and individuals’ intervention by adults. Our results give important insight into how adults with ASD can be supported in the management of adherence to the sleep–wake routines to mitigate the worsening of emotional states and aggressive behaviors during the ongoing COVID-19 outbreak. This could also have a positive impact in the case of future health crises or the familiar unforeseen .The results of the present investigation may inform interventions. Parent-coaching programs and specific intervention for adults with ASD on how to manage sleep–wake routines and their distress levels are pivotal. As suggested by Devnani and colleagues , bedtime


In vitro and in vivo release of PTX and CMPT were investigated to find the release mechanism from nanofibers compared to direct administration of pristine PTX and CMPT. The mean fiber diameter for composite and core–shell nanofibers with shell feeding rates of 0.3, 0.5, and 0.7 mL h−1 was about 225, 330, 520, and 640 nm, respectively. In vivo release studies indicated that the blood concentration of CMPT and PTX for rats fed with core–shell nanofibers reached the highest values of 26.8 ± 0.04 μg mL−1, and 26.5 ± 0.05 μg mL−1 in 36 h, and 24 h and reduced slowly within 84 h, and 48 h, respectively. The maximum cytotoxicity was 75% in the presence PVA/κ-carrageenan/CMPT/Au/pegylated-PU/PTX core–shell nanofibers. In vivo antitumor activity results confirmed the synergic effect of Au, CMPT and PTX anticancer drugs on the reduction of tumor volume without change in mouse weight by the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers. The obtained results indicated that the simultaneous loading of CMPT and PTX anticancer drugs and Au nanoparticles is more beneficial for lung cancer treatment.Gold nanoparticles, paclitaxel (PTX), and camptothecin (CMPT) were loaded into the PVA/κ-carrageenan/pegylated-PU composite and core–shell nanofibers prepared by two-nozzle and coaxial electrospinning methods. The capability of composite and core–shell nanofibers was investigated for the targeted delivery of anticancer drugs in lung cancer treatment.  in vivo release from core–shell nanofibers against lung cancer.Core–shell nanofibers and  In other study, the combined effect of PTX and CMPT was investigated against melanoma,3 breast, pancreatic,4 and medullary thyroid carcinomas.5 Chen et al.6 attached PTX and CMPT anticancer drugs on the 2-nitroimidazole against hypoxic tumors. In another study, CMPT and PTX were conjugated with two cyclic cell-penetrating peptides to inhibit MCF-7 breast cancer cells.7 Hariri et al.8 investigated the targeted delivery of PTX and CMPT from a cross-linked sponge against lung cancer. The use of targeted drug delivery systems such as liposomes,9,10 microspheres,11,12 nanoparticles,13,14 and nanofibers15–18 could provide the sustained delivery of anticancer drugs.The combination of paclitaxel (PTX) and camptothecin (CMPT) could provide several advantages over monotherapy. In previous studies, better treatment of various cancers, including lung, breast, and melanoma, is demonstrated by the co-delivery of PTX and CMPT compared to the monotherapy of PTX or CMPT1-4. For instance, the concentrations of PTX and CMPT could be controlled by their loading into the liposome.19–23 Carrageenan could also interact with inorganic materials such as graphene oxide (GO), metal–organic frameworks (MOFs) and proteins. κ-carrageenan, and κ-carrageenan-based composites have been used in various drug delivery systems. For instance, Sun et al.20 interacted κ-carrageenan with zein nanoparticles. Javanbakht et al.21 synthesized κ-carrageenan/MOFs composite hydrogel for oral delivery. Vinothini et al.22 used κ-carrageenan-grafted graphene oxide for drug delivery of DOX. Tort & Acartürk23 investigated the capability of electrospun κ-carrageenan nanofibers for oral mucositis treatment. The use of nanofibers prepared by electrospinning technique is an effective strategy for loading the high content of drugs due to their high porosity, high surface area, small size, good flexibility, and interconnecting channels.24 However, there are still limitations for electrospun nanofibers, due to their rapid degradation over time. The various nanofibers, including composite, multi-layered,25 and core–shell nanofibers,17,18 could provide the prolonged-release profiles. In recent studies, the hydrophobic polymers such as poly(ε-caprolactone),26 polyurethane (PU),27 poly(lactic acid) (PLA),28 and poly(lactic-co-glycolic acid) (PLGA)29 were used to increase the stability of polysaccharide nanofibers in aquatic systems.κ-Carrageenan, an anionic sulfonated polysaccharide, is extracted from red algae and used for biomedical applications such as food, tissue engineering and drug delivery systems.30 The degradation rate of PUs is mainly due to the cleavage of hydrolytic bonds present in their soft segments. The composition of the soft segments could control the degradation rate of the PUs. The degradation rate of PUs with hydrophilic soft segments such as poly(ethylene glycol) is faster than PUs with hydrophobic soft segments such as polycaprolactone diol.31 Loading of anticancer drugs into the PUs, and its derivates could increase the availability of the anticancer agents at the tumor sites, suppress the cancer cells that did not kill by the initial dose of drug31,32 and decrease the adverse side effects. For instance, Gajbhiye et al.33 reviewed the performance of biodegradable PU nano-constructs for the targeted delivery of anticancer drugs. Yin et al.34 indicated that PTX molecules were released slowly from liposome-encapsulated PU scaffolds compared to PTX release from PU. Liu et al.35 investigated the potential PU functionalized with amine, and carboxyl group micelles for incorporating of doxorubicin hydrochloride (DOX) and PTX. In previous studies, the capability of drug-loaded PU nanofibers for various cancers treatment was studied by our group.17,18,36,37 Recently, inorganic materials such as metal oxides, zeolites, MOFs and noble metals were loaded into the nanofibrous matrix to increase the delivery of anticancer drugs on the surface of the cancerous tissues. Gold-based nanomaterials with various shapes, including nanoparticles,38–40 nanocages,41,42 and nanorods43–45 are incorporated into the different forms of drug delivery systems for targeted delivery and imaging in cancer therapy. Gold nanoparticles (Au NPs), due to their high stability, and easier synthesis were used to improve the attachment of cancerous cells and increase the therapeutic efficacy.46,47Most PUs are non-degradable and have little use in biomedical applications. On the other hand, the natural/synthetic biodegradable polymers are stiff with low flexibility or soft with poor mechanical properties. To overcome these challenges, the biodegradable PUs, composed of a hard segment, soft segment, and chain extender, have been introduced as one of the most popular polymers due to their low cost, high biocompatibility, and excellent efficiency for drug delivery systems.In the present study, PTX and CMPT were loaded into the κ-carrageenan/Au/pegylated-PU composite nanofibers prepared by two-nozzle and coaxial electrospinning methods for targeted delivery of anticancer drugs against lung cancer treatment. It was hypothesized that the co-delivery of PTX and CMPT from nanofibers and the use of gold nanoparticles in the nanofibers structure could enhance the targeted delivery of anticancer drugs on cancerous tissues.2.2.1Mn = 2000 Da, PEG) supplied from Sigma-Aldrich (USA); hexamethylene diisocyanate (HDI) and 1,4-butanediol (BDO) purchased from Merck Company (Germany) were used to synthesize the pegylated polyurethane. Polyvinyl alcohol  and κ-carrageenan were used to prepare PVA/κ-carrageenan nanofibers. Paclitaxel and camptothecin supplied from Sigma-Aldrich (USA) were utilized as anticancer drugs. HAuCl4, and sodium citrate provided from Sigma-Aldrich (USA) were applied to synthesize the gold nanoparticles.Poly(ethylene glycol) . To load PTX molecules into the pegylated PU, 1 and 2 mg mL−1 PTX were added into the pegylated-PU solution under sonication for 30 min.The shell solution was the PTX-loaded pegylated polyurethane (PU). The pegylated polyurethane was synthesized by reacting PEG, HDI, and BDO as described previously by Yao 4 was used to synthesize Au nanoparticles.37 2 wt% κ-carrageenan (dissolved in distilled water) and 10 wt% PVA (dissolved in distilled water) were mixed under stirring for 6 h (3 : 7 v/v). To load CMPT and Au nanoparticles into the PVA/κ-carrageenan solution, 2 wt% Au suspension (with respect to the PVA/κ-carrageenan solution v/v) and 1, 2 mg mL−1 CMPT were added into the PVA/κ-carrageenan solution under sonication for 30 min.The core solution was the CMPT/Au-loaded PVA/κ-carrageenan solution. The citrate reduction of HAuCl2.3−1 for both solutions to produce the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite nanofibers under an electrospinning time of 4 h.To prepare PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite nanofibers, the prepared pegylated PU/PTX and PVA/κ-carrageenan/CMPT/Au solutions were separately transferred into the two syringes (needle tip: 19 gauge) and then placed at both counter sides of the cylindrical collector which was placed an aluminum foil on the collector. The applied high voltage was varied between 15 and 25 kV. Tip–collector distance was constant at 12 cm. The feeding rate was between 0.3–1 mL h−1. The shell solution feeding rate varied between 0.3 and 0.7 mL h−1.To prepare the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers, the prepared core and shell solutions were transferred into the two syringes (tip needle: 27 and 14 gauges). The voltage, tip–collector distance, and core solution feeding rate were constant at 20 kV, 12 cm, and 0.3 mL h2.4−1 with a resolution of 2 cm−1 on the Fourier-transform infrared spectroscopy . X-ray diffraction (XRD) analysis ranged from 5° to 80° using an X-ray diffractometer . Morphology of nanoparticles and nanofibers was carried out using a scanning electron microscope  and a transmission electron microscope .Fourier transform infrared (FTIR) analysis was implemented ranging from 500–4000 cm2.5To evaluate the drug loading measurements in the nanofibers, drug entrapment efficiency (DEE%) and drug loading efficiency (DLE%) were calculated as follows:2.6In vitro release studies were implemented by immersion of 100 mg drug-loaded nanofibers in 500 mL of phosphate-buffered saline (PBS) solutions with a rotation rate of 50 rpm at the temperature of 37 °C, and pH values of 5.5 and 7.4. At preplanned times, 2 mL of aliquot was withdrawn, and 2 mL of fresh PBS was added. The final concentrations of PTX and CMPT were determined using High-performance liquid chromatography  and UV/Vis spectrophotometer  at 230 nm, and 360 nm, respectively. HPLC conditions are: a reversed-phase HPLC method, column: C-18 column, mobile phase: acetonitrile, methanol and water , temperature: 25 °C and flow rate of 1.0 mL min−1. Experiments were repeated three times, and the results were reported as mean ± S.D. The experimental data was statistically analyzed using an analysis of variance (ANOVA) as well as a t-test (P < 0.05).Q(t) = K0t), Higuchi (Q(t) = KHt0.5), and Korsmeyer–Peppas (Q(t) = Atn) equations.The release data were fitted by pharmacokinetic models, including zero order  that were maintained under a maximum isolation environment for 6 weeks based on Institutional Animals Ethics Committee (94/PO/ReBi/S/1999/CPCSEA). All animal procedures were performed in accordance with the Guidelines for Care and Use of Laboratory Animals of Tehran University and approved by the Animal Ethics Committee of National Institute for Medical Research Development (NIMAD), Tehran, Iran. Then, nanofibers-implemented 15 old mice were divided into five groups of three . The mice dose of PTX and CMPT was 5 mg kg−1. The nanofibrous scaffolds were implanted into the lower right flank of each mouse. At predetermined intervals , 0.5 mL of blood samples were withdrawn and were stored in a centrifuge tube. The samples were centrifuged at 5000 rpm for 5 min to separate the plasma that was frozen at −20 °C until HPLC and UV assays to determine the concentrations of PTX and CMPT, respectively.For investigating the 2.82 and 37 °C for 24, 48 and 72 h. 5 × 104 cells per well were transferred in a 48-well plate and treated with 1 and 2 mg mL−1 concentrations of pure drugs and their equivalent doses of drugs-loaded nanofibers. The MTT assay was implemented by using a microplate reader  at the wavelength of 570 nm.27 Briefly, the MTT assay was carried out as follows: 20 μL of MTT solution with a concentration of 5 mg mL−1 in PBS (pH 7.4) was added to each well, and then, were incubated for a further 4 h. Then, the solution was aspirated cautiously from each well. After treating the cells with Sorenson buffer, the optical density of each well was readied at 570 nm.To investigate the biocompatibility, and cytotoxicity of nanofibers, the pure drugs and drugs-loaded nanofibers were cut into flakes and placed in each well of L929 murine fibroblast and A549 lung cancer cell lines. Cells were purchased from the Institute Pasteur of Iran, and cultured in RPMI-1640 media under 5% CO2.96 A549 lung cancer cells were subcutaneously injected into the left hind flank of each anesthetized mice after isolation for 6 weeks. When the tumor volume reached 100 mm3, the mice were treated with nanofibrous samples, and experiments were continued for 20 days. The relative tumor volume with respect to the initial volume of tumor (V0 = 100 mm3) before treatment was calculated as V/V0. Briefly, animals were anesthetized by intra-peritoneal injection of pentobarbital at 20 mg kg−1, and a small incision was made on the skin to expose the tumor. A small incision was made into the tumor, and synthesized fibers were inserted into the tumor and then the wound was closed using subcutaneous suturing. The tumor volume is calculated as length × width × (length + width)/2.The tumor-bearing mice were divided into 5 groups of three. 2 × 103.3.1−1, 2920 cm−1, 1690 cm−1, 1425 cm−1, 1080 cm−1 and 887 cm−1 were assigned to the –OH stretching, CH2 asymmetric stretching, C PBM data was replaced with SVG by xgml2pxml:<glyph-data id="z.dbd" format="PBM" resolution="300" x-size="8" y-size="10" xml:space="preserve">00000000000000000000000000000000111111110000000011111111000000000000000000000000</glyph-data><svg xmlns="http://www.w3.org/2000/svg" version="1.0" width="13.200000pt" height="16.000000pt" viewBox="0 0 13.200000 16.000000" preserveAspectRatio="xMidYMid meet"><metadata>Created by potrace 1.16, written by Peter Selinger 2001-2019</metadata><g transform="translate scale" fill="currentColor" stroke="none"><path d="M0 440 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z M0 280 l0 -40 320 0 320 0 0 40 0 40 -320 0 -320 0 0 -40z"/></g></svg>O stretching, CH2 bending, C–O stretching, and C–C stretching, respectively. For pure κ-carrageenan, the observed peaks at around 3320 cm−1, 1420 cm−1, 1220 cm−1, 1150 cm−1, 930 cm−1, and 840 cm−1 were due to the –OH stretching, C–O–H bending, OSO stretching, C–O–C absorption, and O–SO3 stretching bands, respectively. The new peaks between 500–700 cm−1 after loading Au nanoparticles into the PVA/κ-carrageenan confirmed the presence of Au nanoparticles in the nanofibrous matrix. The shift of carbonyl stretching vibrations correspond to the ketone groups from 1610 cm−1 to 1660 cm−1, and the lactone groups from 1720 cm−1 to 1745 cm−1 demonstrated the interaction of CMPT molecules with nanofibrous matrix. For pegylated PU, the appeared peaks at 3350 cm−1, 2930 cm−1, 2840 cm−1, 2225 cm−1, 1730 cm−1, 1644 cm−1, 1550 cm−1, 1460 cm−1, and 1105 cm−1 were related to the N–H stretching, asymmetric CH2 stretching, symmetric CH2 stretching, –NC–O absorption, CO stretching, urea absorption, N–H bending, CH2 bending, and C–O–C absorption, respectively. The detected peaks, in the FTIR spectrum of pure paclitaxel, at 3630 cm−1, 3095 cm−1, 1721 cm−1, 1650 cm−1, 1245 cm−1 and 1078 cm−1 were due to the presence of O–H, CH2, CO, C–C, C–N and C–O groups. The prominent peaks of pegylated PU and paclitaxel have overlapped.FTIR spectra of PVA, κ-carrageenan, Au, CMPT, PVA/κ-carrageenan/CMPT/Au, pegylated-PU, PTX, and pegylated-PU/PTX are illustrated in −1) are presented in −1 led to increase the fiber diameter from 225 nm to 470 nm. Therefore, an applied voltage of 20 kV, tip–collector distance of 12 cm and feeding rate of 0.3 mL h−1 were selected to fabricate composite nanofibers for further experiments. SEM images from PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers with different shell feeding rates , core feeding rate of 0.3 mL h−1, the voltage of 20 kV, and the tip–collector distance of 12 cm are presented in −1 to 0.5 mL h−1, and 0.7 mL h−1 led to increased fiber diameter from 330 nm to 520 and 640 nm, respectively. The comparison of the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite and core–shell nanofibers indicated that the composite nanofibers had a sharp distribution of fibers compared with broader distribution of core–shell nanofibers at studied condition. However, the non-alignment of fibers was detected for both composite and core–shell nanofibers, and thus have a randomly distributed nanofibrous structure for synthesized nanofibers. TEM image from core–shell nanofibers demonstrated the core-sheath structure of nanofibers prepared by coaxial electrospinning.SEM images of PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite nanofibers under different applied voltages  and feeding rates   were smaller than 0.45 from core–shell nanofibers which indicated that CMPT molecules were fled from the core–shell nanofibers following the Fickian mechanism. The linear release achieved for CMPT release from core–shell nanofibers demonstrated an excellent fitting of release data with the zero-order pharmacokinetic model. The “n” values for PTX release from both composite and core–shell nanofibers and “n” values higher than 0.45 for CMPT release from composite nanofibers confirmed the non-Fickian diffusion mechanism.DEE (%) and DLE (%) are evaluated for PTX and CMPT-loaded nanofibers which results are presented in pH: 7.4) . The obtequation . The valin vivo PTX and CMPT (10 mg of each drug) release profiles from nanofibers are presented in −1 PTX and CMPT solutions were used as control. Using pure PTX and CMPT solutions, plasma concentrations of PTX and CMPT came to their highest within 1 h and lower to average level at about 6 h for both anticancer drugs. When rats were fed with composite nanofibers, the blood concentration of CMPT and PTX reached the highest values of 29.3 ± 0.05 μg mL−1 and 26.8 ± 0.03 μg mL−1 in 6 h and 12 h and reduced slowly within 24 h and 48 h, respectively. Additionally, owing to the drug concentration gradient distribution from the inner layer to shell layer and then granted by core–shell nanofibers, which stores most drug in the inner layer, the curve of CMPT and PTX release from core–shell nanofibers exhibited a sustained release for about 84 h and 48 h, respectively due to the continuous release of drugs from core–shell nanofibers.The 3.3−1). The sustained release of CMPT and PTX from nanofibers resulted in more cytotoxicity of core–shell nanofibers than composite nanofibers. In vitro cytotoxicity results showed that its inhibition effect on tumor cells by the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers was remarkable, but the toxicity for normal cells was slight. Similar trends are reported by other researchers.49,50 The simultaneous incorporation of Au nanoparticles and co-delivery of PTX and CMPT into the core–shell nanofibers led to effective treatment of A549 lung cancer cells.The cell viability of synthesized composite and core–shell nanofibers toward L929 normal cells is implemented to investigate the biocompatibility of synthesized nanofibers. The results are illustrated in 3.4in vivo antitumor efficacy of the PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite and core–shell nanofibers was investigated on the A549 tumor-bearing mice with an initial tumor volume of 100 mm3 which the results of tumor volume change and the weight of mice after treating with nanofibers are presented in 's body weight after therapy revealed that no significant change occurred for all mice after injecting tumors for 20 days -loaded poly(l-lactic acid) nanofibers (PLLA/DOX@MSNs) against human spca-1 lung cancer cells. The maximum cell viability was 73.10%. The release trend of DOX from PLLA/DOX@MSNs composite nanofiber was similar to the release profiles of CMPT and PTX from PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite nanofibers . The inhibition rate of titanocene dichloride-loaded PLLA nanofibers was 68.2% (240 mg L−1 drug concentration).52 The maximum cell viability of A549 lung cancer cells by the chitosan/PLLA/TiO2/DOX/GO nanofiber and a magnetic field was about 82% after 86 h.53 Therefore, the co-incorporation of Au nanoparticles and anticancer drugs into the nanofibers demonstrated an optimal therapy effect on the tumor inhibition without changing the body weight.The  20 days . For com4.−1 were optimum values for the fabrication of PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX composite nanofibers with an average diameter of 225 nm. The mean fiber diameter for core–shell nanofibers produced under shell feeding rates of 0.3, 0.5, and 0.7 mL h−1 were 330, 520 and 640 nm, respectively. The higher DEE than 95% for PTX and CMPT confirmed an effective loading of anticancer drugs into the nanofibers. Time durations for PTX vb. CMPT release from core–shell nanofibers with 0.3, 0.5 and 0.7 mL h−1 shell feeding rates were 60, 48, 40 h vs. 96, 72, 60 h, respectively. The linear release is achieved for CMPT release from core–shell nanofibers. The PTX release data of composite, core–shell nanofibers and CMP release data of composite nanofibers were best described using the Peppas' equation. In vivo release studies indicated that rats fed with core–shell nanofibers, the blood concentration of CMPT and PTX reached the highest values of 26.8 ± 0.04 μg mL−1 and 26.5 ± 0.05 μg mL−1 in 36 h and 24 h and kept in the constant values between 36–84 h and 24–48 and finally reduced after 84 h and 48 h, respectively. The L929 cell viability higher than 90% for both composite and core–shell nanofibers confirmed the high biocompatibility of the synthesized composite and core–shell nanofibrous samples. The maximum cytotoxicity was 75% in the presence PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers. In vivo antitumor efficacy results of A549 tumor-bearing mice treated with composite and core–shell nanofibers demonstrated the best effect on the reduction of tumor volume and enhancement of tumor inhibition without changing the mice's weight in the presence PVA/κ-carrageenan/CMPT/Au/pegylated PU/PTX core–shell nanofibers.In this work, Au nanoparticles, CMPT and PTX anticancer drugs were successfully incorporated into the PVA/κ-carrageenan/pegylated PU composite and core–shell nanofibers. The applied voltage of 20 kV, tip–collector distance of 12 cm and feeding rate of 0.3 mL hANOVAAnalysis of varianceBDO1,4-ButanediolCMPTCamptothecinDOXDoxorubicin hydrochlorideDEEDrug entrapment efficiencyDLEDrug loading efficiencyFTIRFourier transform infraredAu NPsGold nanoparticlesGOGraphene oxideHDIHexamethylene diisocyanateHPLCHigh-performance liquid chromatographyMOFsMetal–organic frameworksDMFN,N-DimethylacetamidePTXPaclitaxelPBSPhosphate buffered salinePEGPoly(ethylene glycol)PLAPoly(lactic acid)PLGAco-glycolic acid)Poly(lactic-PUPolyurethanePVAPolyvinyl alcoholSEMScanning electron microscopeTEMTransmission electron microscopeXRDX-ray diffractionThere are no conflicts to declare.


An effective strategy for combatting AMR in Indonesia is to make the use of antibiotics in hospitals more rational with the help of an Antimicrobial Resistance Control Program (AMR-CP). This study aims to analyze the implementation of the AMR-CP in hospitals by conducting in-depth interviews with health professionals from ten hospitals and health officers of ten provincial health offices in ten different provinces and observation towards its documents. The sample location was selected by purposive sampling. Informants at the hospitals were hospital directors, chairmen of the AMR-CP team, chairmen of the medical committee, persons in charge of the microbiology laboratory, clinicians, nurses, clinical pharmacists, and those program managers at the provincial health offices who are responsible for administering antibiotics. Information is first collected and then a thematic analysis is applied along with triangulation to confirm the validity of information from multiple sources, including document observation results. The analysis is adapted to the framework of the system . Results show that hospitals in Indonesia already have the resources to implement AMR-CP, including AMR-CP team and microbiology laboratories. Six hospitals examined also have clinicians trained in microbiology. Though hospital leadership and its commitment to implementing AMR-CP are favorable, there is room for improvement. AMR-CP teams organize routine activities for socialization and training, develop standard operating procedures (SOPs) for antibiotic use, antibiotic patterns surveillance, and bacterial mapping. Some obstacles to implementing AMR-CP policies are posed by the human resources, facilities, budget, antibiotics and reagent shortages, and clinician compliance with SOPs. The study concludes that there was an improvement in antibiotic sensitivity patterns, rational use of antibiotics, use of microbiological laboratories, and cost-efficiency. It recommends the government and healthcare providers continue to improve AMR-CP in hospitals and promote AMR-CP policy by making the regional health office of the hospital a representative of the regional government. The World Health Organization (WHO) declared that antimicrobial resistance (AMR) is one of the top ten threats to global health. The loss of effective antimicrobials increases both morbidity and mortality from infections. In 2019, there were an estimated 4.95 million AMR-related deaths. Lower respiratory tract infections account for more than 1.5 million resistance-related deaths. WHO's strategy for combatting AMR is leadership strengthening to address AMR, driving public health impact for the AMR response globally, research and development to improve access to value AMR prevention and care, and scrutinizing the AMR burden and AMR response in every country [E. coli and K. pneumonia that are resistant to antimicrobials. Carbapenems, fluoroquinolones, and third-generation cephalosporins are some of those [According to data from global antimicrobial resistance and use surveillance system gathered from 20 hospitals in Indonesia, there has been a growth in the percentage of some bacteria, such as in S. aureus and E. coli. Of the 3,995 S. aureus isolates, 25% were resistant to tetracycline. The level of E. coli's resistance to gentamicin, cefotaxime, and ciprofloxacin was low in admission  but high in discharge , respectively [Hospitals must be given careful consideration because they are a significant source of AMR. Researchers at Dr. Kariadi Hospital in Semarang and at Dr. Soetomo Hospital in Surabaya, both in Indonesia, reported that there was antimicrobial resistance ectively .Several studies have shown that the incorrect application of antibiotic therapy was responsible for 30–50% of cases. In some cases, the right treatment was not indicated; in others, the choice of agent was wrong; and in others, the therapy lasted either too long or too short . For theIn this study, we discuss the extent to which AMR-CP in Indonesia helps to rationalize the use of antibiotics in hospitals. We conduct a comprehensive qualitative analysis, the results of which can be used as scientific evidence by the government, health care facilities, and medical practitioners. A more rational use of antibiotics can thereby be achieved, especially in Indonesian hospitals.This is a qualitative study that explores efforts to control antibiotic resistance in hospitals by rationalizing the use of antibiotics. Data were collected through in-depth interviews and observations. A written consent agreement was requested from the informants before the interviews began. The ethics committee of the National Institution of Health Research and Development thus issued ethical clearance for this study, which was conducted from February to October 2018.The hospitals where data were collected were selected according to the following criteria: they have a microbiology laboratory, they have implemented an antimicrobial resistance control program, and clinical pharmacy services are already running. Based on these criteria, 10 hospitals were selected to serve as the sample of the survey. Almost all hospitals selected were public and teaching hospitals, and one hospital was both public and in a network of teaching hospitals. The selection of informants refers to Minister of Health (MOH) Decree No. 8/2015 which regulates the composition of the AMR-CP team, especially those involved in the rational use of antibiotics both from the management and implementation sides, which are directly related to the use of antibiotics. Therefore, informants from the hospital include the chairman of the AMR control program team at the hospital, the chairman of the medical committee, the person in charge of the microbiology laboratory, and the specialist doctors who prescribe antibiotics frequently, such as specialist in internal medicine or pulmonary diseases, the nurse in charge of the ward, the clinical pharmacist, and the director of medical health services. The age of these informants ranged from 30 to 55 years old. They have at least one year of employment in the selected hospital and are related to the use of antibiotics. The interview duration was 1-2 hours per person and the audio recorded. The interview was conducted after research permit applications at the hospitals were granted. The research team and contact persons in each sampled hospital arranged the data collection process, including informants' availability and appropriate schedules. When the data collection began, the research team informed the hospital director of the research objectives and benefits. Effective coordination between the research team and the hospital management allowed the research data collection process to run smoothly. There were 62 informants who were interviewed. Some held multiple positions, for example, chairing the medical committee and serving as an expert in internal/pulmonary disorders, or simultaneously chairing the medical committee and the AMR-CP.Before data collection, the researcher met with the head of the health office and obtained informed consent. Informants at the provincial health office included program managers in charge of the drug/antibiotics use program. There were 20 informants in the health offices who were interviewed.The interview focuses on the policies about administering antibiotics to patients in hospitals, the implementation of AMR-CP, and the issues it raises. Several important inputs and outputs of AMR-CP implementation were observed, such as the decree for the establishment of the AMR-CP team, the availability of microbiology laboratories and clinical microbiology specialists, and the following documents: standard operational procedures (SOP), reports on the use of antibiotics, and program reports. All the interviewers were trained researchers who have been experienced in qualitative research interviews with a health-academic background, such as pharmacists and medical doctors. This study confirmed that there was no relation between the informants and the researchers. Most of the authors (6 out of 10) conducted interviews. Two researchers interviewed each informant: one acted as an interviewer and dialogued with the informant, and another documented both notes and recordings. All field notes were taken during the interview. The interviewing researcher transcribed the recording into a narrative. The interview process was only conducted once at a predetermined time because all questions had been answered completely, so the researchers did not repeat the visits and the transcript did not return to the informants. However, at the end of the study, researchers organized seminar that invited hospital informants and provincial health office representatives to provide preliminary study findings and ask for confirmation from the participants. If seminar participants submit confirmation, this confirmation will be discussed to reach an agreement and used as research results.In this study, data were collected using observation lists and interview guides. Before collecting data and information, trials were conducted in two hospitals and one health office in two different areas from the study locations to test the instrument's validity and reliability. The trial results are processed, discussed within the team, and used to improve the instruments.Interviews with informants were conducted privately at the hospital, in the workspace of each informant, using the Indonesian language without being accompanied by another person or translator. The interview might be interrupted when the informants suddenly need to attend to patients; the researchers would wait and resume the interview once the informants had concluded their interrupted duties. In this instance, the interview lasted longer. The informant was encouraged to provide accurate information based on the circumstances that existed in the hospital at the time of the interview. Given this significance, the researchers' guarantees of confidentiality and the requirement for information were explained before the interview.A theme-based analysis was conducted: first, the researchers transcribed the results of the interviews into the narrative; then they put them into categories and compressed them; finally, they entered the results into a matrix based on the theme and the hospital. The information in the matrix was color-coded to identify different themes, opinions, and languages. Important information was selected, and common issues were grouped together manually. The research team repeatedly discussed valuable information along with connectivity. Triangulation was carried out and checked with the results from the observations. We did all these analyses manually. The research team specifically looked for conformity between information from various sources. Once the objectivity of the data was confirmed, the results were discussed with experts and scholars in the fields of epidemiology and public health. On that basis, conclusions were drawn and recommendations for further study were made.The information below is a summary report on 10 hospitals where informants were interviewed. The system concept of input, process, and output helped organize discussions of themes and the results of the observations. The themes for input are hospital policy/regulation, including its AMR-CP team and human resources; leader and management commitment; infrastructure;, and financing. The themes for the process are socialization, programs and activities, obstacles, and clinician compliance, while the output is AMR-CP's work results.All issues resulting from interviews and document observations refer to MOH Decree No. 8/2015 regarding AMR-CP in the hospital, with the results below.The results of in-depth interviews show that the hospital has carried out an antimicrobial resistance control program. The director of the hospital decreed that an AMR-CP team be formed in 2009 , in 2014 , in 2015 , in 2016 , and in 2017 , and one hospital was not included in the decree. The AMR-CP team should consist of clinicians, nurses, clinical pharmacists, the person in charge of the microbiology laboratory, members of the infection prevention committee, and members of the pharmacy and therapy committee, with only one exception, and that was one hospital that located in DKI Jakarta Province did not comply to this policy. All AMR-CP teams thus report to the hospital director. However, all the informants were familiar with and understood the government regulation concerning the antimicrobial resistance control program in hospitals. The National Hospital Accreditation, furthermore, has required an AMR-CP team since 2017.“……… support for activity is good but insufficient financial support.”Results from the in-depth interviews show that hospital leaders and management are committed to the implementation of AMR-CP, though some stated that their commitment still needs improvement. Information from management, practitioners, and the AMR-CP team is sometimes contradictory. Management stated that they had given full support to the implementation of AMR-CP, but the AMR-CP team stated it still needed improvement. The commitment was that management gave the chairmen and members of the AMR-CP team the opportunity to attend AMR training or workshops; supported teamwork needs, such as new computers, a secretariat, rooms, and staff; financed the programs that the team and its leaders attended; and recruited clinical microbiology specialists in the hospitals. On the contrary, the reason that leaders' and management's commitment still needs to be improved is that there are still AMR-CP teams that have no working space and lack funding for AMR-CP activities. The following is a statement submitted by the AMR-CP team chairman of one hospital:“……… We also conduct outreach to patients and their families about the rational use of antibiotics. We do this in a hospital meeting room and show them through exposure and questions and answers.”The results showed that all hospitals carry out internal socialization activities, whether in the form of AMR-CP or general hospital meetings where one of the topics of discussion is AMR-CP. The socialization meetings were mostly aimed at clinicians, medical students who are doing internships, pharmacists, nurses, and other health workers. Meetings in some hospitals took the form of workshops and training. There is one hospital that conducts outreach to patients and their families to educate them about the rational use of antibiotics. The following is said by one chairman of AMR-CP in one hospital:The frequency of meetings varies, some hospitals hold them every 3 months, but others only 1-2 times a year. Meetings are more frequent if the hospital is seeking accreditation.“... for hospital accreditation, we were asked for the data of AMR surveillance or bacterial map, usually yearly data….”The results show that the hospital has carried out AMR-CP activities, but its performance could be improved. The activities of some hospitals are still limited to AMR-CP preparation and socialization meetings. The activities at hospitals whose teams have been established for a longer time are more comprehensive and routine. Some respondents said that AMR-CP's activities were running slowly and even stuttering. The activities run more smoothly when the hospital is accredited. The following is the statement of the chairman of AMR-CP at one hospital:The types of SOPs and the guidelines made for antibiotic control in hospitals are shown in Obstacles reported in the interviews consisted of human resources, facilities, budget, availability of antibiotics, and the clinician's adherence to SOPs. Many hospitals stated that their AMR-CP budget was still insufficient. The budget for meetings, socialization, and stationery is relatively enough. There were hospitals that stated the budget for AMR-CP activities was sufficient but that funds for microbiological examinations were not. The AMR-CP team consists of doctors and other hospital health workers, who are busy; consequently, they do not coordinate well. Doctors still need refreshment training to understand antibiotic resistance better. Not all hospitals are equipped with facilities to support AMR-CP activities. The handling of specimens, the availability of reagents, and quality microbiological examinations still present problems. Shortages of antibiotics can cause antibiotics not to be used in accordance with the guidelines.Based on the study result, the clinician's adherence to the guidelines/SOP and compliance with the results of antibiotic sensitivity tests are linked to the performance of the AMR-CP as described in “…. clinician compliance here is also influenced by BPJS guidelines, because if they use high-line antibiotics without microbiological tests, they will not receive reimbursement............”Clinician adherence to the guidelines or SOPs for the use and restriction of antibiotics in hospitals varies widely: several of them were good, others were less compliant, and some hospitals had no evaluation. Compliance with the results of the sensitivity test is determined on the basis of the National Health Insurance treatment guidelines. These guidelines stipulate that, if a sensitivity test is not carried out, a higher line of antibiotics cannot be given. However, if it is still given to patients without proof of the sensitivity test results, NHS will not reimburse the treatment costs. This condition leads doctors to comply with the results of sensitivity tests but only for the use of higher-line antibiotics by means of second- or third-line antibiotics. The following stated by one medical health services director:Although other factors may influence the work performance of AMR-CP, however, from This study found that only the program managers of health offices in Java have a good understanding of MOH Decree No. 8/2015 concerning the antimicrobial resistance control program. It seems that other provincial health office managers know very little about the policy. Three out of ten health offices stated that they had introduced the AMR control program to hospitals in their area. The health offices in Java already had the data on hospitals in the area that our study was attempting to obtain, while others did not have any data, because they did not know about the AMR-CP activities in hospitals in their area.“…… we have done socialization before, but rarely because it is not a priority program”The results of the interview likewise show that the health office is not yet committed to controlling AMR. This may be due to the fact that the health office itself does not fully understand AMR-CP. Furthermore, regarding the AMR policy, one officer in the health office stated:“.... There are no specific activities, AMR-CP activities are included and are part of pharmaceutical activities for rational and national medicine for hospitals…”The health office thus confirmed the health officials had not been properly socialized about AMR-CP because the ministry of health quite often carries out AMR-CP socialization directly in the hospital without involving the health office. There was no funding for the AMR-CP program in the health office because it is not a priority program. In addition, MOH Decree No. 8/2015 did not provide the Provincial Health Office with technical guidelines for supervising hospitals. The health office has thus not monitored or evaluated the application of AMR-CP. The hospital AMR-CP team had also never submitted a report on AMR-CP activities to the health office. Several health offices said they could find out about the hospital's AMR-CP implementation if the hospital underwent accreditation, because they are usually invited to do so at that time. The statement below is from one of the program managers of the provincial health office:The framework system analysis starts with the input, including MOH Decree No. 8/2015 to form an AMR-CP team in the hospital. That policy aims to raise awareness and understanding, show commitment to solving the problem of antimicrobial resistance, and help create a national movement of hospitals, health professionals, communities, pharmaceutical companies, and local governments under the coordination of the Ministry of Health.Thailand already started the Antimicrobial Resistance Containment and Prevention Program in 2011 . IndonesThe interviews confirm that all hospital informants understood the regulation of AMR-CP. Almost all hospitals have formed AMR-CP, which involves all relevant health professionals as mandated by the policy. The weakness of the policy is that it does not involve the local health office as a regional government representative in AMR-CP of the hospital, even though, based on the constitution, local health office is the regional health coordinator .The hospitals in this study had the resources to implement AMR-CP policies, such as having a microbiology laboratory. Six hospitals had microbiology clinicians, and most hospitals had SOPs for using and restricting antibiotics. The AMR-CP team makes reports and documents about the use of antibiotics, including maps of bacteria. These reports, which consist of pathogenic bacteria and antibiotic resistance, can be used to make local policy decisions by management together with the AMR-CP team. These decisions must be made according to their respective conditions, especially the development of infection prevention and control programs , access The analysis of commitment that informants believed the leadership and management had to implement AMR-CP was encouraging, though there is room for improvement. A high degree of commitment is shown in facilitating the AMR-CP team to participate in training, appropriate human resources, support infrastructure, and finance AMR-CP activities. Informants who stated that their commitment needed to be improved felt that there was a lack of AMR-CP workrooms and funding for AMR-CP activities. The hospital director, together with the AMR-CP team, should therefore set measurable work goals for the AMR-CP team to accomplish and facilitate its successful completion of them. Targets need to be made so that AMR-CP programs and activities can be clearer and more focused on achieving goals .All hospitals promoted the socialization of AMR-CP policy, especially among health workers and internship doctors and among medical college students in the form of workshops and training. Afari-Asiedu et al.  reportedAlmost all of the informants said that AMR-CP activities in hospitals had not been optimal. Seven hospitals performed bacterial mapping, and the other three hospitals never did, because AMR-CP had only been established very recently and their microbiology laboratory was relatively new (±one year). Bacterial maps are important, as they make data on bacterial epidemiology and patterns of antibiotic resistance in Indonesia available for healthcare professionals to evaluate. Bacterial mapping thus helps to improve the AMR-CP program and provides a reference for the development of empirical treatment guidelines, especially in hospitals that still have limited local data. AMR surveillance studies in 31 hospitals showed slightly different patterns of antibiotic susceptibility, depending on what type of hospital and which clinical specimens .As far as the types of SOPs and guidelines used to control antibiotics are concerned, the study shows that all hospitals made SOPs, but the types vary greatly. The results of another study stated that there were antibiotic guidelines in five out of six general hospitals in Jakarta surveyed, and that adherence to the guidelines was only around 52.2%. The prescribing and discontinuation of antibiotics and how long they are used for were unplanned and not well documented. Furthermore, documentation of the use of antimicrobials is very poor, and adherence to the guidelines is very low . Based oObstacles to implementing AMR-CP policies were presented by limitations in human resources, facilities, or budget, as well as the availability of drugs, antibiotics, reagents for sensitivity tests, and clinician compliance with SOPs. Not all hospitals are equipped with facilities to support AMR-CP activities. Hospitals on Java have better facilities and human resources as this island is the most developed area in Indonesia . The hanStrict compliance with guidelines must be observed, in addition to the rational prescribing of antimicrobials . ResultsResearch in Chinese hospitals has shown that infection with multidrug-resistant bacteria (MDRB) has become a severe clinical and therapeutic dilemma. The government put pressure on hospitals to implement AMR, establish proper infrastructure for the rational use of antibiotics, and develop a professional team to ensure AMR control . MeanwhiThe study results showed that AMR-CP activities in hospitals lead to encouraging results, such as changes in antibiotic sensitivity patterns, increased rational use of antibiotics, increased use of microbiological laboratories, and greater cost-efficiency. However, three hospitals still have not evaluated the AMR-CP team's ability to control antibiotic resistance in hospitals. Implementing an antibiotic stewardship program, leadership and management commitment, as well as the expertise of the team members, and an effective antimicrobial use policy helped to increase the rational use of antibiotics, decrease the prevalence of resistance, and provide significant economic benefits –34. TherSomething else this study found is that most provincial health offices do not fully understand AMR-CP in hospitals or what it does. Health offices on the island of Java, by contrast, have a better understanding and better data on hospitals in their area that have conducted AMR-CP (three provinces). Other health offices, however, do not have data and do not know about what AMR-CP does in the hospitals in their area. Coordination between the Health Office and hospitals is therefore the key to raising awareness, improving understanding, and expressing a shared commitment to AMR so that it becomes a national movement as the government mandated in Minister of Health Decree No. 8/2015.The availability of the hospital samples that fulfilled the criteria was limited. Accordingly, more hospitals are located in Java than in other areas, and all hospitals are public and network of teaching hospital, which may produce different results if they are not teaching hospitals.The work performed by Hospital Antimicrobials Resistance Control Programs started to improve the rational use of antibiotics and drug cost efficiency in hospitals; however, it is still too early to say that AMR control in hospitals has had an impact on reducing AMR. Therefore, the government and healthcare providers should continue to strengthen AMR-CP in hospitals. The hospital management should also make available antibiotics and reagents for sensitivity tests in accordance with the hospital's needs through good drug planning and procurement. Hospital leaders and the AMR-CP team should set measurable objectives and monitor and evaluate AMR-CP activities, so that AMR-CP can more readily achieve its objectives. AMR-CP policy must be improved by making the regional health office of the hospital a representative of the regional government and thus also by turning AMR-CP into a national movement.