The results demonstrated that nanofibers supported on PP with a grammage of around only 2 g/m2 presented the best compromise between filtration efficiencies of PM0.3, PM0.5, and PM3.0 and the pressure drop. The filtering electrospun membranes loaded with benzalkonium chloride (ADBAC) as a biocidal agent were successfully tested against E. coli and S. aureus and against human coronavirus strain HCoV-229E. This new biocidal filter based on electrospun nanofibers supported on PP nonwoven fabric could be a promising solution for personal and collective protection in a pandemic context.The 2019 coronavirus outbreak and worsening air pollution have triggered the search for manufacturing effective protective masks preventing both particulate matter and biohazard absorption through the respiratory tract. Therefore, the design of advanced filtering textiles combining efficient physical barrier properties with antimicrobial properties is more newsworthy than ever. The objective of this work was to produce a filtering electrospun membrane incorporating a biocidal agent that would offer both optimal filtration efficiency and fast deactivation of entrapped viruses and bacteria. After the eco-friendly electrospinning process, polyvinyl alcohol (PVA) nanofibers were stabilized by crosslinking with 1,2,3,4-butanetetracarboxylic acid (BTCA). To compensate their low mechanical properties, nanofiber membranes with variable grammages were directly electrospun on a meltblown polypropylene (PP) support of 30 g/m Many studies have demonstrated that the decrease in air quality has serious impacts on human health, and can result in morbidity, disabilities, and mental disorder. The larger surface area that ultrafine particles have may carry other pollutants, which can penetrate human bronchi and lungs through the respiratory tract and lead to lung and heart disease, and also cancer ,2.The transmission of infectious agents, such as bacteria and viruses, can occur in several ways. The acts of coughing, sneezing, and speaking may spread respiratory infections through droplets (>5–10 µm) and aerosols (<5 µm) in the form of airborne particulate matter that may be propelled up to 7–8 m and remain in suspension for hours in non-ventilated rooms ,4.The SARS-CoV-2 virus has spread to over 220 countries, affecting over 200 million people and killing over 4 million people as of September 2021, and at the end of January 2020, the World Health Organization (WHO) declared a global health emergency . The higElectrospinning is a versatile and low-cost technology allowing for the production of nanofibers from a very large choice of polymers ,9. In th2.5), and reduced breathing resistance (pressure drop) [Electrospun nanofiber membranes present small diameters of several hundreds of nanometers, a large surface-area-to-volume ratio, and small interconnected pores  and are,re drop) ,21. The re drop) .Pseudomonas [Antimicrobial nanofibers can be easily obtained by blending/dissolving/emulsifying antimicrobial agents  in the precursor polymer solutions . In thisudomonas . The posudomonas . PVA is In addition, PVA presents good thermal and chemical stabilities, and electrospun PVA nanofibers can be stabilized in water by crosslinking with polycarboxylic acids. Crosslinking agents such as 3,3′,4,4′-benzophenone tetracarboxylic acid ,29,30,31Antimicrobial nanofibers based on PVA have been reported in the literature, loaded with silver nanoparticles , Ag-zeol2 polypropylene nonwoven fabric (M30). The first challenge was to provoke the crosslinking of the nanofibers for their stabilization at a temperature respecting the dimensional stability of polypropylene (melting in the range of 145 °C). The technique used for the crosslinking reaction characterization was FTIR, and the assessment of nanofiber stability was with ageing in a water batch followed by SEM observation. Then, we had to define the best compromise between antagonist filtration performances and breathability of the filters. Therefore, filter samples of increasing grammages of nanofibers were prepared and tested in terms of filtration efficiency and air permeability using the appropriate equipment for the counting of calibrated particulate matter and pressure drop measurement. The ultimate objective was then to measure the biocidal properties of the ADBAC-loaded nanofibers. The challenge here was to reach a fast and a significant biocide activity of the nanofibers. Nanofibers loaded with two concentrations of ADBAC were tested against Gram-positive and Gram-negative bacteria (S. aureus and E. coli), and against human coronavirus strain HCoV-229E.To summarize, in the present context of the COVID-19 pandemic, there is an abundance of recent literature on the development of air filtering systems through different technologies and on the antimicrobial functionalization of all types of fibers  and electrospun nanofibers. Some focus on the filtration performances of their filtering systems and some on the antimicrobial efficiency. The present work aimed to consider at the same time both approaches through the development of a filtering structure based on the electrospinning technique that would present advanced filtration efficiency compliant with standards of respiratory masks, and that would also present fast and significant biocide activity against bacteria and a human coronavirus. Therefore, we optimized the electrospun solution composition based on PVA of different molecular weights, BTCA as a crosslinking agent, ammonium hypophosphite as a catalyst for the crosslinking reaction, and ADBAC as the biocide agent. Due to the light weight of the electrospun membranes and their mechanical weakness, the nanofibers were electrospun directly on a 30 g/m4H2PO2), and 1,2,3,4-butanetetracarboxylic acid (BTCA) were purchased from Sigma Aldrich . Benzalkonium chloride  was formulated as 50% w/v aqueous solution purchased from Mon Droguiste . Electrospun membranes were supported on meltblown nonwoven polypropylene of 30 g/m2 basis weight (M30) provided by Lydall ; the average diameter was 2.65 µm  grades were used, of low , medium , and high  molecular weights, all presenting 87–89% degrees of hydrolysis (data from the supplier) . Polyvinw/v in distilled water at 80 °C and stirred for 4 h. BTCA as a crosslinking agent (0.24% w/v to 0.96% w/v) and ADBAC as an antimicrobial agent (0.4% w/v and 1.4% w/v) were then added and, finally, ammonium hypophosphite (AH) (0.5% w/v) as a catalyst for the crosslinking reaction was added to the solution followed by stirring for 15 min. The compositions of the electrospun solutions are reported in Electrospun solutions were prepared by solubilizing each PVA grade  at concentrations of 8% 2 (M30) running at a speed of 0.6 mm/s over a metallic table equipped with a roll-to-roll system. Electrospun membranes were then heat-treated at 125 °C for 30 min using a ventilated oven  for NF stabilization by crosslinking the reaction between PVA and BTCA.For the preliminary study of the electrospinning parameters, the precursor solutions were loaded in a 5 mL plastic syringe connected to a 21-gauge needle as a spinneret (Terumo) by the intermediate of a polyethylene catheter . A homemade electrospinning device was used for the preliminary tests of optimizing the electrospinning parameters. The solution was delivered to the spinneret by a syringe pump (Fisher Scientific) at a flow rate of 0.5 mL/h and a voltage of 20 and 25 kV. The nanofibers (NFs) were collected on an aluminum foil placed at 20 cm from the spinneret. For the elaboration of filtering electrospun membranes supported on M30, a Fluidnatek LE-500 electrospinning device  was used. The solution was loaded in a 20 mL syringe connected to a five-needle spinneret at a flow rate of 1.6 mL/min. Nanofibers were spread on a meltblown nonwoven textile with a basis weight of 30 g/m−1.The viscosities of the polymer solutions were measured by using a MCR 301 rheometer . The 25 mm diameter circular parallel plate geometry was used with a 1.0 mm gap. The tests were examined with a shear rate ranging from 0.1 to 300 sThe morphology of the electrospun membranes was characterized using scanning electron microscopy  operating at 5 kV on platinum-sputter-coated samples. The fiber diameters were determined by using ImageJ software. Diameter measurements of 60 nanofibers were collected.−1 at a resolution of 4 cm−1.A Fourier transform infrared spectroscopy (FTIR) analysis was conducted to identify the esterification of PVA and BTCA using a spectrometer UATR Two  with an attenuated total reflectance accessory (ATR). Spectra were collected at room temperature in the spectral range of 4000–500 cm0.3, PM0.5, and PM3.0  was registered. The pressure drop was measured by a manometer linked to a vacuum pump under an airflow of 11.5 L/min passing through the filters. Tested samples were M30 nonwoven textiles covered by electrospun nanofiber membranes with different basis weights corresponding to electrospinning times of 30, 45, 60, 75, 90, 120, 150, 180, 210, and 240 min. Six measurements were performed to ensure data reproducibility for basis weight values. Three membranes were tested to determine the filtration efficiency and pressure drop.The filtration efficiency of samples was evaluated by employing a portable particle counter  under a fixed velocity of airflow of 50 L/min. Filtration of airborne particulate matter PMKill time is a method that makes it possible, by direct contact, to test the antibacterial activity of the electrospun membranes and to evaluate the bacterial reduction kinetics. E. coli and S. aureus were selected as representative examples of Gram-negative and Gram-positive bacteria, respectively. The antibacterial activity was evaluated after 20 min, 2 h, and 4 h of contact between membranes and bacteria. The membranes were sterilized by UV irradiation for 20 min.Antimicrobial assessments were carried out by following the AATCC (American Association of Textile Chemists and Colorists) Test Method 100–2019 . cystine in Krebs–Ringer phosphate solution. Then, this suspension was diluted 7 times by decimal dilutions. Each diluted suspension was inoculated and incubated for 24 h at 37 °C to determine the real initial concentration. The tenth dilution of the initial suspension was used as the inoculum.First, the bacteria were transferred onto agar plates 24 h before the test. The culture obtained was suspended in 10 mL of An amount of 200 µL of the freshly prepared bacterial suspensions was placed onto the surfaces of the electrospun layer membranes and was incubated at 37 °C. After 20 min of contact time, the samples were transferred individually into 2 mL of sterilized phosphate-buffered solution (PBS), treated for 1 min in an ultrasonic bath, and vortexed for 30 min to detach the bacteria from the membranes and re-suspend them.The suspensions were diluted to the tenth 4 times, placed onto agar plates, and incubated at 37 °C for 24 h. The number of surviving bacteria was determined by counting the colony-forming units (CFU) in triplicate for each experiment. The same protocol was repeated for 2 h and 4 h of membrane contact.2. The principle was to contaminate textile samples with a known suspension of the virus. An amount of 200 µL of the suspension was deposited in micro-droplets on 400 mg ± 50 mg of pieces of the membrane (2 cm × 2 cm). The samples were previously sterilized by UV irradiation for 30 min. Membranes (treated and untreated) were kept at 20 °C for 5 min, 20 min, 1 h, 2 h, and 4 h. At the end of the contact times, the textiles were immersed in 10 mL of neutralizer (DMEM + glutamax supplemented with 2% FBS and 1% antibiotics) to stop the action of the active substance. The number of surviving viruses was determined quantitatively by Spearman and Kärber’s method. The results in TCID50/mL in the neutralizer were multiplied by 10 to have the viral load on samples.Antiviral activity assessments were carried out by following NF EN 18,184  with minor adaptations . Tests were conducted using human coronavirus strain 229E (HCoV-229E) produced and titrated on Huh-7 cells. DMEM with glutamax supplemented with 10% fetal bovine serum (FBS) and 1% antibiotics was used as a medium and the cells were incubated for 6–7 days at 33 °C with 5% COPVA electrospinning has been widely reported and is considered a green process due to the ability to use water as a solvent. However, because of the water saturation of breathed airflow, PVA nanofibers as-spun swelled when placed inside a face mask worn for 4 h, necessitating a stabilization strategy. Wijanarko et al.  reportedw/v of BTCA , the low melting temperature of PP (approximately 150 °C) was a limiting parameter for the curing step of the composite PP-PVA membrane. Indeed, preliminary tests revealed that the M30 substrate shrank when exposed to a curing temperature of 130 °C. As the result, the curing temperature applied for nanofiber crosslinking was limited to 125 °C in order to preserve the PP nonwoven textile. Then, nanofibers underwent a curing step to provoke the chemical crosslinking by esterification of PVA with BTCA in a damp environment of breathed-out air passing through the mask. As the strategy was to electrospin a thin PVA nanofiber network onto a PP 30 g/mw/v) and AH (0.5% w/w), cured at 125 °C for 30 min, and then immersed in water for 4 h. SEM images in w/v and 0.81% w/v of BTCA underwent swelling, tortuosity, and fusion. In contrast, the BTCA concentration of 0.96% w/v clearly prevented the deterioration of the nanofibrous network in water. Thus, this series of tests of the immersion of cured nanofibers in water demonstrated that optimal concentrations of BTCA of 0.96% w/v and ammonium hypophosphite of 0.5% w/v could preserve the nanofibers’ structure.Membranes were prepared from solution containing 8% PVA-H with variable BTCA compositions  were transformed into film-like materials. According to Limpan et al. , the beh−1 associated with the esterification process was masked by the carbonyl band of vinyl acetate groups contained in PVA [The FTIR analysis of these nanofibers before and after thermal treatment was conducted  as a substrate to create a mechanically resistant bilayered filter. Thus, M30 supports were covered with nanofibers from the solution of 8% PVA-H/0.96% BTCA/0.04% ADBAC/0.5% AH during variable electrospinning times at a flow of 0.5 mL/h and resulted in nanofibrous layers with variable basis weights. The SEM picture in Due to the poor mechanical properties of the lightweight electrospun membranes, the solutions based on the optimal parameters described above were electrospun over a variable time period on a conductive collector covered by a meltblown PP nonwoven textile  up to 96 ± 0.01 Pa as the basis weight was increased up to 4 g/m2. From 4 g/m2, the pressure drop increased drastically up to 256 ± 6.0 Pa, corresponding to an air permeability that is not suitable for use as a respiratory mask. Based on data from 2 and 2.76 ± 0.84 g/m2 were the minimum and maximum grammages acceptable, respectively, with ΔP ranging from 12.5 ± 3.54 to 63 ± 2.0 Pa. In particular, the sample corresponding to an electrospinning time of 75 min and a grammage of 2.13 ± 0.86 g/m2 displayed a ΔP value of 49 ± 1.0 Pa.2 and 1.45 ± 0.91 g/m2 displayed filtration efficiencies in the same range as M30 due to the low density and large mesh size of these nanofiber networks. The slight decrease in efficiency toward particles of 0.3 µm and 0.5 µm in both these samples could be attributed to the loss of electrostatic charges present on raw M30 during the electrospinning process [2, the η values exceeded the threshold standard values, reaching 85.84 ± 1.15% for 0.3 µm, 98.37 ± 0.18% for 0.5 µm, and 99.79 ± 0.30% for 3 µm particles defined by the European standard EN 14683. Interestingly, our findings demonstrate that an electrospun membrane with a grammage as low as 2 g/m2 has a higher filtration efficiency than a meltblown microfiber-based nonwoven textile with a superior grammage of several tens of g/m2. Furthermore, the light weight of the electrospun filters preserves acceptable air permeability. As a result, electrospinning provides a good compromise between the lightness of the filter, air permeability, and filtration efficiency. Nonetheless, the literature has widely reported the advantages of electrospun mats in air filtration applications; for instance, such an observation was reported by Leung and Sun [2 compared to the 20–40 g/m2 necessary for a microfiber filter. Choi et al. [0.3—99.996%) and a low-pressure drop (104 Pa). Although the value of 104 Pa is higher than the one obtained by our work, it was acceptable according to the standard filtration test (EN 779:2012), which employs rigid solid NaCl particles. In another study by Zhang et al. [2.5) efficiency and a 70 Pa pressure drop. Focusing on the COVID-19 pandemic and air pollution, Xu et al. [2.5) of up to 99% and a pressure drop > 100 Pa. He et al. [0.3 (99.1% and 79.2 Pa).The filtration efficiency η of M30-supported nanofibers was then investigated and is reported in  process . From NF and Sun  who demoi et al.  reportedi et al.  producedg et al. , reducedu et al.  designede et al.  developeTo highlight the particle removal efficiency, membranes used in air filtration tests (1 h of air filtration test under an air flow of 50 L/min) were analyzed by SEM b. It canη) and pressure drop (ΔP) parameters: QF = −ln(1 − η)/ΔP [The performance of the filters for each particulate matter could also be evaluated by the quality factor (QF), relating both filtration efficiency ( − η)/ΔP ,62,63,640.5, the highest QF values ranged from 0.0727 Pa−1 (2.76 ± 0.84 g/m2) to 0.1663 Pa−1 (0.66 ± 0.27 g/m2), with the 2.13 ± 0.86 g/m2 basis weight showing a QF of 0.0840 Pa−1, coinciding with the results of the ideal grammage related to the pressure drop mentioned above. However, it is crucial to highlight that this factor is unique in terms of PM0.5 filtration efficiency, and when findings from PM0.3 were analyzed, membranes with basis weights of 0.66 ± 0.27 and 1.45 ± 0.91 g/m2 provided an ineffective filtration efficiency  of lower than 70.92% (PM0.3) as defined by European standard EN 14683. Considering data from the quality factor for PM−1 and ΔP of 73 Pa for PM2.5. In another recent research study, Cui et al. [−1 for PM1.0.Similar results were obtained in work conducted by Zhang et al. , who prei et al.  reported2 supported on a M30 meltblown PP substrate was the best compromise for achieving optimal filtration efficiency and good air permeability.To summarize, filtration performance experiments led us to conclude that a basis weight of nanofibers in the range of 2 g/mS. aureus and E. coli of the electrospun nanofibers prepared from solutions containing 0.4% w/v and 1.4% w/v of ADBAC was tested. The number of surviving bacteria put in contact with nanofibers was assessed as a function of exposure times. For comparison, the activity of the nanofibers with/without ADBAC and M30 as a control was also assessed.The antibacterial activity against S. aureus and E. coli of M30 coated with nanofibers. Without ADBAC, meltblown nonwoven M30 and M30 coated with nanofibers showed no significant difference against S. aureus and E. coli, with a reduction of approximately 1.0 log10 for all exposure times.w/v ADBAC solution displayed a very slight reduction of 1.0 log10 against both S. aureus and E. coli, which was not significant when compared to the raw M30 control.Nanofibers prepared from the 0.4% w/v ADBAC demonstrated a significant antibacterial effect, with bacterial charge decreasing from 1.71 log10 to 1.93 log10 against S. aureus, and from 2.46 log10 to 2.68 log10 against E. coli, respectively. Additionally, our results showed that ADBAC is more effective against Gram-negative E. coli than against Gram-positive S. aureus, which is consistent with results found in the literature [w/v in the electrospun solution.After 2 and 4 h of exposure, electrospun nanofibers from precursor solutions containing 1.4% terature . The mic2) not loaded with ADBAC as a control and nanofibers resulting from solutions containing 0.4% and 1.4% w/v ADBAC.The antiviral assays were performed to investigate the virucidal activity of the ADBAC loaded filters against the human coronavirus strain HCoV-229E (used as a surrogate for SARS-CoV-2). The experiment was carried out with samples consisting of M30 covered by nanofibers (grammage 2 g/mw/v ADBAC and 1.4% w/v ADBAC nanofibers exhibited 91.75% (1.1 log) and 98.53% (1.8 log) antiviral efficiency, respectively, after 20 min of contact. Log reductions observed on the textile without ADBAC correspond to the natural decay of the virus when deposited on a surface. While exhibiting some virucidal activity, 0.4% w/v ADBAC nanofibers did not reach a 2 log reduction before 4 h of contact time; in contrast, at contact times of 1 h to 4 h, the antiviral activity of 1.4% w/v ADBAC nanofibers had significant values ranging from 99% to 99.9% (2 to 3 log), which is comparable to other antiviral textiles [textiles ,69,70.2 provided optimal coverage of the M30 support. Interestingly, this basis weight of 2.13 g/m2 displayed an excellent filtration efficiency of 85.84%, 98.37%, and 99.79% for PM0.3, PM0.5, and PM3.0, respectively, and a low-pressure drop of 49 Pa. Therefore, a nanofiber grammage in the range of 2 g/m2 represented the ideal compromise between the antagonist parameters of filtration efficiency and air permeability. Nanofibers containing two ADBAC concentrations were tested in antibacterial and antiviral tests. The electrospun nanofiber membrane obtained from solutions containing 0.4% w/v and 1.4% w/v ADBAC were tested in microbiological and virological tests. Only samples with the highest ADBAC content demonstrated significant antibacterial and antiviral activities, i.e., reductions of 1.9 and 2.5 log units from two hours of contact against both E. coli and S. aureus and reductions of 2.0 to 3.0 log units from one hour of contact against human coronavirus HCoV-229E also exhibited a significant viral reduction of 99%. The development of masks/air filters with advanced filtration and biocidal properties plays a crucial role in protecting against pathogens, such as bacterial or viral threats such as the coronavirus that recently caused the COVID-19 pandemic. In this study, we designed a novel self-decontaminating electrospun PVA filter to be used as a biocidal layer in the production of a face mask. To compensate for the low mechanical properties of electrospun membranes, PVA-based nanofibers were collected on a meltblown polypropylene filter M30. After electrospinning, PVA nanofibers were cured for provoking esterification and crosslinking with BTCA in order to stabilize the nanofibrous network when exposed to the damp air flow of respiration. Ammonium hypophosphite added to the electrospun solution catalyzed the esterification and allowed the crosslinking of PVA fibers at a curing temperature of only 125 °C that preserved the polypropylene meltblown nonwoven support. SEM experiments revealed that an electrospun membrane with a grammage of 2.13 g/mFinally, the nonwoven-supported biocidal electrospun nanofibers developed here could be used as a filtering layer for the manufacture of respiratory masks whose advanced filtration and antimicrobial properties would ensure: (a) the enhanced individual protection of the mask wearer against airborne vectorized pathogens, (b) the collective protection through inactivation of pathogens expelled by contaminated persons and trapped in the mask structure, and (c) the prevention of cross-contamination by used masks thrown on scrapheaps thanks to the self-decontaminating properties .


Neisseria gonorrhoeae and gonorrhoea treatment failures were increasing, a response plan to control and manage multidrug-resistant N. gonorrhoeae (MDR-NG) in Europe was published in 2012. The three main areas of the plan were to: (i) strengthen surveillance of antimicrobial resistance (AMR), (ii) implement monitoring of treatment failures and (iii) establish a communication strategy to increase awareness and disseminate AMR results. Since 2012, several additional extensively drug-resistant N. gonorrhoeae (XDR-NG) strains have emerged, and strains with high-level ceftriaxone resistance spread internationally. This prompted an evaluation and review of the 2012 European Centre for Disease Prevention and Control (ECDC) response plan, revealing an overall improvement in many aspects of monitoring AMR in N. gonorrhoeae; however, treatment failure monitoring was a weakness. Accordingly, the plan was updated in 2019 to further support European Union/European Economic Area (EU/EEA) countries in controlling and managing the threat of MDR/XDR-NG in Europe through further strengthening of AMR surveillance and clinical management including treatment failure monitoring. The plan will be assessed biennially to ensure its effectiveness and its value. Along with prevention, diagnostic, treatment and epidemiological surveillance strategies, AMR surveillance is essential for effective control of gonorrhoea.Because cefixime and ceftriaxone resistance in  Neisseria gonorrhoeae (NG) has developed antimicrobial resistance (AMR) to all classes of therapeutic antimicrobials, most recently to third-generation cephalosporins [N. gonorrhoeae across Europe, but the degree of representativeness is affected by suboptimal isolate numbers and low completeness of reporting [Gonorrhoea is the second most commonly reported bacterial sexually transmitted infection (STI) in the European Union/European Economic Area (EU/EEA), with 117,881 cases reported in 2019, representing an increase of 17% since 2018 [osporins . Surveilosporins . Euro-GAosporins . Additioosporins . A revieeporting .Response plan to control and manage the threat of multidrug-resistant gonorrhoea in Europe in 2012 [As a response to the emergence of in vitro resistance to cefixime and to treatment failures with cefixime and subsequently ceftriaxone in the EU/EEA and internationally , ECDC an in 2012 . Similar in 2012  and by n in 2012  and by t in 2012 . In addi in 2012 .Regular monitoring of the gonococcal AMR situation and AMR response plan indicators, and evaluating, reviewing and subsequent updating of national and international response plans are essential. Since the 2012 ECDC response plan  was publDecreasing azithromycin susceptibility and sporadic resistance to ceftriaxone threaten the effectiveness of dual-therapy and ceftriaxone monotherapy regimens . CeftriaOur aim was to describe the evaluation of the 2012 ECDC response plan, by analysing the progress of indicators from 2012 to 2017, as well as the subsequent review and update of the response plan to further support EU/EEA countries in implementing national strategies and interventions to control the threat of multidrug-resistant (MDR)- and XDR-NG in a multidisciplinary approach.The main goal of the 2012 ECDC response plan was to mitigate the impact of MDR-NG on the prevention and control of gonorrhoea by serving as a guide for EU/EEA countries . Three mTo evaluate the effectiveness of the 2012 ECDC response plan , membersWe also assessed indicators related to Euro-GASP . The numDecreasing susceptibility to azithromycin, along with increasing reports of ceftriaxone-resistant strains and gonorrhoea treatment failures and of MDR/XDR-NG, made an evaluation, detailed review and update of the 2012 ECDC response plan imperative . The 201N. gonorrhoeae isolate data to the epidemiological and clinical data of the gonorrhoea cases.There are three main components in the 2019 ECDC response plan . FirstlyN. gonorrhoeae isolates should be collected and ideally reported promptly to ECDC. Where possible, N. gonorrhoeae XDR or ceftriaxone-resistant isolates and those from suspected treatment failures should be shared with the Euro-GASP hub for further verification, including whole genome sequencing, in order to inform the European guideline on the diagnosis and treatment of gonorrhoea [N. gonorrhoeae strain before and after treatment and to identify the presence of AMR determinants in treatment failure cases, but additionally has a role in improving AMR surveillance by providing a genomic background to monitor the molecular epidemiology of circulating strains , to detect new and emerging AMR determinants, to ultimately predict AMR and to investigate the genetic relatedness of isolates from national and international outbreaks [Secondly, a national agreement on adopting the treatment failure case definitions proposed in the 2019 ECDC response plan  and an onorrhoea  and to mutbreaks .Thirdly, the effectiveness of the 2019 ECDC response plan should be monitored at the national and European level . More deN. gonorrhoeae is imperative. The 2019 ECDC response plan should assist in controlling and managing the threat of MDR/XDR-NG in Europe through strengthening AMR surveillance and clinical management including treatment failure monitoring. The effectiveness of the 2019 ECDC response plan should be monitored regularly to identify and address areas for improvement promptly. Control of AMR in N. gonorrhoeae is ineffective without a comprehensive approach, therefore the 2019 ECDC response plan needs strong support from comprehensive management and control strategies nationally and internationally, including appropriate STI prevention (e.g. promotion of condom use), diagnostic and testing algorithms (e.g. triple-site testing in men who have sex with men), treatment, test of cure, notification and treatment of partners and robust epidemiological surveillance to identify key groups at risk of gonorrhoea and gonococcal AMR.Preventing further emergence and spread of AMR in


This study aimed to present the annual rates of psychiatric hospitalisations and primary psychiatric diagnoses among people who are incarcerated in France from 2009 to 2019.Despite the poor mental health status of people who are incarcerated, few studies have examined the number of psychiatric hospitalisations in this population. Since 2010, France has progressively opened nine full-time inpatient psychiatric wards exclusively for people who are incarcerated, called “specially adapted hospital units”  incarcerated people were hospitalised for psychiatric care . The main diagnoses were psychotic disorders (27.4%), personality disorders (23.2%), and stress-related disorders (20.2%). The annual number of incarcerated people hospitalised in psychiatric care increased from 3263 in 2009 to 4914 in 2019. The gradual increase in the activity of UHSAs  was not associated with a reduction in the rate of hospitalisation of incarcerated people in local psychiatric hospitals.Between Jan 1, 2009, and Dec 31, 2019, 32,228 (92.2% men, The creation of psychiatric hospitals specifically dedicated to the prison population has not stopped the hospitalisation of people who are incarcerated at psychiatric hospitals. These findings suggest that access to psychiatric hospitalisation remains problematic for people who are incarcerated in France.There was no funding source for this study. Despite the poor mental health status of people in prison, only a few cross-sectional studies have examined the number of psychiatric hospitalisations in this population. To appraise the current evidence, we searched PubMed to identify articles published from Jan 1, 1980 to Dec 31, 2021 using the key words “psychiatric hospitalisation”, “prison” and “incarceration”. In France, the government have built nine full-time inpatient psychiatric wards (440 beds) exclusively dedicated to people who are incarcerated, but no evaluation of the impact that the creation of these structures has had on the psychiatric hospitalisation of people who are incarcerated has been carried out.We examined the longitudinal retrospective administrative data of psychiatric hospitalisations for people in French jails and prisons between 2009 and 2019. Our results showed that the number of incarcerated people hospitalised in psychiatric care per year has substantially increased during this period. Importantly, the creation of these units was not associated with a reduction in the hospitalisations of incarcerated people in local psychiatric hospitals during the study period.Planning psychiatric hospitalisations of people in prison is a challenging task, and our findings suggest that access to psychiatric hospitalisation remains problematic for people who are incarcerated in France. The creation of specialist units has improved the equivalence of psychiatric care inside and outside the walls of the prison by allowing voluntary hospitalisation for people who are incarcerated. Nevertheless, it has not led to a reduction in the rate of incarcerated individuals hospitalised in local psychiatric hospitals.Alt-text: Unlabelled boxGlobal Clinical Impressions Scale).More than 11 million people are currently incarcerated around the world.,unités pour malades difficiles, UMDs). This situation was associated with several issues in psychiatric hospitals, particularly the inappropriate use of isolation and mechanical restraint.,unités hospitalières spécialement aménagées, UHSAs) have been created in recent years.The legal regulations for psychiatric treatment of people who are incarcerated diagnosed with a psychiatric disorder are quite different throughout the world.,The nine UHSAs that have opened progressively in France since 2010  are full-time inpatient psychiatric wards exclusively for people who are incarcerated.Since the first UHSA was built in 2010 in Lyon, only one cross-sectional study has been conducted to examine the activity of the UHSAs.This 11-year retrospective longitudinal study (2009–2019) aimed to estimate the number of psychiatric hospitalisations for people who are incarcerated in France, stratified by calendar year and type of facility. We hypothesised that the creation of UHSAs decreased the admissions of people who are incarcerated to general psychiatric beds. The secondary objectives were to present patients’ characteristics, including age, sex, and clinical diagnoses, stratified by type of facility, across the study period of 2009–2019.REporting of studies Conducted using Observational Routinely collected health Data (RECORD) statement, which completes the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement when conducting retrospective observational studies.,This retrospective study was performed in accordance with the Programme de médicalisation des systèmes d'information (PMSI) database, which includes individual-level data about the date of admission, length of stay, hospital code number, sector code, and outcome  for all inpatient stays in psychiatric hospitals in France. The sociodemographic data from these records include sex, age, and place of residence. The principal diagnosis, defined as the main reason for admission, and the associated diagnoses related to comorbidities are documented in the PMSI database according to the French version of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). A unique national identification number for each patient allows the data from all hospital stays for the same patient to be linked.We used the Santé Publique France) legally allows full access to national hospital discharge databases,Ethical approval was not needed for the present study because we had access to an anonymous administrative database. Moreover, the national French Public Health Agency (jails (67%), which house people on remand or people with a residual sentence below two years, and people incarcerated in prisons (33%), which house people with long sentences. In this article, we used the term “prison” to refer to both prisons and jails.We conducted a retrospective cohort study, and we included data related to all psychiatric hospitalisations for people who are incarcerated in France between 2009 and 2019. We did not distinguish between people incarcerated in -Service medico-psychologique regional, SMPR);the hospital code number corresponding to UHSA, UMD, or daytime hospital psychiatric beds inside the prison ;-the types of care ;-the specific sector code used for psychiatric facilities in prison (“P”).Cases were identified through the following criteria:Service medico-psychologique regional, SMPRs) and 3  were included in this study (see As no data on level 1 (consultation and ambulatory care) are documented in the PMSI, only data on levels 2  and psychiatric hospitals can accommodate both incarcerated and nonincarcerated people. For this study, we only included data from people who are incarcerated. As they are not considered incarcerated in France, people who cannot stand trial due to mental illness and people found not criminally responsible on account of a mental disorder were not included in the present study.Finally, additional indicators of psychiatric hospitalisations were collected for nonincarcerated people from the PMSI database for comparison purposes.We used several variables from the PMSI database: age and sex, date of admission, outcome , principal diagnosis, type of psychiatric facility, and legal mode (voluntary versus involuntary care).y = ax + b). These lines minimize the sum of squared deviations between each point and the line.Qualitative variables are presented with absolute numbers and percentages. Quantitative variables are presented as the median and interquartile range (IQR). The results are illustrated using line charts. The regression lines result from the affine function  the annual number of people who are incarcerated hospitalised in psychiatric facilities  from 2009 to 2019; for each year, it was calculated as the number of incarcerated people present on January 1 of the year plus the number of incarcerated people entering a psychiatric facility during the year, (2) the annual number of nonincarcerated people hospitalised in psychiatric care per year in France from 2009 to 2019; for each year, it was calculated as the number of nonincarcerated people present on January 1 of the year plus the number of nonincarcerated people entering a psychiatric facility during the year, and (3) the number of incarcerated people on January 1 of each year, from 2009 to 2019. The annual percentage increase in the number of individuals compared to the number measured in 2009 was computed for the 3 populations.Second, we present age, sex, and the principal ICD-10-coded diagnoses of incarcerated people hospitalised in psychiatric care. The principal ICD-10-coded diagnosis was collected for each stay; several primary diagnoses were thus possible for individuals with multiple hospitalisations. As a result, patients with multiple stays and diverging primary diagnoses were counted more than once for the analysis of diagnoses. We indicate the number of people with multiple diagnoses.Third, we describe the number of people with 1, 2, 3, and 4 or more hospitalisations. We also present the distribution of the study population in the different psychiatric facilities  using a Venn diagram. The latter is based on all hospitalizations that occurred during the study period (2009–2019).-annual rates of psychiatric hospitalisation among people who are incarcerated ;-annual rates of psychiatric hospitalisation among people who are incarcerated for each facility ;-annual rates of psychiatric hospitalisation among people who are incarcerated for daytime psychiatric hospitalisation (SMPRs) ;-annual rates of psychiatric hospitalisation among people who are incarcerated for full-time psychiatric hospitalisation ;First, we present the number of hospitalisations per year for people who are incarcerated according to the type of facility: UHSAs, psychiatric hospitals, SMPRs, and maximum-security units (UMDs) as well as the number of beds available in UHSAs. Importantly, when counting the number of stays per year, some overlapping stays were taken into account for consecutive years, resulting in a total per year higher than the number of stays for the study period (11 years). We also measured the following for the 2009–2019 period:A Mann-Kendall Trend Test was performed to determine whether a trend existed in the four time series. The ratio of stays per patient was computed each year as the number of annual hospitalisations divided by the number of patients who had one or more stays during the year.Second, we present the median (IQR) duration of hospitalisation in each facility. The length of stay for each hospitalisation was calculated as the date of admission to either the date of discharge or December 31, 2019, if the patient was still hospitalised. We also present the legal mode  for hospitalisations in UHSAs. We describe the legal mode (voluntary versus involuntary) on admissions but also at discharge to identify hospitalisations that switched over in the middle.Third, we focus on hospitalisations in UHSAs to determine the proportion of hospitalisations in these facilities directly preceded by a stay in another facility or directly followed by a stay in another facility.There was no funding source for this study. CCC had access to the PMSI database. All authors had access to aggregated data from this source as well as all other data used in the study. All authors decided to submit the manuscript for publication.Between Jan 1, 2009, and Dec 31, 2019, 32,228 people who are incarcerated were hospitalised for psychiatric care .Supplementary Fig. 1), i.e., an increase of 50.6% .The number of incarcerated people hospitalised in psychiatric care per year in France ranged from 3263 to 4914 between 2009 and 2019  were men. The median age at the first hospitalisation was 32 years (IQR: 25–40), with 31 years (IQR: 25–40) and 34 years (IQR: 26–44) for men and women, respectively (p < 0.0001).The age, sex, and diagnoses of the study population are presented in factors influencing health status and contact with health services) were used for 3112 individuals (9.7%), and other diagnoses were coded for 240 individuals (0.7%).A psychiatric diagnosis was documented for 26,813 individuals (83.2%). There was no psychiatric diagnosis for 5415 individuals (16.8%). among them, the information was missing for 2063 individuals (6.4%), the codes Z00-Z99 , disorders of adult personality and behaviour (23.2%), and neurotic, stress-related and somatoform disorders (20.2%). 18.0% of patients had multiple diagnoses.n = 19,799) had only one hospitalisation during the study period. The number (%) of people with 2, 3, and 4 or more hospitalisations was 6016 (18.7%), 2585 (8.0%) and 3828 (11.9%), respectively. The maximum number of hospitalisations for a single individual was 51. While most people stayed in only one type of facility, approximately one-fifth of patients were hospitalised in different (at least two) types of facilities . The exclusive distribution is described in Supplementary Fig. 2.Most incarcerated people . Psychiatric hospitals, SMPRs, and maximum-security units (UMDs) accounted for 40.5% , 31.1% , and 1.6% (n = 1042) of the other stays, respectively.Overall, 64,481 stays were analysed. Approximately one-third (28.2%) of the stays occurred in UHSAs . The number of stays in UHSAs increased from 300  in 2010 to 3252 in 2019 . This increase corresponds to the progressive opening of these structures between 2009 and 2019 (the number of available beds in UHSAs is presented in p < 0.001) and no trend for psychiatric hospitals (p = 0.061), SMPRs (p = 0.436), and maximum-security units (p = 0.310).Annual rates of hospitalisation  among people who are incarcerated are presented in Between 2009 and 2019, the number of annual stays increased from 4358 to 8187, i.e., an increase of 87.86%, while the number of annual patients increased from 3263 to 4914, i.e., an increase of 50.60%. The number of stays increased faster than the number of patients, with the ratio of stay per patient increasing from 1.3 in 2009 to 1.7 in 2019.The median duration of hospitalisation was 19 (IQR: 7–49) days. The median duration of full-time stays  and daytime hospital stays (SMPRs) were 14 (IQR: 6–34) and 37 (IQR: 14–104) days, respectively. The median duration of hospitalisation in UHSAs, psychiatric hospitals, and maximum-security units was 26 (IQR: 14–50) days, 8 (IQR: 4–20), and 54.5 (IQR: 8–233) days, respectively. n = 11,638) were voluntary, and 36% (n = 6535) were involuntary. At discharge, 87.5% of stays  were voluntary, and 12.5% (n = 2248) were involuntary.On admission to a UHSA, 64% of the stays  in UHSAs were directly preceded by a stay in another facility, with eight (0.3%), 2270 (77.8%), 700 (23.1%) and 58 (1.9%) from another UHSA, psychiatric hospitals, SMPRs and maximum-security units (UMDs), respectively. Of note, 1340 (7.3%) stays in the UHSA were directly followed by a stay in another facility, with eight (0.6%), 359 (26.8%), 908 (67.8%), and 65 (4.9%) in another UHSA, psychiatric hospitals, SMPRs and maximum-security units, respectively.Developing systems for tracking the use of involuntary care and psychiatric hospitalisation in correctional contexts has recently been highlighted as a key factor for understanding the psychiatric needs of people who are incarcerated.,hospital beds that are built tend to be used”,,Linking the use of health care services with the need for care remains difficult. Nevertheless, the hypothesis of growth in the mental health needs of the prison population to explain the significant increase in the number of psychiatric hospitalisations for people who are incarcerated must be discussed. It is important to note that the overall prison population has also grown over this period, from 62,252 in 2009 to 70,059 in 2019. As the poor state of mental health in French prisons is well documented,,Planning psychiatric hospitalisations of people in prison is challenging.,The persistence of a high number of people who are incarcerated admitted to psychiatric hospitals, despite the creation of UHSAs, is probably a consequence of several factors. First, it could be explained by an insufficient number of available beds (440) in these new structures. Indeed, if no bed is available in the neighboring UHSAs, the incarcerated patient is referred to the local psychiatric hospital, which could explain why the number of individuals who are incarcerated admitted to general psychiatric settings remained stable over the study period. This observation has led the French government to consider the construction of three new UHSAs (140 beds) in the coming years.Regarding daytime hospitals within prisons (SMPRs), their activity remained relatively stable between 2009 and 2019, apart from a slight transitory decrease at the time of the creation of the first UHSAs (2013). This probably reflects a reorientation of the type of psychiatric care within SMPRs with the opening of the UHSAs. Indeed, it can be hypothesized that the patients suffering from the most severe mental illnesses, frequently admitted to SMPRs before the creation of the UHSAs, were gradually redirected to these more appropriate care facilities. Another hypothesis is that this decrease, also observed for the number of people (not incarcerated) hospitalised in psychiatric care, could reflect a change in the PMSI data coding methods. Indeed, some psychiatric care activities were no longer considered hospitalisations after 2013. Unlike the UHSAs, the SMPRs are located within prisons and therefore allow the provision of psychiatric care without transferring the person who is incarcerated. However, no involuntary care is possible in these facilities because French law does not allow compulsory psychiatric treatment in prison.Surprisingly, the number of incarcerated people hospitalised in maximum-security units (UMDs) remained low. Only 826 out of 32,228 patients were admitted to maximum-security units during the study period, from 84 stays in 2009 to 102 stays in 2019. Maximum-security units are facilities designed to care for the most difficult patients, especially those with a high risk of violence.Several limitations of the present work should be acknowledged. First, we only had access to health data from the PMSI with limited sociodemographic data (only age and sex were available). No information about the severity of the index offence or the criminal history was available. Second, the use of administrative data does not allow for any confirmation of the diagnosis or the actual clinical status of the patient. However, our information is derived from diagnoses based on comprehensive clinical assessments by psychiatrists in hospital settings, and although diagnoses may vary among practitioners, high levels of agreement have been found for schizophrenia and bipolar disorders in France.This work paves the way for many avenues of research to explain the trends observed in the present study. First, future studies should explore whether hospitalisations in USHAs are appropriate and investigate the quality of care in such facilities compared with psychiatric hospitals. Qualitative studies on care pathways would help to interpret the findings. Metrics such as suicide rates in prison could also be used to assess the impact of UHSAs on the mental health of people who are incarcerated. Second, we focused on hospitalisations for the present study, with little attention given to outpatient care, which is the mainstay of psychiatric treatment in both community and correctional settings. Access to outpatient care in French jails and prisons should be examined in future studies. Third, although it has not been rigorously tested, it seems that UHSAs accommodate more women proportionally see . Future We conducted the first longitudinal study investigating the number of hospitalisations in psychiatry for people who are incarcerated in France. We showed that the number of people in prison hospitalised in psychiatric care increased drastically between 2009 and 2019 in France. Importantly, the creation of psychiatric hospitals specifically dedicated to this population (UHSAs) has not stopped the hospitalisation of people who are incarcerated in psychiatric hospitals. Further arrangements in the French justice system to optimize access to psychiatric care for people in prison will need to be developed and investigated in the future.TF, CCC, MB and AL participated in the conception and design of the study; CCC participated in the acquisition of data; CCC, MB and AL performed the analyses and verified the underlying data; and TF wrote the first draft of the manuscript. All authors participated in the writing and revision of the successive drafts of the manuscript and approved the final version. All authors had full access to all the data in the study and accepted responsibility to submit for publication.https://www.snds.gouv.fr/SNDS/Accueil), and cannot be shared.This administrative data is only available through request from the French National System of Health Data , which manages this sensitive information (There was no funding source for this study.We declare no competing interests.


Kaposi sarcoma (KS) is caused by human herpesvirus 8 (HHV-8). Epidemic KS is described in the human immunodeficiency virus (HIV) population with acquired immune deficiency syndrome (AIDS). It primarily affects the skin, but it may uncommonly disseminate to involve extracutaneous sites such as the gastrointestinal (GI) tract, liver, and lungs.3, and HIV viral load (VL) was 500 copies/ml. This case demonstrated an atypical natural history of pulmonary KS in an HIV patient as pulmonary and disseminated mucocutaneous KS occurred with a relatively higher CD4 count (≥500 cells/mm3). It also reminds pulmonologists and infectious disease specialists to consider pulmonary KS as a differential diagnosis of acute hypoxemic respiratory failure in HIV patients, even in the absence of other clinical and laboratory criteria that define the AIDS stage.In this case report, the authors report a 26-year-old homosexual male who was admitted with acute hypoxemic respiratory failure. He was diagnosed with an HIV infection about five months before index presentation, and he was commenced on highly active antiretroviral therapy (HAART). Physical examination was remarkable for diffuse cutaneous nodules over the lower extremities, back, and oropharynx. Chest imaging revealed diffuse bilateral infiltrates, mediastinal adenopathy, and a persistent bilateral pleural effusion. Extensive diagnostic workup was negative for underlying infectious etiology. Transbronchial biopsy demonstrated proliferated spindle cells that stained positive for HHV-8 in keeping with pulmonary KS. Skin biopsies also concurred with the diagnosis of cutaneous KS. Interestingly, the cluster of differentiation 4 (CD4) count was 647 cells/mm Kaposi sarcoma (KS) is an angioproliferative tumor of the blood and lymphatic vessels, which is strongly associated with human herpesvirus 8 (HHV8), also known as the KS . The cut3, who was admitted with acute hypoxemic respiratory failure, and he was found to have an extensive pulmonary KS. The occurrence of pulmonary and disseminated cutaneous KS with a relatively higher CD4 count (≥500 cells/mm3) in our patient represents a clinical rarity that was seldom reported in the available literature ), and bacterial and fungal cultures yielded no growth. Transbronchial biopsies from the lesions of the right upper and middle lobes demonstrated spindle-shaped fibroblast-like proliferated cells Figure  that tes2 was administered with good tolerance and was then scheduled every 21 days as an outpatient.A diagnosis of pulmonary and mucocutaneous KS in the setting of IRIS was made. Abdominal imaging and endoscopic examination revealed no evidence of visceral KS or other suspicious gastrointestinal AIDS-defining lesions. The patient was continued on his current regime of HAART per the infectious diseases team, and he underwent a series of thoracocentesis under interventional radiology (IR) guidance. Oncology consultation recommended initiating inpatient systemic chemotherapy considering the severity of the pulmonary KS. Doxorubicin liposome 20 mg/mAfter three weeks, the patient was discharged on ambient air in a stable condition with a pleural catheter in-situ. Follow-up chest imaging at six weeks revealed an interval reduction of bilateral airspace opacities and decreased bilateral pleural effusions, while the mucocutaneous disease remained stable with no new lesions.3 were 18.9, 3.6, and 4.1, respectively, compared to those with ≥500 cells/mm3 [Epidemic or AIDS-related KS is primarily prevalent in homosexual and bisexual males in the resource-rich Western countries ,2,5,7. HThe mucocutaneous lesions of KS appear most frequently on the lower extremities, trunk, genitalia, and oral mucosa . FurtherPulmonary KS is usually associated with extensive mucocutaneous disease in more than 90% of cases . NeverthChest radiograph commonly shows septal infiltration and patchy reticular opacities (60%), followed by ill-defined nodular densities (25%) ,12. WhilThe presumptive diagnosis of pulmonary KS is clinically based on the epidemiology , the severity of immunodeficiency, presence of mucocutaneous lesions, probable radiological appearances, and exclusion of other infectious or neoplastic etiologies (as shown in our patient). The diagnosis is usually confirmed when characteristic endobronchial lesions (such as violaceous or bright red maculopapular lesions) are identified during bronchoscopy along the mucosa of the lower bronchi and less likely trachea ,9. OccasThe principal management of pulmonary KS is HAART, which has led to a significant reduction in the incidence of the disease and altered its natural history with improved survival ,12. ConcPulmonary KS should be considered a possible differential diagnosis of acute hypoxemic respiratory failure in HIV patients, even in the absence of other clinical and laboratory criteria that define the AIDS stage. The occurrence of pulmonary and disseminated mucocutaneous KS with a relatively high CD4 count is a clinical rarity that was seldom reported. Multidisciplinary management with the early involvement of infectious disease specialists and pulmonologists is essential to achieve a better outcome in HIV patients with acute hypoxemic respiratory failure secondary to pulmonary KS.


Tizanidine is an alpha-2 adrenergic agonist used commonly by medical professionals to treat patients' chronic spasticity, muscle spasms, and neuralgia usually associated with myofascial components. This medication is also used very frequently in detoxification centers on patients treated for analgesic withdrawal, especially those who are suffering from rebound headaches due to the discontinuation of analgesics. Tizanidine is metabolized in the human body by the cytochrome P450 CYP1A2. On the other hand, ciprofloxacin is a common antibiotic belonging to the class of fluoroquinolones and is used to treat various infections. Ciprofloxacin inhibits the bacterial DNA-gyrase enzyme resulting in the destruction of the organism. Ciprofloxacin is also an inhibitor of the cytochrome P450 CYP1A2. Even though these two medications show obvious interaction still, however, both these medications are often prescribed together, and their interactions/contraindications are often overlooked by many physicians and other providers. We hereby describe the case report of the interaction between tizanidine and ciprofloxacin, along with the adverse outcome related to the concomitant use of these two drugs. Tizanidine is an alpha-2 adrenergic agonist used to treat moderate-to-severe muscle spasms usually caused by diseases like multiple sclerosis, spinal cord injuries, and various other medical conditions. Cytochrome P450 CYP1A2 metabolizes tizanidine in the liver, which is then excreted through urine and feces [The patient is a 48-year-old female with a past medical history of lower back pain due to obesity for which she takes 4 mg of tizanidine orally daily along with ibuprofen 200 mg orally as needed. She presents to the hospital with a chief complaint of left flank pain, nausea, and vomiting that has been going on for the past 24 hours. The patient had a CT scan of the abdomen and pelvis performed, which showed a 1.2 cm stone obstructing the left ureter as seen in Figure The patient was also found to have a urinary tract infection (UTI) and also elevated white blood cell count. The details of the vital signs and laboratory findings are listed in Tables Table Klebsiella, which was pan-sensitive. The patient was then transferred from the ICU floor to the medsurg floor. She spent less than 24 hours in the ICU. The patient was monitored for 24 more hours and then was later discharged home with Augmentin 875 twice daily for 14 days with a urology follow-up and primary care practitioner follow-up within the next two weeks.In the ICU, the patient was started on broad-spectrum antibiotics, and tizanidine was discontinued. She was also started on a levophed drip to help with hypotension but was quickly weaned off within 24 hours. The patient had a urine drug screen performed which was only positive for opiates, likely secondary to her taking morphine in the hospital for pain. The urine drug screen was otherwise negative. The patient had an echocardiogram performed which was normal; carotid ultrasound was normal; a CT head without contrast was also performed, which was normal as well. The telemetry monitor did not show any arrhythmias. The patient had a repeat blood test performed, including lactic acid, which was completely normal. The patient's urine culture grew Tizanidine is a common short-acting muscle relaxant used to treat muscle spasms and chronic muscle spasticity in patients. Tizanidine is an alpha-2 adrenergic agonist, which causes a decrease in muscle spasticity and causes muscle relaxation. Tizanidine's main side effects are also derived from its mechanism of action, i.e., alpha-2 agonist properties, which can cause hypothermia, somnolence, hypotension, dizziness, and bradycardia. Tizanidine's half-life is approximately 3 hours. Tizanidine is metabolized via the cytochrome P450 CYP1A2 pathway in the liver [Ciprofloxacin is an antibiotic that belongs to the class of fluoroquinolones and is considered a CYP1A2 inhibitor. Therefore, concomitant use of tizanidine with ciprofloxacin should be avoided because it has been shown that ciprofloxacin increases the plasma concentration of tizanidine by 5-20 times, resulting in severe toxicity of tizanidine in the patient . AdminisBecause of these side effects, the tizanidine and ciprofloxacin combination is contraindicated. Even though both these drugs are contraindicated, we still see them being coadministered together in both the inpatient and outpatient settings. One possible reason for their coadministration is the overlap in the indication field. For example, muscle spasticity and injury are frequently treated with tizanidine; however, UTIs and other bladder infections are usually treated early with fluoroquinolones like ciprofloxacin .Results from multiple studies show that despite the presence of formal contraindication between tizanidine and ciprofloxacin, these drugs are still being prescribed together in clinical practice. Ciprofloxacin is a cytochrome P450 CYP1A2 inhibitor; therefore, when ciprofloxacin is given with tizanidine, it causes a high concentration of tizanidine in the human body because tizanidine is metabolized mainly by cytochrome P450 CYP1A2. A high concentration of tizanidine can cause adverse effects like fatigue, hypotension, and bradycardia. Therefore, the concomitant use of ciprofloxacin with tizanidine should be avoided. More education is needed regarding this drug interaction to avoid this known drug interaction.


This cross-sectional study examines the association between prioritization of COVID-19 vaccination for state prison systems and the rate of vaccination among incarcerated persons. COVID-19 can spread rapidly in these facilities owing to crowding, inability to socially distance, poor ventilation, continuous admissions and releases, and daily work staff.3 In contrast, the National Academies of Sciences, Engineering, and Medicine recommended that incarcerated persons be vaccinated in the second phase.4 This study assessed COVID-19 vaccine rollout in state prison systems and the association between vaccination prioritization policies and the percentage of incarcerated persons vaccinated for COVID-19.Owing to limited vaccine supply in December 2020 and early 2021, the Advisory Committee on Immunization Practices recommended that states allocate COVID-19 vaccines in phases and did not prioritize incarcerated persons for vaccination, nor did many states.STROBE reporting guideline.This longitudinal cross-sectional study used state data on weekly COVID-19 vaccination counts among incarcerated persons and monthly prison population counts from the Marshall Project and Associated Press. Phases and dates of incarcerated persons' vaccination eligibility were obtained from the COVID-19 US State Policy database. Boston University’s institutional review board waived deemed the study non–human participants research and waived informed consent. We followed the 5 The analysis period was October 20, 2020, to June 20, 2021 (last week of available data); the unit of analysis was state-week. Models included fixed effects for state and week to control for time-invariant differences between treated and untreated states and national trends in incarcerated persons’ vaccination. A secondary analysis assessed June 2021 vaccination rates among incarcerated persons vs the general adult population by month of incarcerated persons’ vaccination prioritization.The sample included states with complete data on incarcerated persons’ vaccination , 21 prioritized incarcerated persons for vaccination and 15 did not. Incarcerated persons became eligible for vaccination from December 12, 2020, to April 12, 2021. States with policies prioritizing incarcerated persons’ vaccination had significant increases in vaccination rates vs other states over time .Only 10 states vaccinated more than 70% of incarcerated persons , and only North Dakota fully vaccinated more than 80%. By June 2021, states prioritizing vaccinations for incarcerated persons earlier in 2021 had higher incarcerated persons’ vaccination rates vs states prioritizing incarcerated persons later or not at all and vs the general population . Even af6Low vaccination rates among incarcerated persons have implications for health equity. Racist policies in policing and drug criminalization sentencing created racial and ethnic disparities in incarceration and chronic disease, which are associated with increased risk of COVID-19 and complications among racial and ethnic minoritized individuals.Our data suggest that state prioritization of incarcerated persons was associated with increased vaccination rates in this population, although vaccination rates may vary owing to state vaccine rollout, availability, or incarcerated persons’ preference. Distrust of staff is common in prisons, and how to encourage vaccination among incarcerated persons should be considered.Our analysis only included states that reported full doses of vaccination and thus may not be generalizable to the US prison population. Better data transparency, including full COVID-19 vaccinations and vaccinations by race and ethnicity, is needed to evaluate vaccinations in prisons.


The conjugation of a dopamine-binding aptamer (DBA) to the pA-AuNPsyields aptananozyme structures catalyzing simultaneously the H2O2-mediated oxidation of dopamine to aminochromethrough the aerobic oxidation of glucose. A set of aptananozymes consistingof DBA conjugated through the 5′- or 3′-end directlyor spacer bridges to pA-AuNPs were synthesized. The set of aptananozymesrevealed enhanced catalytic activities toward the H2O2-catalyzed oxidation of dopamine to dopachrome, as comparedto the separated pA-AuNPs and DBA constituents, and structure–functionrelationships within the series of aptananozymes were demonstrated.The enhanced catalytic function of the aptananozymes was attributedto the concentration of the dopamine at the catalytic interfaces bymeans of aptamer–dopamine complexes. The dual catalytic activitiesof aptananozymes were further applied to design bioreactors catalyzingthe effective aerobic oxidation of dopamine in the presence of glucose.Mechanistic studies demonstrated that the aptananozymes generate reactiveoxygen species. Accordingly, the AS1411 aptamer, recognizing the nucleolinreceptor associated with cancer cells, was conjugated to the pA-AuNPs,yielding a nanozyme for the chemodynamic treatment of cancer cells.The AS1411 aptamer targets the aptananozyme to the cancer cells andfacilitates the selective permeation of the nanozyme into the cells.Selective cytotoxicity toward MDA-MB-231 breast cancer cells (ca. 70% cell death) as compared to MCF-10A epithelial cells(ca. 2% cell death) is demonstrated.Polyadenine-stabilized Au nanoparticles (pA-AuNPs) revealdualnanozyme catalytic activities toward the H Organiccatalytic particles, including, for example, melamine23 or polydopamine24 nanoparticles,and NMOFs, such as Zr-based NMOFs modified with metal ions26 or MOF-818,27 have revealed nanozymeactivities. Diverse enzyme activities have been emulated by nanozymes,including peroxidase,30 oxidase,33 laccase,34 superoxide dismutase,35 catalase,36 isomerase,37 and hydrolase39 activities. Also, hybrid multi-enzyme nanoparticle carriers or hybridsconsisting of enzyme/nanozyme nanoparticles have been reported ascomposite nanoreactors for operating catalytic or biocatalytic cascades.41 Different applications of nanozymes43 or nanoreactorcomposites44 have been demonstrated, includingtheir use as sensors46 and imaging agents,48 in medical applications such as cancer therapy,50 for treatment of diseases such as Alzheimer’s52 or Parkinson’s disease,54 and for catalyticrelease of cardiovascular drugs.55 In addition,nanozymes have been used as antibacterial and wound-healing agentsby generating reactive oxygen species (ROS)56 and applied as catalysts for the degradation of pollutants.57Substantial research efforts are directedto the development ofinorganic, organic, or metal–organic framework nanoparticles(NMOFs) as catalysts mimicking native enzymes, 2+-ion-modified C-dots nanozyme with β-cyclodextrinreceptor binding units or the coating of nanocatalysts with molecularlyimprinted matrices.58While nanozymes demonstrate enhanced stabilitiesas compared tonative enzymes, they reveal lower catalytic activities and lack thestereoselectivity and chiroselectivity that are fundamental featuresof enzymes. As the high catalytic stereoselectivity and chiroselectivityfunctions of native enzymes originate from the well-defined structuraland chiral architecture of the active site that provides cooperativebinding of the substrate  and spatial proximityof the substrate to the catalytic site, efforts to mimic these featuresby nanozymes have been reported. These include the functionalizationof the Cu61 or catalyticproperties of nucleic acids (DNAzymes)62 have been recently applied to develop nanozymes.64 The conjugation of aptamers to DNAzymes yielded enzyme-like conjugates(nucleoapzymes) revealing improved binding of the reaction substrateand enhanced catalytic and chiroselective properties.66 In addition, the functionalization of Cu2+-ion-modifiedC-dots with the dopamine aptamer or the tyrosinamide aptamer yieldedhighly active nanozymes for the oxidation of dopamine to aminochrome,the chiroselective oxidation of l-/d-DOPA to l-/d-dopachrome, and oxygen insertion into aryl C–Hbonds of tyrosinamide for its oxidation into amidodopachrome. Thisclass of aptamer-modified nanozymes was termed by us “aptananozymes”.67The sequence-specificrecognition properties of nucleic acids (aptamers)68 such as sensing,69 imaging,70 assemblyof chiroplasmonic structures71 and switches,72 construction of optical nanodevices,73 and the use of their thermoplasmonic propertiesas nanothermometers.74 Recently, polyadenine-stabilizedAuNPs (pA-AuNPs) demonstrated peroxidase-like nanozyme activities75 reflected by the oxidation of 2,2′-azino-bis(3-ethylbenzothiazoline-6-sulfonicacid) (ABTS2–) by H2O2 toform ABTS•–.Nucleic acid-modified gold nanoparticles(AuNPs) have found diverseapplications,2O2. Furthermore, we find that the pA-AuNPs act,also, as a nanozyme that catalyzes the aerobic oxidation of glucoseto gluconic acid and H2O2. This allows the useof pA-AuNPs as a bioreactor nanozyme that catalyzes the cascaded aerobicoxidation of dopamine to aminochrome in the presence of glucose. Thatis, in contrast to native enzymes that reveal a dictated catalyticfunction, we find that a single AuNP nanozyme can catalyze two differentcatalytic transformations, e.g., catalyzed oxidationof dopamine by H2O2 and aerobic oxidation ofglucose. This not only demonstrates the diversity of nanozymes vs. native enzymes, but also allows us to apply a singlenanozyme as a bioreactor that activates a cascaded biocatalytic processwhere the catalyzed aerobic oxidation of glucose to gluconic acidand H2O2 catalyzes oxidation of dopamine toaminochrome. The peroxidase activity of pA-AuNPs toward the oxidationof dopamine is, however, quite low. To enhance the nanozyme activity,we tether a series of dopamine-binding aptamers (DBAs) directly totheir 3′- or 5′-end or through spacer units to yieldaptananozyme bioreactors, 2O2 and a 13-fold-enhancedoxidation of dopamine in the presence of glucose, as compared to theseparated nanozyme/aptamer units. In addition, we demonstrate thechiroselective oxidation of l-/d-DOPA to l-/d-dopachrome by H2O2 and the DBA-functionalizedpA-AuNPs, aptananozyme, and the chiroselective oxidation of l-/d-DOPA to l-/d-dopachrome by glucoseand the aptananozyme bioreactor. It should be noted that previousstudies demonstrated the catalytic activities of “naked”AuNPs toward the aerobic oxidation of glucose,31 yet surface functionalization of the AuNPs led to catalyticallyinactive particles. Thus, the demonstration that pA-AuNPs retain theirglucose oxidase nanozyme activities is significant and moreover importantas it allows the conjugation of aptamer tethers to the pA-AuNPs thatenable sequestered biocatalytic cascades by the aptananozyme reactorand aptamer-guided therapeutic applications (vide infra) by the aptananozyme. The mechanism of the DBA-functionalized pA-AuNPs-catalyzedoxidation of dopamine by H2O2 involves the generationof •OH as ROS intermediates.Here we wish to reporton the peroxidase-like nanozyme activityof pA-AuNPs toward the oxidation of dopamine to aminochrome by H•OH by thepA-AuNPs is used to engineer AS1411 aptamer-functionalized pA-AuNPsas functional aptananozymes for the chemodynamic treatment of MDA-MB-231cancer cells. The cytotoxicity of the AS1411/pA-AuNPs toward MDA-MB-231cancer cells and toward MDA-MB-231 xenogragt tumor-bearing mice isaddressed.The glucose-mediated generation of 75Supporting Information, Figures S1–S3.)The resulting pA-AuNPs reveal peroxidase-like activities and resultin the oxidation of dopamine by H2O2 to formaminochrome, Figure S4. In addition, wefind that pA-AuNPs reveal glucose oxidase activities and, in the presenceof glucose, catalyze the aerobic oxidation of glucose to gluconicacid and H2O2, Figure S5. The dual catalytic activities of the pA-AuNPs allowed, then, theuse of the pA-AuNPs as a nanozyme bioreactor for the catalyzed aerobicoxidation of dopamine to aminochrome in the presence of glucose, Figure S6. In this system, the aerobic oxidationof glucose to gluconic acid and H2O2, and theresulting H2O2 in the vicinity of the catalyticparticles, allows the subsequent cascade oxidation of dopamine toaminochrome. The pA-AuNPs were synthesizedaccording to the reported procedure,2O2-catalyzed oxidation of dopamine toaminochrome and the cascaded aerobic oxidation of dopamine, in thepresence of glucose, is moderate, as compared to other peroxidase-mimickingnanozymes. The importance of the systems rests on the dual catalyticbioreactor activities of the particles. To improve the catalytic activitiesof the pA-AuNPs system, we applied the concept of aptananozyme, wherethe DBA was tethered to the pA-AuNPs. In these systems, the DBA tetheredto the particles concentrate the dopamine substrate at the aptamer-bindingsite, thereby allowing the effective utilization of H2O2, While the pA-AuNPs reveal dual catalyticactivities and establisha nanozyme bioreactor function, the effectiveness of the system towardthe H1)to the pA stabilizer units (aptananozyme I) and the 5′-endaptamer sequence (2) to the pA sequence (aptananozymeII), and the 5′-end aptamer tethered to the pA sequence via a four-base spacer TGTA bridge (3), aneight-base spacer (TGTA)2 (4), and a 12-basespacer (TGTA)3 sequence (5) . (The aptamer and aptamer–spacersequences elongated at the respective 3′- or 5′-endof the pA hairpin were used to synthesize the pA-AuNPs.) All pA-AuNPsinclude an identical loading of the modified pA-aptamer strands onthe AuNPs . 2O2) usingthe aptananozyme I, curve (a), aptananozyme II, curve (b), aptananozymeIII, curve (c), and aptananozyme IV and V, curves (d) and (e), respectively.The time-dependent absorbance changes corresponding to aminochromeformation were applied to follow the kinetics of dopamine oxidationby the respective aptananozymes. For comparison, the rate of oxidationof dopamine by H2O2 in the presence of the pA-AuNPsmodified with the nucleic acid (2a), consisting of thescrambled bases of DBA, is presented in curve (f), and the rate ofoxidation of the dopamine by the separated pA-AuNPs/aptamer constituentsin the presence of H2O2 is displayed in curve(g). The catalytic rates of the aptamer-modified nanozymes reveala Michaelis–Menten-type kinetic behavior and reach saturationlevels, consistent with the saturation of the aptamer-binding receptorsites. All aptamer-modified nanozymes show substantially enhancedcatalytic oxidation of dopamine, as compared to the control systemsof the separated nanozyme/aptamer couple or the nanozyme conjugatedby scrambled bases aptamer (2a). The enhancement of thedopamine oxidation rate by the aptamer-modified nanozymes followsthe order I < II < III < IV, indicating the following: (i)The tethering of the 5′-end to the pA-AuNPs yields a nanozymeof slightly higher catalytic activity as compared to the 3′-end-modifiedaptamer tethered to the pA-AuNPs. (ii) The introduction of a spacerunit bridging the 5′-end of the aptamer to the pA-AuNPs improvesthe catalytic performance of the nanozyme, and the eight-bases-bridgedspacer leads to superior catalytic properties of the nanozyme IV >III. Nonetheless, further elongation of the spacer bridge to 12 basesdecreases the catalytic performance of the nanozyme V < IV. Thecatalytic properties of the aptamer-functionalized pA-AuNPs nanozymesfollow the binding properties between the aptamer–pA-AuNPsconjugates and dopamine substrate. (iii) The kinetic features, KM and Vmax, associatedwith the different aptamers-functionalized pA-AuNPs are summarizedin Kd) of different aptananozymesto dopamine substrates are also included in Figure S7 and (4)-modified pA-AuNPs reveal a 10-fold enhanced activity as comparedto the separated aptamer/pA-AuNPs constituents. The enhanced catalyticactivities of the aptananozymes are attributed to the binding of dopamineto the aptamer units resulting in the local concentration of the reactionsubstrate (molarity effect) at the catalytic interface. That is, theaffinity binding of dopamine to the aptamer receptor controls thecatalytic efficacies of the aptananozymes, similar to the functionsof native enzymes, where the affinity binding of the substrates guidesthe biocatalytic performance. (ii) The order of the catalytic activitiesfollows the order of disassociation constants to the aptamer units.The introduction of the oligonucleotide-TGTA units improves the bindingfeatures of the aptamer toward dopamine. Presumably, the AuNPs surfaceperturbs the association of dopamine to the aptamer-binding sites,and the spacer units added to the aptamer scaffolds introduce flexibilityinto the aptamer sequence that eliminates the steric binding perturbationtoward the ligand introduced by the particles. (iii) For the long12 (TGTA)3 bridge, a decrease in the catalytic activityis observed. This is attributed to the spatial separation of the substratefrom the catalytic interface. Similar steric effects of long spacerbridges were observed for other nucleoapzyme66 and aptananozyme systems.67 (iv) Therandom sequence aptamer-modified pA-AuNPs, curve (v), reveal slightlyenhanced oxidation of dopamine, as compared to the separated pA-AuNPs/aptamerconstituents. This slight rate enhancement is attributed to the electrostaticconcentration of the positively charged dopamine at the catalyticinterface. A series of DBAs were conjugated to thepA units stabilizing theAuNPs, Figure S8, and the accompanying discussion depictsthe glucose oxidase activities of the aptananozyme IV. In this experiment,the aerobic oxidation of glucose yields gluconic acid and H2O2, and the resulting H2O2 is quantitativelyprobed by the H2O2 oxidation of Amplex Red tothe fluorescent Resorufin. All DBA-functionalized pA-AuNPs, i.e.,aptananozymes I–V, reveal similar glucose oxidase activities,and their activities are very similar to the oxidase activity of thepA-AuNPs lacking the conjugated DBA aptamer. That is, the glucoseoxidase activities of the pA-AuNPs are not influenced by the coupledDBA aptamer sequences, Figure S9. Realizingthat the series of DBA-conjugated pA-AuNPs, aptananozymes I–V,exhibit dual nanozyme catalytic functions toward the aerobic oxidationof glucose and peroxidase activities toward the oxidation of dopamineby H2O2 to aminochrome, the set of aptananozymeswas applied as bioreactor systems to guide the cascaded catalyticoxidation of dopamine by the aerobic oxidation of glucose, The DBA-functionalized pA-AuNPs, aptananozymes, revealoxidase-likecatalytic activities toward the oxidation of glucose, 2O2. For comparison, the ratesof oxidation of dopamine in the presence of the (2a) nucleicacid-modified pA-AuNPs, where (2a) includes the scrambledsequence of the DBA conjugated to the pA sequence-stabilized AuNPs,and the oxidation rates of dopamine by the separated pA-stabilizedAuNPs and the DBA, in the presence of glucose, are presented in curves(f) and (g), respectively. All aptananozyme bioreactors stimulatethe glucose-driven aerobic catalytic cascade, leading to the formationof aminochrome. While the cascaded oxidation of dopamine in the presenceof glucose and the bare pA-AuNPs is inefficient, curve (g), effectiveglucose-driven oxidation of dopamine in the presence of all aptananozymeassemblies proceeds, following the order aptananozyme I < aptananozymeII < aptananozyme III < aptananozyme IV. The aptananozyme V,consisting of the 12 spacers bridges separating the dopamine aptamerfrom pA stabilizing AuNPs, reveals the lowest cascaded activity amongthe aptananozyme assemblies. The aptananozyme IV, consisting of the8 spacers separating the dopamine aptamer from pA stabilizing theAuNPs, reveals a ca. 13-fold enhanced cascade activityas compared to the bare pA-AuNPs and the separated DBA, curve (d) vs. curve (g). Interestingly, the rates of aerobic oxidationof glucose by the (4)-pA-AuNPs and the non-aptamer-conjugatedpA-AuNPs (in the presence of the separated DBA) to form gluconic acidand H2O2 are almost similar, Figure S9. Thus, effective oxidation of dopamine by the (4)-stabilized pA-AuNPs  can beattributed to the dopamine aptamer linked to the aptananozyme bioreactorassembly. That is, for the separated pA-AuNPs/DBA system, the concentrationof dopamine near the nanozyme interface is low. As a result, the H2O2 formed by the aerobic oxidation of glucose escapesto the bulk solution, leading to inefficient diffusional oxidationof dopamine. In turn, the concentration of dopamine by the aptananozymecatalyst tethered with aptamer unit (4) (or other aptamerstructures) leads to effective utilization of the H2O2 generated by the aptananozyme-catalyzed aerobic oxidationof glucose, resulting in the efficient cascaded oxidation of dopamine,forming aminochrome. That is, the formation of H2O2 at the DBA-functionalized pA-AuNPs interface yields a highlocal concentration of H2O2 for the sequestered,cascaded oxidation of dopamine.44  The efficiencies of the catalyzedglucose-driven aerobic oxidation of dopamine to aminochrome by aptananozymesfollow the order I < II < III < IV and fit well with the Kd values of different aptananozymes toward dopamineand their efficacies to concentrate dopamine at the bioreactor interface.l-DOPA or d-DOPA upon binding tothe chiral aptamer would yield aptamer–ligand complexes ofdifferent binding affinities. Accordingly, the concentration of l-DOPA or d-DOPA at the (4)-modified pA-AuNPswill be dictated by the affinities of diastereomeric ligand–aptamercomplexes, and thus, chiroselective oxidation of l-/d-DOPA should proceed. l-DOPA, curve (a),and d-DOPA, curve (b), by H2O2, 20mM, in the presence of (4)-functionalized pA-AuNPs. Forcomparison, curves (c) and (d) show the rates of oxidation of l-/d-DOPA by the non-aptamer pA-stabilized AuNPs. The(4)-modified pA-AuNPs, aptananozyme IV, reveals chiroselectiveoxidation of the DOPA ligands, and the rates of oxidation of l-DOPA are ca. 2.1-fold enhanced as compared to therates of oxidation of d-DOPA, 4)-aptamer-binding site (Kd of l-DOPA and d-DOPA to the (4)-modified pA-AuNPs corresponding to 4.2 μM and 11.3 μM,respectively, Figure S11). That is, thehigher binding affinity of l-DOPA to the aptamer site improvesthe concentration of the ligand at the catalytic interface, resultingin the chiroselective oxidation. In turn, the polyA-non-aptamer-modifiedAuNPs do not show any chiral discrimination toward the oxidation of l-/d-DOPA, l-/d-DOPA by thechiral interface are too weak to induce any detectable chiroselectiveoxidation. The chiroselective oxidation ofl-/d-DOPAby H2O2 to dopachrome was, then, extended toinclude the chiroselective oxidation of l-/d-DOPAby applying the pA-AuNPs-DBA aptananozyme bioreactor system to catalyzethe aerobic oxidation of glucose as the H2O2 source. l-/d-DOPA by the glucose and aptananozyme bioreactor in the presenceof variable concentrations of l-/d- DOPA. The oxidationof l-DOPA, curve (a), is two-fold enhanced as compared tothe rate of oxidation of d-DOPA, curve (b). For comparison,the rates of oxidation of the l-/d-DOPA, at differentconcentrations of l-/d-DOPA, by the separated pA-AuNPsnanozyme reactor and the diffusional dopamine aptamer are displayedin curves (c) and (d). The rates of l-/d-DOPA oxidationby the separated glucose/nanozyme reactor are very low, and no chiroselectivityis detectable. The enhanced oxidation rates of l-/d-oxidation are attributed to concentration of the l-/d-DOPA at the catalytic aptananozymes reactor interface by meansof the aptamer constituents. The chiroselectivity follows the enhancedbinding affinity of l-DOPA, as compared to d-DOPA,to the chiral aptamer units.The chiral features of the dopamine aptamer suggestthat the diastereomericinteractions of 2O2 or upon interaction with glucose under aerobic conditions.Electron paramagnetic resonance (EPR) experiments confirm that subjectingthe aptananozymes to H2O2 yields hydroxyl radicals, Figure S12A, as ROS. Similarly, treatment ofthe aptananozyme with glucose under aerobic conditions leads to thedetection of the hydroxyl radical, •OH, as ROS, Figure S12B. Control experiments indicated thattreatment of the aptananozyme with glucose, under nitrogen, did notlead to hydroxyl radicals, Figure S12C.These results are consistent with the supporting experiments thatindicated the aptananozyme catalyzed aerobic oxidation of glucoseto gluconic acid and H2O2. The resulting H2O2 provides, then, the source for •OH. That is, the formation of hydroxyl radicals as the reactive speciesin the catalyzed oxidation of the catechol substrates by H2O2, or the aptananozyme-catalyzed oxidation of the catecholsubstrates in the presence of glucose, under aerobic conditions, isconfirmed. Furthermore, addition of dopamine to the mixture of H2O2 and the aptananozyme or the mixture of glucoseand the aptananozyme led to the depletion of the •OH in the systems, Figure S12D,E, implyingthat the •OH is consumed by dopamine. Accordingly,and in view of a detailed kinetic study examining the reaction of •OH with catechol derivatives,76 a possible mechanism for the •OH-driven formationof aminochrome is provided in Figure S13. Along this path, the •OH-driven oxidation ofthe catechol substrates yields a geminal ortho bis-phenoxy biradicalthat is a canonic form of the o-benzoquinone state.The intramolecular 1,4-Michael addition within the ortho quinone productsof dopamine or l-/d-DOPA yields the aminochromeor dopachrome products.An important aspect involves addressing the mechanisticpath bywhich the DBA-functionalized pA-AuNPs, i.e., the aptananozymes, catalyzethe oxidation of the different catechol derivatives by H78 The limitations associated with the use of nanozymes for chemodynamictreatment of cancer cells include, however, poor cellular permeationand insufficient selective discrimination between cancer cells andnormal cells. The discovery that pA-AuNPs catalyze the aerobic oxidationof glucose (present in cancer cells) to form gluconic acid and H2O2, while generating intermediate ROS products,suggested that the pA-AuNPs could act as reactive nanozymes for chemodynamictreatment of cancer cells. However, to overcome the difficulties associatedwith nanozymes for chemodynamic treatment of cancer cells, we decidedto conjugate the AS1411 aptamer, that binds to the nucleolin receptorassociated with different cancer cells,80 to the pA-AuNPsnanozymes as a means to target the nanozyme to cancer cells and facilitatethe permeation of the nanozymes into the cancer cells, thereby enhancingthe selectivity and chemodynamic efficacy of the nanozymes. Accordingly,the AS1411 aptamer tethered to the pA-hairpin, (6), wasused to stabilize the formation of single hybrid AS1411 aptamer–pA-AuNPs, 2O2 or upon treatment with glucose underaerobic conditions. The formation of the ROS species was confirmedby the reported assay81 that followed thedepletion of the absorbance of 1,3-diphenyl-isobenzofuran (DPBF) uponreaction with the ROS products. 2O2 and the (6)-pA-AuNPs nanozyme, and 6)-pA-AuNPs nanozyme-catalyzed oxidationof glucose under aerobic conditions. 2O2 or O2/glucose in the presence or absenceof the (6)-AuNPs.  The results indicate that the nanozymeis, indeed, essential to generate the ROS intermediates.Recent studies demonstrated that ROSgenerated by nanozymes actas cytotoxic agents against cancer cells, and thus these catalyticnanostructures may act as chemodynamic agents for cancer therapy.ex =488 nm; λem = 517 nm). N = 4 frames at each time interval). Evidently, only theMDA-MB-231 cancer cells treated with the AS1411-conjugated pA-AuNPsdemonstrate the accumulation of the ROS products, 2/glucose-driven catalyzed generation of the ROS products.The selective chemodynamic treatment of the MDA-MB-231 cancer cellsby the ROS agents is demonstrated in ca. 70% of cell death was observed.Using a series of concentrations of the AS1411-pA-AuNPs probing thecytotoxicity toward MDA-MB-231 breast cancer cells, Figure S15, the IC50 value of the aptananozymewas estimated to be ca. 1.27 nM. The results areconsistent with the selective aptamer-assisted permeation of the AS1411/pA-AuNPsinto the cancer cells.The capacity of the AS1411 aptamer/pA-AuNPs conjugateto generateROS products was, then, applied to examine the use of the NPs as intracellularagents for targeted chemodynamic treatment of cancer cells. In theseexperiments, MDA-MB-231 breast cancer cells and MCF-10A epithelialbreast cells were treated with the AS1411 aptamer/pA-AuNPs with theaim to probe the potential selective cytotoxicity of the NPs towardcancer cells that are associated with the nucleolin receptor. As aresult, the ROS generation capacity revealed by the aerobic catalyzedoxidation of intracellular glucose, invivo experiments, 3) were subjected to intra-tumoral(IT) injection of the AS1411/pA-AuNPs or control systems consistingof pA-stabilized AuNPs, lacking the aptamer tether, pA-AuNPs, or pA-stabilizedAuNPs conjugated to a randomized base sequence of the AS1411 aptamer,r-AS1411/pA-AuNPs. The tumor-bearing mice were subjected to a totalnumber of seven injections at time intervals of 2–3 days.  •OH as toxic ROS agent. Furthermore, The chemodynamic cytotoxicity of the AS1411/pA-AuNPstoward MDA-MB-231breast cancer cells was, then, followed by preliminary 2O2 that is coupled tothe effective hydrogen peroxide-catalyzed oxidation of dopamine (or l-/d- DOPA) to aminochrome (or l-/d-dopachrome). The aptamer strands linked to the nanozyme particlesprovide binding sites for the association of the catechol substatesin spatial proximity to the catalyst. Concentration of the substratesat the catalytic surface resulted in effective oxidation of the substrateand provided chiral receptor binding sites for the chiroselectiveoxidation of l-/d-DOPA to l-/d-dopachrome. The binding modes of the aptamers and the strands’flexibilities dominated by spacer bridges affect the binding propertiesof the aptamers and the resulting enhanced catalytic activities ofthe aptananozymes. An important result of the study is, however, thedemonstration that a single nanoparticle stimulates simultaneouslytwo different catalytic processes. This feature of the aptananozymeis rarely observed for native enzymes that catalyze a single targetor chemical transformation. The dual catalytic activities of the artificialaptananozyme enabled a cascaded catalytic transformation within theconfined structure of the aptananozyme that acted as a bioreactor.The mechanistic analysis of the aerobic oxidation of the catecholsubstrates by glucose demonstrated the participation of ROS intermediatesin the reactions.This study has expanded the scope of aptamer-modifiednanozymes(aptananozymes) to a system performing simultaneous and cascaded catalysis.The system involved the pA-AuNPs-catalyzed aerobic oxidation of glucoseto gluconic acid and Hin vivo experiments in MDA-MB-231 xenograft tumor-bearing mice revealedthe high chemodynamic cytotoxic efficacy of the AS1411/pA-AuNPs. Thefunctionalization of the pA-AuNPs with sequence-specific aptamers,and their capacity to yield ROS products through the aerobic oxidationof glucose, makes it possible to design functional pA-AuNPs aptananozymesfor other cancer biomarkers, diverse diseases, and antibacterial applications.The capacity of the pA-AuNPs to generate ROSproducts by the aerobicoxidation of glucose was further applied to tailor aptamer-functionalizedpA-AuNPs conjugates for the chemodynamic treatment of cancer cells.In these experiments, the AS1411 aptamer, recognizing the nucleolinreceptor associated with different cancer cells, was conjugated tothe pA-AuNPs nanozyme, to yield a functional selective nanozyme catalystfor the chemodynamic treatment of cancer cells, using the aerobicoxidation of glucose as the source for the intracellular formationof ROS products. The selective permeation and chemodynamic treatmentof MDA-MB-231 cancer cells, as compared to MCF-10A epithelial cells,was demonstrated. In addition, preliminary The sequences of the nucleic acidsused in the study are shownhere.1: 5′-CGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCGGTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTAC-3′2: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACCGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCG-3′3: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACTGTACGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCG-3′4: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACTGTATGTACGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCG-3′5: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACTGTATGTATGTACGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCG-3′6: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACGGTGGTGGTGGTTGTGGTGGTGGTGGTTT-3′2a: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTACGACTAGCGTGTGTGATGGGACCTTAGGCCGTCACGGGGCTTAGT-3′DBA: 5′-CGACGCCAGTTTGAAGGTTCGTTCGCAGGTGTGGAGTGACGTCG-3′pA-strand: 5′-GTAACAACAGTCAAAAAAAAAAAAAAAAAAAAGACTGTTGTTAC-3′Supporting Information.The detailed procedure to prepare the different aptananozymes,their structural characterization, and the kinetic experiments toevaluate their catalytic functions of the aptananozymes are detailedin the