Conventional coronary angiography (CAG) is currently the gold standard technique for the assessment of coronary arteries prior to cardiac valve surgery. Although CAG is a relatively safe procedure, however, it is still an invasive procedure, and it has potential hazards and complications. Coronary computed tomography angiography (CCTA) is a non-invasive technique that has emerged robustly as an excellent and attractive tool for delineating coronary anatomy. Therefore, we sought to evaluate the accuracy of CCTA when compared with the gold standard CAG in the evaluation of coronary arteries before valve surgery. We screened 111 consecutive patients with VHD undergoing a routine cardiac catheterization for preoperative evaluation of CAD. Fifty patients were eligible and underwent both CAG and CCTA. Significant coronary stenosis was defined as a luminal diameter decrease of ≥ 50%. Additionally, ectasia, calcifications, and congenital coronary anomalies were analyzed. Also, we compared both techniques regarding radiation dose, contrast volume, and complications. Non-evaluable segments were excluded from all levels of analysis. Sixty-one patients were excluded from the study due to various reasons.Among the 50 patients of the study population, 27 (54%) were males. The prevalence of significant CAD in the study population was 19.6% according to the patient-based analysis, and CAG could have been avoided in 80.4% of patients with a true-negative CCTA result. Diagnostic accuracy of CCTA for detection of significant stenosis was evaluated regarding sensitivity and specificity, positive predictive value, negative predictive value, and overall accuracy of CCTA, which was 87.5%, 99.6%,87.5%, 99.6%, and 99.2%, respectively, for segmental-based analysis; 86%, 100%, 100%, 99%, and 99%, respectively, for vessel-based analysis; and 77.8%,100%,100%, 94.9%, and 95.7%, respectively, for patient-based analysis. Fewer rates of complications were encountered with CCTA. Additional information obtained like calcifications and congenital anomalies was diagnosed better with CCTA than CAG.Owing mainly to its high negative predictive value, a well-performed CCTA exam is an excellent method to rule out coronary artery disease, specially in patients who are not at high risk of atherosclerosis. Preoperative coronary angiography (CAG) for the assessment of concomitant significant coronary artery stenosis is a well-established standard procedure , 2. AlthTherefore, we sought to evaluate the accuracy of coronary computed tomography angiography when compared with the gold standard coronary angiography in the evaluation of coronary arteries before valve surgery.Prospectively, we screened 111 consecutive patients with valvular heart disease undergoing a routine cardiac catheterization for preoperative evaluation of CAD, during a 26-month period (December 2016 to January 2019). Sixty-one patients were excluded from the study due to various reasons . The final population was 50 patients, who provided written informed consent, had no history of CAD, and were hemodynamically stable before both tests.Both CCTA and CAG examinations were performed within a 1-week duration. The first test performed was CAG in 96% of patients. One hour prior to CCTA, heart rate control was attempted in every patient—if the baseline heart rate was > 65 bpm—using an oral beta blocker (2.5–10 mg bisoprolol). Patients with uncontrolled heart rates needed an additional bolus of intravenous propranolol (1–2 mg).Before the scan, all patients received 0.5 mg of sublingual nitroglycerin. Both CCTA and CAG data were evaluated by operators blinded to the results of the other test.All CAG procedures were performed by two experienced cardiologists (> 10 years’ experience in the cath lab). Vascular access was obtained through a femoral or radial approach.Coronary artery segments reported to contain a stenotic lesion (or occlusion) of ≥ 50% were evaluated by quantitative coronary angiography (QCA) in two orthogonal views. Segments distal to a totally occluded vessel were excluded from the analysis. All other segments were included for the evaluation of the agreement with CCTA. Each coronary artery segment was classified as normal, atherosclerotic , stenotic , or absent .All patients had CCTA conducted using a dual-source 64 CT system .The study included a pre-scan calcium scoring, followed by a contrast-enhanced scan. All patients received non-ionic, low-osmolar contrast. The entire scan was ECG-gated used to retrospectively reconstruct datasets at the mid-to-late diastolic phase of each cardiac cycle (75%).Using the results of selective coronary angiography as the gold standard, the evaluation was performed on a per-segment, per-vessel, and per-patient basis. Data obtained from CCTA were evaluated using trans-axial images, as well as other reconstruction modalities: multiplanar reconstructions (MPR), maximal intensity projection (MIP), and curved MPR. Coronary segments were described according to the “Braunwald coronary anatomic model” that classify coronary segments into an 18-segment model, and it was used to evaluate coronary tree by both methods. All segments—evaluated by both CCTA and CAG—were labeled either as “significant” stenosis  or “insignificant” stenosis .Data were analyzed using MedCalc© version-15.8 . Numerical variables were presented as mean ± SD (range) and categorical variables as number and percentage. Paired numerical data were compared using paired samples t-test and paired categorical data using the McNemar test. The diagnostic accuracy of CCTA was compared with coronary angiography using 2 × 2 contingency tables to calculate the sensitivity, specificity, positive and negative predictive values, and overall accuracy for each segment, each vessel separately, and each patient.The studied population includes 23 (46%) females and 27 (54%) males. The mean age was 51 ± 7.7 years. The demographic characteristics are presented in Table The average heart rate during the CCTA scan was 67.5 ± 17.7 beats/min (range 55–79). The average scan time of the CCTA scan was significantly shorter (12 ± 3 s) when compared with 839 ± 285 s as the total fluoroscopic time during diagnostic CAG.In this study, there were 8 (16%) patients who encountered complication from CCTA scan; one patient (2%) had transient renal impairment, 3 patients (6%) had dyspnea, 4 patients (8%) had contrast allergy, and 4 patients (8%) had flushing. On the other hand, 13 patients (26%) had complications from CAG; 2% had vasovagal reaction, 8% had contrast allergy, and 18% suffered local hematoma at vascular access. The average contrast volume of CCTA was 85.4 ± 6.1 ml, which was lower compared with 95.4 ± 31.7 ml at CAG. The average total radiation dose for CCTA was 1115 ± 496.5 mGy, which was comparable to 1112.7 ± 413.9 mGy at CAG.Regarding per-segment analyses, a total of 900 coronary segments were subjected to evaluation by both techniques. Among those 900 segments, 136 segments were anatomically absent (segment 15 “left-PDA” being the most absent). When comparing the results of CCTA with invasive angiography, a total net of 764 segments were suitable for evaluation and distributed as seen in Table Non-evaluable segments in coronary angiography were 43 segments . The cause of being non-evaluable was the difficult engagement of the left coronary ostium: either due to aortic-root dilatation in most cases or aortic coarctation in one case. In contrast, there was no non-evaluable segment by CCTA; this was attributed in our study to low calcium score, proper CCTA techniques, and appropriate patient preparation.In a segment-based analysis (for identifying significant coronary lesion (stenosis ≥ 50%)), sensitivity, specificity, PPV, and NPV of CCTA were 87.5%, 99.6%, 87.5%, and 99.6% respectively, with a diagnostic accuracy of 99.2% Fig. .Fig. 1CRegarding vessel-based analyses, only 190/200 vessels were evaluable, while 10 vessels contained non-evaluable segments and were excluded from further analysis. Logically, segments of one vessel branch were combined. The coronary tree was classified into the left main trunk (LMT), left anterior descending artery (LAD), left circumflex artery (LCX), and right coronary artery (RCA). The vessels with only a single segment interpretable were excluded from the vessel-based analysis. The distribution of normal and non-significantly stenotic vessels versus significantly stenotic and totally occluded vessels among both techniques is illustrated in Table From the previous table, we concluded that assessment of LMT, RCA, and LCX in this study was performed accurately; CCTA could rule out successfully significant lesion at LMT and detected four significant RCA lesions and three significant LCX lesions. In other words, CCTA could exclude with confidence the presence of LMT, RCA, and LCX significant stenosis among the rest of the patients with 100% diagnostic accuracy. Although there was a little decrease in diagnostic accuracy of CCTA compared to CAG regarding the diagnosis of significant stenosis in LAD vessel, however, it reaches 95.7%, which still represents a high level of diagnostic accuracy as seen in Table Regarding patient-based analyses, all patients who had vessels with unevaluable segments by coronary angiography were excluded from the assessment of diagnostic accuracy. In this study, we found 39 (84.8%) patients by CCTA who had no significant stenosis, compared to 37 (80.4%) patients by CAG. At the same time, there were only 7 15.2%) patients by CCTA who had significant stenosis, compared to 9 (19.6%) patients by CAG. The diagnostic accuracy of CCTA for the diagnosis of significant CAD was high (compared to standard coronary angiography), which is illustrated in Fig. 5.2% patiOnly one patient (2%) had a total coronary calcium score of 400 or more. The mean total coronary calcium score, according to the Agatston scoring system, was 50 ± 146 units. A total of 766 coronary segments were evaluated for calcification; 739 (96.5%) segments by CCTA versus 718 (93.6%) segments by CAG were free of calcification. At the same time, 27 (3.5%) segments by CCTA versus 4 (0.5%) segments by CAG showed calcifications of variable degree , and this difference was statistically significant (p = 0.01).There were 45 (5.9%) segments by CCTA versus 30 (3.9%) segments by CAG that showed various degrees of coronary ectasia. However, this difference was statistically insignificant (p = 0.06).A total of 200 coronary vessels were evaluated for the presence or absence of congenital anomalies regarding the origin and course. There were 11 (5.5%) vessels by CCTA versus 3 (1.5%) vessels by CAG that showed anomalous origin or course, and this difference was statistically significant (p = 0.03).There were 11 patients who had dilated ascending aorta ranging from 4.1 to 7.4 cm. Also, one patient had LV apical thrombus, and another patient had consolidated patches of pneumonia. Lastly, one patient had encysted pleural effusion.Our current prospective study was conducted to answer some frequently asked questions: “Do we really need an invasive preoperative coronary angiography study prior to every single valve surgery in eligible patient?” and “Is there any other available non-invasive test that can accomplish this task accurately without taking the patient to the cath lab?”The main finding of our study is that CCTA has high diagnostic accuracy and therefore can rule out significant CAD in most of the studied patients with valvular heart disease. Moreover, it can provide more accurate data about the anatomy of the coronary arteries and its wall’s pathology like calcifications, and in some cases, it is the only possible accurate imaging tool that could visualize the coronaries in some situations like in cases with hugely dilated aortic root and aortic coarctation.The published ACC/AHA guidelines 2014 stated that CCTA is reasonable to exclude the presence of significant obstructive CAD in selected patients with a low/intermediate pretest probability of CAD, while a positive CCTA is to be confirmed with invasive CAG . ActuallOur results showed a high degree of accuracy of how CCTA could clinch the presence of CAD and significant coronary stenosis (≥ 50%). Per-segment analysis of data obtained showed very high specificity, NPV, and overall accuracy of CCTA in the assessment of coronary obstruction. These results were important for the exclusion of significant CAD before surgery. Our findings were consistent with several previously published reports like Hoffmann et al. who studied the diagnostic accuracy of 16-slice CCTA compared with invasive CAG in 1384 consecutive patients primarily with suspected CAD and concluded that sensitivity, specificity, PPV, and NPV of per-segment analysis of CCTA were 95%, 98%, 87%, and 99%, respectively, which is nearly similar to our study results [Another systematic review made by d’Othee et al. about the diagnostic accuracy of CCTA includes 50 patients, and they reported similar results to ours, with a high sensitivity and specificity of 64-CCTA for detecting significant coronary stenosis  and a very good overall PPV of 80% and a NPV of 97% .So, according to our study, CCTA had a high specificity, NPV, and overall accuracy with very good sensitivity and PPV to rule out significant CAD on a segment-based analysis. These results were reached by including only evaluable coronary segments in the statistical analysis. However, if non-evaluable segments were included as in some previously mentioned studies, a number of false-positive segments would increase and the diagnostic accuracy of CCTA would be affected, mainly affecting the specificity and PPV, as shown in some previously mentioned studies –10. AlsoA per-vessel analysis is usually more important than per-segment analysis; because a single distal segment stenosis usually will not have a significant impact on the management of such patients.For vessel-based analysis, the diagnostic accuracy of CCTA in our study was 100% for all vessels except LAD (95.7%) due to missing two significantly diseased vessels at LAD territory. Anyhow, these two LAD vessels were diseased distally, and missing them would not affect the overall strategy of management. Actually, CCTA detected successfully four significant RCA lesions and three significant LCX lesions. Also, it excluded the presence of any left main significant lesion with 100% diagnostic accuracy.It is obvious that the high diagnostic accuracy of CCTA is noticed for all vessels except distal LAD in 2 cases, due to the very small caliber of the vessel distally. Actually, these 2 vessels affected markedly the sensitivity and NPV per-LAD analysis . As well known, this can be explained statistically by the fact that these two “false-negative” results affect the mathematical calculation of the sensitivity and negative predictive value.These study results are consistent with previous studies showing a fairly high diagnostic accuracy of CCTA on each vessel-based assessment. One example was demonstrated by Pouleur et al. who evaluated the diagnostic accuracy of 40-slice multidetector CT to detect coronary disease in patients prior to cardiac valve surgery. The per-vessel analysis for 82 patients by CCTA showed significantly higher accuracy for the left main (99%) followed by RCA (93%) then LCX (91%) while the lower accuracy was in LAD (88%), which nearly agrees with our results . Also, BActually, the previous studies and others  agree wiHowever, the finding of interest is the persistently high NPV in our and other studies, which was not influenced by including the non-evaluable segment in the analysis. This is of great value as this ensures the value of the CCTA as a rule-out modality of significant coronary stenosis. This concept is consistent with the findings addressed by Abdulla et al. who conducted a meta-analysis including 27 studies and reported the negative effect of these non-evaluable segments on the specificity and PPV of CCTA .For patient-based analysis, there were 39 (84.8%) patients by CCTA versus 37 (80.4%) patients by CAG who had no significant stenosis. Table Also, we noticed from the revision of most of the previous studies that the specificity and PPV were mostly affected and were lower than our study. It is explained by our exclusion of the non-evaluable segments, while the other studies include them and considered them positive, which increase the false-positive results –10, 16.The non-evaluable segments in our study were not at CCTA but at coronary angiography due to the difficult catheter engagement of the left coronary artery, either due to aortic root dilatation or aortic coarctation. Figures Although CT coronary angiography for preoperative evaluation in VHD is increasingly being used with high accuracy for the detection of significant coronary stenosis, there is slightly lower diagnostic yield in cases of aortic stenosis (AS) due to the frequent aortic and coronary calcifications . A word Additional information provided by CCTA in our study was not limited to coronary calcifications but was extended to include better data for the detection of coronary artery anomalies. CCTA is a 3D imaging modality that can view the heart in any plane, with a large field of view, which allows better visualization of the coronary anomaly.Finally, complications were less frequent and less harmful with the CCTA technique than with CAG. This is explained by the nature of each technique, being non-invasive and quick with CCTA, but invasive and longer in time with CAG.We acknowledge that our study has several limitations. The study was conducted at two centers only (not multicenter) with experience in CCTA, and as such, results may not be representative for all centers. Limited by our resources, we could utilize only dual-source 64-detector scanners, which really accomplished the task needed; however, a higher grade CT scanner with 256 or 320 slices or even more with improved technology may actually reduce the scan time, lower radiation exposure, and improve spatial resolution. Another limit is the small number of sample size (n = 50), and of those, only patients scheduled for elective valve surgery were included. Also, there was a limited number of patients with isolated one valve lesion (only two patients) as rheumatic valvular heart disease is endemic in our region. Also, there were no patients with previous coronary bypass surgery or stents in our study. Also, the study did not include patients with rhythm disturbance , so accuracy in our study was slightly higher and all CCTA images were interpretable. Finally, as mentioned before, we did not include non-evaluable segments in the per-segment and per-vessel analysis as done in previous similar studies.Owing to its high negative predictive value, CCTA is useful to rule out CAD in the majority of patients. The potential role of CCTA proposed here is not to replace cardiac catheterization as the gold standard preoperative tool in CAD assessment, but rather a trial to avoid taking every single eligible patient to the invasive cath lab before sending him/her next to the surgical theater. Consequently, our findings support the potential for the reduction of unnecessary downstream testing and catheter-related complications and costs. By relevance, a normal CCTA examination confers an excellent prognosis, thus supporting its clinical utility if used preoperatively in patients with suspected CAD and planned for valve surgery. We believe more studies are needed to understand better which populations would be fitting for coronary CTA to assess the presence or absence of CAD.


Prevotella (20.9%) was the major genus, whereas at D. − 3–D.3, Alistipes (6.9–12.7%) and Bacteroides (5.2–8.5%) were the major genera. Lactobacillus and Escherichia were notably observed at D. − 3 (1.2%) and D. − 3–D.3 (0.2–0.4%), respectively. For AMR, a distinct cluster of AMR determinants was observed at D.8, mainly conferring resistance to macrolide–lincosamide–streptogramin (mefA), β-lactam (cfxA6 and aci1) and phenicol (rlmN). In contrast, at D. − 3–D.3, a high abundance of determinants with aminoglycoside (AMG) -aph(2''), aadA and acrF), β-lactam , multidrug resistance (MDR) , phenicol (catB4 and cmlA4), and sulfonamide patterns (sul3) was observed. Canonical correlation analysis (CCA) plot associated Escherichia coli with aac(6')-aph(2''), emrA, mdtB, catB4 and cmlA4 at D. − 3, D.0 and/or D.3 whereas at D.8 associations between Prevotella and mefA, cfxA6 and aci1 were identified. The weaning age and diet factor played an important role in the microbial community composition.This study aimed to characterize the alteration of the fecal microbiome and antimicrobial resistance (AMR) determinants in 24 piglets at day 3 pre-weaning (D. − 3), weaning day (D.0), days 3 (D.3) and 8 post-weaning (D.8), using whole-genome shotgun sequencing. Distinct clusters of microbiomes and AMR determinants were observed at D.8 when  The new environment due to farm management includes being transferred from a farrowing pen to an early-weaning unit, being mixed with unfamiliar pigs, and feed changes from highly digestible milk protein and sugars to creep feed and complex solid feed4. All of these factors can impair immune functions and lead to post-weaning diarrhoea syndrome (PWDS), resulting in diarrhoea, dehydration, depression, inappetence and weight loss. PWDS is usually associated with enterotoxigenic Escherichia coli strains (ETEC)5. The severe enteric infections might lead to the overuse of antibiotics. Imbalance of the normal gut microbiota in pigs has been reported to be associated with enteric diseases such as PWD and with the flare up of pathogens even not in the gastrointestinal tract system such as Mycoplasma hyopneumoniae7. The enhancement of gut microbiome ability to increase disease resistance in pigs and reduce antibiotic use are the major challenges in pig industry. Several nonantibiotic alternatives have been applied to decrease gut microbiota dysbiosis in pig industry such as zinc supplements, essential oils, short- and medium-chain organic acids, prebiotics and probiotics11.During the weaning period, piglets face several stress factors owing to either physiological changes or farm management. Physiological changes include (1) loss of protective sow’s milk immune cells, lactoferrin and lysozyme, (2) the presence of probiotic lactic acid bacteria, and (3) the shrinkage of villi in the small intestine, which reduces nutrient digestion and absorptionLactobacillus plantarum, Bacillus licheniformis and Bacillus subtilis. L. platarum, normal flora in porcine gastrointestinal tracts, has been reported to induce endogenous antimicrobial peptide synthesis in weaning piglets and improve pig growth and pork quality13. Pigs that received a probiotic-containing Bacillus licheniformis were shown to reduce porcine epidemic diarrhea virus infected vero cells14. In addition, a probiotic‐containing Bacillus licheniformis and Bacillus subtilis spores could improve productive performance and carcass quality in pigs15. However, probiotic microorganisms such as Enterococcus faecium and B. subtilis might serve as a reservoir for antimicrobial resistance (AMR) determinants17. Subtherapeutic antibiotics have been widely used to improve growth performance and food efficiency of weaned piglets. Low-dose chlortetracycline (0.5–1 g/sow daily) was used to increase breeding, conception rate, farrowing rates and litter size in sows18. Nonetheless, antimicrobial growth promoters can promote AMR strains of both Gram-positive and Gram-negative bacteria19. The utilization of antibiotics as growth promoters has been totally banned in the European Union since January 1, 200620. In Thailand, utilization of antibiotics as growth promoters in food animals is banned22. In fact, antimicrobial prophylaxis at therapeutic doses has been generally used on commercial farms for a short time period to treat and prevent bacterial infection during parturition and weaning. These chemicals might cause antibiotic selective pressure and lead to bacterial genome evolution, allowing AMR variants to survive and multiply and disturbing gut microbial balance23. AMR of several antimicrobials has been reported in weaned pigs (from 0 to 28 days post-weaning), receiving chlortetracycline at a therapeutic dose and penicillin at a metaphylactic dose24. Resistant bacteria play an important role not only in pig health management but also in human health as AMR could be passed to human via direct contact or as a consumer25. Since environment can also be a reservoir for AMR resistome and maintain AMR genes, the ‘One Health’ approach to AMR surveillance in humans, animals and environments is required, not only at the laboratory level but also at the epidemiological, clinical and population levels26.In fact, several probiotic microorganisms are commonly used to inhibit bacterial infection such as The objective of this study is to characterize the effect of weaning on the alteration of gut microbiome communities and AMR determinants in 24 commercial piglets (Landrace × Large White × Duroc Jersey) at day 3 pre-weaning (D. − 3), weaning day (D.0), days 3 (D.3) and 8 post-weaning (D.8) from 3 sows, using whole-genome shotgun sequencing.Bacteroidetes and Firmicutes constituted approximately 80% of all bacteria phyla  . Prevotella and Treponema were more abundant at D.8 compared with D. − 3–D.3 (P < 0.05).The Shannon diversity index showed no statistical difference of the microbiomes across weaning ages  Table . Relativsat, aac(6′)-aph(2″), aadA and acrF, resistance to β-lactam, including fus-1 (oxa-85), cepA and mrdA, resistance to MDR, including gadW, mdtE, emrA, evgS, tolC and mdtB, resistance to phenicol, including catB4 and cmlA4, and resistance to sulfonamide, including sul3. In contrast, a higher abundance of AMR determinants conferring resistance to MLS, mefA, resistance to β-lactam, cfxA6 and aci1, and resistance to phenicols, rlmN, was observed at D.8 , tetracycline and macrolide-lincosamide-streptogramin (MLS), followed by multidrug resistance (MDR), β-lactam and phenicols Table . D.8 shoE. coli on at least 2 days during D. − 3–D.3 compared with D.8, including AMG (aac(6')-aph(2'')), MDR (emrA and mdtB), and phenicol (cat4B and cmlA4) resistance patterns. In contrast, AMR gene abundances possibly correlated with Prevotella at D.8 were in MLS (mefA) and β-lactam (cfxA6 and aci1) resistance patterns . This is possibly due to different feeding schedules, breeds and farm environments between the studies, and other factors may also affect the alpha diversity changes. However, we found that the microbial community of piglets at D.8 significantly differed from earlier sampling dates, probably as the consequence of physiological changes and post-weaning farm management practices. Moreover, the PERMANOVA results revealed that the weaning age and diet played an important role in gut microbiome populations  compared with cow’s milk (4.2%) or human milk (3.2–3.6%)32. Alistipes had been reported to produce sulfonolipids, which play an important role in cell signaling and morphogenesis in animals, in mice fed with high-fat diets33. Bacteroides in infants were described to utilize human milk oligosaccharides (HMOs), bioactive components of milk that could not be completely digested by the host, using mucus-utilization pathways34. HMOs played several important roles in neonatal development, such as being prebiotics for gut microbiota and protecting the mucosal surface from pathogen binding, etc35. Similar to human milk, higher fucosylated compounds in porcine milk oligosaccharide were reported to be correlated with lower sialylated compounds at D.7 and D.14 of lactation compared with D.0 and a pre-colostrum period. The fucose consuming taxa containing genes encoding fucose-permease enzymes were also changed from Enterobacteriaceae in nursing pigs to Lactobacillaceae in weaned pigs36. Piglets are considered a good model for the study of human infant nutrition issues because of similar nutritional physiology such as a postnatal development of intestinal microbiota, the effect of gut microbiota diversity in early life on immune systems, and milk oligosaccharides37. In addition, Bacteroides in the piglet fecal microbiome has been shown to contain large amounts of genes encoding key catalytic enzymes such as sialidases and beta-hexosaminidases, that could digest sow milk glycans38. Clostridium was the major genus at D.0 and D.3, whilst the predominantly polysaccharide-degrading Prevotella was the major population at D.8. Soluble-fiber-degrading Treponema was also observed at higher abundance at D.8. Our results were similar to a previous report of Prevotella being markedly increased in weaned animals, supplanting the Bacteroides population38. The dynamic of the fecal microbiome population has been reported in antibiotic-free nursing and 7-day post-weaning piglets. Bacteroides was reported to be the most abundant microbe in nursing pigs, whereas in weaned piglets, Prevotella was enriched39. In our study, not only weaning age but diet was also shown to be associated with the microbial community composition. The same pre-starter (nursery) feed was provided throughout this study at the age of day 7–day 32 (D.8) . However, low amounts were observed at all ages (0.22–1.17%) despite being fed probiotics, containing Lactobacillus acidophilus and Lactobacillus plantarum, at postnatal D.1–3. According to a previous report, lactobacilli with probiotic potential were sensitive to several antibiotics used on the farms43. An antibiotic susceptibility test should be performed. On the other hand, low amounts of, or rare, probiotic microorganisms observed indicated that they did not serve as a reservoir for AMR determinants.This study revealed the population of fecal microbes and AMR determinants in commercial piglets aged 21–32 days. The Shannon diversity index is used to measure species richness and evenness. Divergent data of alpha diversity have been reported in piglets during weaning period. Increased indices were demonstrated in pigs at 10 and 21 days after weaning, compared with the weaning day and 10 days before the weaning day, showing the mature gut microbiomeontent 7.–10.1% cosat) and aac(6')-aph(2''), encoding a bifunctional enzyme, AAC(6′)-APH(2"). Sat and aac(6')-aph(2'') encoded enzymes linked to the antibiotic inactivation mechanism by acetyltransferase. sat conferred resistance to streptothricin via acetylation of the drug44. Streptothricin was not used on our farms but the other AMG, kanamycin, was intramuscularly injected into the sows on parturition day, and neomycin was mixed with feed for piglets at D.25–D.8. SAT has been shown to acetylate kanamycin and neomycin at lower levels than streptothricin45. From our study, high abundance of sat was observed at D.8, although lower than at D. − 3–D.3 (Supplementary Table aac(6′)-aph(2″), it was carried on transposons, causing AMG resistance not only in Gram-positive bacteria, but also in Gram-negative E. coli clinical isolates46. From the CCA plot in our study, we found correlation of aac(6')-aph(2'') with E. coli in the D. − 3–D.3 group  efflux pumps. The EmrA periplasmic adaptor has been reported to link the outer membrane protein TolC as an EmrAB–TolC tripartite efflux system in E. coli, similar to that of AcrAB–TolC complex, which is in the resistance-nodulation-cell division (RND) family of transporters47. EmrAB–TolC and AcrAB–TolC complexes have been reported to play an important role in the tolerance of E. coli to bile salts in the GI tract48. In our study, we observed high abundance of tolC and acrB. We also observed higher abundance of mdtB at D. − 3–D.3. mdtB encodes MdtB, a part of the MdtABC system, which is in the RND family similar to the AcrAB–TolC system49. We also found high abundance of mdtE. MdtE is part of the MdtEF–TolC tripartite efflux system, conferring resistance to several compounds such as erythromycin, cloxacillin and oxacillin50. We also found high catB abundance at D. − 3–D.3 . Both genes have been previously reported in E. coli, corresponding to our CCA plot results  was also observed. The cfxA6 gene was positively correlated with Prevotella , the associated AMR gene abundance was high as well. The occurrence of cfxA in β-lactamase-positive and negative Prevotella strains should be investigated further.On the other hand, the highest abundance of AMR determinant at D.8 was lla Fig. . cfxA wa23. In this study, tet(40) presents at the highest relative abundances across all samples, following by tetW. It encodes tetracycline efflux transporters under a MFS antibiotic efflux pump AMR gene family58. tet(40) is commonly found in pig gut microbiome. tet(40) from feces of organic pigs could present as a single tetracycline-resistance gene on a putative transposon and could be linked to tetW on a putative plasmid58. High tet(40) abundance has been reported in healthy sows not receiving antibiotics since weaning, probably reflecting the natural resistome59. In our study, sows were treated with chlortetracycline in feed at D. − 7–D. − 6 before parturition, whereas piglets from birth did not receive any tetracycline drug or its derivatives. However, residues of tetracycline and its derivatives have been reported in human breast milk60. The detection of antimicrobial residues in sow milk and of reservoirs of AMR genes in environments, such as soil and water, and the transmission of AMR genes among the microbiome should be investigated further. A limitation of the present study is the lack of phenotypic–genotypic comparison of resistance which is not available for frozen fecal samples.Tetracyclines are bacteriostatic antibiotics with broad spectrum activity. Tetracycline has been shown to be a selective pressure in fattening pigs, resulting in a greater number of tetracycline-resistant isolates61. As several antibiotics have been used on the farm for decades, such as tetracycline and AMG, and a number of strong positive correlations were observed, co-selection should be a concern. However, the withdrawal of antibiotics might not be able to solve such problems, as AMR determinants still presented even though pigs did not receive antibiotic, probably due to mobile genetic elements in the ecosystem58.The maintenance of AMR determinants on the farm is a complex problem. Several factors are involved, such as selective pressure, co-selection whereby the use of one antibiotic causes resistance to other drugs, and horizontal and vertical transmission of AMR determinants in the chromosome, plasmid, transposon or integron by bacteria62. The strategy of using these biotics was to replace the AMR microorganism communities with good microorganism populations. Another technique that has been successful in treating diseases relating to gut microbiota dysbiosis in humans is fecal microbiota transplantation (FMT). FMT has been reported to decolonize several AMR pathogens such as methicillin-resistant bacteria, extended spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and vancomycin-resistant enterococci63.In order to resolve the AMR concerns in the weaning pigs, manipulation of gut microbiota has been suggested. Due to the absence of maternal immunity in weaning piglets, biotic supplements including probiotics, fermented prebiotics and synbiotics should be considered to strengthen gut microbiota. In neonatal piglets and pregnant and lactating sows fed with prebiotics-supplemented diets, the activity of bacteria and intestinal immunity, in addition to immunity in piglets were significantly increasedThis study unveiled alteration of microbiome and AMR determinants in piglets at D. − 3–D.8 and that at D.8 or 8 days after weaning, piglets showed a different microbiome community and AMR determinants compared with other ages, reflecting the effects of weaning activity, dietary changes to a solid diet and farm transferring. The tracking of AMR gene abundance in other pig ages such as fattening pigs, slaughterhouse, pork in the markets and pig farmers should be investigated.All methods were carried out in accordance with guidelines and regulations and the study was carried out in compliance with the ARRIVE guidelines. All animals were managed following the ethical guidelines required under the Chulalongkorn University Animal Care and Use Committee (CU-ACUC), Thailand .A total of twenty-four crossbred Landrace × Large White × Duroc Jersey piglets from three sows raised on a local commercial farm were used in the study. Pigs were raised under the evaporative cooling housing system which can control air temperature and humidity in a building. The programs of feeds, antibiotics and probiotics for pregnant sows and piglets are shown in Table DNA was extracted from 180 mg fecal samples using a QIAamp Fast DNA Stool Mini kit  according to the manufacturer’s protocol. Genomic DNA was cleaned and concentrated by a Genomic DNA Clean & Concentrator Kit-10 , according to the manufacturer’s directions. DNA concentration and purity were determined using a NanoDrop ND-1000 Spectrophotometer V3.7  and the integrity of total DNA samples was evaluated with a 2100 Bioanalyzer . DNA samples were stored at − 20 °C until further analysis.DNA library preparation was performed according to the TruSeq Nano DNA Sample Preparation Kit protocol . The samples were sheared on a Covaris S220 or E220 focused ultrasonicator  to approximately 450 bp, following the manufacturer’s recommendation, and uniquely tagged with one of the TruSeq LT DNA barcodes (Illumina). The finished libraries were quantitated using a Quant-iT PicoGreen dsDNA Kit (Thermo Fisher Scientific) and the average library size was determined using a Bioanalyzer 2100 instrument, using a DNA 7500 chip (Agilent Technologies). Library concentrations were then normalized to 4 nM and validated by qPCR on a ViiA-7 real-time thermocycler (Thermo Fisher Scientific), using the KAPA Library Quantification Kit for Illumina platforms . The libraries were then pooled at equimolar concentrations and sequenced on an Illumina HiSeq2500 sequencer in rapid mode at a read length of 250 bp (paired-end read).64. DIAMOND version 0.9.10.111 was used to map the trimmed read pairs to the NCBI non-redundant (NR) protein database, retrieved on June 8, 201865. An operational taxonomic unit (OTU) table was constructed from the taxonomic classification results with a 97% confidence threshold. OTUs with their total number of mapped reads across all samples occupying less than 0.005% of overall mapped reads were filtered out, which was then subsampled to 1 262 472 reads per sample. This subsampling value is 80% of the sample with the lowest number of paired reads after trimming. The OTU table filtering and subsampling, in addition to subsequent alpha and beta diversity analyses, were performed using the QIIME 2 platform (https://qiime2.org/)66. A principal coordinates analysis (PCoA) plot of fecal microbiome taxonomy was constructed based on a pairwise dissimilarity matrix.The sequencing reads for all samples were trimmed using Trimmomatic version 0.38https://cge.cbs.dtu.dk/services/ResFinder/; accessed 21 September 2018)67, ARG-ANNOT version 468, and CARD version 2.0.3 databases using ARGDIT70. This reference sequence set was then clustered using CD-HIT with a 90% sequence identity threshold71. The trimmed read pairs were mapped to the reference AMR gene sequences using Bowtie 272 and those mapped pairs were assigned to the reference AMR gene sequence clusters accordingly. The gene abundances in fragments per kilobase of exon model per million mapped reads (FPKM) were then calculated from the mapped read counts of the clusters. Any cluster with its total abundance across all samples lower than 0.005% of the overall abundance was discarded. A stacked bar graph showing relative abundance distribution of antimicrobial resistance genes by antimicrobial drug resistance patterns was constructed from the proportion of read counts from the ResFinder annotation and presented using Microsoft Excel. Beta diversity analysis and a PCoA plot were performed for AMR abundance as for taxonomic abundance.The reference AMR gene sequences were obtained by integrating the ResFinder version 3.2  plots showed interrelationships between taxon profile and AMR profiles, using the regularized version implemented in the R package CCA because of there being a larger number of variables (taxa or AMR sequences) than samples74; (2) Alpha diversity of the samples was estimated using the Shannon index. Compositional difference between any two samples (beta diversity) was quantified with Bray–Curtis dissimilarity, and the PCoA plot at the family level was computed from the pairwise dissimilarity matrix obtained. This PCoA plot was visualized through the Emperor plugin for QIIME 275. Both PERMANOVA and alpha diversity calculations employed uniformly subsampled data, as described above.For DIAMOND results of microbiome communities, two statistical analyses were performed between groups of samples, namely: (1) permutational multivariate analysis of variance (PERMANOVA) to examine differences in microbiome community composition among groups of samples, under the null hypothesis of no differences among groups. PERMANOVA was performed using the adonis function in the R package vegan (version 2.5-2)76. Statistical analyses of Shannon diversity index and relative abundance of microbial phyla and microbial genera were performed using the Kruskal–Wallis test. For AMR gene data, we employed the function manyglm with a negative binomial distribution and with the offset component set to the log of the sum of FPKM values for each sample. Day of sampling was treated as the factor of interest. We estimated P-values using the anova.manyglm function, using 1000 bootstrap resamples (resample parameters set to ‘PIT-trap’) and we unadjusted for multiple hypothesis testing using the step-down procedure specified by the parameter uni.p set to "adjusted". All other parameters in anova.manyglm had default settings. Differential abundance of AMR genes corresponding to antimicrobial drug resistance patterns was analyzed using the DESeq2 version 1.30.0 in R software77, and data were visualized using ggplot2 version 3.2.1 in the tidyverse package .For both taxa and detected AMR determinants, we tested for differences in relative abundance of each taxon or AMR sequence entity, respectively, among groups using generalized linear models (GLM) implemented in the R package mvabundThe study was approved by the Chulalongkorn University Animal Care and Use Committee (CU-ACUC), Bangkok, Thailand .Supplementary Information.


While the potential of cellulose nanofibers to enhance the mechanical and barrier properties of paper is well-known, there are many uncertainties with respect to how to apply them. In this study, we use not only bulk addition of micro-/nanofibers and bar coating with oxidized nanofibers, but also a combination of these and, as a novel element, electrospray deposition of nanofiber dispersions. Characterization involved testing the strength of uncoated and coated paper sheets, their resistance to air flow, their Bendtsen roughness, and their apparent density, plus visualization of their surface and cross-sections by scanning electron microscopy. As expected, bulk addition to the unrefined pulp was sufficient to attain substantial strengthening, but this enhancement was limited to approximately 124%. Following this, surface addition by bar coating improved air resistance, but not strength, since, as applying nanocellulose at high consistency was technically unfeasible, this was performed several times with detrimental drying stages in between. However, replacing bar coating with electrospraying helped us overcome these apparent limitations, producing enhancements in both barrier and tensile properties. It is concluded that electrosprayed nanofibers, owing to their uniform deposition and favorable interactions, operate as an effective binder between fibers (and/or fines). Nanocellulose, especially in the forms of cellulose nanofibers (CNFs) and cellulose micro-/nanofibers (CMNFs), has been generating increasing interest among researchers and manufacturers ,2,3. FroTraditionally, paper has been deemed a low value-added commodity. Such consideration still holds true, given that, at least among European papermakers, value added amounted to only 22% of the total turnover in 2019 and 2020, and it has been like this since 2010 . HoweverNonetheless, CNF-reinforced paper has severe limitations as a composite material, mainly arising from the fact that both the matrix and the reinforcing phase of the material are cellulosic. On the one hand, it is difficult to imagine that the water resistance of a fully cellulosic material could match those of a polymer resin, such as polyethylene terephthalate. On the other hand, when it comes to its mechanical properties, certain improvements have been made since Eriksen et al. obtained increments of up to 30% in the tensile strength of thermomechanical pulp handsheets  . One of In this study, we suggest a combined approach, encompassing simultaneous bulk addition of CMNFs and surface addition of CNFs, to enhance paper strength and air resistance. As a novel approach, we consider the hypothesis that surface addition by electrospraying, instead of conventional coating, can overcome the limitations of the typical procedures used for nanocellulose-reinforced paper. The basis of this hypothesis is that momentum transfer is severely hindered in dispersions of nanoscale oxycellulose, but the application of an external electric field allows control of the flowrate of droplets over a surface. Electrospray deposition has seldom been used on paper, although some applications of poly(lactic acid) nanoparticles on paperboard have been considered ,28. PartProduction of both types of cellulose nanofibers, TEMPO-oxidized nanofibers, glucanase-hydrolyzed nanofibers, and paper sheets were carried out using an unrefined bleached hardwood kraft pulp (BHKP) supplied by Torraspapel S.A.  as raw material. The bleached eucalyptus fibers used originally had an average length of 700 µm and an average diameter of 16 µm, as measured by means of a MorFi Compact analyzer .The chemical reagents used for TEMPO catalyzed oxidation were sodium bromide 99%, sodium hypochlorite 15%, sodium hydroxide 0.5 M, and TEMPO catalyst. All reagents were purchased from Merck KGaA  and used without further purification.Production of the glucanase-hydrolyzed nanofibers was carried out by a 2% endo-β-1,4-glucanases commercial enzyme cocktail Novozym 476 , with an activity factor of 4500 CNF-CA/g cellulose (obtained on a sodium carboxymethyl cellulose substrate).3, provided by the paper company LC Paper S.A. .The dual retention system used in the nanofibers bulk addition was composed of cationic corn starch, C*Bond HR, supplied by Cargill Ltd. , with a degree of substitution of 0.042–0.049, and colloidal silica, with particle size in the range 8–30 nm and a density of 1.2 g/cmA general scheme of the experimental procedure is presented in The pretreatment of BHKP for the glucanase-hydrolyzed nanofibers production was conducted in an atmospheric reactor at 50 °C, following the procedure described by Tarrés et al. . BrieflyBleached eucalyptus fibers were oxidized by the addition of 15 mmol of sodium hypochlorite per gram of cellulose. The TEMPO-catalyzed oxidation was performed in the presence of 0.1 g NaBr and 0.016 g TEMPO per g of fibers, according to the methodology described by Saito et al. 2007 . The oxiBoth pretreated fibers were homogenized in PANDA Plus high-pressure homogenizer . The homogenization process was carried out by passing a 1 wt.% suspension of pretreated fibers by a sequence of 3 passes at 300 bar, 3 passes at 600 bar, and 3 passes at 900 bar.The characterization of the nanofibers obtained was presented in previous works ,31. The 2 were produced in a Rapid Köthen paper sheet former .Endoglucanase-hydrolyzed micro-/nanofibers were added in bulk at 0, 1.5, 3, and 4.5 wt.%, based on dry pulp weight. Then, a dual retention system (0.8 wt.% of cationic starch and 0.5 wt.% of silica) was added maintaining the pulp suspension, whose consistency was 0.2 wt.%, under constant stirring. Finally, paper sheets of approximately 76 g/m2). In the case of the bar coater, a suspension of nanofibers at 0.45 wt.% was used in one, two, or three layers. The sheet was dried after each application. The electrospray application was carried out using a suspension of nanofibers at 0.3% for 20, 40, or 60 min.The surface application of TEMPO-oxidized nanofibers was conducted by two different systems, bar coater  and electrospraying . In both cases, applications were carried out to obtain three degrees of coating, based on the increase in basis weight , while partially restraining shrinking by attaching the sheets to a steel surface. Then, sheets, still with a moisture content above 20 wt.%, were briefly hot-pressed at 93 °C in the drier of the aforementioned Rapid Köthen system (1 min).The paper structure and the coating characteristics were analyzed by scanning electron microscopy (SEM) . The evolution of air resistance was determined by Gurley porosity test following the methodology described in the standard . TensileMicrographs of paper sheets containing up to 4.5 wt.% CMNFs are displayed in The effect of bulk addition on important mechanical and surface properties is presented in In order to envisage the way oxidized CNF-based coatings interact with fibers and fines on the surface of paper sheets, Cross-sectional SEM images of sheets are displayed in The high viscosity of oxidized CNF dispersions imposes a restriction on the quantity of nanofibers that can be placed on the surface of paper in a single application, as high consistencies carry evident problems of runnability. This is why, as described above, bar coating was performed as multiple layers, but this multistage treatment implied drying after every application. The rate of this drying, due to the hydrophilic character of nanofibers, was slowed down with increasing CNF content . Table 2While conventional coating processes imply the use of excess suspension and doctoring away or recycling the excess, electrospray deposition allows for nearly total material efficiency; almost all the small drops generated by liquid atomization end up, slowly, covering the surface of paper. The nearly sealed surface that can be recognized in It has been shown, by micrographs and by the positive effects on air resistance, that bulk addition of CMNFs had a compacting effect on paper sheets, particularly along the Z direction. Likewise, strengthening was obvious, especially from 0% to 3%, by which the breaking length roughly doubled its value (up to 3.6 km). These results support the positive effects on paper strength that have previously been reported in the literature . It shouBar coating consistently helped decrease porosity at the surface. Thus, the surface application of anionic nanofibers protected the sheet from air flow for longer in the air permeability (Gurley) test, up to 197 s. However, effects on tensile properties were not unambiguous. Even combining bulk incorporation and coating, breaking length did not go beyond 4 km. In fact, bar coating of the most resistant reinforced sheets had a negative impact on the performance in tensile tests. This loss can be partially explained by wetting and re-drying up to three times. During drying, fibers approach each other, closing or tightening the pores and decreasing the specific surface area . The fibWith respect to the original contribution of this study, electrospray deposition allowed oxycellulose nanofibers to bind in an effective way to the superficial fibers and fines of paper resulting in the apparent homogeneity of the surface in micrographs d–f. In c−3 from uncoated papers with 60 min of electrospray deposition. This is consistent with the micrograph at The most notable achievement was not the enhancement of air barrier properties, but increase in paper strength (in relative terms). This is not to imply that a strengthening coating layer is an unexpected outcome, since positive effects on mechanical properties have been observed even for conventional coating formulations . In thesTo the question of which stage of papermaking offers the best opportunity to enhance the properties of the end-product, either bulk addition of surface treatment, this study provides a clear answer—both. However, bar coating, a rather conventional surface treatment process, only succeeded in sealing the paper against air flow, while there were limited or even adverse effects on paper strength. The most plausible reason lies in the need for re-drying after every coating layer, given the limitations of a single application. Electrospraying was able to deposit at least as much of the CNF dispersion as 3 layers of bar coating with only one post-drying step. The applied nanofiber layer not only slowed down air flow, attaining a Gurley air resistance over 300 s, but also led to a significant increase in the breaking length, especially when compared to the unrefined reference handsheets with no bulk addition of CMNFs. Overall, atomization by electrical stimuli overcame the large limitations to momentum transfer that CNF suspensions usually imply in a single application case and avoided fiber collapse by re-drying in the case of multilayer coating. While electrospray deposition is currently not feasible for a paper machine, an adaptation of the concept to the existing technology  is worth pursuing.


In the Netherlands, approximately 350,000 patients are referred to a cardiologist for a first evaluation of cardiac complaints. It is estimated that half of this population are assessed for chest pain. As such, there is an ongoing interest in the diagnostic workup of patients with chest pain and suspected coronary artery disease (CAD). In recent years, there have been important technical developments in the field of coronary computed tomographic angiography (CCTA). New trials have been published, and clinical guidelines have advocated a more important role for CCTA in clinical practice. Further advances in hardware and advances analytics will lead to a core role for CCTA at the centre of every clinical cardiovascular practice.The SCOT-HEART  demonstrated the added value of CCTA to standard of care (which included an exercise electrocardiogram in most patients) . The addThe large randomised controlled PROMISE , which included over 10,000 patients with stable angina pectoris, demonstrated that CCTA was non-inferior to a functional testing approach  with respect to the composite endpoint of death, myocardial infarction, hospitalisation for unstable angina or major procedural complications . HoweverNetherlands Heart Journal, Boerhout et al. argue an even more dominant role for CCTA than used so far in patients with new-onset stable angina presenting at the outpatient clinic [In this issue of the t clinic . They deCambridge Dictionary, a gatekeeper is described as ‘someone who has the power to decide who gets particular resources and opportunities, and who does not’. In the published flow chart, CCTA will dictate treatment strategy (including medication for primary prevention) and which patient should be referred for further additional noninvasive or invasive testing [In the  testing . Indeed,However, Boerhout and colleagues add an important notion by suggesting the use of CCTA for the individual patient. In the case of angina with no obstructive coronary artery disease, CCTA cannot discriminate between patients with and without functional disorders of the vessels. CCTA can merely be used to state that there is nonobstructive CAD. The evaluation of symptoms, including the information from CCTA, allows tailored medical treatment. This strategy may reduce the number of invasive procedures, both in nonobstructive and obstructive CAD, if invasive procedures are reserved for those patients who do not respond adequately to installed medical therapy. This means intracoronary function testing in nonobstructive CAD and revascularisation in obstructive CAD.Therefore, the evaluation conducted by the physician remains the cornerstone of diagnosis and treatment in patients with chest pain and can be regarded as the real gatekeeper for patient management. We are lucky that this is the case, as it makes evaluation in a large number of patients with chest pain an interesting challenge for the medical detectives (MDs).


Antimicrobial resistance (AMR) poses an increasing public health threat to low- and lower-middle income countries. Recent studies found that in fact poor governance and transparency correlate more strongly with AMR than factors such as antibiotic use. While many African countries now have national action plans (NAPs) on AMR, it is unclear whether information is publicly available on their implementation, surveillance and financing.Here, the transparency of information related to AMR national action plans in 15 African countries is assessed, based on a governance framework for AMR action plans. Public availability is assessed for AMR documents, progress reports, AMR surveillance data, budget allocations, as well as bodies and persons responsible for implementation of NAPs. Government websites and search engines were perused using search terms related to the studied criteria and countries.Results show that most countries have a national action plan publicly available. AMR surveillance data was available for a few countries, but systematic progress reports and funding allocations were absent in all but one country. Information on a body mandated to coordinate NAP implementation was available for most countries, but their functionality remain unclear. Most countries have nominated at least one person responsible for AMR nationally. In general, information was often fragmented and frequently available on external, non-government websites. It appears that commitments on AMR made in the often comprehensive NAPs are rarely met in a timely manner, exhibiting rather weak accountability for AMR results. The article provides concrete policy recommendations on how transparency and accountability may be improved with little effort.Making information available can enable stakeholders such as civil society to demand accountability for results and lead to much needed specific actions on curbing AMR in countries.The online version contains supplementary material available at 10.1186/s13756-021-01040-4. Antimicrobial resistance (AMR) is deemed one of the central public health challenges of the twenty-first century. The former United Nations director general Ban Ki-moon called AMR “a fundamental, long-term threat to human health, sustainable food production and development. […] Without AMR containment, the Sustainable Development Goals for 2030, such as ending poverty, ending hunger, ensuring healthy lives, reducing inequality, and revitalizing global partnerships are unlikely to be achieved.” . PolicieTo tackle AMR globally through a holistic and multi-sectoral One Health approach, the Food and Agriculture Organization of the UN, the World Organization for Animal Health, and the World Health Organization (WHO) formed a tripartite collaboration. This tripartite body advises countries on how to develop a national action plan (NAP) on AMR and has established a NAP database for monitoring progress on a global scale . The gloIn 2015 the WHO found that only 34 out of 133 participating in a survey reported on having a NAP to tackle AMR  Since thIn the absence of effective national government accountability, the implementation of NAPs is unlikely to progress significantly and fast enough on a global scale. Being held accountable for meeting the policy commitments written down in the AMR NAPs is essential to achieving sustained funding and action on AMR. One current theory of change stipulates that transparency, by informing stakeholders, facilitates their participation in policy making and thereby enables accountability , 25. IntAssessments of governance, transparency and accountability in the health and pharmaceutical sector have been put forward in recent years to identify vulnerabilities, gaps as well as strengths in health systems and encourage governments to make more information publicly available , 31. AndThis paper offers the first operationalization of Anderson et al.’s framework to assess public availability of key information on AMR NAPs. It further provides the first comprehensive overview of key information on AMR NAPs in Africa, which can inform interested stakeholders such as policy makers and civil society and help build capacity in countries. It is hoped that this study encourages countries to prioritize sharing timely information on AMR NAPs in the future, to facilitate sustained action against AMR.The objective of this research is to assess transparency and accountability aspects of AMR NAP implementation in 15 African countries.For this study, African countries have been selected if they met the following criteria: (1) have English as an official language and also (2) responded to having developed a national action plan in the self-assessment questionnaire submitted to the tripartite AMR database in 2018/2019, i.e. answering C, D or E in response to item 5.1 “Country progress with development of a national action plan on AMR”. The countries included were: Ethiopia, Ghana, Kenya, Liberia, Malawi, Mauritius, Namibia, Nigeria, Seychelles, Sierra Leone, South Africa, Tanzania, Uganda, Zambia and Zimbabwe.Assessment criteria were selected and adapted from the NAP governance assessment framework by Anderson et al. , specifiIn the accountability domain, Anderson et al. (2019) also ask whether agreements exist regarding what happens if objectives are not met. This aspect has not been included in this study as a recent study of AMR NAPs in South East Asia found that “implications of unmet objectives were absent” . If presSearches were conducted in English between July and November 2020. Two types of searches were performed using keywords and synonyms representing the assessment criteria. During the first search, the relevant One Health ministries were identified for each country , other information was only found in a fragmented manner (progress reports) or hardly at all . And overview of all results across assessment criteria and countries is presented in Table For 11 of the 15 countries a NAP was publicly available. The comprehensiveness, lengths, structure and content of plans was very diverse. Some included targets and costing (e.g. Ghana), others were more general and announced the development of implementation plans and budgeting in further documents (e.g. Ethiopia). South Africa, for example, has produced the NAP in two separate documents, the “National strategy framework” and an implementation plan. Ethiopia has a “Strategy for the prevention and containment of AMR”, which can be found in the WHO library of national AMR action plans. However, the implementation action plan announced therein to follow as a separate document has not been found as a result of this search. Similar to Ethiopia, some countries used other titles than national action plan for their documents, such as “national strategic plan” (Sierra Leone) and “national strategy framework” (South Africa), which may complicate finding this information for interested stakeholders. Table Some NAPs could not be found, such as that of Namibia, which seems to be waiting for approval since 2018. According to the Fleming Fund, which supports LMICs to generate, share and use AMR data, Malawi has developed a NAP, published as the “National AMR Strategy”  and screNo written national annual progress reports have been identified that systematically address progress of the NAP for any country. South Africa has made annual PowerPoint progress reports available, in which progress on different aspects of the AMR strategy is detailed . For mosThe most comprehensive external progress reports found were the Medicines, Technologies, and Pharmaceutical services (MTaPS) Program annual and quarter reports, available for Ethiopia, Kenya, Tanzania and Uganda . HoweverFor several countries, information such as new AMR guidelines were found, that had been developed during the NAP implementation timespan. These findings indicate that progress is indeed happening, but is not systematically communicated. Other articles explicitly state that implementation is stalling, as for example in Namibia where “due to resource issues and competing priorities, the implementation of [the Namibian] action plan has faced challenges” .Four countries have reported AMR surveillance data in the WHO GLASS report 2019/2020 for all or most of the GLASS pathogen indicators . Six couThe Fleming fund notes in one of its reports that there is little perceived use of surveillance data on any level and also low demand for that data from policy makers . It can Information about funds allocated to AMR activities were hardly available, particularly with regard to government budget. An official allocation of federal budget was only found for Nigeria, labelled as “Implementation of National Action Plan for antimicrobial response in Nigeria” and “Sustaining Antimicrobial Resistance surveillance in sentinel sites in Nigeria” . While sIt could be hypothesized that the lacking availability of information on funding allocations means that no funding is dedicated to AMR activities. However, for several countries specific AMR related activities have been reported, such as guidelines development, workshops and surveillance activities. For example, in the “Guidelines for the prudent use of antimicrobials in animals” in Kenya, it is stated that these had been made possible through the Standards and Market Access Program (SMAP) of the Ministry of Agriculture, Livestock, Fisheries and Irrigation with support from the European Union (Guidelines). However, no AMR allocations could be found in the federal budget. It therefore seems that national budgets so far do not provide sufficient detail to identify allocations to AMR.For all countries that have a NAP publicly available, the name of at least one governance body responsible for tasks related to the NAP could be ascertained. The names of these bodies differ between countries  for AMR”, suggesting that the committee has not been officially established yet . In NigeSome NAPs included implementation matrixes listing outputs and the body responsible for each. However, very often numerous bodies were mentioned for each output as well as heterogeneous group such as “academia”, somewhat thwarting the idea of responsibility.No country seems to have (publicly) nominated one responsible person for each of the three sectors, human health, animals and environmental health  did find information on AMR on the same website. It can be assumed that most citizens are unaware of how to use this function. This could lead stakeholders to assume that no NAP or progress exists and discourage them from actively demanding information. Another observation was that documents were often not available from official websites of the national government, but rather from other organizations such as funding bodies or health organizations. Contact details for national focal points were usually not available, making it difficult for stakeholders to know from whom they can request information. In summary, the following steps are considered useful to improve transparency and accountability with regard to AMR NAPs:The findings presented in this study are considered timely and policy relevant as they suggest that not only transparency, but also progress on AMR NAP implementation seems to be precariously lagging in many countries and accountability is urgently needed to ensure that NAP commitments are met in the future. This is particularly important considering the current preference given to resources for COVID-19 containment, which could further exacerbate already insufficient funding and political will on AMR. However, AMR is a more permanent and potentially much more severe pandemic, which can be slowed through better transparency and accountability.It is important to reiterate that this study is looking at the public availability of information online. Even in cases where no information was found, this information might exist at government level internally, in hard copy format or in national languages. It should also be acknowledged that in many of the studied countries, the process to develop and implement policies tackling AMR have only commenced in recent years. Furthermore, the potential impact of COVID-19 pandemic on AMR related work has to be kept in mind. In many countries, the resources redirected towards the COVID-19 response will have aggravated problems to secure financing of AMR activities and hindered progress. It can be hoped that more progress can be observed in the coming years, such as development of surveillance systems as well as data collection and sharing thereof.Anderson et al. ask to apply caution when using the framework for cross-country comparisons since the quality of documents and measures might differ significantly and ticking the same box for all countries does not mean the same quality or results . It shouThe Tripartite results for the 2019/2020 survey were published while this study was conducted and they show some discrepancies with the findings presented here . Table 6The difficulties to find health budget line item information are in accordance with results from a recent study which found that national budgets did not include enough detail on Ministry of Health budget allocations to identify immunization . GriffitGood standards and formats for transparency on AMR have yet to be developed. Countries taking the lead now can set good examples and inspire others to follow suit. Just as pathogens, transparency can be contagious. Establishing transparency is often a rather low hanging fruit, as it merely requires making information publicly available that already exists at government level. In Zambia, for example, a workshop was held where participants were updated on the AMR National Action Plan implementation status . Since tIt can be assumed that many governments shy away from making available information on something that has not been achieved or is behind schedule. However, accountability also means explaining the reasons for not meeting commitments, which strengthens public trust in governments. This trust in turn is essential to the successful implementation of AMR activities, such as doctors accepting new practices of prescribing and patients following advice on taking antibiotics. Transparency can also enable and inspire participation and may activate stakeholders that want to advance the process and apply scrutiny in a productive way. One example is the Roll Back Antimicrobial Resistance Initiative in Tanzania, with Erick Venant as a local champion, that helps to implement the national AMR agenda and has called for the acceleration of the NAP implementation . A recenSimilarly, international organizations and donors can contribute to strengthening transparency. For example, the WHO library for AMR NAPs as well as the FAOLEX database of the Food and Agriculture Organization are currently lacking several existing NAPs and could be updated more regularly to include all current versions. Donors that finance AMR NAP development and implementation could tie their funding to transparency clauses and require the public disclosure of e.g. annual progress reports and all funding allocations.In summary, the findings of this study reflect conclusions from the Interagency Working Group on AMR and others: particularly in LMICs, the biggest challenge is not formulating action plans, but implementing them , 56, 57.While there is no one-fit-all solution that can be easily applied, the Interagency Working Group on AMR also emphasizes the importance of strengthening transparency and accountability to close the implementation gap . Khan etAn open discussion about the current approach in many LMICs would be helpful, which is that often donors fund the development of elaborate and ambitious NAPs. However, what is their use if these NAPs are then sitting on the shelves and are only very partially implemented? More focused plans could help to achieve accountability for a limited number of prioritized commitments. The University of Glasgow has launched a novel research project in Zambia to make prioritization an essential component of controlling AMR in LMICs. Through a workshop with all sectors involved Zambia has already produced a document prioritizing activities of their NAP in 2019 . It remaThe results of this study showed that most countries have published their AMR NAPs and the number of countries sharing their surveillance data on AMR is slowly increasing. However, transparency on progress and funding allocations of AMR is very limited. It appears that governments rarely meet commitments on AMR made in the often comprehensive and detailed action plans, exhibiting rather weak accountability for AMR results. Increasing transparency on progress—or reasons for lack thereof—would strengthen accountability and enable stakeholders such as civil society to demand much needed specific actions on curbing AMR in countries around the world.Additional file 1: Additional information on results and websites searched.


Coronary computed tomography angiography (CCTA) is a comprehensive, non-invasive and cost-effective imaging assessment approach, which can provide the ability to identify the characteristics and morphology of high-risk atherosclerotic plaques associated with acute coronary syndrome (ACS). The development of CCTA and latest advances in emerging technologies, such as computational fluid dynamics (CFD), have made it possible not only to identify the morphological characteristics of high-risk plaques non-invasively, but also to assess the hemodynamic parameters, the environment surrounding coronaries and so on, which may help to predict the risk of ACS. In this review, we present how CCTA was used to characterize the composition and morphology of high-risk plaques prone to ACS and the current role of CCTA, including emerging CCTA technologies, advanced analysis, and characterization techniques in prognosticating the occurrence of ACS. Acute coronary syndrome (ACS) may be the first manifestation of coronary artery disease (CAD), mainly caused by the rupture or erosion of unstable plaques –4, whichHowever, these invasive diagnostic approaches with low positive predictive value and unclear cost-effectiveness have not been widely used in clinical practice . CoronarIn this review, we delineate the current understanding of the pathology of the atherosclerotic plaques associated with ACS and corresponding manifestations on CCTA in clinical practice. The application of CCTA in characterizing the composition and morphology of high-risk plaques prone to ACS and prognosticating the occurrence of ACS are further described. Finally, the progress in emerging CCTA technologies, advanced analysis and characterization techniques are also reviewed. The new techniques can provide the comprehensive assessment of high-risk plaques and surrounding environment, and may provide personalized risk assessment of future ACS events and further guide clinical decision-making.The detection and characterization of plaque by CCTA is based on histopathology, therefore, and therefore it is vital to grasp the histopathological characteristics and evolution process of high-risk atherosclerotic plaque.Atherosclerosis, most often observed at the branch points and low shear stress areas of blood vessels, is a multifactorial systemic disease and has a chronic and progressive process . About tThe characteristics of high-risk plaques are related to the vulnerability of plaques . Based oThe percentage of stenosis is important information on CCTA. When coronary heart disease cannot be ruled out clinically, the percentage of stenosis on CCTA can help to rule out patients in stable condition and with low possibility of coronary heart disease –27. Howein vivo detection of coronary artery, IVUS examination confirmed that the cross-sectional area of the vessel at the atherosclerotic site was significantly larger than that at the proximal reference segment, then the concept of positive remodeling was proposed which refers to the compensatory increase of vessel wall when atherosclerotic plaque volume increases continuously, thus maintaining the effective area in the lumen , which is defined as mean attenuation <30 Hounsfield units (HU) of at least three regions of interest (ROIs) in general , 45 Figb. HoweveSpotty calcification is the initial state of calcification. Since calcification is one of the consequences of local inflammation, spotty calcification may indicate active local inflammation. Mechanical stimulation on fibrous cap caused by spotty calcification and local inflammation may lead to the plaque with spotty calcification easy to rupture, thereby accelerating disease progression –48. Ther2)   correspo rupture . The den rupture , 14.Although the risk of plaque instability increases with the degree of coronary stenosis, most of the culprit lesions found in ACS are considered non-obstructive before rupture. Previous studies indicated that the characteristics of high-risk plaques identified by CCTA have a prognostic value independent of stenosis and atherosclerotic burden  see Tab.In 2007, Motoyama et al. found that compared with SA lesions, the frequency of positive remodeling, non-calcified plaques or low-attenuation plaques (<30 HU) and spotty calcification on CCTA was higher in ACS culprit lesions, and these three characteristics could independently predict the occurrence of ACS. Moreover, among the three plaque features, positive remodeling has the highest accuracy in ACS prediction . In addiP = 0.01)  . These r = 0.01) , 54, 55. = 0.01) .In a number of cross-sectional studies, investigators found that spotty calcification was associated with culprit lesions in ACS –52, 55. P < 0.001], which indicated napkin ring sign was an independent predictor of ACS  of ACS in patients with the napkin ring sign was 5.55 [95% confidence interval (CI), 2.0–14.70; r of ACS . In a lor of ACS .post-hoc analysis of the SCOT-HEART study, the adverse plaque was defined as a plaque with one or more of the features above observed. The results revealed that patients with adverse plaques had three times higher risk of myocardial infarction than patients without adverse plaques, and the prediction effect was stronger when combined with the presence of stenosis  has used advanced fluid dynamics analysis method which combines the advantages of CCTA and traditional FFR  is the ratio of the pressure at the distal end of the stenosis to the pressure at the proximal end of the normal vessel in a state of maximum hyperemic condition. In recent years, FFR derived from CCTA , wall shear stress (WSS) and axial plaque stress are important hemodynamic parameters, which has been reported to be associated with the occurrence of adverse clinical events   . These sVascular inflammation can promote the progression of coronary atherosclerosis and vulnerable plaque rupture, leading to the occurrence of ACS . EpicardInflammation of adipose tissue around the plaque will directly affect the formation and stability of coronary plaque. Therefore, PCAT attenuation measured by CCTA is a promising indicator for identifying high-risk plaques. In patients with ACS, cases of PCAT stranding have been reported around culprit lesions . GoellerAlthough FAI can detect the changes of PCAT composition caused by coronary artery inflammation, it can only measure the average density of the ROI and cannot fully reflect the fine structural characteristics of the ROI. Inflammation, fibrosis, and angiogenesis are three main causes of adipose tissue dysfunction . AdvanceModern CCTA assessment provides a series of advantages by combining the coronary anatomy, plaque morphology, atherosclerotic plaque load and coronary blood flow, which allows for the evaluation of morphological and functional characteristics of high-risk plaques, and the individual risk of ACS.In addition to CCTA, positron emission tomography (PET), magnetic resonance coronary angiography (MRCA), IVUS, OCT, and other imaging modalities are also effective methods to assess coronary atherosclerotic plaques –98. Notain vivo, offering prognostic implication of patients at higher risk of ACS . Furthermore, combining multi-dimensional methods can comprehensively evaluate the anatomy and biology of the coronary artery, and further integrate CCTA into clinical practice. However, the identification of high-risk plaque characteristics based on CCTA and emerging technologies such as FAI have not been verified in randomized controlled trials with definite results, which requires verification of the clinical benefits of CCTA applications in the future.GL substantially planned, wrote, and revised the manuscript and made illustrates and the table. WY polished and revised the manuscript. JO and XL contributed to the collection of CT images. ZT and TL contributed to linguistic revision of the manuscript. HL substantially contributed to instruction of the writing and revision of the manuscript. All authors read and approved the final manuscript.The work was supported by the Key R&D Program of Guangdong Province of China (No. 2018B030339001 to HL), the National Natural Science Foundation of China (No. 81974262 to HL), Guangdong Basic and Applied Basic Research Foundation (No. 2020A1515010650 to HL), and Guangdong Nurses Association Research Foundation (No. gdshsxh2021b077 to XL).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Platelet-rich thrombosis leads to the occlusion of arteries. Whether the association between platelet count and closure of hemodynamically significant patent ductus arteriosus (hsPDA) exists remains inconclusive. Given that neonatal platelet count is significantly affected by infection, this study aims to evaluate the association of platelet parameters before ibuprofen treatment with the closure of hsPDA in very low birth weight (VLBW) infants without concurrent infection.Methods: A retrospective study was conducted at the NICU of Shenzhen Maternity and Child Healthcare Hospital from January 2016 to August 2020. VLBW infants diagnosed with hsPDA, treated with oral ibuprofen and without concurrent infection were included in this study. The platelet parameters were retrieved from the whole-blood test routinely performed within 24 h before starting treatment of oral ibuprofen. A multiple regression model was built to evaluate the association between platelet parameters before ibuprofen treatment and successful closure of hsPDA.Results: A total of 129 premature infants with hsPDA were analyzed in this study. After oral ibuprofen treatment, successful closure of hsPDA was achieved in 70 (54.3%) infants. The gestational age at birth and birth weight in infants with successful or failed closure of hsPDA after ibuprofen treatment were 28.3 vs. 27.6 weeks (p = 0.016) and 1,120 vs. 960 g (p = 0.043), respectively. The rate of mechanical ventilation in infants with successful closure of hsPDA was significantly lower compared to those with failed closure of hsPDA, 31.4 vs. 54.2%, p = 0.014. The platelet count in infants with successful closure of hsPDA after ibuprofen treatment was significantly higher compared to those with failed closure of hsPDA, 212 vs. 183 (in a unit of 109/L), respectively (p = 0.024). Multivariate logistic regression analysis showed that a higher platelet count (≥181 × 109/L) before ibuprofen treatment was independently associated with successful closure of hsPDA .Conclusion: The findings in this study suggest that a higher platelet count before oral ibuprofen treatment may predict the probability of successful closure of hsPDA in VLBW infants. Despitemonoxide . Howevermonoxide –9. In admonoxide , 9–11.per se can result in late ductal reopening and PDA closure failures  born with a birth weight <1,500 g, (2) diagnosed with hsPDA, and (3) received ibuprofen treatment. HsPDA was diagnosed when the ductus diameter exceeds 1.5 mm, left atrial inner diameter/aortic root (LA/AO) exceeds 1.4, and combined left to right shunt by echocardiography (2). We excluded infants from pregnancies with maternal complications such as preeclampsia, maternal autoimmune diseases, and intrauterine infection. Infants with congenital heart diseases, fetal and neonatal alloimmune disorders, intrauterine growth restriction (IUGR), and concurrent infection  were also excluded from this study. Finally, infants with ibuprofen treatment started later than 7 days of postnatal age due to fasting were also excluded.Infants' characteristics were collected, including gestational age (GA), birth weight (BW), gender, mode of delivery, antenatal glucocorticoid use, twins, APGAR scores at 1 and 5 min, and mechanical ventilation (≥24 h). Platelet counts (PLT), plateletcrit (PCT), mean platelet volume (MPV), and platelet distribution width (PDW) were retrieved from a whole blood test routinely performed within 24 h before ibuprofen treatment using the Mindray 5390 analyzer platform . The standard biosecurity and institutional safety procedures were not relevant for the current study.® Specification: 15 ml: 0.6 g) at a daily dose of 10 mg/(kg·day) for 3 consecutive days  or median [interquartile range (IQR)] for continuous variables and frequency (percentage) for categorical variables. Receiver operating characteristic (ROC) curve was used to determine the cutoff for platelet parameters. Multivariable logistic regression was used to assess the independent contribution of potential factors to the outcome. The odds ratio and 95% confidence interval were calculated. Statistical analysis was performed with the IBM SPSS Statistics 24 software. A p < 0.05 was considered statistically significant.Student p = 0.016) and 1,120 vs. 960 g (p = 0.043), respectively. The rate of mechanical ventilation in infants with successful closure of hsPDA was significantly lower compared to those with failed closure of hsPDA, 31.4 vs. 54.2%, p = 0.014 ; the confidence interval (CI) was 0.483–0.685; sensitivity, 0.729; specificity, 0.508; and Youden index, 0.220 , p = 0.029]. Besides, a higher gestational age showed a positive tendency of successful closure of PDA by ibuprofen while no statistical significance was reached (p = 0.062). Thrombocytopenia before the first course was not independently associated with hsPDA closure after ibuprofen treatment, although a tendency toward decreased chance of closure was observed .Multivariate logistic analysis was performed to assess the independent contribution of platelet level before ibuprofen treatment to the outcome of PDA closure . A plate9/L) before ibuprofen treatment was found to be independently associated with the closure of hsPDA in VLBW infants without concurrent infection.In the current study, the rate of successful closure of hsPDA was 54.3% after the first ibuprofen course in VLBW infants, which is consistent with the data reported in the literature . FurtherSince Echtler et al.  first reThese conflicting findings drive us to reflect the possible explanations for those conflicting findings, which could be owing to the heterogeneity in the population , 10, 24,9/L) independently increased the probability of successful closure of hsPDA after ibuprofen treatment . The cutoff value was modestly higher than 150 × 109/L, which is the diagnosis criteria of thrombocytopenia. Although thrombocytopenia was suggested to be related to ductus closure in preterm infants , irrespective of whether ductus was closed. In line with this finding, Sallmon et al.  before ibuprofen treatment was independently associated with the successful closure of hsPDA.In conclusion, a higher platelet count . Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.JZho and XC conceptualized and designed the study, and wrote the first draft of the manuscripts. JZho, BL, and YF carried out the clinical data collection. YY, JZha, and DZ performed data analysis. XC and CY reviewed and revised the manuscript. All authors have read and approved the final manuscript.This study was supported by the Guangdong Basic and Applied Science Committee (2020B1515120034 to CY), the Shenzhen Fund for Guangdong Provincial High-level Clinical Key Specialties (SZGSP009), and the Shenzhen Science and Technology Innovation Committee (JCYJ20190809170009528 to XC).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


However, awareness of dangers of increasing incidences of antimicrobial resistance (AMR) in hospitals and communities remained low.a cross-sectional survey of awareness of 195 HCWs and 265 MCs toward EVD and AMR was conducted through a structured questionnaire.majority of HCWs (95.4%) and MCs (82.8%) still have knowledge of EVD´s danger and give reasons like its unique way of killing and unavailability of drugs for their awareness. Only 17.2% of MCs are aware of AMR as a problem, and only 3.4% of MCs and 10.3% of HCWs agreed that AMR is more dangerous than EVD. On the contrary, 76.4% of doctors, 95.1% nurses, 67.9% laboratory scientists, 66.7% pharmacists, 77.4% students and 100% of civil servants, drivers and religious leaders believed that EVD is more horrific and spread faster. They both attributed the rapid awareness of EVD in Nigeria, despite being new at the time of the outbreak, to the seriousness with which stakeholders and the media fought EVD, the gesture AMR is yet to receive. Though both HCWs and MCs agreed that prevention, not treatment is the best option to tackle Ebola like-diseases, but surprisingly, about 37% and 65% of HCWs and MCs respectively, still believe that traditional medicines can be used to treat Ebola related illnesses.AMR awareness remains low among MCs and some HCWs when compared with EVD. It is recommended that efforts put in place during EVD outbreak by all stakeholders and the media need to be doubled to increase the knowledge of both HCWs and MCs toward AMR. Escherichia coli, Staphylococcus aureus, and Klebsiella pneumonia in many hospitals and communities in the region . With a lack of knowledge and lack of effective surveillance systems and infection control in place, AMR will continue to spread from HCWs to another or patient under their custody.The general knowledge of AMR among MCs and some HCWs was low. Most MCs have never heard of AMR in the last 1-5 years. This is a clear indication that the awareness of the menace of AMR in general and ARPs in specific is low in the community. Even though media houses have been recognized by many as a good source of public information on HIV/AIDs, malaria, cancer, and other related diseases , it seemBoth HCWs and MCs strongly believed that effective preventive measures are key to EVD management and not treatment. Few traditional healers still hold to their ancient belief that traditional medicine could be useful. Similar beliefs have been reported elsewhere in some West African countries . This fuKnowledge and awareness of EVD is high among HCWs and MCs, but there is a significant gap in knowledge of AMR in some HCWs and majority of MCs. The study also showed that the majority of HCWs and MCs believe that EVD is more dangerous than AMR and ARPs. While most HCWs believe that prudent use of antibiotics and hand washing are the best way to control the spread of ARPs, some MCs opt for traditional mode of treatment. Heightened publicity and awareness campaigns by government, HCWs, religious leaders, media houses and other stakeholders significantly assisted in increasing MCs knowledge and awareness of EVD and its control in Nigeria. Extending such publicity and awareness campaigns to antimicrobial stewardship programs in hospitals and in communities especially rural areas and among less-educated MCs is highly recommended since the problem of AMR cannot be handled alone by HCWs without the cooperation of MCs and other stakeholders.HCW awareness, knowledge and attitude toward EVD in Nigeria;Role of media in disseminating EVD awareness in Nigeria;Little data on HCW awareness, knowledge and attitude toward ARPs in Nigeria.A significant gap of knowledge of AMR among some predominantly educated HCWs and most less and non-educated MCs in Nigeria was established;The heightened rates of AMR in hospitals and communities in Nigeria are because of lack of proper awareness of HCWs and MCs on its danger and it requires urgent public health interventions;Public awareness strategies put in place by the government, religious leaders, and media that led to immediate control of the EVD outbreak is needed to slow/stop the spread of AMR.