Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context. Antimicrobial effectiveness has been diminishing due to microorganisms acquiring resistance . LaggingGovernments and institutions have taken actions to address AMR and minimise its consequences ,9, impleInterventions to tackle AMR can play a key role in building resilience towards AMR , but resWhile building a strong evidence base by incorporating implementation science in the design of interventions will take time, it is desirable to explore what information can be extracted from those that have already implemented interventions. Identifying factors that challenge or contribute to intervention success was a key objective of the present exploratory study, where success can be briefly defined as the intended goal and what each intervention wants to achieve. Based on our previous identification of interventions on AMR ,15,16, wTwenty-one interventions were analysed and their general contexts are shown in Based on thematic analysis of responses, we found eight main success factor themes . Key subOverall actions to maximise the chance of success in AMR interventions start long before their implementation and, once implemented, interventions still need to be flexible and supported with training, feedback, or advice. Behaviour and acceptance towards the intervention of individuals and institutions are often overlooked, but they seem to have a remarkable impact on success. Influencing behavioural change in combatting AMR is a challenge that involves not only the health sector, but many actors where we lack previous experience or who have not previously been engaged . This isIt seems that causes leading to successful interventions rely on reinforcement of new routines and correct behaviour that can be promoted by initial training and awareness campaigns, regular follow-ups with feedback, and refresher training that enhances continuous collaboration, motivation, and education. Attitudes and feelings were highlighted as key sub-themes  and these tend to induce motivation, security, and self-esteem of individuals, plus support and engagement from institutions. Confidence and awareness are established through engagement and shared responsibilities, with collaboration and co-ordination encouraging support of each other, humility, and reflexivity. These factors may lead to building trust and support between individuals, different role positions, and institutions, engaging support and collaboration between sectors and/or professionals. Behavioural change, awareness, and recognition of trade-offs associated with our actions have been highlighted cornerstones in the fight against AMR ,42,43. MAntimicrobial stewardship initiatives have been calling for the need to adopt a wider multidisciplinary and multifaceted approach involving experts from social, psychological, and behavioural sciences ,47. AsseThemes related to AMU (AMU) and resistance prevalence (infection control) were the least frequently reported for having successful outcomes and, when they were, it was mainly as indicators . Resistance prevalence initiated a quarter of interventions, mainly focused on surveillance, which is still inconsistently implemented globally ; improviEvidently, financial resources are vital for success of interventions. Increasing budgets may not be easy but can benefit from public awareness (another key sub-theme), which can lead to institutional pressure to invest more at all levels. Most factors mentioned as obstacles to success  could be transformed into success factors . Still, asking about obstacles and success factors separately can help identify features that contribute to success that may be overlooked or unnoticed when they work well or are taken for granted. Only one sub-theme (resources of the system), which belonged to the broader “capacity of the system” theme, was seen only as an obstacle . NonetheThe information extracted highlights the value and importance of participatory studies to better address AMR. Differences between success factors and obstacles depending on context were not observed, probably as a consequence of the homogeneity of interventions analysed and the broad focus of the study. We also found that interventions were triggered reactively, largely focused on humans, and thus action was taken after a concern had arisen. However, AMR affects the “One Health” spectrum, which requires preventive, proactive, and broader interventions applied in multiple sectors to allow development of economies towards the Sustainable Development Goals that have direct or indirect relationships with AMR .Better understanding of factors that contribute to intervention success would benefit from more qualitative research. While there are different qualitative approaches, thematic analysis has been widely accepted as a flexible and consistent framework for capturing perspectives . ResearcLimitations of our study are connected to the fairly homogenous context, type, and location where the majority of analysed interventions took place and the broad aim of the study. Interventions are impacted by cultural, political, historical, and societal circumstances and publications do not follow reporting guidelines and, if they do, those may need to be updated for capturing relevant details to AMR. Moreover, types of interventions included were not equally represented nor equally assessed. All these facts can lead to restriction in capturing important themes to intervention success .Success factors mentioned in reports or publications are often more objective and easier to assess as they are in line with the intended effect of the intervention, while factors retrieved from this qualitative analysis reflected and relied-on subjective responses independent of the level of assessment of the intervention. Engagement of interdisciplinary experts, health professionals, designers, and implementers of interventions worldwide is needed to learn from non-traditional studies in AMR, such as participatory studies, and to capture key features of intervention success. Moreover, engagement of such profiles will help to have a more inclusive view and supporting information to capture or strengthen new themes or sub-themes that this analysis may have missed or may have identified as anecdotes. The unexpected consequences of our actions are difficult to foresee, but preparedness and system thinking approaches, as well as greater and more consistent reporting of experiences will equip interventionists with useful tools and knowledge before implementing new interventions. Broad system integration has been shown to positively affect resilience and tolerance in adverse situations or shocks . InterveWe examined interventions to gain a preliminary understanding as part of the AMResilience project ,15,16, wNon-traditional analyses in the AMR field, such as exploratory qualitative studies, can provide us with novel evidence-based insights to alleviate the AMR problem from different perspectives in a proactive manner. Due to gaps in communication, reporting, and differences in contexts, replication of AMR interventions is difficult, with details and experiences often missing or elusive. Lessons from previous experiences can help to identify key factors for such interventions to be successful, and implementation frameworks will enhance interventional science and build resilience to AMR. Themes and sub-themes captured in our exploratory study are meant to encourage more complete appraisal, communication, discussion, and sharing of experiences among different professionals and, ultimately, help to inform context-dependant intervention design and implementation. The themes identified can also be useful for guiding production of reports best suited to helping policy development, which is the focus of many organisations and governments worldwide.


A significantly higher prevalence of KIR2DL2 in c-KS patients than in all the other subjects was also confirmed comparing age-matched groups. Based on these results, the inhibitory KIR2DL2 genotype appears to be a possible cofactor which increases the risk of developing c-KS in HHV8-positive, immunocompetent subjects, while it seems less relevant in e-KS pathogenesis.KIR2DL2, an inhibitory Killer cell Immunoglobulin-like Receptor (KIR), has been shown to predispose to the development of several herpesvirus-associated diseases by inhibiting the efficiency of Natural Killer (NK) cells against virus-infected cells. The aim of this observational study was to assess the prevalence of KIR2DL2 and Human Herpes Virus 8 (HHV8) in patients affected with classical and endemic Kaposi sarcoma (KS), as well as in controls. Blood samples collected from 17 Caucasian, HIV-negative, immunocompetent patients affected with classical KS (c-KS), 12 African, HIV-negative patients with endemic KS (e-KS), 83 healthy subjects and 26 psoriatic patients were processed for genotypization by PCR for two KIR alleles, such as KIR2DL2 and KIR2DL3 and analyzed for HHV-8 presence. The totality of both c-KS and e-KS patients presented HHV-8 infection, whereas HHV8 was found in 26.9% of psoriatic subjects and 19.3% of healthy subjects. KIR2DL2 was found in the 76.5% of c-KS subjects, while the receptor was found in 41.7% of the e-KS group, 34.6% of psoriatic patients and 43.4% of healthy controls ( Human Herpes Virus 8 (HHV8) was originally isolated in 1994 . The inf-proliferative disorders occurring prevalently in immunosuppressed subjects [HHV8 infection has been associated with several malignancies, mainly of hematologic origin, including Multicentric Castleman’s Disease (MCD) and Primary Effusion Lymphomas (PEL), and post-transplant and germinotropic LPDs (GLPDs) rare lymphosubjects . Moreovesubjects .-angiogenic activity, which give rise to the typical KS lesions [The role of HHV-8 is crucial in Kaposi sarcoma (KS) development . Among t lesions .Nevertheless, HHV8 infection is not sufficient to provoke such progression, since only a small rate of HHV8-infected individuals develops KS . Additio-regulated surface markers. On the contrary, the lytic phase of HHV-8 infection involves the expression of numerous genes and the production of viral particles [-viruses, in most cases HHV8 infection is controlled throughout life by immune surveillance. In this case, the virus remains latent within cells and clinically silent. On the other hand, since it has developed a variety of mechanisms to evade the host immune system [HHV8 infection has a biphasic cycle comprising latent and lytic phases . Latencyarticles , 28. Like system , 30, HHVe system . The kine system . HHV8 ise system .However, it is not currently understood in detail which components of the human immune response are essential for this pathophysiological process , 19.’ efficiency against transformed or virus-infected cells and, accordingly, the susceptibility of subjects to symptomatic herpesvirus infection [Natural Killer (NK) cells are cytotoxic leucocytes involved both in innate immune defense against viral infections and tumor cells and in the regulation of adaptive immune responses , 8, 12. nfection , 25. Spenfection , 31, 33.nfection , 31, 33.On the base of these data, a potential role of KIR genotype in KS pathogenesis as well might be supposed, even though the actual scenario is not clearly defined. Indeed, the combination of the activating haplotype KIR3DS1 and HLA-B Bw4-80I has been found to increase the risk of classic KS in a cohort of HHV8-positive and HIV-negative patients,  but not These previous findings support the hypothesis that KIR gene polymorphisms can, to some extent, account for the complex interactions between genetic background, HHV8 infection and the immune system, as cofactors in KS development.Starting from this assumption, the main aims of the present study were to assess the prevalence of the inhibitory KIR2DL2 receptor in HIV-negative patients affected with classical KS and to compare it to that of African patients with endemic KS, psoriatic patients and healthy controls. This assessment could provide some insights into inhibitory KIR genotype involvement in the physiopathological process of KS.In the present mono-centric, observational study we included all adult (≥ 18 yrs.), Caucasian, HIV-negative subjects affected with histologically proven classic KS consecutively referring to our outpatient Dermatology clinics over a 6-month period. Patients were excluded in the presence of the following: (1) lack of histological confirmation, (2) presence of ethnic, clinical, laboratory or history criteria suggesting varieties of KS other than the classical one, (3) chronic immunosuppressive treatments for any health condition, (4) refusal to undergo blood sampling or inclusion in the study.The following three different control populations were recruited: (1) healthy donor subjects, (2) psoriatic patients and (3) HIV-negative African patients affected with endemic KS. Both healthy donors and psoriatic patients, whose blood samples were stored in the archive of the laboratory of the University of Ferrara, were contacted for their agreement to use part of their blood samples for the specific purposes of this study. We established a priori the inclusion of healthy controls and psoriatic patients in order to have a gender distribution comparable to that of the enrolled KS patients. No age-based selections were made. Only the blood samples belonging to subjects who gave their consent were used. Healthy controls and psoriatic patients did not have concurrent documented infectious diseases. No further exclusion criteria were applied. Endemic KS skin lesions from Ugandan patients, stored in the archive of the laboratory of the University of Ferrara since their use in a previous study , were thThis was a spontaneous survey, with no funding from external sources. The principles outlined in the Helsinki Declaration of 1975, as revised in 1983, have been followed for all the patients included. The study was approved by the University-Hospital of Ferrara institutional review board (project identification code 162/2020/Oss/AOUFe). Both patients and controls, with the sole exception of patients with endemic KS, provided their written informed consent.Blood samples collected from the four study populations were processed for genomic DNA extraction using the QIAamp DNA blood Mini Kit  following the manufacturer’s protocol .KIR alleles (KIR2DL2 and KIR2DL3) were genotyped by PCR by specific primers pairs  reported, specific for ORF50 gene, followed by nested PCR .HIV-negative, Caucasian classic KS (c-KS) and African endemic KS (e-KS) patients were characterized for the presence of HHV-8 infection and compared to psoriatic and healthy groups. As shown in Fig. p < 0.0001, χ2-test; these rates were all comparable to each other).The same groups were also compared considering KIR2DL2 frequency Fig. b. We convs 32 years, respectively; p < 0,0001, Student-t test), in order to verify the reliability of these results regardless of age, we analyzed KIR2DL2 frequency dividing both the psoriatic and healthy groups accordingly with the mean ages of c-KS and e-KS patients (Table 2-test), but not in the e-KS group (Fig. Given the significant difference between c-KS and e-KS groups’ mean age (77.3 -virus infections, including those from HHV-8 [In the present study we assessed the prevalence of a specific inhibitory KIR receptor, namely KIR2DL2, among KS patients in order to evaluate its possible role on HHV8 seroprevalence and KS development. In particular, we were interested in assessing its potential involvement in two varieties of KS, i.e., classic and endemic KS, in comparison with controls. We chose to investigate KIR2DL2, among others, since this receptor has been found, even by us, to facilitate herpesom HHV-8 , 31, 33.Our first finding was that the totality of subjects were positive for HHV8 in both c-KS and e-KS cohort, as expected. This confirms the well-recognized etiologic role of HHV8 in KS. On the other hand, HHV8 seroprevalence among psoriatic and healthy subjects was fully in line with its prevalence in the general population resident in a mid-endemic area, like the province of Ferrara, northern Italy , 33.With reference to the main aim of this study, we found that KIR2DL2 prevalence was significantly higher in c-KS patients than in all the other study groups, including e-KS patients Fig. . A higheOur results may appear in contrast with previous findings , 22. In The study results should be viewed in light of some limitations. First of all, the small sample size of the study might have reduced the statistical power of these findings. Larger studies including a higher number of patients are needed to confirm our results. Furthermore, the HLA counterpart of the KIR2DL2 receptor was not typed. As some of us have shown in previous studies conducted under different clinical settings, this point would be important in order to know the proportion of patients with a possible activation of KIR-HLA complex . The c-KIn conclusion, our study assessed for the first time the prevalence of the inhibitory KIR allotype KIR2DL2 in HIV-negative patients affected with classical KS, in comparison with African subjects affected with e-KS and controls. Based on our results, KIR2DL2 did not seem to influence the HHV8 seroprevalence in KS subjects, while it was significantly more present in c-KS patients than in the other groups. A likely impairment of NK-mediated immunity, due to the inhibitory KIR2DL2 genotype, may be a cofactor that increases the risk of developing c-KS in HHV8-positive subjects. This specific genotype may be one of the predisposing factors that concur on the development of KS in a part of subjects positive for HHV8, in the absence of further recognized risk factors. Our results also highlighted the different relevance of KIR2DL2 on the outcome of HHV8 infection in HIV-negative Caucasian and African endemic KS populations.


Type 2 diabetes mellitus (T2DM) can result in microvascular complications such as neuropathy, retinopathy, nephropathy, and cerebral small vessel disease, and contribute to macrovascular complications, such as heart failure, peripheral arterial disease, and large vessel stroke. T2DM also increases the risks of depression and dementia for reasons that remain largely unclear. Perturbations in the cytochrome P450-soluble epoxide hydrolase (CYP-sEH) pathway have been implicated in each of these diabetes complications. Here we review evidence from the clinical and animal literature suggesting the involvement of the CYP-sEH pathway in T2DM complications across organ systems, and highlight possible mechanisms  that may be relevant to the therapeutic potential of the pathway. These mechanisms may be broadly relevant to understanding, preventing and treating microvascular complications affecting the brain and other organ systems in T2DM. Type 2 diabetes mellitus (T2DM) is a metabolic disease that affects approximately 463 million people worldwide, contributing to 1.5 million deaths in 2019 ..2+ influDiabetic nephropathy or diabetic kidney disease is the most frequent cause of end-stage renal disease . ChronicAutophagy dysfunction has emerged as a potential target in early diabetic nephropathy. Decreased renal levels of autophagy proteins, such as lysosomal-associated membrane protein 2 (Lamp2), autophagy-related gene 5 (Atg5), PTEN-induced putative kinase 1 (PINK1) and Parkin, have been reported in mice with HFD/STZ-induced hyperglycemia  p62 protsEH inhibition, particularly in podocytes, may also slow nephropathy progression by preventing tubular cell injury . In STZ-Ephx2 (the gene that encodes sEH) has been associated with increased oxidized LDL, carotid intima-media thickness, and mortality in individuals with diabetic chronic kidney disease . Ep. Ep2+-acischemia . Adminisischemia  and mainischemia .Ephx2, which reduces the hydrolase activity of sEH, has been shown to be protective against essential hypertension in humans [The rs751141 polymorphism of n humans . sEH mayn humans . In an An humans . Adminstn humans .People with T2DM are more likely to experience large-vessel stroke, and exhibit increased rates of stroke recurrence and mortality compared to individuals without T2DM . Large-vInhibition of sEH may be useful in this regard. Sustained hyperglycemia has been shown to increase sEH expression in cerebral vessels in a high fat diet, streptozotocin and nicotinamide (HFD+STZ/NA) mice model of T2DM , where tBenefits might be predicted, based on the properties of EpETrEs to enhance cerebral blood flow, vasodilation and expression of vascular endothelial cell growth factor (VEGF) and brain derived neurotrophic factor (BDNF), which are beneficial in revascularization of the peri-infarct cortex ,61. ActiEphx2 gene has been associated with increased risk of ischemic stroke in individuals with [Ephx2 rs751141 and CYP2C8 rs17110453 polymorphisms may also act as a two-locus interaction which further increases the likelihood of ischemic stroke [The rs751141 polymorphism of the als with  and withals with  The rs75als with  and was als with . The Ephc stroke .T2DM is associated with an increased rate of cognitive decline, and elevated risks of incident dementia due to Alzheimer’s disease (AD) and vascular cognitive impairment (VCI), with advancing diabetes duration . HallmarRecent clinical studies have found higher concentrations of sEH-related oxylipins in people with extensive WMH. Notably, higher serum levels of LA-derived 12,13-DiHOME  and the ratios of 12,13-DiHOME/12(13)EpOME  and 9,10-DiHOME/9(10)EpOME , were associated with WMH volumes and poorer executive function in older people . SimilarHigher plasma diols have been found in AD patients compared to cognitively normal controls, regardless of diabetes status . GeneticAlthough clinical studies in T2DM are lacking , hippocaBreakdown of the blood-brain barrier (BBB) via the CYP-sEH pathway has been linked to cognitive decline in db/db mice, sEH was upregulated and accompanied by a decrease in 14(15)-EpETrE levels in brain microvascular endothelial cells (MECs) . ReducedIndividuals with T2DM are an increased risk of developing depression, however the underlying mechanisms remain unclear . DepressPerturbations in the CYP450-sEH pathway have now been reported in clinical studies of seasonal depression , major dIn the context of T2DM, only one study has examined CYP-sEH metabolites and depressive symptoms . Higher Ephx2 (which encodes the sEH enzyme) resulted in resilience to developing depressive-like symptoms [Animal studies in non-T2DM models further emphasize the potential mood benefits of targeting the oxylipin pathway. In chronically-stressed mice, sEH inhibition reduced immobility in the tail suspension test and forced swim test, suggesting antidepressant potential . Chronicsymptoms . Adminissymptoms . Elevatesymptoms  which miEvidence supporting the involvement of the CYP450-sEH pathway in T2DM complications largely stems from cell and animal work and human genetics studies. Translation of these findings into clinical studies, both observational and trials, remains a challenge and an opportunity.Clinical biomarker studies can help to generate hypotheses about the pathophysiology, or confirm the involvement of a pathway; although observational studies cannot imply causation due to their correlative nature. In terms of biomarkers, to date, only one observational clinical study has examined oxylipins in people with T2DM-associated complications, where higher serum diols were found in people with depression  and retiThe most compelling arguments for the involvement of the pathway still come from animal studies, which report beneficial effects of sEH inhibition across T2DM complications. For instance, inhibition of sEH promoted associations between endothelial membrane proteins in murine pericytes  and epitEvidence suggests that certain epoxides may help reduce inflammation and apoptosis that could be relevant to diabetes complications. In mice with diabetic neuropathy, administration of EpDPE isomers had analgesic effects . In anotAt the molecular level, the actions of sEH inhibitors have been suggested to be due to their effects on ER stress . AccordiIt has been suggested that sEH inhibitors might alleviate T2DM complications by prolonging the benefits of the epoxides, with effects often being attributed to AA-derived EpETrEs based on the benefits seen with administration of exogenous epoxides  While thIn the context of microangiopathic brain disease, it has been hypothesized that increased sEH activity and synthesis of cytotoxic diols within the small vessels of target tissues may contribute to end organ damage ,70,71. IIn addition to further observational clinical evidence, studies of systems physiology and mechanistic effects of diols are needed. Given that oxylipins are derived from different parent fatty acids , there rIn human serum, the diol species often correlate with one another, as do epoxides , making Ephx2) appears to be the most important in EpETrE metabolism [There are also multiple epoxide hydrolases, of which sEH  and organ specific biomarkers into future clinical studies might be useful to clarify potential roles in various complications. Only clinical trials could establish therapeutic efficacy, which are needed to determine whether sEH inhibition may prevent or treat microvascular T2DM complications.


Interviews were conducted by an independent interviewer and were audio-recorded and transcribed. Conventional qualitative content analysis was undertaken. Four main categories were identified: (1) understanding of AMR and observing AMR, (2) barriers to antimicrobial stewardship, (3) personal factors in, and as a result of, inappropriate antibiotic usage and (4) how to tackle AMR. Healthcare professionals showed poor awareness regarding the spread of AMR and identified inappropriate prescribing behaviours by their inter- and intra-professional colleagues. Patient demands and the influence of pharmaceutical companies were factors contributing to poor prescribing behaviour. Suggestions for the future are stricter regulation of AMR control policy, effective government involvement, and awareness campaigns for healthcare professionals and the public.Antimicrobial resistance (AMR) is a global health threat, but little is known about the perceptions regarding antimicrobials and AMR among healthcare professionals in Sri Lanka. This research aimed to take a One Health approach to explore the knowledge, attitudes and perceptions of antibiotic stewardship and AMR among healthcare professionals in Sri Lanka. A qualitative study, using telephone interviews, allowing for an in-depth exploration of attitudes, beliefs and perspectives was conducted. Healthcare professionals from both the medical and veterinary sectors were included ( Antimicrobial resistance (AMR) is becoming a major public and animal health issue worldwide. It raises human and animal morbidity and mortality rates while increasing the prevalence of AMR organisms in the environment . AlthougAccording to the World Health Organisation (WHO), antimicrobial stewardship is defined as “A coherent set of actions which promote the responsible use of antimicrobials. This definition can be applied to actions at the individual level as well as national and global level, and across human health, animal health and the environment” . In 2015Gaps still exist in the knowledge, attitudes and perceptions (KAP) of AMR among healthcare professionals, and it has been suggested that it is necessary to improve the quality of teaching materials in the training of health professionals . The antPublished literature supports the notion of antibiotic overprescribing practises. For example, the majority of doctors surveyed in one hospital in Lima, Peru (72%) ‘agreed’ that they overused antibiotics . IrratioOther studies have demonstrated that practitioners do not feel AMR is a problem, or highlight the lack of impact practitioners believe they have on the situation. A group of primary care physicians who participated in a qualitative study in Spain felt that AMR was not a problem at a community level . GeneralIn Sri Lanka, a few studies have been conducted to evaluate KAP on AMR among healthcare professionals ,17,18. TWhile KAP studies can provide a quantitative overview of knowledge, the potential differences in understanding within different groups of professionals and the complexity of the issue warrants in-depth investigation of KAP on AMR among healthcare professionals. Although our understanding of KAP on AMR among medical healthcare professionals is beginning to increase, KAP on AMR among veterinary healthcare professionals in Sri Lanka has yet to be researched. Bacteria are not limited to one species and therefore the human and animal sector use many of the same antibiotics, both contributing to the accumulation of residues in the environment. Hence, understanding KAP on AMR transmission within the ecosystem among all health service personnel, including both the human and veterinary fields, is important. In order to better establish AMR mitigating programmes, multi-sector collaboration is needed. It is not only important to evaluate KAP among antibiotic prescribers (Physicians and Veterinarians), but also within professions, occupations and groups who work alongside them. Subsequently, allied healthcare professionals should also be evaluated within the research. In Sri Lanka, this would relate to nurses and pharmacists from the human healthcare field, and from the veterinary field, livestock development instructors who advise farmers on farm animal management, disease control and prevention methods. All of these groups potentially have a role to play in a One Health approach to antimicrobial stewardship and are therefore important stakeholders in research on this topic.Studies that treat a country’s population as homogenous may also lose the depth of understanding of AMR KAPs. Within Sri Lanka, animal and human healthcare facilities are unequally distributed throughout the country, and rural areas have fewer healthcare facilities . FurtherThe focus of this research was to take a One Health approach to explore the social dimensions of antibiotic stewardship and KAP regarding AMR among Sri Lankan healthcare professionals from rural and urban areas. This required a qualitative study methodology, which allows for an in-depth assessment of knowledge, attitudes, beliefs and perspectives. It was anticipated that exploring this question through the One Health lens by incorporating both the human and animal sectors will help to guide the development of interventions to decrease AMR. This study was conducted as part of a larger study investigating the potential role of wildlife in AMR and ecosystem contamination in Sri Lanka.Overall, 29 healthcare professionals participated in the study; 20 were from an urban area and 9 from a rural area, with a total of 19 human healthcare professionals and 10 veterinary healthcare professionals. The demographic characteristics of the participants can be seen in Almost all the interviewed health service personnel said that they were aware of AMR. The majority acquired their knowledge regarding AMR when they obtained their tertiary education such as an undergraduate degree or diploma, while also reporting that their professional experience helped them to develop their knowledge. Some participants also discussed obtaining knowledge via media and continuing self-study.“As health professionals, we were taught microbiology. But with time, the theories that were taught eventually have faded away from our minds. However, from the news and other discussions in society, I get some information regarding antimicrobial resistance”.[UML1]In human healthcare, participants observed neonatal deaths and urinary tract infections as consequences of AMR. In animals, the veterinary healthcare professionals described experiences of mastitis, swine fever, urinary tract infections and poultry disease. Participants also acknowledged their understanding of AMR was changing but identified the struggle to adapt to new knowledge.“There is a myth called ‘prevention of secondary infection’, which was taught in our university. We were misled, therefore, still, I use antibiotics to prevent secondary infection even in viral diseases based on that theory. In that case, I opt to use the strongest antibiotic I got. I think this is a big mistake made by practitioners”.[RVE]Inaccuracies in understanding were identified from the transcripts. For example, some recognised non-bacterial aetiological diseases also as a consequence of AMR. Inaccuracies in understanding and behaviour were also highlighted by the participants regarding their colleagues; one participant [RHD1] criticised physicians who prescribed antibiotics for viral infections.“Currently with the involvement of private pharmaceutical companies and private vets farmers use Gumboro plus [Vaccine] against Gumboro disease [Viral diseases]. I think in the future there will not be any [antibiotic] treatment for Gumboro and many birds will die as a consequence”.[ULD1]Participants provided additional examples of other professionals prescribing inappropriately and contributing to the AMR issue. The majority of healthcare professionals mentioned that other physicians who were operating private practises/private medical centres prescribe higher-order antibiotics and were trying to prescribe medicines including antibiotics that could cure diseases within a shorter duration and/or after taking a few doses. As a result, several participants used the term “one-shot doctor” [RVE1 &RHD1] to characterise these sorts of practitioners.One livestock development officer placed the blame for poor prescribing behaviour on veterinarians.“Especially because of ignorance. Avoiding necessary steps is a problem. Some vets do not treat animals following all necessary steps; take steps towards higher antibiotics and proper care. Because of such Vets, animals reared by peoples as their livelihood, who can live for a long time happen to close their eyes pretty soon”.[ULD2]Healthcare professionals demonstrated a variable understanding of AMR development in the discussions. A very limited number of participants said that AMR develops in bacteria. However, most thought that AMR development takes place in the human body. Further, they thought the occurrence of AMR was related to the body immunity of the respective person.“When high antibiotics are given to patients as a practise, their bodies find it difficult to restore to good health because the bodies get used to it”.[RNU2]“What causes is a person’s immunity and factors related, I think”.[UNU4]The majority of participants believed that humans who recurrently used antibiotics and/or who take the same antibiotic long-term will have the potential to develop AMR, with those who have taken antibiotics since childhood being more prone to developing AMR. On the other hand, some participants said AMR can be developed by the gene as an inherent characteristic of the human being.“Maybe because people grow with high antibiotics since their childhoods. With the way of the society, we live in, I feel that maybe the kids who are being born today might be inherited”.[UNU1]Another stated that the brand of antibiotic may have a relationship with the occurrence of AMR.“Sometimes people name a brand of drugs as the ‘best brand’. I have identified that it has its problems regarding the production of drugs. Just take Ciprofloxacin as an example, it is an Antibiotic and normally the best brand of this drug is XXX. XXX costs about Rs.80. Just assume that another brand of the same drug costs Rs.50. They are the same drug at different prices, yet the way each answer the body is so different. Then resistance is different”.[UPM1]Participants also mentioned that overuse and/or misuse of antibiotics, failure to take antibiotics on time and/or at recommended intervals trigger AMR.The majority of participants were unable to explain the transmission routes of AMR. Many of them believed that AMR cannot be transmitted between humans and/or animals, since AMR developed in the human and/or animal body.“Do you think that there could be any possible way of getting it to humans and animals by getting collected in the environment? Nobody has ever told me such a thing. I don’t think so”.[UHD1]Even though some participants were able to identify animal-originated food and urine and/or faeces as a transmission route for AMR, almost all of them were not aware of the environmental route of transmission of AMR.“I’ve never heard that Antibiotic resistance could occur from water or soil. It is a rare occurrence; mainly Antibiotic resistance happens through food. Maybe these other ways could be counted under the same category too, I am not much aware”.[UVE1]Human healthcare professionals and veterinary healthcare professionals reported similar barriers to antibiotic stewardship as explored below. Participants explored their challenges as well as the poor behaviour of ‘other’ members of their own and different groups.Patients demanding antibiotics were identified as common by participants. Patients used different techniques to gain antibiotics, including re-using old prescriptions and providing the wrong clinical history.“There are some folks who lie to their doctors uttering fake symptoms relying on the thought that intake of more medicine can bring a healthy life. The doctor prescribes medicine for the symptoms a patient tells. This scenario is unlike in a hospital. In a hospital, a doctor gets the chance to visit the patients 2–3 times a day but in private dispensaries, a doctor meets his patients just once. A patient faking ailment could be easily understood in a hospital but it is unable to do so in a private dispensary or clinic”.[RHD1]Patients were thought to consider antibiotics as a quick fix and a natural expectation for various ailments.“A [teacher] once taught us to address this as ‘Capsule Syndrome’. You know, patients are not satisfied unless we prescribe them some kind of capsules”.[UDD1]Even those patients working within the healthcare system were reported as showing demanding behaviours by the prescribers.In the livestock field, veterinarians had pressure from farmers to prescribe higher antibiotics.“Once when Swine fever was spreading among our pigs, some vets prescribed Augmentin for them. This happened in some other range, not in ours. Knowing this, a few guys from our range arrived in my place and we bickered on the very matter. They asked me to prescribe Augmentin and I kept on saying no. Augmentin is the main drug given to humans. That’s the only drug available even when a child gets pneumonia. There is the injection but it is inappropriate to give it to animals”.[UVE3]Over-the-counter prescription of antibiotics was also identified as common practice by participants. Farmers treated livestock with over-the-counter medications based on their own diagnoses and/or imitated the treatments prescribed by veterinary doctors previously.“If the doctor leaves a used bottle of vaccines/drugs on the premises, some people are used to keeping the empty container with them and use that particular medicine as they wish. Mostly this happens in piggeries. People buy whatever medicines they expect would cure their animals and inject themselves”.[ULD2]During the interviews, it was highlighted that some farmers hesitated to follow professional recommendations. However, underlying reasons for this behaviour were not hypothesised.“We always advise farmers not to milk the cow or sell it for meat for a certain period of days if an injection was given. But some farmers do not seem to care about these health pieces of advice and they keep on doing whatever they want”.[UVE2]The requirement to meet expectations in order to maintain professional standing and not lose customers (patients) was discussed as a reason for prescribing higher antibiotics at private clinics.“Whether one works in a government or private institution, he/she tries to continue and be successful at P.P (Private Practise). So for that, the doctor needs to have a good name among crowds. He cannot obtain this by prescribing normal antibiotics and tends to cure ailments with high antibiotics. Patients like this kind of doctor as what they expect are to get cured as soon as possible”.[ULD1]It was reported that patients were able to change doctors with ease should they not receive the treatment they expected, thus pressuring doctors to treat, or else simply move the issue onto another doctor.“Being a doctor if I don’t prescribe antibiotics people often say that It’s not worth getting treatment from me. They turn to the doctor who is prescribing it for them”.[UHD4]The majority of participants stated that multinational and national pharmaceutical companies had a significant influence on both the human and veterinary sectors.“Either pharmaceutical companies directly contact the farmers or farmers directly contact the pharmaceutical companies to decide to choice of antibiotic”.[UVE4]“Medical Reps of companies promote it (antibiotics). These things really do happen”.[UPM1]The explanation for this was considered to be that they had to encourage antibiotics due to commercial commitments.“There are some agents in a few companies. Their high officials are vet surgeons who are passed out graduates of the Faculty of Veterinary, just like us. If they love the country’s future, they have a responsibility to take steps toward misuse of Antibiotics. But sadly, their business is marketing and having sales goals. So they release the drugs into the market in a desperate way”.[UVE3]The majority of participants stated that policymakers were unable to implement current laws and regulations. Pharmaceutical companies were also hypothesized to potentially provide them with a commission, which may be the reason behind the poor strength of rules and regulations.“The main problem occurs from private companies. Those companies obtain huge profits by selling those drugs. That becomes the main obstacle. Plus, there certainly could be parties like political ministers who benefit from commissions through these things, who knows? Sri Lankan medical workers are generally not genuine. Most of the time, our higher officials and some of the medical workers are money minded and very dirtily avaricious”.[UVE3]Poorly implemented rules were suggested to result in the introduction of low-quality pharmaceuticals into the market and hospitals. The misuse of antibiotics was also questioned and highlighted the antibiotic growth promoter which was legally banned.“There might be rules imposed over these matters, but as a person who is engaged in this field for years now, what I have understood is that the regulations are weak indeed. Some farmers use antibiotics just as how fertilisers and pesticides are used in farming. There are regulations but in a slumbering state. I think antibiotic growth promoters are being used recklessly despite there are regulations on antibiotic growth promoters”.[UVE1]It was identified that professionally unqualified personnel prescribed antibiotics to patients in hospitals as well as in pharmacies where the medications are distributed. This situation was condemned by the participants.“There is a hospital attendant who is acting as Ayurvedic doctor and often prescribes antibiotics to patients”.[UPM2]“Generally speaking, in Sri Lanka, 75% of the pharmacies are run by non- pharmacists. They don’t have any formal education background and even they don’t have a conscience”.[UNU3]Reasons for patients’ and farmers’ behaviours regarding antibiotics which were deemed to be inappropriate were thought to include patient financial difficulties, as identified by a pharmacist who noted that patients altered the recommended dose as they could not afford the full dose.Overprescribing was also performed to assist patients, for example, if physicians assumed their patients would have difficulty attaining the required antibiotics, due to the inability to return to the hospital for a second antibiotic or due to future complications.“I live in [area] which is a rural area. Imagine a mother coming from 10–12 km away from the town to treat her baby. They have to wait in the queue for some time. The doctor also might have a feeling about future complications that should be treated early to prevent further inconvenience faced by that poor mother”.[RPM1]Veterinarians also demonstrated understanding regarding farmers using antibiotics to treat their animals themselves, as they acknowledged difficulties in access to veterinarians throughout Sri Lanka.“If we consider the veterinary field, there are a limited number of government veterinary surgeon’s offices. It’s virtually impossible to handle all the issues that arise in this area by government vet office or veterinary investigation centre alone. The farmers were left with no choice other than to give some medicine available to save their flocks without seeking veterinary advice. Therefore, they try with all the medicines available”.[UVE4]Poor patient–prescriber relationships were identified during the interviews, limiting patients’ ability to understand antibiotics and AMR. It was mentioned that physicians were unable to explain the situation and aetiology of the disease to their patients. A reason behind this was a high patient volume in hospitals.“The doctors here in Sri Lanka are not used to explaining even in simple terms about the illness to their respective patients…. Some doctors clearly explain everything and how to intake the prescribed medicines. Yet some doctors do not do this… when a lack of communication takes place, most patients just change their doctor and carry on. If the same happens there too, he carries on with the same process so that a single patient changes 2–3 doctors for one ailment”.[RDH1]Participants recognised poor behaviours as contributing to AMR as well as a subsequent personal inability to treat animals.“I got a very heartbreaking storyrecently happened to me. … resistance had been developed against all the antibiotics available. We didn’t have any antibiotic to treat that animal”.[UVE4]In an effort to maintain their ground on not prescribing or using antibiotics, participants reported disagreements with patients, including negative retorts such as being shouted at, as well as disagreements with other professionals.“Even though we quarrelled, I did not take steps to do the above, yet one of our vets did not hesitate to. From a drug company or some pharmacy, they have had obtained the necessary amount of Augmentin”.[UVE3]Almost all of the attendees agreed that combating AMR in Sri Lanka was a concerning issue. However, a dentistry practitioner stated that it was not a major concern in their field, and a livestock development officer believed that they were not responsible for combating AMR because they were not prescribing antibiotics.“This issue does not affect us. we do not prescribe Antibiotics for animals. What we do is guide people on how to give animals antibiotics properly and effectively only as per prescribed”.[ULD2]“As dental surgeons, we use Antibiotics. But we do not use many varieties. So that I don’t think that this phenomenon might be happening large scale in our field”.[UDD1]The majority of participants suggested that legislation be strengthened to prevent over-the-counter prescriptions. Veterinary professionals recommended establishing a procedure to monitor animal-derived commodities.“There are rules and regulations. We always discuss these new ideas and proposals for making the system clear and strong. The problem is that all those confines to ‘discussions’, just ‘discussions. These discussions happen for a long time, but there is no change takes place”.[UVE1]“Milk is not checked properly now in Sri Lanka. Maybe there are rules and regulations on these matters but they are not functioning correctly.”[ULD2]Both veterinary and human healthcare participants noted diagnostic uncertainty as one of the most prevalent issues they faced, suggesting the need for improvements and expanding diagnostic capabilities and human resources, especially in rural settings.“My clinic is located in the [area]. If I need to get a culture report I have to submit samples to [place]. But with my busy work schedule, it is almost impossible to do it in time. Therefore, it would cause more damage to the animal when the culture report arrives. So, it must minimise those types of difficulties”.[RVE2]Some veterinarians emphasised the value of biosecurity management on livestock farms as a possible approach to combat AMR.“it is important to implement biosecurity of the farm to prevent disease occurrence and spread”.[UVE3]Healthcare professionals had variable thoughts on conducting awareness programs. The majority of the participants suggested that antimicrobial stewardship awareness programs should be conducted to sensitise the general public and healthcare professionals on antibiotics.“The very first thing must be spreading awareness among people. People must be convinced how important Antibiotics are”.[UHD3]Other participants felt that educating health care personnel should take priority over the general public, with one participant considering educating the public to be potentially dangerous.“Some people still use this knowledge for illegal causes. Just a little knowledge on any drug can make people go buy it as they wish”.[UMF1]Many participants believed that educating field officers and allied healthcare professionals was more necessary than educating doctors because doctors were already aware of the problem, while allied professionals would appreciate an increase in competence and confidence regarding the issue.“Many officials in this field provide us with limited knowledge about medicine. So how can we raise our voices when we see people trying to get drugs in various unaccepted ways? We might get the power to raise our voice if only we had a proper understanding of drugs, their uses and side effects either during our training period or at MOH levels. Bearing a little knowledge, we cannot do this, so I hope we get the chance to be knowledgeable. Public Health Inspector and Midwife are two good examples on whom to be acknowledged”.[UMF1]Overall, many participants criticised the attitudes of both the public and healthcare professionals, and it was suggested that Sri Lankans’ attitudes should be altered.“Indeed, the very first change which must take place is the change in people’s attitudes”.[ULD1]“The problem lies not in raising awareness but in people’s attitudes. Even I am the same”.[RVE1]This study investigated the KAPs of both human and animal healthcare professionals in Sri Lanka regarding antibiotic stewardship and AMR. To the best of our knowledge, this is the first qualitative study conducted on these topics in Sri Lanka, enabling a deeper exploration of the participants’ KAP than via quantitative surveys alone.Healthcare professionals who participated in this study were familiar with the term “antibiotic resistance”. However, this study proposes that many healthcare professionals need to revise their antibiotic prescription behaviour to follow proper and updated guidance. To help them achieve this goal, it is recommended that deliberate and continuous professional development programmes should be established to update the understanding regarding how AMR develops and spreads among all groups and professions within the One Health umbrella. In addition, consideration of the education regarding AMR within pre-qualification teaching, including degrees and diploma studies, is warranted following the guidelines of the WHO .The participants in this study regularly judged and blamed other professionals for their prescription behaviours, but often lacked self-awareness regarding their own poor behaviour. Some participants criticised other professionals for prescribing antibiotics to patients who had symptoms of viral infections. This behaviour may be due to a lack of basic antibiotic knowledge, or due to complexities in real-world practise. A common reason given for these inappropriate prescriptions was the diagnostic uncertainty of diseases and the prevention of secondary infections and complications ,23.The findings revealed that participants had poor comprehension of the development of AMR. Despite the fact that AMR evolves in bacteria, many of the participants in our study believed it began in the human or animal body. In addition, many participants did not understand the routes of AMR transmission within the ecosystem. Even though some participants were able to explain AMR transmission via animal-originated foods, soil and water, no one was able to explain the potential role of wild animals in AMR transmission in the ecosystem. In the context of ‘One Health’, poor understanding by participants of the development of AMR may lead them to underestimate the risks of AMR transmission between wild and farm animals, and between animals and humans ,25.As noted above, a lack of self-awareness regarding an individual’s gaps in knowledge and understanding was likely to be a major barrier to good antibiotic stewardship by healthcare professionals. Many participants commented on the behaviour of their clients that may contribute to the development and spread of AMR. These behaviours, by patients and livestock farmers, included the direct over-the-counter purchase of inappropriate antibiotics for self-medication and medication of farm and domestic animals, lack of adherence to the dosing schedules of prescribed antibiotics and the use of antibiotics prescribed for others. Similar problems of inappropriate usage of antibiotics by patients and farmers has been reported worldwide ,28,29,30Both the human and veterinary healthcare participants in our study were under pressure from their clients to over-prescribe antibiotics. Antibiotic-demanding behaviour among clients has been reported in other studies ,35,36. SSimilar to our findings, the influence of pharmaceutical companies was mentioned in other studies conducted in countries such as Nigeria, India and Uganda ,46,47. PAntimicrobials used to treat infectious diseases in animals may be the same or similar to those used in people, and the ecosystem may link the development of AMR in humans and animals. Addressing the issue of AMR requires a One Health approach with multisector collaboration ,51; profThis study has emphasised the importance of conducting AMR awareness programmes to educate the public and healthcare professionals. However, many medical participants in our study, despite showing several misunderstandings and prescribing misbehaviours with regard to AMR, thought that their knowledge was more than adequate and that they would not benefit from involvement in such programmes. Some general practitioners were unaware of new developments in understanding and prevention of AMR. It is clearly desirable that outreach programmes dealing with AMR are directed toward the medical profession. The results of our study also demonstrated the potential value of awareness programmes to enhance KAP on AMR among other healthcare workers. For example, field officers such as midwives, public health inspectors and livestock development officers who work closely with the community may play a significant role in knowledge dissemination among the wider community.Where participants were aware of the ramifications of AMR on their own personal day-to-day lives, they spoke in a way which indicated sadness and a feeling of helplessness for their own patients. For professionals who spend their lives trying to help others, as indicated by the sub-category of ‘Understanding the patient and farmer’s perspectives’, this emotional impact of AMR may be significant. ‘Helplessness’ has been recently explored in this journal among patients who chose to self-medicate with antibiotics for protection against COVID-19 , and a sThis study has some limitations. It was conducted in two areas; therefore, the finding of our study cannot be generalised to the whole country or to other countries. However, the inclusion of both rural and urban participants enabled the results to include a range of views. Future quantitative studies may aim to establish the prevalence of the views identified within this study among healthcare professionals in Sri Lanka and other countries. Telephone interviews were conducted due to limitations on personal interactions imposed by COVID-19. Face-to-face interviews were the original preference of the project team, as they can facilitate the development of a good rapport between interviewer and interviewee as well as provide the ability to use visual cues to guide probing questions. However, telephone interviews are a well-used method in qualitative research, and studies have suggested that telephone interviews can produce the same results as face-to-face . An indeA qualitative research approach was chosen because of its ability to offer in-depth explorations of complex phenomena that have not yet been discussed extensively in the literature. Furthermore, semi-structured interviews were conducted because of the possibility to explore the participants’ perceptions and let them speak freely. This study was approved by the institute of ethical clearance committee, Faculty of Medicine, University of Peradeniya, Sri Lanka. Ethics grant No. 2020/EC/28.Non-probability sampling—namely, purposive sampling—was used to identify potential participants. The sampling aimed to achieve maximum variation based on the participant’s role and study site, as elaborated upon below. All potential participants lived and/or worked in the two study areas. All human and veterinary healthcare professionals from the locations were eligible to take part in the study. This included, for example, physicians, nurses, midwives and pharmacists  from the human healthcare service as well as veterinarians and livestock development instructors from the veterinary healthcare service. Two methods were used to identify interviewees. First, field-level government officers, mainly “Grama Niladhari” and “Smurdhi Development officers”, of the respective area were contacted by author YDG and through them, contact details  of healthcare professionals were collected. Second, hospital websites and telephone directories were used to collect additional contact details. This study also embraced the snowball sampling technique to access possible interview partners as identified during the interview or recommended by the interviewees.Two areas of Sri Lanka were chosen for their distinct characteristics, particularly their urban or rural setting, to enhance diversity within the sample.A one-square-kilometre region was identified as a study site from the urban area which was located in the Gampaha district of the Western province of Sri Lanka. Infrastructure for healthcare and the number of healthcare professionals and related workers in the urban area is comparatively higher than in the rural area. Another square kilometre area was identified from a rural area, which was located in the Badulla District of Uva province of Sri Lanka. Nearly all citizens living in the rural area belong to an indigenous tribal community called ‘Veddas’. The health system in the rural setting is enriched by a mix of Allopathic  and Ayurvedic  systems of medicine that exist together; however, in the urban area, Allopathic medicine has become dominant and caters to the majority of the health needs of the people.Author YDG contacted all participants and provided a formal introduction to the study and obtained informed consent. Contact details were then passed to an independent interviewer to arrange the interview. The interviewer was a trained researcher, female, holding a Bachelor of Arts in Sociology degree from the faculty of Arts, University of Peradeniya, Sri Lanka. She had experience in conducting health-related qualitative studies, but no prior experience with, or knowledge of antibiotics or AMR. To avoid potential bias of the interviewer during the interview, the interviewer was blinded to the profession of the participant.An interview guide consisting of three main open-ended questions, and two to four prompts under each main question was developed by the research team. Overall, the questions aimed to provide data to answer the research question and were therefore focused on experiences with AMR and perceptions of ways to tackle AMR. Four telephone interviews were conducted as a pilot study and minor modifications were made as per the feedback of participants, including the addition of new prompts and edits to the order of the prompts to enable the desired exploration of the research question. The final interview guide can be seen in the Conventional qualitative content analysis techniques were used to analyse the data, as described by Hseih and Shannon (2005) . In brieThis study revealed some of the social dimensions of antibiotic usage and AMR in Sri Lanka. Healthcare professionals had a knowledge gap with regard to antibiotic stewardship and AMR. Interventions to enhance the quality of antibiotic prescribing and usage should be addressed both to health professionals and to the general public.


Klinefelter Syndrome (KS) is characterized by the presence of an extra X chromosome. It was first diagnosed in 1942 in a group of azoospermic men. KS is the most common chromosomal abnormality encountered in infertile men and accounts for more than 10% of the causes of azoospermia. Men who are azoospermic may still father children via testicular sperm extraction followed by intracytoplasmic sperm injection (ICSI). This review article summarizes the success rates of the available techniques for surgical sperm retrieval (SSR) in KS including conventional testicular sperm extraction (cTESE) and micro testicular sperm extraction (mTESE), as well as the risks of these procedures for future fertility. The evidence indicates that the SSR rate is as successful in non-mosaic men with KS as those with normal karyotypes, with retrieval rates of up to 55% reported. The influence of different factors that affect the chances of a successful outcome are discussed. In particular, the impact of aneuploidy rate, physical characteristics, co-morbidities, reproductive endocrine balance and the use of different hormone management therapies are highlighted. Evidence is presented to suggest that the single most significant determinant for successful SSR is the age of the patient. The success of SSR is also influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team. Rescue mTESE may be used successfully following failed TESE in KS patients in combination with hormone stimulation. In 1942, Harry Klinefelter published a case series of 9 syndromic men with gynaecomastia, hypogonadism and infertility  and is dGene cluster and pathway analysis showed four possible mechanisms responsible for reduced spermatogenesis in KS patients: impaired development of spermatogonia to mature spermatozoa, defects in the testis architecture, pathophysiology of the testis environment, and apoptosis of the germinal and somatic cells . Men witCurrent practice for management of infertility for men with azoospermia generally includes TESE in order to retrieve sperm where there may be localized foci of spermatognesis. Because of the pathology associated with KS, TESE has resulted in limited success, however the implementation of the more advanced technique of micro TESE has increased recovery rates in these men. This review aims to discuss the success rates of the different types of SSR methods and to discuss the factors that may influence the outcome.Adult men with KS who are azoospermic may have small, patchy islands of spermatogenesis in the testes . SSR aimP < 0.01). Testicular sperm retrieval rates for KS patients with NOA are similar to other men with NOA. A literature review including 13 studies and 373 men with KS demonstrated an overall success rate for SSR of 44% with a range of 16–60%  . Howeverf 16–60%  and anotf 16–60% . On the f 16–60% . There wThese studies indicate a wide range of SSR rates in both NOA and KS patients. Discrepancies in results can be attributed in part to the differences in data collection and analysis. Many of these studies failed to take into account other variables such as varicocele, cryptorchidism, prior treatment for conditions such as cancer, or hormone replacement therapy etc. that may all affect the success rate of SSR and introduce bias into the data analysis. Furthermore, outcomes were reported for SSR for the different techniques but were not necessarily confined to a single attempt at SSR. These data are also influenced by the inclusion of separate studies that measure SSR rates using either mTESE or cTESE alone, rather than by direct comparison. Interestingly, when Corona et al.  restrictDifferences in SSR success rates may also be explained by differences in patient cohorts across the globe, severity of co-morbidities, and lifestyle factors. The success of SSR is influenced by surgical technique and operative time, as well as the skills of the surgeon and embryology team and the time allocated to searching for spermatozoa in the processed tissue , 26. In The majority of men with KS present with 47, XXY while 10–20% are mosaic Klinefelter's (46 XY/47XXY) or variants with more than one extra sex chromosome  or with partial fragments of supranumery X chromosomes  . KS men p < 0.001). Co-morbidities may also include a propensity for insulin resistance, dyslipidemia and obesity as well as an increased risk of thrombosis and cardiovascular disease  and abnormal testicular histology are associated with worse SSR outcomes , 40. Men disease  all of w disease  and may Ninety % of adults with KS suffer from NOA and hypergonadotropic hypogonadism with low to borderline-normal testosterone levels, increased luteinising hormone (LH), follicle-stimulating hormone (FSH) and oestradiol levels . While mAntioestrogens (selective estrogenic receptor modulators -SERMs) such as clomiphene citrate and tamoxifen; human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) have been used successfully in men with NOA prior to SSR –59. SERMMen with KS show progressive hyalinisation and fibrosis of the seminiferous tubules over time , 64. ThuInfertility is a characteristic of KS, however with current understanding of the pathogenesis of this syndrome and advances in assisted reproductive techniques, KS men are able to father their own biological children. There is good evidence that KS men with NOA can be successfully treated with SSR to retrieve spermatozoa from localized regions of the seminiferous tubules. As KS men generally have smaller testicular volume, mTESE is therefore advised as the treatment of choice to minimize localized testicular damage. While there is some disagreement in the literature regarding the impact of testicular volume, hormone balance and age of the patient on the success rates of SSR, overall, increasing age appears to be a significant factor. Furthermore, these factors may be indicative of the quantity and quality of spermatozoa retrieved during these procedures rather than the predictability of finding spermatozoa. Stopping testosterone replacement therapy and empirical hormonal stimulation, improves outcomes of both TESE and rescue TESE in KS men. However, more studies are required to standardize protocols and confirm the efficacy of these treatments. The evidence advocates performing SSR in younger men, however as levels of testosterone and subsequent androgenisation may be normal in the majority of KS men , the synAR and SH contributed to the conception and design of the review. YK wrote the manuscript and it was critically revised by SH. AR reviewed all drafts and provided support throughout the writing of the manuscript. All authors approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Aripiprazole (ARI) is an atypical antipsychotic drug with D2 partial agonist properties, usually prescribed to treat mood disorders (major depression or bipolar disorder) and schizophrenic disorder (schizophrenia or schizoaffective disorder). Dopamine receptor agonists, as is ARI, have been implicated in some cases of impulse-control problems, such as gambling disorder (GD), increased spending, hypersexuality and compulsive eating.Currently, it is hypothesized that aripiprazole may cause impulse-control problems because it can produce a hyperdopaminergic state in the mesolimbic pathway (reward system) through its predominant action on dopamine D3 receptors. We intend to do a non-systematic review of the scientific information regarding this subject.The authors revised the published literature about this topic, selecting relevant articles, systematic reviews and case reports, with the topic words: “aripiprazol”, “gambling disorder” and “dopamine receptor” in scientific data base.Overall, a few cases of ARI-induced pathological gambling as well as ARI-induced hypersexuality have been reported. In one study it was verified that comorbid psychiatric and substance use disorders were common among those who have experienced GD or worsened GD after beginning ARI treatment. In another study, it was verified that the group of patients who reported this alleged side-effect were mostly young , mostly men (88.2%) and most lived alone.Attributing to dopamine agonists the only factor that can explain the onset of GD is simplistic and dangerous. Many other potential risk factors, including individual vulnerability factors  as well as environmental factors, must be considered.No significant relationships.


The combination of the BT nanosheets with the rGO surface was investigated by X-ray diffraction, X-ray photoelectron spectroscopy, field-emission scanning electron microscopy, transmission electron microscopy, Raman spectroscopy, and Fourier-transform infrared spectroscopy. Electrochemical impedance spectroscopy, cyclic voltammetry, and differential pulse voltammetry were performed to analyze the electrochemical-dopamine-detection characteristics of the BT/rGO nanocomposite. The BT/rGO-modified electrode exhibited higher catalytic activity for electrocatalytic oxidation of 100 µM dopamine  than that of the BT-modified , rGO-modified , and bare glassy carbon electrode ; this was attributed to the synergistic effect of the electron transfer promoted by the highly conductive rGO and the large specific surface area/high charge-carrier mobility of the two-dimensional BT nanosheets. The BT/rGO-modified electrode showed a detection limit of 0.06 µM for dopamine in a linear range of 10–1000 µM. Additionally, it exhibited satisfactory reproducibility, stability, selectivity, and acceptable recovery in real samples.Dopamine is a neurotransmitter that helps cells to transmit pulsed chemicals. Therefore, dopamine detection is crucial from the viewpoint of human health. Dopamine determination is typically achieved via chromatography, fluorescence, electrochemiluminescence, colorimetry, and enzyme-linked methods. However, most of these methods employ specific biological enzymes or involve complex detection processes. Therefore, non-enzymatic electrochemical sensors are attracting attention owing to their high sensitivity, speed, and simplicity. In this study, a simple one-step fabrication of a Bi Dopamine is a neurotransmitter that plays a significant role in the central nervous, renal, cardiovascular, and hormonal systems . High doTypical methods for the determination of dopamine include chromatography , fluoresIn particular, a variety of nanomaterials, such as metals or metal oxides ,13,14,152-hybridized carbon atoms in a two-dimensional (2D) hexagonal framework, have a large theoretical surface area (2630 m2/g), excellent electrical conductivity (6.4 S/m), decent chemical and thermal stability, and a low production cost 3−/4− (5.0 mM). CV curves of [Fe(CN)6]3−/4− were obtained using various modified GCEs at a scan rate of 100 mV/s  containing [Fe(CN)100 mV/s a. BT/rGOct), was considerably larger for the BT-modified electrode than that for the bare GCE owing to the poor conductivity of the randomly distributed BT. However, the rGO- and BT/rGO-modified electrodes had smaller semicircular diameters than that of the bare GCE.Nyquist plots of the bare GCE, rGO, BT, and BT/rGO systems were obtained from 10 Hz to 100 kHz b. The dict values increased in the following order: rGO < BT/rGO < bare GCE < BT . These results highlight the potential of employing BT/rGO in electrochemical sensors based on its high electrical conductivity and sensitivity.In particular, the rGO-modified electrode displayed a significantly smaller semicircle b, inset pa) at 2.86 µA corresponding to an anodic peak potential (Epa) of 0.35 V  containing dopamine (100 µM) at a scan rate of 100 mV/s. The bare GCE exhibited a CV response as an anodic peak current (If 0.35 V a. Moreovpa (94.91 µA) and lower Epa (0.24 V). The DPV results in pa of BT/rGO was likely due to the synergistic effect of the decent electrical conductivity of rGO and the BT-nanosheet-enabled improvements in specific surface area and charge transfer. These results indicate the effectiveness of the BT/rGO nanocomposite as a non-enzymatic electrochemical sensor for dopamine.In particular, BT/rGO exhibited a pair of redox peaks at a higher I+ ions [The effects of pH on the electrochemical performance of BT/rGO were investigated by CV in PBS (0.1 M) containing dopamine (100 µM) at a scan rate of 100 mV/s . As the + ions .π or electrostatic interaction between dopamine (NH3+) with graphene (COO−) induced lower current since dopamine solution changed to neutral form  [In contrast, at high pH value (>7.0), the absence of cation- = 8.87) ,62. ThusThe slope corresponding to the aforementioned Equation (56.33 mV/pH) is close to the theoretical value provided by the Nernst Equation (59.2 mV/pH at 25 °C) , indicatExperiments were performed with PBS  containing dopamine (500 µM) to determine the electrochemical characteristics of dopamine with respect to the BT/rGO electrode at different scan rates. Reversible CV curves of dopamine were acquired at scan rates of 20–200 mV/s a. The repa vs. the square root of scan rate; the following linear regression equations were derived: Ipa (µA) = pc (µA) = pc represents the cathodic peak  of electrochemical sensors .pa (µA) = 0.028C (µM) + 0.947 (R2 = 0.997).The DPV sensitivity data for different concentrations of dopamine in PBS  were obtained c. The ox−1cm−2. Additionally, the LOD for dopamine was calculated to be 0.06 µM from the linear calibration plot based on the equation LOD = 3Sb/S, where Sb and S represent the standard deviation and slope, respectively, . The senThe BT/rGO-based dopamine sensor showed a wide range of linear detection (10–1000 µM) and the lowest LOD (0.06 µM) among the listed specimens . Furthermore, a comparison of rGO-based dopamine sensors that exhibit a wide linear range (20–1000 µM) reveals that the LOD reported herein was 1/40th that of previously reported data, confirming the superior performance of the BT/rGO-based composite.3+ or Te4+ of pristine 2D BT nanosheets to form a BT/rGO nanocomposite [Based on the dopamine-sensing performance of the BT/rGO nanocomposite, the related mechanism of electrochemical detection was elucidated . The oxyomposite . The 2D omposite .These materials are highly mobile, and the delocalized surface states can promote interfacial charge transfer between the electrode surface and analyte, along with simultaneously enhancing the signal-to-noise ratio of the sensing current . The eleElectrons from the 2D nanosheets can be rapidly transferred to the rGO surface owing to the band barrier, thereby, boosting the electrical conductivity. These discussions indicate that the ultrahigh sensitivity of the BT/rGO nanocomposite in terms of its electrochemical behavior was primarily derived from the rapid charge-transfer interactions between the target dopamine molecules and BT/rGO-nanocomposite-modified electrode and the high conductivity of the BT/rGO nanocomposite.The selectivity of the BT/rGO-modified GCE was analyzed using different interferents, including glucose, ascorbic acid, L-cysteine, calcium chloride, sodium acetate, sodium citrate, urea, and uric acid, which are representative of common interfering compounds. No noticeable response was observed toward the other interferents even though the interfering materials (1 mM) were injected at a concentration 10× that of dopamine 100 µM; a. The seFurthermore, the repeatability of the BT/rGO-modified electrode was investigated by performing three measurements using a single modified electrode in one day. The relative standard deviation (RSD) of the repeatability was calculated to be 1.89% b. The reFinally, the feasibility of the sensor was tested by injecting it with dopamine hydrochloride, which was diluted with PBS  to provide a suitable concentration range for dopamine detection. After injecting dopamine hydrochloride at several concentrations, the current response was examined using the DPV method , which yA rapid one-step synthesis of BT/rGO was demonstrated for a non-enzymatic electrochemical dopamine sensor. The analysis revealed that BT nanosheets and rGO were successfully combined to form nanocomposites. In terms of the surface morphologies of the composites, crystallized BT nanosheets grew uniformly on the surface of rGO nanosheets. The modification of glassy carbon electrodes (GCEs) with BT/rGO led to an outstanding electrocatalytic activity  for dopamine (100 µM), which was 7- to 33-times higher in terms of electrocatalytic oxidation than that of GCEs with BT , rGO , and bare GCE .−1cm−2) for dopamine owing to the synergic effects of the large specific surface area/high charge mobility of BT and the decent electrical conductivity of rGO. The obtained BT/rGO-modified electrode exhibited acceptable selectivity, stability, reproducibility, and repeatability. Additionally, the fabricated sensor was tested on real samples, and satisfactory results were obtained. The successfully combined BT/rGO nanocomposite is a promising candidate for thermoelectric materials, photocatalysts, and other electrochemical sensors.The EIS, CV, and DPV results revealed a low detection potential, high redox peak current, low limit of detection (0.06 µM), wide linear range (10–1000 µM), and superior selectivity (222.93 µA·mM


The significance of tumor microenvironment (TME) heterogeneity is increasingly becoming recognized as playing an essential role in tumorigenesis and malignant biological behaviors. Dr. Hanahan D  presentsOf note, inter-patient molecular heterogeneity has hampered the clinical practice of an expanding variety of targeted therapies and personalizing their prescriptions. An inter-patient molecular heterogeneity investigation using genomic and transcriptomic data for 4890 tumors from The Cancer Genome Atlas database showed that the repertoires of molecular targets of the clinical recommendations for accepted drugs were not congruent with the gene mutation patterns of different cancer types . Enhancevia copy number and cluster mutations , Science and Health Joint Research Project of Chongqing Municipality (2020GDRC013).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.


In spite of advances in medical technology, the repair of Achilles tendon ruptures remains challenging. Reconstruction with an autograft tendon provides the advantage of a higher healing rate; nevertheless, the development of donor-site morbidity cannot be ignored. We developed biodegradable, drug-eluting, nanofibrous membranes employing an electrospinning technique and evaluated their effectiveness on the healing of allograft tendons. Poly-D-L-lactide-glycolide was used as the polymeric material for the nanofibers, while doxycycline was selected as the drug for delivery. The in vitro and in vivo drug-release profiles were investigated. The biomechanical properties of allografted Achilles tendons repaired using the nanofibrous membranes were tested in euthanized rabbits at 2-, 4-, and 6-week time intervals. Histological examination was performed for the evaluation of tissue reaction and tendon healing. The level of postoperative animal activity was also monitored using an animal behavior cage. The experimental results showed that the degradable nanofibers used as a vehicle could provide sustained release of doxycycline for 42 days after surgery with very low systemic drug concentration. Allograft Achilles tendon reconstruction assisted by drug-loaded nanofibers was associated with better biomechanical properties at 6 weeks post-surgery. In addition, the animals exhibited a better level of activity after surgery. The use of drug-eluting, nanofibrous membranes could enhance healing in Achilles tendon allograft reconstruction surgery. The Achilles tendon is the strongest and largest tendon in the human body. Achilles tendon rupture is a common injury of the foot and ankle, which has a large influence on an individual’s level of sports activity . The ratFollowing tendon injury, matrix metalloproteinases (MMPs) play an important role in the healing process ,14. MMPsVarious efforts have been completed to develop antibacterial, nanofibrous, skin scaffolds for wound-healing applications ,42,43. TThis study further explored whether the resorbable, doxycycline-eluting nanofibers could also enhance the healing of Achilles tendons reconstructed with allografts . Doxycycline-incorporated nanofibers were prepared using a lab-made electrospinning device. After electrospinning, the in vitro characteristics of the doxycycline-incorporated, PLGA nanofibrous mats were evaluated, and the in vivo efficacy of nanofibers was assessed using a rabbit model. Histological assay was also completed.PLGA , doxycycline hyclate  and hexafluoroisopropanol were purchased from Sigma–Aldrich  .w/v) and 7.5% (w/v), respectively, were initially blended with as-purchased hexafluoroisopropanol (1 mL) using a magnetic stirrer for 2 h. The PLGA/drug solution was delivered and electrospun by a syringe pump with a volumetric flow rate of 0.1 mL/h. The travel distance between the tip of the needle and the ground electrode was 15 cm, and the voltage applied to the polymer solutions was +15 kV. After electrospinning, the PLGA/doxycycline nanofibers were gathered on the aluminum sheet. All nanofibrous samples were prepared at ambient temperature (25 °C) and 65% relative humidity. Nanofibrous membranes with a thickness of approximately 0.2 mm  were thus obtained; each membrane took approximately 3 h to be successfully electrospun. All electrospun nanofibers were placed in a vacuum oven at 40 °C for 3 days to vaporize the residual solvents.Electrospinning experiments were completed on a lab-scale device, which involved a syringe and a needle , a ground electrode, an aluminum sheet, and a high-voltage supply . PLGA (3n = 3).We used a field-emission scanning electron microscope  to evaluate the doxycycline-embedded fibers after they were coated with gold. A total of 50 arbitrarily selected nanofibers were characterized employing commercial Image J image code  for each sample to determine the diameter distribution  . Nitrogen was used as the gas of choice in the analysis, and the built-in software was used to process the data. The scanning temperature ranged from 30–350 °C, while the nanofibrous specimens were heated at 10 °C/min.n = 3) along with 1 mL of phosphate buffer solution in each tube. After the glass tubes were incubated for 24 h at 37 °C, the eluent was collected and analyzed. During the next 24 h, 1 mL of fresh phosphate-buffered saline was added, and the procedure was repeated for 42 days. The levels of doxycycline in the mixtures were evaluated through high-performance liquid chromatography .The release pattern of the doxycycline from the drug-loaded, biodegradable, nanofibrous membranes was obtained through an in vitro elution method. Samples cut from the electrospun mats (1 cm × 1 cm) were placed inside glass tubes  were included in the study; 3 animals were used for in vivo drug-release testing, while the remaining 21 animals were employed for the tendon biomechanical and postoperative activity experiments. A total of 3 of the 21 animals did not undergo surgery and served as the healthy group in the activity test. v/v). After anesthesia, each rabbit was placed onto a disinfected, disposable sheet with the continuous administration of vaporized isoflurane through a mask.For anesthesia, the rabbits were placed into a transparent chamber (40 cm × 20 cm × 28 cm) filled with vaporized isoflurane  with a concentration of 2% . A 4 cm longitudinal skin incision was made with a No. 10 blade over the posterolateral side of the right leg. Gentle dissection of the Achilles tendon was performed circumferentially with Mosquito . In casen = 3). Meanwhile, blood sampling (1 mL) was also performed by syringe via puncture on the marginal ear vein (n = 3). The blood sample was freshly centrifuged at 2500 rpm for 15 min so as to separate plasma from whole blood. The drug levels of doxycycline in the tissue and plasma were evaluated using Hitachi L-2200R high-performance liquid chromatography  [v/v/v). The absorbency was monitored at 245 nm, and the flow rate was 1.0 mL/min.Three rabbits were enrolled for the in vivo drug-release experiments. At 1, 3, 14, 28, and 42 days post-implantation, the rabbits were euthanized, and the tissues around the membrane were sampled  . The mobn = 3); control rabbits that underwent surgery only (no membrane), experimental rabbits that underwent surgery and the implantation of the doxycycline-loaded nanofibers, and healthy rabbits that did not undergo surgery).Nine rabbits were used in the activity test, including three normal rabbits, three in the experimental group, and three in the control group . Following the operation, each rabbit was raised in an animal behavior cage (n = 3). The tensile test was performed using a Lloyd tensiometer  equipped with a 2.5 kN load cell, according to the ASTM D638 standard. The tendon was clamped at both ends onto the tensiometer and pulled at a speed of 6 mm/min for 10 cm.A total of 18 animals were enrolled in the tensile strength study. To minimize the use of animals, 6 rabbits from the activity test, after being monitored for 1 week, were re-included in this analysis. The rabbits were euthanized by intravenous injections of lidocaine (10 mL) 2, 4, and 6 weeks after surgery. The right Achilles tendons and the left healthy tendons (with an approximate length of 5 cm) were harvested for further biomechanical strength testing . Hematoxylin and eosin staining was used for histological evaluation. We evaluated six different parameters, including fiber structure, fiber arrangement, nuclei rounding, white blood cell accumulation, vascularity, and cell density. Each parameter was scored from 0 to 3; with 0 representing normal and 3 representing totally abnormal. With this semi-quantitative scoring system , histolot-test for statistical evaluation between different two-group combinations. Statistical significance was set at p-values below 0.05.We used the paired p < 0.05). Similar results were noted at 4 weeks (p > 0.05). At 6 weeks after surgery, the maximum load was markedly lower in the control group (p > 0.05), testifying to the extraordinary ability of doxycycline-loaded nanofibers in promoting the healing of the reconstructed, allografted Achilles tendons.At 2 weeks A, the ma 4 weeks B. The maol group C. The map < 0.05). Nonetheless, there was no significant difference between the doxycycline and healthy groups. Therefore, rabbits undergoing allografted Achilles tendon reconstruction with a doxycycline-loaded biodegradable nanofibrous membrane had a level of activity similar to that of the healthy rabbits and higher activity levels compared to those of the control rabbits.The activity of the animals post-operation was evaluated using an animal behavior cage. The total number of times the sensors were triggered in each group is shown in Allograft tendon reconstruction has become increasingly important, especially when there is a shortage of suitable available local tissue. The advantages of using allograft tissue involve the avoidance of donor site morbidity, high tensile strength, reduced operational time, smaller surgical incisions, and a low risk of arthrofibrosis ,56. HoweIn the literature, oral administration of doxycycline has been found to maintain an effective drug concentration over a long period of time ,27. KessThe progress of nanotechnology in drug-delivery provides the potential for enhanced treatments with targeted delivery and minimized side effects through the employment of designed nanomaterials, as well as via the formation of delivery systems from nanoscale molecules and/or vehicles. In this study, degradable nanofibers were manufactured for the sustainable discharge of doxycycline into the target area for allograft tendon reconstruction. Owing to their excessive surface-area-to-volume ratio, nanofibers offer an advantageous vehicle for the transport of water-insoluble or poorly soluble pharmaceuticals. Another great advantage of nanofibrous mats lies in their similarity with the natural fibrillary extracellular matrix (ECM), which facilitates cell attachment and proliferation for biomedical applications.In this work, we prepared degradable, PLGA nanofibers that provide the sustained release of doxycycline. The experimental results showed that electrospun nanofibers exhibit a tri-phasic drug-release behavior  in vitroPrevious studies demonstrated that the effect of doxycycline on tendons becomes significant from at least 3 weeks after surgery ,25,27,47There are limitations associated with this study. First, the number of animals employed in this work has been low. Second, we did not examine the relationship between drug concentration and tendon healing so as to optimize the drug loadings in the nanofibers for tendon reconstructions. Third, the thermo-interaction between PLGA and doxycycline remained unclear. Fourth, more research will be needed to better comprehend the microscopic mechanism leading to the reduction of extensibility in reconstructed allografts. Finally, the relevance of the present findings to tendon reconstruction with allograft in humans remains uncertain. These will be the topics of our future research.We evaluated the efficacy of doxycycline-loaded, biodegradable nanofibers for allograft tendon reconstruction in rabbits. The experimental results showed that the nanofiber can provide persistent release of doxycycline for 42 days. The concentration of doxycycline was markedly higher in local tendon tissue than in blood, indicating a very low systemic drug effect. Despite the doxycycline concentration in the rabbit’s tissue being high at day 1, it was still inferior to that when orally administered. In particular, the drug level in the animal’s blood was much lower than that found when the drug is administered orally, demonstrating the advantage of local drug delivery through nanofibers. In addition, animals receiving allograft tendon reconstruction with doxycycline-loaded nanofibers exhibited stronger tendons and higher levels of activity after surgery. The reconstructed allograft tendons showed less extensibility than the healthy tendons. Histological assays did not display any notable tissue inflammation. Resorbable nanofibers with sustained discharge of doxycycline demonstrated the potential for the reconstruction of Achilles tendons via allografting.


Escherichia coli is the predominant pathogen of urinary tract infections in the United States. Understanding regional patterns of uropathogenic E. coli antimicrobial resistance (AMR) may help further the practice of antibiotic stewardship through the creation of region-specific antibiograms. In this study, we analyzed regional patterns of uropathogenic E. coli AMR among outpatients in Washington state.E. coli isolate from each patient was included in the analyses. We conducted separate relative risk regressions with robust standard errors for five antibiotics , classified as “susceptible” or “non-susceptible.” The state is divided into nine Public Health Emergency Preparedness Regions (PHEPRs), which served as the exposures for the analysis, with adjustment for sex, year of isolate collection, and age group .Deidentified results from antibiotic susceptibility tests performed by Quest Diagnostics on Washington state outpatient isolates from 2013 through 2019 were analyzed. Only the first We included 40,865 isolates in the study . Compared to the Central PHEPR (containing Seattle), most other regions had significantly lower adjusted relative risks (aRR) of AMR; no regions had significantly higher aRR of resistance for any of the five antibiotics. Differences in resistance between Central and other regions varied by antibiotic. Regional AMR differences were largest for CRO  and smallest for AMP. Other patterns observed include a lower aRR of AMR for females compared to males for AMP, CIP, CRO, and GEN; higher aRR of AMR for CRO for recent years (2015-2019) compared to 2013; and higher AMR with age for CIP and CRO.Given the differences in resistance across Washington’s PHEPRs, antibiograms should be tailored to provide the most regionally accurate information to prescribers. The emergent situation surrounding AMR calls for more specific outpatient antibiograms to enable healthcare providers to improve health outcomes and mitigate emerging resistance to antibiotics among outpatients.Ann Salm, PhD, Quest Diagnostics Inc.: Employed and own stock in Quest Diagnostics Inc.|Quest Diagnostics Inc.: Stocks/Bonds Hema Kapoor, MD, D(ABMM), Quest Diagnsotics: Stocks/Bonds Stephen E. Hawes, PhD, InBios International: Advisor/Consultant Jeff Radcliff, B.S., Quest Diagnostics: Employee|Quest Diagnostics: Stocks/Bonds.