N = 15) and a revised version of the Debriefing Instrument for Patients (N = 114) . Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD = 0.93) and F mean 1.07 (SD = 0.83). Overall rating of the interview was 8.30 (SD = 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD = 0.52), F 0.58 (SD = 0.93) and A 1.42 (SD = 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients’ illness narratives. We argue for further refinements of the CFI.This study is an evaluation of clinicians’ and patients’ experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians’ experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians ( Due to globalization and migration, there is an increasing need for culturally sensitive assessment tools in mental health care. Several studies show a healthy-migrant effect in some countries, in that immigrants are on average healthier than members of the native-born population . HoweverTo enhance awareness of culture and context in applying psychiatric diagnoses, DSM-5, the Diagnostic and Statistical Manual of Mental Disorders of the The operationalization of the CFI in DSM-5 was based on research with previous regional interview guides, developed in different countries and languages. The points of departure were the Outline for Cultural Formulation (OCF) in DSM-IV  and an iThe CFI calls for systematic assessment of cultural and contextual factors related to four domains: 1) definition of the problem, 2) perception of cause, context, and support, 3) self-coping and past help seeking, and 4) current help seeking. The CFI can be used for the initial assessment of all patients, and may be especially helpful in transcultural diagnostic processes . The core CFI with 16 questions can be supplemented, if needed, by an informant version and by questions from 12 supplementary modules supporting further information-gathering .Using the CFI is a patient-centred method to support the exploration of the impact of culture and context in an individualized and non-stereotypic way. The value of culturally sensitive diagnostic methods has been shown in earlier studies evaluating the OCF in DSM-IV .Before the CFI was included in DSM-5, its Clinical Utility, Feasibility and Acceptability were evaluated in a multi-centre field trial . The resThe results of the DSM field trial studies revealed differences between centres, necessitating local evaluations. Further, in the DSM-5 field trial, clinicians had only used the CFI on a limited number of occasions, which is why an evaluation of the perceptions of more experienced CFI users may add valuable knowledge. Despite the DSM-5 field trial, which indicated that the pilot version of the CFI in DSM-5 was a useful tool, few studies have evaluated the final version of the CFI that is included in DSM-5. In a qualitative study, in a Mexican setting, the CFI was found to be a way of building trust and increasing providers’ understanding of contextual factors influencing mental illness . In anotThe present study aimed to assess the clinical utility, feasibility and acceptability of the core CFI in DSM-5 for both clinicians and patients, and to explore clinicians’ experiences of using the core CFI in an outpatient clinical setting in Stockholm, Sweden.The present study was conducted from August 2015 to May 2017. Data were collected from the intervention group in a clinical RCT comparing CFI and non-CFI clinical assessments. We collected data from the clinicians (trained in using the CFI) and from patients in the CFI intervention group. A mixed-method approach was chosen, using questionnaires and focus group interviews with the clinicians.The study was conducted at an outpatient psychiatric facility, Praktikertjänst Psychiatry AB in Stockholm Sweden. In 2017, its Järva Clinic had 114 full-time employees, including psychiatrists, psychiatric nurses, psychologists, clinical social-workers, and caretakers, at three different geographical sites, and treated 4,038 individual patients. The catchment area in western Stockholm has a very mixed population, with suburbs that are home to many immigrants and refugees. The proportion of patients with an immigrant background (first and second generation) is 75%. Many have a refugee background, and most of the immigrant patients come from Asia  and Africa . The socio-economic status of the population is precarious, and the occurrence of physical and mental health problems is high. The most common activities undertaken at the clinic are: outreach programs, investigations, various sorts of psychotherapy, psychopharmacological treatment, socialization groups, home visits, basic somatic examinations, prescriptions, referrals and collaboration with social services. The clinic has employees who master a total of 23 different languages between them, but it employs interpreters when needed.1 were used. Although clinicians from different professions may perform the standardized psychiatric assessments and treatment planning, a psychologist or psychiatrist is responsible for making the formal diagnostic categorization according to ICD-10. This categorization should be based on all information gathered in the standard diagnostic procedure.In the study, the core CFI interview, without any supplement, was included in the standard psychiatric diagnostic procedure, which, in Stockholm County Council, contains a clinical diagnostic interview. Additionally, several web-based screening toolsn = 19), Europe (n = 11), Asia (n = 4), South America (n = 4), and Africa (n = 4), while the origins of 14 patients were unknown. Most had lived in Sweden for more than 10 years. Some patients had been referred to the clinic, mainly from primary care clinics, while some came on their own initiative (25%). All were included as participants in the current study.The CFI was applied in consultations with 114 patients who had not been in contact with psychiatric care during the preceding two years. Accordingly, the clinicians and the patients had no previous contact. Forty-two patients were known to be non-Swedish born, with their origins in the Middle East , who was also a member of the DSM-5 Cross Cultural Issues Subgroup (DCCIS) . The numTo assess perception of the CFI, we used the Debriefing Instrument for Patients (DIP) and for Clinicians (DIC). Both instruments were designed for the DSM-5 CFI field trial to measure three factors: Clinical Utility, Feasibility, and Acceptability . SwedishDue to psychometric concerns about the DIP that were raised in the field study, we reached an agreement with its authors to revise the instrument by removing items that were difficult to understand and translate. Items reported to be problematic were the two negatively worded items: ‘Took more time to share my perspective than I wanted’ in the case of Feasibility, and ‘Were too personal’ in the case of Acceptability. We did not want to exclude these items, which were considered relevant to patients; and, during the decision process, we chose to prioritize aspects of face validity and assumptions regarding patient relevance. All items were discussed with clinicians from the catchment area. This process resulted in several changes: (1) the omission of three items from the original Clinical Utility factor: Item 5 (‘Gave me confidence that the clinician understood my situation’), item 6 (‘Helped me identify things that could get in the way of my treatment’), and Item.8 . (See All items (apart from DIP/Acceptability) in the DIP and DIC had five response alternatives. Scoring followed the previous study , with 2 No revisions were made to the DIC, which has questions for the scoring of Clinical Utility, Feasibility, and Acceptability. The DIC also includes three open-ended questions: ‘Which of the CFI questions were the most useful? Why?’, ‘Which were least useful? Why?’, and ‘What would the challenges be to incorporate the CFI questions into your routine clinical practice?’ Additionally, the DIC includes questions where the clinician is asked to rate whether the written CFI guidelines, ‘… were clear and easy to understand’ and ‘… prepared me well to administer the CFI questions’ .N = 114) upon completion of the CFI interview. They had the option to complete this privately or with assistance from the clinician or an interpreter. They were able to return the questionnaire to the clinician or anonymously in a box at the clinic reception. The questionnaire was translated and available in 12 languages. An interpreter was used in consultations with 22 patients. They did not reveal their identity or provide any baseline data on the form. All clinicians (N = 15) received their questionnaire after all their interviews had been performed, i.e., upon completion of the RCT intervention.Patients were invited to take part in the study during their initial meeting with a clinician. Patients who agreed to participate received the DIP questionnaire  conducted the interviews in the presence of an observer; a semi-structured interview guide was used for the interviews (Appendix 1). Four clinicians were no longer employed at the clinic by the time of the focus group interviews, and could not be reached, leaving 11 eligible participants. One potential participant in each focus group was absent from work at time of interview resulting in nine actual participants, five in one group and four in the other.There were 3.8% item records missing for the DIP and 2.6% missing for the DIC. Missing data were imputed using the mean of the remaining items within each factor. There were no instances of more than one missing item score per factor. The negatively worded item ‘Took more time to share my perspective than I wanted’ was scored in reverse. We computed means and standard deviations for each item in both instruments, as well as for the factors Clinical Utility and Feasibility for both instruments, and Acceptability for the DIC. The open-ended questions in the DIC questionnaire were analysed and included in the results from the focus group interviews. Where applicable, we assessed internal consistency by means of Cronbach’s alpha for the DIP Clinical Utility factor and for all the DIC factors. Cronbach’s alpha for Clinical Utility was 0.88 in the case of the DIP (five items). For the DIC, internal consistency was 0.82 for Clinical Utility (10 items) and 0.82 for Feasibility (four items). Due to the very low internal consistency of the DIC Acceptability factor , we excluded item 15 (‘Helped make the patient feel more at ease during the interview’), resulting in a factor of three items with a still-low internal consistency of 0.55.’ experiences were identified. The analytic process is illustrated in Qualitative data from the clinicians consisted of two transcribed focus group interviews and answers to the open questions in the DIC questionnaires. The interviews and the open-ended questions in the DIC questionnaire were analysed for themes using qualitative content analysis , with suOral and written information for patients, translated into 12 languages, was given, underlining that participation was voluntary and could be withdrawn at any time without negative consequences. Ethical approval for the study was obtained from the Regional Ethical Review Board in Stockholm (2015/243-31/2).SD = 0.93) with individual items ranging between 0.70 and 1.09. The Feasibility mean was 1.07 (SD = 0.83). Overall perception (rating) of the questions in the interview had a mean of 8.30 (SD = 1.75) on the VAS (between 0 and 10). Eight patients, 14.5%, reported that they perceived some questions in the interview as discomforting. Among the 57 patients, six patients responded to the open question regarding how they were troubled or made to feel uncomfortable; the following answers were given: “(It was) generally uncomfortable to talk about.”; “(It was) painful to realize that the cause of my problems has to do with me.”; “I had trouble understanding what the question about identity meant.”; “The question about what kind of help I want was difficult to answer – don’t know.”; “Difficult to explain question number four (Why do you think this is happening to you? What do you think are the causes of your problem?).”; “The question about culture and background. I am afraid that other people will think badly about me because I have become rather Swedish.”Among the patients, 57 out of a total of 114 (50%) returned their questionnaires. In a few instances (exact numbers not known), the patient did not receive a questionnaire due to clinicians’ lack of time. All responders used the Swedish DIP version. The DIP results are presented in SD = 0.52). Further, all the individual items were positively rated: from ‘Gave me confidence in the diagnosis’  to ‘Helped me identify additional aspects or dimensions of the patient’s clinical problems’ . The Feasibility factor mean was lower , and one item was negatively rated, ‘Were easily understood by the patient’ . Acceptability was rated the highest, ; mean scores among the items on the factor ranged from M = 1.20; SD = 0.77 to M = 1.53; SD = 0.52 for both ‘Facilitated a good assessment of cultural factors relevant to clinical care’ and ‘I would recommend for use by other mental health clinicians’. The mean of item 15, ‘Helped make the patient feel more at ease during the interview’  was lower than that of the items it contained, M = 1.00 (SD = 0.96). Two additional questions about the instructions for the interview had positive ratings .All 15 clinicians responded to the DIC . The CliClinicians talked about their experiences of using the CFI in comparison with their ordinary clinical procedure. From the analysis of the clinicians’ experiences of using the CFI, the following themes were retrieved: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and, affecting clinical reasoning and assessment. The themes and sub-themes are presented in The first theme focuses on how the clinicians approach the patient in a new way when using the CFI compared with the ordinary procedure. The theme includes the following sub-themes: different questions; exploring the problem together; facilitating the patient’s narrative; and, illuminating the patient’s resources.“Sometimes they say good that you ask, nobody else has asked this, they say” .“It [the CFI] is quite broad and covers a lot of questions I would like to ask when I formulate a patient’s case.”The clinicians reported that the CFI interview supported them in approaching the patient and the problem with curiosity, as part of a mutual exploration of the problem. The CFI questions created a sense of working together and engaged the clinicians in an enhanced listening mode, since they were not confined to ordinary checklists and templates. Examples were:“You explore together, instead of labelling the patient. Because that might silence the patient; this, instead, opens things up in a way.”“… that you are not so bound to these interview templates and the like; here … you simply need to step back and listen more to the individual.”According to the clinicians, the CFI allowed the patient’s narrative to play a central role in the clinical situation. It generated subtleties in the information gathered and elicited new dimensions of the patient and the problem, while also accessing patients’ views on their daily life. The clinicians found this to result in a more complex picture, enhancing their understanding of the problem and the person. Examples included:“It results in another description, another picture of their daily life” (compared to their ordinary procedures).“There are subtleties somehow; it’s the individual’s narrative, not my templates that I check if the patient has this and this.”The CFI helped shed light on the patient’s resources, such as previous coping strategies, family members’ roles, and how the existing or lack of resources contributed to, or interfered with, treatment and care. Examples:“What they themselves have … had as their coping strategies. Where you sometimes also find … they were on the right track and then I have tried to support those … bits.”“It becomes more like having a full picture of how this person lives, what social resources there are, how this person thinks.”The informants described how using the CFI entailed asking questions different to those in their ordinary procedure, and how they needed to abandon their original assumptions. They found the CFI particularly helpful when talking about delicate matters, such as religiosity and sexual orientation or, for some patients, just talking about having mental health problems, and also for eliciting new and unexpected information. The clinicians reported that the CFI questions about identity and cultural background were ones that the patients had not been asked before. They described the CFI as valuable in initial clinical assessment; for example:The second theme focused on how the CFI started a process of co-creating better rapport, in cooperation with the patient, and a revised and shared understanding of the individual and the problem. Information on the patient’s perspective created a richer picture for the clinicians. They described how the CFI questions had an empowering effect on patients by making them feel acknowledged and listened to. The theme includes the sub-themes: building rapport; a richer picture of the patient; contextualizing the person and the problem; a revised understanding; and, empowering the patient.“It is like … perhaps it becomes a better atmosphere than when you … pressurise the patient too much. It [the CFI] allows their own words to come through in a way.”“I think that one of the patients I interviewed, he… he thought it was a bit … well – interesting. He was kind of happy to take part. After that, when I see him, I feel that our clinician–patient alliance has become very good.”The clinicians also emphasised the need to adjust the wording of the CFI questions and the time needed for the CFI according to the requirements of the patient.The CFI was found to support a good working alliance, where the open questions allowed the patient’s view to emerge, and enabled a positive alliance-building atmosphere to be created. For clinicians, abandoning the mandatory structure made for more of a listening approach that contributed to good rapport with the patient.The CFI helped clinicians to obtain a more holistic perspective. A clinician’s narrow focus on the patient’s psychiatric diagnostic label could be broadened when a more comprehensive picture of the person and the context of the problem emerged. As one participant stated: “It [the CFI] gives a much richer picture.”Family members’ perceptions of the problem, and the traditions and beliefs that sometimes affect the patient and treatment adherence, were revealed by the CFI. It was found useful when exploring the patient’s contextual situation, even with patients without an immigrant background. The clinicians did not refer to background and identity as closely related to ethnicity, and made a point of ethnicity not being the most important factor in information related to background and identity.“What context are they living in, what is important to their identity, or how might it be related to cultural factors. What particularly complicates their receiving of help or their being understood and seen.”The CFI helped clinicians and patients to reach a revised understanding of the problem, including the need for help. For example, in the case of a patient exposed to a great deal of violence while growing up, the CFI questions helped the clinician to get a more nuanced understanding of the patient and the patient’s problem. Examples included:“You get their picture of how they understand … causes and how they view matters … if they even see a connection with their identity and background, if they have thought of it like that. Yes, that’s a good thing, I think.”“… it’s more like you increase your understanding in a way. A bit more … a deepened understanding. A bit more … how this person looks at it.”The CFI was regarded as contributing to making patients feel important; the clinicians perceived the patients’ as experiencing being listened to, having their contributions regarded as valuable and important, and that they were “empowered”. As one participant put it, the CFI gave: “…a sense that the patients feel that they are seen; they are interviewed, they are in … a context.”The clinicians also saw the CFI questions as providing a good opportunity for the patients to formulate their reflections, helping them to place themselves and their problem into a context; for example:The third theme concerns how the CFI questions impact clinical reasoning and assessment. It focuses on how the CFI contributes diagnostic clues and has an impact on choice of treatment. The clinicians said that using the CFI seemed to make the patient’s voice echo in the medical records. The sub-themes are: detecting diagnostic clues; effects on choice of treatment; facilitating the patient’s contribution; and an echo of the patient’s voice.“I guess it has also sometimes … well become clear that it is not psychiatric care they need, but in fact other things that … that have a greater influence on their ill health.”“That you get information, but maybe you ask more before you make a diagnostic decision. That it takes more… But it is a piece in the puzzle, definitely.”Answers to the CFI questions supported clinicians in trying to identify the most appropriate treatment and prognoses for treatment adherence. The answers also revealed the patient’s ability to reflect and provide information about coping strategies from the past – useful in further treatment planning and care. Examples:“These challenges they have managed before, that will… Then there is good hope that this will actually work, despite the complex situation.”“If they say they only believe in pharmacological treatment then … then I will not put in two years of therapy so to say.”The clinicians found that the CFI supported the patient’s contribution, making the clinical assessment more patient-centred. The open CFI questions moved clinical conversations to a more in-depth level where patients were supported in talking about their problems; for example: “Sometimes when you ask these concrete questions they have the courage to talk about a problem that they may never have told anybody about.” One clinician referred to a patient who said: “… but now when you ask this question, I have the courage to speak out, and that was … It has helped me to manage my illness.”The information gained through the CFI gave the clinicians diagnostic clues and helped them identify which aspects of the problem were related to psychiatric illness. Additionally, it contributed to knowledge about problematic aspects in the patient’s background, clarifying what the clinicians should examine more closely. Examples:Documentation from the CFI in the medical records was evident in quotes of the patient’s own words, thereby leaving an echo of the patient’s voice, unlike in the usual documentation of a diagnostic procedure. Examples include: “And it is the patient’s words and narratives I should write down, not my assessments,” and “No, you have to write down their answers, you cannot kind of reinterpret them.”The clinicians had diverse views on the wordings of the CFI questions, particularly the question that included both identity and background. Some clinicians thought the phrasing of the questions was abstract and complicated for some patients, especially those with a low intellectual capacity or low educational level and psychotic patients. In consultations involving an interpreter, the clinicians found the CFI and the support text explaining the questions to be too complicated. For example: “All the questions are useful. Some of them are difficult for the patient to understand, the one about cultural identity for example, but they are good questions” (quote from a questionnaire).“Since it is such a structured interview, it has been helpful to kind of have something to lean on, I think.”“Timewise it can be hard to fit it in.”“You have more to document, so there is something else to make time for. But, apart from that, it is not difficult.”While all clinicians participate in treatment planning, it is psychologists and psychiatrists who are responsible for making the formal diagnostic ICD-10 categorization. The participating clinicians were concerned that time constraints hindered the MDs in making full use of the CFI information in their diagnostic decisions. However, the interviewed clinicians used the information gathered in their treatment planning and recommended its use.The practical aspects of implementation and actual use of the CFI findings were discussed in the focus group interviews. The discussion took place in relation to the actual work situation, with a high influx of new patients and all the different measurements in the standardized initial assessment procedure. Examples were:The study aimed to assess the Clinical Utility, Feasibility and Acceptability of the core CFI in DSM-5 for both clinicians and patients, and to explore clinicians’ experiences of using the CFI with new patients in a multicultural clinical setting in Sweden. The patient and clinician questionnaires, as well as focus group interviews with clinicians, show positive results for the Clinical Utility, Feasibility and Acceptability of the core CFI.One strength of the study is its mixed method design, which provides us with both quantitative data on patients’ and clinicians’ views of the CFI in DSM-5 and in-depth information on the clinicians’ experiences of using the CFI questions in their clinical assessments. The study was conducted in a naturalistic setting, which has both limitations and strengths. Sampling and data collection, in some instances, suffered from shortcomings in rigour, which may have reduced reliability. However, validity is strengthened by the study having taken place in a busy clinical setting, with a very mixed multicultural population, including migrants, refugees, and people who were illiterate or who had language difficulties.An interpreter was used with 22 of the patients in the study, which has both strengths and limitations. A strength is that translation gave the patients the opportunity to express themselves in their mother tongue. A limitation is that there were translation difficulties with some of the CFI questions. A different strength is that the clinicians were experienced in working in multicultural settings.One significant limitation of this study is the low response rate from patients, which may have several explanations. Due to clinicians’ lack of time, the DIP questionnaire was not always administered to the patient after the CFI. Some patients received the questionnaire but did not return it, possibly due to concerns about anonymity or because responding to the questionnaire entailed having to rate their new clinical contact. It is also possible that they did not prioritize the completion of the DIP form because they were struggling to cope with initial contact with a new clinic and suffering from poor mental health. A limitation is that, due to the DIP anonymity, we cannot analyse the results in relation to social and cultural characteristics of the patients. We revised the DIP, which we believe increased comprehensibility of the instrument in the current Swedish context. But one obvious drawback of revision is that it reduced generalizability, including comparability with earlier studies. Further, the revision probably resulted in reduced variance.The small sample size of 15 clinicians may be a limitation, but those involved were given the opportunity to use the CFI with many patients, thereby increasing their competence in using it. Some of the clinicians did not use the CFI more than one or a few times, and, for a few of them, it had been a long time since they had used the CFI when the focus group interview took place. However, most of the clinicians used the CFI for several patients as a part of their routine work, and the focus group interviews were conducted when the data collection for the study was nearly finalised. There were very few missing observations in either the DIC or the DIP, and in no instance was there more than one score missing within a single factor. The results from the clinician sample, consisting of only 15 subjects, however, was particularly vulnerable to missing data. Thus, in order not to lose all the data for any individual participant on any factor, we imputed missing data using the mean of the remaining item scores for each factor. Imputation may, in theory, have led to a loss of variance, but – given the limited number of missing observations – we do not think it has had any significant impact on our results or interpretations.The results indicate that the patients’ perceptions of the Clinical Utility, Feasibility and Acceptability of the CFI were mainly positive. As our sample is small and the response rate is low (50%), results should be interpreted with some caution. Importantly, we revised the questionnaire, which is why comparisons with earlier studies are not definitive and mainly serve purpose of orientation rather than strict comparison. We had removed three out of eight items from the Clinical Utility factor and one out of three from the Feasibility factor. The main reason for this was that we assumed an improvement in relevance and comprehensibility for the patient. There were very few missing records, which are not believed to have had an impact on results.The mean for Feasibility (1.07) is slightly lower than in the international field trial of the pilot version of the CFI in DSM-5 (1.33) . The meaThe results for Clinical Utility, Feasibility and Acceptability of the CFI from the DIC were positive, except for the question, ‘Were easily understood by the patients’, which stood out as the only question with a negative response value. It might be that the translation from English to Swedish contributed to this, with the questions in Swedish being perceived as more abstract than the original questions in English. The clinical situation, with interpreters and several patients not having Swedish as their mother tongue, may also have contributed to language difficulties using the CFI. The results from the DIC tended to be more positive than those from the field trial. A possible explanation is that the clinicians in the current study had become more experienced in using the CFI since they had used it over a lengthy period of time, i.e., 1.5 years. They also had had lengthy experience of working in a multicultural clinical setting, which might have had an impact on the results for the highest rated DIC subdomain, Acceptability. These results may be generalizable to settings where clinicians have substantial experience of a multicultural setting and training in using the CFI. Although there were fewer clinicians than patients responding to the instruments, the standard deviations were generally smaller for the DIC than for the DIP, indicating that the clinicians are a small but homogenous group. While the clinicians seemed to think that the CFI questions were difficult for the patients to understand, the patients’ DIP results for ‘The questions were easy to understand’ were high.In the focus group interviews, the clinicians compared using the CFI with their ordinary procedures. The CFI compelled the clinicians to approach patients in a new manner, making them ask different questions and explore the problem together. The clinicians found that the new approach facilitated the patient’s narration and illuminated the patient’s resources. The clinicians described how the CFI contributed to co-creating a better rapport, in co-operation with the patient, creating a richer picture of the patient, and contextualizing the person and the problem. This resulted in mutual revised understanding and had an empowering effect on the patient. The information gathered from the CFI also affected clinical reasoning and assessment by providing the clinicians with diagnostic clues to choice of treatment. The CFI also facilitated the patient’s contribution and left an echo of the patient’s voice in the medical record. The results support using the CFI at initial contact, making psychiatric assessment more patient-centred by facilitating patients’ illness narratives.Although the clinicians participating in the focus group reported positive experiences of using the CFI, they were concerned about clinical implementation, since they feared that time constraints might restrict the possibility of making full use of the CFI information in diagnostic decisions. This may explain why the Feasibility subdomain was rated lower than the other subdomains in the DIC. The present study found time constraints and difficulties in conveying the CFI findings to all the members of the clinical team to be major concerns regarding implementation. They may result in important information about the patient being lost in terms of clinical use.Results from the focus group interviews were used to gain a deeper understanding of the results from the DIP and DIC questionnaires. The clinicians had a positive perception of the overall use of the CFI questions, which is confirmed by the DIC results. There was a consensus among the clinicians regarding their experiences of using the CFI and clinical implementation. However, there was variety in their comments concerning the wordings of the CFI questions.The clinicians said that they would recommend the use of the CFI to other mental health care practitioners and regarded it as a useful tool for gathering valuable information at the initial clinical assessment. The DIC results and focus group interviews are consistent in this regard. The focus group interviews reveal that the clinicians found the interview questions to be difficult for some patients to understand, as reflected in the negative responses to the DIC item ‘Were easily understood by the patients’. Even so, overall, the clinicians found the CFI helpful with regard to understanding the patients’ problems, for themselves as well as for the patients. The clinicians said that the responses to the CFI questions brought out subtleties in the information gathered and influenced their clinical reasoning and assessment. This is confirmed by positive results for the item, ‘Helped me identify additional aspects or dimensions of the patient’s clinical problems’ from the DIC. The DIC results showed that the clinicians experienced the CFI questions as facilitating a good assessment of cultural factors relevant to clinical care, which is confirmed by the focus group interview findings, where the clinicians reported the effects of the CFI responses on choice of treatment.The findings from the focus group interviews are in line with those in the study by Aggarwal and colleagues (2015) on how the CFI affects medical communication. Their results showed increased clinician/patient rapport, with the CFI producing information based on the patient’s story and eliciting the patient’s perception of the illness. Our results also correspond with those of the Mexican study of the CFI , in the Patients and clinicians valued the core CFI. Clinicians praised the person-centred approach that facilitated the patients’ narratives, clarified their context, and contributed to the co-creation of shared understanding. The narrative approach also worked well with interpreters, but sometimes gave rise to difficulties in the translation of abstract wordings. For successful clinical implementation, our findings highlight the importance of teamwork. Even in busy clinical settings, it is important to allow time to listen to the patient’s narrative and to transmit the information gathered by the CFI to all the professionals that are engaged in the psychiatric assessment of the individual patient. This can be a challenge in settings with a shortage of psychiatrists, and where there are clinical models of working with a division of labour between professions, combined with time pressure. Implementation of the CFI requires a context where there is shared concern for the information gathered. If not, there is a risk that the information will be detached from the formal diagnostic categorisation and other aspects of assessment and treatment.Our study also indicates that, for clinical use, revising some of the questions is beneficial. In particular, the abstract questions about identity and background were difficult for some patients to understand, and it was also difficult for clinicians to use the explanatory text in the CFI. This was of especial concern in interactions with patients with poor language proficiency and when interpreters were used. However, for others, the questions worked well and provided valuable new information. On the basis of experiences in Pune (India), Paralikar, Deshmukh, and Weiss (2020) suggest that assessing cultural identity requires that an interviewer focus on a patient’s self-ascribed identity and not the views of others or the clinician. They also point to the need for further research on the role of cultural identity.This study makes a contribution to knowledge about the Clinical Utility, Feasibility and Acceptability of the core CFI in DSM-5. Patients and clinicians participating in the study found that the CFI in DSM-5 was a feasible, acceptable and clinically useful assessment tool. Findings from the focus group interviews suggest that using the CFI at initial contact can contribute to making psychiatric assessment patient-centred by facilitating the patient’s illness narrative. The results reveal difficulties in CFI wording for some patients, indicating the need for adjustments to make the questions more comprehensible. Additionally, arguments are presented for further refinements of the CFI and for clinical evaluations in diverse settings.


Antimicrobial resistance (AMR) is of growing concern globally and AMR status in sub-Saharan Africa (SSA) is undefined due to a lack of real-time data recording, surveillance and regulation. World Health Organization (WHO) Joint External Evaluation (JEE) reports are voluntary, collaborative processes to assess country capacities and preparedness to prevent, detect and rapidly respond to public health risks, including AMR. The data from SSA JEE reports were analysed to gain an overview of how SSA is working towards AMR preparedness and where strengths and weaknesses lie.SSA country JEE AMR preparedness scores were analysed. A cumulative mean of all the SSA country AMR preparedness scores was calculated and compared to the overall mean SSA JEE score. AMR preparedness indicators were analysed, and data were weighted by region.The mean SSA AMR preparedness score was 53% less than the overall mean SSA JEE score. East Africa had the highest percentage of countries reporting having AMR National Action Plans in place, as well as human and animal pathogen AMR surveillance programmes. Southern Africa reported the highest percentage of countries with training programmes and antimicrobial stewardship.The low mean AMR preparedness score compared to overall JEE score, along with the majority of countries lacking implemented National Action Plans, suggests that until now AMR has not been a priority for most SSA countries. By identifying regional and One Health strengths, AMR preparedness can be fortified across SSA with a multisectoral approach. The fivStaphylococcus aureus (MRSA), extended-spectrum β-lactamase-producing (ESBL) Enterobacteriaceae, carbapenemase-producing Enterobacteriaceae (CRE), multi-resistant Pseudomonas aeruginosa, vancomycin-resistant enterococci, and multi-drug resistant Acinetobacter baumannii [Western countries took up the challenges of the WHO action plan and several initiatives from Western Europe and the USA were established , 5. Fromaumannii .In contrast to high income countries, there are numerous additional challenges to implementing effective and sustainable AMR surveillance programmes in low and middle income countries such as those in Africa. These range from a lack of infrastructural and institutional capacities, lack of investment and human resources, underutilisation of available data and scarce dissemination to regulatory bodies , 7. RoutAt a global level, the realisation of the increasingly serious nature of AMR has led to the formation of several initiatives to improve the surveillance and capture of AMR data. The WHO has created a number of AMR surveillance initiatives, including the tripartite database WHONET , the AdvThe need for a One Health approach cannot be understated. Whilst the global threat of AMR has repeatedly been attributed to inappropriate use of antimicrobials in human and animal husbandry, AMR in animals and humans without previous exposure to antimicrobials has been observed. This highlights the complex evolution and transmission dynamics among people, domestic and wild animals and the environment –16. AvoiAlongside surveillance databases and committees, the need to identify country-specific preparedness for potential public health risks, including AMR, resulted in the publication of Joint External Evaluations (JEEs) . JEEs arJEE reports are broken down into four areas  related hazards and points of entry’), and 19 sub-areas within these, one of which is ‘AMR’, which is further broken down into four categories. To help to identify whether a country has certain AMR indicators, a number of technical questions for each category are provided in the JEE for the country to answer, then scores are calculated based on the presence or absence of these indicators. A score of 1 denotes no capacity, 2 limited capacity, 3 developed capacity, 4 demonstrated capacity and 5 sustainable capacity.Whilst tackling AMR can be broken down into many areas, as described in the JEEs, it is only by looking at the whole picture that effective gains can be made. JEE reports are created for individual countries and their results have thus far not been compared, to identify strengths and weaknesses across SSA. By exploring the JEE reports in more detail and comparing SSA countries and regions, it was possible to generate an overview of how the continent is working towards AMR preparedness. By breaking this down into African regions , strengths can be pinpointed and adapted by countries who may need assistance. The knowledge gained from the JEE AMR preparedness score comparisons can be used to inform future AMR policies.p < 0.05) between categories using GraphPad Prism 8.4.2.In this report, we aimed to identify the overall AMR preparedness across SSA using the scores from the JEE reports, so that strengths and weaknesses could be identified. To do this we analysed the 44 completed JEE reports from SSA countries, which were accessed between 6th November 2018 and 22nd March 2020 . The meaThe percentage of countries which fell into each score category was also calculated. Information from the accompanying technical questions was extracted and analysed to identify what percentage of the countries reported having AMR indicators in place. The other most commonly noted AMR structures were also collated and included, to give a deeper insight Table . Althougp = < 0.0001).The mean SSA ‘AMR’ score was 1.42 (range 1.00–3.50), ranking it 17th among the 19 sub-areas when all sub-area mean scores for SSA were calculated (Table p = 0.0207). ‘IPC’ had the highest mean score of 1.70 (range 1.00–5.00), while ‘Antimicrobial Stewardship’ had the lowest mean score of 1.23 (range 1.00–3.00).When the mean of each AMR category was calculated there was a significant difference between the mean SSA category scores  stating that they conducted routine veterinary pathogen AMR surveillance. Many countries reported that they conducted ad hoc, or research-based surveillance studies, but did not have a national programme in place. 66% of countries routinely collected and tested human pathogen samples for AMR and 25% collected and tested animal pathogens for AMR. The majority (59%) of SSA countries reported sending their AMR samples to a dedicated AMR National Reference Laboratory.‘Infection Prevention and Control’ had the highest mean SSA category score and 25% of countries reported that they conduct training on AMR in an IPC capacity. Most countries (95%) did not have fully functional WASH or environmental health standards in place across all healthcare facilities. This category also had technical questions relating to animal IPC, although only six countries  specifically referred to animal IPC, and only Central African Republic mentioned animal IPC as a ‘strength’ rather than a ‘challenge’. The majority of answers from the technical questions centred around health care-associated infections.For ‘Antimicrobial Stewardship’, 32% of countries stated that they had national guidelines for the appropriate distribution and use of antimicrobials. Prescription-only rules for the clinical use of antimicrobials were reported in 43% of countries, but the percentage of countries reporting legislation of antimicrobials for veterinary use was lower (32%). Most countries who reported having legislation in place stated that despite these regulations, issues with counterfeit drugs and the lack of enforcement was a problem. Some countries are in the process of making antimicrobials prescription-only, whilst others report extensive concerns over the uncontrolled use of unregulated and counterfeit antimicrobials. This is especially true for the veterinary sector, with antimicrobials often reported to be sold in village shops manned by store workers untrained in antimicrobial use. Antimicrobials were often reported to be used as a supplement to enhance growth and prevent diseases in poultry farms and beef and dairy production, although a few countries reported that antimicrobial use for animal growth promotion had been banned.When assessing the AMR preparedness indicators by region, East Africa had the greatest number of countries with a National Action Plan (41%), national human and animal pathogen AMR surveillance programmes  and routine animal pathogen AMR testing (47%)  should make surveillance and reporting easier . A systeAlthough this study has shown that ‘Infection Prevention and Control’ had the highest SSA average score out of the four AMR categories, it still has room for improvement. As part of the National Action Plan, a national IPC programme for human health, animal health and food production  must be implemented, so that a One Health system for integrated assessments of the safety and functionality of facilities for public health emergencies is in place. Steps are being made, as AMR is mentioned in the IPC guidelines published by WHO AFRO . Althoug‘Antimicrobial Stewardship’ scored the lowest of all the AMR categories, suggesting that by focussing on this, real gains can be made in the fight against AMR. Whilst the introduction of antimicrobial stewardship has proved successful in some countries, and can be used as a template for others , 35, thiWith the two highest regional mean AMR scores, AMR preparedness lessons can be learned from both East and Southern Africa. East Africa, with the highest percentage of countries with multisectoral National Action Plans, collection of animal pathogen AMR data and both human and animal pathogen AMR surveillance, appears to have embraced the One Health approach and the importance of surveillance. Southern Africa has the highest percentage of countries with antimicrobial stewardship guidelines in place, as well as the highest percentage of countries with human and animal antimicrobial legislation in place.This study has compared the AMR section of the JEE reports for SSA to compare countries and regions and identify key strengths that can be adapted and utilised across the continent. The key points identified in this study suggest that SSA countries need to fully involve clinical, veterinary and environmental departments if they are to build a robust One Health AMR preparedness response. To do this, they must share their experiences and adapt the successful programmes from countries with strong AMR responses to suit their own unique needs to ensure a standardised and coordinated assault on AMR.


Second, NQE can localize methyl rotors by temporarily changing molecular bond orders and leading to the emergence of localized transient rotor states. Third, for noncovalent van der Waals interactions the strengthening comes from the increase of the polarizability given the expanded average interatomic distances induced by NQE. The implications of these boosted interactions include counterintuitive hydroxyl–hydroxyl bonding, hindered methyl rotor dynamics, and molecular stiffening which generates smoother free-energy surfaces. Our findings yield new insights into the versatile role of nuclear quantum fluctuations in molecules and materials.Nuclear quantum effects (NQE) tend to generate delocalized molecular dynamics due to the inclusion of the zero point energy and its coupling with the anharmonicities in interatomic interactions. Here, we present evidence that NQE often enhance electronic interactions and, in turn, can result in dynamical molecular stabilization at finite temperature. The underlying physical mechanism promoted by NQE depends on the particular interaction under consideration. First, the effective reduction of interatomic distances between functional groups within a molecule can enhance the  The inclusion of nuclear quantum effects (NQE) in atomistic simulations of chemical systems is of key importance. Here the authors use machine learned force fields trained on coupled cluster reference data to show the dynamical strengthening of covalent and non-covalent molecular interactions induced by NQE. Within the Born-Oppenheimer (BO) approximation, NQE tend to lower energy barriers and stimulate tunneling. In addition, the inclusion of NQE promotes a delocalized sampling of the molecular configuration space, consequently exploring regions of the potential-energy surface (PES) inaccessible by classical dynamics. As a result, this can enhance or inhibit certain molecular interactions7. A clear example is the hydrogen bond, where the NQE affect interactions in biological systems and molecular crystals by delocalizing protons. In the case of bulk water, NQE can even qualitatively change its fundamental physical and chemical properties9. In general, the study of NQE in molecular and biological systems is a thriving research field covering from rigid and fluxional molecules13 to liquids and DNA base pairs19, allowing the analysis of, for example, interactions between neighboring molecules via hydrogen bonding20, spectroscopic properties22 and proton transport23. Nevertheless, previous works have been mainly focused on the general implications of proton delocalization and much less is known about how NQE influence other types of covalent and non-covalent interactions. Particularly, biological systems often use combinations of covalent and non-covalent interactions for carrying out a wide variety of different processes. Therefore, it is crucial to understand whether NQE can also play an important role beyond hydrogen bonding.Nuclear delocalization is a fundamental feature of quantum mechanics resulting from Heisenberg’s uncertainty principle. In molecules, light elements such as protons and first row atoms are especially prone to delocalization. Even molecules or materials with heavier atoms and strong bonds can exhibit significant nuclear quantum effects (NQE)n → π* interactions, methyl rotors, as well as electrostatic and van der Waals interactions. The faithful description of such weak molecular interactions require high levels of theory  which is not always computationally affordable when performing long ab initio path integral molecular dynamics (PIMD) simulations. In this study, we have performed PIMD simulations using machine learned molecular force fields constructed using the sGDML framework28 and trained on coupled cluster reference data [CCSD(T) or CCSD depending on the size of the molecule]  as priors, which enables particularly data-efficient models. In previous work, we have demonstrated that sGDML yields accurate descriptions of quantum effects in small flexible molecules25. Performing predictive calculations require a series of stringent demands on the setting of the simulations, such as highly accurate description of the quantum interactions, extensive sampling of the potential energy surface, as well as the incorporation of the nuclear quantum fluctuations. Thereby, in this article we have used coupled-cluster reference data as well as accurate density-functional approximations to train the sGDML molecular force fields and the NQE were included via the path integral molecular dynamics formalism. The molecular dynamics simulations were performed at room temperature using the i-PI package and its interface to the sGDML force field29, and all the simulations presented here were done for at least 500 ps with time steps of 0.2 fs. Additional post-processing ab initio calculations were done using methods such as natural bond orbital (NBO)30 to compute the n → π* interactions and symmetry-adapted perturbation theory (SAPT)31 to study the non-covalent intermolecular interactions. The SAPT and coupled cluster calculations were done using the Psi4 package32, while the NBO calculations we done using the ORCA package33. See Methodology section and Supplementary Notes To do so, we employ the symmetric gradient domain machine learning (sGDML) framework to reconstruct the molecular force fieldsn → π* interaction. It arises from the delocalization of lone–pair electrons on electronegative atoms  into an antibonding π* orbital of an aromatic ring or a carbonyl group . In what follows, we use the NBO definition for the n → π* energy45, whereby a positive energy value means stabilization and zero energy means absence of overlap between n and π* orbitals. Hence, a positive value of the n → π* energy in Fig. n electron delocalization into π* is presented in Fig. ∘). From these results we see that the n → π* interaction contributes ~40% of the global energy minimum relative to the transition state. Additionally, we also found that the two main degrees of freedom describing dO⋯C distance, also known as Bürgi-Dunitz parameter41, and the ester’s dihedral angle, as shown in Fig. To elucidate this matter, here we study the aspirin molecule as a proof of concept. For this molecule the mum Fig. a and twomum Fig. b, c, thementclass2pt{minimmentclass2pt{minimmentclass2pt{minimmentclass2pt{minimmentclass2pt{minimn → π* interaction  functional group is a pervasive fragment in chemical and biological systems, playing a fundamental role in, for example, geneticskBT. In the particular case of the Me group, rotational barriers can be much lower than kBT. For this reason the Me group is often considered to be a nearly free rotor at room temperature . The toluene molecule is one of the simplest representative examples of a molecule with a Me group. The Me rotor in toluene has a sixfold rotational PES whose best experimental estimates for the energetic barrier range from ≈0.014 to 0.028 kcal mol−1 (≈4.9–9.8 cm−1)50, while theoretical results at the CCSD(T) level of theory give ≈ 0.024 kcal mol−1  is the frequency-dependent polarizability evaluated at imaginary frequencies58. In the case of atoms, it was recently demonstrated that the dipole polarizability is given by RvdW is the vdW radius59. This implies that subtle increments of the molecular volume driven by temperature or NQE will considerably increase the polarizability, and consequently strengthen vdW interactions. In this regard, Aguado et al.60 and Sharipov et al.61 reported studies where they estimated measurable corrections to polarizability by zero-point vibrations for sodium clusters and polyatomic molecules, respectively. In consequence, NQE should have an inevitable impact on dispersion forces according to the Casimir-Polder formula.The previous examples dealt with intramolecular interactions. Now we proceed to analyze the potential role of NQE on van der Waals dispersion interactions. There is a plethora of literature on the importance of van der Waals forces in nature, from small molecules to water solvation of proteinsAs a proof of concept, we have considered here the benzene dimer in its three most studied conformations see Fig. . But bef31 as implemented in Psi432. Each one of the points in the curves displayed in Fig. Relaxed in Fig. Now, we proceed to investigate the implications of such NQE-induced increase of the molecular polarizability on noncovalent intermolecular interactions. In order to approximate the intermolecular interaction between the benzene pair at finite temperature (300 K), we have performed a noncovalent energy surface scanning calculation using molecular configurations sampled from classical MD and PIMD simulations. The interaction energy was computed using symmetry-adapted perturbation theory (SAPT)62. If we consider the thermal dilation of the molecules, we see that the interaction energy increases as expected, but it is only the inclusion of the nuclear quantum fluctuations which reveals the trends in the benzene–benzene interaction at finite temperature. From Fig. 63. In fact, we notice that the T-shaped arrangement of the dimer barely profits  from the thermal or nuclear quantum fluctuations, contrary to the case of the parallel configuration which is the one that benefits the most (~20%).From all the cases considered in this study, our main result is the consistent trend displayed by the inclusion of nuclear quantum fluctuations in enhancing the total interaction energy relative to the classical simulations. The results in Fig. From the results presented here, we can conclude that indeed the NQE increase the molecular polarizability and therefore enhance noncovalent interactions. Furthermore, these results suggest that NQE could have a strong impact on large dispersion-dominated biological systems such as proteins and solvated molecules due to their cumulative nature.Here we studied a model where the benzene molecules are maintained at a fixed distance from each other. While the presented model might be considered idealized, such situations are abundant in nature when the mutual distance between polarizable moieties is effectively fixed by intramolecular constraints or external conditions such as pressure or by confinement of molecules in nanostructures.n → π* interaction or increase the electrostatic energy between partial charges, which indeed drastically lowers the energy of the system. On the other hand, the NQE-induced dilation of the molecular effective volume and polarizability increase is the underlying mechanism behind the strengthening of noncovalent van der Waals interactions.The results presented in this study show convincing evidence of intra- and inter-molecular interactions enhanced by NQE, which then promote localized dynamics in molecular configuration space. This finding is counterintuitive, given that it is commonly assumed that NQE tend to delocalize molecular dynamics by expanding covalent bond lengths, increasing non-covalent distances or lowering energetic barriers. Nevertheless, the effects of NQE delocalization are far from being trivial in complex molecular conformations that are stabilized by an interplay between covalent and non-covalent interactions. These interactions can conspire to reshape the molecular bond length distribution and the free energy landscape. Even relatively small changes in bond lengths can, in a cumulative manner, bring together non-bonded fragments of the molecules altering their local environments and facilitating the occurrence of unexpected processes. The underlying mechanism responsible for the NQE-induced localization varies depending on the particular interaction. Localization can happen by breaking molecular symmetry as in the case of the Me rotor via increasing the total potential energy and creating a transient well-like potential which confines its dynamics see Fig. E. AlternIt is clear that in large and complex molecules  there are many more interactions than the ones discussed here, but the diverse selection of interactions and processes in this study represents several important classes of phenomena that are commonly present in biological systems. A valid argument in this regard is the fact that many of these interactions are weak compared to covalent forces or even hydrogen bonds. Interestingly, this assumption is mostly based on theoretical calculations where the finite temperature effects are ignored. More importantly, here we have shown that nuclear quantum fluctuations can contribute considerably to the enhancement of these seemingly weak interactions. In the case of dispersion interactions, it is worth to highlight that here we have found that they can be considerably strengthened by NQE. This result suggests that we could have been underestimating the true contribution of vdW forces, given their ubiquity and paramount role in the description of chemical and biological mechanisms.It is worth to remark that even for efficient machine-learning models, it is not yet computationally feasible to describe real biological systems with tens of thousands of atoms while preserving the accuracy needed to describe many of the subtle quantum effects. Thereby a proper understanding of NQE and their implications on covalent and noncovalent molecular interactions in biologically relevant fragments  could be the key to design atomistic molecular force fields capable of accurately capturing complex electronic and nuclear quantum-mechanical effects at finite temperature.21. The sGDML method has been used to obtain accurate reconstructions of flexible molecular force fields from reference datasets of high-level ab initio calculations25. More specifically, the different levels of generalization accuracies and applicability of the sGDML framework have been assessed by (1) reproducing the exact trajectories from electronic structure-based MD simulations starting from the same initial conditions26, (2) recovering the interatomic distance distribution for several molecules relative to ab initio simulations26, and (3) by corroborating experimental molecular vibrational spectra and the statistical occupation values of molecular conformers 21.The molecular interactions used for the simulations performed in this work were generated with the symmetric Gradient-Domain Machine Learning (sGDML) framework64. Instead, sGDML imposes energy conservation as inductive bias, a fundamental property of closed classical and quantum mechanical systems that does not limit generalization. This allows highly data efficient reconstruction of molecular force fields, without sacrificing generality.Unlike traditional classical force fields, the sGDML approach imposes no hypothesized interaction pattern for the atoms and can thus model any complex molecular interactions69 and kernel-based models77, cf. also refs. 78 and 79. Nevertheless, the sGDML framework offers many advantages desirable when performing highly accurate PIMD simulations, such as high data efficiency during training for reaching state-of-the-art prediction accuracies and computational efficiency24. Therefore, to fully reach the limits of the sGDML models’ accuracy, an appropriate number of training data points has to be used. In particular, sGDML models display a fast saturation of the generalization accuracy with the size of the training set21. In this work, we have used models trained on 1000 molecular configurations, clearly reaching the saturation limit21. The generalization error across the potential energy surface for all the molecules included in this study is below 0.2 kcal/mol for energies and below 0.7 kcal mol−1 Å−1 for forces 25.There have been many attempts to accurately learn molecular force fields by using mainly neural networks51 using the really_tight basis set settings as implemented in the FHI-aims code80. Such reference level of theory was used given that PBE0+MBD yields better relative energies of equilibrium configurations with respect to CCSD(T)/cc-pVDZ compared to CCSD/cc-pVDZ for this specific molecule. See Supplementary Table really_tight basis set refer to the Supplementary Note For this study we have used a variety of quantum chemistry levels of theory. The selection of the reference level of theory for each molecule in this study was done based on its accuracy relative to CCSD(T)/cc-pVDZ method. The results for aspirin were generated with models trained on CCSD calculations using the Dunning’s correlation-consistent basis set cc-pVDZ, while in the cases of toluene and benzene, we have used CCSD(T)/cc-pVDZ data directly. It is important to highlight that for the small molecules considered in this work, the convergence of their thermodynamical and statistical properties do not require large basis sets, and in particular for the above mentioned molecules this means that their intramolecular interactions are already well captured with cc-pVDZ basis set. As an example, we have performed classical MD and PIMD simulations using a sGDML model for aspirin trained on CCSD/cc-pVTZ reference calculations, results that display the same behavior as the ones reported in Fig. really_tight reference calculations for toluene and aspirin. These additional reference calculations are free from any basis set artifacts and are converged to meV-level accuracy. Overall, PIMD simulations with these additional sGDML models fully support the results and conclusions presented in the main manuscript. The generated results and their description can be found in the Supplementary Figs. To confirm the robustness of our conclusions, we also carried out a range of classical MD and PIMD simulations using sGDML models trained on different levels of theory, such as Hartree-Fock/aug-cc-pVQZ and PBE0+MBD/26, page 284.All the datasets used in this work were generated by the representative sampling method as reported in ref. 45 calculations coupled with ORCA 4.1.233 at CCSD/cc-pVDZ level of theory were taken as the stabilization energies due to n → π* interactions. Such interactions, which play an important role in molecular reactivity and conformation , comprise delocalization of lone-pair electrons (n) of an electronegative atom into an empty π*–antibonding orbital of an aromatic ring or a carbonyl group82.Natural Bond Orbital (NBO) second order perturbative energies Supplementary InformationPeer Review File


Trichophyton rubrum, and it is most commonly located on the anterior aspect of the lower limbs in women. Here, we report a case of Majocchi’s granuloma on the forearm, a site that is rarely involved, in a 62-year-old woman who had been bitten by a dog. Histological examination revealed a dense dermal infiltrate composed of lymphoplasmacytic cells and neutrophils, with hyphae in the dermis. The presence of the fungus, Trichophyton tonsurans, was confirmed by mycological examination and molecular methods. Therefore, histological and mycological examination confirmed the diagnosis of Majocchi’s granuloma. The patient was treated with local moxibustion and itraconazole, 200 mg/day, for 60 days, which facilitated a complete resolution of the lesions.Majocchi's granuloma is an uncommon fungal infection of the dermis and subcutaneous tissue. The most frequently identified cause of Majocchi’s granuloma is anthropophilic  Trichophyton rubrum is the most common cause of Majocchi’s granuloma, followed by Trichophyton mentagrophytes, Trichophyton violaceum, and Trichophyton tonsurans [Trichophyton tonsurans. All these characteristics are different from common Majocchi’s granuloma. The patient was cured by oral itraconazole after 2 months of treatment.Majocchi's granuloma is an uncommon presentation of skin infection caused by invasion of fungus, which is divided into two types according to the patient's health condition and clinical manifestations. The first type is perifolliculitis that occurs mainly in healthy individuals and in the lower limbs, it is usually caused by penetrating trauma, clinical manifestations usually appear as perifollicular papules. The second type is subcutaneous nodules that usually happens in immunosuppressed hosts and in the upper limbs, clinical manifestations characterized by groups of nodules . Trichoponsurans . In thisA 62-year-old female patient presented to our hospital with a complaint of a lump on her left forearm for 5 months, and the condition had been aggravated for the last month. The lump was not painful or itchy. The patient had her left forearm bitten by a dog 5 months prior. At that time, she was treated at a pet hospital and injected with a rabies vaccine. The wound healed very slowly but failed to heal completely, leaving a small red nodules. In the month prior, the red nodules had increased significantly in size without pain or itching, and there was a small amount of pus after squeezing. She self treated with an oral cephalosporin for one week. No topical treatments, including topical steroids, were used. Her condition did not improve, so she came to our hospital for treatment. She had no history of any other disease.Physical examination revealed a 3 × 3.5 cm sized lump on her left forearm, with a clear boundary, a few scales and scabs on the surface, and no tenderness Fig. a. Her trLaboratory investigations showed normal liver, kidney, immune function test results and T lymphocyte subsets were normal. The results of human immunodeficiency virus (HIV) were negative. Fungal microscopy was negative. PAS staining was positive for hyphae Fig. .Fig. 2PATrichophyton tonsurans.A fungal culture was performed in a 27 °C incubator and showed the fungi growing slowly with a variable texture. The surfaces of colonies were velvety Fig. a. White Trichophyton tonsurans in GenBank, and was eventually diagnosed as Trichophyton tonsurans through ITS molecular diagnosis .Histological examination showed excessive keratinization of the epidermis and epithelioma-like hyperplasia of the spinous layer Fig. . Dense lThe patient was given itraconazole 100 mg twice daily. At the same time, the patient was given moxibustion treatment, which used a burning moxa to stimulate the lumps twice a day for 20 min each time. At the beginning of the moxibustion, the lumps were swollen and exuded pus (Fig. Majocchi’s granuloma is an uncommon fungal infection that is generally seen among patients presenting with skin tinea and immunocompromised diseases. The long-term use of steroids, chemotherapy or antineoplastic therapy or other immunosuppressive conditions may have a higher risk of developing Majocchi’s granuloma . HoweverTrichophyton rubrum, but in this case, we showed that Trichophyton tonsurans caused the Majocchi's granuloma through histological and mycological examination.The source of Majocchi’s granuloma can be a prior dermatophyte infection, exposure to infected or asymptomatic animals or humans, and local or general immunosuppressive conditions. The main cause of Majocchi’s granuloma is Trichophyton tonsurans have been reported, but most of those patients also suffered from diseases that cause immunodeficiencies, such as AIDS [Trichophyton tonsurans has rarely been reported. However, to further confirm the diagnosis of Majocchi’s granuloma, a series of auxiliary examinations should be performed, such as tissue pathology, PAS staining, GMS staining and fungal culture.Several cases of Majocchi's granuloma caused by  as AIDS , organ t as AIDS , etc. NoDermatophytes degrade the keratin in nonliving keratinized tissues to survive. However, in the case of Majocchi’s granuloma, the mechanism whereby the fungus survived in the dermis and subcutaneous tissue is unclear. We speculate that it is likely related to an impaired skin barrier. In this case, the patient was free of other diseases that may cause immunocompromised conditions, but had her left forearm bitten by a dog before. Therefore, we speculated that the Majocchi’s granuloma in this patient may occur because of damage to the integrity of the epidermal barrier and follicular disruption after being bitten by a dog. Then, fungi, along with keratin and necrotic materials, entered the dermis and caused an inflammatory response during infection.There are no consensus guidelines for the treatment of Majocchi’s granuloma. Some dermatologists recommend oral antifungal agents such as terbinafine or itraconazole and the duration of therapy should be at least 4–8 weeks and should be continued until all lesions are resolved , 8. This


Antimicrobial resistance (AMR) is the major issue posing a serious global health threat. Low- and middle-income countries are likely to be the most affected, both in terms of impact on public health and economic burden. Recent studies highlighted the role of resistance networks on the transmission of AMR organisms, with this network being driven by complex interactions between clinical  and other components, including environmental factors . Many studies have highlighted the role of wastewater as a significant environmental reservoir of AMR as it represents an ideal environment for AMR bacteria (ARB) and antimicrobial resistant genes (ARGs) to persist. Although the treatment process can help in removing or reducing the ARB load, it has limited impact on ARGs. ARGs are not degradable; therefore, they can be spread among microbial communities in the environment through horizontal gene transfer, which is the main resistance mechanism in most Gram-negative bacteria. Here we analysed the recent literature to highlight the contribution of wastewater to the emergence, persistence and transmission of AMR under different settings, particularly those associated with mass gathering events .  Antibiotics are one of the greatest tools of medicine. However, since the development of fluoroquinolones in early 1970, no new major groups of antibacterial drugs have been developed . AMR is Acinetobacter baumannii (carbapenem-resistant), Pseudomonas aeruginosa (carbapenem-resistant) and various Enterobacteriaceae members, including Klebsiella spp., Escherichia coli, Serratia spp., and Proteus spp. (carbapenem-resistant and extended-spectrum ß-lactamase (ESBL)-producing), which are associated with severe and, often deadly, infections, including bloodstream infections and pneumonia. The high-priority category includes Enterococcus faecium (vancomycin-resistant); Staphylococcus aureus ; Helicobacter pylori (clarithromycin-resistant); Campylobacter spp. (fluoroquinolone-resistant); Salmonella spp. (fluoroquinolone-resistant) and Neisseria gonorrhoeae , which are causative agents associated with more common infections, such as general infections, gastroenteritis and gonorrhoea. The medium-priority category includes Streptococcus pneumoniae (penicillin-non-susceptible), Haemophilus influenzae (ampicillin-resistant) and Shigella spp. (fluoroquinolone-resistant).Recently, the WHO identified 12 bacterial species and their accompanying AMR profiles that pose the greatest threat to human health . This liAMR is driven by complex interacting factors that could be described as a resistance network . This neTransmission of AMR can spread between people, animals and the environment via a number of different routes . The envMany studies have highlighted the impact of the diverse nature of the reservoirs of AMR genes (ARGs) on promoting the emergence and transmission of AMR organisms . AMR is Enterobacteriaceae [Many studies have highlighted the role of sewage as a major environmental reservoir of AMR, as it represents an ideal environment for AMR microorganisms and ARGs to persist ,31,32. Teriaceae ,34.In this study, we aimed to systematically review the literature to identify the role of wastewater in promoting the transmission of AMR and to characterise the key factors implicated in the persistence of ARB and ARGs in this environmental component. We extended the analysis to characterise AMR transmission in environmental samples associated with key religious mass gathering events—Kumbh Mela and Hajj in India and Saudi Arabia, respectively.Searches were systematically carried out in four databases: Embase, Medline, PubMed and Web of Science Core Collection to obtain all articles that reported AMR in sewage samples. The key terms “antimicrobial resistance” OR “AMR” in combination with “sewage” were used to obtain the articles available between 2009–2019, with the search conducted on 21st June 2019. EndNote X7.5 (Thomson Reuters) was used for bibliography management. The duplicates were removed, and initial screening was performed by assessing titles, abstracts and keywords with an explicit focus on the use of molecular approaches, including whole genome sequencing and metagenomics, in detecting AMR. The search was extended to include special settings, such as mass gatherings at Hajj and Kumbh Mela. Articles were included if they were written in English and included an observational study design where sewage samples were investigated molecularly for the detection of AMR. We excluded articles if they were written in languages other than English, reviews, opinion articles and editorials. Potential articles were evaluated on the inclusion criteria by retrieving the full text and were subsequently included in the analysis .1461 articles were obtained in the initial literature search and five articles found by hand searches, which included 809 duplicates. After removing the duplicates, the first screening removed non-English records and irrelevant abstracts, resulting in 251 remaining articles. Full-text was retrieved to screen the articles on the selection criteria, and a total of 63 papers were eligible for inclusion in the analysis . All papFrom the 1466 articles that were identified, 63 studies conducted on wastewater samples between 2004 and 2018 (published in the period 2009–2019) were included in the data analysis. The analysed studies documenting the detection of ARBs and/or ARGs in different types of wastewaters are listed in These studies highlight the role of aquatic ecosystems, particularly wastewater, as a key reservoir of AMR bacteria and ARGs in the environment. High levels of both ARBs and/or ARGs were detected in samples collected from different types of wastewater, including municipal sewage ,47,54,81A number of studies have also demonstrated elevated levels of AMR detected in samples that have been collected from downstream water ,44; the The majority of the studies have used integrated molecular and phenotypic approaches to characterise the resistance profiles and virulence contents associated with AMR bacteria. Many studies (n = 47) have used advanced molecular approaches, including polymerase chain reaction (PCR) followed by Sanger sequencing and/or quantitative PCR, to characterise the AMR genotypes. Recent studies (n = 16) have used whole-genome sequencing and metagenomic analyses to comprehensively detect the microbial and AMR determinants in wastewater samples. The latter aimed to assess the abundance and distribution of microbes and associated AMR agents (mobile genetic elements (MGE), including plasmids, transposons, integrons and insertion sequences) and to identify the factors that determine the persistence of AMR bacteria and ARGs in wastewater.Enterobacteriaceae members, including Escherichia coli, Klebsiella spp., Shigella spp., Salmonella spp., Vibrio spp., Acinetobacter spp. and Enterococcus spp., were among the most common AMR bacteria identified in the wastewater samples investigated in the analysed studies  being found to remain high throughout the different stages of the treatment process and, therefore, were subsequently discharged into the environment [Generally, high levels of ARB, including MDR strains and diverse ARGs, have been detected in influent wastewater (untreated) collected from various sources, particularly low-income settings ,44; hospironment . V. cholerae, Shigella boydii and Aeromonas caviae, which had not been previously reported to carry blaNDM-1, have been isolated for the first time from drinking water  and seepage samples  from New Delhi [E. coli and K. pneumoniae [blaNDM-1-bearing plasmids by enterobacteria, aeromonads and V. cholerae have been shown to be stable, transmissible and exhibit the typical resistance pattern of NDM-1 [blaNDM-1 on plasmids, blaNDM-1-bearing chromosomes have been first identified in environmental isolates of Aeromonas caviae and V. cholerae [Acinetobacter cumulans from hospital wastewater [K. pneumoniae strain carrying blaKPC-2, which is rarely detected in clinical settings, has been identified in WWTP effluent wastewater in Japan [NDM-1 producing strains, including ew Delhi . This iseumoniae . The carof NDM-1 . Althougcholerae . Anotherstewater . These sstewater . Additioin Japan .blaOXA-109, blaOXA-368 and blaOXA-2) in varied bacterial species recovered from wastewater samples [19 bacteria carrying class 1 integrons enter the United Kingdom’s environment by the disposal of sewage sludge each year [blaTEM and blaCTX-M9) and mecA encoding for penicillin-binding protein were detected in all DNA phages that have been recovered from urban sewage and river water samples [Additionally, many studies have detected high levels of integrons ,78,79,81 samples . Higher  samples . It has ach year . In anot samples .ereB, mefA&E and ermB) and antibacterial residues  in urban wastewaters and the presence of erythromycin resistant genes [Collectively, the analysed studies demonstrate the potential role of wastewater  as an environmental reservoir that assists in the emergence and dissemination of novel variants of AMR bacteria. This is mainly promoted through the coexistence of diverse species of bacteria and high levels of ARGs in these environments, which increases the probability of the transfer of ARGs carried on mobile elements among closely related species. The untreated wastewaters also contain high levels of antimicrobial drugs, which pose an important selective pressure for the emergence and dissemination of AMR bacteria . Recentlnt genes . HoweverEnterobacteriaceae) and ESBL-producing bacteria  [Enterococcus spp., have been identified in hospital wastewater-associated samples [Recent studies have reported the detection of elevated levels of clinically important AMR bacteria and ARGs in hospital effluent wastewater and environmental water sources that receive untreated hospital waste ,47,50,58umoniae) ,50,58 an samples ,47. K. pneumoniae, Enterobacter cloacae and E. coli [; MDR Listeria spp. [Vibrio spp. [E. coli strains associated with neonatal meningitis, intestinal and extraintestinal serotypes in final effluents of WWTPs [Conventional and advanced WWTPs have employed different biological, physical and chemical process to clean wastewater from pollutants and contaminants so that they can be reused and/or returned back to the environment. The efficiency of removal of AMR bacteria from effluent wastewater (treated) varies according to the treatment procedure employed . Therefo E. coli ; MDR Lisria spp.  and MDR rio spp. , have beof WWTPs . High leof WWTPs .Enterobacteriaceae, MRSA and VRE, and several ARGs associated with resistance to β-lactam, vancomycin (vanA) and methicilin (mecA) [Importantly, there is growing evidence that wastewater treatment does not have a profound impact on eliminating the ARGs present in hospital wastewater, with no significant difference in ARG abundance between influent and effluent hospital wastewater samples . Anothern (mecA) . sulA and blaCTX-M) being higher in ARB from influent compared to effluent samples [intI1-bearing bacteria  were higher in effluent compared to influent wastewater, with intI1 being detected in 20.4%, 30.9% and 38.9% of bacteria recovered from influent, activated sludge and effluent wastewater, respectively [Enterobacteriaceae strains carrying class 1 and class 2 integrons  were identified in different stages of a municipal wastewater treatment plant  [Consistently, Gram-negative and -positive isolates dominated in WWTP influent and effluent samples, respectively, with the frequency of detection of tetracycline-, sulphonamide-, streptomycin- and β-lactam-resistance genes (except  samples . The abuectively . In anotctively) . Howeverctively) .Collectively, these studies demonstrated WWTPs as hotspots for the emergence of ARBs and highlighted the impact of the treatment technology employed and potential roles of specific stages of treatment processes, particularly those characterised by high biomass and biodiversity , in maintaining diverse ARGs and promoting particular populations of ARBs. Advanced treatment processes, including membrane filtration, ozonation and UV-irradiation, are highly efficient in reducing the abundance of AMR in effluent wastewater to levels observed in low-impacted surface water . Most of the studies that reported AMR in wastewater have been conducted within one or a few countries. The majority of the studies were conducted in Asia (n = 22), followed by Europe (n = 23), Africa (n = 10), South America (n = 9), North America (n = 7), Central America (n = 1) and Oceania (n = 2). No studies have been conducted to investigate the transmission of AMR bacteria and ARGs in environmental samples associated with key religious mass gatherings (Kumbh Mela and Hajj) occurring in low-income settings. Kumbh Mela and Hajj are the largest and most diverse mass gathering events that have been associated with an increased risk of infectious disease emergence and transmission ,101. Kumbh Mela, the world’s largest religious gathering that attracts millions of Hindu pilgrims, is celebrated at four riverbank pilgrimage sites, including Ganges-Yamuna-mythical Saraswati rivers confluence, Ganges, Godavari and Shipra . The batE. coli [Salmonella [Acinetobacter spp. [Hajj has already been associated with an increased risk of airborne, foodborne and zoonotic infections . Recent E. coli  and extelmonella , as wellter spp. . The release of antimicrobial drugs, ARBs and ARGs originating from human and animal waste to the environment is a global problem that has serious implications on public health. Therefore, strengthening knowledge on the spread of AMR through surveillance and research was one of the key strategic objectives of the WHO global action plan that was launched in 2015 . Here, wE. coli and typhoidal and non-typhoidal serotypes of Salmonella, have been shown to be able to persist in the environmental water for relatively long times [The analysed studies highlighted the role of wastewaters as major sources of antimicrobial agents, ARBs and ARGs in the environment. Particular types of wastewaters  have been characterised by high levels of clinically relevant ARBs and ARGs. These environments can provide an ideal platform allowing the transfer of ARGs among the bacterial populations either before or after being discharged into the environment. This is alarming considering that many clinically relevant bacterial species, including enterotoxigenic ng times ,114,115.Wastewater treatments have been shown to be effective in reducing the ARB loads in effluent samples. However, there is increasing evidence that effluent samples from wastewater treatment plants, wastewater discharges of pharmaceutical production facilities, hospitals and other healthcare facilities are hotspots  for selective pressure processes that promote the emergence and dissemination of novel AMR mechanisms and new variants of ARBs and ARGs. However, it is noted that the positive selection process and the dynamics of the emergence of novel variants of ARGs and ARBs within WWTPs and their associated impacts on human health remain poorly documented and characterised. The WHO has highlighted the need for greater attention and action to develop quantitative microbial risk assessments and supporting guidance to address human health risks associated with environmental exposures to antimicrobial agents, their metabolites, ARBs and ARGs . Interestingly, a recent pioneer study has proposed a culture-independent metagenomic analysis of untreated wastewater as an effective approach to track and predict the dissemination of AMR bacteria and ARGs globally . The autThis approach can be applied in challenging settings  to study the paradigm of AMR dynamics and epidemiology and inform on the processes leading to the emergence and the dissemination of AMR infectious agents and, therefore, help in developing management strategies.We conducted a research study that uses the opportunity presented each year by the Hajj pilgrimage and advanced shotgun-based metagenomic approaches to characterise the global population of enteric microorganisms circulating in environmental Hajj settings. This will provide an annual snapshot of the AMR bacteria and MGEs associated with each global locality and help in identifying the dynamics of emergence and dissemination of AMR in the environment. 2 of land, of which only 4 km2 can be occupied by pilgrims) for at least 3–5 days. The pilgrims are distributed in campaigns across Mina according to their geographical origin . The wastewater is disposed of through septic tanks (onsite sewage facilities) that are associated with the pilgrims’ campaign. We conducted the first study to use shotgun-based metagenomic analysis to characterise the abundance and distribution of microbial communities and resistance determinants in wastewater samples from septic tanks in Mina representing different campaigns  and East and Southeast Asian countries). The results indicated that high levels of ARGs, including ESBL and aminoglycoside markers, were detected in all sites tested. However, significant variations in the distribution of the bacterial species and the abundance of ARGs were identified. Hajj is a unique mass gathering event that has been associated with an increased potential for the emergence and dissemination of AMR infections, raising major public health concerns within the host country and globally. The enormously diverse population of 3 million pilgrims, originating from 190 countries all over the world come together to perform the same activities within a relatively short period of time and over a limited area of land. Importantly, the pilgrims are required to stay in tents in Mina (a nonpopulated valley covering approximately 20 kmSimilarly, Kumbh Mela in India represents the world’s largest periodic mass gathering event that involving bathing in small-specified rivers sites. Recent studies have highlighted the striking impact of mass bathing on river ecosystems, including the AMR microbial contents and dissemination of human infectious agents ,116,117.Many studies have highlighted the roles of surface fresh and aquatic water, rural groundwater and sewage in the dissemination of AMR pathogens. The emergence of AMRs is part of a complicated ecological and evolutionary network, with the use of antimicrobial drugs anywhere within the system potentially selecting for resistance to that drug elsewhere in the network . Gram-ne