The continuous flow intersection [CFI) is an unconventional intersection design which has been used in many cities all over the world. However, as an important parameter for the geometric design, signal timing, and operation evaluation, the saturation flow rate at CFI has not been carefully examined. In this paper, a saturation flow rate adjustment model for CFI intersections is established based on field data under the calculation framework of the HCM2016. Four movements related with CFI, namely the left-turn at the CFI approach, through movement at the CFI approach, left-turn at the pre-signal, and exit movement at the pre-signal, are discussed. The proposed model is validated and the relative error is less than 10%. The treatments to mitigate the negative impact on the saturation flow rate at the CFI are also recommended. The results show the saturation flow rate of the first three movements are decreased due to the CFI control. For the left-turn, through movement, and left-turn at the pre-signal, the degree of the reduction of the saturation flow rate are mainly related to the heavy vehicle ratio, the proportion of lane changing vehicles, and the length of displaced left-turn lanes, respectively. The saturation flow rate is the maximum capacity of continuous traffic flow at intersections during the green time in an hour, which is a vital parameter to calculate vehicle delay and queue length at signalized intersections and a basic parameter to determine the green ratio. Therefore, analysing saturation flow rate is of great significance to the geometric design, signal timing, and operation evaluation of signalized intersections. Many works have been done to establish the adjustment factors of signalized intersection capacity. For some influencing factors with common cognition, such as the lane width, heavy vehicles, grade, parking, bus blockage, area type, lane utilization, right turns, left turns, and pedestrians and bicycles, have been subordinated to the widely used highway capacity manuals, such as HCM2016 , drivingWith the increasing traffic demand in recent years, various unconventional intersection designs have been investigated by traffic engineers to reduce congestion and improve operational efficiency in the urban road network –14. One The advantages of CFI design are mainly embodied in setting sub intersections at the upstream of the main intersection, which can divide left-turn vehicles in advance and relieve conflicts between left-turn and opposing-through vehicles at main intersections by pre-signals . In the However, the adjustment of the saturation flow rate for unconventional intersection has not been included in the highway capacity manual, such as HCM2016 [In order to deal with the deficiency, the objective of this study is to develop a saturation flow rate adjustment model for CFI intersections based on field collected data under the calculation framework of the HCM2016 [The rest of this paper is organized as follows: Section 2 introduced the data collection. The difference in saturation flow rates between the CFI intersections and the conventional intersections was compared and the corresponding saturation flow rate adjustment model was established in Section 3. Section 4 validated the proposed model. Section 5 discussed the recommendations for improvement. Finally, the conclusions were presented.To obtain the actual operational data, the intersection of Caitian Road—Fuhua Road in Shenzhen, China, was selected as a case for evaluation analysis. This intersection is located in the downtown of Shenzhen. The north and south legs of this intersection have adopted the design of CFI from October 15th, 2017, which is the first CFI built in China. The east and west legs of this intersection are under the conventional design. Its geometric layout and signal timing are illustrated in S denotes the saturation flow rate, veh/h; and h is the average saturation headway in a signal cycle, s.According to HCM2016 [l means the last vehicle in queue; hi means the lost time for ith vehicle in queue, s.Headway is the time between successive vehicles as they pass a point on a lane or roadway, measured from the same point on each vehicle. When the signal turns green, the queue begins to move. The driver of the first vehicle in the queue must observe the signal change to green and react to the change by releasing the brake and accelerating through the intersection. As a result, the first headway will be comparatively long. The third and fourth vehicles follow a similar procedure, each achieving a slightly lower headway than the preceding vehicle. After four vehicles, the effect of the start-up reaction and acceleration has typically dissipated. Successive vehicles then move past the stop line at a more constant headway until the last vehicle in the original queue has passed the stop line. The HCM  recommenThe method of video recording was applied to further obtain the average headway of each lane. To ensure that the data are at the sufficient level of accuracy and precision, a specially developed image processing software used to collect the headway has been employed, which has been successfully used in data collection in our previous work . Heavy vBoth the saturation flow rate of the CFI approach and that of the conventional approach were collected in one intersection because only the north and south legs of this intersection have adopted the CFI design. It can ensure the comparability between different groups because the drivers’ driving behaviours of them can be assumed to be the same. Though there are various factors influencing the saturation flow rate, the emphasis of this paper is on the change of saturation flow rate caused by CFI design and what leads to these changes. Therefore, a special intersection where both the CFI design and the conventional design are simultaneously used was selected to study differences between these two designs. Thanks to such an intersection, the interference of other factors is removed as much as possible. There is no need to consider other influencing factors in HCM.In this paper, the differences between the saturation flow rate of CFI approaches and the conventional approaches were analysed by obtaining the correction coefficient. Therefore, according to the different movements, the traffic data were divided into six groups for further comparison and the detailed schematic diagram of each traffic group is illustrated in Group 1 is the through movement at the conventional approach, which is used as a benchmark for through movement.Group 2 is the left-turn at the conventional approach, which is used as a benchmark for left-turn.Group 3 is the through movement at the main stop-line of CFI.Group 4 is the left-turn at the main stop-line of CFI.Group 5 is the movement of left-turn vehicles entering the displaced left-turn lanes at the pre-signal of CFI.Group 6 is the exit movement entering the road segment at the pre-signal of CFI.Basic statistical results of saturation headway are shown in Sig < 0.05) expect for Group 1 vs Group 6. Therefore, the design of the CFI has significant impact on the saturation flow rate. The correction coefficients of the saturate flow rate should be explored.First, the normality of each group data is tested by Kolmogorov-Smirnov test. The result is shown in The saturation headways of the left-turn (Group 4) and through movement (Group 3) at the main-signal of the CFI are compared with those at conventional approaches (Groups 2 and 1), respectively, as shown in It can be known that the distribution curves of saturation headways at CFI approaches are always more dispersed and closer the right with the comparison of that of the conventional approaches, which indicates the saturation headway and its dispersion degree at CFI approaches are higher. High CFI headway implies less utilisation of traffic lane capacity. Among them, the distribution curve of Group 5 in The normality of each group data was tested by the method of Kolmogorov-Smirnov and the results shown the significance of K-S test in each group is less than 0.01, which indicates none of the six sets of data comfort to normal distribution, as shown in Therefore, nonparametric test should be employed to analyse each group data’s difference. Based on the analysis of the average rank, the method of Mann-Whitney U is used to test whether the populations of two samples are the same at the same location. The test principle is to combine two samples and get the rank of each data in ascending order firstly and then calculate the average rank of two samples. The calculation results are shown in In this paper, all raw data were divided into two parts. In this section, the correction coefficients of saturation flow rate for different movements at the CFI are established by 80% of the field data. The proposed model will be validated using the left 20% data.The construction of CFI generally results in a smaller turning radius, which is the main difference in the operation of the left-turn at the main intersection between CFI and conventional approach, as shown in fCL is the adjustment coefficient for left-turn at the CFI approach; and PHV is the proportion of the heavy vehicles.Therefore, the saturation flow rate of left-turn vehicles at the CFI is 87.4% and 82.0% of the conventional intersection for passenger cars and heavy vehicles, respectively. It indicates the difference in left-turn operating at the CFI of heavy vehicles compared with passenger cars. Thus, the adjustment coefficient of saturation flow rate for left-turn at the CFI approach can be calculated by The construction of CFI generally results in the problem of lane offset in the direction of through traffic due to the different number of left-turn lanes, as shown in Pc is from 0 to 0.3.fCT is the adjustment coefficient for through movement at the CFI approach; and Pc is the proportion of lane changing vehicles.Among the tested fitted curves, linear model, exponential model, polynomial model and Gauss model are more appropriate with high goodness of fit. It can be seen that most of scatters are located on these curves and the R-square of all these models is greater than 0.9. Considering the model’s practical application, the simpler the model is, the easier it is to be calculated. Therefore, the concisest model (Linear) was chose to further get the relationship between the adjustment coefficient of saturation flow rate and proportion of lane changing by using the saturation flow rate of Group 1 as a benchmark, and the equation is shown in When the left-turn vehicles enter the displaced left-turn lanes at the pre-signal of CFI (Group 5), these vehicles should queue and wait for the red light of the main-signal, as shown in d) was analysed. The fitting results are shown in d).h5 is the headway of vehicles enter the displaced left-turn lanes at the pre-signal of CFI; and d is the distance between the end of queue and the pre-stop line, m, which can be further determined by the length of displaced left-turn lane and the queue length.The relationship between the headway and the distance between the end of queue and the pre-stop line , the applicable range of L in d, which is from 20 m to 120 m.fCP is the adjustment coefficient for left-turn vehicles at the pre-signal of CFI.Substituting Eqs fCL refers to the adjustment for left-turn at the CFI approach, which can be calculated using fCT refers to the adjustment for through movement at the CFI approach, which can be calculated using fCP refers to the adjustment for left-turn at the pre-signal of CFI, which can be calculated using fC is the adjustment coefficient for CFI.Considering the above four movements, the saturation flow rate adjustment for CFI can be calculated by To validate the accuracy of correction model in each direction, 20% measured data were chosen randomly. The difference between measured saturation flow rate and fitting data calculated by each adjustment function for different movements was compared respectively.PHV is 14.15% in the left 20% data, so the fCL = 0.874 − 0.054PHV = 0.866. Then, the adjusted saturation flow rate is 1381 veh/h while the measured saturation flow rate is 1346veh/h. The relative error of this correction model is 2.67%. Therefore, the correction model of saturation flow rate for left-turn at the CFI approach is reasonable.The correction coefficient of Group 4 can be calculated by The correction coefficient of Group 3 can be calculated by L and g are different at the south and north approach, the correction coefficient for through at the CFI needs to be calculated respectively when testing the validation of the correction model. The actual information about Caitian Road are recorded in the first three columns of Since the parameters of In this chapter, methods to mitigate the negative impact on the saturation flow rate at the CFI were proposed according to the influencing factors analysed in Section ‘Modelling’.For the left-turn at the CFI approach, the saturation flow rate of passenger cars and heavy vehicles is 87.4% and 82% respectively, which means the vehicle type affects the traffic flow. Thus, to satisfy different kinds of vehicles and improve the left-turn saturation flow rate at continuous flow intersections, the stop line of the intersecting conventional intersection can be moved backward so that the turning radius will be increased.For the through movement at the CFI approach, since the lane choice and lane changes caused by lane dislocation is the main reason why the through saturation flow rate of the CFI is less than that of the conventional intersection, the striking coloured guide line can be used and some physical facilities can be added between lanes at the intersection such as yellow flashing lights to streamline the traffic flow and reduce the proportion of lane changing. Moreover, the entrance lanes and exit-lanes can be marked with numbers to guide drivers to drive along its original lane.For the left-turn at the per-signal, the length of displaced left-turn lanes is a main factor influencing the saturation flow rate. Once the green time of pre-signal is given, it can be determined by A saturation flow rate adjustment model for CFI is established in this paper. Four movements related with CFI, namely the left-turn at the CFI approach, the through movement at the CFI approach, left-turn at the pre-signal, and exit movement at the pre-signal, are discussed. The proposed model is validated by comparing with the field data. The results show the relative error is less than 8.0%. The methods to mitigate the negative impact on the saturation flow rate at the CFI are also recommended. From the analysis, the following conclusions can be drawn:Overall, the saturation flow rate of the left-turn at the CFI approach, through movement at the CFI approach, and left-turn at the pre-signal are significantly lower than that of the conventional approaches, while exit movement at the pre-signal will not be affected.PHV), the proportion of lane changing vehicles (Pc), and the comprehensive influence of length of displaced left-turn lanes (L), green time (g) and vehicular speed (v), respectively. These main influencing factors are considered in the proposed saturation flow rate adjustment model.For the left-turn, through movement, and left-turn at the pre-signal, the degree of the reduction of the saturation flow rate are mainly related to the heavy vehicle ratio (To mitigate the negative impact, the following methods are recommended: moving backward the main-stop line to increase the turning radius, guide line marking and variable message signs can be added to streamline the traffic flow.In practice, more detailed design of the guidance information, such as traffic signs and lane markings, should be conducted with the consideration of the local driving behaviour to streamline the traffic flow, which can be the direction of the future study.


Nanofibers are one of the most attractive materials in various applications due to their unique properties and promising characteristics for the next generation of materials in the fields of energy, environment, and health. Among the many fabrication methods, electrospinning is one of the most efficient technologies which has brought about remarkable progress in the fabrication of nanofibers with high surface area, high aspect ratio, and porosity features. However, neat nanofibers generally have low mechanical strength, thermal instability, and limited functionalities. Therefore, composite and modified structures of electrospun nanofibers have been developed to improve the advantages of nanofibers and overcome their drawbacks. The combination of electrospinning technology and high-quality nanomaterials via materials science advances as well as new modification techniques have led to the fabrication of composite and modified nanofibers with desired properties for different applications. In this review, we present the recent progress on the fabrication and applications of electrospun nanofiber composites to sketch a progress line for advancements in various categories. Firstly, the different methods for fabrication of composite and modified nanofibers have been investigated. Then, the current innovations of composite nanofibers in environmental, healthcare, and energy fields have been described, and the improvements in each field are explained in detail. The continued growth of composite and modified nanofiber technology reveals its versatile properties that offer alternatives for many of current industrial and domestic issues and applications. Electrospun nanofiber technology has gained tremendous interest due to its versatility and the possibility to fabricate many designs and functionalities from various materials and strategies. In the technical definition, nanofibers are fibers with diameters in the range of tens of nanometers to less than 1 µm. In other words, they have a very high aspect ratio and are observed as one-dimensional materials. These features give them unique properties which can be applied in various applications. They also have unlimited assembly configurations and functionalities depending on the solution properties, environmental factors, and technical variables , dry-spiElectrospun nanofiber-based composites are a growing type of materials that can provide different and diverse properties and functionalities. They have the advantage of polymers in being flexible, easy to fabricate, cheap, easy to mold, and lightweight ,14. In aTo understand the limitations of electrospun composite and modified nanofibers and the development they have gone through, the process of their preparation and fabrication are addressed in this review. A quick check in the literature shows a sharp increase in studies about electrospun composites and modified nanofibers, especially in the past decade. The potential of electrospun nanofiber composites is enormous, but more studies are needed to integrate both robust performance and economy. This literature review describes the different applications of nanofiber composites with emphasis on new application developments, knowing there is still a lot to be explored and improved. The advantages and disadvantages of electrospun composite nanofibers in various applications are discussed here in detail. Unlike other reviews, this review is more focused on composite and modified nanofiber materials (as opposed to pristine nanofibers) from their fabrication, material types, nanofiber structures, and multifunctionalities toward a wide range of applications, including environmental, health, energy, textile electronics, and others see . It is h(1)2, carbon nanotubes, graphene oxide, etc.);Fabrication of mixed-matrix composite nanofibers Production of nanofibers utilizing two or more precursors and fabrication of core–shell nanofiber or bi- or multicomponent-based composite nanofibers, and;(3)Fabrication of polymeric nanofiber and then subsequent post-treatment of the surface to produce composite electrospun nanofiber.Electrospinning is a facile technique to fabricate ultrafine fibers with long length and narrow diameter. The electrospinning equipment consists of a syringe or capillary tube serving as a container for polymer solution, a metallic needle (or spinneret) for jetting of solution, a high-voltage power supply 10–60 kV), and a grounded collector for collecting nanofibers . A high-0–60 kV, The desired design and morphology of the resulting nanofiber composites can be controlled by manipulating electrospinning parameters  and also by the post-treatment modification process . MateriaThere are many types of electrospinning configurations based on the type and design of the spinneret and collector see . The spiAnother electrospinning system which is designed for potential mass production is critical bubble electrospinning. In this method, electrospinning starts from multiple points on the surface of a single bubble, and nanofiber threads are fabricated simultaneously. As shown in Electrospinning has the advantages of providing a high level of fabrication flexibility to control the nanofiber microstructure, arrangement, and diameter, and also benefits from the option of wide material selection, easy incorporation of additives, straightforward process, and a practical way to generate nanostructures . HoweverMixed-matrix nanofibers use inorganic materials mixed into a polymer solution for nanofiber formation . In otheThin-film nanofiber composite (TFNC) membranes have multiple layers: a support layer, one nonwoven nanofiber middle layer, and a top layer as a barrier b 35]. T. T35]. TSurface functionalization offers high binding affinity, improved separation performance, and increased loading capacity to overcome the challenge of binding and compatibility of nanoparticle with the polymer matrix . SurfacePlasma treatment modifies the chemical composition of the surface to tailor wetting properties and surface adhesion of the membrane without affecting the bulk characteristics . The appAnother method for improving hydrophilicity is by chemical crosslinking, which stabilizes the nanofibers with the promotion of coupling and bonding reactions between polymer chains . ElectroCeramics are composed of different metallic materials, although many non-metallic and biomaterial compounds can be treated to become ceramic materials. Ceramics are usually composed of oxides, sulfides, carbides, or nitrides, and most of them have a crystalline structure. Ceramics are formed from anions and cations with high attraction forces that give outstanding physical and chemical properties . They ar2 or Ar) changes the polymer structure to a carbon and graphite structure, which increases the adsorption ability of the nanofibers [2 and increase the nitrides in the nanofiber structure. Calcination with a high heating rate breaks the nanofibers and, thus, production of continuous ceramic nanofibers is not possible [Ceramic nanofibers are usually fabricated by the sol–gel technique and using polymer reagent routes. Polymeric solutions containing precursors are electrospun and, afterwards, the nanofibers go through chemical conversion or thermal treatment for synthesis of ceramic nanofibers. Ceramic nanofibers can be improved with hydrothermal, carbothermal, and pyrolysis post-treatment , whereinnofibers . In thispossible ,52. In opossible .2O3 electrospun composite ceramic nanofibers were fabricated using a co-electrospinning technique [The concentration of the ceramic precursors and polymer should be adequately controlled to produce continuous ceramic nanofiber with a desirable diameter. A high ceramic precursor concentration increases the diameter of the nanofibers and a low concentration of ceramic causes breaking of the nanofibers in the calcination step ,54. A neechnique . The fabechnique .In another work, electrospun ceramic nanofibers were fabricated using a non-isothermal method. In this study, colloidal silica (CS) and tetraethyl orthosilicate (TEOS) were electrospun and calcined at 1000 °C to prepare ceramic nanofibers, which, when compared to common silica nanofibers, have lower crystallinity, smaller grain size, and more grains . Yang etElectrospun nanofiber composite membranes have attracted increasing interest in recent years for their application in membrane separation, desalination, water and wastewater treatment, oil/water separation, and adsorption. In separation technologies, the membrane performance is mainly based on the membrane’s flux and selectivity ,59. High2·h or LMH) and about 99.9% separation efficiency. In another study, Alias el al. fabricated composite hollow fiber membrane for purification of oilfield wastewater. In this study, polyacrylonitrile/graphitic carbon nitride (PAN/GCN) composite nanofibers were produced using electrospinning of the solution on the alumina hollow fiber membrane collector [2·h) and high rejection efficiency (99%) after 3 h filtration can be obtained [Nanofibers have average pore sizes between 0.1 micron to a few microns, which is the usual range for microfiltration membranes. Due to the wider pore size distribution, they cannot be used directly for brine treatment but can be used for pre-treatment, agricultural applications, removal of viruses and bacteria, etc. ,65. Manyollector . The eleobtained .Nanofiber composites have been also been widely investigated in many emerging desalination technologies such as membrane distillation (MD) and forward osmosis (FO). In MD, a hydrophobic membrane is used as a separation layer between a hot feed and cool permeate. The driving force is the partial vapor pressure difference brought about by temperature difference across the membrane ,69. MD t2 nanoparticles were embedded in electrospun PVDF nanofiber membrane to add roughness and achieve superhydrophobic condition (contact angle > 150°) and narrow pore size distribution in the range of 1.2–1.4 µm. The membranes were used in the MD system, and results showed superb performance for water treatment process  [2 nanofibers were first fabricated by electrospinning and then ferrate solution was sprayed on the nanofibers via the electrospraying technique  . Guo et jection)  fabricatique see . The mem2 nanoparticles for MD application. The other side of the membrane surface was coated with Ag nanoparticles and carboxylated MWCNTs. This resulted in a Janus membrane with superhydrophobic–hydrophilic characteristics. The modified membrane showed more than 99.8% salt rejection and its long-time fouling results halved compared to that of the neat membrane [The rough surface of nanofiber membranes provides hydrophobicity, and with some modifications, can even lead to omniphobic surfaces that are promising for treating challenging wastewaters. Omniphobic membranes are designed with re-entrant surface morphology and low surface energy and, thus, they have the ability to resist wetting from both water and low-surface-tension fluids, which is attractive for use in MD ,81,82. Amembrane . A tri-l2·h and 99.9% salt rejection after a 15 h AGMD test [Elmarghany et al. utilized this design and strategy to prepare porous nanocomposite with PES–CNTs as the middle layer, and both sides were coated with electrospun PVDF–HFP copolymer incorporated with CNTs (PVDF–HFP/CNTs) . The resGMD test . Wang etGMD test  reportedGMD test . The midGMD test . HoweverGMD test ,91. For GMD test . A phaseGMD test  preparedGMD test . In anotGMD test , a nanofGMD test .2), glutaraldehyde vapor (GA), and trifluoroacetic acid (TFA) [2 crosslinked SA membranes and can maintain this efficiency even for five cycles. Another report [2·h  for Blue 14 dye. The good thing about the nanofiber structure design is that it can easily be adapted to selectively adsorb some specific dyes while maintaining the integrity and robustness of the nanofiber membrane. The challenge in its design is on how to effectively expose the added nanoparticles on the nanofiber surface while making sure that they are also embedded strongly so as to prevent nanoparticle leakage. Homaeigohar et al. utilized a nanofiber support for immobilizing TiO2 nanoparticles to photocatalytically degrade dye pollutants from wastewater. The incorporation of TiO2 nanoparticles significantly increased the wettability of the nanofibers that led to extended contact of nanofibers and pollutants. The composite nanofiber mats obtained 95% removal of methylene blue via synergistic adsorption and photo-UV photodegradation processes.Adsorption, a surface-based process, is used to selectively adhere molecules, atoms, and ions onto a material surface usually with high surface area. It is considered the treatment choice for low concentrations of pollutants due to its low cost, easy regeneration, simple design, manageable operation, and effectiveness properties ,93. Howeid (TFA) . Using mr report  preparedAs wastewater treatment has turned into a vital issue, the removal or elimination of heavy metals has become an important task to protect the environment and human health. Karim et al.  demonstr2 nanofiber with superhydrophilic and oleophobic characteristics coated on the polyamide/PVA-co-PE nanofibers as substrate. The fabricated composite nanofibers were tested for oil-in-water emulsion and oil/water separation. Nanofiber addition increased the ability of SiO2 nanoparticles to form film and bonds. In addition, the nanofiber composite-coated membrane has the benefit of environmental friendliness, lower cost, and high throughput [2-coated PAN nanofiber membrane. The acquired TiO2/PAN–Si electrospun composite nanofiber demonstrated a good superoleophobicity, superhydrophilicity, and self-cleaning properties for application in the separation of oil/water emulsions. The emulsion separation performance was evaluated, and the results demonstrated that the drop size and oil type have a direct influence on the separation performance. Fouling was found in the separation of soybean oil because of the smaller oil drop size; nonetheless, it can be eradicated by UV irradiation. After five cycles, the TiO2/PAN–Si membrane flux can be fully recovered, showing good performance with the highest flux of 200,000 L·m−2·h−1·bar−1 [Nanofiber membranes have become an attractive option for the separation of oil from other components because of its ability to absorb and reuse. Oily wastewater damages health, ecological balance, and the environment, creating the demand for efficient technology to separate oil and water. The technologies developed to remove oil take a high amount of time, have low efficiency and high energy cost, and can cause secondary pollution. The most common treatment methods are pressure-driven separation or gravity and adsorption . The secroughput . Furtherroughput . Wang etroughput  prepared−1·bar−1 . Table 13 in PAN solution was enough for the filtration membrane to demonstrate great antibacterial activity and filtration efficiency. This report suggests that Ag/PAN nanofiber membranes can be used for wide air filtration applications, even in large-scale production [2/PVA electrospun composite nanofibers were successfully fabricated using the electrospinning–calcination method for NOx–SCR catalytic reactions. This reaction is performed to prevent pollutant gases, which are formed during car combustion process, from entering the air. The catalytic performance of the nanofibers was analyzed and results showed that due to high porosity and unique morphological structure, the nanofiber composites were stable (>120 h) with high reusability [Air pollution is a major issue for many countries in the world. The presence of particulates, volatile organic compounds (VOCs), mineral powder, carbon, bacteria, etc., in the atmosphere can be inhaled by people and endanger their health; thus, it is necessary to filter out these pollutants ,127. Usioduction . Huang eoduction  fabricatsability . Table 2Electrospun nanofibers have been widely investigated in the field of biomedical and tissue engineering due to their interesting properties and versatility to be designed into various morphologies, such as nonwoven form, aligned nanofibers, core–shell structure, and hybrid nanocomposites. In tissue engineering, scaffolds are used to supply support to regenerate damaged tissues. The unique characteristics of electrospun nanofibers, such as loose structure, high porosity, and superb flexibility can mimic the extracellular matrix (ECM) for cells to grow and, thus, they have attracted great attention for use in tissue engineering. Moreover, most polymers―including biodegradable and biocompatible materials―can be electrospun, which is perfect for application . GeneralNanofibers can be used as substrate material for some biomaterials that are quickly degraded. For example, gelatin, which is a congener protein of collagen, has been used as biomaterial but has fast degradation, and its high hydrophilic surface makes it inappropriate as the base material . Thus, aElectrospun nanofibrous dressings have high surface-to-volume ratio, allow gas permeation, help to regulate wound moisture, enhance tissue regeneration, promote removal of exudates, and have high porosity, which makes them ideal for use in wound healing. Previous studies have shown low inflammatory reaction and fast re-epithelization with the use of nanofiber-based wound dressing . NanofibGarcia-Orue et al.  preparedBredigite polymer electrospun nanofibers have been widely studied to investigate their applicability in wound-dressing activities. It has been used as a scaffold in some studies, but results revealed that while the bioactivity of the composite nanofibers was improved, and the low dispersibility and high agglomeration of nanoparticles decrease the efficiency of prepared electrospun nanofibers . In anotThe use of composite nanofibers has demonstrated great potential for biomedical applications. Nonetheless, effective elaboration of well-blended composite fibers is a great challenge at the molecular level because of poor miscibility between polymers and ceramic particles, ending up in a poorly blended composite with weak mechanical strength and incontrollable material properties . ChitosaThe energy sector has, for years, been investigating and improving its technology in order to provide cleaner and cost-effective energy. Nanofibers are part of the improvement of the different energy technologies. Nanofiber membranes have been used as catalyst to provide high activity, high durability, and high poisoning resistance for fuel cells and can be utilized as electrodes for lithium ion batteries to improve their capacity and performance .2 nanofibers decorated with biofunctional amino acid molecule chains  to build efficient proton-conducting amino acid channels. [For improvements of proton exchange membrane fuel cells (PEMFCs), it is crucial to develop an ionomer membrane that attains high proton conductivity and low permeability for gas while maintaining high thermal, chemical, and mechanical stability, low deformation, and low cost. Due to the high surface area and controllable characteristics, nanofibers can be used as proton exchange membranes where filler materials are added or can be hybridized with other materials to provide the needed functionalities of the membrane. Perfluorosulfonic acid membranes (Nafion series) were usually used as PEMs. However, their high cost, serious proton conductivity reduction at high temperatures, high methanol permeability, and poor dimensional stability are reasons for considering other alternatives . Wang ethannels. . The ovehannels. .Lithium-ion batteries (LIBs) are used for energy storage in many portable electronic devices like digital cameras, laptops, mobile phones, and communication equipment due to their high operational voltage, high energy density, low self-discharge rate, and long cycling life. The separators in batteries are used to prevent physical contact between the cathode and anode and maintain liquid electrolyte for rapid transport of ions, important to the battery’s safety . PolyoleGenerally, polymer electrolytes are made of solid polymer electrolytes (SPEs) and gel polymer electrolytes (GPEs). GPEs can result in short circuit, explosion, overheating, and insufficient capacity due to the polymer meltdown at high temperature. To reduce the risk and avoid this problem, polymer skeletons must have good thermal stability . Wang etThe unique properties of electrospun nanofibers, like electrochemical activity and large surface area, make them highly desirable for use in electrochemical energy devices such as supercapacitors. Many materials such as carbon, metal sulfides, and nanocomposites have been utilized in the form of nanofibers as electrodes for supercapacitors. They are also prepared in various architectures such solid, core–sheath, or hollow designs. For example, carbon nanofiber electrodes can be prepared by carbonizing polymer precursors such as PAN and polyimide at high temperature under an inert atmosphere. A wide variety of nanofiber designs and morphologies have been tested and promising results as supercapacitor electrodes have been obtained. However, further tuning of the properties of the nanofibers, such as architecture and morphology as well as composition optimization, is still needed to enhance their overall performance. 3D nanofiber structure is said to be a good design that enables a shorter diffusion pathway for the electrolytes. One is referred to a comprehensive review by Lu et al.  of the p3 nanowires and PVDF composite nanofibers was “sandwiched” and survived without failure after at least 1,000,000 compression cycles. The randomly oriented electrospun nanofiber membrane can be used without extra poling treatment in a piezoelectric power generator to generate several volts [Flexible and wearable electronics are currently in high demand because of their foldability and stretchability. Energy devices that are flexible can store or convert energy by bending repetitions, folding or stretching without loss of performance, with high potential in wearable and portable electronics like touch screens, wearable sensors, military garment devices, and biomedical devices . Electrial volts . Bairagial volts  fabricat3 (44 ppb in a response time of 17 s) with high accuracy with respect to other nitrogenated compounds from the combination of IN2O3-reduced graphene solution mixture. Metal oxides fibers are widely used as gas sensing materials due to their electrical, thermal, and mechanical properties. The accuracy of the sensors directly depends on the morphology and available surface area of the fibers. Therefore, electrospun nanofibers can bring a tremendous opportunity to improve the gas sensing capacity of the metal oxides by preparing of 1D nanofibers having very high aspect ratio and large-scale and cost-effective production capabilities. Khalil et al. have fabricated electrospun nickel oxide nanofibers for using in the gas sensing industry. Results demonstrated that the special morphology of electrospun nanofibers leads to faster and more complete resistance recovery [2 electrospun nanofibers were also fabricated for hydrogen gas sensing at low temperatures and obtained the highest response, resulting in favorable accuracy for working in low-temperature environments [For sensor applications, electrospun nanofibers have been used due to the flexibility in material selection, ease in incorporating active agents, and the possession of high surface area to volume ratio. Sensors of this type can be more sensitive than electronic sensors depending on the selected material . Textilerecovery . SnO2 elronments .The potential of electrospun nanofiber composites has been highlighted in this review, showing many applications of this structure in different fields. The facile fabrication, high surface area, and controllable morphology and structure of electrospun nanofibers provide vast opportunities for functionalization, incorporation of fillers, and modification to enhance the overall properties of the nanocomposites. There have been enormous developments in the fabrication, modification, and applications of electrospun nanofiber composites; however, most of these have been in the academic aspect while they have still not widely adopted for commercial and large-scale applications . Nonethe2 size. However, the industrial upscaling of nanofibers, especially in their nanocomposite forms, is rather limited and still in the development stage, although some companies like Elmarco (https://www.elmarco.com/) and Fnm Co. (http://en.fnm.ir/) can supply industrial-level capacity electrospinning devices with some modifications from the conventional single-needle spinneret design. Muti-spinneret electrospinning for mass production may be good, but it can undergo unstable jets due to the proximity of jets, leading to non-uniform fibers. Rotating drums or needleless spinning could be used but may suffer from non-uniform fibers especially for nanofiber composites where filler nanoparticles or functionalization steps are added. Most of the industrial applications are for air filtration, including nanofiber facial masks, but high-temperature nanofiber filters and battery separators have also been reported to have large production capacity (~2000 m2/day) [http://nicast.com/) and Xeltis (http://xeltis.com/) have also started using electrospun nanofibers. Nicast has fabricated a vascular access for hemodialysis using nanofibers while Xeltis used electrospun nanofibers for blood vessel or heart valve fabrication for cardiovascular restoration. The continuous development of new electrospinning devices with high throughput will eventually lead to the mass production of nanofiber composites in the future.Perhaps the greatest challenge still faced by nanofiber composites is the mass production capacity. There are many companies that offer lab-scale setup for electrospinning, which can produce sample sizes from A4 paper size to even in excess of 1 m m2/day) . Some co


A national strategy to combat antimicrobial resistance (AMR) has been subject to cyclic processes in Norway since 1998. In 2020, a renewed process cycle was launched. Here, we describe the process and the approach of the process. In addition, we describe two concepts from philosophy of science that may help to frame the process: AMR is an example of a super wicked problem, and post-normal science provides tools to analyze the problem from a new angle. The international struggle against antimicrobial resistance (AMR) is a matter of huge importance, with no simple solutions in sight ,2. Over The increasing challenge with resistant microbes can reasonably be compared with the climate change problem. Although the scientific basis and the political implications of AMR and climate change are different, there are many commonalities in terms of complexity, the difficulties finding solutions, and the acuteness of the problem. Furthermore, like climate change, AMR is a global problem that cannot be solved by individual countries alone. Still, initiatives and actions at the national level are needed, and engagement from governmental bodies is part of the solution.Within human medicine the general current approach is to prevent infections, improve appropriateness of antimicrobial use through antibiotic stewardship, and improve sanitation and hygiene. In countries with a strong primary healthcare sector, most infections are managed at that level. Hence, a substantial proportion of antibiotic prescriptions are issued by primary care physicians, implying that this part of the healthcare sector needs to be heavily involved in any strategy to reduce AMR.In 1998, Norwegian governmental institutions started a national strategy process to combat AMR, with revision and renewal every five year. Currently, such a revision process is ongoing; hence, the content of the new strategy is not yet ready to be published. The aim of the current paper is to describe the strategy process with emphasis on the relevance for the primary healthcare sector. We also analyze the process by use of two concepts from philosophy of science; wicked problems and post-normal science.One of the first steps towards a national strategy was taken in 1998, when the Norwegian Ministry of Health and Social Affairs appointed a project group with the mandate to establish a coordinating plan to fight AMR. The group delivered its report including an action plan in 1999. The action plan resulted in the establishment of the Norwegian Surveillance System for Antibiotics Resistance in Microbes in 2000 and the Norwegian Prescription Database with data available from 2004. Since then, Norwegian health authorities and government have hosted a cyclic strategic process against AMR, directed at the national and international level. The current strategy is based on a report from a multidisciplinary expert group, published in 2014 . The NatBox 1Reduction of total use of antibioticsMore correct use of antibioticsIncrease knowledge about driving forces and spread of AMR resistanceEngage in international collaboration to strengthen access, correct use and development of new antibiotics, vaccines, and better diagnostic toolsBox 2Antibiotics use in the population reduced by 30% (defined daily dose (DDD)/1000 inhabitants/day) compared to the 2012 levelNorway among the three lowest prescribing countries in EuropeAverage prescription of antibiotics reduced from 450 to 250 per 1000 inhabitants per yearPrescriptions of antibiotics for respiratory infections reduced by 20% compared to the 2012 levelConduct studies of AMR burden of disease, consequences of too little use of antibiotics and effects of infection controlIn 2020, a new multidisciplinary expert group was appointed by the national government, again with the mandate to lay the basis for a renewed strategy against AMR. The group is specifically asked to update relevant knowledge from 2014, with emphasis on knowledge of strategic relevance. The current group has expertise from the healthcare sector (including primary and secondary levels), microbiology, veterinary medicine, ocean, agriculture, and the wildlife/environment sector. The strategy process has consistently aimed to apply a One Health perspective, which implies a collaborative effort to attain optimal health for people, domestic animals, wildlife, plants and the environment . The groNorway is organized with a strong primary care sector based on general practitioners (GPs) who also run out-of-hours services, a home care system and municipal care institutions for fragile elderly people. Generally, all Norwegian citizens are registered with a GP, who is their primary contact for any medical encounter. The prescription rate for antibiotics is generally low, and AMR is still a relatively minor concern, although increasing . Three oBy 2020, these goals were completely or nearly reached, and Norwegian primary care physicians should be proud of their contribution. The achievement is even more impressive as the antibiotic prescribing rate always has been low in Norway. Whether this success may be ascribed to the national strategy alone is debatable. There was a trend towards less prescribing before the strategy was launched, and this is part of an international trend in comparable countries such as Nordic countries and the UK ,11,12. HTwo aspects for further reduction of antibiotics prescribing rates should be thoroughly discussed in the upcoming process: firstly, avoiding so-called unnecessary prescribing, and secondly, the balance between low prescribing rate and risk for adverse patient outcomes ,14,15. TAn important question for the current expert group is what strategies are purposeful for Norwegian primary care in a situation with an already low prescription rate. There is room for improvement in terms of reducing the number of frequent prescribers, increasing the proportion of narrow spectrum antibiotics, reducing the duration of courses etc. ,18. HoweThe AMR problem has been described as an example of a “super wicked problem” . “Wicked(1) The time to solve the problem is running out; (2) Those who are responsible for solving the problem are also partly creating the problem; (3) The mandate for responsible agencies to act is weak; (4) Political acts are not consistent with the need for response. Although, from a legal perspective, the government could assign agencies with a mandate, it is still unclear as to how this could be executed. Societal problems within this category are so complex and have so many different causes that we cannot expect to solve them, but we should nevertheless do our best to minimize their negative effects. The concept of a problem being “super wicked” should not be confused with any problem which is serious or difficult to solve. One may argue that, e.g., the present COVID-19 pandemic is a dramatic example of a very serious global health challenge; still, the emergence and handling of a novel virus and the possible development of a vaccine represent a relatively simple conceptual framework.facts are uncertain implies acknowledging that there is a real difference between questions that can be solved by more research and inherent  uncertainty, where reliable predictions cannot be made now or in the future [Stakes are high means that the outcomes may be successful or devastating depending on the decisions made, and this is difficult to judge beforehand. We do not know how severe the AMR consequences will be in the future, whether we act this way or the other [Values under dispute may be of political, moral or economic character, implying that two people may view the same situation differently: for a patient, the possibility of relief of symptoms will probably outcompete the consideration for consequences of AMR for the rest of the society. On the other hand, this may be a constant worry for the primary care physician. Countries with different sets of cultural dimensions have been shown to struggle differently with inappropriate antibiotic prescriptions [decisions are urgent, and we cannot wait for science to establish the facts before we act. Professor Peter Gluckman, the former chief science adviser in New Zealand, has launched a set of principles for science advice to the government, based on a post-normal science strategy [The scientific approach to most problems is consequently necessary and useful; however, it is not sufficient to address super wicked problems. Although it does not provide a solution, a useful way of thinking in situations with fundamental uncertainty and an urgent need to act has been developed by Funtowicz and Ravetz ,23: the e future . For prihe other ,26. In triptions . Finallystrategy . These mIn conclusion, perceiving AMR as a super wicked problem may help in understanding its scope. Applying post-normal science analytic tools may be useful to address the specific challenges that primary care is faced with internationally within the AMR context. Traditional strategies must be accompanied by new approaches and perspectives. Although the Norwegian strategy so far has been a success in terms of reducing antibiotic prescriptions, this is only a surrogate endpoint. To reach the real goal of reducing AMR, we need a global, multidisciplinary, innovative approach involving all stakeholders. There is no simple solution, and the struggle will be endless, but we still cannot give up.


The Cultural Formulation Interview (CFI) includes a set of 16 questions formulated for clinicians to obtain information about cultural influences on an individual’s clinical presentation during a mental health assessment. The CFI is a newly formulated interview that has been evaluated in various localities, but not in South Africa.We assessed the awareness and attitudes of South African psychiatrists and psychiatrists in training towards the CFI and its use in their patient care.Participants were recruited via the South African Society of Psychiatrists (SASOP) database and were invited to complete an online questionnaire.Certain demographic aspects of psychiatrists and psychiatrists in training were compared with regard to their awareness of and attitudes towards the CFI.n = 35) were aware of the CFI, and of these, only 5.3% (n = 4) used the CFI. There was generally a positive attitude towards the CFI with the majority of the participants agreeing that the CFI is easy to understand and relevant in clinical practice; however, none of the results showed statistical significance. Most participants who were aware of the CFI  were of the opinion that the CFI would prolong their patient assessment time.Of the 75 participants who completed the questionnaire, only 46.7% (Most participants had a positive attitude towards the CFI. The negative response regarding the CFI prolonging patient assessment time could be a potential barrier in its clinical application. This study is an essential first step for further research into the CFI and its use in SA and contributed towards improving awareness of the CFI. Immigration and emigration, by choice or through displacement, for economic and political reasons, destabilise cultural mindsets and require adaptation to new environments, values and ways of life. The African view of mental illness and health currently encompasses a wide spectrum of systems – from ancestors and folk belief in witchcraft to modern medical science. All these systems function simultaneously within the African culture and within some individuals. As a multicultural society with a predominantly African culture, South Africa provides a great opportunity for mental health professionals to develop cultural sensitivity and apply it in practice.Diagnostic and statistical manual of mental health disorders, Fifth Edition (DSM-5).4Cultural competence refers to the knowledge and skills that are needed to function effectively and appropriately in culturally diverse situations. Cultural competence is a framework of practice for culturally diverse settings that can be applied when working with issues of mental health. Some of the critiques against it are that it focusses on providers and disregard the patients and their communities, and it draws on static notions of cultures. There is increasing acknowledgement of cultural diversity in mental health systems. One such example is the inclusion of the Cultural Formulation Interview (CFI) in the 6The CFI provides a systematic review of the individual’s cultural background and is a positive step towards exploring the cultural identity, conceptualisation of illness, psychosocial stressors and vulnerabilities of patients. It considers the role of the cultural context in the expression and evaluation of symptoms and dysfunction, and the effect that differences may have on the relationship between the individual and the clinician. Interventions that introduce clinicians to patient cultural views may increase patient participation throughout the interview. They also enhance clinician–patient information exchange, interpersonal rapport and preferences to treatment. Therefore, cultural formulation is an essential component of any comprehensive assessment, because culture can shape every aspect of patient care in psychiatry.12 The OCF was operationalised by the formulation of the CFI with the intention of enhancing the cultural validity of diagnostic assessment, facilitating treatment planning and promoting individual participation and satisfaction.13Past studies focussed on the Outline for Cultural Formulation (OCF) and the challenges of implementing OCF in clinical practice and in research.6 Cultural Formulation Interview field trials and cross-cultural evaluations have been conducted that involved training and use of the CFI. A study that included 318 patients and 75 clinicians from 6 countries, including Canada, India, Kenya, the Netherlands, Peru and USA, supported the feasibility, acceptability and clinical utility of the CFI. Clinician’s attitudes towards the CFI improved significantly after the first interview, and subsequent interviews also required less time. Clinicians with culturally diverse patients rated the CFI more positively.15Before publication of the DSM-5, considerable efforts went into identifying possible barriers to implementing the CFI in practice. The CFI was tested for feasibility, acceptability and perceived utility amongst patients and clinicians. Clinicians identified barriers regarding uncertainty about questions on culture, redundancy, patients for whom the CFI may not work well, extra time, length, training and experience needed to deploy the CFI. The length of time to complete the interview was seen as a potential barrier in the feasibility and acceptability of these interviews in widespread clinical practice.17 Despite South Africa’s cultural heritage, there is little evidence that local psychiatrists are aware of the revised CFI, and it is unknown if the CFI will be widely acknowledged and used by various mental healthcare providers in South Africa.South African mental health practitioners have attempted to describe culture-bound syndromes and their effect on diagnosis. They have also investigated the relationship between cultural beliefs and the content of delusions in Xhosa-speaking patients with schizophrenia and highlighted the value of using culturally sensitive assessment tools, but no studies about the use of the CFI in practice have been performed in South Africa.18 However, a literature search with Pub Med/MEDLINE, Medscape and Google Scholar could not find any studies that focussed on the use of the CFI in South Africa. To lay the foundation for research into this area, this study aimed to assess and compare the awareness and attitudes of psychiatrists and psychiatry registrars (psychiatrists in training) in South Africa towards the CFI. As lack of awareness or negative attitudes towards the CFI may hinder its effective implementation and use in clinical practice, this study is an essential first step for further research, to improve awareness of the CFI and to encourage its use.The CFI has been discussed in the context of the South African Society of Psychiatrists (SASOP) guidelines for the integration of spirituality in the approach to psychiatric patients. These guidelines highlight the differences between religion, spirituality and culture, with religion being considered as a component of an integrated cultural whole. The guidelines recommended the integration of spirituality and cultural competencies in psychiatric training and practice.An exploratory, quantitative, cross-sectional survey was conducted amongst South African psychiatrists and psychiatry registrars by using Survey Monkey, an online web browser-based survey software application.Over a 6-month period, from February to August 2016, the survey was sent out per email to all psychiatrists on the SASOP database. South African Society of Psychiatrists is a non-profit company with the aim to promote, maintain and protect the interest of the discipline of psychiatry and its members. The survey was sent out on three occasions, every second month, during the 6-month period to an estimated 500 individual email addresses.Convenience sampling was used and participation was open to psychiatrists registered with the Health Professions Council of South Africa (HPCSA), practising in either the private or the public sector. Psychiatry registrars in their 4-year training programme and registered with the HPCSA could also participate. Medical officers not recognised by the HPCSA for training in psychiatry were excluded. The participants who did not complete the full questionnaire were also excluded.The variables measured include: socio-demographic factors (including area of practice and years of experience), awareness and attitudes towards the CFI and if it is applied in clinical practice.6The self-administered questionnaire was specifically designed to measure the attitudes of psychiatrists and registrars towards the CFI. Some of the constructs of this scale were derived from themes proposed by Aggarwal et al. and modified specifically for this study.As part of pilot testing, the questionnaire was presented at the Department of Psychiatry, University of Pretoria, research meetings for input from consultants and registrars and to refine the item formulation. The questionnaire was a nine-item Likert scale survey with four response categories, i.e. strongly disagree, disagree, agree and strongly agree. Components were rephrased in a closed-ended statement format for simplicity and to save time, to be more specific, to allow similar meanings to be communicated and to maintain consistency in responses to allow comparison between respondents.After enquiring about the awareness and use of the CFI, the statements in the questionnaire were: (1) It is easy to understand; (2) It might prolong my patients assessment; (3) It is relevant in clinical practice; (4) It is of benefit to my patients; (5) I will try to apply it in my practice; (6) It can assist in formulating a diagnosis; (7) It can assist in formulating a treatment plan; (8) It is good enough to assess cultural factors affecting illness presentation; and (9) Training on how to apply it in practice is necessary.αs = 0.78, indicating acceptable internal consistency. However, when one of the components which had higher scale of αs = 0.80 (CFI might prolong assessment time) was removed, this increased the summed αs of the other eight components to 0.80. This indicated a good internal consistency for the questionnaire according to Cronbach’s alpha.The response category was compared with different demographic factors. The responses to the questions were dependent on how the questions were phrased; thus agreeing or strongly agreeing to the component did not necessarily indicate a positive response to some of the components. To measure whether the items on this questionnaire all reliably measure the same construct, the internal consistency of the questionnaire was evaluated by carrying out a reliability test by using Cronbach’s alpha. The reliability results showed that each item of the attitude questionnaire had scores of α ≥ 0.7 and all of them summed together scored www.psychiatry.org/dsm5 was provided for participants who were interested in understanding the depth of the CFI questionnaire. This gave participants an opportunity to familiarise themselves with the CFI before answering the questionnaire. The CFI recommends the consideration of various cultural aspects when performing psychiatric assessments and formulations and comprises a set of 16 questions. The four domains of assessment are: cultural definition of the problem, cultural perceptions of cause, context and support, cultural factors affecting self-coping and past help-seeking and cultural factors affecting current help-seeking.13Each participant received an email invitation, with a link to the demographic data sheet, study questionnaire and the supplementary CFI questionnaire. A reference webpage, For categorical data including age, years of experience, registration category and area of practice, descriptive statistics were used. Data were summarised in cross tables reporting frequencies and percentages. Fisher’s exact test was used to measure associations between attitude and awareness components and socio-demographic factors. Testing was performed at the 0.05 level of significance. The internal consistencies of the attitude items included in the questionnaire were assessed by using Cronbach’s alpha.Ethical approval was obtained from the Research Ethics Committee of the Faculty of Health Sciences, University of Pretoria (reference number: 190/2015). The study has been structured in accordance with the Declaration of Helsinki (last update: October 2013). An information leaflet was included with information about the study, and this was followed by a statement indicating that completion and submission of the questionnaire affirmed informed consent by the participant. Once the questionnaire had been submitted, the participants could not withdraw from participating. Data were automatically stored electronically within the link and only accessible to the researcher.n = 75) completed the full questionnaire, of whom 66.7% (n = 50) were psychiatrists and 33.3% (n = 25) were psychiatrists in training. In terms of gender, 61% (n = 46) of participants were female and 39% (n = 29) of participants were male.There was a response rate of approximately 19% with 93 responses received, but only 80.6% (n = 39) practised in both inpatient and outpatient settings, 25.3% (n = 19) exclusively in inpatient settings and 22.7% (n = 17) exclusively in outpatient settings. For the ages of respondents, years of experience in mental health and area of practice, refer to Of all the respondents, 52% (n = 35) were aware of the CFI; of these only 5.3% (n = 4) used the CFI and all 4 were practising in academic settings. Of the 35 participants who were aware of the CFI, 62.9% (n = 22) were psychiatrists, 74.3% (n = 26) were practising in the public/academic sector, 25.7% (n = 9) had < 5 years of experience, 42.8% (n = 15) had 6–20 years of experience and 18 (51%) of those spent most of their time in both inpatient and outpatients settings.Of the 75 participants who completed the questionnaire, only 46.7% (n = 35) were mostly in agreement with the attitude questionnaire components. Almost half of the participants  strongly agreed and 43% (n = 15) agreed that the CFI might prolong patient assessment time  and district settings  strongly agreed that the CFI may prolong their patient assessment time compared with participants in academic settings , who just agreed (p = 0.035). Furthermore, participants in private , in academic  and in district settings  agreed that training is necessary (p = 0.039).Significantly, participants in private  and those with 6–15 years of experience  strongly agreed that the CFI would prolong patient assessment time, compared with participants with > 15 years of experience  who just agreed.Participants with < 5-years of experience  of psychiatrists in training strongly agreed and 52% (n = 26) of psychiatrists just agreed. However, none of the results showed statistical significance.Regarding the CFI prolonging assessment time, 56% (n = 9) of participants in inpatient settings and 49 % (n = 19) in both settings strongly agreed that the CFI might prolong assessment time compared with 68% (n = 23) of participants in outpatient settings. Significantly, 53% (n = 9) of participants in inpatient settings strongly agreed that the CFI is relevant in clinical practice compared with 58% (n = 11) in outpatient settings and 77% (n = 30) in both settings (p = 0.041). Forty-seven per cent (n = 8) of respondents in inpatient settings agreed, and another 47% (n = 8) in outpatients settings strongly agreed that the CFI would benefit their patients.We asked participants to indicate whether they spend most of their time in outpatient or inpatient settings or in both, and also compared these responses. Most participants in all three categories agreed with most of the attitude components. However, 53% (n = 36) agreed that the CFI was easy to understand and 48% (n = 14) of male participants agreed that the CFI may prolong assessment time. Of the female participants, 70% (n = 32) agreed that the CFI was relevant to clinical practice, 74% (n = 34) agreed that their patients would benefit, and significantly 80% (n = 37) agreed that they would try to apply the CFI to their practice (p = 0.015). Most of the female participants agreed that the CFI would assist in formulating a diagnosis  and treatment plan . Male participants agreed that the CFI was good enough to assess cultural factors affecting illness presentation  and that training on the application of the CFI in practice was necessary .Regarding the association of the attitude components with gender, most female participants  of the respondents were aware of the CFI. Taking into consideration that SASOP released a position statement that culture, religion and spirituality should be considered in the current approach to the local practice and training of specialist psychiatrists, the expectation was that more participants will be aware of this important instrument.14 In this way, the current study created an awareness of the CFI amongst respondents who were not aware of the instrument. A recent update about the CFI indicated that the CFI has been evaluated in many countries, but not in South Africa. In the USA, Canada, Kenya, Peru, the Netherlands, India and Mexico, it was generally found to be clinically acceptable and useful in varied settings.19It has been reported that awareness of the CFI amongst healthcare providers was low before the CFI was incorporated into the DSM-5 manual. Studies assessing the feasibility and use of the CFI may serve a dual purpose of creating awareness of the CFI amongst participants and facilitate future use of the CFI in clinical practice.6 The CFI serves to identify unique cultural aspects that may influence diagnosis and treatment. It is possible that some clinicians still do not acknowledge the role of cultural context on diagnosis and treatment of various mental health-related conditions. This can hinder the use of the CFI in clinical settings, but research to confirm this, specifically in South Africa, is not available.In our study, it was found that despite knowing about the CFI, very few participants used the CFI for clinical assessments. The various reasons that may exist for such a behaviour were not investigated in our study. Previously, it was reported that clinicians might not be motivated or buy into the use of the CFI or may transition into regular clinical assessment after conducting the CFI, defeating the purpose of the CFI.In our study, psychiatrists in academic settings had the greatest awareness of the CFI and formed the majority of respondents. These psychiatrists possibly had better access to information in academic hospitals as the DSM-5 and the CFI were frequently used in academic teaching and training in South Africa, but it might also be biased because of the higher number of respondents from the academic setting.14 This was found to be similar in our study where participants who were aware of the CFI showed positive responses towards eight of the nine attitude questionnaire components, including those that asked whether they found the CFI easy to understand and relevant in clinical practice.In the DSM-5 field trial, participants found the CFI useful with respect to diagnosis, treatment planning and understanding the patient’s situation, including the role of culture in mental illness.21 In our study, there was a similar finding that despite the positive responses to most of the attitude questions, most participants strongly agreed that the CFI would prolong their patient assessment time. However, in a recently published mixed-method field trial, the administration of the CFI resulted in shorter follow-up interviews. The long-term benefits of using the CFI improved clinicians’ feasibility ratings, and clinicians should be made aware of this possible benefit to improve implementation of CFI use in clinical practice.14Before the CFI was incorporated into the DSM-5, time needed to use the CFI in practice was seen as an implementation barrier, and lack of time has previously been described as a barrier to adherence to guidelines.22 It has been shown that as little as 1 h of training on the CFI can improve clinicians’ ability to work with culturally diverse patients.19Most of the participants, irrespective of whether they practise in academic, private or district settings, agreed that physicians needed training to learn how to apply the CFI in practice. From the DSM-5 CFI field trials, it was found that clinicians across countries preferred case-based behavioural simulations in cultural competence training and this will need further investigation in implementation in the South African setting.13 In this study, it was also found that female psychiatrists were more willing to apply the CFI in their clinical practice than males. Although the reason for this finding was not investigated, it is likely influenced by the sample that consisted predominantly of females, similar to previous studies.23South African psychiatrists in inpatient settings strongly agreed that the CFI is relevant in clinical practice compared with psychiatrists spending more time in outpatient settings, who simply agreed that the CFI was relevant. The reason for this difference was not investigated as part of this study, but the American Psychiatric Association has stated that the revised CFI is applicable and useful in all clinical settings.There was a poor response rate to the online survey, with fewer responses than initially anticipated. The smaller sample sizes might have affected the statistical significance of some of the results. In a study exploring specialists’ response rates to web-based surveys, 16.9% of psychiatrists were found to be non-responders in the follow-up survey. The contributing factors identified were survey burden, too many survey requests and lack of time to complete them and no interest or seeing no benefit in completing the survey.24The same reasons could have contributed to the poor response rates seen in our study.Previous studies have shown that the attitudes of clinicians can be influenced by training, and the participants in our study were not trained to apply the CFI and most of them have not applied the CFI in clinical practice. However, the respondents had the opportunity to look at the CFI through the reference website that was provided to gain a better understanding of the questionnaire. Despite the limitations identified, our work improved the awareness of the CFI in South Africa and contributes to research about the CFI and potential barriers to its implementation.In our study, we did not give respondents an opportunity to use the CFI before giving a response. Future research could give an indication of whether the participants still strongly agree that the CFI prolongs assessment time after they have an opportunity to use it. A qualitative approach is recommended to try and establish reasons for the differences seen amongst the various groups in our study and to get more detailed information about attitudes towards cultural influences in psychiatric assessments and use of tools such as the CFI. The focus of future research could be to establish the preferred training methods for our study population in the use of this type of instrument.19 This study is an essential first step for further research into the CFI and its use in SA and contributes towards improving awareness of the CFI amongst South African psychiatrists.Lack of awareness and a negative attitude towards interventions can hinder the effective implementation of the CFI in clinical practice. The CFI is designed to be used by clinicians in any setting to assist with the gathering of essential data to produce a cultural formulation. Overall, the participants in our study had a positive attitude towards the CFI. The attitude findings did not differ much when compared according to demographics. However, the overall negative response regarding the CFI prolonging patient assessment time could still be a potential barrier in its clinical application. It will be important for future advocacy or research efforts to make clinicians aware of the potential benefits of incorporating the CFI into their assessments, whilst also informing them that it has been found that with practice, the CFI takes only approximately 20 min to complete. The CFI can be an effective way to initiate cultural assessments, and preliminary evidence indicates that the CFI can improve clinical communication and enhance clinician–patient rapport.


Sphingosine-1-phosphate (S1P) is a pleiotropic sphingolipid derived by the phosphorylation of sphingosine either by sphingosine kinase 1 (SPHK1) or SPHK2. Importantly, S1P acts through five different types of G-protein coupled S1P receptors (S1PRs) in immune cells to elicit inflammation and other immunological processes by enhancing the production of various cytokines, chemokines, and growth factors. The airway inflammation in asthma and other respiratory diseases is augmented by the activation of immune cells and the induction of T-helper cell type 2 (Th2)-associated cytokines and chemokines. Therefore, studying the S1P mediated signaling in airway inflammation is crucial to formulate effective treatment and management strategies for asthma and other respiratory diseases. The central aim of this study is to characterize the molecular targets induced through the S1P/S1PR axis and dissect the therapeutic importance of this key axis in asthma, airway inflammation, and other related respiratory diseases. To achieve this, we have adopted both high throughput next-generation knowledge discovery platforms such as SwissTargetPrediction, WebGestalt, Open Targets Platform, and Ingenuity Pathway Analysis  to delineate the molecular targets of S1P and further validated the upstream regulators of S1P signaling using cutting edge multiple analyte profiling (xMAP) technology  to define the importance of S1P signaling in asthma and other respiratory diseases in humans. Sphingosine-1-phosphate (S1P), a sphingolipid, is one of the essential modulators of various cellular processes such as differentiation, survival, growth, etc. . SphingoT-lymphocyte exit from primary and secondary lymph organs (S1P is the ligand for G-protein coupled receptors (GPCRs) that belong to the Endothelial Differentiation Gene (EDG) family of proteins termed as S1P receptors (S1PRs) . S1P canh organs . It was h organs . Recentlh organs . The sphh organs . The clih organs . It was h organs . The pheh organs .To address this important problem, we have designed this study to delineate the functions of S1P in the development of asthma and other respiratory diseases. Here, we have utilized both next-generation knowledge discovery platforms such as SwissTargetPrediction, WebGestalt, Open Targets Platform, and Ingenuity Pathway Analysis  to delineate the molecular targets of S1P and validated the upstream regulators of S1P signaling using cutting edge multiple analyte profiling (xMAP) technology  .in silico prediction of the molecular targets of S1P was performed using Swiss Target Prediction, a virtual screening web tool  of the molecular targets of S1P derived using Swiss Target Prediction was used in the WebGestalt tool (wGSEA) . Using wnt study . The latnt study .P < 0.05) for computing the False Discovery Rate (FDR) (P < 0.05), and the significance Level (Top 10).To functionally characterize the S1P-induced molecular profile, we analyzed the molecular targets of S1P obtained by Swiss Target Prediction using ORA . Here, the enrichment method was chosen as ORA, the selected organism was Homo sapiens, and gene ontology  was selected for each type of analysis. The reference list for each analysis included all mapped Entrez gene IDs from the selected platform genome. The parameters for the enrichment analysis included the minimum number of IDs in the category (5), the maximum number of IDs in the category (2000), the Benjamini Hochberg (BH) method (P < 0.05) regulated by the S1P signaling and its associated molecular networks.The Open Targets Platform was used to find the S1P molecular targets associated with respiratory diseases . The eviP < 0.05), affecting the respiratory diseases through S1P/SPHK pathway to deduce unique disease-causing gene clusters.Ingenuity pathway analysis (IPA) software has a cutting edge up to date next generation knowledge base consists of clarified scientific information from publications, databases, and other relevant resources . Here, wn = 12) were used as control and the asthma patients (n = 12) were with moderate to severe disease state, non-smokers, and without any other co-morbid conditions such as chronic obstructive pulmonary disease (COPD), other types of pulmonary diseases and disorders, diabetes, cancer, autoimmune diseases, etc. The institutional ethical approval was obtained before collecting the samples and the study was approved by the Scientific Research Committee, Deanship of Scientific Research (DSR), King Abdulaziz University (KAU), Jeddah. The peripheral blood isolated was kept at room temperature for clotting and then centrifuged at 3000 rpm for 10 min for the separation of serum and the aliquots were stored at −80°C till the xMAP assays were done . The values were represented as mean ± SD. Furthermore, an F-test to compare the variances and simple correlation analysis of S1P levels against cytokines and chemokines in the serum of asthma patients was also performed using GraphPad Prism (Version 8.3) software.The raw xMAP data was analyzed by the xPONENT analysis software (Version 4.2)  to determine the absolute concentration of cytokines and growth factors in both healthy control and asthma groups . The staIn the present study, the SwissTargetPrediction was performed for S1P (C18H38NO5P) using both Canonical [CCCCCCCCCCCCCC = CC(C(COP(= O)(O)O)N)O] and Isomeric (CCCCCCCCCCCCC/C = C/[C@H]([C@H](COP(= O) (O)O)N)O) Simplified Molecular Input Line Entry System (SMILES) codes  computedP < 0.01; Q < 0.01) in ORA  in the ORA  in ORA . The GO  the ORA . The mol the ORA .P < 0.05) affected by the molecular targets of S1P. The top 15 respiratory diseases significantly  induced by S1P and its molecular targets were lung disease, respiratory system disease, respiratory system neoplasm, bronchial disease, lung carcinoma, asthma, interstitial lung disease, COPD, Rare genetic respiratory disease, idiopathic pulmonary fibrosis, pulmonary fibrosis, acute lung injury, pneumonia, whooping cough, and non-small cell lung adenocarcinoma . About 263 molecules play a significant role (P < 0.05) as upstream regulators of the molecular targets of S1P  increased in the serum of asthma patients compared the healthy controls. Similarly, the growth factors that were found to be upstream of S1P signaling such as HGF, VEGF, and CSF2 were significantly (P < 0.01) increased in the serum of asthma patients compared to the healthy controls. The S1P levels were significantly increased in the serum of asthma patients compared to the healthy controls. All the cytokines and growth factors analyzed by the Luminex xMAP assay were positively correlated with the S1P levels in the serum of asthmatics , King Abdulaziz University (KAU), Jeddah. The patients/participants provided their written informed consent to participate in this study.All authors designed and conducted the experiments, analyzed the data, wrote the manuscript, and contributed to the editing of the manuscript and the scientific discussions. SB, LD, and PP proposed the research idea.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.The handling editor declared a past co-authorship with one of the authors PP.