Neisseria gonorrhoeae (NG), compromising gonorrhea treatment, is a global public health concern. Improved, quality-assured NG AMR monitoring at the global level is essential. This mini-review examined NG AMR susceptibility surveillance and AMR data from the African continent from 2001 to 2020. Eligible peer-reviewed publications (n = 30) containing NG AMR data for antimicrobials currently recommended for gonorrhea treatment were included. Overall, very limited NG surveillance and AMR data was available. Furthermore, the NG AMR surveillance studies varied greatly regarding surveillance protocols , methodologies  gradient strip test, disc diffusion test] and interpretative criteria), and quality assurance . Moreover, most studies examined a suboptimal number of NG isolates, i.e., less than the WHO Global Gonococcal Antimicrobial Surveillance Program (GASP) and WHO Enhanced GASP (EGASP) recommendations of ≥100 isolates per setting and year. The notable inter-study variability and frequently small sample sizes make appropriate inter-study and inter-country comparisons of AMR data difficult. In conclusion, it is imperative to establish an enhanced, standardized and quality-assured NG AMR surveillance, ideally including patient metadata and genome sequencing as in WHO EGASP, in Africa, the region with the highest gonorrhea incidence globally. This will enable the monitoring of AMR trends, detection of emerging AMR, and timely refinements of national and international gonorrhea treatment guidelines. To achieve this aim, national and international leadership, political and financial commitments are imperative.Antimicrobial resistance (AMR) in  Antimicrobial-resistant (AMR) infections are a threat to the global public health and associated with significant morbidity and mortality . People Neisseria gonorrhoeae (NG) has emerged to all antimicrobials available for empirical first-line treatment  are public health concerns worldwide and the World Health Organization (WHO) estimated in 2020 that 82 million global incident gonorrhea cases among adults occur annually, with the highest incidence in Sub-Saharan countries of the WHO African region . Complicreatment ,b, 2021.The WHO has listed key AMR priority pathogens, which included NG as an urgent public health threat for which the global AMR surveillance needs to be substantially enhanced . For theIn this mini-review, we summarize NG AMR surveillance, AMR testing methods, including internal quality control strains, and AMR data from the African continent from 2001 to 2020. We included papers examining one or several of the four WHO GASP, EGASP and GLASS recommended antimicrobials, i.e., ceftriaxone, cefixime, azithromycin and ciprofloxacin. These antimicrobials represent current or recent first-line treatment for gonorrhea in most countries worldwide .www.eucast.org] or Clinical Laboratory and Standards Institute ), and quality control strains.Eligible peer-reviewed articles including NG AMR surveillance and AMR data in Africa were identified through an advanced search for best match in PubMed online databases for publications from 2001 to 2020. The search terms and strategies, and eligibility criteria are fully detailed in n = 17) of studies examining AMR in ≥100 NG isolates per setting and year, i.e., in accordance to WHO’s recommendations. Study period also widely differed with 40% (n = 12) of the studies conducted during 0–6 months, 6.7% (n = 2) during 7–12 months, 23.3% (n = 7) during 13–24 months, and 26.7% (n = 8) for more than 24 months. One study (3.3%) did not specify the exact surveillance period. For AMR testing, 76.7% (n = 23) of studies performed MIC determination, which is recommended by WHO, with 33.3% (n = 10) and 53.3% (n = 16) using agar dilution and MIC gradient strip test, respectively, including 10.0% (n = 3) using both methods. Seven (23.3%) studies used only disc diffusion method for NG AMR testing, which is not recommended by WHO. Twenty (66.7%) studies reported using CLSI breakpoints, seven (23.3%) EUCAST breakpoints, and one (3.3%) both CLSI (for agar dilution results) and EUCAST (for MIC gradient strip test results) breakpoints. Two (6.7%) studies did not report the breakpoints used. The quality control of the AMR testing included the CLSI-recommended NG ATCC 49226 reference strain , WHO NG reference strains , other NG ATCC strains , only clinical NG strains , and five (16.7%) studies did not report any NG quality control strains  and financial commitments are imperative. However, it is also important to increase the awareness among healthcare staff  that regular, representative and quality-assured NG AMR surveillance should be the foundation of national AMR action plans to manage and control gonorrhea, part of routine diagnostics and/or surveillance, and used to inform revisions of national gonorrhea treatment recommendations. Due to the fastidious nature of NG, it is additionally essential to provide training to staff at clinics and laboratories concerning appropriate: (1) sample collection, transportation and preservation; (2) laboratory methodologies, especially high-quality sensitive and specific culture and AMR testing; and (3) quality assurance, including use of internal quality controls and external quality assessment . FinallyIn conclusion, it is imperative to establish an enhanced, standardized and quality-assured NG AMR surveillance, ideally including patient metadata and genome sequencing as in WHO EGASP, in Africa, which is the region with the highest gonorrhea incidence globally. This will enable the monitoring of AMR trends, detection of emerging AMR, and timely refinements of national and international gonorrhea treatment guidelines. To achieve this aim, national and international leadership, political and financial commitments are imperative.FK, RK, and MU conceived and designed the study and wrote the first draft of the manuscript. GM, JK, ON, PK, BS, and DG supported the literature review. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Antimicrobial resistance (AMR) is one of the main health concerns worldwide and addressing the problem through the One Health approach is essential to manage the burden of AMR emergence and transmission. Prudent use of antibiotics and compliance to the prescribed therapy are key actions to prevent the impact of AMR in animals and humans. As regards companion animals, the effective use of antibiotics depends on the collaboration of pet-owners with prescribing vets. To improve compliance, it is important to improve pet-owner understanding of AMR-associated risks. We conducted an online survey to investigate AMR knowledge amongst dog owners with a focus on canine acute diarrhea (AD) management. AD is a good example to consider. The disease is stressful for owners that seek veterinary help for their dog’s condition. Some cases of canine AD are still treated with antibiotic courses as first-line medication despite antimicrobial administration often being unnecessary. Rather, it has been observed that dietary management and administration of nutraceuticals can positively impact on the resolution of symptoms. Respondents to our survey were reasonably aware of AMR existence and AMR-associated risks. Almost all of them agreed that treating canine AD with nutraceuticals would represent a valuable alternative to antibiotics.p = 0.004). Most of the owners expected a rapid recovery of clinical signs after a first episode of AD and accepted natural dietary supplementation for treating the condition. Ninety-five percent of the respondents believed that public funding should be spent to study AMR. Even though an acceptable degree of AMR awareness emerged, we feel that further efforts should be made to increase public AMR knowledge and to stimulate proactive measures to fight the phenomenon. On the other hand, the development of guidelines for the treatment of uncomplicated canine AD would help clinicians to rationalize antimicrobial use.An ad hoc questionnaire was designed in order to investigate AMR knowledge amongst Italian dog owners, owner expectations concerning pharmacological treatment of canine AD, and client attitudes towards and compliance with alternative strategies to antimicrobial administration. A total of 250 questionnaires were returned. Most of respondents were female, aged 36–70 and workers. More than a half of participants owned one dog with mixed breed, with Labrador retriever, golden retriever, dachshund, and border collie being the most represented breeds. On average, each dog was treated with an oral antibiotic 1.044 times per year. Intestinal diseases were among the main reasons (19%) for antibiotic prescription. Oral antibiotic courses without veterinary consultation (21%) and anticipated termination of the therapy (17.1%) were less common than reported elsewhere. The majority of respondents knew the meaning of AMR with a significant inverse association between the level of education and the tendency to administer antimicrobials without consulting a clinician ( Antimicrobial resistance (AMR) is an advancing global menace to public and animal health. Overuse or misuse of antimicrobials are established risk factors accelerating the development of AMR . While iEscherichia coli, and Salmonella [Escherichia coli and Salmonella, percentages of single and/or multidrug AMR of 53.4% and 85.1%, respectively, have been identified from other authors [Resistance is problematic in many pathogens and commensals of canine origin, including staphylococci, enterococci, lmonella ,6,7. Forlmonella , 13 out lmonella  and for  authors ,11. The close human–animal bond mentioned above also leads to an increased risk of transmission of zoonotic bacteria and resistance determinants ,12. FurtAn online cross-sectional survey was administered from April 2020 to November 2020 to dog owners living in Italy, to investigate their perceptions of the AMR emerging issue and of antimicrobial use, especially with respect to canine AD. The questionnaire was created in the Italian language using Google Forms©, (accessed on 10 March 2019), , “non-workers” , or “retired/homemakers” , species of animals kept other than dogs, and caregiver attitude for referring their dogs to a trusted veterinarian or a specialist  2018/679). Respondents agreed to participate in the study voluntarily by self-enrolling. They were informed that their answers would be published in a scientific paper. By completing and returning the survey, they agreed to the inclusion of their data.p < 0.05.The data collected in the survey were transferred to a spreadsheet  and underwent descriptive analysis. Results are reported as frequency (n/N) and percentage (%). Some items were further analyzed to assess a relevant association. In detail, the considered variables were: (a) the influence of the educational level on AMR awareness, (b) the influence of the educational level on AMR concern, (c) the influence of the respondent age on AMR concern, (d) the influence of education level/age on the administration of oral antimicrobials without consulting a veterinarian, (e) the influence of education level/age on the number of antimicrobial courses stopped before the end of the treatment, and (f) the influence of the employment status on the respondents’ willingness to personally fund academic research into AMR. The statistical analysis, based on either the chi-square test or Fisher’s exact test for small samples, was carried out by using “R”, a free software environment for statistical computing and graphics (version 3.6.3), and ORs with 95 percent confidence interval are reported for significant results. Statistical significance was set at A total of 250 completed questionnaires was returned. The demographics of respondents are summarized in Forty-four percent (111/250) of respondents had administered at least one oral antimicrobial course over the previous 12 months. On average, each dog was treated with an oral antibiotic 1.044 times per year and 23 respondents out of 111 (21%) admitted to having administered an oral antibiotic course without a veterinary consultation. Among them, 65% (15/23) administered drug leftovers from previous prescriptions, 17% (4/23) purchased the antibiotics at the pharmacy without prescription, and 17% (4/23) purchased the antibiotics using an old prescription . AccordiTwo values in the figure (“AM was given by a family member or a friend” and “AM was purchased on internet”) were not plotted because they were zero. AM: antimicrobials.Respondents were also asked to what extent an oral antibiotic is needed to treat dog AD; multiple answers were possible. Forty-seven percent (158/250) said that antimicrobial treatment should be administered when the cause of diarrhea has been identified; 15% (50/250) thought that it is recommended in the case of bloody diarrhea; 10% (35/250) said that it is needed if diarrhea persists for more than two days regardless of its characteristics; 9% (30/250) thought that it is needed if the dog has fever; 9% (30/250) said that it should not be used; and 8% (27/250) said that it should be used in cases of diarrhea with mucus . Most owA value in the figure (“If my dog was senior”) was not plotted because it was zero. AM: antimicrobials.Eighty-four percent of respondents knew the meaning of AMR and the large majority (96%) thought it was a major problem. Owners felt that public research is needed to face the AMR challenges (97%). Ninety-five percent believed that public funding should be spent in this field but only 33% of them would have been willing to personally fund targeted public research. p = 0.2) was found between knowledge of what AMR means and the level of education or between the education level and the belief that AMR is a problem of major concern (p = 1). No significant relationship emerged between the age of respondents and the belief that AMR is a major problem (p = 0.99). Otherwise, the education level significantly inversely influenced the attitude to administer an oral antimicrobial without consulting a veterinarian  and a trend was shown with respect to age (p = 0.07). No significant relationship was observed between the age of respondents (p = 0.27) and the number of antimicrobial courses stopped before the end of the treatment. There was also no relationship between employment status and respondents’ willingness to personally fund academic research into AMR (p = 0.82). However, among the “worker” category, 37% (72/193) said that they would personally fund the research, 48% (93/193) answered ‘I don’t know’, and 15% (28/193) would not be willing to fund it. Among the “unemployed” class, 22% (7/32) answered positively, 66% (21/32) did not know, and 12% (4/32) answered negatively. Among the “retired/homemaker“ class, 20% (5/25) answered they would fund academic research, 20% (5/25) they would not, and 60% (15/25) were doubtful.No significant relationship   about 70The majority of respondents owned one dog, belonging mainly to a mixed breed, and half of these dogs cohabited with at least another animal species. These data are in line with Carvelli et al. (2020)  who repoOur survey demonstrated that each dog had been treated with an oral antimicrobial course 1.044 times over the previous 12 months and 17.1% of participants shortened the recommended duration of antimicrobial treatment. A study conducted in Portugal between 2018 and 2019 showed that only 60% of pet owners completed the full course of treatment recommended by the veterinarian despite administering antimicrobials at the prescribed dose . DespiteAlthough in Italy antibiotics must be sold exclusively with a prescription by a health professional, according to our findings 21% of participants still resort to antimicrobial administration without consulting a veterinarian. This lower percentage compared to other countries, could reflect a good knowledge of the importance of antibiotic prescription even though it cannot be excluded that respondents were less likely to admit self-medication practices. The majority of Greek small-animal veterinarians participating to a survey declared that pet owners frequently administer antibiotics before bringing the animal to the practice . The main = 21) would still like them to be prescribed [Ten per cent of respondents to our survey declared they would take their pet to another veterinarian should the consulted professional refuse to prescribe an antibiotic treatment. This is not surprising as it has already been reported that both physicians and veterinarians often perceive patient/owner demand for antibiotics ,46. A stescribed . Owner eescribed . More efWe felt intriguing to investigate owner perception about antimicrobial administration in cases of dog AD as the symptom represents one of the most common causes of veterinary consultation in dogs in Western countries. Moreover, even though microbiological or parasitological tests are rarely carried during such emergencies, use of systemic antimicrobials is quite common. According to Singleton et al. 2019)  systemic19  systeThe present study suggests the existence of a not negligible level of public awareness and concern about AMR. A high percentage of dog owners feel that AMR is a major problem. Nevertheless, 16% of respondents admitted they did not know about AMR, and a small percentage of respondents seemed to be less worried about the impact of AMR on themselves or their families than on their pet’s health. Our findings agree with previous reports describing improvement in Italian pet-owner knowledge related to AMR, while also stressing the need to further develop awareness and responsibility at an individual level . It has The significant relationship between prudent administration of antimicrobials and level of education was expected. A cross-sectional survey among Italian adults had in fact already demonstrated that higher education levels are predictors of good knowledge about antibiotics and AMR . Our survey provided evidence that most respondents thought that public research is needed to deal with the AMR problem and 95% believed that public funding should be spent in this field. By contrast, only one third (33%) of the respondents were willing to personally fund the research. As this survey was carried out in the midst of the COVID-19 crisis, the results may be partially explained by the emotional states that frequently mark pandemics, such as uncertainty and economic anxiety. On the other hand, citizen engagement in AMR research should be further stimulated at different levels. Within most national action plans for AMR, citizens are expected to be recipients of awareness activities or education interventions rather than actively engage in proactive self-care measures to reduce the need of antibiotics . In someFor ethical reasons our research relied on voluntary participation. This could have implied engagement by highly committed owners with a higher-than-average perception on risks associated with antimicrobial usage and AMR. One must also consider that although the definition of AMR was provided in the questionnaire, its thorough understanding can be challenging. In addition, social desirability bias cannot be excluded. Our data provide information concerning dog owners’ perceptions of AMR-associated risks and challenges. Compared with previous studies carried out elsewhere, an acceptable degree of awareness emerged. Nevertheless, further efforts should be made to increase public AMR knowledge and concern and to stimulate proactive measures to fight the phenomenon. This, in turn, would positively affect the individual propensity to fund public research on the topic. The focus on canine AD allowed us to investigate pet-owner willingness to use natural dietary supplements instead of antimicrobials to manage this clinical condition. Both in humans and in veterinary medicine, probiotics, prebiotics, postbiotics, and antioxidants are showing promising results in the treatment of gastrointestinal diseases. The outcomes of our survey are rather encouraging as the majority of respondents demonstrated a high propensity to use this alternative approach. We suggest that the development of globally accepted guidelines for the treatment of canine AD would help clinicians to rationalize antimicrobial use. Likewise, vets should be aware of their role in educating owners to compliant antibiotic use and in improving caregivers’ engagement in the AMR fight, by promoting, for instance, participation in surveys distributed by medical facilities or research institutes. A possible limitation of the study could be the method of enrolling respondents, as only owners who voluntarily filled in the questionnaire were recruited. Moreover, the online recruiting process could also have selected only that part of the Italian population that is more active on social-media platforms, possibly excluding caregivers with poor informatics skills.


The ring enlargement reduces the molecular strain for easier molecular deformation, which contributes to the higher piezoelectric response in [3.2.1‐abco]ReO4. This work opens up a new avenue for exploring high piezoelectric polycrystalline molecular ferroelectrics with great potential in piezoelectric applications.Inorganic ferroelectrics have long dominated research and applications, taking advantage of high piezoelectric performance in bulk polycrystalline ceramic forms. Molecular ferroelectrics have attracted growing interest because of their environmental friendliness, easy processing, lightweight, and good biocompatibility, while realizing the considerable piezoelectricity in their bulk polycrystalline forms remains a great challenge. Herein, for the first time, through ring enlargement, a molecular ferroelectric 1‐azabicyclo[3.2.1]octonium perrhenate ([3.2.1‐abco]ReO 4) is precisely designed by the novel chemical design strategy of ring enlargement. Intriguingly, its polycrystalline pellet can show a piezoelectric coefficient d33 as large as 118 pC/N, larger than that of the parent 1‐azabicyclo[2.2.1]heptanium perrhenate ([2.2.1–abch]ReO4) and those of most polycrystalline or even single‐crystal molecular ferroelectrics.A high piezoelectric molecular ferroelectric 1‐azabicyclo[3.2.1]octonium perrhenate ([3.2.1‐abco]ReO In terms of practical applications, inorganic ferroelectrics have long dominated the mainstream due to their high piezoelectric performances and the key benefit that they can be used in bulk polycrystalline forms, e.g., ceramics, as represented by PbO3 with piezoelectric coefficient d33 up to 200–750 pC/N. Inorganic ferroelectric ceramics can be processed into any desired shape from solid powders by high‐temperature sintering. In recent years, molecular ferroelectric crystals have been gaining growing attention as potential alternatives or beneficial complements to inorganic ones, due to their advantages of environmental friendliness, low‐toxicity, lightweight, good biocompatibility, structural diversity and adjustability. Various types of molecular ferroelectrics have thus far been reported, including organic–inorganic hybrids, pure organic crystals, organic salts, organic co‐crystals,etc. some of which exhibited high piezoelectric performances that are comparable to or even better than those of inorganic ones. For example, the organic–inorganic [Me3NCH2Cl]CdCl3 crystal shows a high d33 of 220 pC/N, exceeding that of inorganic BaTiO3 (190 pC/N). However, ferroelectric properties of almost all molecular ferroelectrics are limited to single crystals, which necessitates addressing the significant challenge of growing single crystals with specific suitable orientations and shapes. It is important and highly desirable to achieve considerable piezoelectricity in the bulk polycrystalline forms of molecular ferroelectrics.Ferroelectrics are a kind of important functional materials with versatile physical properties such as ferroelectricity, pyroelectricity, piezoelectricity, and nonlinear optical activity.1 Amon Plastic crystals, as a class of molecular materials composed of molecules with globular or quasi‐spherical structures, have a plastic mesophase between the solid and liquid phases. In the plastic crystal phase, organic molecules can easily isotropically rotate in the 3D lattice to bring about highly symmetric cubic crystal structures. Together with the low symmetric polar phases with molecular orientational ordering, this unique feature tends to generate multiaxial ferroelectricity, allowing for changes in the direction of polar axis and offering the possibility for effective ferroelectric polarization switching in polycrystalline forms. Equally importantly, different from other types of molecular crystals that are brittle and fragile to only form loosely bound aggregates of crystal grains, plastic crystals have good malleability and can extend without cracking, enabling the easy preparation of monolithic bulk polycrystals by pressing powders and favoring the autonomous self‐healing in some molecular piezoelectric crystals. Remarkable progress in plastic ferroelectric crystals has been made in the past few years, some of which bulk polycrystalline forms can show substantial piezoelectricity. For instance, [C(NH2)3]ClO4 and [(CH3)4N][GaCl4] polycrystalline ferroelectric was found to show a d33 of 10 and 80 pC/N, respectively. Harada et al. reported the piezoelectric response of several polycrystalline molecular ferroelectrics including guanidinium tetrafluoroborate (d33 = 18 pC/N), [(CH3)4N][FeCl4] (d33 = 80 pC/N), 1‐azabicyclo[2.2.1]heptanium perrhenate . However, high‐piezoelectric‐performance polycrystalline molecular ferroelectrics are still very rare. Moreover, although the strategies for obtaining high piezoelectricity in molecular ferroelectric single crystals have been well developed, such as the bond‐weakening approach and heavy halogen substitution, it remains a great challenge to design polycrystalline molecular ferroelectrics with high piezoelectricity.Inorganic ferroelectrics can realize high performance in polycrystalline ceramic forms due to their multiaxial ferroelectricity, which enables the multiple orientation tunability of the polarization.8b Pla4 (Scheme 4), which is able to show high piezoelectric performance in polycrystalline pellet form, behaving like to the inorganic ferroelectric ceramics. Benefit from the ring enlargement reduced molecular strain, the [3.2.1‐abco]ReO4 polycrystalline pellet exhibits a remarkably large d33 up to 118 pC/N, which is higher than that of the parent [2.2.1‐abch]ReO4 (90 pC/N)  Å, V = 266.62(4) Å3), belonging to the cubic crystal system and the m3¯m Laue class. Both cations and anions are severely disordered in this highest symmetric site, showing structurally isotropic tumbling and losing chemical sense  Å and α = 89.73°, V = 256.67(10) Å3 at 300 K, space group R3m), where the cations and anions are still orientationally disordered  Å, b = 9.0504(6) Å, and c = 8.9667(7) Å at 253 K. Structurally, the cations are located on two mirror planes perpendicular to the a‐ and b‐axis directions respectively and thereby adopt a different orientation state compared to that of phase I  of the complex dielectric constant of polycrystalline pellet for [3.2.1‐abco]ReO4. Accompanying the phase transition between phase I and II, the ε′ shows a sharp λ‐shaped anomaly with a peak value up to 2041, which is a typical characteristic of paraelectric‐ferroelectric phase transitions, indicating a drastic change in the electric polarization. The temperature‐dependent ε′ values well obeyed the Curie−Weiss law, ε′ = C/(T − θ), above the TC of 340 K  measurements to investigate the crystal symmetry of each phase . When the temperature reaches near the Curie temperature of 340 K, the SHG intensity sharply drops into an inactive state, meaning that it enters the centrosymmetric paraelectric phase.Solid–solid phase transition behaviors generally give rise to abnormal changes in electrical properties, i.e., anomalies in dielectric constants. d33 is one of the most important parameters for evaluating the piezoelectric performance of materials, expressed as the induced charge per unit force generated in the direction of the applied force. Considering the potential of practical applications, we mainly focus on the piezoelectricity of its room temperature 3m phase, of which the piezoelectric coefficient matrix was given in Equation Figure 4 shows remarkably large piezoelectric response with a high d33 value of 118 pC/N at room temperature after poling processing, which is higher than that of the parent [2.2.1‐abch]ReO4 (90 pC/N). Meanwhile, such a high d33 value of 118 pC/N is among the highest one in polycrystalline molecular ferroelectric, higher than those of guanidinium tetrafluoroborate (18 pC/N), [(CH3)4N][GaCl4] (80 pC/N), [(CH3)4N][FeCl4] (80 pC/N), and [(CH3)4N][FeBrCl3] (110 pC/N), The d33 of [3.2.1‐abco]ReO4 is even larger than most single‐crystal molecular ferroelectrics including imidazolium perchlorate (41 pC/N), NDABCO‐NH4‐Br3 (63 pC/N), (RM3HQ)2NH4La(NO3)6 (81 pC/N), (RM3HQ)2RbLa(NO3)6 (106 pC/N), and [(CH3)3NCH2Br][MnBr3] (112 pC/N) , some classical inorganic ferroelectrics like LiNbO3 (14 pC/N) , and polymer ferroelectric PVDF (≈30 pC/N). We have measured the quasi‐static piezoelectric coefficients (d33) of a dozen polycrystalline pellets of [3.2.1‐abco]ReO4 at room temperature after poling processing, which is in the range of 107–118 pC/N with the average value of 114 pC/N, demonstrating satisfactory reproducibility of high piezoelectric response. Together with the easy fabrication process and ready availability of polycrystalline samples for various desired shapes, these attributes make [3.2.1‐abco]ReO4 highly attractive for a diverse range of piezoelectric‐related applications.Crystals with polar structures naturally exhibit piezoelectric responses due to the lack of inversion centers. The longitudinal piezoelectric coefficient 4. The well‐shaped polarization−electric field (P−E) hysteresis loops in the temperature range of 300−338 K offer decisive proof for ferroelectricity, with remnant polarization (Pr) of 4.3−5.1 µC cm−2  is higher than the typical molecular ferroelectric single‐crystal triglycine sulfate (2.8 µC cm−2), and comparable to those of other polycrystalline molecular ferroelectric such as [(CH3)4N][FeBrCl3] (4.5 µC cm−2) and [3.2.1‐dabco]BF4 (5.5 µC cm−2). Notably, the coercive field (Ec) shows a decrease with increasing temperature and obtains a small Ec of 7.6 kV cm−1 at 338 K, which should be due to the weakening of the coupling stabilizing effect between domains. Such good ferroelectric performances with small Ec values shown from polycrystalline pellets are expected to enable low voltage polarization switching of thin films of [3.2.1‐abco]ReO4. Under an AC frequency of 250 Hz, we observed well‐defined polarization−voltage hysteresis loops with a low coercive voltage of 2.2 V and a Pr value of 4.6 µC cm−2  and hardness (H) of [3.2.1‐abco]ReO4 thin film by nanoindentation characterization, which is widely used to characterize the mechanical properties of molecular crystals. From the fitted load–displacement curves based on the Oliver–Pharr model, we obtained the E and H of [3.2.1‐abco]ReO4 to be 6.93 GPa and 57.3 MPa, respectively  is a mainstream technique for characterizing ferroelectric behaviors, which images the ferroelectric domains by mapping the piezoelectric strain in the sample surface generated under AC bias. Surface scanning while detecting vertical  surface vibration can yield a domain pattern that reflects the OP component of the polarization. Lateral PFM detects the in‐plane (IP) component of the polarization. The PFM images representing the IP and OP phase and amplitude signals of [3.2.1‐abco]ReOFigure Further, an attempt was made to visualize the polarization switching process through the domain writing experiment. 4 after ring enlargement. We quantitatively assess the magnitude of molecular strains of [3.2.1‐abco]+ cation in [3.2.1‐abco]ReO4 and [2.2.1‐abch]+ cation in [2.2.1‐abch]ReO4. We first optimize the molecular geometry at b3lyp‐D3(BJ)/6‐31G(d) level. The bond angle of each methylene can be directly measured from the two obtained stable molecular cations , which is reduced into −4.24% in [3.2.1‐abco]+ cation. The two ethylene groups  are symmetric about the mirror, with the degree of methylene group deformation of −3.21% and −3.02% in [2.2.1‐abch]+ cation, which are slightly reduced into −2.27% and −1.97% in [3.2.1‐abco]+ cation. And finally, the deformation of the carbon bond has experienced great change from ≈3% to 0.43%–1.44%  by adding a methylene. Based on all the above data, we define the average absolute value of the degree of deformation of each methylene as the molecular strain. Therefore, the total molecular strain is reduced from 3.93% ([2.2.1‐abch]+) to 1.85% ([3.2.1‐abco]+) by ring enlargement. The reduction of molecular strain enables the easier deformation of polar [3.2.1‐abco]+ cation. When the external stress is applied to the 3m ferroelectric phase of [3.2.1‐abco]ReO4 where [3.2.1‐abco]+ cation shows rotating orientational disorder, the easier molecular deformation induces a larger change of the polarization and the higher piezoelectric response.To investigate the enhancement of piezoelectric response in [3.2.1‐abco]ReOs Figure 7. Then,34) with a large d33 up to 118 pC/N in the polycrystalline pellet form, which is higher than that of the parent 1‐azabicyclo[2.2.1]heptanium perrhenate (90 pC/N) and those of most molecular ferroelectrics in polycrystalline or even single crystal forms. The multipolar axis characteristic and plastic malleability allows [3.2.1‐abco]ReO4 to display macroscopic ferroelectricity in both polycrystalline pellet and thin‐film forms, which enable low‐voltage operations and high‐frequency performance of polarization switching. Combined with the room‐temperature fabrication of either aqueous method for single crystals or simple cold‐pressing method for polycrystalline forms, the [3.2.1‐abco]ReO4 manifests promising prospects in a wide range of applications such as soft piezoelectric devices, sensor elements, flexible and biomedical electronics, etc. The emergence of such type of molecular polycrystalline ferroelectrics has brought unprecedented feasibility for commercial applications, and with continuous in‐depth research, to finally launch a shaking challenge to the current preeminence of inorganic ferroelectric ceramics.In summary, through ring enlargement, we have synthesized a polycrystalline molecular ferroelectric 1‐azabicyclo[3.2.1]octonium perrhenate   spectrum of [3.2.1‐abco]ReO4  glass substrate. High‐quality thin films with thicknesses of ≈500 nm was formed after slow solvent evaporation at 300 K. The polycrystalline pellet with thickness of ≈0.2 mm was prepared by cold‐pressing of ground crystal powders in a cylinder mold.1‐Azabicyclo[3.2.1]octane was synthesized according to the reported literature.25 ReO−1 was measured. The polycrystalline powder sample was placed in aluminum crucibles. It was performed temperature‐dependent SHG intensity on Ins 1 210 058, INSTEC Instruments using an unexpanded laser beam with low divergence , and a Linkam LTS420 thermal stage was equipped to control the temperature. The laser was Vibrant 355 II, OPOTEK. The complex dielectric permittivity curves were measured on an automatic impedance Tonghui 2828 analyzer at the frequency of 1 MHz with the AC (Alternating Current) voltage of 1.0 V. For the dielectric measurements, the polycrystalline sample into powder and pressed it into a thin plate was first grounded. Then the conductive silver glue on both top and bottom plate surfaces as the electrodes of the sample sheet was deposited. Finally, silver conducting glue to stick the copper wire on it for connection with the six‐hole socket to form a capacitor was used.The DSC curves on a PerkinElmer DSC 6000 instrument under a nitrogen atmosphere at a heating and cooling rate of 10 K min4/Ag architecture. For the thin film samples, the liquid GaIn eutectic was dropped on the sample as the top electrode to form an ITO/[3.2.1‐abco]ReO4/GaIn capacitor architecture. The P–E measurements were performed on a probe station equipped with a Precision Premier II Ferroelectric Tester (Radiant Technologies), and typical triangular wave was applied with different combinations of voltages and periods.For the polycrystalline pellet, the sample was pasted with conductive silver glue on both faces to form an Ag/[3.2.1‐abco]ReOPFM measurements were carried out on a commercial scanning probe microscope  instrument to characterize the surface morphology, domain structure, PFM switching spectroscopy, and domain switching. Conductive Pt/Ir‐coated silicon probes  with a nominal spring constant of ≈2.8 nN/nm and a free‐air resonance frequency of ≈75 kHz were used. To enhance the signal‐to‐noise ratio, the resonance‐enhanced mode was used, with the tip driven with an AC voltage of 5 V at the vertical contact resonance (≈300 kHz) and an AC voltage of 2 V at the lateral contact resonance (≈620 kHz).E) and hardness (H). The sample was firmly fixed onto the sample stage by cyanoacrylate glue. Standard load function was set with peak load of 200 µN during test. The H and E values were obtained by fitting the load‐displacement curve based on the Oliver‐Pharr method using the pre‐installed software on the device. The load‐displacement data were collected from four different positions with a distance of 10 µm to minimize test error.A Bruker Hysitron TI Premier nanoindenter with a Berkovich probe (tip radius of 150 nm) was utilized to perform nanoindentaion test to reveal elastic modulus (4 polycrystalline pellet was treated with an electric field of 10 kV cm−1 in dimethyl silicone at the temperature of 323 K for 30 min.The [3.2.1‐abco]ReOThe authors declare no conflict of interest.Supporting InformationClick here for additional data file.Supporting InformationClick here for additional data file.


In the hypoconnected subnetwork of schizophrenia patients, lower left supplementary motor area-left caudate connectivity was associated with a higher NM signal . We demonstrated the association between NM and FST circuit connectivity. Considering that the NM-MRI signal reflects dopamine function, our results suggest that dopamine underlies changes in FST circuit connectivity, which supports the dopamine hypothesis. In addition, this study reveals implications for the future use of NM-MRI in investigations of the dopamine system.Changes in dopamine and fronto-striato-thalamic (FST) circuit functional connectivity are prominent in schizophrenia. Dopamine is thought to underlie connectivity changes, but experimental evidence for this hypothesis is lacking. Previous studies examined the association in some of the connections using positron emission tomography (PET) and functional MRI (fMRI); however, PET has disadvantages in scanning patients, such as invasiveness. Excessive dopamine induces neuromelanin (NM) accumulation, and NM-MRI is suggested as a noninvasive proxy measure of dopamine function. We aimed to investigate the association between NM and FST circuit connectivity at the network level in patients with schizophrenia. We analysed substantia nigra NM-MRI and resting-state fMRI data from 29 schizophrenia patients and 63 age- and sex-matched healthy controls (HCs). We identified the FST subnetwork with abnormal connectivity found in schizophrenia patients compared to that of HCs and investigated the relationship between constituting connectivity and NM-MRI signal. We found a higher NM signal ( In postmortem studies, the concentrations of dopamine were increased in schizophrenia patients4. Recent positron emission tomography (PET) and single photon emission computed tomography (SPECT) studies reported robust increases in in vivo striatal dopamine synthesis and release6. According to the dopamine hypothesis, the most influential hypothesis regarding schizophrenia, schizophrenia occurs when increased striatal dopamine caused by various risk factors induces functional impairment7.Schizophrenia is closely related to dopamine impairment. This relationship became known through the discovery of antipsychotic drugs targeting dopamine receptors, and all licenced antipsychotic drugs used in clinical practice today affect the dopamine system9. In the FST circuit, which links the frontal cortex, basal ganglia, and thalamus, dopaminergic signalling from the midbrain affects the cortex via basal ganglia regions, including the striatum, substantia nigra (SN), and globus pallidus11. Functional connectivity alterations in the FST circuit have been reported in schizophrenia12. Changes in striatal connectivity are one of the most prominent findings in schizophrenia14. Previous studies speculated the involvement of dopamine in the underlying pathophysiology of dysconnectivity given the characteristics of the structures12. However, functional MRI (fMRI)-only studies cannot show a direct association with molecules.Dopamine changes in the midbrain are presumed to cause dysfunctions through connectivity changes in the fronto-striato-thalamic (FST) circuit18. In multimodal studies, there were associations between dopamine synthesis capacity and cortico-thalamic and fronto-striatal connectivity and between dopamine receptor density and striatal connectivity in schizophrenia patients20. However, prior investigations examined the association only for limited connections. In particular, basal ganglia regions with a small volume were excluded due to inaccurate delineation21. Therefore, further studies are needed to examine the association at the network level, including the small basal ganglia regions. In addition, PET imaging has several disadvantages, such as radioactive substance use, long acquisition time, and limited accessibility, that make it difficult to scan patients. Hence, alternative molecular imaging methods can contribute to further investigations of patients.Previous studies have attempted to reveal the association between dopamine function and FST circuit connectivity using both PET and fMRI23. Neuromelanin (NM) is synthesised by the oxidation of cytosolic dopamine and thus accumulates in the midbrain24. In nonneurodegenerative conditions, NM is produced as an alternative to excess dopamine and plays a neuroprotective role26. Preclinical studies have shown that increased dopamine results in NM accumulation in the SN27. NM-MRI captures paramagnetic NM-iron complexes, the form in which NM is present in cells, and the signal is proportional to the concentration of NM22. Furthermore, the NM-MRI signal in the SN is correlated with PET dopamine measures, including striatal dopamine release29. Taken together, the NM-MRI signals reflect dopamine activity in the nigro-striatal pathway22.Neuromelanin-MRI (NM-MRI) is a noninvasive proxy measure of dopamine functionIn this study, we aimed to investigate the association between FST circuit functional connectivity and NM in schizophrenia patients using fMRI and NM-MRI. We examined for the first time the association between dopamine system measures and individual connectivity in the FST circuit at the network level in schizophrenia. Here, we used NM-MRI considering its advantages over traditional molecular imaging methods, such as its noninvasiveness. Given that the NM-MRI signal reflects dopamine function, the association can contribute to the demonstration of the dopamine hypothesis. For this aim, we identified dysconnected subnetworks in the FST circuit and examined the relationship between its constituting connectivity and the NM-MRI signal. We hypothesised that schizophrenia patients would show changes in NM-MRI signal and FST circuit connectivity and that there would be a significant association between them.www.youthclinic.org), a centre for the prospective and longitudinal investigation of people at high risk for schizophrenia, at Seoul National University Hospital (SNUH). In this study, schizophrenia patients were subjects who were diagnosed with schizophrenia according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)30. Symptom severity was assessed using the Positive and Negative Symptom Scale (PANSS)31. The Global Assessment of Functioning (GAF) scale was used to evaluate the overall functioning of schizophrenia patients. The Hamilton Rating Scale for Depression (HAMD)32 and the Hamilton Rating Scale for Anxiety (HAMA)33 were used to evaluate the severity of participants’ depression and anxiety. Healthy controls were recruited via internet advertisements. To screen for the presence of psychiatric disorders or symptoms, healthy controls were evaluated using the Structured Clinical Interview for DSM-IV-Non-Patient Version (SCID-NP). Healthy controls with a past or current axis-I diagnosis and any first- to third-degree biological relatives who had a lifetime history of psychotic disorders were excluded from this study. The subjects’ intelligence quotient (IQ) was measured with the Korean version of the Wechsler Adult Intelligence Scale (K-WAIS)34.We acquired data from 30 schizophrenia patients and 64 age- and sex-matched healthy controls. Schizophrenia patients were recruited from the inpatient and outpatient clinics of the Department of Neuropsychiatry and Seoul Youth Clinic , or intellectual disability (IQ < 70). Written informed consent was obtained from all participants and the parents of subjects younger than 18 after a full explanation of the procedures was provided . This study was conducted according to the Declaration of Helsinki (2013) and approved by the Institutional Review Board of SNUH (IRB No. H-2210-123-1371).3, repetition time/echo time 80/4.94 ms, flip angle 25°, and slices 32). Before each excitation, a magnetisation transfer pulse was applied to enhance the NM contrast35.We acquired anatomical, resting-state functional, and NM images using a 3 T MRI scanner (Siemens Magnetom Trio). T1-weighted anatomical images were scanned using a magnetisation-prepared rapid gradient echo sequence . Resting-state functional images were acquired for 6 min and 44 s using a gradient echo planar imaging pulse sequence . Field map images consisting of echo planar imaging data with opposite phase encoding directions (right-to-left and left-to-right) were also collected for susceptibility distortion correction for functional images . During the fMRI session, participants were instructed to remain relaxed, keep their eyes closed, and not fall asleep. We scanned NM-sensitive images using a 3D gradient echo sequence (voxel dimension 0.8 × 0.8 × 1.5 mmhttps://github.com/HALFpipe)36, a semiautomated pipeline that relies on fMRIPrep37. The pipeline included susceptibility distortion estimation, spatial normalisation, grand mean scaling, independent component analysis (ICA)-based denoising, and temporal filtering. For spatial normalisation, the MNI152NLin2009cAsym template (2 mm) was defined as the standard space. Grand mean scaling was applied with a mean value of 10,000, and denoising was performed with the ICA-based automatic removal of motion artefacts (ICA-AROMA) method. Temporal filtering was conducted using a frequency-based temporal filter (0.01–0.1 Hz). Quality assessment was performed according to the ENIGMA HALFpipe quality control manual, and two subjects were excluded from further analyses due to high motion (mean framewise displacement (FD) > 0.5 mm, maximum FD > 3 mm).We preprocessed the brain imaging data using ENIGMA HALFpipe version 1.2.1  atlas were combined. SN pars compacta and SN pars reticulata masks were also derived from the Pauli et al. (2018) atlas. The ROI masks were combined to create an FST atlas consisting of 28 regions.We created an FST atlas spanning the bilateral frontal cortex, striatum, thalamus, globus pallidus, and SN using 3 different atlases Fig. . For theAtlas-based connectivity analysis was performed in HALFpipe version 1.2.1, and time series were extracted from the 28 nodes of the FST atlas. Functional connectivity between pairs of nodes was estimated by calculating the Pearson correlation coefficient. As a result, a pairwise connectivity matrix between atlas regions was calculated for each participant.40. Using the NBS toolbox version 1.2 (http://www.nitrc.org/projects/nbs/), we first conducted a mass univariate two-sample t-test on each connection with the primary threshold of t = 2.5 (corresponding to p = 0.01) to identify suprathreshold edges. To validate the robustness of our results, we additionally repeated the analysis across different primary thresholds (t = 2.1–2.9 corresponding to p = 0.04–0.005). Next, we yielded an empirical null distribution of the size of the largest network components by permuting data 5000 times. In each permutation, data were randomly relabelled into two groups, and suprathreshold connections were defined at the same statistical threshold. The FWER-corrected p-value was then calculated as the proportion of permutations for which the largest component size was the same or greater. Because we had focal interest confined to the FST circuit, we used the component intensity  rather than the component extent as the measure of component size.We tested whether there are dysconnected subnetworks in the FST circuit in schizophrenia patients using the network-based statistics (NBS) approach, a nonparametric statistical method to control the familywise error rate (FWER) when conducting mass univariate hypothesis testing41. First, three contiguous slices with the greatest SN area in the middle slice were selected. Then, 3 mm diameter circular masks were drawn at the lateral and medial parts of the SN. As a reference region, 4.5 mm diameter circular masks were drawn at the crus cerebri (CC). As a result, a total of 12 (4*3) and 6 (2*3) masks were drawn for the SN and CC, respectively. Next, we calculated the contrast ratio (CR) using the average signal intensity of SN (SISN) and CC (SICC) with the following equation: CR = (SISN – SICC)/SICC. Following prior NM-MRI studies43, we applied a thresholding method to define high-intensity NM-containing voxels in the SN. We used the upper quartile voxel values when calculating the SISN. We used the CR value in subsequent analyses. The measurements were performed in a blinded manner.NM images were analysed using the manual segmentation method following Wang et al. (2018) in FSLeyes version 1.0.13t-test or chi-square test. We examined NM CR differences between groups using a t-test. The 95% confidence interval (CI) of the mean NM CR was calculated, as well as the mean in each group. Based on the NBS analysis results, we performed a multiple linear regression analysis to find specific subnetwork connections accounting for the NM level. In the analysis, the independent variables were abnormal subnetwork connections in schizophrenia, while the dependent variable was the NM level. We used the stepwise method for variable selection, which iteratively adds or removes independent variables based on their statistical significance.The statistical analyses were conducted using SPSS version 25. Demographic differences were tested using a t = 6.01, p < 0.001).We used data from 29 schizophrenia patients  and 63 healthy controls  in the analysis .We examined group differences in NM CR between schizophrenia patients  and healthy controls  , which consisted of 18 nodes and 26 edges , while the other connections were excluded from the model. The model explained 11.20% of the variance (adjusted R2 = 0.11), and there was a negative effect between the predictor and dependent variable (β = −0.38). In contrast, there was no subnetwork connectivity that significantly predicted the NM level in healthy controls.We predicted the NM level from the subnetwork connectivity in schizophrenia patients using multiple linear regression analysis Fig. . Among tIn this study, we confirmed changes in NM-MRI signal and functional connectivity of the FST circuit and found a significant association between these changes in schizophrenia patients. In the circuit, functional connectivity impairment was primarily in the cortex, striatum, and substantia nigra regions, among which left SMA-left caudate connectivity was associated with NM. This association indicates that the two pathological changes are interrelated in schizophrenia pathophysiology. Moreover, given that NM-MRI provides a proxy measure for dopamine activity, these results suggest that dopamine underlies the connectivity changes in the FST circuit.22. This result is consistent with the findings of previous NM-MRI and postmortem studies that reported increased NM levels in the SN in schizophrenia patients47. In dopamine metabolism, excessive dopamine induces an increase in NM synthesis26. Moreover, previous multimodal studies reported a positive correlation between NM-MRI signals and PET dopamine measures, such as dopamine release and dopamine receptor availability29. In this context, the higher NM-MRI signal in our study may suggest an increase in dopaminergic function. As mentioned above, increased dopamine is one of the most prominent abnormalities in schizophrenia8.We observed a higher NM-MRI signal in schizophrenia patients than in healthy controls; a higher signal indicates increased NM accumulation in the SN49. Preclinical models of schizophrenia pathophysiology explain this hypoconnectivity: spontaneous phasic dopamine release in schizophrenia patients leads to increased noise in dopamine signalling in the striatum, which in turn reduces functional connectivity in the FST circuit50. In contrast, some studies have reported increased connectivity, such as in the thalamic subnuclei, in schizophrenia patients14. These connections may not have been found in our study due to network-level statistics or the inclusion of the total thalamus rather than the subnuclei.Our study found a hypoconnected FST circuit subnetwork in schizophrenia patients, which includes the cortex, striatum, and substantia nigra regions. Consistent with this, previous studies have shown hypoconnectivity in cortico-cortical, striato-cortical, and nigro-striatal connections in schizophrenia patients8. Specifically, striatal connectivity alterations were prominent in the caudate14. In addition, cortical connectivity changes based on the aberrant striatum regions were primarily in the sensorimotor cortex12. These findings are in line with our results showing multiple caudate-sensorimotor cortex dysconnectivity. In our study, we also found connectivity changes in the nigro-striatal pathway. Previous studies suggested that reduced nigro-striatal connectivity may reflect reduced tonic activity and increased phasic activity in the pathway, given that rs-fMRI measures low-frequency fluctuations that are central to tonic activity12.The dysconnected FST subnetwork included many striatal connections. The striatum is where dopaminergic projections from the midbrain arrive, and connectivity changes in this region are among the most consistent findings in schizophrenia20. In addition, our results of the association primarily identified in the SMA-caudate connection correspond with regional characteristics. According to recent neurochemistry studies, dopaminergic aberrations were greater in the dorsal striatum than in the limbic striatum52. The dorsal striatum encompasses the caudate region and receives cortical projections mainly from the SMA, motor area, and dorsolateral prefrontal cortex10. Taken together, this study adds to other evidence suggesting that midbrain dopamine changes underlie aberrant connectivity of the FST circuit. In contrast, healthy controls showed no correlation between NM and connectivity. NM is formed from excessive dopamine26, and its signal level and variability were relatively lower in healthy subjects. This low variability may have caused the absence of correlation.The FST circuit connectivity significantly predicted NM levels in schizophrenia patients. More specifically, lower left SMA-left caudate connectivity was associated with higher NM levels. Considering that NM levels reflect dopamine function, this result is consistent with previous findings showing an association between dopamine measures and striatal connectivity in schizophrenia patients56. PET is a typical molecular imaging method but has limitations in clinical settings due to its invasiveness, cost, etc. NM-MRI is safer in terms of radiation exposure and has better accessibility. In this study, we confirmed that NM-MRI results are consistent with existing molecular imaging results and examined the association between NM-MRI signals and functional connectivity for the first time. Overall, this study has implications for the future use of NM-MRI to examine dopamine function in research and clinical practice.This study suggests the possibility of using NM-MRI for various investigations of the dopamine system. For example, treatment response studies reported a linkage between responsiveness and dopamine and noted a need for using molecular imaging for response prediction14. Future studies using higher resolution are needed to examine the subregions. Next, considering that psychosis may affect only a subregion of the SN22, the manual segmentation method may have diluted the effect size. Future studies would be advised to consider automated methods for greater anatomical precision. Finally, our association results do not indicate a causal relationship. Further investigations, for example, using sophisticated models, are required to determine causality within the pathophysiology.The main strength of this study is that it examined the association between FST circuit individual connectivity and dopamine system molecules at the network level in schizophrenia patients. Furthermore, this study showed the results of investigating the dopamine system using NM-MRI, a promising molecular imaging method. This study has several limitations. Schizophrenia patients in our study were medicated. Although there was no significant correlation between the analysis results and clinical variables, including medication (Supplementary Table We demonstrated a negative association between NM and FST circuit connectivity in schizophrenia patients using NM-MRI and fMRI. This shows a linkage between abnormal neurochemistry and functional abnormalities in the pathophysiology of schizophrenia. Furthermore, considering that the NM-MRI signal reflects dopamine function, our results suggest that dopamine underlies connectivity changes in the FST circuit. Together, these results expand our understanding of schizophrenia pathophysiology by providing experimental evidence supporting the dopamine hypothesis. In addition, this study has implications for the future use of NM-MRI in studies on the dopamine system.Supplemental Material


This review documents the status of AMR education and awareness in the WHO African region, as well as specific initiatives by its member states in implementing education and awareness interventions, as a strategic objective of the Global Action Plan on AMR, i.e., improve knowledge and understanding on AMR through effective communication, education, and training. A systematic search was conducted in Google Scholar, PubMed, and African Journals Online Library according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, for articles published in English. Retrieval and screening of articles was performed using a structured search protocol following a pre-set inclusion/exclusion criterion. Eighty-five published articles reporting 92 different studies from 19 Member States met inclusion criteria and were included in the final qualitative synthesis. Nigeria (21) and Ethiopia (16) had most of the studies, while the rest were distributed across the remaining 17 Member States. The majority of the articles were on knowledge, attitude, and practices with regard to AMR and antimicrobial use and most of them documented a general lack and suboptimal knowledge, poor attitude and practices, and widespread self-medication. This review shows low levels of knowledge of AMR coupled with extensive misuse of antimicrobial medicines by different target audiences. These findings underscore the urgent need for enhanced and context-specific educational and positive behavioural change interventions. Antimicrobial resistance (AMR) has been acknowledged as one of the top ten public health threats facing humanity . It is aIn response to the threat of AMR in the context of the One Health approach, in 2015 the World Health Organization (WHO) endorsed a Global Action Plan (GAP) on AMR that serves as a blueprint for country-specific National Action Plans (NAPs) . One of Antimicrobial use and misuse across sectors and the spread of resistant pathogens and resistance determinants within and between sectors have been cited as the major drivers of AMR ,7. AntimA systematic search was carried out in Google Scholar, PubMed, and African Journals Online Library according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Published articles on AMR awareness and understanding documented from original studies conducted in the 47 countries of the WHO African Region were obtained. The search was carried out using relevant keywords which were pooled together using the Boolean term “OR”. The keywords were combined to form a final search strategy using the Boolean term “AND” as shown in The criteria for inclusion of the articles in the qualitative synthesis were: The articles must be original and published in English, they should document findings related to AMR awareness, understanding, education, communication, and training in countries within the WHO African Region, and must be available in full text.The initial 729,727 records from the databases were screened according to the relevance of the title. Of the 165 remaining articles, 44 duplicates (articles from more than one database) were removed. The retained articles (121) were further screened for inclusion by reading through the abstract and noting the presence of one or more of the keywords. The final screening was based on the inclusion criteria stated above and the articles that did not meet all the criteria were excluded from the final synthesis. Relevant information synthesized from each article included the country where the study was conducted and the year of publication, the type of research tools and how they were deployed , study settings , study participants , number of study participants, as well as key findings including knowledge, understanding and awareness levels, trainings, and other relevant findings.The 85 articles available for qualitative synthesis reported 92 (80 single-country studies and five multi-country studies) original studies within the WHO African Region . The selThe majority of the country surveys were among human healthcare practitioners  and undergraduate healthcare students . The country surveys also involved general public/community dwellers (11), animal producers/farmers (10), patients (5), veterinary drug retailers and dispensers (4), community drug retailers (2), and veterinarians and veterinary paraprofessionals (2). Three other studies surveyed more than one group of respondents.Human healthcare professionals (HCPs) generally have good knowledge of AMR as a global and national problem; it is, however, less appreciated as an issue in their local institutions or wards in day-to-day practice. Many HCPs perceived AMR as a problem for individuals who misuse antibiotics. Most HCPs identified drivers of AMR as overuse and misuse, fewer of the professionals identified other factors promoting the emergence and spread of AMR such as lack of antibiograms, lack of antibiotic treatment guidelines, poor hospital hygiene and infection prevention and control measures, and lack of awareness campaigns and education. Only one study conveyed that AMR can be promoted by poor access to antimicrobials. Many studies documented poor training on AMR among human HCPs, some reported low levels of formal training or up-to-date AMR information with the few available knowledge acquired as far back as during medical training. Some studies clearly reported requests by HCPs for more education on AMR; a study among Ethiopian medical interns reported that as high as 94% of respondents wanted more education on AMR. The review further shows that AMR knowledge levels/scores differed significantly across different professionals; it was generally better among physicians and pharmacists when compared to nurses and other HCPs . In addiSix studies involved veterinary care workers and revealed that awareness and knowledge of AMR were higher among pharmacists than other veterinary drug dispensers. A third of all the dispensers in one of the studies knew that AMR could be caused by misuse. Good knowledge of veterinary pharmacists was associated with work experience of more than one year. A study of veterinary paraprofessionals in five community districts revealed that most did not attend refresher courses and seminars on AMR.Twenty-six studies engaged university undergraduate students including 21 studies of human health care students , 3 studies of veterinary students, and 2 studies involving students in general. Pharmacy students and medical students had better knowledge of AMR, its drivers, and how AMR could be curtailed when compared with nursing students, medical laboratory science students, and other paramedical students. The knowledge level is generally poor among university students studying non-healthcare-related courses. In fact, one of the surveys involving 1320 participants showed that general university students displayed less knowledge than community dwellers that self-medication promotes AMR. The review also revealed that students at higher levels had better knowledge of AMR than those at lower levels. Most studies revealed a robust knowledge among healthcare students that AMR constitutes a global problem, many studies however revealed poor students’ knowledge that it is a local hospital problem affecting routine practice. Healthcare students in many studies did not also recognise that hand hygiene and IPC measures play important roles in the control of AMR. The review also showed a complete absence or inadequacy of training on AMR in healthcare.Ten studies across the countries were among animal farmers among who were poultry farmers (5) and pastoralists/livestock farmers (3). Awareness and knowledge of AMR are generally poor and may vary across different country regions, and such awareness could be better among commercial than subsistent poultry farmers. The studies showed that many farmers did not perceive AMR as a public health issue, some perceived it as a problem of foreign countries, and some perceived it as a local problem that only affects individuals who regularly take antibiotics. The studies also showed that large numbers of farmers did not see antimicrobial use in animals as a promoter of AMR while many farmers did not have the knowledge that drug-resistant organisms can be transmitted from animals to humans.The five studies among hospital patients (three in-patients and two out-patients) showed poor awareness and knowledge of AMR. The studies showed that a large number of patients neither know that inappropriate use of antimicrobials promotes AMR nor know that resistant infections prolong hospitalization and increase healthcare costs. A study, however, showed that the knowledge that AMR could affect mortality was good.A review of the 11 studies which incorporated community dwellers and the general public showed a low level of awareness and education on AMR and poor knowledge of drivers of AMR. It further showed the possibilities of geographical variation in AMR knowledge. A study revealed that more than 50% of the public did not know that AMR is difficult to treat, and another study showed that more than 40% of the public did not know that AMR is more costly to treat. Less than one-tenth knew that hand washing can prevent transmission of AMR. Furthermore, knowledge of AMR was noted to be better among respondents with higher levels of education.Antimicrobial use is mostly influenced by knowledge, perception, prevailing attitudes, and practices on antimicrobials. Education and awareness play a critical role in addressing the use of antimicrobials and ultimately AMR, as it is an overarching objective that cuts across the other four objectives of both the global action plan and member state’s Action Plans for control of AMR. Expeditious and effective implementation of the One Health national plans to mitigate AMR requires an all-encompassing, robust, and society-wide education utilising target-specific, efficient communication strategies aimed at the government and policymakers, healthcare workers, veterinarians, animal farmers and food producers, community drug vendors, and high school, undergraduate, and graduate students, as well as the general public.Despite a majority of countries  in the region holding regular public awareness campaigns against AMR and its drivers , our revThis review noted an inappreciable knowledge of AMR even among human HCWs; findings in a multi-country survey across Ghana, Nigeria, and Tanzania are particularly noteworthy showing that respondents with good awareness of AMR was not up to 60% in the majority of the countries and awareness scores differed significantly among the different professionals within each country . This reFurthermore, the findings justify the use of unconventional approaches to systematizing education thereby promoting and ensuring sustainable behaviour change for addressing AMR threats. Countries within the region can leverage several educational initiatives targeted at different groups of people to improve awareness and education on AMR, for example, e-Bug Europe and MicroMundo for pre-university students, the “Do Bugs Need Drugs” program which is an initiative of Alberta Health Services and the British Columbia Centre for Disease Control, WHO-AFRO regional debate initiative which took place in Senegal during the 2022 continental World AMR Awareness Week celebration, the debate kit launched by of the Spanish National Plan for AMR, and the ReAct Campaign which educate on the nature as well as drivers of AMR. There are other smaller initiatives such as the “Bugs in Bangkok” board game, and the WHO-supported Dr. Ameyo Stella Adadevoh (DRASA) Health Trust model which provided a club way to teach secondary school students about AMR in Nigeria ,102. LikFarmers across the region showed abysmal levels of knowledge of AMR, many of them neither correlated the use of antimicrobials on their animals to AMR nor fathomed a possibility that resistant bugs could be transmitted from animals to humans. For example, a study from Ethiopia involving 571 rural farmers documented that only 41% knew that excessive use of antimicrobials in their animals can cause AMR. In the same vein, a Cameroon study of 358 farmers, among several others, reported a deficit in the knowledge that AMR could be transmitted from their animals to humans or the environment ,27. ThesTo the best of our knowledge, this review is the first to document the status of AMR education and awareness in the WHO African Region. This review opens up the knowledge gaps in AMR across the board and sheds light on the need to design evidence-based, pragmatic, cost-effective, targeted interventions to improve public awareness and knowledge of AMR. The review reveals a need for improved educational strategies within member countries focusing on the inclusive academic curriculum at all levels of studies, continuous professional development, as well as utilising innovative and context-specific approaches for effective and sustained awareness and education on AMR.Articles included in this systematic review were restricted only to those published in English.


Health technology innovation is increasingly supported by a bottom-up approach to priority setting, aiming to better reflect the concerns of its intended beneficiaries. Web-based forums provide parents with an outlet to share concerns, advice, and information related to parenting and the health and well-being of their children. They provide a rich source of data on parenting concerns and priorities that could inform future child health research and innovation.The aim of the study is to identify common concerns expressed on 2 major web-based forums and cluster these to identify potential family health concern topics as indicative priority areas for future research and innovation.We text-mined the r/Parenting subreddit  and the parenting section of Mumsnet  to create a large corpus of posts. A generative statistical model  was used to identify the most discussed topics in the corpus, and content analysis was applied to identify the parenting concerns found in a subset of posts.A model with 25 topics produced the highest coherence and a wide range of meaningful parenting concern topics. The most frequently expressed parenting concerns are related to their child’s sleep, self-care, eating (and food), behavior, childcare context, and the parental context including parental conflict. Topics directly associated with infants, such as potty training and bottle feeding, were more common on Mumsnet, while parental context and screen time were more common on r/Parenting.Latent Dirichlet allocation topic modeling can be applied to gain a rapid, yet meaningful overview of parent concerns expressed on a large and diverse set of social media posts and used to complement traditional insight gathering methods. Parents framed their concerns in terms of children’s everyday health concerns, generating topics that overlap significantly with established family health concern topics. We provide evidence of the range of family health concerns found at these sources and hope this can be used to generate material for use alongside traditional insight gathering methods. Innovation for health and care is increasingly supported by bottom-up approaches to priority setting -4, refleThe views of parents and children have made important contributions to setting priorities and the conduct of childhood research -10. PareSocial media sites and web-based forums contain the thoughts, questions, opinions, and concerns of parents on a range of topics, where they initiate and drive discussions. Anonymous social media content can augment traditional methods ,10 used Similar methods can be used to identify the unmet needs of families more generally. In this way, it will become feasible to rapidly scope the thoughts and concerns of parents regarding parenting and the health and well-being of their families. Identifying parents’ views in this manner draws from a variety of first-hand experiences and expressions of specific needs, providing a rich source of data on family health concerns for which sufficient information or solutions are likely yet to be found. Here, we aim to provide valuable insight that can be used to identify unmet needs and inform innovation priorities -10.This study was approved (REF 2417/25036) by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University's Research Ethics Committee.Mumsnet is a UK-based forum that is widely used to seek advice or emotional support  through Reddit is a large and widely used general-purpose social media platform. It contains subreddits (subforums) for a wide range of topics, including several on parenting, with r/Parenting the largest of these parenting subreddits. Reddit has increasingly been recognized as an important resource for researchers ,22, inclPosts were collected from the r/Parenting subreddit between January 1, 2010, and February 1, 2022, using a custom Python  script which called the Pushshift application programming interface  and fromWe then preprocessed the data, again using custom Python code, to create a corpus for the topic model. This involved removing stopwords . We alsv, previously shown to correlate well with human-assessed topic coherence [Frequently discussed family health concern topics were detected using latent Dirichlet allocation (LDA), a generative statistical model, previously described in detail elsewhere . This inoherence .Using the topic distribution calculated for each post, we estimated the probability of each post belonging to a topic. Posts were considered as belonging to a topic if the probability was greater than 75%.a=log (∅)+log (∅)/P, where ∅ is the probability of the word given the topic, P is the probability of the word appearing in the corpus, and a is the association.Topics were interpreted in 2 ways. First, the top 4 words associated with the topic were identified and used to name the topic. This association was calculated using the equation Second, to further facilitate the interpretation of topics as indicative parenting or family health priority areas, we applied a 2-step qualitative analysis to a subset of 50 posts belonging to each topic. The first step was to identify parenting concerns without reference to any prior categories, and the second step was to place each post, if possible, into one or more of the parenting question categories identified by Lavigne et al . The posPosts were distributed among 4 researchers.Researchers read through each post.They identified and noted down each parenting or family health concern (if any) the post contains.They also identified whether the post could be categorized into one or more of the 11 question categories identified by Lavigne et al .Posts were collated back together, discussed by the researchers, and then collective decisions were made on any that were unclear.P=.07).The parenting or family health concerns occurring 3 or more times within the sample of 50 posts were taken forward as a signal of specific areas of concern. This threshold was selected because it gave a greater than 90% (93.2%) probability of the concern occurring in at least 1% of all posts in the topic  posts to a topic with greater than 75% probability and that when we used this to filter posts, topics contained between 313 posts (head+roll+crawl+stair and door+open+mommi+lock) and 4295 posts (sleep+night+wake+feed). From the topic validation, we found that, for most LDA topics (14/25), the posts associated with them contained a coherent set of parental concern categories. Other topics (10/25) appeared to have 2 or more distinct but closely related and co-occurring concerns, for example, the topic sleep+night+wake+feed contained the categories bottle feeding, breastfeeding, infant crying, routine, sleeping in parents’ bed, sleeping routine, nap, regression, and waking up at night. Here, sleep issues co-occur with breastfeeding, and many posts in this topic discuss breastfeeding and sleep. The topic told+behaviour+tell+punish contains posts on intimate partner violence , generalized concerns around separation and children spending time with their fathers, bad behavior, and behavioral problems. While most topics contain concerns that are related or those we would expect to co-occur, the topic parti+birthdai+seat+christma is an amalgamation of concerns around celebratory events (birthdays or Christmas) and car seats (safety concerns and advice about buying).Traditional priority-setting approaches are an important comparator for topics extracted from large web-based data sets. Here, we make detailed comparisons between our topics and those identified by Lavigne et al  using trSleeping or night-time waking category. Others contained a plurality of categories, for example, the LDA topic door+open+mommi-lock is split between Child development and learning, Safety and injury prevention, Mental health, Parenting and behaviour, Sleeping or night-time waking, and Growth, nutrition and physical activity.In 15 out of 25 of LDA topics, a majority of posts could be assigned to one or more of the parenting question categories devised by Lavigne et al . Figure For 10/25 of the LDA topics, a majority of posts were not attributable to any of the categories identified by Lavigne et al . In 5 ouEnvironmental toxins is the only one without representation. Parenting and behaviour, Child development and learning, Growth, nutrition and physical activity, Sleeping or night-time waking, Screen time and media exposure, and Preventing childhood infections and other diseases are all well represented—presenting in multiple topics and as a majority in at least one. Mental health and Poverty and access to care are present in multiple topics without being a majority in any, and Oral health, vision, and hearing is present in small numbers in 3 topics.The topics identified here cover 10 out of 11 of the Lavigne et al  categoriWe have collated posts from the r/Parenting forum and the Mumsnet parenting forum and then used LDA to model the most common topics of discussion. We found that a model with 25 topics was the most coherent. An analysis of the content of posts associated with these topics indicated that most topics brought together posts on a related set of parenting concerns, and we found significant overlap between the content of our LDA topics and parenting priority categories identified using traditional priority-setting methods .v) [v correlates more strongly with human interpretability than other evaluation functions for certain benchmark data sets [A key strength of this work is that topic modeling using LDA allows us to use a large collection of posts, revealing the latent semantic structure present within them; however, its outputs can vary significantly depending on parameterization, and the evaluation of output quality is a contentious issue . We havev)  to optimv) . While tata sets , there iThe additional methods used to interpret the topics identified using LDA are also a strength of this work. Applying content analysis allows the context of each post and a subjective interpretation to feed into the description of the topic, while assignment to previously established parenting priority categories  leverageHowever, our content analysis and categorization also have limitations. To reduce the labor requirements of the task, we have analyzed a sample of 50 posts from each topic . TherefAnother limitation of this work comes from the representativeness of the social media users as a sample of the wider population . As therTo address this, we envision that future work will take the outputs generated here (the descriptions of the topics) and use them as material for targeted engagement with underrepresented groups such as those on low incomes. This will allow an assessment of whether the views expressed on these forums differ from those of the underrepresented groups and will allow us to bring in the voice of these groups and allow expression of their concerns. We also envision that these data sources may be used to shape future research priorities and identify unmet needs across health and childcare provision, highlighting further the importance of acknowledging the underrepresented voices.Previous priority-setting work has identified robust parental concerns relating to childhood chronic disease , preventOur results strengthen the evidence signaling parent priorities in 10 of the 11 parent priority categories presented by Lavigne et al  on pediaBoth Mumsnet and Reddit have been the subject of prior research into parental concerns and pediatric or maternal health -20,37,41Previous work using Reddit as a data source has used LDA alongside thematic analysis to investigate parental discussion of fussy eating . Using sThis work differs from the above by presenting an overview of discussion on 2 broadly defined parenting forums rather than a more detailed analysis of specific issues. Previous work that has taken a similarly broad approach includes an analysis of the posts on the subreddits r/Mommit and r/Daddit, again combining LDA topic modeling with qualitative analysis to give a broad overview of discussion topics and presenting a comparison between the 2 forums . We builRecent work has also applied LDA modeling to parenting forums such as Momsholic . They foHere, we present further evidence on the priorities and concerns of parents through the identification of topics commonly discussed on 2 well-used parenting advice forums (Mumsnet and r/Parenting). Our results show that LDA can be used to identify common parenting concerns from large-scale parenting forum data, and alongside the content analysis outlined here can be used to provide an indicative map of concerns and priorities commonly discussed. This provides a method for the rapid identification of concerns and priorities from these, or similar, large-scale data sources. We also hope our results can be used as a signpost for others looking to use data from these sources, for example, in the development of content for targeted engagement or qualitative research with families.