Mothers in the alternative lifestyle group more frequently adhered to specific living rules and identified themselves with anthroposophy more than mothers in the conventional lifestyle group. The results revealed significant differences in antibiotic use during pregnancy and in children from 3 months to 10 years of age between the two groups. The rate of antibiotic use in children was consistently lower in the alternative lifestyle group than in the conventional lifestyle group. Antibiotic use in pregnancy was higher in low educated women, and maternal antibiotic use during lactation was higher after an instrumented delivery in hospital. Antibiotic use in the infant was higher when they had older sibs or were born in hospital, and lower in those who had been longer breastfed. After adjustment for these factors, the differences in antibiotic use between the alternative and conventional groups remained. The results suggest that an alternative lifestyle is associated with cautious antibiotic use during pregnancy, lactation and in children.Alternative lifestyles are likely to be associated with distinct usage of specific medicinal products. Our goal was to find out whether the intake of antibiotics during pregnancy and by children differs according to whether the mothers have alternative or conventional lifestyles. Therefore, we investigated the use of antibiotics by pregnant women and by children up to 11 years of age participating in the KOALA Birth Cohort Study. This cohort comprises two recruitment groups of mother–infant pairs, one with alternative lifestyles (selected via organic food shops, anthroposophic clinicians and midwives, anthroposophic under-five clinics, Rudolf Steiner schools and relevant magazines,  Lifestyles perceived to be distinct from those of the majority of people are often called “alternative lifestyles”. Such lifestyles are frequently supported by underlying ideologies and may influence daily practical decisions, such as those concerning school choice for children, diet composition and use of conventional or complementary medicine therapies and medications. Whereas medications from complementary medicine are likely to be frequently used, conventional medications, especially if perceived as problematic, are expected to be avoided.Antibiotics are among the most useful but also most problematic medications. Whereas their use in the treatment of bacterial infections has had a markedly favorable impact on public health, this success is clouded by the worryingly increasing spread of antibiotic resistance. According to the WHO , antibiAntibiotics are the most frequently used medication among children worldwide ,4,5,6,7.The KOALA Birth Cohort Study is a prospective cohort study of mother–infant pairs in the Netherlands with two distinct recruitment groups: one with conventional lifestyles and the other with alternative lifestyles . The aimAs depicted in There were several indications that women in the alternative lifestyle group had lifestyles that differed from the conventional one. First, they more often adhered to certain living rules  and anthroposophy (14.3% vs. 0.1%)) than the women in the conventional lifestyle group. Secondly, they more often actively chose to consume organic food (87.3% vs. 20.8%) and biodynamic products (73.2% vs. 7.2%).From the beginning of the pregnancy until week 34, a higher percentage of women in the alternative group reported genital Candida infections (22.7% vs. 14.1%) and oral aphthae (12.9% vs. 8.0%) than the conventional group. After the third month of pregnancy, a higher percentage of women in the conventional lifestyle group reported diarrhea and urinary infections see . SimilarPregnancy duration was similar in the two groups (39.6 vs. 39.5 weeks), whereas neonates in the alternative group were on average slightly though statistically significantly heavier at birth than those of the conventional group (3582 vs. 3487 g).p = 0.026). In the last month of pregnancy, the antibiotics use was lower (2.9% vs. 4.4%) and the difference between the two groups was not statistically significant (p = 0.144). After delivery, a significant difference was found between both groups in the use of penicillin or other antibiotics during breastfeeding (p = 0.003): within the alternative group, 9.8% (44/447) of the breastfeeding women used antibiotics; in the conventional group, 15.5% (252/1631) did so.As shown in Given the distinct maternal demographic and lifestyle characteristics in the alternative and conventional lifestyle groups see , we set p = 0.052). The difference in antibiotic use between the conventional and alternative groups was relatively small between 3 and 7 months of age , but it increased over time from 7 months to 2 years of age  as the outcome variable (yes/no) in the periods covered by the questionnaires. The numbers of subjects may differ slightly from the baseline table due to a few missing values in covariables. ORs with 95% CI were used. Statistically significant results are printed bold. Breastfeeding was included as a continuous variable in months up to the end of the age period, e.g., for age periods 4–7 breastfeeding ranged from 0 (never breastfed) to 7 months (breastfeeding up to and including the 7th month). The ORs were multiplicative; for instance, the OR of 0.92 per month of breastfeeding translates to 0.92^3 = 0.78 for a contrast between 3 and 0 months. The same is true for a contrast between 7 and 3 months of breastfeeding, which would agree with about a 20% lower risk of antibiotic use, and 0.92^7 = 0.56 for a contrast between 7 and 0 months of breastfeeding, agreeing with about a 40% lower risk of antibiotic use .From the age of 6 to 11 years, the number of antibiotic treatments decreased with age in both lifestyle groups, even though, within the alternative group, a slight increase in antibiotic use could be observed for the ages of 8–11 years see . Fewer cTaken together, our data show that pregnant and breastfeeding women, as well as children, in the alternative lifestyle group generally used antibiotics less often than in the conventional lifestyle group. Interestingly, the differences between the two groups with regard to maternal antibiotic use were significant during pregnancy and breastfeeding and continued in their offspring from the beginning, increasing up to age 6–7. Thereafter, the difference was attenuated. Use of penicillin followed the pattern of the remaining antibiotics, except at age two, when use of penicillin was similar in both lifestyle groups. Among the children, the number of antibiotic treatments per person-year was lower in the alternative group than in the conventional group.The KOALA Birth Cohort Study is being carried out in the Netherlands, a country with one of the lowest frequencies of antibiotics consumption worldwide . AccordiThe main limitation of the present analysis was the lack of information on children’s health outcomes and complications/hospitalizations. Moreover, it would also have been interesting to add information on how physicians who were consulted by participants in the two recruitment groups worked; for instance, how much time they invested in patient care, how many patients they saw per day and how much communication with the parents/caregivers occurred per infectious syndrome.The higher educational level of the alternative group mothers could have contributed to the lower antibiotic use for themselves and among their children. A Danish cohort study showed that the prevalence of antibiotic use was higher among mothers with a lower level of education . Similarconditio sine qua non for–the use of anthroposophic medicine. This type of medicine (see below) advocates prudent use of childhood vaccination and antibiotic use to favor the development of natural immunity to infections in children ?”; thereafter, a distinction was made between treatment with penicillin and treatment with other antibiotics. The text on penicillin-only treatments was: “Penicillin for strep throat or skin infection ”; the text on other antibiotics was: “Antibiotic treatment for other infections or inflammations such as ear infection, bladder infection etc. ”.Descriptive data on the alternative and conventional groups were analyzed using descriptive statistics with the IBM SPSS Statistics 25 statistical software; the results were presented as numbers and percentages. The baseline measurement was available for 2834 respondents in total, of whom 2343 were from the conventional lifestyle recruitment group and 491 from the alternative lifestyle recruitment group. Numbers and percentages of the two groups were compared by categorical variables on the use of antibiotics during pregnancy, breastfeeding and oral treatment of the child. In total, 18 outcome variables related to antibiotic use were analyzed. Furthermore, several demographic, lifestyle and health-related characteristics of the alternative and conventional recruitment groups were analyzed as independent determinants.p < 0.05. Logistic regression was used to estimate the OR for antibiotic use, comparing the alternative and conventional lifestyle groups, without and with adjustment for the possible confounders. The KOALA cohort study has a long follow-up period and not all respondents participated in the study for the same amount of time. To take this into account, person-years were used to calculate the number of antibiotic treatments given to the respondents. For the period from 3 months to 12 months, one antibiotic treatment was assumed; for children aged 2 years to 11 years, the number of antibiotic treatments  was available. The time period corresponding to the antibiotic intake consisted of the number of months until the questionnaire on the child’s antibiotic use had been returned.Differences between both recruitment groups were evaluated by Chi-square test and analysis of variance for continuous and categorical variables, respectively. Statistical significance was set at


The use of DL-methionine (MET) in poultry diet formulation is vital for poultry growth because poultry do not synthesize sufficient amounts of MET needed for proper growth and performance, and currently there are insufficient natural sources of MET to fulfill the dietary needs of broiler chickens. However, the use of MET is restricted in the United States in organic poultry diets. Therefore, the objective of this study was to examine the effect of feeding different levels of dietary MET on organic broiler live performance and yield of a modern commercial broiler strain. This study gives us insight into how broiler growth and yield is affected when the allowable levels of methionine for organic broilers is further reduced, or zero methionine is used.p < 0.01) feed conversion ratio (FCR) at day 46/48 than broilers fed 0.5 g MET/kg. Broilers without supplemental MET had the worst (p < 0.01) feed conversion and average daily gain (ADG) at day 46/48. Birds fed 0 g MET/kg of feed had lower (p < 0.05) whole eviscerated carcass without giblets (WOG), yield than birds fed 2 g MET/kg of feed. Additionally, birds fed 0 g MET/kg of feed had lower (p < 0.05) breast fillet and tender percent yields than birds fed supplemental MET. Elimination of MET from organic broiler diets resulted in reduced ADG, breast fillet yield and feed efficiency of meat yield of broilers raised to day 46/48. Reduction in MET supplementation below current levels reduced the efficiency of meat production of organic broilers raised to day 46/48.This study was designed to evaluate the effects of dietary supplemental DL-methionine (MET) on live performance and meat yield for broilers raised to a common weight. A total of 1552 one-day old Ross 708, sexed broilers were randomly distributed to 32 pens resulting in eight treatments (TRT) of four replicates with 44 male or 53 female/pen. A randomized complete block with a 2 × 4  factorial arrangement of TRT was used. A common weight of 2400 g was approached by day 46 (1 and 2 g MET/kg feed) and day 48 (0 and 0.5 g MET/kg feed). Supplementation of MET at 1, and 2 g/kg had a lower ( Methionine (MET), a sulfur containing amino acid, is considered an essential amino acid in poultry because poultry cannot naturally synthesize sufficient amounts to sustain normal body functions . MET is Diets with very limited or no amounts of synthetic MET can result in reduced performance and production which would result in low economic returns in both organic and conventional poultry production . NaturalThere is currently no single formula, resolution or feeding plan that has the potential to completely eliminate the use of non-natural MET in organic poultry . Due to Due to recent changes to allowable organic poultry methionine levels, it is important for the industry to continue to investigate natural methionine supplementation sources. Therefore, this study was designed to examine the effect of varying levels of dietary MET on organic broiler live performance and yield. This study is novel because it explores a treatment with no added dietary methionine to shed light on what raising organic broilers would be like without industrial sources of methionine, with primary focus on the effects on performance and yield.The animal experiment was conducted in accordance with the recommendations and guidelines of the University of Maryland Eastern Shore Institutional Animal Care and Use Committee (AUP-Timmons-2021-4) and agreed with the standards for experiments held by the research farm.2 per bird with 16 pens containing 44 males per pen and 16 pens containing 53 females per pen. Pen density was 26.4 and 32.2 kg/sq. m for male and female chicks, respectively. Each pen was blocked based on room location and considered an experimental unit. Broilers were allocated at hatch to respective pens and fed one of the four MET diets in a three-phase feeding program . The dietary treatments were 0 g (0%), 0.5 g (0.05%), 1.0 g (0.1%) and 2.0 g (0.2%) MET per kg of feed. Birds fed the 0 and 0.5 g MET/kg diets were raised to 48 d of age to approach a common target weight of 2.72 kg (6 lb) for all TRT. The dependent variables measured included BW, FCR, feed consumed or feed intake (FI), livability (Liv), average daily gain (ADG), yield, proximate analysis of the meat, plasma total antioxidant capacity, and relative feed efficiency. The basal corn-soybean meal diet was formulated to meet or exceed the NRC (1994) requirement for maximum growth performance, except MET.The study was conducted at a commercial research farm in Maryland. A total of one thousand five hundred and fifty-two (1552) sex-sorted day-old Ross 708 chicks were used in this study. The experimental design was a randomized complete block with a 2 × 4 factorial arrangement of TRTs (2 sexes × 4 MET levels) with four replicates per TRT. Birds were placed in 32 pens approximately 1 ftad libitum and birds were raised on reused litter to a depth of five cm. The house temperature was controlled by a thermostat and maintained at 31 °C for the first week and then decreased and maintained at 27 °C to the end of the trial. The lighting program was 24 h of light and three-foot candles for days zero to seven and from day eight to processing, there were eight consecutive hours of darkness and 16 h of consecutive light using 0.75-foot candles. Similar management conditions  were provided to all replicates.The study was conducted in a closed-sided poultry building with a concrete floor with 48 square feet per pen. Males and females were raised in different pens. The broilers were reared in suitable pens under the same managerial, hygienic and environmental conditions. Pens were equipped with two plastic hanging feeders and automatic water drinking stations per pen. Feed and water were offered Broiler chicks were vaccinated against Marek’s, Newcastle, infectious bronchitis and Bursal diseases. Chicks were group weighed by pen before placement. Birds were raised from day 0 to 46 or 48 depending on desired end weight. Birds were fed diets with DL-methionine (MET) . The three feed phases used in this study were the starter phase (0–21 days), the grower phase (22–35 days), and the finisher phase (36–46 or 36–48 days). Ingredients, calculated nutrients, and analyzed nutrients in the three-phase feed are presented in Feed samples were analyzed in the lab using the AOAC 994.12/985.28 method for amino acid profile  and the AOAC 923.01 method for sulfur. Energy  was analyzed using a modified Atwater calculation, consisting of carbohydrates by difference and by the following tests: Ash AOAC 942.05, fat AOAC 920.39, fiber AOAC 978.10, moisture AOAC 930.15 and protein AOAC 990.03. The basal diet was provided by a commercial poultry feed mill.Approximately 0.45 kg of litter was collected from each pen weekly and analyzed for moisture and pH levels as described in . The ammonia readings of the litter were collected inside each floor pen using an RAE LP-1200 piston hand pump and calorimetric gas detection tubes  following the manufacturer’s protocol.g for 10 min, plasma samples were collected and stored at −80 °C for further analysis.Blood samples were collected on day 45 to evaluate the effects of methionine on antioxidant capacity in live birds using oxygen radical absorbance capacity (ORAC). Two milliliters of blood were collected from the wing and vein of two broilers, randomly selected from each pen (64 samples) by venipuncture into EDTA-coated tubes. After centrifugation of the blood samples at 1500× On days 46 and 48, 320 birds were randomly selected (10 birds per pen), weighed and wing-banded for processing. On day 46, the 160 birds in the TRT groups receiving 1 and 2 g of MET per kg of feed were processed while the 160 birds receiving 0 and 0.5 g of MET per kg of feed were processed on day 48.Birds were euthanized and processed using commercial processing methods. Whole eviscerated carcasses without giblets (WOG) were drained and chilled for about 2 h in a static chiller and later stored in a walk-in refrigerator at 5 °C overnight.g. The hexane layer (top layer) was removed and another 800 µL of hexane was added and mixed again for 3 min. Once again, the mixture was allowed to stand for 2 min and then centrifuged again for 5 min at 14,000× g. Using nitrogen gas, the remaining hexane was evaporated. The mixture was mixed with 800 µL of 0.5 M perchloric acid for 3 min before being centrifuge at 14,000× g for 5 min. The super natant was collected and sored at −20 °C for the total antioxidant capacity (TAC).Plasma (200 µL) was mixed with 400 µL of ethanol and 200 µL of water for 3 min. Then, 800 µL of hexane were added and mixed for 3 min. The mixture was allowed to stand for 2 min before being centrifuged for 5 min at 14,000× Proximate analysis  of raw breast meat samples was also conducted. Protein, ash, and moisture contents were determined using the Association of Official Analytical Chemists methods . Lipid analysis was conducted using Folch methods described by Ahn et al. (1995) .Yield measurements were harvested manually (deboned) at a commercial deboning plant. After the WOG weight was obtained, the carcasses were cut into drumsticks, thighs, boneless thighs, wings, breast skin, deboned breast fillet, and tender. A weight was obtained for each part. The WOG yield was calculated as a percentage of the fasted live weight. The parts yield was calculated as a percentage of the chilled WOG weight.p < 0.05.Data for all variables were analyzed by two way analysis of variance (ANOVA) with the model including the main effects of sex, methionine level and their interaction using the general linear model of Statistix version 9.0 . Tukeys all-pairwise comparison test was used to determine mean differences among treatments. Significant differences among treatments were determined at a probability of An analysis of feed efficiency (FE) of yield parts was conducted to evaluate the efficiency of converting feed to yield meat parts. The feed efficiency was analyzed by first calculating a feed efficiency for each part by dividing the feed consumed by the mass of each “yield part” (Equation (1)).The mass of each “yield part” is calculated by multiplying the body weight of birds from day 46/48 MET Level main effect by the percent yields of each “yield part.” (See Equation (2))The feed efficiency of each part is then compared relative to feed efficiency at the standard treatment of 1 g MET/kg feed (FER). The comparison of feed efficiencies is calculated first by calculating the average feed efficiency for each part at 1 g MET/kg. The average feed efficiency at 1 g MET/kg feed for each part is then divided by the feed efficiency of each part and multiplied by 100 to give a percent relative feed efficiency (Equation (3)).p > 0.05) interactions between sex × MET level on live performance parameters for all phases. Supplementing MET to the diets promoted bird growth. Birds fed diets with 0 g supplemental Met/kg had lower (p < 0.05) BW when compared to birds fed diets with supplemental MET levels at day 21 and 35 and when compared with birds fed 0.5 g MET/kg at day 46/48. These results demonstrate that supplemental MET contributes to body weight gain. MET helps with metabolism and in synthesizing the proteins that contribute to muscle, organ and feather formation, all which contribute to BW.Broilers have differing requirements for growth, performance and yield depending on age, breed, and gender. Ross broiler nutrition specifications for conventional broilers raised to 2.50–3.00 kg target live weight states the total methionine requirement for maximum weight gain, feed and feed efficiency are 0.56, 0.51, 0.47, and 0.44% for starter grower, finisher one and finisher two, respectively. Additionally, the total methionine + cysteine requirements for Ross conventional broilers are 1.08, 0.99, 0.90, and 0.85%, respectively, for starter grower, finisher one and finisher two. In this study the focus was on organic broiler nutritional requirements, which are much lower than the requirements for Ross broilers for growth, performance and meat yield in terms of methionine. The live performance results are provided in In an experiment by Chattopadhyay et al. (2006), they found that broilers fed 10 g of DL-MET/kg diet supplementation for 0–21 and 0–42 days had significantly higher BW than the control group for the same periods. The group with 10 g of herbal MET/kg diet supplementation had no significant increase in BW, while when herbal MET supplementation was increased to 15 g/kg diet there was significant improvement in BW for day 0–21 and day 0–42 compared with the control. These results demonstrate that lower levels of DL-MET than natural MET sources  are required to improve the BW of broilers. The results of the current study suggests that by day 46/68, feeding higher levels of DL-MET resulted in improved body weight.p < 0.001) BWG, FI, and better FCR compared to a basal diet with 0 MET supplementation [Majdeddin, et al. (2019) reported that increasing the levels of MET with cysteine levels the same across all groups  requirements), medium (at TSAA requirement), and high (0.4 g/kg above TSAA requirements)) improved growth . Agostinentation . Thirty entation .Rubin et al. (2007) supplemented a broiler basal diet with 0.31, 0.51%, and 0.66% MET at day 21 and found that birds fed the lowest MET level had significantly less BW than the birds fed the two higher levels of MET . Once agMulyantini et al. (2010) indicated that an increase in digestible MET  significantly increased the BW of birds at 21 days of age . Ahmed aApart from supplemental MET, reduced crude protein in broiler diets may result in negative growth performance . The crup < 0.01) than female broiler throughout the trial  than the WG of females from placement to day 42 [The result of the present study agrees with findings by Hernández et al. (2012) in a study where the weight gain (WG) of male broilers was higher  indicated that increasing digestible MET levels significantly improved the FCR of birds at 21 days of age . A reducp < 0.05), indicating that 2 g MET/kg of feed in the diet enabled the broilers to utilize their feed more efficiently than birds fed 0 g MET/kg of feed. Furthermore, the results seem to suggest that the birds should be fed different levels of MET at different phases.At day 35, there was a significant difference in feed efficiency between broilers fed 0 g MET/kg of feed and those fed 2 g MET/kg of feed (p ≤ 0.05) FCR than birds fed 2 g MET/kg diet at day 35, and at day 46/48, birds fed the 0 g MET/kg diet had the highest FCR and birds fed the 1, and 2 g MET/kg diets led to lower (p < 0.01) FCR than the FCR of broilers fed 0.5 g MET/kg. Other studies have exhibited the same trend of improved FCR with increased MET supplementation beyond day 21. Several researchers including Halder and Roy, (2007), Rubin et al. (2007) and Ahmed and Abbas, (2011) have reported improved FCR with MET supplementation [The birds fed the 0 g MET/kg diet had higher  FCR compared with the FCR of female broilers  FI than birds fed 1 and 2 g MET/kg diets. Ribeiro et al. (2005) reported no change in FI due to MET supplementation [In this study, by day 46/48, birds fed 0.5 gMET/kg diet had higher  than female broilers throughout all the growth phases. The results from this trial are in agreement with studies by Taha et al. (2011). These researchers reported that male broilers of three strains consumed significantly more feed than the females [There were significant differences in FI based on sex . Male br females . Male brp < 0.05 less than the percent moisture of the litter from pens raised with birds fed the 0 g MET dietary TRT at day 21. The litter moistures from the 0.5 g and 2 g MET groups were not significantly different from 0 g MET (The litter moisture from the pens fed the 1 g MET/kg dietary TRT was  0 g MET .p < 0.01) litter percent moisture than birds fed either 0.5 or 1 g of MET/kg of feed  observed no significant difference in the litter moisture at day 42 , which iThere were no significant effects of MET levels or sex and there were no significant interactions on the contents of ash, moisture, lipid and protein in breast meat . There wp < 0.01) between broilers fed 2 g of MET and 0 g of MET/kg of feed. In this study, the highest level of supplemental MET increased the WOG yield. It was anticipated that there would be an increase in WOG yield with increasing MET supplementation and that the WOG of male broilers would be higher for all treatments. It may be difficult to predict or note differences in WOG. The breast fillet is of more significance because it is directly tied to muscle accretion. The WOG includes other parts of the broilers (besides the breast fillet) for which there may be various factors at play with regards to growth, development and metabolism of those parts.MET has been reported to improve performance as well as increase meat yield ,12,33,34In contrast, Corzo et al. (2005) studied the effects of AA density on carcass trait yields at day 56 and found no significant effect of diet on WOG percentage . Althougp < 0.05). The results of the current research reveal that the percent breast fillet was affected by feeding different levels of DL-MET. There was a direct relationship between the breast fillet percentage and MET since as MET level increased, breast fillet percentage also increased. In short, MET supplementation improved breast meat yield.The percentage of breast fillet from birds fed the 0 g MET/kg TRT was significantly lower compared to the percentage of breast fillet from birds fed the 0.5, 1 and 2 g MET/kg . There wSupplemental MET increases breast muscle . IncreasSchutte and Pack (1995a) reported that the requirement for TSAA, including MET for high breast meat yield, is greater than the requirement for high BW . Based op < 0.01) breast meat fillet percentage compared to the breast meat percentage from male broilers  compared to the tender percentage from broilers fed 0 g MET/kg of feed (3.81%) (p < 0.001) in the diets, and it was also reflected in the significant (p < 0.001) difference in weight gain between concentration groups [The tender percentages from the broilers fed the three highest levels of supplemental MET were significantly higher ( (3.81%) . Supplemn groups .p < 0.01) percentage of drumsticks than female broilers  found that there were considerable benefits for feed cost per kg broiler weight or per kg breast weight when birds were fed a diet supplemented with digestible DL-MET . The FE In conclusion, it took two extra days for birds fed 0 and 0.5 g of MET/kg of diet to attain a weight closer to those fed 1 and 2 g of supplemental MET/kg of diet. This shows that if the USDA further reduces the synthetic organic broiler MET requirement for growth and yield, more time will be needed for raising the birds, leading to extra labor and production costs. These added costs will be passed on to the consumer. Birds fed diets with supplemental DL-MET level had better results in FCR at the end of the trial. MET supplementation increased the ADG. Birds fed 0.5 g/kg had higher BW than birds fed diets with no added MET. These performance results show the important role that methionine plays in organic broiler diets. As a result, the use of DL-MET could increase muscle accretion resulting in more yield. Methionine has an immune function and can affect feathering and many other metabolic functions, and it has many potential effects on broiler health. Efficiency is sacrificed with the elimination of supplemental levels of DL-MET, which can lead to increased monetary and environmental costs of organic meat production. Agencies should critically review the overall benefits of DL-MET when making decisions, especially the decision to eliminate industrial sources of MET. This research is necessary because it demonstrates how industrial methionine is essential to the poultry industry, contributing to producing broiler meat at optimum efficiency.


METproto-oncogene (MET) or the expression of programmed cell death protein 1 ligand (PD-L1) is common. Herein, we investigated the relation between MET gene amplification and PD-L1 expression in patients with advanced NSCLC and no other actionable oncogenic driver . Our retrospective observational study analyzed data from 48 patients  admitted to the Germans Trias i Pujol Hospital, Spain, between July 2015 and February 2019. Patients presenting MET amplification showed a higher proportion of PD-L1 expression  and overexpression  than those with non-amplified MET. PD-L1 expression was not significantly different when analyzed by sex (p = 0.624), smoking history (p = 0.429), and Eastern Cooperative Oncology Group Performance Status (p = 0.597) Overall survival rates were not significantly affected by MET amplification (high and intermediate amplification vs low amplification and non-amplificated) (p = 0.252) nor PD-L1 expression (> vs =< 50%) (p = 0.893). In conclusion, a positive correlation was found between MET gene amplification and PD-L1 expression and highly expressed (above 50%) in patients with NSCLC and no other actionable oncogenic driver. It could be translated as new guided-treatment oportunities for these patients.Non-small cell lung cancers (NSCLC) are the most common type of lung cancer and can be classified according to the presence of mutually exclusive oncogenic drivers. The majority of NSCLC patients present a non-actionable oncogenic driver, and treatment resistance through the amplification of the  EGFR) (10–15%) followed by rearrangements in anaplastic lymphoma kinase (ALK) (3–7%) and ROS1 (1–2%) genes [Cancer represents a heavy burden for society as a whole, with a high medical, economic, and psychosocial impact. Lung cancer is one of the most common cancers and has the highest death toll among them; 20% of all cancer-related deaths are attributed to lung cancer . The vasse (ALK) –7% and R%) genes , 5.MET proto-oncogene (MET), also considered an oncogenic driver [MET can either be activated through MET gene amplification, with a prevalence of 1–5%, or exon 14 skipping mutations, occurring in around 3% of NSCLCs [MET is c-MET, whose ligand is the hepatocyte growth factor. Excessive c-MET activation in advanced cancers can cause tumor cell proliferation, motility, migration, and invasion [MET gene amplification, preventing tumor growth, proliferation, and dissemination [On the other hand, the emergence of treatment resistance is unavoidable . In casec driver , 7. In Ninvasion . Therapimination . In addimination . In sevemination , 12. Themination .EGFR [ROS1 rearrangement [ALK mutations [MET gene amplification up-regulated PD-L1 expression, especially correlating with PD-L1 overexpression—considered as such for a tumor proportion score > 50% [MET amplification and PD-L1 expression in advanced NSCLC patients presenting no other actionable oncogenic driver other than MET.Several studies have proven that PD-L1 expression is correlated with wild-type EGFR , 14, 15,angement , while iutations . Besidesre > 50% , 15. HowMET gene amplification and PD-L1 expression in patients with advanced NSCLC and no other actionable oncogenic driver . We also analyzed the difference in PD-L1 expression according to sex, Eastern Cooperative Oncology Group Performance Status (PS), and smoking history of our studied population. Finally, we aimed to establish the effect of PD-L1 expression and MET gene amplification on the survival rates of our cohort.Therefore, the main aim of this study was to investigate the relation between MET/CEP7 ratio, i.e., amplified MET. Positive PD-L1 expression was found in 27 (54%) patients, among which 19 (38%) showed high—over 50%—expression levels, i.e., PD-L1overexpression. In 2 (4%) patients PD-L1 was not possible to determine; hence, our analyses were performed on a total of 48 patients.The baseline characteristics of our cohort are summarized in MET (93%) than among those with non-amplified MET  (MET (64%) than among those with non-amplified MET . However, most patients did not overexpress PD-L1  (A higher proportion of positive PD-L1 expression was found among patients with amplified < 0.001) . Likewis29, 62%) .p = 0.624), smoking history (p = 0.429), and PS (p = 0.597)  . HoweverMET  was not statistically significant from those with non-amplified MET    of our cohort was 16.3 months  . The dif= 0.252) . Likewis= 0.184) .MET gene amplification and PD-L1 expression in patients with NSCLC and no other actionable oncogenic driver . Indeed, although the absolute numbers were the same, the proportion of patients expressing and overexpressing PD-L1 was higher among those with amplified MET.To the best of our knowledge, this was the first study to show a positive correlation between MET amplified and non-amplified groups, but these proportions were invariably higher in those exhibiting MET amplification. The correlation between MET amplification and PD-L1 expression has been previously studied in NSCLCs with other actionable oncogenic drivers, especially EGFR-mutation. The retrospective study abovementioned found that PD-L1 expression was correlated with MET amplification in proportions close to ours [MET gene amplification was significantly associated with PD-L1 expression [in vitro study with cells resistant to erlotinib [MET amplified patients and demonstrated a positive correlation between MET amplification and PD-L1 expression [The baseline characteristics of our NSCLC cohort showed, as expected, a predominance of the male sex, current or former smokers, and adenocarcinoma. The ratios found in our study for positive PD-L1 expression (52%) and overexpression 36%) were in agreement with those reported previously on 791 NSCLC patients (63% of PD-L1 positive and 30% of overexpression) . Likewis to ours . Also, ipression . Besides% were inpression .Globally, more than 80% of lung cancers in men and almost 60% in women are caused by tobacco smoking . TherefoMET amplification showed no statistically significant impact in OS, in contrast with previous studies [MET positivity or amplification, which lack consensus, and in the number of patients with stage IV tumors; in those patients, MET amplification did not further impact the OS [MET (38.0 months) groups displayed a non-negligible difference, but the small size of our sample precluded statistical confirmation of this result. Although PD-L1 has been found to be a poor prognosis factor [The OS of our cohort was in line with those reported for NSCLC patients with no actionable oncogenic driver . However studies –27. Thist the OS . Howevers factor , 16, we s factor –30. ThisMET gene amplification in patients with advanced NSCLC and no other actionable oncogenic driver. However, we were limited by the small sample size available and the inherent constraints of a retrospective study. In addition, the absence of a general consensus on cut-off values for MET amplification compelled us to use arbitrary ones. Therefore, we urge the community to arrive at this most needed consensus and to undertake prospective and large studies to validate or refute the results here described.The main strength of our study was the homogeneity of the sample, which allowed, for the first time, to study the correlation between PD-L1 expression and MET gene amplification and PD-L1 expression and overexpression in patients with NSCLC and no other actionable oncogenic driver. In our study, PD-L1 expression was not affected by sex, PS, or smoking history, and PD-L1 expression and MET gene amplification did not affect the OS rates of our cohort. Further studies are needed to appraise the impact this finding may have on possible treatments for these patients.In conclusion, a positive correlation was found between Grupo Español de Cáncer de Pulmón). The SLCG is an independent cooperative group formed mostly by oncologists and counting more than 500 members. In 2015, the SLCG decided to start a nationwide multicenter epidemiological study aimed at ascertaining the characteristics of lung cancer cases, their treatments, and survival, in an effort to offset the existing lack of information caused by the absence of a cancer registry with national coverage. Current regional registries barely cover 30% of the Spanish population and only exist in some particular regions. The TTR was opened to all Spanish hospitals and the first patient was enrolled in August 2016. The recruitment is still ongoing with more than 75 hospitals taking part. The methodology group of the SLCG designed specifically an electronic questionnaire to be used by the TTR. The information from all participants was entered through an electronic questionnaire by clinicians. The questionnaire had different sections: 1) demographic data ; 2) detailed history of tobacco use; 3) lung cancer characteristics at diagnosis (including a full list of possible symptoms); 4) all treatments received (with detailed information on each); 5) presence of specific mutations in driver genes at diagnosis; 6) disease progression; and 7) survival data.This was a retrospective observational study carried with data recorded in the Spanish Thoracic Tumor Registry (TTR), a National Registry of lung cancer cases managed and sponsored by the Spanish Lung Cancer Group (SLCG) .This study used data from patients admitted to the Catalan Institute of Oncology Badalona Germans Trias i Pujol Hospital between July 2015 and February 2019. We collected data recorded in the Spanish TTR from patients of our center. We included data from patients with advanced NSCLC and whose The TTR has been approved by the Clinical Research Ethics Committee of Puerta de Hierro University Hospital.MET amplification by fluorescence in situ hybridization (FISH) using the Zyto Light® SPEC MET/CEN 7 Dual Color Probe. Briefly, we deparaffinized 4-μm-thick paraffin-embedded tissue sections and processed them with the Histology FISH Accessory Kit (Dako). After pretreatment and enzymatic digestion according to the manufacturer’s instructions, we codenatured slides for 4 min at 85°C and hybridized them overnight at 37°C on a Hybridizer (Dako). Following hybridization, we removed coverslips and washed slides at 65°C for 2 min in 2 X SSC/0.3% Tween-20. After dehydration in a graded ethanol series, we counterstained samples with fluorescence mounting medium containing 4′,6-diamidino-2-phenylindole (DAPI). Finally, we scored hybridization signals in at least 20 non-overlapping nuclei.We evaluated MET amplification. Several approaches based either on gene copy number, the ratio of MET to chromosome enumerating probe against chromosome 7 (CEP7), or a combination thereof have been proposed [MET/CEP7 ratios: not positive (< 1.8), low (≥ 1.8 to ≤ 2.2), intermediate (> 2.2 to < 5) and high amplified (≥ 5). Accordingly, we classified our samples with MET/CEP7 ratio ≤ 2.2 (not positive or low) as non-amplified MET and those with MET/CEP7 ratio > 2.2 (intermediate or high) as amplified MET.No consensus exists on the most appropriate diagnostic cut-off point for proposed . In our proposed , who catWe processed tissue slides in a BenchMark ULTRA platform instrument  and stained them with SP263 antibody, which we prediluted according to the manufacturer’s instructions. Following the established recommendations, we quantified the percentage of cells with membrane positivity  for each tumor. We did not assess tumor necrosis areas and discarded cases in which at least 50 viable cells were not available . We detep < 0.05.We described categorical variables as absolute frequencies and percentages and continuous variables as median and ranges. We compared categorical variables using the chi-square test. We calculated OS from the date of diagnosis to the date of last follow-up or death. We conducted survival analysis with the Kaplan-Meier method and we compared differences among groups and subgroups with the log-rank test. We set the statistical significance level at


This work presents a microwave reflectometry-based system for monitoring large concrete structures , through the combined use of punctual and diffused sensing elements. In particular, the adoption of punctual probes on a reference concrete specimen allows the development of an innovative and accurate calibration procedure, useful to obtain the value of the water content on a larger structure made of the same material. Additionally, a wire-like diffused sensing element can be permanently embedded in buildings and used to monitor the structure along the entire length of the sensing element. The adopted diffused sensing element can be used not only to detect dielectric variation during the curing process, but also throughout the service life of the structure. The combined use of punctual and diffused sensing elements represents an important innovation from a procedural point of view, able to provide detailed and quantitative information on the health status of the structure both during and after construction. Construction 4.0 indicates the digital transformation of the construction sector, and it includes the introduction of digital solutions to build faster, cheaper and smarter monitoring solutions for maintenance and prognostics ,6,7,8,12As well known, the hardening phase begins immediately after setting, with a series of physical and chemical interactions between cement and mixing water and this phase is considered completed within the first 28 days, period when an accurate monitoring is essential. A premature removal of formworks may lead to an insufficient strength of the structure and to the presence of cracks, ultimately leading to the collapse of the entire structure ,14. ConcOn the other hand, an ex-post monitoring through an embedded low-cost diffused sensing element can be able to promptly detect deterioration of the structures, due to age or environmental loads as floods, for example in the case of dams .Starting from these considerations, in this paper, an innovative, real-time, low cost, with portable instrumentation concrete monitoring technique based on microwave reflectometry is proposed, through the combined use of diffuse sensing elements and punctual probes. The goal of the proposed method is twofold: (1) an ex-ante monitoring of concrete curing with PCPs and a specific calibration procedure; and (2) an ex-post monitoring, carried out through diffuse sensing elements, for the detection of dielectric anomalies as a result of degradation or stress of the structure.With regard to the ex-ante monitoring, in fact, concrete exhibits good performance throughout the service life of the structure when the concrete curing proceeds correctly and completely. For this reason, an innovative and accurate calibration procedure (to be performed in each specific application case) becomes a key element in the concrete curing process, allowing to assess the water content value of the structure by simply considering that of a concrete specimen. Additionally, there are special cementitious compounds that employ additives that reduce the setting time of concrete, for very fast constructions. In these cases, the water content is a useful parameter to consider when analyzing the quality and setting status of concrete.On the other hand, the continuous ex-post monitoring through permanent, diffuse sensing elements can give early indications of structural problems. In this way, thanks to the detection of electrical impedance variations or dielectric variations caused by degradation phenomena through the diffuse sensing elements, safety measures can be considered in time, and intervention on the structure can be performed immediately.The present work is organized as follows. The properties of concrete are often examined through stress and compression resistance tests on core samples extracted from the structure. Materials are analyzed through techniques to destroy them, which could also cause damage to the concrete building, which is an unintended option. In recent years, the focus is mainly on non-destructive strength evaluation techniques ,17, whicAt the current state of the art, calorimetry represents the standard method to monitor the hydration process of concrete: in fact, the hydration balance of cement is exothermic, and for this reason, hydration can be monitored by measuring the heat released by means of an isothermal calorimeter ,19,20. TBased on these considerations, this work proposes an innovative strategy based to microwave reflectometry for monitoring concrete curing. In particular, a dual sensor system with diffuse sensing element (d-SE) and punctual coaxial probes (PCPs) was used for the intended purposes. The punctual detection is used to identify a calibration procedure using a reference concrete specimen. This procedure allows to relate the data collected in the frequency range of interest to the value of water content. A dedicated algorithm was developed in order to employ the calibration procedure carried out on the specimen, even on the large structure from which the specimen was extracted. This aspect is particularly important because structures of large dimensions cannot be weighed or subjected to the gravimetric procedure: the adoption of a dedicated algorithm that exploits PCPs on a reference concrete specimen allows to circumvent this limit. As an additional detection capability, a long diffused wire-like low-cost sensing element, permanently embedded in buildings, is used to get feedback along the entire profile of the structure and to detect possible dielectric variations both during the curing process and also throughout the service life. The combined use of punctual and diffused can provide detailed and quantitative information on the state of hydration and health of the structure. Ultimately, a broadband and low cost reflectometric system using both PCPs and d-SEs with strategic methodological procedure was validated.Microwave reflectometry is an electromagnetic (EM) measurement technique, employed for a number of diagnostics and monitoring applications. While one of the major application fields remains soil moisture content monitoring ,30,31,32In microwave reflectometry, an EM test signal is propagated through a sensing element inserted in the system under test (SUT). As a result of the dielectric interaction with the SUT, the test signal is partially reflected towards the measuring instrument. Through the analysis of the reflected signal and through an application-tailored processing, it is possible to retrieve the desired information on the SUT .Microwave reflectometry-based measurements can be performed either in time domain (time domain reflectometry—TDR) or in frequency domain (frequency domain reflectometry—FDR). Depending on the specific application, one approach may be more suitable than the other. In this work, a combined method is used: in particular, TDR technique is used with d-SEs and FDR technique is used with PCPs.In TDR measurements, the EM stimulus is usually a step-like signal that propagates along the SE, through the SUT, and any impedance variation, generally due to changes in dielectric properties, causes the partial reflection of the propagating signal. The reflection coefficient The quantity FDR is often used for the characterization of the dielectric behavior of materials. FDR measurements are generally carried out by connecting the sensing element to a vector network analyzer (VNA), which is used to measure the reflection scattering parameter, c errors ,38.For the validation of the proposed monitoring system, two structures were prepared from the same concrete mix: (1) a beam with dimensions 300 cm × 25 cm × 25 cm; and (2) a cubic specimen with sides 15 cm. As mentioned in the One PCP was used in the specimen and one in the beam. As detailed later, the PCP in the specimen allowed us to obtain a calibration curve from measurements on the specimen, which could later be used for on-site measurements. On the other hand, the PCP in the beam was used to verify that the MR response of the specimen was consistent and in accordance with the specimen results.Generally, d-SEs can be permanently embedded in buildings, structures, infrastructures at the time of construction, and they are capable to return a response based on diffuse dielectric characteristics of the structure, also particularly useful for early identification of destructive phenomena.From As described later in The nanoVNA is a compact, low-cost VNA (dimensions 15 cm × 10 cm × 6 cm), with 50 kHz–3 GHz frequency range. One of the advantages of FD measurements is the possibility of carrying out a preliminary calibration procedure through measurements on standard electrical loads , thus allowing to reduce the influence of systematic errors. To this purpose, a preliminary calibration procedure was carried out on each of the PCPs, before inserting them in the concrete samples. The calibration data were stored in the software of the miniaturized VNA thus compensating for each daily measurement.The TDR200 is a low-cost, portable TDR measuring instrument, with approximate dimensions 22 cm × 5 cm × 11 cm. The TDR200 generates a step-like voltage signal, with a 200-ps rise time, which corresponds to a frequency bandwidth of approximately 1.7 GHz.It is important to mention that the presence of steel in the concrete beam did not affect the investigated method and the measurement results; this was also verified through specific full-wave simulations carried out through CST Microwave Studio software (not reported here for the sake of brevity).The overall experimental procedure is outlined in The first step required us to measure the The second phase of the procedure outlined in Finally, the The During the observation period, the Each lbox see , in ordeTo demonstrate that the calibration surface obtained from the specimen could also be used for the beam monitoring, it was important to verify that the frequency behavior found on the reference cubic specimen was consistent with that of the beam. To this purpose, during the 28-day observation period, FD measurements were carried out also through the PCP inserted in the concrete beam, as shown in As mentioned in N is the number of frequency points. Through a Matlab routine, we singled out from the calibration surface the moisture content values, Let us suppose that we wanted to assess Then, the algorithm calculated the average of the moisture content values obtained from the previous step:Then, from the calibration surface , as reported in TDR measurements were carried daily throughout the observation period. It should be mentioned that the abscissae aluation . As can From each daily TDR reflectogram, the apparent length of the d-SE, ed using . Employied using , the corThe final step, as shown in the flowchart in It should be mentioned that in The d-SEs are also particularly useful in the identification of degradation phenomena occurred ex-post along the structure, thanks to their ability to immediately identify a dielectric variation in correspondence of an incipient failure. In this case, alert mechanisms could also be used to promptly intervene in case of incipient cracks.Mechanical tests on the beam were carried out for validation purposes of ex-post concrete strength monitoring. The tests were conducted to analyze whether the diffuse sensor cable is sensitive to mechanical deformation. The beam was subjected to several tests with concentrated weights varying from 1000 kgf to 9000 kgf, with an increase of 1000 kgf at each test. More specifically, the beam was tested under four-point bending with a net span of 2.8 m and a shear span of 0.95 m. Load was applied by means of a 100-ton hydraulic jack connected to a manual pump and recorded with a 30-ton load cell. During the mechanical test, also TDR measurements were carried out on the d-SE. As explained in These mechanical tests highlighted how the diffuse sensing element could detect any degradation phenomena in time, for accurate ex-post monitoring of the strength and health of the concrete.In this work, a combined punctual and diffused approach for smart monitoring of concrete structures was presented. The use of punctual sensors on a reference concrete specimen allowed to implement an innovative procedure for extrapolating the water content of large structures, based on measurements carried out on small specimens. This is particularly useful for allowing accurate monitoring of the hydration process of concrete structures. While pouring the concrete mix for a building, in fact, it is easy to use the same concrete mix to obtain a small sample on which to perform the needed measurements and the gravimetric procedure (not feasible on large concrete structures). Hence, a dedicated algorithm was developed to relate on-site measurements to a water content value using the calibration surface obtained from the specimen having the same dielectric properties as the structure to be monitored.Finally, the simultaneous use of d-ES also allows to monitor ex-post the large concrete structure throughout its service life, both in terms of water content and possible mechanical deformation.Future work will be dedicated to the comparison with other traditional measurement techniques and to the possibility of relating the water content data to the strength properties developed by the structure during the hydration period.


Since the 2000s, French authorities have put in place various national plans to make the general public aware of antibiotic stewardship. Twenty years later, France is still one of the countries with the highest use of antibiotics in Europe.Our study explored the general public’s perceptions of antibiotic resistance, their behaviour around antibiotic use and their expectations regarding awareness campaigns.A qualitative study was performed from March 2018 to March 2019 in a French region using focus groups. Two types of public were targeted: parents of young children and retired people. The interview guide contained open-ended questions organized around three main themes: perceptions of antibiotic resistance; experience and use of antibiotics; and health information and campaigns.Nine focus groups were created, including 17 parents and 19 retirees. Participants did not link antibiotic overuse and antibiotic resistance. Antibiotic resistance was not perceived as a personal responsibility but as a suffered phenomenon on which the participants could not act. The blame was particularly put on the presence of antibiotics in the environment. Although participants expressed trust in their GPs, antibiotics remained perceived as the only solution for them to be cured quickly.The study highlighted that the GPs were the preferred information source regarding the use of antibiotics. Actions targeting the public and health professionals will have little impact if, at the same time, efforts on work environment representation are not undertaken. In France, the health authorities have implemented national action plans for 20 years, all including interventions to raise awareness among the general public.,,,,,,,To target and evaluate antibiotic stewardship actions, various studies have been conducted to explore general public perceptions of antibiotic resistance.,While it can be assumed that fighting antibiotic resistance requires the public to be more informed about the risks of antibiotic misuse, ultimately promoting behavioural change, current data tend to show that campaigns targeting the general population are necessary but not sufficient.The objective of the present qualitative study was to explore the general public’s perceptions of antibiotic resistance, as well as their attitudes around antibiotic use and their expectations regarding awareness campaigns.,To best answer our research objective, a qualitative approach was chosen. We opted for the focus group (FG) technique as it allows collection of a broad variety of ideas, opinions and beliefs on a specific topic.FGs were organized with parents of young children and retired people, two populations consuming more antibiotics than the rest of the general population.Recruitment modes were diverse. Parents were recruited either through primary schools or sports’ clubs where parents often stayed to watch their children during the training. Retired people were recruited through cultural and recreational groups. The first contact was always an e-mail sent to the institution  explaining the study’s objectives. Once the agreement for organizing an FG in the institution had been received, researchers spent time during activities to invite parents/retired people to participate in the FG. FGs were held at the activity’s venues and at one participant’s home for one parent FG. All but one FG were conducted in Nancy, a middle-sized city in Northeastern France, with one FG organized in Paris. All FGs took place between March 2018 and March 2019 and were planned for a 40 to 60 min duration.FGs followed an interview guide constructed around three main themes: perceptions of antibiotic resistance; attitudes around antibiotic use; and expectations towards awareness campaigns. The interview guide was created by F.C.  and reviewed by J.K. (a sociologist), C.P.  and N.T. (a pharmacist). The guide was tested during the first FG interview and no modification was made. Each FG interview was conducted by two researchers  with one leading the discussion and the other one taking notes.FG interviews were recorded after verbal informed consent was obtained and were transcribed. FG interviews were continued until data saturation was reached. Participation was voluntary and not compensated.Anonymized transcripts were analysed, once all FG interviews had been performed, using a comprehensive thematic analysis using QSR International’s NVivo 11 software. The analysis grid was constructed by three researchers ; each of the themes and subthemes were discussed within the research team until a consensus on a final list of themes was reached. Each FG was then coded according to the analysis grid.The study was completely anonymous at all stages and no information on the health of participants was collected. No ethical approval was thus required in accordance with French law.Thirty-six participants (19 retired people and 17 parents) were recruited while organizing nine FGs Table. Most paThree main issues emerged from data analysis: knowledge and perceptions of antibiotic resistance; the ambiguous approach to antibiotic prescription; and the social role of antibiotics.Illustrative verbatim quotations are listed in Table1.When asked about antibiotic resistance, most participants had never heard of it before. They had difficulty explaining the term and often resorted to their experience or one of a relative. In most FGs, the consequences of antibiotic resistance were not a concern and remained unclear and distant. The awareness obtained during the FG interviews about the severity of the situation was alarming for some participants. They were confused about the mechanism of antibiotic resistance, often described as the body becoming resistant. According to participants, overuse of antibiotics would lead to ‘habituation’: the bodies of individuals who took too many antibiotics would no longer respond to treatment. Another cause of ‘habituation’ could be the failure to comply with the prescribed treatment duration, which would allow the disease to return more strongly. Participants had an individual and bodily vision of resistance. They were positive one can build immunity, but antibiotic resistance cannot be transmitted from one person to another.2.When they tried to explain the main causes of antibiotic resistance, participants mentioned the presence of antibiotics in the environment, particularly linked to agricultural activities and water. The blame was put on farmers who irresponsibly give antibiotics to their animals and on people who did not properly dispose of their antibiotics, with these ending up in soil or water. Transmission between humans and the environment was perceived only in the direction of the environment to humans and was worrying.Antibiotic resistance was not felt as a personal responsibility but as a suffered phenomenon on which the participants could not act. The 2002 awareness campaign ‘antibiotics are not automatic’ was well accepted by all generations and mentioned by almost all FG participants. They perceived the message, however, as emphasizing the GP’s sole responsibility.Regarding their behaviour toward antibiotic prescription, participants made a distinction between the medical community, health authorities and their GP.Participants were particularly suspicious towards the medical community. Except for their family GP, ‘doctors’ were described as prescribers who did not take the time to come up with a proper diagnosis during the consultation. Participants distinguished the ‘old generation’ from the ‘new generation’. The new generation was described as more informed, prescribing only when necessary and performing diagnostic tests, unlike the ‘old generation’ who used antibiotics because it was quick and easy.Antibiotic awareness campaigns were seen as an attempt by the health authorities to decrease medication costs and the deficit of the French National Health Insurance. Cost reduction was viewed poorly, especially in a context where antibiotics enjoyed great popularity and were considered as an absolute necessity. Participants negatively saw the perceived priority set by the government on health budget cuts and its failure to consider the consequence of sick leave, which also has a cost. In addition, they were condemning the pressure exerted by health authorities on doctors to reduce their prescriptions.Despite their expressed mistrust of authorities, health agencies and the medical community, the participants expressed an entire trust in their doctors. They described their family GP as someone who understood them and ‘knew them’. They felt they could discuss the prescription with him/her but would respect their decision no matter what.1.Although some individuals admitted overusing antibiotics and requesting them when they were not recommended by their doctors, participants felt they had a good knowledge of their bodies and only took them when necessary. Indeed, in their expectations of being cured, they often felt frustrated if no antibiotics were given to them when they felt really sick. While they considered that they did not ask for antibiotics, many of them returned to see their doctor after 3 or 4 days if they did not feel better. Other participants expressed their surprise that no antibiotics were prescribed to them. The support provided by the doctor to the patient during the healing process was often synonymous with the prescription of an ‘effective treatment’ and antibiotics were frequently regarded as the treatment of choice. Antibiotics were perceived as a special treatment and the only solution for them to be cured quickly.2.When asked about the non-prescription of antibiotics, all generations of participants expressed concern about sick leave. Sick leave was negatively perceived and difficult to experience; staying at home to rest for a common infection without any ‘effective’ treatment was an idea badly accepted by participants. Although they were aware that antibiotics were not effective for viral infections, the need to be active—for parents to be at work, for retired persons to take care of their grandchildren or being able to do their activities—was again their main priority regardless of their understanding of antibiotic use. Some participants, in order to prevent consulting their GP, were prone to self-medicate or medicate their children. Leftovers of previous antibiotic prescriptions were then preserved and sometimes leftovers of different treatments were combined. Antibiotics were seen as the only solution to cure any infection quickly. If they were not prescribed, participants were expecting an alternative treatment.Participants had partial knowledge about antibiotic resistance and its mechanisms. Its consequences were not experienced as a concern or seen as a close threat and the predictions were considered alarming. Antibiotic resistance was not perceived as a personal responsibility.In their perception of antibiotic resistance stakeholders, they distinguished health authorities—whom they mistrusted—and the medical community—deemed to have little competence—from their family GP, whom they generally trusted.The idea of being powerless over their illness and having to wait for a spontaneous recovery was very frustrating and difficult to accept. Despite their knowledge of the ineffectiveness of antibiotics for viral infections, the need to stay active and their negative perception of sick leave led them to set up strategies to get antibiotics. Some participants returned to their doctors several times while others kept leftover antibiotics.,,,,,,Despite numerous awareness campaigns targeting the general population in France, participants had partial knowledge on antibiotic resistance. As described in many studies, participants thought it was their bodies that were becoming resistant, not the bacteria.,,,As is well described in the literature, antibiotics were considered as the miracle treatment and a validation of the severity of the disease.,,,Participants made a real distinction between the trust they have in their family GP, the suspicion towards the medical community and the disapproval of economic choices perceived to be driving health authorities. To the best of our knowledge this result had never been observed or reported. This may be explained by crises and health scandals having amplified distrust attitudes towards health expertise in France and in the rest of the world over the last few years.,Often seen as an effective treatment and a way to heal quickly, participants expressed that antibiotics constitute an effective treatment to avoid sick leave. Sick leave was negatively perceived and difficult to experience for participants, therefore leading to overuse of antibiotics. This reflects another societal issue: the relationship between work and health status. While there exists today abundant literature on how patients with chronic disease, disability or long-term illness may encounter difficulties and need to adjust to the work market—and possibly on how the work environment finds solutions to keep them at work—the question of sick leave for acute illnesses, to our knowledge, is poorly documented. However, our study results highlight the social pressure for French people to return to work as soon as possible, and for retired people in our sample to recover quickly to stay active, notably regarding family duties. The phenomenon of presenteeism is today known but often explored with regards to poor workers’ performance and mental health risks;The qualitative approach in this study was particularly appropriate; the FGs, through group dynamics and confrontation of points of view, permitted participants’ poor behaviour to be situated within their perception of antibiotics as miracle cures and antibiotic resistance as a distant threat. Identification and description of these perceptions and misconceptions will help target and implement specific interventions. However, the study presents some limitations. A possible selection bias cannot be excluded because: (i) those who agreed to participate are probably more knowledgeable about antibiotic stewardship than those who refuse; (ii) the sample had an over-representation of women, who are known to have better knowledge of antibiotics than men;Widely promoted these days, the notion of ‘One Health’ is becoming increasingly important for antibiotic resistance. The interviews showed that participants were very concerned about the presence of antibiotics in the environment and its consequences for their health. The participants’ interpretation of the presence of antibiotics in the environment (in particular in water), perceived to be mostly due to animal breeding, for example, was for them the main cause of antibiotic resistance. They denied their own involvement and responsibility for their suboptimal behaviour around their use of antibiotics. It is therefore crucial that awareness campaigns include a coherent One Health approach, to avoid misinterpretation and suspicion from the general public. This is all the more important since we are currently living in a context where one builds up a distrust in the authorities.Participants expressed their doubts and dissatisfaction with political decisions affecting their daily lives. Any development of public health interventions must consider that the population is distrustful from the outset. The current context and its implications on health policy interpretations will not be changeable through public health interventions.During the interviews, the need to be treated with antibiotics even in the case of viral infections highlighted an important drift of the idea ‘I can’t be sick’. Antibiotics are considered to be the miracle cure. Going home from the doctor, feeling very sick, without any antibiotic because the infection is viral, was unthinkable for the participants. Limiting the treatment to symptomatic medications is perceived as a lack of acknowledgement. Messages in awareness campaigns often associate viral infections with a benign and self-limiting illness. Asking individuals to be patient and to let the disease progress seems very poorly accepted. A spontaneous evolution of the disease towards healing over time, with a positive perception of the self-healing capacity of the body, are counterintuitive ideas as contemporary society leaves little place for disease and inactivity.Patients’ trust in their family GP has made them the ideal ambassadors for antibiotic stewardship. This privileged position is a double-edged sword. Many high antibiotic prescribers are not convinced they overprescribe. In turn, their patients are unaware of good prescribing practices and current awareness campaign messages are not very effective on them. It is therefore a priority to inform and train doctors, to assist them in changing their communication and prescribing habits, as they have an essential role to play.This study showed that antibiotic resistance was considered an emerging problem by French people. Awareness campaigns targeting the public should take into consideration the following key findings: GPs play a vital role in the communication around antibiotic resistance and should be part of a wider One Health approach. Furthermore, actions targeting the public and health professionals will have little impact if, at the same time, efforts on work environment representations are not undertaken.dlaa073_Supplementary_DataClick here for additional data file.


The dynamic response behavior of concrete is constantly concerned because of seismic, impact and explosion events in the service of constructions. As a classic device for testing the dynamic mechanical properties of materials, the splitting Hopkinson pressure bar was used to carry out dynamic splitting tests on concrete in this paper. The variation of the dynamic tensile strength against the stress rate was fitted by the incubation time criterion. The full-field strain distribution on the observed surface of the specimen at the crack initiation stage was obtained by the digital image correlation (DIC) method. Morphological characteristics of the fragmentized process of concrete specimens in splitting processes were obtained by combining the image processing techniques and the FracPaQ. The size distribution of fragments of concrete specimens was obtained by sieving. The results show that the strain concentration zone and crack initiation appear along the loading direction through the center of the specimen. The secondary cracks initiated occurred at the contact end of the specimen, which expanded along the strain concentration zone and then interacted with the main crack. At the early stage of crack extension, the main crack dominates the normalized length of fracture traces in the horizontal direction. The normalized length of the vertical fracture trace increases with the main cracks opening width and the expansion of the secondary crack. The relationship between the length and angle of fracture traces in the dynamic splitting process of concrete conforms to the Gaussian function. Finally, the fragment sizes decrease with the stress rates of impact loads. Concrete is a common construction material used in many applications, such as construction, underground engineering, military bunkers, etc. During the service period, concrete may be subjected to dynamic loads within a wide range of strain rates, including earthquake, impact and penetration, explosion and blasting, etc.  As a typ−1–104 s−1. Xia and Yao [Generally speaking, the dynamic properties of materials can be determined by the split Hopkinson pressure bar (SHPB), which can provide dynamic loads with strain rates in the range of 10 and Yao  introduc and Yao  suggest  and Yao . Zhao an and Yao  studied  and Yao  used the and Yao  conducteDIF) and strain rate [DIF and the strain rate into two parts, namely the equation below the strain rate threshold and the subsequent equation. After the inflection point, different formulas can be found in the literature to describe the variation of DIF with the strain rate. In the experimental study of Ross et al. [DIF of tensile strength of concrete changes linearly with the logarithm of strain rate, and there is a strain rate sensitive threshold at 1 s−1. However, Hao et al. recommend the use of bilinear [In the past, many researchers proposed several expressions to describe the relationship between concrete tensile strength  , a MATLAIn this paper, the mechanical behaviors of concrete in the dynamic splitting test are investigated. The stress wave signals collected by the dynamic strain gauge are analyzed, and the variation of the concrete dynamic tensile strength against the stress rate is observed. The strain field of concrete specimens at the initiation of cracking was obtained by high-speed image analysis with the DIC technique. Fracture traces generated by FracPaQ are used to quantify the morphological characteristics of concrete specimens in the splitting process. Finally, the split fragments of concrete are sieved, and the statistics and the influence of the stress rate on fragment size distribution are revealed.−3, a maximum particle size of 5 mm and a fineness modulus of 2.60 was used as fine aggregate. The mineralogical composition of the river sand includes (weight percent): quartz of 59.8%; amphibole of 24.3%; albite of 9.7% and other minerals of 6.2%. The tap water, the chemical composition of which includes: chloride of 70.8 mg/L; sulfate of 31.2 mg/L; nitrate of 8.81 mg/L; and some other components of <1 mg/L, was applied. Crushed stone with a particle size of 5~20 mm was used as coarse aggregate. The polycarboxylic acid superplasticizer  was used as a water-reducer. The proportion of concrete mix is shown in The raw materials used for concrete specimen preparation are as follows: the cement was ordinary Portland cement , and relevant parameters are shown in When the thickness of the disk specimen was about half of its diameter, the influence of the inertia effect on test results could be eliminated. Therefore, a cylinder with a diameter of Φ 100 mm and a thickness of 50 mm was selected for the dynamic splitting specimen. The static Brazilian test was performed on cylindrical specimens with the same size of Φ 100 × 50 mm. This method was widely adopted by researchers to characterize the dynamic properties of materials ,33. Sinc−1. In each group, three specimens were tested, and the average static compressive strength and tensile strength of concrete were 52.5 MPa and 3.0 MPa, respectively.With a TBM machine , static compressive and splitting tests were carried out as shown in The SHPB system mainly consists of a bullet, an incident bar, a transmission bar, a damper and a set of data acquisition systems, as shown in In the SHPB system , the bullet is driven by an air gun using compressed nitrogen. Then the bullet strikes the incident bar, producing a stress wave (moving to the right) in the incident bar. When the stress wave reaches the interface between the concrete specimen and the incident bar, a part of the wave is reflected back to the incident bar to generate the reflected tensile wave. The remaining wave passes through the concrete specimen and transmits into the transmission bar. These waves can be recorded by the strain gauges on the incident bar and transmission bar.D and B are the diameter and thickness of the specimen, respectively, and E and A are the elastic modulus and cross-sectional area of the compression bar, iε(t), rε(t) and tε(t) are the incident wave, reflected wave and transmitted wave, respectively.Gomez’s study  shows thThe DIC measurement technology  can calculate the displacement and strain information through the change of pattern or texture on the specimen surface. In the experiment, a speckle pattern with random gray distribution is required to be generated on the specimen surface, which is called a speckle field. Without affecting the mechanical behavior of the specimen, the speckle field varies with the deformation of the specimen . A speckX1, Y1) is the center coordinate of the first speckle,  and  are the center coordinate of the speckle in the speckle field with regular distribution and random distribution, respectively. a is the center distance of two speckles in the speckle field with regular distribution, and ρ is the duty ratio. The number of speckles n in the digital speckle field is related to the resolution A of the camera, which is determined by Formula (5). f(r) represents a pseudo-random function with an interval of , and r is a random factor with a range of .A digital speckle field is generated by controlling the number of speckles, the coordinates of the center of the circle and the radius of the circle. The digital speckle field is generated by Equations (2)–(5) :(2)Xi=2×r = 0.15, ρ = 0.4, d = 1.3 mm. The generated digital speckle field and the specimen containing speckle are shown in In general, when the resolution of the camera is certain and the speckle diameter, random factor and duty ratio are determined, a digital speckle field in the form of a random distribution vector graph can be generated according to Equation (3). After several comparisons, the parameters of digital speckle are The responses of concrete specimens S1 and S6 measured by the SHPB system under two different impact loads are shown in −1 can be obtained. The dynamic tensile strength of concrete is 9.64 MPa. Similarly, as shown in −1, the dynamic tensile strength of concrete is 23.64 MPa. In the process of dynamic loading, whether the specimen can achieve stress equilibrium is an important indicator for the validity of data processing. η is introduced. Its variation with time is used to reflect the loading state of concrete in the process of resisting impact load [σA represents the sum of stress at the incident end, i.e., iσ(t) + rσ(t), σB represents the stress at transmission end σt(t), then the expression of η is written as:The dynamic tensile strength of concrete is affected by the stress rate, which can be obtained from the stress time history curve. As shown in act load . σA repr−1, the stress wave reaches the stress equilibrium at 59 μs after repeated reflection in the specimen, and the stress equilibrium factor is approximately zero. When t = 225.6 μs, the stress equilibrium factor deviates from zero due to the curve fluctuation of σA and σB caused by the fracture of the concrete specimen. A similar phenomenon exists in the specimen with a loading rate of 423.1 GPa·s−1, but the difference is that the specimen loses stress equilibrium at 198.4 μs. Although the specimens lose their stress equilibriums at different times under the two loading rates, it could be seen that both specimens were in the unloading stage, which met the prerequisite conditions  of the SHPB experiment. Therefore, the experimental results are reliable. The contrast between As shown in The dynamic increase factor (DIF) is usually used to describe the increase in tensile strength of concrete materials at a higher loading rate, that is, the ratio of the dynamic strength to quasi-static strength, as shown in Equation (7):r in the material meets the following conditions:τ is the incubation time, which is the characteristic constant response to the load on the time scale and is not affected by specimen geometry, load pulse shape or loading mode. δ is a material constant, which is used to reflect the sensitive size of the material fracture zone, so it can characterize the characteristics of the fracture at a spatial scale. The function σ (integrand function) represents the gradient of stress eigenvalues in space and time. Different physical quantities can be selected according to different criteria, such as compressive strength and tensile strength. σ0 corresponds to the static critical strength of the function. Assuming that the stress field near the fracture point only depends on time, Equation (8) of the incubation time criterion can be simplified and rewritten as:According to the structural-temporal criterion proposed by Petrov , the faiIf Equation (9) is used to study the relationship between the critical strength of materials and the stress rate, it should be assumed that the stress growth of materials can be considered linear at a certain stress rate until the peak of failure stress is reached ,40. So, H(t) is the step function. Substitute the above equation into Equation (9), and the instantaneous peak stress can be obtained:In the formula, t* ≥ τ in Equation (11). For example, in the static process Obviously, for a low-stress rate, the instantaneous peak stress conforms to the condition The scattered points in The digital image correlation (DIC) technique is a non-contact method to measure deformation. The full-field strain of DIC analysis is based on pixel subset matching of the camera captured image. In order to capture the strain field before the macroscopic crack appeared, a high-speed camera was arranged along the direction perpendicular to the circular section of the specimen. Images can be captured at a frame rate of up to 80,000 fps (frames per second) with a resolution of 256 × 256 pixels. To avoid damage to the equipment caused by the projectile of concrete fragments, the specimen is protected in a recycling box containing a polymethyl methacrylate (PMMA) shield. The first frame was captured by a high-speed camera as a reference image for DIC analysis. The frame with no obvious stress fluctuation in the calculated results was defined as 0 μs. Generally, cracks that expand along the direction parallel to the loading diameter are called primary cracks, and cracks that originate and expand in other parts are called secondary cracks.−1, corresponding to the typical results of waveform curves in t = 175 μs and develops continuously along the diameter to the two contact points. In the process of strain concentration zone expansion, the crack starts and develops along the strain concentration zone, leading to splitting failure. It is worth noting that although strain concentration occurs at the two contact points, the main crack starts from the center, and the strain expands from the center to both ends, forming a strain concentration area. −1, which is a typical result of the waveform curve in t = 200 μs. With the increase of time, the high-strain area becomes larger and expands, and there is a strain concentration area with secondary at the end, as shown in It can be seen from As shown in Theoretically, for the direct tensile experiment, the tensile stress in the cross-section is a constant uniform field, and the geometric center of the disk is the only point that meets the tensile failure condition, and its value is equal to the uniaxial tensile strength. However, the compressive stress at the loading end is much greater than the tensile stress under plate loading, which may lead to collapse or shear failure at the loading end. In addition, crack initiation of concrete materials is also easy to appear in the pores, cracks or multiphase interface stress concentration of concrete disk specimens, so the location of crack initiation is relatively random. It can be seen that dynamic Brazilian splitting does not necessarily start from the center, and the position of initiation is closely related to the structure of the specimen.In the above section, the strain field of the specimen was observed by DIC technology before the visible crack appeared. The local high strain propagation process, to a certain extent, predicted the development trajectory of the crack in the subsequent dynamic loading process. With the opening of the main crack on the surface of the specimen, the secondary crack mainly caused by shear failure appears gradually at the contact point between the specimen and the pressure bar. The process of primary crack opening and secondary crack initiation and propagation in typical concrete splitting results is shown in −1. It can be clearly seen that the width of the main crack far from the specimen center is smaller than that of the main crack at the specimen center, indicating that the main crack expands and runs through from the specimen center to the loading point, which is similar to the failure characteristics of S1 specimen and is a typical failure characteristic of Brazil test. Shear cracks all occur after the main crack expands to the loading point, which is at the end of crack propagation and reflects the stress mutation. The crack propagation process of S1, S6 and S8 specimens indicates that the initiation location of secondary cracks is basically at the end of the specimen. After the primary crack cracks, the high level of stress region in the specimen extends to the end of the specimen, resulting in the edge cracking of the specimen and the secondary cracks. It can be considered that the secondary crack expands along the edge of the strain concentration zone from the end and then crosses and merges with the primary crack. Therefore, cracks near the center of concrete are mainly caused by tensile failure of the axial primary crack parallel to the loading direction, while other cracks are caused by shear failure of secondary cracks resulting from further compression. According to the main crack widths at different times, the average opening velocities of the main crack were 6.37 m/s, 10.89 m/s and 10.95 m/s, respectively, at the stress rates of 103.1 GPa·s−1, 423.1 GPa·s−1 and 428.3 GPa·s−1 in the observation period.Two types of cracks are generally observed from Based on the pixel information of binary images, FracPaQ can use the Hough transform method to find collinear patterns of pixels in the image and produce fracture traces. The fracture trace is a line segment whose endpoints are distributed along the crack contour. In other words, the cracks in the binary image are filled with fracture traces. The number and length of fracture traces can be influenced by adjusting the number of Hough peaks and the Hough threshold. y0 is the offset of the X-axis, xc is the center of symmetry, w is the width, and A is the amplitude.In order to further describe the fracture characteristics of dynamic splitting of concrete specimens, the length distribution of fracture traces at Y-axis deviation angle  of typical results under three stress rates were obtained, as shown in y0 also increases with the increase of time, and more and more scattered points are distributed under the curve, which indicates that the crack opening width is larger, and more fracture track lines are filled with the increase of time. This corresponds to the pattern shown in the rose diagram in Then, Equation (12) is used to fit the length scatter data of specimens S1, S6 and S8 at different times, and the fitting parameters are shown in −1 and 378.5 GPa·s−1, respectively. The fragments with an aperture of more than 20 mm show a typical dynamic splitting failure pattern. The S2 specimen is symmetrically divided into two parts, and the fracture surface is relatively smooth compared with the S5 specimen. When the stress rate is large and the crack expands in concrete and meets the aggregate particle, the crack does not change the propagation direction in the mortar matrix but directly passes through the aggregate particle. This results in the fracture of aggregate particles and a relatively straight section. The stress rate of the S5 specimen is higher than that of S2. Under normal circumstances, the section of the S5 specimen should be smoother. However, it can be seen from The typical failure pattern of the specimen in the dynamic splitting test is split into two halves along the loading direction. When the stress rate is large, there may be triangular failure zones at both ends of the specimen. However, visual estimates showed that the remaining fragments were too similar in size to discern a pattern. Therefore, a standard set of screens ranging in size from 0.045 mm to 20 mm were used to screen debris. P(x), which is the mass fraction of fragments passed through a sieve size of x:xmax is the maximum size (P(xmax) = 100%), x50 is the median size (P(x50) = 50%), and b is the fluctuation parameter. Volume-based particle size (x = V is the fragment volume) is often used to characterize irregularly shaped fragments in sieving analysis. The value of xmax can be determined by directly measuring the size of the maximum fragment. Since the specimen is mostly divided into two parts in the dynamic splitting test, xmax can be set as 50 mm.In order to describe the fragments size distribution of concrete specimens under different stress rates, the Swebrec function with three parameters  is used x50 under different stress rates is between 42 mm and 45 mm, with little difference. Due to the different distribution characteristics of concrete in the dynamic splitting test, the distribution rules are predicted based on the data points (11 data points) of the fine pieces (less than 20 mm). The screening data set and fitting curve are shown in (1)Based on the SHPB test results, the rate-dependent effect of concrete was determined by using the incubation time criterion, and the incubation time was 96.2 μs. The dynamic tensile strength enhancement is determined by the quasi-static strength and incubation time.(2)The DIC technique was used to obtain the full-field strain of the observed surface at the main crack initiation stage. In addition, multiple main cracks may appear to run through the specimen, and the time of the main cracks running through the specimen is consistent with the time of the stress balance factor curve deviating from zero.(3)By using image processing technology, the crack information of concrete specimens in the fracturing is extracted. According to the binarization results, the average opening velocity of the main crack increases with the increase of stress rate. The initiation of secondary cracks occurred at the end of the specimen, which expanded along the edge of the strain concentration area and then crossed and merged with the main crack.(4)The crack pixel information is converted into fracture trace coordinates by FracPaQ. At the early stage of crack initiation, the normalized length of fracture traces corresponding to the main crack in the horizontal direction is dominant. The normalized length of the vertical fracture path increases with the increase of the main crack opening width and the expansion of the secondary crack. The relationship between the length and angle of fracture traces of dynamic splitting specimens at each moment in the process of crushing conforms to the Gaussian function.(5)The Swebrec function was used to fit the sieving results of dynamic Brazilian concrete specimens. The results showed that with the increasing stress rate, the percentage of mass passing increased, which meant that the fragment size decreased with the increase of stress rate.In this paper, the SHPB system was used to carry out the dynamic splitting test on concrete under different loading rates. Based on the experimental results the incubation times of concrete specimens with 100 mm diameter and 50 mm high were determined, the deformation characteristics of the cracking initiation stage were revealed by the DIC technique, and the dynamic splitting failure process was described by the Gaussian function. The detailed conclusions are as follows: