Both glucagon-like peptide-1 receptor agonists (GLP-1RAs) and metformin (MET) have markedly antiobesity effects in overweight/obese polycystic ovary syndrome (PCOS) patients. However, there was no literature to compare the antiobesity effects of these two medicines. Therefore, a systematic review and meta-analysis were conducted in our present study to evaluate the antiobesity effects of GLP-1RAs either as monotherapy or combined with MET in comparison with MET alone in overweight/obese PCOS patients.  All randomized controlled trials (RCTs) which reported the efficacy of GLP-1RAs and MET in overweight/obese PCOS patients in Medline (from Pubmed), Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases were independently searched by two reviewers. The random-effect model was used to pool data extracted from the included literature. The weighted mean difference (WMD) and 95% confidence interval (CI) were used to present the meta-analysis results (PROSPERO registration number: CRD42020173199). N = 318, WMD = −2.61, 95% CI: −3.51 to −1.72, P ≤ 0.001, I2 = 77.5%), more obvious reduction of waist circumference , and body mass index (BMI)  in overweight/obese PCOS patients when compared with MET alone. Further sensitivity analysis demonstrated that the meta-analysis results of the efficacy differences in terms of body weight, waist circumference, and BMI were relatively stable and reliable.  A total of eight eligible RCTs were finally enrolled in our meta-analysis from the 587 retrieved literature. The results showed that GLP-1RAs alone or combined with MET was associated with a greater weight loss ( Our meta-analysis demonstrated that the antiobesity effect of GLP-1RAs alone or combined with MET  was superior to MET  alone in terms of weight loss, the reduction of waist circumference, and BMI. More large-scale, high-quality RCTs are needed to further confirm these results in PCOS patients. Polycystic ovary syndrome (PCOS) is the most common ovarian disorder in women of childbearing age. The incidence rate of PCOS varies from 6.1% to 19.9% among different populations and diagnostic criteria . PCOS isSince the etiology of PCOS is unclear, a healthy diet and physical activity are considered as the mainstay in current status. Besides, owing to the fact that there is a strong association between PCOS and dysglycemia, many hypoglycemic agents are used to manage PCOS women, showing an obvious improvement in terms of impaired glucose tolerance and impaired fasting glucose . MetformGlucagon-like peptide-1 receptor agonists (GLP-1RAs) are new drugs for T2DM, which can bind to GLP-1 receptors to promote insulin secretion and inhibit glucagon secretion in a glucose-dependent manner, resulting in the restoration of blood glucose control. The benefits of GLP-1RAs are the lower risk of hypoglycemia and cardiovascular disease than other antidiabetic agents , 18. GLPOur study was registered on PROSPERO (PROSPERO registration number: CRD42020173199).All randomized controlled trials (RCTs) which compared the efficacy of GLP-1RAs with MET in PCOS patients in Medline (from Pubmed), Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases were searched by two reviewers (LXR and LTB) independently from inception until October 2020. The following MeSH terms and relevant terms were used in the search process, including polycystic ovary syndrome, glucagon-like peptide-1 receptor agonist, exenatide, and liraglutide. The language of publication was not limited. The search strategy for Medline (from Pubmed) was presented in the Supplementary RCTs.2 and obesity as BMI ≥ 28 kg/m2 [The patients were overweight/obese premenopausal women diagnosed with PCOS by any recognized diagnostic criteria , 23. The28 kg/m2 .GLP-1RAs (exenatide or liraglutide) alone or combined with MET were compared with MET alone without dosages limitations. The trials that did not use MET as control were excluded.The primary outcome was weight loss. The secondary outcomes were the reduction of waist circumference and BMI. Studies without the primary outcome were also excluded. Any discrepancies between the two reviewers (LXR and LTB) were resolved by consensus with a third reviewer (GFY).The Revised Cochrane Risk of Bias Tool for Randomized Trials (RoB 2) was used by two reviewers (LXR and LTB) to assess independently the risks of the enrolled studies, including the aspects of the randomization process, the deviations from the intended interventions, the missing outcome data, the measurements of the outcomes, and the selection of the reported results .Two reviewers established a data extraction form and independently extracted the data from the selected literature. The extracted data focused on general information , participant characteristics , interventions , and predefined outcomes . For studies with missing or incomplete outcomes, the corresponding author of these papers was contacted for more information. For data in selected RCTs not presented as we expected, data conversation was performed according to the method recommended in the Cochrane Handbook.I2 test was used for the heterogeneity test. The random-effect model was used in all analyses regardless of the I2 value. The metaregression was adopted to explore the sources of heterogeneity. Further sensitivity analysis was conducted to assess whether the results of the meta-analysis were stable or not. P < 0.05 was considered to be statistically significant.Statistical analysis was performed using Stata 15.1 software. Since all outcomes were continuous variables, weighted mean difference (WMD) and 95% confidence interval (CI) were used to present the results. The The PRISMA  flow chart was used to show the process of the studies selection as presented in The characteristics of the enrolled studies were summarized in Tables μg BID) combined with MET (1000 mg BID) in one RCTs [The patients involved in these RCTs were all overweight/obese premenopausal women diagnosed with PCOS according to the revised Rotterdam criteria or National Institute of Child Health and Human Development criteria , 23. As one RCTs . MET . Further sensitivity analysis showed that removing anyone of the RCTs had little or no effect on the above result, as presented in Supplementary P=0.389, Begg's test: P ≥ 0.999).Eight RCTs had reported weight loss of GLP-1RAs alone or combined with MET in comparison with MET alone in overweight/obese PCOS patients as detailed in Tables N = 252, WMD = −1.93, 95% CI: −2.20 to −1.65, P ≤ 0.001, I2 = 0.0%). Moreover, the effect of GLP-1RAs combined with MET on weight loss was also more obvious than MET alone in overweight/obese PCOS patients .Next, a subgroup analysis was conducted by intervention regimens. The results showed that there was a greater weight loss effect of GLP-1RAs alone than MET alone in overweight/obese PCOS patients . Further sensitivity analysis showed that removing anyone of the RCTs had little or no effect on the above result, as presented in Supplementary P=0.078, Begg's test: P=0.452).Six RCTs had compared GLP-1RAs alone or combined with MET and MET alone in terms of the waist circumference reduction in overweight/obese PCOS patients as detailed in Tables N = 231, WMD = −3.36, 95% CI: −4.48 to −2.24, P ≤ 0.001, I2 = 20.1%). As expected, a similar result was observed in the comparison of GLP-1RAs combined with MET and MET alone in overweight/obese PCOS women .Next, the results of subgroup analysis by intervention regimens showed that the waist circumference reduction effect of overweight/obese PCOS patients treated with GLP-1RAs alone was more obvious than those who treated with MET alone . Further sensitivity analysis found that removing anyone of the RCTs had little or no effect on the above result, as detailed in Supplementary P=0.135), but was observed by Egger's test (P=0.004).Eight RCTs had reported the BMI reduction of GLP-1RAs alone or combined with MET in comparison with MET alone in overweight/obese PCOS patients as detailed in Tables N = 252, WMD = −0.86, 95% CI: −1.81 to 0.08, P=0.072, I2 = 89.6%). Similarly, no statistical difference of BMI reduction was also observed between GLP-1RAs combined with MET and MET alone .In addition, the results of the subgroup analysis by intervention regimens revealed that there was no statistically significant difference between GLP-1RAs alone and MET alone in terms of BMI reduction in overweight/obese PCOS patients (P=0.019), suggesting GLP-1RAs alone and GLP-1RAs combined with MET had different degrees of weight loss in comparison with MET alone in overweight/obese PCOS patients. A similar result showed that different population  might be one of the sources of heterogeneity in the meta-analysis of BMI reduction, suggesting the BMI reduction degree of GLP-1RAs either as monotherapy or combined with MET varied in different populations.The metaregression analysis was conducted to explore the sources of heterogeneity in meta-analysis of weight loss, the reduction of waist circumference, and BMI. The results showed that two different regimens in the intervention group might be one of the sources of heterogeneity in the meta-analysis of weight loss (regression coefficient = −2.68, 95% CI: −4.51 to −0.85, Our meta-analysis evaluated the antiobesity effects of GLP-1RAs either as monotherapy or in combination with MET in comparison with MET alone in overweight/obese PCOS women. The results indicated that GLP-RAs alone or combined with MET were associated with greater weight loss and a more obvious reduction of waist circumference and BMI when compared with MET alone.As stated in our introduction section, overweight/obesity is a common phenotype in most PCOS patients, and a 5%–10% weight loss can bring obvious benefits in terms of metabolic symptoms and fertility . MET is Abdominal obesity is extremely harmful to PCOS patients and hence waist circumference reduction is also an important indicator for evaluating the antiobesity effects of these two medicines . It was BMI reduction is also considered a secondary outcome for a comprehensive assessment of the antiobesity effects of these two medicines in overweight/obese PCOS patients. Most of our selected RCTs indicated that both GLP-1RAs and MET had a significant effect of reducing BMI in PCOS patients, with the former having a greater effect –31. Our In terms of safety, differences in terms of adverse event incidence between GLP-1RAs or combined with MET and MET alone were not evaluated in our study. However, Lamos' review  showed GTo the best of our knowledge, this was the first systematic review and meta-analysis which comprehensively evaluates the antiobesity effects of two regimens—GLP-1RAs alone or combined with MET and MET alone in overweight/obese PCOS patients. Our meta-analysis showed that GLP-1RAs combined with MET was a better choice for PCOS patients who had a poor response to GLP-1RAs alone or MET alone in terms of weight loss. Moreover, PCOS patients' race should be taken into consideration in the clinical use of GLP-1RAs in order to have a better effect in terms of BMI reduction. However, this study also has some limitations. First of all, the selected RCTs in the meta-analysis of weight loss degree and BMI reduction degree had considerable heterogeneity. Despite the significant heterogeneity of those studies, sensitivity analysis showed that the results of the above meta-analysis were relatively stable and reliable. Secondly, Egger's test showed that there might be a potential publication bias in the meta-analysis of BMI reduction degree. However, the number of RCTs recruited in our study was small, so the significance of publication bias was limited. In addition, there were different definitions of overweight/obesity in the included studies, which might have an impact on our results.Taken together, our meta-analysis provided evidence that the antiobesity effects of GLP-1RAs alone or combined with MET were superior to MET alone in terms of weight loss, reduction of waist circumference, and BMI. However, the sample size is selected RCTs was small, and most of the RCTs were of moderate quality. More large-sample, high-quality RCTs are needed to further confirm these results in overweight/obese PCOS patients in the future.


Since waste tires constitute a serious environmental concern, several studies are devoted to the use of finely divided recycled rubber for the production of rubberized concrete by partial substitution of the mineral aggregate fraction. The introduction of rubber into concrete presents several advantages . Unfortunately, the addition of a high content of rubber into concrete causes an important loss of mechanical resistance of the final composite. In this context, several scientific studies are devoted to investigate the best technical solutions for favoring the interfacial adhesion between rubber and cement paste, but the interpretation of the literature is often misleading. To overcome this issue, the metadata extrapolated from the single scientific works were critically re-analyzed, forming reference diagrams where the variability fields of the different rubber concrete formulations  were defined and the best performances discussed. This study evidenced the twofold role of reference diagrams, able in both presenting the data in an unambiguous manner (for a successful comparison) and providing the guidelines for future works in this research field. Along with human activities, the solid waste increment in landfills opened a Pandora’s box related to the end-of-life waste management, prompting worldwide researchers to identify the best technologies for favoring waste disposal and (if possible) their recycling, aiming at environmental and economic sustainability ,4,5,6,7.In this context, the possibility of partially substituting the mineral aggregate (sand and gravel) fraction in concrete with recycled tires crumb rubber is a technical solution that is extremely appealing, as it leads to cement-based composite materials that can have significantly improved ductility, tenacity, impact resistance and thermal/electrical/acoustic insulation capacities . AdditioDespite the many benefits given by the introduction of rubber in concrete, a significant reduction of both the mechanical resistance and specific mass has been registered. These side-effects are attributable not only to the different mechanical response of the rubber component compared to the mineral aggregates, but mainly to the poor interfacial adhesion between the rubber element with the cement paste ,24, whicNevertheless, promising mechanical properties (mostly the increased toughness) encouraged the evaluation of structural performances of rubber concrete where high resistance to dynamic stress is required, such as in the case of earthquake-resistant structures . HoweverIn the current literature, rubber concrete is presented with very different formulations that are sometimes improperly compared. In fact, the literature suggests that typical parameters affecting the mechanical response of rubber concrete are (i) the rubber content (expressed either as aggregate substitution level or as volume/weight percentage), (ii) the granulometry of both the substituted mineral aggregate (coarse or fine) and the added rubber, (iii) the introduction of additives  and (iv) the quantities of all components within the formulation and the water-to-cement ratio, (v) the effects of appropriate pre-treatments  and surface functionalization (or coatings) of the rubber to favor the interface interaction with the inorganic matrix (cement paste).In this study we aim at improving the ease of comparison between the different procedures, formulations and strategies that are currently employed to improve the properties of rubber-containing concrete. We provide a rational evaluation of the experimental results reported in the literature, first by building a reference diagram that shows the variability of mechanical response of different rubber concrete formulations. Then, we evidence the effect of different approaches used in the published literature on the final properties of rubber concrete. The final goal is to provide a preliminary assessment tool (to be adopted in future research) that allows a rapid estimation of the mechanical behavior of the produced material relative to the performance of current state-of-the-art tools.Some works focused on the use of end-of-life tires have been selected from electronic databases , others from the recent review by Roychand et al. .A list of studies focused on the mechanical properties of different rubber concrete formulations was produced. From the initial list, 46 publications ,65,66,67The selected case studies were further analyzed in depth by verifying the effective relevance of their content with the aim of this study. Following this exclusion principle, 11 publications ,38,39,40After this preliminary screening, the publications effectively analyzed in this study were 27. Since, in some cases, more than one series of samples per publication has been considered, detailed acronyms have been adopted to unequivocally recognize a specific data series in the reference diagrams. To simplify the comprehension (and the readability) of the diagrams, The main relevant mechanical test for evaluating the mechanical response of concrete is the evaluation of the compression strength. All the case studies considered present compression strength results, with most following ASTM C39/C39M  as the rThe first step in the analysis was the extraction of numerical values from the compression tests of each publication. In some cases, such values were not directly reported in the text, but graphically represented in a diagram. To extrapolate the numerical values from plots and graphics, the software WebPlotDigitizer 3.8  has been employed. x-axis and the y-axis do not present comparable data.The data extracted from the selected publications were plotted in Considering the compression strength, it is evident in The effect of the control concrete value is very evident, but also the differences in the declared substitutions have a profound effect on the lack of clarity of The revision of the stated formulation pointed out a significant inconsistency among the analyzed papers in the mode to declare the reference quantities. Hence, all the declared formulations were analyzed case-by-case in order to obtain the principal components of the mix design and the characterizing parameters . In most cases, in fact, the percentage of substitution did not refer unequivocally to the total volume of the aggregates, but it preferentially refers to a type (or portion) of aggregate . To guarantee uniformity in the data interpretation, the substitution level in the composites was “normalized” by referring always to the total volume of aggregates present in the control mixture.3, which cannot be used to quantify the volume substitution.Additionally, the vis-a-vis revision of the selected publications revealed a further remarkable inconsistency that affected the data interpretation. In fact, some authors chose the weight parameters as either specific weight or bulk density. Moreover, the choice of these parameters for every formulation was different case-by-case, often showing inconsistent values, thus making the numerical values here extrapolated extremely wide and difficult to compare. For instance, Youssf et al. , series To overcome this issue, the composition of the formulations that were not clearly defined or outside a reasonable range was further recalculated by using, for the specific weight, the average value of all the studies where the data were clear and consistent with literature values. These weight parameters are reported in Therefore, the aggregate content and the relative volumetric percentage of substitution with rubber were recalculated for all compositions using, when needed, the reference values reported in Despite this, it is important to notice that the analyzed formulations still show a considerable variability of the components used, namely (i) type of cement paste and aggregates adopted, (ii) presence/absence of additives, fly ashes, slags, silica and other additional components and (iii) amount and proportion of each component within the concrete formulation. For all these reasons, even after this consistent data homogenization, resulting case studies still present a significant degree of heterogeneity. However, at the end of this elaboration process, all case studies are coherent among each other. y-axis becomes 37% and is no longer 100% as in By using the diagram presented in The reference diagram relative to compression tests  clearly In general, the data described in In order to rationalize these trends, the diagrams were further analyzed, studying specific aspects of the formulations reported in the literature that could have beneficial or detrimental effects on the mechanical properties of the rubber concrete. Another important parameter that could affect the rubber concrete performance is the type of aggregate that is substituted—fine, coarse, or both—and it is reported in However, it is very interesting to study in bigger detail the effect of the substitution of the different size fractions on the mechanical properties. In most cases, the coarse aggregate was replaced with coarse rubber and the fine aggregate with fine rubber, but there are cases where different sizes were used for the substitution. In the 2A  and in tIn In order to rationally unveil the reason why some particular case studies present better mechanical responses than the others, here we reported a brief technical analysis of the best formulations selected. Additionally, on the basis of the reference diagrams proposed in this study, a critical analysis of the formulations and of the boundary conditions has been reported, with the aim of better understanding and proposing new guidelines for favoring the development of high-performance rubber concrete.Among the different case studies here analyzed, the three series proposed by Najim et al.  and TopçThe results obtained by the series from Zheng et al.  It seems that the substitution of the aggregate with a larger fraction of rubber is not effective ,47, whil(ii)Prior to proceeding with the addition of water, the cement paste, the mineral aggregates and rubbers should be premixed to favor the homogeneous dispersion of the components within the final composite .(iii)As pointed out by He et al., Liu et al. and Sgobba et al. ,24,50, t(iv)Lastly, using a high-performance cement as matrix can significantly reduce the loss of mechanical properties for high substitution degree of the mineral aggregate fraction ,63,65,67Given the graphs of reference, some points are evident to obtain good mechanical results for high percentages of substitution of the aggregate.Quite recently, several efforts were realized for trying to minimize the anthropogenic impact on the natural environment, and promising results were obtained in term of sustainability. Among the different classes of human-derived technological wastes, end-of-life rubber tires caught the attention of worldwide experts since, from one side, they are potentially dangerous for both environment and human health if normally landfilled or thermally converted, whereas from the other side they can be extremely appealing if re-processed to produce useful products. In this context, the possibility of partially substituting the mineral aggregate fraction in concrete with recycled rubber tires to produce cement-based composite materials with significantly improved toughness, impact resistance, and thermal/electrical/acoustic insulation capacities is an exceptionally promising solution. Unfortunately, this solution presents some technical limitations, such as the decline of the composite mechanical resistance at high content of rubber.On the basis of the most recent results reported in the literature, we reported here a literature survey coupled with a critical analysis of the metadata extrapolated from scientific papers. Reference diagrams showing the variability fields of the different rubber concrete formulations in terms of mechanical responses as a function of the rubber content were presented and best performances  critically discussed. This study evidenced the twofold role of reference diagrams able to i) present the data in an unambiguous manner (for a successful comparison) and ii) provide the guidelines for improving the interaction between rubber and cement paste. Results obtained pointed out the importance of i) correlating the crumb rubber size with the one of the relative mineral aggregate fraction that has been substituted, ii) premixing the solid elements for homogenizing the final composition, iii) pre-treating the rubber prior to use in the composite and iv) selecting a cement paste able to guarantee a reduction of the loss of mechanical properties in the final composite. Additionally, this study evidenced also how it is important to use a common language in science for a correct interpretation of the data. Therefore, in order to significantly reduce any misleading conclusions, authors hope that the approach here proposed will be extendedly adopted in the future.


Antibiotic resistance is a major public health concern, accelerated by antibiotic overuse. Inadequate knowledge among the public has been associated with inappropriate use of antibiotics. This study determined the impact of a self-developed educational leaflet for addressing specific knowledge gaps in antibiotic use among the public.This was an experimental study conducted at five hospitals and 20 primary health care clinics in the state of Perak. Adults over 18 years of age were recruited using sequential sampling. The first phase of data collection consisted of a pre-intervention assessment, an educational session, and an immediate post-intervention assessment. Each educational session was conducted by trained pharmacists and lasted approximately 15 min for each participant. A two-week post-intervention assessment was then conducted via a phone call to re-assess the participants using the same questionnaire.p < 0.001).Out of 300 questionnaires distributed, 234 were completed for our study. The mean age of participants was 40.7 ± 14.6 years old. Most of the respondents were female , Malay , and had tertiary education . A mean score was generated for each domain, with knowledge towards antibiotic resistance: 2.83 ± 1.28 pre-intervention, 3.76 ± 0.62 immediate post-intervention, and 3.67 ± 0.78 two-weeks post-intervention ; knowledge towards antibiotic use: 2.03 ± 1.56 pre-intervention, 4.56 ± 1.46 immediate post-intervention, and 4.32 ± 1.48 two-weeks post-intervention ; perception towards antibiotic use: 2.83 ± 1.38 pre-intervention, 4.25 ± 1.06 immediate post-intervention, and 4.22 ± 1.02 two-weeks post-intervention . Significant improvement in the mean scores were found before and after intervention in all domains (The educational leaflet was able to address salient knowledge gaps in the participants and remained sustainable over a two-week follow-up. Thus, its inclusion into future antibiotic awareness campaigns should be encouraged. Over the decades, escalation of antimicrobial resistance has resulted in it becoming a global public health concern. The World Health Organization (WHO) defines antimicrobial resistance as the ability of a microorganism to resist an antimicrobial drug that was initially effective against it . Misuse Consequently, common infectious diseases have resulted in greater morbidity, prolonged treatment, increased cost, and eventually more death . RecentlThe Malaysia National Medical Care Survey 2010 reported that upper respiratory tract infection (URTI) is the most commonly presenting illness in Malaysia, making up more than a quarter of primary care encounters, resulting in a consultation rate of 29.6% . Half ofStreptococcus pneumoniae  were included in the final analysis. Respondents’ demographic characteristics and background experience were reported in a descriptive manner. A chi-square test was used to explore the association between demographic characteristics and the level of knowledge. Multiple linear regression analysis was performed to identify significant predictors of the total knowledge score. McNemar’s test was performed to analyse the difference between Pre and P1, P1 and P2, and Pre and P2. Repeated measures ANOVA was employed to measure changes in re-intervention and post-intervention mean scores.There were 300 respondents recruited and 234 respondents (78%) who completed the study were included in the final analysis. Among them, a majority were Malay , female  and university graduates . The mean age was 40.7 ± 14.6 years. A quarter of respondents  declared having previous exposure to an antibiotic awareness campaign while half of the respondents  reported having a family member working as a healthcare professional. A total of 213 respondents (91.5%) claimed that they had taken antibiotics at least once in their lifetime with 46% of them (98/213) reported to have taken antibiotics less than once a year and 20 respondents (8.5%) claimed to be antibiotic-naïve (Table p = 0.030).Out of the 213 respondents who had been exposed to at least one antibiotic in their lifetime, 18 admitted that they had initiated an antibiotic treatment on their own without consulting a doctor. Those with previous exposure to antibiotic campaigns have a lower tendency to self-medicate  when compared to those without prior exposure to the campaigns . Correct responses to statement KR4  also increased significantly at the two-weeks post-intervention assessment  . Notably, only 9.8% (Pre: 23/234) respondents were able to identify the types of conditions that can be treated using antibiotics. There was a significant improvement after the educational intervention   understood that antibiotics could not treat viral infections. Significant improvement was observed after the educational intervention . There was also an increase in concern about the impact of antibiotic resistance on their health and family . A significant improvement in respondents’ perception on antibiotic use was observed after the educational intervention (p < 0.001)  believed that they had a role to play in stopping antibiotic resistance. A significant improvement  was observed at two-weeks post-intervention .The mean knowledge score on antibiotic use significantly increased from 2.03 ± 1.56 (Pre) to 4.32 ± 1.48 (P2). Similarly, the mean knowledge score on antibiotic resistance increased from 2.83  ± 1.28 (Pre) to 3.67  ± 0.78 (P2) while the mean knowledge score on antibiotic perception also improved from 2.83  ± 1.38 (Pre) to 4.22 ± 1.02 (P2). All increments were significant . . However, the score difference between the two groups was not significant at the two-weeks post-intervention assessment for all domains.At the beginning, respondents who were exposed to a previous antibiotic awareness campaign scored higher in all three domains in comparison to those without prior exposure , antibiotic use mean score , and antibiotic perception mean score (3.12 ± 1.28 p = 0.001). At two-weeks post-intervention, the mean score between the two groups did not differ statistically.Prior to intervention, those respondents with family members working as healthcare professionals had a significantly higher total score   comparedIn terms of knowledge on antibiotic use, the majority of the respondents were not able to identify illnesses treatable by antibiotics –34. SimiIn a recent local study, 52.7% respondents agreed that antibiotics could work on viruses . To addrWhile knowledge of antibiotics was significantly associated with prudent antibiotic use, public perception was equally important. Three-quarters of the respondents perceived that they did not have a role in curbing antibiotic resistance before the intervention. Respondents were worried about the consequences of antibiotic resistance (KR1&PU4) but were not convinced that they could help in the fight against it. These findings were similarly reported in a previous survey, where around three-quarters of respondents in Vietnam, Indonesia, and China agreed that there was little they could do in the antibiotic resistance fight . Our intFurthermore, more than half of the respondents had inappropriate expectations for antibiotics when having fever, sore throat, or runny nose. Similar responses were observed in Poland, where 41% of respondents expected antibiotics for flu while 23% expected antibiotics when having sore throat . MisaligIt is important to note that respondents with at least one family member working as a healthcare professional possessed better antibiotic knowledge and perception at baseline. Public preference to seek informal advice from family and friends rather than formal healthcare was observed in previous studies , 38. TheThis study has several strengths. Our intervention tool  was designed to address several knowledge gaps among the Perak state population, based on a previous study by Choo et al. . Unlike 21, which assumed a substantial increase in the mean knowledge score. This resulted in a smaller sample size, which might have affected the power of our study. Due to the fact that the questionnaires were available in multiple languages and majority of the respondents had a higher level of education, the intervention’s impact might have been skewed towards a more effective direction. While previous literature found that better knowledge was associated with more prudent antibiotic use24, we did not assess the participants’ practice of using of antibiotics; hence, we could not affirm this relationship. Non-response bias may present, as those who did not respond to the questionnaire may differ in terms of attitude towards antibiotics and willingness to acquire new information, compared to those who responded.This study had its limitation: the findings only reflected the population in Perak (i.e. the state level) and not the entire country. We calculated the sample size based on previous literatureThe impact of face-to-face interactive and targeted educational intervention was proven in this study. In the future, expanding the coverage of the antibiotic awareness campaign through a digital or online interactive web-based medium may be useful to enhance public awareness—further studies are certainly warranted.The face-to-face, targeted educational intervention method effectively improved respondents’ antibiotic resistance knowledge and antibiotic use knowledge and perception. This understanding was also sustained over two weeks. The implementation of educational material tailored according to the audience’s knowledge gap is warranted in future antibiotic awareness campaigns.


Concrete and wood are commonly used to manufacture artificial reefs (ARs) worldwide for marine resource enhancement and habitat restoration. Although microbial biofilms play an important role in marine ecosystems, the microbial communities that colonize concrete and wooden ARs and their temporal succession have rarely been studied. In this study, the temporal succession of the microbial communities on concrete and wooden AR blocks and the driving factors were investigated. The composition of the microbial communities underwent successive shifts over time: among the six dominant phyla, the relative abundances of Proteobacteria, Cyanobacteria and Gracilibacteria significantly decreased in wood, as did that of Cyanobacteria in concrete. Operational taxonomic units (OTU) richness and Shannon index were significantly higher in concrete than in wood. Non-metric multidimensional scaling ordination placed the microbial communities in two distinct clusters corresponding to the two substrate materials. The macrobenthic compositions of concrete and wood were broadly similar and shifted over time, especially in the first five weeks. The Shannon index of the microbial communities in concrete and wood increased significantly with the organism coverage. The results provide fundamental data on microbial community succession during the initial deployment of ARs and contribute to understanding the ecological effects of ARs. Artificial reefs (ARs) are underwater structures that are either made of waste materials or are purpose-built constructions with the main function of protecting and enhancing marine resources and recovering and repairing habitats damaged by anthropogenic intervention or climate change ,2,3,4. WA major topic in the study of ARs is the ecological succession of periphyton and its structural and functional relationship with ARs of various materials ,9,10,11.In marine ecosystems, microbial biofilms are major primary producers that play an important role in the biochemical cycle and induce the settlement and recruitment of macroalga spores and invertebrate larvae ,15. The Concrete and wood, as common raw materials for the construction of ARs, differ considerably in material properties, surface roughness and organic composition. The effects of concrete and wood on the macrobenthic community have been studied in riverine  and inshIn the current study, the main objectives of the study were (1) to investigate the development and succession of microbial communities on concrete and wooden AR blocks over time; and (2) to initially explore whether these communities were associated with the substrate and macrobenthic community.4 m3 have been deployed here since 2006 and are mainly composed of concrete reefs and abandoned boats. A total of 58 abandoned boats with dimensions of 12 × 3 × 3 m (length × width × height) were placed on the muddy sand bottom in 2012, at depths ranging from 8.5 to 16.0 m. According to diving observations, only the frames of the boats remain. The beams of the boats are approximately 2 m above the sea floor and were used to hang the AR blocks in this study.The study was conducted in Shuangdao Bay, on the northeast of the Shandong peninsula, China. ARs with a total volume exceeding 3 × 10Populus L.) and concrete. Sixty pairs of blocks were built, with each pair containing one block of each substrate material, with dimensions of 20 × 20 × 5 cm. A hole (1 cm diameter) was drilled in the center of each wooden block and lifting eye bolts in stainless steel were anchored in the center of each concrete block. Each pair of wooden and concrete blocks was connected with a 1.5 m length of 1 cm nylon rope. The rope was tied to the eyebolts first, then a knot was made 0.5 m from each eyebolt, and another knot was also made after tying each wooden block through the hole . All samples made of the same substrate material and collected at the same time were assigned to one group and named Cn or Wn. The wooden and concrete blocks were transferred immediately into sterile sampling bags after draining them of water, stored in an ice box and returned to the laboratory within 1 h. The water in the vicinity of the ARs was also sampled. All macrofauna species present on the blocks were recorded and photographed, and species were determined to the lowest taxonomic level according to the morphological characteristics. The microbial biofilms were thoroughly rubbed with sterile brushes, the blocks and brushes were rinsed with sterile seawater, the rinsing water samples were filtered through 0.22-μm polycarbonate membranes after passing through a 50-μm pore prefilter to remove macrobiota, and the membranes were stored at −80 °C until DNA extraction.After the deposition of the ARs, sampling was conducted weekly for the first 8 weeks and monthly thereafter, with three pairs of AR blocks sampled each time (three concrete and three wood blocks). Due to the influence of winter weather, continuous sampling could not be conducted after December, and we found that the blocks had all been carried away by the waves by the time of the diving survey was conducted the following spring. In addition, one concrete block was lost during the third sampling time. In total, 65 blocks were sampled. The samples were denoted Cn.1, Cn.2, and Cn.3 for concrete and Wn.1, Wn.2, and Wn.3 for wood  and dissolved oxygen (DO) content of the water in the vicinity of the ARs were measured in situ using a handheld multi-parameter water quality meter , and the salinity (S) and pH were measured with a water quality instrument . The total dissolved inorganic nitrogen (DIN) and phosphate (PO43-) were determined using a SAN++ flow injection analyzer  in the laboratory.® High-Fidelity PCR Master Mix ; 0.2 µM of forward and reverse primers, and about 10 ng template DNA. The PCR mixture consisted of initial denaturation at 98 °C for 1 min, followed by 30 cycles of denaturation at 98 °C for 10 s, annealing at 50 °C for 30 s, and elongation at 72 °C for 30 s, and finally by extension at 72 °C for 5 min. The PCR products were mixed and purified using a Gene JET Gel Extraction Kit . Sequencing libraries were generated with the Ion Plus Fragment Library Kit 48 rxns . The libraries were assessed and sequenced on a Qubit@ 2.0 Fluorometer  and an Ion S5 XL platform at Novogene Bioinformatics Technology Co Ltd. , respectively. The acquired sequences were filtered for quality using the QIIME 2 pipeline [Total DNA was extracted using the Fast DNA SPIN Kit  following the manufacturer’s protocols, and the DNA concentration and purity were assessed by agarose gel electrophoresis. The V3-V4 regions of the bacterial 16S ribosomal DNA (16S rRNA) gene were amplified using the specific primers 341F (5′-CCT AYG GGR BGC ASC AG-3′) and 806R (5′-GGA CTA CNN GGG TAT CTA AT-3′). The volume and amplification protocol of polymerase chain reaction (PCR) were determined according to the method of Ammon et al. 2018)  with sli18  with pipeline  by compapipeline . The OTUpipeline  with an t-tests were carried out to determine the significant differences in microbial β-diversity between the concrete and wooden AR samples. To detect significant taxonomic differences between concrete and wood, a least discriminant analysis (LDA) was used to identify biomarkers (threshold > 4.0) [p value of less than 0.05, using Gephi (v. 0.9.2) [The α- and β-diversity analyses of the microbial communities were conducted in the R environment (v.4.0.2) using the vegan (v. 2.5-6) and psych (v. 2.0.9) packages. The α-diversity  of each sample was calculated with QIIME 2 . Non-metd > 4.0) . The macd > 4.0) . The lin. 0.9.2) . A redunp < 0.01) (p < 0.01), and that in C10 was also significantly higher than that in C1 (p < 0.05). For the wooden groups, the Shannon diversity values in W4 were significantly lower than in W3 (p < 0.05) and W7 (p < 0.01).A total of 2,316,840 and 2,422,059 high-quality 16S rRNA sequences were normalised from the concrete and wooden AR samples, respectively. The Good’s coverage was 97.26 ± 0.66%, which indicated that the sequence libraries covered most of the microbial community in these samples. Among the OTUs identified, 5870 were shared between the concrete and wooden samples and 2034 were specific to concrete, accounting for 25.73% of the total concrete-associated OTUs, and 13.51% of the OTUs in the wooden samples were wood-specific A. The av < 0.01) B. ComparR = 0.462, p = 0.001; Adonis: R2 = 0.164, p = 0.001). According to NMDS analysis, the concrete or wooden samples collected at the same or adjacent sampling times had similar microbial community structures and tended to group together.NMDS ordination was used to differentiate the microbial community structures between the concrete and wooden samples C and shor = −0.368, p = 0.035), Cyanobacteria , and Gracilibacteria  in wood, as did that of Cyanobacteria  in concrete. In contrast, the relative abundance of Firmicutes in concrete significantly increased over time, and the rest of phyla in concrete and wood remained more or less changed over time (p > 0.05).Two kingdoms were identified in this study, including bacteria and archaea (mainly Thaumarchaeota). To analyze the temporal succession of the composition of the microbial communities from the concrete and wooden AR samples, the relative abundances were studied at the phylum level. The most dominant phylum was Proteobacteria , followed by Bacteroidetes . The other major microbial phyla (with a relative abundance of greater than 1.0%) were Cyanobacteria, Actinobacteria, Firmicutes, and Verrucomicrobia in concrete, whereas only two, Actinobacteria and Firmicutes, were found in wood A. The mip < 0.05) within concrete, within wood and between concrete and wood, respectively  and co-exclusion (negative) of patterns of microbial genera were distinct between concrete and wood. More negative interactions presented in the network of wood  than in concrete , suggesting greater co-exclusion between genera in wooden samples. The network nodes of concrete and wood at the phylum level were similar, wherein Proteobacteria and Bacteroidetes were the dominant phyla, accounting for 80.88% and 89.86% of the nodes in concrete and wood, respectively.Hydroides ezoensis was the pioneer sessile organism observed on the AR blocks at the second week, followed by Anomia chinensis and Chlamys farreri. Ciona intestinalis, Watersipora subovoidea and Crassostrea gigas were found at the fifth week. Some species only presented at one sampling time across the sampling period, such as Ceramiales sp. (fifth week on wood), Mytilus edulis and Ophiactis affinis (fifth month on concrete). The dominant species also varied over time: H. ezoensis, C. intestinalis, and W. subovoidea were the dominant species in the first three weeks, fourth to fifth weeks and fifth week, respectively, whereas from the sixth week to the end of the study, C. gigas became the absolute dominant species.A total of 14 macrofauna and algal taxa were identified on the concrete and wooden AR blocks, including Mollusca (6 taxa), Annelida (2 taxa), Arthropoda (2 taxa), Echinodermata (1 taxon), Urochordata (1 taxon), Bryozoa (1 taxon), and Rhodophyta (1 taxon) . The macC. gigas, and this was also the case on the concrete blocks. The organism coverage on the concrete blocks was higher than that on wood except in the fifth and seventh weeks.The organism coverage was calculated to further reveal the succession of the macrobiotic biofouling community on the AR blocks A. The orr = 0.409, p < 0.05) and wooden  groups. The number of OTUs of samples in the wood group showed a significant positive correlation with organism coverage, but that relationship was not significant in concrete.Linear least-squares regression was performed between organism coverage and the α-diversity of the microbial communities to study the correlations between macrobenthos and microbes B. The va43-P ranged from 54.64 to 100.00 μg/L and 5.02 to 13.75 μg/L, respectively. The highest values of DIN and PO4-P were in the samples collected in the eighth week and third month, and the lowest values were found in the second week and fourth month, respectively.The sea water in the vicinity of the ARs was characterized in terms of six environmental variables . The watp < 0.01). The two axes explained 50.11% of the variation in the data: DO, pH and DIN showed positive correlations with RDA1; T, DO and PO4-P showed positive correlations with RDA2; and the rest of the variables showed negative correlations with RDA1 and RDA2, respectively.An RDA was conducted based on the OTU level to explore the relationship between the microbial community structure and environmental variables . The varAmong the most important functions of artificial reefs are their ecological effects: periphyton, which includes microorganisms, algae, and invertebrates, gradually colonizes the bare reef surface after deployment and initiates the succession process . These eBalanus amphitrite and Ciona intestinalis after the latter settle on the reef [The AR microbial community shows distinct temporal succession, especially when comparing seasons. The abundances of the microbial community settled on a hard substrate increase over time at the early stage of biofilm formation ,29,30, athe reef , which ithe reef  and lotithe reef . In addithe reef ,17. HereAlthough their relative abundances shifted over time, Proteobacteria and Bacteroidetes remained the most dominant phyla colonizing the concrete and wooden blocks, which was in line with previous studies of biofilms ,17,35,36t-test confirmed that the difference was significant (p < 0.01)  . We deteCeramiales sp., M. edulis, and O. affinis. For both substrates, the organism number and coverage tended to increase over time until the final sampling time. With the blocks having been hung approximately 10 m underwater, the diver observed that only a few Rhodophyta species were growing on the beam of the boat and no macroalgae were found on the sand bottom, whilst the spores are mainly released during spring. The above factors might have resulted in the low abundance of macroalgae in this study. Barnacles are often observed among the pioneer colonizing species on ARs [The compositions of the macrobenthic communities that colonized the concrete and wooden ARs were similar except for a few species with low abundance, such as s on ARs ,45, wherMicro- and macro-organisms undergo well-known synergistic interaction, and marine colonization processes can be described as successive steps, with the formation of microbial biofilms preceding the settlement of macro-organisms. Therefore, microbial biofilms have been suggested as key mediators for macrobiotic colonization . StudiesConcrete and wood both presented good biocompatibility in this study. However, the wooden blocks were more seriously damaged than the concrete in the later stage of the experiment. The substrate texture of wood is relatively soft and easily worn by waves and corroded by sea water and marine boring organisms, which makes it more suitable for installation in freshwater environments with slow currents, such as rivers, streams and lakes ,51,52,53The temporal succession of the microbial communities colonizing concrete and wooden ARs was studied. The microbial communities underwent successive shifts in composition, with Proteobacteria and Bacteroidetes as the most dominant phyla across the whole period. The microbial community structure on concrete was significantly different from that on wood, with 30, 33 and 17 biomarkers detected within concrete, within wood and between the two substrate groups, respectively. The macrobiotic biofouling communities attached on concrete and wood also presented temporal shifts, whereas no distinct differences of macrobiotic community structure were observed between the two materials. Environmental variables, i.e., temperature, dissolved oxygen, pH, salinity and dissolved inorganic nitrogen, drove the shift of the microbial community structure. Considering the complex interactions between micro- and macro-organisms, more influencing factors should be considered in future research.


We report a case of atypical presentation of IgG4-related disease (IgG4-RD) with recurrent scleritis and optic nerve involvement.A 61-year-old male presented with ocular pain and injection in his left eye for 2 months. Ocular examination together with ancillary testing led to the diagnosis of scleritis, which relapsed in spite of several courses of steroid treatment. After cessation of steroid, the patient complained of severe retro-orbital pain and blurred vision. His best corrected vision was count finger, the pupil was mid-dilated and a relative afferent pupillary defect was found. Funduscopic examination demonstrated disc swelling. Magnetic resonance imaging (MRI) showed enhancing soft tissue encasing the left globe, medial rectus muscle and optic nerve. Systemic work-up revealed multiple nodules in right lower lung and a biopsy showed histopathological characteristics of IgG4-RD. Long-term treatment with corticosteroids and a steroid-sparing agent (methotrexate) led to significant improvement in signs and symptoms with no recurrence for 2 years.This case highlights the significance of IgG4-RD in the differential diagnosis of recurrent scleritis. IgG4-RD may cause optic neuropathy resulting in visual loss. Early diagnosis and proper treatment can prevent irreversible organ damage and devastating visual morbidity. IgG4-related disease (IgG4-RD) is a newly identified clinical entity characterized by an IgG4-positive multi-organ lymphoplasmacytic infiltrate, associated with fibrosis or sclerosis –3. SinceOphthalmic involvement predominantly affects the lacrimal gland and typically presents as idiopathic orbital inflammation and chronic sclerosing dacryoadenitis , 8. HereA 61-year-old man presented with unilateral ocular pain and injection for 2 months. His best corrected visual acuity was 20/20 bilaterally and intraocular pressures were normal. Slit lamp examination showed a localized inflamed superonasal bulbar conjunctival swelling in the form of scleritis in his left eye  demonstrated enhancing soft tissue encasing the left globe, where medial rectus muscle and optic nerve were enlarged and enhanced with scleral thickening Fig. . On systThe patient was diagnosed as IgG4-RD and began intravenous (IV) injection of hydrocortisone 50 mg tid for 1 week, followed by IV methylprednisolone 60 mg for 4 days. He was treated with 25 mg of oral methylprednisolone daily for 2 weeks, the dose was gradually reduced by 5 mg every 2 weeks and maintained methotrexate 10 mg once a week. Long-term treatment with corticosteroids and a steroid-sparing agent (methotrexate) led to significant improvement in signs and symptoms. Visual acuity was improved into 20/40 and no recurrence was observed after 2 years of follow-up.In 2011, comprehensive diagnostic criteria for IgG4-RD was defined as meeting two or more and including 1) of the following: 1) clinical examination shows characteristic diffuse/localized swelling or masses in single or multiple organs, 2) hematologic examination shows elevated serum IgG4 concentrations (≥135 mg/dl), 3) histopathologic examination shows: marked lymphocyte and plasmacyte infiltration and fibrosis, infiltration of IgG4+ plasma cells: ratio of IgG4+ to IgG + cells > 40% and > 10 IgG4+ plasma cells/HPF . In thisIgG4-related ophthalmic disease (IgG4-ROD) forms a significant proportion of what has previously been labeled idiopathic orbital inflammation or reactive lymphoid hyperplasia. The lacrimal gland is most commonly involved but other orbital structures affected include the EOM, eyelid, the supraorbital and infraorbital nerves –9. IgG4-Long diagnostic delay in IgG4-RD, between 3.8 years and 7.5 years in other reports , 14, is Corticosteroids are typically the first line of therapy for IgG4-RD. Most patients respond well to oral glucocorticoid within several weeks, but the lesion sometimes recurs during steroid tapering or following the withdrawal. Immunosuppressive agents such as methotrexate, azathioprine, cyclophosphamide, 6-mercaptopurin and bortezomib have been used in IgG4-ROD for steroid-sparing effect. Since lymphoplasmocyic infiltration with CD20+ cells is one of the hallmarks of the disease, rituximab  may be a treatment of choice, with a response rate of 90% in refractory cases , 19. AltMany systemic diseases such as the autoimmune connective tissue diseases of rheumatoid arthritis, systemic lupus erythematosus, sero-negative spondylarthropathies and vasculitides such as granulomatosis with polyangiitis and polyarteritis nodosa had been reported to cause scleritis . RecentlHere, we presented a rare case of atypical presentation of IgG4-ROD with recurrent scleritis, optic neuropathy and EOM involvement. In cases of scleritis, the differential diagnosis should include IgG4-RD and serum IgG4 level is warranted as a part of the initial assessment of scleritis. Although this is the most common laboratory test performed for the diagnosis of IgG4-RD, serum IgG4 levels are normal in 30 ~ 40% patients, indicating a reduced sensitivity . TherefoIgG4-RD should be suspected in the face of any chronic inflammatory ophthalmological conditions and can be added as a novel cause of scleritis. It is important to promptly and accurately recognize IgG4-RD to allow commencement of appropriate treatment and to improve prognosis of patients. Early diagnosis and proper treatment can prevent irreversible organ damage and devastating visual morbidity.


The results show that except for the effect of the addition of both polypropylene micro- and macrofibers on the relative volume of pores, all other modifications result in statistically significant changes in the values of stereological parameters. Nevertheless, it is shown that neither polymer dispersions nor fibers have a statistically significant impact on shielding properties, but that they do influence compressive strength.In this paper an analysis of the influence of polymer modification on the microstructure, shielding properties against neutrons, and compressive strength of heavy-weight magnetite concrete is carried out. The modifications involve the addition of acrylic or epoxy dispersions as well as micro- or/and macrofibers. A computer image analysis method is used to evaluate the microstructure of concretes and parameters of pore structure are calculated; these parameters include relative volume fraction, relative specific surface area, and pore arrangement ratios, including a proprietary ratio based on Voronoi tessellation. An assessment of significance of differences between stereological parameters of reference concrete and polymer modified concretes, as well as the impact of polymer form (dispersion or fibers) on shielding properties and compressive strength is carried out using Student’s  The behavior of every material is related to its microstructure somehow. This is why understanding the relation between microstructure and properties is a basic approach of materials science and engineering. Hence, concrete design as a combination of a traditional approach based on relation composition-technology properties, with an analysis of microstructure, including searching for quantitative relations between microstructure and properties, could be the key to optimization of concrete’s technical properties.The microstructure of concrete can be observed, registered, and analyzed at different levels, starting from the macroscopic through to the microscopic and nanometric scale, depending on the type of information to be obtained. Concrete microstructure encompasses a wide range of structural levels, from the atomic scale to that of the engineering macroscale. It may be composed of phases like aggregate grains, cement hydration products, unhydrated cement particles, fibers, and additions  as It is believed that both quantitative and qualitative descriptions of processes and relations at a specific level should be sought at lower levels. Hence, seeking for relations between concrete properties and the microstructure seems to be reasonable. One of the basic relations between the microstructure and the properties of cement composites is the influence of porosity on strength ,7,8. It The methods of microstructure analysis use different physical and chemical processes. Generally, they can be divided into microscopic technics, which enable the observations of microstructure morphology , and volumetric technics, which provide averaged information about the microstructure in a given volume of a material . The group of volumetric techniques includes methods of testing the pore structure, e.g., mercury porosimetry, water or nitrogen absorption, and image analysis. Among these methods, only the image analysis method allows for testing the arrangement of pores apart from obtaining the volume fraction and specific surface area as well as the size distribution of pores, etc.In this article the image analysis method is used to evaluate the microstructure of heavy-weight concretes modified by polymer addition in the form of dispersions or fibers. This type of concrete is recommended for shielding against ionizing radiation. Concrete has been applied as a shield against high-energy photons (gamma radiation) and neutrons since the beginning of the use of nuclear reactions in energy, medicine, and research. In the case of shielding against high-energy photons (gamma radiation) the increase in concrete density by change of aggregate type, e.g., from a normal to a heavy-weight type, is sufficiently effective ,13. ProtWhen the energy of moving neutrons decreases to the appropriate level , the neutrons are absorbed by one of the nuclei of the atoms in the concrete. Otherwise, the neutrons leave the matter of the shield. As most concrete components are not the best absorbers, absorption efficiency should be improved by addition of some special components containing gadolinium or boron.From the point of view of concrete modification, it is also important to note that some modifiers introduced into the concrete mix may cause a decrease in compression strength, which is the basic characteristic of concrete as a structural material .The aim of this paper was to analyze how the polymer dispersions or fibers may influence the microstructure, effectiveness of neutron radiation shielding, and compressive strength.Image analysis is a type of stereological method; stereological methods are used for quantitative description of three-dimensional objects in a material volume based on measurements performed on two-dimensional images of a material microstructure (images of sample cross sections). The first attempts at applying this method in the construction sector took place at the beginning of the 1950s. These attempts involved comparing the observed microstructure with the scale of previously defined patterns in order to estimate grain size in metallic materials. They led to the development of one of the most known relations between the microstructure and properties which indicates that a reduction in average grain size causes an increase in tensile strength and hardness ,22. The The investigation of the microstructure by the image analysis method is carried out on the surface of specially prepared samples which are called microsections. The key to obtaining correct and representative results is the precise taking of samples of a sufficient size whose surfaces then have to be prepared by grinding and polishing to ensure the representativeness of images that are taken of the microstructure. Preparation of the samples’ surfaces is preceded by sample mounting in a polymer resin in order to protect fragile materials or coatings, to distinguish pores from the rest of the microstructure constituents (if the polymer resin is colored), and to standardize sample sizes so they can be placed in a sample holder for grinding and polishing machines.The images of the microstructure are commonly captured using light microscopes; however, it is also possible to use photo cameras or computer scanners . The tecThe obtained images of the microstructure are first subjected to qualitative analysis in order to distinguish the constituents of the microstructure and to isolate those of them that are the subject of the image analysis by using digital image processing. Digital image processing is any modification of an image that changes the values of the RGB components  or structure or form of objects on a binary image . The process of isolating a selected area of an image is called segmentation and it is performed on the basis of uniformity criteria, e.g., color, brightness level, and texture. The simplest means of image segmentation is binarization. This modification divides all the pixels into black pixels belonging to selected constituents of the microstructure and white pixels belonging to an insignificant background on the basis of a given brightness threshold .The images of the microstructure after segmentation are subjected to quantitative analysis, mainly using computer programs that enable faster, more accurate, and more repeatable results than manual analysis. The binary image is the only type of image that programs which are currently used are able to analyze and unequivocally recognize various types of objects within; these objects are defined as coherent sets of points  in which a transition between any two points is continuous without entering an area of different value (white pixels).V are represented by plane shapes with areas of A, interfacial transition zones between grains of aggregate and the hardened cement matrix are represented by curvilinear lines with length L, and cracks or fibers are likened to points P (A), parameters describing the three-dimensional microstructure of a material are calculated (V). One of the basic stereological relations is the Cavalieri-Hacquert relation. It states that the volume fraction of selected objects (phase) in the volume unit of a material (VV) is equal to the surface area of selected objects in the image of the microstructure related to the area of the whole image, which is also equal to the number of points hitting selected objects in the image related to all points of the sample grid (Equation (1)). Another example is the Saltykov relation, which is used to calculate the relative surface area of selected objects in the volume unit of a material (VS). In the Saltykov method the image of the microstructure is pierced with a large number of vertical test lines with total length L; then, an expression is set up for the density of intersections with selected objects on the microstructure image (number of intersections n) (Equation (2)). The aforementioned equations areVV is the volume fraction of the selected objects in a volume unit of the material, AA is the surface area of objects related to the image area, PP is the number of points hitting selected objects related to all points of the sample grid, VS is the surface area of selected objects in a volume unit of a material, and LP is the number, n, of intersections of lines with a total length L with selected objects.It should be noted that microstructure image capture causes a reduction in the number of dimensions of its constituents, i.e., three-dimensional objects like grains of aggregate or pores with a volume of points P . On the In the case of concrete, parameters which are commonly calculated describe the geometrical features of aggregate grains and pores, e.g., number, size, volume fraction, surface, shape, and arrangement  26,27].,27.26,27In this work concretes with heavy-weight aggregate and modified with polymer additives were studied. The reference concrete was a heavy-weight concrete with magnetite aggregate and slag cement CEM III/A 42.5N LH/HSR/NA . Aggregate mixtures contained fine aggregate (fraction 0/2 mm), which was river sand, and coarse magnetite aggregate with a maximum grain size of 16 mm (fraction 2/8 mm and 8/16 mm). The cement was characterized by an extended setting time, normal early compressive strength, high resistance to sulphate aggression, low hydration heat, and low alkali content. It was composed of Portland clinker (35–50%), granulated blast furnace slag (50–65%), and a setting time regulator, namely, calcium sulfate (5%). The reason for choosing this type of cement was the fact that the tested concretes were intended for shielding structures of reactors in nuclear power plants or research centers, which are usually massive structures and require a reduction in cement hydration heat to limit thermal stress.M was modified with the addition of acrylic (MPCC1) or epoxy dispersion (MPCC2) as well as addition of polypropylene macro- (MF1) and/or microfibers (MF2 and MF3). Acrylic dispersion involved a liquid containing carboxylate styrene-butadiene latex, which is generally used to modify mixes of concretes and mortars. Epoxy dispersion involved two-component water dispersion used mainly as a colorless impregnate and a concrete ground strengthener for concrete as well as a modifier of mortar mixes. The amount of both acrylic and epoxy dispersion addition was set at a level of 7.0% in relation to the weight of the cement considering only the weight of polymer itself, which was equal to about 47.0% of the dispersion mass. Two types of polypropylene fibers were used, namely, microfibers 12.0 mm in length and 0.038 mm in diameter and macrofibers 39.0 mm in length and 0.78 in diameter. The quantity of micro- and macrofibers used was equal to 0.6 and 3.5 kg per m3 concrete mix, respectively.The reference magnetite concrete The water/cement ratio of the concrete mixtures was fixed to 0.4. Consistence was measured by the slump test method and kept at an S4 level (160–210 mm) by changing the amount of the superplasticizing admixture.A detailed composition of the concretes used in the study is given in HVL) expressing the thickness of the absorbing material needed for a reduction in the incident radiation intensity by a factor of two. Using the appropriate recombination techniques, the neutron radiation dose equivalent was determined, and based on the neutron radiation dose equivalent reduction curves, one HVL per concrete was calculated. The details of the experiments on shielding effectiveness and other technical characteristics of tested concretes have been presented elsewhere [The investigation of the effectiveness of shielding against neutrons was measured using a Pu–Be source and a specially prepared stand that allowed placing 500 mm × 500 mm × 50 mm concrete slabs perpendicularly to the positioning mechanism of the radiation source . The mealsewhere .A compressive strength test was carried out on 10 cm × 10 cm × 10 cm cubic samples at an age of 28 days. Compressive strength for each concrete was the mean value of results obtained for three samples.VV, the relative surface area VS and the ratio of pore arrangement The microstructure of the concretes was evaluated by computer image analysis. A set of three samples with the dimensions 40 mm × 40 mm × 160 mm was prepared for each concrete and cured for 28 days. The procedure of sample preparation for microstructure studies involved (1) cutting out three slices about 40 mm × 40 mm × 10 mm in size a from thR of the volume of the cement matrix  to total air content. In the case of R > 4.342 Equation (3) is used, while for R ≤ 4.342 Equation (4) must be applied. Equation (3) and Equation (4) areR is the ratio of the volume of the cement matrix and total air content, α is the specific surface area of pores, P is the volume of the cement matrix, totT is the total length of measurement lines, and N is the total number of chords passing through the pores.The ratio of pore arrangement 2Vd, should be characterized by the lowest possible coefficient of variation CV(2Vd). Voronoi tessellation of binary images of pore structure was also performed using MATLAB.In the method proposed here for the evaluation of pore arrangement, the straight lines divide distances between pairs of closest pores (the centers of pores) in half, and the intersections of these lines determine the corners of polygons , which are so-called “impact zones” see d which bCV.Stereological parameters calculated by computer image analysis were characterized by mean value t-test. In essence, this test compares differences in means of two sets of independent measurements, assuming normality of data and equality of variances across comparison groups. As a result, a t statistic and p value are calculated and compared with critical values of the t distribution for the appropriate number of degrees of freedom and defined significance level, respectively. If the value of the t statistic is sufficiently high and the p value is lower than the defined significance level, the difference between the means could be considered to be “statistically significant”, that is, that the underlying distributions very likely have different means. In the presented paper, for the purpose of calculations, the null hypothesis proposed that no statistical significance would exist between the means of the stereological parameters, shielding properties, and compressive strength of M concrete and other concretes ; the alternative hypothesis was that the differences between the means would be significant, with the significance level being p = 0.05.The influence of polymer addition on the microstructure of reference concrete as well as shielding against neutrons and compressive strength was determined using a mathematical statistics method, namely, Student’s The details of the experimental program are presented in M had a different influence on the HVL. The addition of acrylic dispersion (MPCC1) or macrofibers (MF1) to M had a minor effect on the HVL, namely, changes were only up to about 3.0%. On the other hand, it was observed that the epoxy dispersion (MPCC2), macrofibers (MF2), and both types of fibers added at the same time caused an increase in HVL from about 5.0% (MPCC2) to 17.0 (MF3); in other words, the thickness of the shield necessary to reduce the radiation by half increased, which means that the shielding effectiveness was weakened. This is not consistent with the results reported in the literature [The experimental results of the shielding properties against neutrons are presented in terature ,19. BecaMPCC1 (with acrylic dispersion addition) and MF1 (with polypropylene microfibers addition) showed compressive strength similar to reference concrete M, while MPCC2 (with epoxy dispersion addition) and MF2 (with polypropylene macrofiber addition) had about 21.0% higher strength than M. By contrast, the addition of both micro- and macrofibers at the same time (MF3) resulted in a large decrease in compressive strength of up to 40.0%. This was probably caused by adding too large an amount of fibers, leading to a drop in workability and to an increase in the dimensions of pores, which was proven using the image analysis method (The results of the compressive strength test are presented in s method . The litMPCC1) and epoxy dispersions (MPCC2) as well as micro- (MF1) and macrofibers (MF2) caused a decrease in the porosity VV of M from about 59% (MPCC2) up to 82% (MPCC1), while the addition of both types of fibers simultaneously (MF3) resulted in a minor increase in VV of about 9%. The decrease in VV after adding acrylic dispersion as well as epoxy dispersion to M was expected, since this type of polymer addition usually causes an increase in the tightness of the microstructure of cement composites, and thus an increase in durability. All performed modifications of M created a decrease in VS of M from 45%  up to 75% . On the other hand, the additions used in the study induced an increase in the M from about 42%  up to 89% . Similar values of VV and radically different values of the MF3 concrete prove that addition of both micro- and macrofibers (MF3) resulted in an increase in pore diameters in relation to the reference concrete (M). Moreover, it was shown that in contrast to the rest of the parameters, the influence of additions on the ratio of uniformity of pore arrangement CV(2Vd) of M was relatively small, with the ratio increasing from about 4%  to 11% . This leads to the conclusion that the uniformity of pore arrangement in the concretes remained almost unchanged.The results of the computer image analysis are presented in VV results was diversified and the largest variability characterized VV of magnetite concrete modified with epoxy dispersion  = 24.41%) due to the presence of macropores reaching a few millimeters in diameter and appearing in a completely random way and overstating the VV of some samples. A slightly lower CV(VV) was noticed in the case of MF3 concrete modified by both micro- and macrofibers, and this heterogeneity of pore structure is not surprising because of the drop in the workability observed during the mix preparation, which caused difficulties with a compaction. The coefficients of variation CV(VS) and CV(The variability of HVL obtained for the reference concrete M and the two groups of concretes modified with polymer dispersions (MPCC1 and MPCC2) or fibers  are presented in HVL because the t statistics were not in the critical region: K = K = p values were much higher than the defined significance level p = 0.05 as well. This meant that the null hypothesis was true . Taking into consideration the similar effect of both forms of polymer additions on the HVL, it could be concluded that concretes modified with polymer dispersions should be used for shielding purposes against ionizing radiation. This is because their mixes are easier to design and place than concrete mixes containing polymer fibers, which additionally may show a decrease in workability.The results of analysis regarding the significance of differences between the fc, obtained for M and two groups of concretes modified with polymer dispersion (MPCC1 and MPCC2) or fibers  are presented in HVL, the fc was statistically significantly dependent on the form of polymer introduced into the reference concrete mix. The t statistics in this case were in the critical region: K = K =p values were significantly lower than the defined significance level p = 0.05. Comparing the influence of additions of both forms of polymers, it can be observed that dispersions influenced fc in a more effective way; the p value for this group of concretes was one order of magnitude lower than for the group of concretes modified with fibers. It is possible to achieve almost the same effect (the compressive strengths of MPCC1 and MF1 and of MPCC2 and MF2 were similar) using polymer dispersions and fibers, so yet again, like in the case of the HVL, it is recommended to use concrete modified with polymer dispersions, not fibers.The results of analysis of the significance of differences between compressive strength, t-test showed that for the defined significance level (p = 0.05), except for the effect of the addition of both micro- and macrofibers (MF3) on porosity VV, all performed modifications of the reference concrete resulted in statistically significant changes in the values of the stereological parameters. This is reflected in the t statistics values, which were almost entirely in the critical region K = p  ) and in 5;+∞) (p ), which p = 0.05), except for the effect of the addition of both polypropylene micro- and macrofibers at the same time on a relative volume of pores, all modifications of the reference concrete resulted in statistically significant changes in the values of stereological parameters. Neither the polymer dispersions nor fibers had a statistically significant impact on HVL, but they influenced the compressive strength.In this paper an analysis of the influence of polymer modification on the microstructure of heavy-weight magnetite concrete was carried out. The obtained results showed that the computer image analysis method is appropriate to use to differentiate the changes in the concrete microstructure introduced by modification with polymers. For the defined significance level (


Octreotide may be useful in noninsulinoma pancreatogenous hypoglycemia syndrome with nesidioblastosis patients who was on hemodialysis. Continuous octreotide subcutaneous infusion can reduce side‐effects and stabilize plasma glucose levels. Octreotide may be useful in noninsulinoma pancreatogenous hypoglycemia syndrome with nesidioblastosis patients who was on hemodialysis. Continuous octreotide subcutaneous infusion can reduce side‐effects and stabilize plasma glucose levels. Continuous subcutaneous infusion of octreotide may be an effective treatment for patients on hemodialysis and cannot tolerate bolus subcutaneous injection of octreotide.Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) with Nesidioblastosis was first described by Laidlaw in 19382A 73‐year‐old man was admitted to our hospital because he had repeated episodes of hypoglycemia before meals for 4 months. He suffered from chronic glomerulonephritis and had been on dialysis for 18 years.Body height and weight were 159 cm and 65.1 kg, respectively, and physical examination was almost normal. Analysis of the daily energy intake pattern showed meals of 1800 kcal/d and snacks of 200 kcal thrice daily, although the plasma glucose level was 40‐70 mg/dL throughout the day. Glycemic support was provided in the form of continuous infusion of 245 g/24 h (10 g/h) dextrose. The results of laboratory tests showed hypoglycemia, hyperinsulinemia, high C‐peptide, low HbA1c, and mild hypocarnitinemia  of 25 µg octreotide twice a day, but the dose failed to suppress insulin level. On the other hand, 50 µg twice a day induced side‐effects. In the next step, we replaced BSI with CSI, which resulted in the disappearance of the side‐effects, and we were able to increase the dose up to 100 µg/24 h. This regimen resulted in clinical meaningful insulin suppression and glucose level control Figure . Two yea3We experienced a case of adult‐onset NIPHS with nesidioblastosis with uncontrolled hypoglycemia after pancreaticoduodenectomy. It was difficult to explain the result of ASVS and to select the most suitable treatment especially in our patient who was on hemodialysis.Determination of the cause of hypoglycemia in patients with chronic kidney disease (CKD) requires careful attention. In CKD patients, glucose intolerance due to peripheral resistance to insulin is common and these patients sometimes present with mild to moderate hyperinsulinemia.It is known that partial pancreatectomy of 60%‐80% controls NIPHS with nesidioblastosis in 50% of patients without additional medications.®) is better or not. In this regard, Kondo et alWe also showed that the use of octreotide in CSI avoided gastrointestinal symptoms compared with BSI. While the actual mechanism is still unknown, we believe the symptoms are related to peak plasma concentrations. In fact, the peak concentration at 100 µg octreotide observed during BSI was higher than 300 µg/24 h with CSI.In conclusion, we reported a case of adult‐onset NIPHS with nesidioblastosis on regular hemodialysis that was successfully treated with pancreaticoduodenectomy and octreotide. CSI of octreotide may be an effective treatment for patients who cannot tolerate BSI.None of the authors have any potential conflicts of interest with this report.RK and AN: involved in writing and editing the manuscript. KM, SK, KN, and YM: involved in revision of the manuscript. All authors: involved in reading and approving final version of the manuscript.This case report was reviewed and approved by the ethics committee of Toranomon Hospital with the identifier No. 1851.


The scanning electron microscopy (SEM), optical microscopy, fourier transform infrared spectroscopy (FTIR), nanoindentation, nanoscratch and three-point flexure tests were performed. The volumetric shrinkage and mechanical properties such as hardness, elastic modulus, resistance, flexural strength and fracture energy were analyzed. With the additions of POSS, the volume shrinkage decreased and the mechanical properties initially increased. The effects of POSS on these properties were studied to provide a reference for clinically selecting a composite resin with excellent properties.Various amounts of methacryl polyhedral oligomeric silsesquioxane (POSS) were explored to be incorporated into novel nano SiO Currently, the composite resin is the most important repairing material for tooth defects. Because of its many advantages such as color, strong plasticity, resistance to dissolution, easy polishing, simple operation, and close to the coefficient of thermal expansion, it is mainly used for fillings and restoration of dental caries and plays a pivotal role in dental restoration ,2,3. How3/2)n, where n is the number of the silicon atoms of the cage (1–3 nm in size) surrounded by organic corner groups (R). Due to its inorganic Si–O core cage structure and optional organic group chains, POSS can enhance matrix properties, such as mechanical strength [Polyhedral oligomeric silsesquioxane (POSS) is an organic–inorganic hybrid nanomaterial ,8. The cstrength ,16,17, tstrength ,19,20 anstrength ,22,23, astrength ,25 and estrength ,26, whicOgliari et al.  simulate2 matrix dental resin composites using light curing method. The scanning electron microscopy (SEM), optical microscopy, fourier transform infrared spectroscopy (FTIR), nanoindentation, nanoscratch and three-point flexure tests were performed, and the effects of the contents of POSS on the volumetric shrinkage, hardness, elastic modulus, resistance flexural strength and fracture energy were studied.In this work, various amounts of methacryl POSS were explored to be incorporated into novel nano SiO2 with an average particle size of 30 nm, purchased from Deco Dokin Co. Shanghai, China. Surface modified KH-550 nano SiO2 is a white powder that mixes better with the matrix and provides better mechanical properties to the matrix compared with dental resin matrix without inorganic filler. All of the above materials can be used as a dental resin matrix. Methacryl POSS was obtained from Hybrid Plastics  and TEGDMA (Tri(ethylenglycol) dimethacrylate, 98%) were purchased from Aldrich Chemical Co., Shanghai, China. The commonly used visible light photo-initiator CQ  and co-initiator (2-(dimethylamino) ethylmethacrylate, DMAEMA, 98%) were selected for this research and purchased from Aldrich Chemical Co., Shanghai, China. The inorganic filler used in this study was surface modified KH-550 nano SiO2 was incorporated into the organic composite solution and magnetically blended uniformly in the vacuum allowing for the escape of air bubbles for 2 h. The mixture solution was poured into metal molds and the visible light curing method was applied. The curing time of each sample was 60 s at room temperature. The prepared samples were immersed in distilled water at 37 °C for 24 h and were stored in configured artificial saliva at 36.5 °C for 4 weeks. The sizes of the specimens were measured accurately and recorded immediately before testing.An organic resin matrix solution containing Bis-GMA, TEGDMA, CQ and DMAEMA was prepared by mixing in a container kept away from light. Methacryl POSS was added to the solution of neat resins. Nano SiOFourier transform infrared (FTIR) spectroscopy analysis was performed using the FTIR spectrometer . The samples involved in this part of the study were POSS and organic composite resins without inorganic filler.A VHX-600E digital microscope  was used for optical microscopy of the nanocomposite resins with a real-time depth composition, two/three dimensional functions, and 500–5000 zoom.The fracture morphology of the POSS dental resin composite was characterized using a field-emission scanning electron microscope .The densities of uncured and cured resin specimens were measured by a pycnometer to determine polymerization shrinkage according to the Archimedes’ principle.-1. The data was averaged from six specimens during each test to get the most accurate results.The G200 Nano Indenter  was employed to study the hardness of the nanocomposite resins. The indenter used in the test was a diamond triangular pyramid Berkovich indenter (TB 20114 ISO). The maximum depth of 2000 nm was used on each sample. The loading speed was maintained at the same strain rate of 0.05 sThe G200 Nano Indenter was also used to measure the resistance of the nanocomposite by the nanoscratch testing. The indenter tip scratched on the sample with a wear load value of 200 mN. The scratch length and speed were set as 400 μm and 10 μm/s, respectively. Three independent scratch tests were carried out for each sample.A T1-FR010TH A50  was used to measure flexural strength by three-point flexure testing (according to ISO4049: 2000) at a crosshead speed of 0.5 mm/min. The specimens were prepared in stainless steel molds with a dimension of 2 mm by 2 mm × 25 mm in length.A three-point flexure test was also used to measure the fracture energy, which is the dissipative outside energy during fracture. Fracture energy can be used as the measurement of the toughness of the materials.-1 was attributed to characteristic absorption peaks of C=C bond. After the curing reaction, the methacrylate double bonds had partly changed and the peak intensity decreased. The band at 1120 cm-1 is attributed to the stretching vibration of Si–O–Si in POSS. With the increasing addition of POSS, the peak intensity increased [The FTIR spectra of composite resins with different POSS additions are shown in ncreased .The volumetric shrinkage of POSS hybrid inorganic dental composite resin was evaluated. The volumetric shrinkage value of the dental resin matrix was 3.59%. With the increasing additions of POSS, the volume shrinkage decreased. The values were about 2.98%, 2.87% and 2.54% with the addition of 2%, 5% and 10% POSS, respectively. POSS reduced the shrinkage of resins obviously due to the limitation of free volume variation. Before curing, large chain monomers such as Bis-GMA and TEGDMA were dispersed in the matrix. After curing, the movement of chains was not limited by amount of cross-linked points and the free volume of resins changed remarkably. When the addition of POSS was incorporated in resins, due to its unique inorganic nanocage surrounded with organic groups, it can attract and even entwine monomer chains, which made monomers disperse more tightly before the reaction. The movement of chains is limited by plenty of cross-linked points. The unique nanocage structure of POSS limited the change of free volume of the resin and the volume of the nanocage of POSS did not change after the reaction.2 are also improved obviously.The small addition of POSS remarkably enhanced the hardness and scratch resistance of the dental resin matrix. The hardness and elastic modulus of composite resins with different POSS additions were shown in 2 particles and the POSS organic–inorganic molecule has higher strength. Modification of nano SiO2 with a coupling agent can reduce particle agglomeration. As a result, the distribution of nano SiO2 is more uniform and the effect of reinforcing and toughening is also obvious.Flexural strength and fracture energy can reflect the ability to withstand complex loads for dental restorations. The results of flexural strength and fracture energy of composite resins with different POSS additions were shown in The POSS particles can increase the properties of the composite resin matrix. The big size effect of the particles can cause stress concentration under loading. The resin matrix around the organic and inorganic materials produces yielding phenomena including cavitation, shear zones and crazing. POSS particles can prevent cracks to a certain extent or terminate crack blunting and crack propagation. A lot of energy is consumed, and the craze damage further develops into cracks under the effect of stress. The mechanism of transition between cracks and cracking damage may be due to the structural defects of the polymer. When the polymer is affected by various external forces, stress concentration and cracking damage occurred ,35,36. I2 and POSS in the composite resin are both nano-scale. They can be distributed uniformly and also expand the interface region between the matrix and the filler [However, once the content of nanoparticles exceeds a certain limit, the internal gaps between cracks will be smaller than the diameter of the clumps. This results in the nanoparticles becoming unable enter the gap and the crack cannot return to the state of craze. The material produces a larger gap or deformation under the impact forces and even generates macroscopic cracks. Therefore, the nanoparticles tend to cause the impact strength and toughness of the resin material to decrease when the stress concentration occurs. In addition, the existence of particles prevents the crack from fracturing. Therefore, the addition of POSS fillers should be within a certain limit or it will have an adverse effect. Since the nano SiOe filler . The resMeanwhile, the mechanical properties of resin materials are closely related to its curing degree. The effect of curing is related to light intensity, time and color of the resin. The addition of inorganic filler will affect its light transmittance, which further reduces the curing effect. Meanwhile, the POSS composite resin is viscous. When it is injected into the mold, it may form tiny bubbles, which will cause a tiny void in the resin and decrease the mechanical properties of the resin.2 dental resin composites using light curing method. The volumetric shrinkage and mechanical properties such as hardness, elastic modulus, resistance, flexural strength and fracture energy were analyzed and the effects of POSS on these properties were studied.In this work, various amounts of methacryl POSS were explored to be incorporated into novel nano SiOWith the additions of POSS, the volume shrinkage decreased remarkably. The values were about 2.98%, 2.87% and 2.54% with the addition of 2%, 5% and 10% POSS, respectively. POSS reduced the shrinkage of resins obviously due to the limitation of free volume variation.As for the mechanical properties, the POSS hybrid inorganic dental composite resin exhibited a positive reinforcement effect when a small amount of POSS was added. When it exceeded 5 wt%, heterogeneous distribution and stress concentration appeared. The mechanical properties of the POSS composite resin reduced. The big size effect of the particles can cause stress concentration under loading. With the enforcement of nanoparticles, they were able to enter the interior of the gap and interface region to exhibit physical cross-linking or a nano effect, which transfers the stress and increases the mechanical properties.