MET exon 14 skipping is an oncogenic targetable driver mutation in lung cancer.Two novel non-canonical splice site variants identified in MET genome.Predicted splicing strength using in silico splicing prediction tools.Tested routine cytological smear slides for RNA-based molecular diagnostics.RT-PCR and Sanger sequencing analysis confirmed MET exon 14 skipping.Non-small Cell Lung cancer (NSCLC) contributes to 85% of total lung cancer diagnoses in the United States. With the discovery of various targetable genetic markers and FDA approval of drugs against these markers, genetic testing has become a routine part of the diagnosis and staging process of NSCLC. MET gain of function mutations have been of particular interest as FDA has recently approved two MET inhibitors for the treatment of NSCLC patients with MET exon 14 skipping (METex14) mutations. However, an effective workflow for the classification of various METex14 mutations in the clinical testing laboratory has not been explored. In this report, we reveal two novel METex14 variants and propose a cost-effective and robust workflow for molecular diagnosis of MET variants contributing to exon 14 skipping with the use of readily available specimen sources.Background and aims: The MET exon 14 skipping (METex14) is an oncogenic driver mutation that provides a therapeutic opportunity in non-small cell lung cancer (NSCLCs) patients. This event often results from sequence changes at the MET canonical splicing sites. We characterize two novel non-canonical splicing site variants of MET that produce METex14. Materials and Methods: Two variants were identified in three advanced-stage NSCLC patients in a next-generation sequencing panel. The potential impact on splicing was predicted using in silico tools. METex14 mutation was confirmed using reverse transcription (RT)-PCR and a Sanger sequencing analysis on RNA extracted from stained cytology smears. Results: The interrogated MET (RefSeq ID NM_000245.3) variants include a single nucleotide substitution, c.3028+3A>T, in intron 14 and a deletion mutation, c.3012_3028del, in exon 14. The in silico prediction analysis exhibited reduced splicing strength in both variants compared with the MET normal transcript. The RT-PCR and subsequent Sanger sequencing analyses confirmed METex14 skipping in all three patients carrying these variants. Conclusion: This study reveals two non-canonical MET splice variants that cause exon 14 skipping, concurrently also proposes a clinical workflow for the classification of such non-canonical splicing site variants detected by routine DNA-based NGS test. It shows the usefulness of in silico prediction to identify potential METex14 driver mutation and exemplifies the opportunity of routine cytology slides for RNA-based testing. Lung cancer is the leading cause of cancer death in the United States, with non-small cell lung cancer (NSCLC) contributing to 85% of total lung cancer diagnoses . NSCLC pMET proto-oncogene is located at chromosome 7q21-q31, which encodes for a receptor tyrosine kinase, c-Met, and is activated by ligand hepatocyte growth factor (HGF). Upon activation, MET phosphorylates its substrate and results in the activation of multiple signaling pathways  leading to cell growth, proliferation, survival, adhesion, migration, and differentiation . MET gaiMET gene exon 14 encodes for a regulatory site in the juxtamembrane domain of c-Met protein. This site bears the binding site of Cbl, an E3 ubiquitin ligase, which leads to c-Met degradation upon binding . TherefoWith 3 years (2017 to 2019) of monitoring of the NSCLC specimens that were undergone in-house via the Cancer hotspot NGS test, we identified 20 cases of MET exon 14 and intron 14 genomic alterations. Out of the 20, we have identified three potential METex14 cases that do not involve canonical splicing sites. Two patients had novel variants identified in intron 14, c.3028+3A>T, and the third patient carried a variant in Exon 14, c.3012_3028del. These three NSCLC specimens were further investigated for the impact of MET exon 14 skipping at the RNA level. For the positive control, a patient’s specimen (cytology slides) with MET exon 14 canonical splicing donor site mutation that causes MET exon 14 skipping was used. For the negative control, an RNA specimen from a patient’s white blood cells without a history of NSCLC was used. The study was conducted according to the approved protocols of Cleveland Clinic’s Institutional Review Board .Genomic DNA was extracted from the bronchial fluid of NSCLC patients, which was preserved in PreservCyt solution using the Maxwell RSC Cell DNA purification kit according to the manufacturer’s instruction . The quantity and quality of purified DNA were evaluated using Nanodrop and Qubit and stored at 4 °C until tested by Cancer hotspot NGS ,23. DireBRAF, EGFR, ERBB2, KRAS, and MET were identified using NextGENe Software . The Integrative Genomics Viewer (IGV) was used to visually inspect the quality of read alignment and variant calls. A quality score of Q30 was used as filtering criteria to determine the sequence read quality. For a given sample, the minimum coverage requirement of targeted regions was 100×. Variants with variant allele frequencies (VAFs) as low as 2% may be identified using this method. The MET RefSeq transcript NM_000245.3 is used for variant data analysis and reporting.Cancer hotspot NGS library preparation was performed as described previously ,23. BrieIn silico splice tools, including SpliceSiteFinder-like, MaxEntScan, NNSplice, and GeneSplicer, were integrated in the Alamut Visual Plus  for the prediction of the MET variant’s impact on gene splicing. In the Alamut Visual Plus, impacts on gene splicing from individual tools are represented either with a vertical blue bar for 5′ donor sites or a vertical green bar for 3′ acceptor sites. Assigned scores, which are proportional to the heights of each bar, are indicators of splicing donor or acceptor signals that impact the splicing strength. Known constitutive signals are displayed as a small blue triangle for 5′ or a green triangle for 3′, close to the sequence letters.RNA specimens from the patients and negative control were reverse transcribed using the Ipsogen Reverse Transcription kit  with random primers. The obtained cDNA was amplified using a forward primer specific to MET Exon 13, 5′-GCTGGTGTTGTCTCAATATCAA-3′ and a reverse primer specific to MET Exon 15, 5′-GGCATGAACCGTTCTGAGAT-3′. The PCR conditions are as follows: 95 °C for 3 min and 45 cycles of 95 °C for 30 s, 55 °C for 3 s, and 72 °C for 2 min. The PCR products were analyzed using Bioanalyzer and the splicing products were subjected to Sanger sequencing. Sanger sequencing was performed using a modified protocol supplied by Applied Biosystems BigDye Terminator 1.1 and 3.1 Cycle sequencing kits. Fragments were then analyzed using Applied Biosystems 48-capillary 3730 Genomic Analyzer.Three advanced-stage NSCLC patients with one exon 14 and the other intron 14 novel MET variants were identified from an in-house lung cancer NGS test. Patients’ demography and clinical characteristics are shown in Since the MET variants were identified near the exon–intron junction, we performed an in silico analysis for possible impact in splicing. Using the splicing prediction tool analysis, we have observed a drastic reduction in splicing strength at the MET intron 14 splicing donor site in both variants (c.3028+3A>T and c.3012_3028del), compared with the MET wild-type transcript B,C, suggTo provide functional evidence of these two MET variants causing a splicing defect and exon 14 skipping, an RT-PCR and Sanger sequencing analysis were performed. The positions of PCR primers and predicted amplicon sizes for MET wild-type (WT) and METex14 are shown in MET mutations that produce MET gain-of-function have been growing in interest among clinicians for their use as an actionable oncogenic therapeutic target for NSCLC patients. Clinical trial data, based on which the first MET-targeted therapy was approved in 2020, indicated that NSCLC patients with METex14 somatic mutation show better outcomes with longer survival ,25,26,27It is well known that the canonical splice donor GT and acceptor AG dinucleotide sites are required for spliceosome interaction and subsequent splicing of the intronic sequences in pre-mRNA. Thus, in a molecular diagnostic laboratory, variants identified at the canonical splice sites are mostly classified as likely pathogenic (LP) or pathogenic due to the well-established biological impacts on gene splicing. Evidence also suggests that the immediate vicinity of 12–30 and 15–33 nucleotides surrounding the intronic donor and acceptor site, respectively, may contribute to the splicing efficiency by proving a preferential low folding strength . In addiTo our knowledge, the presence of the c.3028+3A>T variant was not reported previously, as searched in the COSMIC, cBioPortal or in the population database, gnomAD. Rather, another variant was reported at the same nucleotide position (c.3028+3A>G) in a patient with pulmonary sarcomatoid carcinoma, which led to MET exon 14 skipping . ConsequWe have observed in the RT-PCR results that WT transcript levels are not proportional to the allelic fractions observed in the DNA-NGS analysis in Patients 1 and 2. WT transcripts were either near the detection limit (Patient 1) or at reduced levels (Patient 2), even when the variant allelic fractions were well below 50%. These observations are likely attributed to either (1) an inaccurate estimation of tumor cells in each specimen; (2) the non-quantification nature of the end-point PCR test; (3) the uneven distribution of the tumor and infiltrating stromal cells in the process of making various types of specimens for different downstream analyses. For the NGS analysis, paraffin blocks were used, whereas cell-smeared slides (Diff-Quick and pap-stained) were used for the RT-PCR assay. Even two smear slides made from the same specimen source will not have equal proportions of normal and malignant cells due to uncontrolled cell separation during the smearing preparation. A similar unproportioned transcript pattern was also seen in the previous reports of METex14 analysis in various RNA-based assays ,21.The ability of a diagnostic laboratory to determine the impact of a variant on gene splicing is essential. Our study warrants the importance of detecting actionable mutations with METex14 for NSCLC patients, including targets in MET exon 14 and surrounding introns. Additionally, METex14 detects better in an RNA-based NGS assay at a 4.2% rate compared to a 1.3% rate in a DNA-based NGS assay, which prompts clinicians to use a supplemental RNA-based panel ,38. Howe


In addition, the causality test revealed the feedback hypothesis available between tourism and HCD in all sample countries except India. In conclusion, the role of tourism development is critically important for sustainable HCD in BRICS. Therefore, in case of a policymaking concern, it is inevitable to address the tourism issues with care for capitalizing on the benefits for tourism development.The motivation of the study is to explore the nexus tourism-led sustainable human capital development (HCD) in Brazil, Russia, India, China, and South Africa (BRICS) for the period 1984–2019. The study applied several econometrical techniques for exposing the empirical association between tourism and HCD, such as the conventional and structural break unit root test, the combined cointegration test, long-run and short-run coefficients detected through implementing the Augmented Autoregressive Distributed Lagged (AARDL), and directional causality by following Toda-Yamamoto with Fourier function. The unit-roots test established variables are integrated in mixed order, wherein variables are stationary at a level or after the first difference. The estimated test statistics from the combined cointegration test and AARDL confirmed the long-run association between tourism, gross capital formation, financial development, and HCD. Tourism revealed a positive and statistically significant tie with HCD in the long run. Moreover, the joint effects of interactive terms TOR Referring to the long-run association, especially from tourism, gross capital formation, and financial development with HCD, the study documented positive and statistically significant links between explanatory variables that tourism, gross capital formation, and financial development have with HCD in both the long-run and short-run. Furthermore, directional causality with Fourier-Toda-Yamamoto (TY) revealed the feedback hypothesis that bidirectional causality runs between tourism and HCD [TOR← → HCD], suggesting the importance of both factors in their respective development.The remaining structure of the manuscript is as follows: Section Literature Review deals with the literature review and conceptual development for the study. Data and econometrical tools are displayed in Section Methodology and Data of the Study. Empirical model estimation and interpretation are reported in Section Estimation and Interpretation. Discussion of the study findings are reported in Section Discussion and the conclusion is available in Section Conclusion.Since the advent of the growth model offered by Solow , educativia the educational system. On the other hand, HCD is critical for development not just for its instrumental value but also for its intrinsic significance as a development target in and of itself.Human capital is essential to economic development and poverty alleviation Becker, . From a Capital accumulation results in technological advancement in an economy, enhancing the advantages of large-scale manufacturing and increasing economic specialization  deals with the direct effects running from explanatory variables to dependent variables in the equation, but the interactive term incorporation in Equation (2) confirms to reveals both direct and indirect effects of tourism on HCD. The variables delimitation and data sources are displayed in HCD is the process of enhancing human potential to achieve a healthy and knowledgeable life, a good quality of living, and the capacity to prosper  is to be implemented to explore each variable's elasticitywith interactive term for joint effects*TOR) and (TOR*GCF) are interactive terms, and X denotes control variables that are FDI and money supply in the economy. E is the error term, and subscript t is the period. All the data were transformed into a natural log before empirical estimation.where HCD stands for human capital development, TOR for tourism development, GCF denotes gross capital formation, FD for financial developmen , whereas γt stands for the random walk factors in the estimation. Kwiatkowski et al.  following another additional F-test as suggested by McNown et al. , and (t-1) is for the lagged period. Based on linear ARDL, the long-run coefficient were available from γn et al. .The study implemented the following equation with error correction terms to capture the short-run dynamics.Researchers used the Granger  causalitt) explain the possible structural changes in the dependent variable (y), β1 stands for the coefficients, and εt stands for the white noise error term in the equation. The above Equation (13) can be transformed with Fourier functions for capturing the unknown structural changes in the following manner.where α(H0 : β1 = β2…………….βP = 0).where k refers to the frequency, t denotes time trend, T shows the number of observations, and %_ and %_ measures the amplitude and displacement of the frequency. The null hypothesis for Fourier–TY test is no causality between variables . The long-run association under the augmented ARDL framework is displayed in The empirical estimation results of the long-run and short-run coefficients are displayed in The role of capital adequacy in capital formation in the economy boosts the present state of human capital accumulation, suggesting the positive and statistically significant association between capital formation and HCD in BRICS nations. In particular, a 10% growth in domestic capital formation in BRICS can increase the process of human capital accumulation by 0.911% in Brazil, 0.979% in Russia, 1.457% in India, 1.109% in China, and 1.556% in South Africa. While referring to short-run coefficients, the positive effects are from gross capital formation to HCD. However, the magnfititutes are more evident in the long-run compared with the short-run. Precisely, a 10% innovation in gross capital formation in the short-run accelerates the HCD process by 0.153% in Brazil, 0.104% in India, 0.125% in China, and 0.129% in South Africa, whereas negative linkage was revealed in Russia with a coefficient of −0.683%.For nexus between financial development and HCD, the study established a positive and statistically significant association in the long run (short run) in Brazil with a coefficient of 0.1378 (0.0233), in Russia with a coefficient of 0.096 (0.0162), in India with a coefficient of 0.1427 (0.0058), in China with a coefficient of 0.1681 (0.097), and in South Africa with a coefficient of 0.0913 (0.0288). Long-run magnfititutes of financial development are evident in comparison to the short-run assessment. More precisely, a 10% further development in the financial system can accelerate the growth of human capital accumulation in the economy by 1.378% in Brazil, 0.96% in Russia, 1.427% in India, 1.681% in China, and 0.913% in South Africa.The coefficient of error correction established negative and statistically significant at a 1% level of significance, suggesting that long-run convergence toward the equilibrium position. More precisely, due to explanatory variables shock in the short-run, the disequilibrium state can be rectified at a speed of 14.4% per period in Brazil, 12.12% per period in Russia, 15.84% per period in India, 36.2% per period in China, and 11.64% per period in South Africa. Furthermore, the study has implemented several residual diagnostic tests for confirming the model's internal consistency, robustness in estimation, and efficiency in managing residual (see Panel-C). Referring to residual diagnostic test statistics, it was revealed that empirical models are free from serial correlation, and normally distributed residuals have no issue for heteroskadacity.*FDD, TOR*GCF for indirect effects of tourism through the channel of financial development and capital formation in the economy. The long-run association under the augmented ARDL framework is dispalyed in overall, tDV, and FIDV are statistically significant at a 1% significance, suggesting the long-run cointegration between research units. The conclusion of long-run association in the empirical model is valid for all sample countries' estimations. Once the cointegration has been detected, the study evaluates the long-run and short-run magnfititutes of explanatory variables on HCD in BRICS nations.Next, we gauge the long-run cointegration between remittances, financial development, cash flows, and HCD by performing Equation (10) with the interactive term: TORThe results of long-run and short-run coefficients empirical estimation with interactive term is displayed in Regarding the role of capital adequacy in human capital formation in the economy, the study has documented the positive tie with HCD in BRICS nations: Brazil (a coefficient of 0.1248), Russia (a coefficient of 0.1525), India (a coefficient of 0.0579), China (a coefficient of 0.0994), and South Africa (a coefficient of 0.1317). In particular, a 10% growth in domestic capital formation in BRICS can increase human capital accumulation by 1.248% in Brazil, 1.525% in Russia, 0.579% in India, 0.994% in China, and 1.317% in South Africa. Regarding short-run coefficients, the adverse effects run from gross capital formation to HCD in Brazil (a coefficient of −0.0243), Russia (a coefficient of −0.0689), India (a coefficient of −0.0426), and South Africa (a coefficient of −0.0086), whereas a positive and statistically significant connection was revealed in China (a coefficient of 0.126).Referring to the association between financial development and HCD in BRICS nations, the study findings documented a positive and statistically significant tie between the measurement of financial development and HCD in the long run and mixed-effects revealed in the short run. In the long run, a 10% growth in the financial system can trigger the present state of HCD by 1.139% in Brazil, 1.646% in Russia, 1.357%, 1.231% in China, and 0.684% in South Africa. On the other hand, financial development in the short-run revealed positive and statistically significant association in China (a coefficient of 0.0425) and South Africa (a coefficient of 00728), whereas a negative and statistically significant association was found in Brazil (a coefficient of −0.0267), Russia (a coefficient −0.0562), and India (a coefficient −0.064). So, it is assumed that financial development has critical importance for sustainable HCD; thus, BRICS nations have to establish uniformity between financial policy formulation and HCD strategies in the economy.*FD) and capital formation (GCF*TOR), the study documented a positive and statistically significant connection between TOR*CF (TOR*FD) with HCD in the long run in Brazil with a coefficient of 0.051 (0.0938), in Russia with a coefficient of 0.0488 (0.0762), in India with a coefficient of 0.1796 (0.0527), in China with a coefficient of 0.0677 (0.0746), and in South Africa with a coefficient of 0.0248 (0.0297). For the short-run assessment, the study documented a mixed nature of association, that is, both positive and negative linkage were revealed, but the coefficients' elasticity is petty insignificant.Referring to the coefficients of interactive terms, that is, the indirect effects of tourism on HCD through the channel of financial development . Referring to residual diagnostic test statistics, it is revealed that empirical models are free from serial correlation, and normally distributed residuals have no issue for heteroskadacity.Next, the directional association in the empirical equation has been derived by implementing the novel TY causality test with the Fourier function familiarized by Enders and Jones . The resvia their job, allowing them to live a respectable existence and extending their life expectancy. Second, tourism development generates cash for the government and provides extra financing for the government to subsidize health and educational services, making them affordable to a broad segment of the population and providing educational and health facilities. Moreover, our present study contradicts the study finding documented by KoŽić  and/or intangible assets  in a nation. The study of Onyinye et al.  argued tThe motivation of the study is to gauge the role of tourism development on sustainable HCD in BRICS for the period 1984-2019. The study applied both conventional and unknown structural break unit root tests, the novel Bayer and Hanck  combinedFirst, the stationarity test with conventional and unknown structural break unit root tests revealed that all the variables were stationary either level or after the first difference but not after the second difference. Findings suggest that variables are integrated in mixed order, preferable for autoregressive distributed lagged implementation.Second, the study implemented the novel combined cointegrated test offered by Bayer and Hanck ; the tesThird, empirical assessment with AARDL revealed long-run cointegration between tourism, gross capital formation, financial developer, and HCD in BRICS nations. In the long run, the coefficients of tourism, gross capital formation, and financial development are positive and statistically significant at a 1% level of significance, suggesting the contributory role toward sustainable HCD in BRICS. Furthermore, in the short run, the magnfititutes of tourism, gross capital formation, and financial development to HCD are positive and statistically significant but insignificant compared with long-run coefficients. The coefficient of joint effect, that is, the interactive terms are positive and statistically significant, implying the indirect effects of tourism through financial development and gross capital formation on HCD, especially in the long run.Fourth, the directional causality with Fourier-TY, following Nazlioglu et al. , documenConsidering all the information revealed with the empirical assessment, we ended with the concluding remarks for further actions in developing and achieving sustainable HCD in BRICS nations. For maintaining sustainable HCD with the assistance of tourism, it is evident that policymakers have to put extra effort into boosting the progress of tourism development because the findings of the interactive term reveal the positive connection to HCD. HCD, according to literature, ensure a skilled workforce in the economy, that is, the transformation of the population into resources with the inclusion of technology and conceptualization development. Precisely, the population having both technical know-how and formal education, that is, population enrolment in schooling, can boost accumulating skilled human resources in the society. Furthermore, tourism inflows increase earning opportunities in the economy and support increasing present living standards. Thus, the capacity to avail education can be an alternative through which tourism can play a role in sustainable economic development in BRICS. Additionally, higher education plays a role in educational tourism, recognizing that “educational tours are an interesting site of study, first, because they are explicitly about learning, and second, because they provide an opportunity for universities to reach beyond their walls and directly teach members of the broader community.” It is asserted that universities can play a pivotal role in teaching ethics outside of the context of academic education by providing moral education that supplements professional skills and by using the entire world as a stage for pedagogy and that it is possible to increase the links between the university and the community by using mixed strategies, such as practical and experiential learning at a local level, and by exposing students to real life.via increased productivity. Bank-based financial inclusion significantly enhances financial inclusion and contributes to faster economic development via inclusive growth in developing nations where bank-based financial systems are prevalent. Furthermore, financial inclusion through microfinance models lowers the cost of financial intermediation for borrowers, resulting in quicker economic growth. Tourism helps reduce poverty in developing nations, especially in the least developed countries, when people and small- and medium-sized enterprises (SMEs) active in the tourism industry have established access to financing in BRICS. Tourism development has revealed the sources of capital flows in the economy because the money flows from tourism receipts increase the capital adequacy in the economy and allow the population to earn extra by garbing the income scope available in the economy, which eventually promotes the prospects of human rights capital in the long run.In other words, government policies for promoting tourism can increase financial activities in the financial system, suggesting that financial development and eventually financial progress allow HCD by offering opportunities, skills, and technological exposure in the economy. Financial inclusion helps tourist businesses and entrepreneurs to acquire institutional financing and bolster the resources necessary for tourism operations. Inextricably linked to innovation, access to financing contributes to economic development The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.JL: introduction, methodology, and first draft preparation. MQ: introduction, methodology, empirical model estimation, and final preparation. Both authors contributed to the article and approved the submitted version.This research project has been funded by the Institute of Advanced Research (IAR) (Grant-IAR/2021/PUB/007).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


As publications on social media have become an important regulator of group opinions, moods and psychological well-being during the spread of COVID-19, it seems necessary to study the contribution of various information as a source of preserving the psychological resources of the population.To analyze the content in communities created during the spread of the COVID-19 pandemic in order to assess the image of health professionals on social media.Using datamining methods, we analyzed publications about medical staff in a large community ‘StopCoronavirus.RF’ which unites more than 400 thousand users.More than 700 thousand entries were ‘liked’ in the community from March 2020 to March 2021; more than 125000 thousand posts were shared, about 290 thousand comments were written, and all community publications were viewed more than 3 billion times. Publications about medical staff working in the ‘red zones’ in Russia are distinguished by the largest number of ‘likes’ (more than 5000) and comments (more than 300). In the publications and comments, the model of modern heroes saving human lives is emphasized. This type of information contributes to the reduction of anxiety and promotion of psychological safety in case of COVID-19 contraction through establishing confidence in the competence of medical staff and their involvement in the fight against the pandemic.These results suggest that the image of a doctor on social media during the pandemic has acquired special value for the population. Publications on the work of medical staff in the ‘red zones’ help to cope with anxiety associated with the COVID-19 pandemic. The study was funded by RFBR, project number 20-04-60174.No significant relationships.


Given the excessive demolition of structures each year, the issues related to the generated structural waste are striking. Bricks being a major constituent in the construction industry, also hold a significant proportion of the construction waste generated annually. The reuse of this brick waste in new constructions is an optimal solution considering cost-effectiveness and sustainability. However, the problems related to the substandard peak stress and ultimate strain of concrete constructed with recycled brick aggregates (CRAs) limit its use in non-structural applications. The present study intends to improve the unsatisfactory mechanical characteristics of CRAs by utilizing low-cost glass fiber chopped strand mat (FCSM) sheets. The efficacy of FCSM sheets was assessed by wrapping them around CRA specimens constructed with different concrete strengths. A remarkable increase in the peak compressive stress and the ultimate strain of the CRA specimens were observed. For low, medium, and high strength CRAs, the ultimate strain improved by up to 320%, 308%, and 294%, respectively, as compared to the respective control specimens. Several existing analytical models were utilized to predict the peak compressive stress and ultimate strain of the CRAs strengthened using FCSM sheets. None of the considered models reproduced experimental results accurately. Therefore, equations were formulated using regression predicting the peak stress and ultimate strain of the CRAs confined with FCSM sheets. The predicted values were found to correlate well with the experimental values. The rapid urbanization and the consequent demolition of existing buildings have raised some serious concerns regarding the proper and safe disposal of construction waste. The risk of an increased carbon footprint looms if proper and adequate measures are not taken regarding the generated construction waste. One possible solution to prevent the costs related to the disposal of construction waste is to reuse it. This not only increases the economic feasibility of the project but also lowers the demand for the rapidly depleting natural aggregate resources . SeveralClay bricks constitute a major role in the construction industry, ascribed to their inexpensive nature and easy availability. As a result, the construction waste generated each year involves a significant portion of clay bricks. For instance, it has been reported that the clay brick waste generated annually in China is increasing in geometric progression  and apprExternal confinement is a technique in which additional materials are applied or wrapped around the concrete members to alter the structural performance of the concrete members. It has been known widely that the external confinement on CNA improves its mechanical characteristics, mainly the peak compressive strength and the ultimate strain ,24,25,26To date, no detailed study is present to assess the efficacy of FCSM sheets in mitigating the unsatisfactory mechanical characteristics of recycled aggregate concrete (CRA). This study aims to fill this gap by strengthening CRA specimens with FCSM sheets and exploring the enhancement in the mechanical characteristics, mainly the peak compressive stress and the ultimate compressive strain. Given that FCSM sheets offer strength mainly in their axial direction, the possibility of using existing compressive stress-strain analytical models for concrete externally confined with FRP in predicting the mechanical characteristics of CRA is also investigated. For this purpose, this study presented experimental findings of the monotonic compression tests applied to concrete constructed with CRA and externally confined with low-cost FCSM wraps. Three concrete strengths were considered, and eight rectilinear specimens were tested for each concrete strength. For each concrete strength, two, three, and four wraps of FCSM were applied.Twenty-four specimens were constructed and tested in this study. Specimens were categorized into three groups depending on the concrete strength see . The des2. The thickness of the FCSM sheet was 0.5 mm and the width of the FCSM roll was 1.0 m. The mechanical properties of the FCSM wraps were estimated by following the recommendations of ASTM D3039M-08 [Aggregates were recycled by crushing solid clay bricks see a using a3039M-08 . The ultIn this study, rectilinear concrete specimens of dimensions of All specimens were constructed in laboratory environments. Steel molds were prepared to cast the specimens, as shown in A universal testing machine (UTM) with a 1000 kN was utilized to apply a compressive monotonic load. The end surfaces of each specimen were properly cleaned and smoothened prior to the testing. Steel plates were attached above and beneath the specimen to guarantee a uniform load application. A load cell with a 500 kN capacity was utilized to measure the load intensity, whereas a logger was used to record the measured data. Two linear variable displacement transducers (LVDT) were employed to measure the compressive shortening of the specimens see .The failure types of specimens in each group are shown in Specimen 20-CON failed in a brittle manner similar to Specimen 15-CON. However, the crushing and splitting of the concrete were detected along its full height. The failure of strengthened specimens in group 2  also accompanied the rupture of the FCSM wraps. However, this rupture was observed in the center of the vertical sides. This suggests that the 13 mm corner radius was sufficient in the higher strength concrete. The ultimate failure modes of the group 3 specimens were similar to those in group 2, as shown in The experimental peak compressive stresses and ultimate strains are presented in Continuous recording of the compressive load and axial shortening was conducted using a data logger. The recorded compressive load was converted to the compressive stress using the cross-sectional area of the specimens, whereas the compressive shortening to the strain us was converted ing the height of the specimens. The measured compressive stress and strain curves of the group 1 specimens are illustrated in The stress versus strain graphs of the group 2 specimens are shown in Finally, the stress versus strain graphs of the group 3 specimens are presented in The effect of the number of FCSM wraps and concrete strength on the increase in the peak compressive stress is shown in The impact of the strength of concrete and the number of FCSM wraps on the increase in the ultimate strain is shown in In this section, existing analytical models were evaluated in approximating the peak compressive stress and ultimate strain. To the authors’ knowledge, no analytical models for FCSM confined concrete are available in the literature. However, several researchers have proposed confinement models for synthetic and natural fiber-reinforced polymer (FRP) confined concrete ,53,54,55tion (2) ,53,54,55tion (2) ,53,54,55tion (3) , ft is ttion (4) .(3)D=b2The accuracy of the analytical models in The existing models were evaluated to predict the ultimate strain of the CRA confined with FCSM wraps. For the low-strength specimens in group 1, the models of ACI-440.2 R-17  and Lam The experimental results were utilized to propose expressions to estimate the peak compressive stress and ultimate strain of the CRA strengthened with FCSM wraps. A nonlinear regression was performed to propose Equations (6) and (7) for the peak stress and ultimate strain of the CRA strengthened with FCSM wraps.This study presented experimental findings of the monotonic compression tests applied to concrete constructed with recycled brick aggregates (CRAs) and externally confined with low-cost FCSM wraps. Three concrete strengths were considered, and eight rectilinear specimens were tested for each concrete strength. For each concrete strength, two, three, and four wraps of FCSM were applied. The subsequent important inferences can be made:The peak compressive stress of the specimens was increased by 61%, 98%, and 140% as compared to the reference specimen for the 2, 3, and 4 wraps of the FCSM applied to the low strength  CRA specimens. For the medium strength CRA , an up to 102% improvement in the peak stress was observed, whereas the peak stress was improved up to 83% for the high strength CRA . The peak stress was found to increase as the number of FCSM wraps increased.The FCSM wraps were efficient in enhancing the compressive ductility of the CRA. For the low, medium, and high strength CRA, the ultimate strain improved up to 320%, 308%, and 294%, respectively, as compared to the respective control specimens.In particular, 3 and 4 wraps of the FCSM resulted in a bilinear stress-strain behavior irrespective of the concrete strength.The improvement in the peak stress and ultimate strain as a result of the FCSM wrap confinement varied in inverse relation to the unconfined concrete strength, irrespective of the number of FCSM wraps.Various existing analytical models of confined concrete were assessed to predict the peak compressive stress and ultimate strain of the CRA strengthened with the FCSM wraps. None of the existing models were found to estimate the peak stress and ultimate strain for all the groups consistently. Therefore, equations for the peak stress and ultimate strain were formulated from a nonlinear regression analysis. The accuracy of the proposed equations was assessed using Pearson’s coefficient


Background: Ventilator-associated pneumonia (VAP) is the most widespread and life-threatening nosocomial infection in intensive care units (ICUs). The duration of antibiotic use is a good predictor of prognosis in patients with VAP, but the ideal duration of antibiotic therapy for VAP in critically ill patients has not been confirmed. Research is therefore needed into the optimal duration of antibiotic use and its impact on VAP.Methods: The Medical Information Mart for Intensive Care database included 1,609 patients with VAP. Chi-square or Student’s t-tests were used to compare groups, and Cox regression analysis was used to investigate the factors influencing the prognoses of patients with VAP. Nonlinear tests were performed on antibiotic use lasting <7, 7–10, and >10 days. Significant factors were included in the model for sensitivity analysis. For the subgroup analyses, the body mass indexes (BMIs) of patients were separated into BMI <30 kg/m2 and BMI ≥30 kg/m2, with the criterion of statistical significance set at p < 0.05. Restricted cubic splines were used to analyze the relationship between antibiotic use duration and mortality risk in patients with VAP.Results: In patients with VAP, the effects of antibiotic use duration on the outcomes were nonlinear. Antibiotic use for 7–10 days in models 1–3 increased the risk of antibiotic use by 2.6020-, 2.1642-, and 2.3263-fold relative to for >10 days, respectively. The risks in models 1–3 for <7 days were 2.6510-, 1.9933-, and 2.5151-fold higher than those in models with >10 days of antibiotic use, respectively. These results were robust across the analyses.Conclusions: The duration of antibiotic treatment had a nonlinear effect on the prognosis of patients with VAP. Antibiotic use durations of <7 days and 7–10 days both presented risks, and the appropriate duration of antibiotic use can ensure the good prognosis of patients with VAP. Ventilator-associated pneumonia (VAP) is one of the most prominent hospital-acquired diseases in intensive care units (ICUs), and has a substantial risk of adverse effects . The preAntibiotics are widely used to treat infectious diseases, and China is one of the world’s major producers and consumers of antibiotics. Antibiotics are used by about half of all hospital outpatients in China, according to linked publications, and antibiotic prescriptions account for about half of all medications dispensed by hospitals. The top five antibiotics taken by Chinese in 2013 were cephalexin, amoxicillin, ofloxacin, tetracycline, and norfloxacin . AntibioPseudomonas aeruginosa and Acinetobacter species  ≥30 kg/m2] had significantly lower 90-days mortality than nonobese patients (BMI <30 kg/m2) in a 2021 study . BMI wasThe purpose of this study was to explore the effect of appropriate timing of antibiotic administration on the survival of VAP patients by applying restricted cubic splines (RCSs) to data in the Medical Information Market for Intensive Care (MIMIC) database.The Computational Physiology Laboratory of Massachusetts Institute of Technology, Beth Israel Deacon Medical Center, and Philips Healthcare jointly published the MIMIC-IV database (version 1.0) for the period of 2008–2019.We received permission from an institutional review board of the Massachusetts Institute of Technology and Beth Israel Deaconess Medical Center for a longitudinal single-center database of clinical information on ICU patients, and data extraction from and access to the database were implemented . Dr. YixPatients with VAP were identified in the MIMIC-IV database. This study gathered data on the demographics, laboratory tests, medications, vital signs, surgical procedures, and other personal information of patients with VAP . We extrThe following variables were extracted from the records of the patients with VAP in the MIMIC-IV database: 1) Demographic data and vital signs at hospital admission ; 2) laboratory test data ; 3) drugs and surgical operations . The impact of antibiotic use duration on the survival of patients with VAP was investigated. The endpoint for this study was survival at discharge.U test, one-way ANOVA, and the Kruskal-Wallis H test were used to make comparisons of nonnormally distributed statistical data. The Kolmogorov-Smirnov test was used to determine if continuous variables were normally distributed. Categorical variables are expressed as percentages or numbers. We excluded confounding variables and outliers with considerable effects, and applied Chi-square tests to categorical variables and Student’s t-tests to continuous variables, with the exceptions of survival status and length of hospital stay.Patients were divided into two groups based on whether they survived during their hospitalization. Median and IQR values and mean ± SD values were used to summarize the nonnormally and normally distributed continuous variables, respectively. Student’s t-test, the Mann-Whitney Before performing the multivariate analysis, a univariate analysis was needed for each factor to determine if the covariance inclusion criteria were met to ascertain variables that affect VAP prognosis. Finally, the duration of antibiotic use was divided into >10, 7–10, and <7 days. A nonlinear test was used to determine whether the duration of antibiotics had a nonlinear effect on VAP prognosis. For subgroup analysis, the patients were divided into nonobese and obese groups.p < 0.05 was considered statistically significant. However, using data that had more than 20% missing or data that had missing points, we used the “vim”  days were younger than those who died at 70  years. Surviving patients were less likely to develop complications such as hypertension, chronic obstructive pulmonary disease (COPD), and diabetes than those who died. All variables affected VAP prognosis differently in this study. The baseline characteristics, laboratory parameters, and vital signs of survivors and deceased patients during hospitalization are listed in p < 0.05. The results indicated that CKD, norepinephrine, vasopressin, cefazolin, tracheostomy, GC, PEG, POUF, TT, antibiotic use duration, APSIII, CCI, SCR, GCS score, SOFA score, LODS, MELD score, SAPSII, BMI, urine output, DBP, MBP, temperature, admission age, hemoglobin, RBC, RDW, ALT, platelet count, bicarbonate, and basophils were prognostic factors for patients with VAP  and 2.6510  for antibiotic use durations of 7–10 and <7 days, respectively. Model 2 included CKD, norepinephrine, vasopressin, cefazolin, tracheostomy, GC, PEG, POUF, TT, SCR, BMI, urine output, DBP, MBP, antibiotic use duration, temperature, admission age, hemoglobin, RBC, RDW, ALT, platelet count, bicarbonate, and basophils (p < 0.001) and 1.9933  for antibiotic use durations of 7–10 and <7 days, respectively. As demonstrated in p < 0.001) and 2.5151  for antibiotic use durations of 7–10 and <7 days, respectively. In all models, the prognostic curves for VAP were nonlinear for antibiotic use duration. the antibiotic use duration curve showed a significant change trend at around 12 days (p < 0.001). Notably, as the adjustment variable increased, the risk for antibiotic use for ≤10 days was more pronounced, and statistically significant that for >10 days.RCSs were used to perform the association analysis between duration of antibiotic use and risk of all-cause mortality from VAP. The RCS test yielded statistically significant findings . Model 1asophils . Model 2p < 0.05). The Cox regression analysis revealed that BMI was a predictive factor for patients with VAP. VAP is a primary risk factor for mortality among critically ill patients. Treatment strategies may benefit from objective prognostic assessment tools . Due to Antibiotic stewardship methods in China include bacterial resistance surveillance at the hospital level, as local antibiotic resistance statistics are crucial for guiding rational antibiotic usage, and the development of antibiotic resistance is closely related to the duration of antibiotic use. In this research, a reliable predictive model for the duration of antibiotic treatment in patients with ventilator-associated pneumonia was developed, which can assist clinicians in making decisions about the prognosis of VAP patients and the optimal duration of antibiotic treatment, improving the patient’s chance of survival and reducing the risk of social labor loss cost and national medical resources .Globally, overuse and inappropriate use of antibiotics is widely known as the primary cause of antibiotic resistance, as well as prolonging hospital stays, increasing treatment costs, and mortality associated with infectious diseases, acute upper respiratory infections, and ventilator-related complications. The most prevalent illnesses linked to antibiotic misuse are acute upper respiratory tract infection and ventilator-associated pneumonia. Antibiotic resistance has posed a serious threat to the effectiveness of existing antibiotics and their prescription regimens, affecting people of all socioeconomic backgrounds in community-acquired and nosocomial infections, as well as high health-care costs that lead to chronic poverty, whether untreated or treated. Excessive risk of morbidity and mortality. Appropriate antibiotic treatment length can effectively prevent drug resistance, better reduce human capital loss, mitigate economic shocks suffered by poor and developing societies and countries, and lower the risk of medical poverty traps .The bactericidal effect of antibiotics has been observed to depend on the time when the MIC is exceeded, and it is recommended to reach a time where the MIC is 100% or even higher. It is reasonable to apply a positive PharmacoKinetics and PharmacoDynamics (PK/PD) target in patients with VAP. In patients with respiratory tract infection, the 30-days survival rate of those receiving long-term β-lactam infusion was dramatically higher than that of patients receiving an intermittent bolus, and antibiotics had a considerable degree of concentration-dependent apoptosis characteristics as well as time-dependent characteristics . The optp < 0.001). All prediction curves for antibiotic use time in RCS had similar performances. Based on antibiotic use of >10 days, this study set a long-term antibiotic range within which the risk of VAP was lowest. Notably, the effect of antibiotic use duration on VAP prognosis was nonlinear with statistical significance (p < 0.001). When performing sensitivity analyses, all models with antibiotic use ≤10 days also had a higher mortality risk than those with >10 days. For models 1-3, the risks of using antibiotics for 7–10 days were 2.6020-, 2.1642-, and 2.3263-fold higher than for an antibiotic use duration of >10 days, respectively, while the risks of model 1–3 with an antibiotic use duration of <7 days were 2.6020-, 2.1642-, and 2.3263-fold higher, respectively.A Cox proportional-hazards regression model fitted with RCS was used in this study to explore the link between the duration of antibiotic use and the risk of all-cause mortality. Compared with a duration of antibiotic use >10 days, patients with VAP and a duration of ≤10 days had a higher mortality risk. The Cox multivariate analysis indicated that the duration of antibiotic use was a prognostic factor for patients with VAP (Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Methicillin-resistant Staphylococcus aureus, and pathogen identification and drug susceptibility assessments should be carried out as soon as possible. Trials to ensure the adequate coverage and appropriate dose and duration of treatment could reduce the mortality from VAP (In the subgroup analyses, the nonobese and obese groups also had a higher risk from antibiotic use ≤10 days compared with >10 days. According to Pugh et al., the VAP recurrence rate was higher for a short course of 8 days than for a longer course of 12–15 days in patients with VAP from nonfermenting Gram-negative bacilli organisms. This increased recurrence risk did not appear to be linked to increased mortality, the need for prolonged mechanical ventilation, or the time spent in the ICU . Insuffifrom VAP .De Oliveira noted that across all age groups, obese patients were not more likely to develop pulmonary complications than those with normal BMI . WardellThis study explored the relationship between duration of antibiotic use and VAP and performed subgroup analyses to identify a cutoff of approximately 12 days for the prediction curve of antibiotic use duration and quantified the risk across the curve, and also found that obesity was associated with reduced ICU mortality in patients with VAP. Future research should explore other approaches for determining the optimal duration of antibiotic use to help clinicians make better decisions for patients with VAP in ICUs.This study had some limitations. First, the data for this study originated in the MIMIC database. There was a potential risk of bias because most participants in this database were white Americans, which restricts the generalizability of the conclusions. Second, some patient indicators were not completely reported, which resulted in information leakage. Third, the severity of VAP could not be precisely determined. Fourth, the retrospective design of the study meant that some other biases were undoubtedly present. Fifth, patient functional outcomes and post-discharge disposition for ventilator-associated pneumonia were unknown due to a lack of long-term follow-up procedures in the MIMIC-IV database. Despite these limitations, we believe that determining the optimal antibiotic duration can help to better understand the prognosis of patients with VAP in ICUs.Considering that patients with VAP are more likely to have unfavorable clinical outcomes, selecting the appropriate antibiotic use duration is critical. VAP patients have a certain risk of death in the ICU, and our study found that the duration of antibiotic use had a nonlinear effect on the prognosis of VAP patients, with the lowest risk of in-hospital mortality in VAP when the duration of antibiotic use was 12 days, which may be a turning point in the prognosis of VAP patients. And so an accurate and reliable prognostic model for the best antibiotic duration to forecast VAP still needs to be developed.In the furture, we will to keep researching the impact of antibiotic use duration on VAP. In order to develop a predictive model with accurate thresholds, sensitivity, and selectivity, as well as a high level of reliability, to help clinicians make concise management and treatment decisions for the prognosis of and maximizing the survival chances of patients with VAP.


Enterobacterales cultured from urine samples from the out-of-hospital setting during the first semester of 2020 and 2021. Overall, antibiotic consumption decreased by 28% from 2019 to 2020 (from 13.9 to 9.97 DDD/1000 inhabitants/day). The main reductions involved penicillins , particularly amoxicillin/clavulanate  and amoxicillin . Overall, 6445 strains of Enterobacterales were analyzed; in 2020, the susceptibility rate of amoxicillin/clavulanate increased from 57.5% to 87% among isolates from the primary care setting (p < 0.001) and from 39% to 72% (p < 0.001) among isolates from LTCF. The reduction in the community use of antibiotics observed in 2020 was followed by a change in the antimicrobial resistance patterns of urinary isolates.After the onset of COVID-19 pandemic, a decrease in antibiotic consumption in the out-of-hospital setting was observed. However, data about the impact of this reduction on antimicrobial resistance are lacking. The aim of this study was to assess antibiotic consumption and antibiotic resistance at the community level in an Italian province before and after the beginning of the COVID-19 pandemic. We carried out an observational study, comparing antibiotic consumption in the community during 2019 and 2020 and the antibiotic resistance patterns of  The COVID-19 pandemic occurred during global efforts to combat the spread of antimicrobial resistance  and causThe aim of this study was to assess antibiotic consumption and antibiotic resistance at the community level in an Italian province before and after the beginning of the COVID-19 pandemic. We assessed community antibiotic consumption in an Italian province during 2019 (the pre-pandemic period) and during 2020 (the pandemic period). The consumption of antibacterials for systemic use (ATC J01) observed during 2020 was 9.97 DDD/1000 inhabitants/day, with a decrease of 28% compared with consumption in 2019 (13.9 DDD/1000 inhabitants/day). The main reductions, expressed in DDD/1000/inhabitants/day, involved penicillins , particularly amoxicillin/clavulanate  and amoxicillin , and other beta-lactams  . With respect to fluoroquinolones (J01MA), the reduction started in 2019 and continued in 2020 . This finding is a consequence of: (i) a specific antimicrobial stewardship intervention directed toward general practitioners in the Bologna province carried out during 2018 and 2019, (ii) the recommendations of the national plan to contrast antimicrobial resistance to reduce the out-of-hospital use of fluoroquinolones by 10% from 2016 to 2020 [The reduction the use of macrolides was driven mainly by the reduction in the use of clarithromycin. Indeed, during the first phase of the pandemic  characterized by great therapeutic uncertainty, azithromycin was used in the treatment of patients diagnosed with COVID-19 in combination with hydroxychloroquine , the redWe also observed a reduction in the use of all other antibiotic classes, except for tetracycline, including those prescribed less frequently .Enterobacterales were analyzed for the purposes of this study: 5887 from the primary care setting and 558 from long-term care facilities (LTCF). In particular, during the first semester of 2020, 2544 and 427 strains were identified from the primary care setting and LTCFs, respectively, while during the first semester of 2021, 3343 and 131 strains were identified from primary care and LTCF, respectively.Overall, 6445 strains of p < 0.001) and from 39% to 72% (p < 0.001) among isolates from LTCFs  increased ,12.On the contrary, despite reasonable concerns, the dreaded increase in antibiotic consumption during the COVID-19 pandemic did not occur in primary care. Instead, the containment measures applied to control COVID-19  probably reduced the circulation of other respiratory viruses , which could lead to the prescription of antibiotics. In addition, the decrease in ambulatory visits for mild illnesses may have had a role in the reduction in antibiotic use in the community. Indeed, several studies describing a reduction in the use of antibiotics in the community during the first wave of COVID-19 pandemic in high-income countries have been published.In the United States, there was an estimated 33% decline in the dispensing of antimicrobials between January and May 2020, with the greatest impact in April and May 2020 . The redIn Australia, a reduction in the dispensing of antimicrobials was also observed from March to May 2020, mainly affecting antibiotics used in the treatment of respiratory tract infections. Subsequently, the dispensing of antimicrobials increased, although it did not reach pre-pandemic values . A Dutch study comparing the follow-up data of prescriptions for outpatients described a decrease in pneumonia, mastoiditis, pyelonephritis and gastrointestinal infections, as well as in antimicrobial treatments .In Andalusia, Spain, a study comparing antibiotic use in the community during the first and second quarters of 2019 and 2020 showed a 7.6% decrease in prescribing antimicrobials. This decrease occurred for all antimicrobials except azithromycin, which remained stable over the study period .In addition, an Italian study described the impact of the COVID-19 lockdown on antibiotic consumption in the Emilia-Romagna Region, comparing consumption in March, April and May 2020 with the same months of the previous two years, focusing on the use of azithromycin use. The rates of consuming antibacterials for systemic use (ATC J01) in the general population showed a deviation of −22%, −44% and −53% in March, April and May 2020, respectively, compared with the average rates registered in the same months in 2018–2019. The rates of azithromycin consumption (ATC J01FA10) in March, April and May 2020 had a deviation of +23%, −2% and −48%, respectively, compared with the averages registered in the same months in 2018–2019 .Our data, which are representative of the local level, are consistent with those reported in the literature. Indeed, we also observed a reduction in the overall antibiotic consumption in the community, with the partial exception of azithromycin. Indeed, during the very first phases of the pandemic, a widely accepted therapeutic approach to COVID-19 included the use of azithromycin in combination with hydroxychloroquine; however, this approach was based on insufficient evidence and was then discouraged. Our data on antibiotic consumption refer to a longer period than the abovementioned studies, as we included antibiotic consumption for all of 2020, confirming a sustained reduction in community antibiotic consumption, without the rebound observed in Australia. This favorable trend has been confirmed at the national level by the Italian report on antibiotic use .E. coli to this drug [It is expected that this change in prescribing antimicrobials following the onset of COVID-19 will have an impact on antimicrobial resistance ,19. Howehis drug ,21.Moreover, the lower selection density of the out-of-hospital setting and the interconnection of the healthcare system could have compromised the possible favorable impact on antibiotic resistance. Indeed, to our knowledge, no studies have been published so far showing that the decrease in antimicrobial consumption during the COVID-19 pandemic in primary care has had a positive effect on resistance in community pathogens.Our study showed an improvement in the antimicrobial resistance patterns of common pathogens causing urinary tract infections following the reduction in antibiotic consumption in the out-of-hospital setting during the COVID-19 pandemic. This is an important finding, because our results highlight that it is possible to reverse the unfavorable trend toward increased antimicrobial resistance through prudent antibiotic use, contrary to what was described in the abovementioned Swedish experience ,21. In oImplementing actions to improve the prescription of antibiotics in primary care is very important to combat the spread of antimicrobial resistance, as most antibiotic prescriptions are related to care received outside the hospital. However, some barriers exist to the effective implementation of antimicrobial stewardship programs in the out-of-hospital setting, such as a lack of specific expertise and dedicated personnel, pressure from pharmaceutical marketing, and patients and caregivers’ expectations about prescribing antimicrobials, which may be stronger than during hospital care . FurtherStreptococcus pneumoniae, Haemophilus influenzae), which could have suffered the consequences of the modified prescription patterns. The level of macrolide resistance in S. pneumoniae could have increased following the widespread use of azithromycin [Our study has several limitations. First, it involved one Italian province, and the results may have been influenced by the local epidemiology and antimicrobial prescription patterns, limiting the possibility of generalizing the results. Second, we assessed only the antimicrobial susceptibility patterns of urinary isolates, excluding other important community pathogens such as respiratory pathogens  of 2020 and 2021, respectively. The data sources were the regional drug database of outpatient prescriptions reimbursed by the Regional Health Service and the local microbiology database. Antibiotics were classified according to the Anatomical Therapeutic Chemical (ATC) classification system of the World Health Organization . AntibioUrine cultures were processed according to the national guidelines of the AMCLI . Identification was performed using MALDI-TOF  and susceptibility testing was performed using a Vitek-2 automated system (bioMérieux). The results were interpreted in accordance with the clinical breakpoints of the European Committee on Antimicrobial Susceptibility Testing .p value < 0.05. The differences in the rates of antimicrobial resistance were compared using the chi-square test. Differences were considered statistically significant in case of a


The Bipartite network showed strong associations between ARGs and mobile genetic elements (MGEs), and Partial Least Squares Path Modeling further revealed that terrestrial disturbance strength (as indicated by DTC) directly affected abiotic environmental conditions and bacterial community composition, and indirectly affected antibiotic resistome via MGEs. These findings provide insights into regional variability of sediment antibiotic resistome and its shaping path across complex ecological gradients, highlighting terrestrial disturbances as determinative forces in shaping coastal sediment antibiotic resistomes.Coastal areas are highly influenced by terrestrial runoffs and anthropogenic disturbances, commonly leading to ecological gradients from bay, nearshore, to offshore areas. Although the occurrence and distribution of sediment antibiotic resistome are explored in various coastal environments, little information is available regarding geographic patterns and determinants of coastal sediment antibiotic resistomes across ecological gradients at the regional scale. Here, using high-throughput quantitative PCR, we investigated the geographic patterns of 285 antibiotic resistance genes (ARGs) in coastal sediments across a  ~  200  km scale in the East China Sea. Sediment bacterial communities and physicochemical properties were characterized to identify the determinants of sediments antibiotic resistome. Higher richness and abundance of ARGs were detected in the bay samples compared with those in nearshore and offshore samples, and significant negative correlations between the richness and/or abundance of ARGs and the distance to coastline (DTC) were identified, whereas different types of ARGs showed inconsistency in their relationships with DTC. The composition of antibiotic resistome showed significant correlations with nutrition-related variables (including NH Xiangshan Bay and Sanmen Bay are typical semi-enclosed with extensive aquaculture activities and weak water-exchange ability. Yushan Islands Reservation  and the Eastern Boundary of the Island-chain serve as the control zones with minimal terrestrial disturbance. This coastal area receives a tremendous amount of river runoffs wrapping around terrestrial pollutants from industrial and agricultural discharges as well as and urban effluents, which are partially transferred and accumulated into the sediments. Previous studies have reported multiple environment gradients, including salinity and nutrients , heavy mIn this study, we collected surface sediment samples from seven representative zones of coastal area of northern Zhejiang across a ~ 200 km scale. Using high-throughput quantitative PCR (HT-qPCR) with 285 validated primer sets targeting nine types of ARGs, we uncovered the comprehensive profiles of sediment antibiotic resistome. By integrating the quantification of antibiotics, environmental variables, mobile genetic elements (MGEs) and 16S rRNA gene amplicon sequencing, we aim to (1) characterize geographic patterns of sediment antibiotic resistomes across complex ecological gradients; (2) explore the relative importance and interplay of biotic factors  and abiotic environmental factors  in shaping sediment antibiotic resistomes.3−-N and NH4+-N in the sediments were extracted with 2 M KCl solution at 25°C, and the concertation of NO3−-N and NH4+-N in extracts was determined using a continuous flow autoanalyzer . Total phosphorus (TP) in extracts was determined with molybdenum blue spectrophotometry. Heavy metals/metalloid (including arsenic (As), cadmium (Cd), chromium (Cr), copper (Cu), mercury (Hg), nickel (Ni), lead (Pb), and zinc (Zn)) in the sediments were measured as previously described (v/v/v). Subsequently, the concentrations of metals in the extracts were determined using inductively coupled plasma mass spectrometry . The concentrations of As and Hg were determined using the atomic fluorescence spectrometer .During a summer cruise , we collected 32 surface sediment samples from 32 stations across seven representative zones of coastal northern Zhejiang, including Hangzhou Bay (HZ), Xiangshan Bay (XS), and Sanmen Bay (SM) as bay areas, Zhoushan Islands (ZS) and Jiushan Islands Conservation and Reservation (JICR) as nearshore areas, and Yushan Islands Reservation (YS) and the Eastern Boundary of the Island-chain (IC) as offshore areas . Surfaceescribed , with moTo understand the overall level of antibiotics in the sediments, the concentrations of 27 target antibiotics were measured. They belong to six major antibacterial classes: tetracyclines ; sulfonamides ; diaminopyrimidines (trimethoprim); fluoroquinolones ; macrolides ; and chloramphenicols (chloramphenicol). Procedures of the sample pretreatment and detection for antibiotics were previously described . BrieflyThe DNA from sediment samples (0.5 g dry-weight basis) was extracted using a Power Soil DNA Isolation Kit  and then stored at -80°C. To characterize bacterial community composition, the V4 region of 16S rRNA gene was amplified with the primers: 515FY (5′- GTGYCAGCMGCCGCGGTAA-3′) and 806RB (5′- GGACTACNVGGGTWTCTAAT-3′) with dual barcodes . The PCRsplit_libraries_fastq.py with QIIME v1.9.1  value of 31 was the detection limit. The relative copy number of ARGs, MGEs, and 16S rRNA gene was calculated based on tC values using the following equation  as previously described . A totalequation :The normalized copy number of ARGs and MGEs was calculated as following :p < 0.01 by at least two methods were considered statistically robust as suggested previously (p < 0.05) for generating the final ordinations. To evaluate the direct and indirect influence of potential determinants  on the compositional variation of antibiotic resistomes, Partial Least Squares Path Modeling (PLS-PM) was constructed using the R package “plspm” (GoF) was used to evaluate overall prediction performance of the model, and higher values indicate better prediction performance.The map of sampling stations, spatial visualization of ARGs, MGEs, environmental variables, antibiotics, and the calculation of the distance of each station to the coastline (DTC) were performed using ArcGIS 10.4. Pearson correlations between environmental variables and DTC were tested using the “lm ” function of the R package “vegan” . Spearmaeviously  and theneviously . Redunda “plspm” . The goo−1 (34.59 μg kg−1 in average). For individual antibiotics, marbofloxacin was detected in 90.6% of all samples, followed by roxithromycin (81.3%) and pefloxacin (71.9%). Six fluoroquinolone antibiotics were detected at concentrations ranging from 2.19 to 12.50 μg kg−1. Likewise, three macrolide antibiotics were detected at concentrations ranging from 1.96 to 9.77 μg kg−1. Methacycline was the one with the highest average concentration up to 13.80 μg kg−1. In general, the average concentration of total target antibiotics in nearshore samples (50.08 μg kg−1) were higher than that in bay (29.74 μg kg−1) or offshore samples  were detected in at least one sample . Macroli4+-N, 1.9–23.4 mg kg−1), nitrate , and total phosphorus  gradually decreased from bay to offshore areas, and metals/metalloid including As, Cu, Ni, Pb, and Zn generally exhibit a similar pattern  and metals/metalloid  showed significant negative correlations with distance to coastline , and PCoA1 value was significantly correlated with DTC . The PCoA further revealed significant differences in bacterial community composition among bay, nearshore, and offshore samples , while the abundances of vancomycin resistance genes and others showed non-significant decreasing trend with DTC  and beta-lactamase (aadA1 and aadA-01) resistance genes were identified as significant indicator ARGs in HZ; tetracycline (tetT and tetX), FCA (floR), and aminoglycoside (strB) resistance genes in XS; MLSB (ermA), beta-lactamase (blaPAO and bla-AAC-1), and sulfonamide (sul2) resistance genes in SM; however, no significant indicator ARGs were identified in ZS or JICR , 2 integron-integrase genes (class 1 integron-integrase gene (intI-1) and clinical class 1 integron-integrase gene (cIntI-1)) were detected across the study region , with relative abundance in total MGEs ranging from 35.3 to 76.6%, whereas tnpA-04 became the dominant MGEs in HZ1 (38.8%) and HZ2 (56.2%). There was no significant difference in richness of MGEs among bay, nearshore, and offshore areas . The normalized abundance of total detected MGEs in bay samples was significantly higher than nearshore and offshore samples  and DTC were identified as key factors shaping the composition of antibiotic resistomes  and Mantel test  confirmed the association between bacterial community and antibiotic resistome. The total abundances of ARGs and MGEs were significantly correlated. Moreover, the abundance of integron-integrase genes (cIntI-1 and intI-1) showed significant correlations with all ARG types except aminoglycoside resistance genes, as was the abundance of transposase gene tnpA-02  had strong correlations with the richness and abundance of ARGs, while heavy metals  were correlated with the abundance of ARGs . Further tnpA-02 . The netth aadA1 .p < 0.01), bacterial community , and MGEs . Abiotic environmental conditions  and bacterial community composition  indirectly shaped the ARG profile by strongly affecting MGEs . Thus, MGEs as a whole was identified as a direct determinant of sediment antibiotic resistomes.The PLS-PM indicated that DTC, abiotic environmental variables, and bacterial community affected sediment antibiotic resistomes in an indirect manner, whereas antibiotics showed non-significant effects on antibiotic resistomes . DTC indEnvironmental pollutions caused by heavy metals, organic compounds , and antibiotics can impose stress on microorganisms, which may increase the richness of antibiotic resistance genes ARGs; . AccordiStudies on different river basins have identified a strong positive correlation between anthropogenic disturbance intensity and normalized abundance of ARGs . We foun4+-N and NO3−-N there. Correspondingly, some previous studies demonstrated that nitrogen level largely shaped the distribution of ARGs in soils  is located in the northern HZ for 30 years, and the discharges from this pig farm have led to a significant increase of ARGs in the surrounding soil  showing significant positive correlations with almost all ARG types (except aminoglycoside resistance genes), and the network further illustrated the specific ARGs strongly correlated with intI-1 and cIntI-1, suggesting that these genes were likely incorporated in integrons. Additionally, no significant correlations were found between transposase genes and ARGs here, which is consistent with previous reports in soil amended with sewage sludge (intI-1 and cIntI-1) were targeted here, and most of integrases do not belong to clinical classes and are diverse in the marine environment . MGEs (including integrons and transposons) mediate horizontal gene transfer, which is a dominant way for the extensive dissemination of ARGs . We foune sludge , riverine sludge , and este sludge . Therefoironment , more coOn the other hand, previous studies have found that vertical transfer is also an important pathway for the dissemination of ARGs in soils  and sewavia affecting horizontal transfer of genes. Given that the distribution pattern of ARGs in coastal sediments could serve as indicators of terrestrial disturbance intensity, long-term monitoring should be conducted to further understand the dissemination processes and assembly mechanisms of antibiotic resistomes and their ecological risk in benthic ecosystems.Despite the broad recognition of anthropogenic activities shaped antibiotics resistomes in coastal environments , our resvia MGEs that largely determined by bacterial community. Our results provide insights into regional variability of sediment antibiotic resistomes and its shaping path across complex ecological gradients, highlighting terrestrial disturbances as major determinative forces in shaping antibiotic resistomes. This work has positive implications for establishing strategies to mitigate the spread of ARGs from terrestrial runoffs and anthropogenic activities to the ocean.This study systematically investigated the geographic patterns and key determinants of coastal sediment antibiotic resistomes across complex ecological gradients at a regional scale (some of which indicated a gradient of anthropogenic disturbance strength). The geographic patterns of antibiotic resistome suggest a strong influence of terrestrial disturbances (including anthropogenic activities like mariculture) on the occurrence and dissemination of ARGs. Specifically, terrestrial disturbance strength directly affected abiotic environmental conditions and bacterial community composition, and indirectly affected antibiotic resistome The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/DZ and KW designed the study. SX, ML, KW, and DZ performed the study. KW, SX, and DZ proposed the data analysis strategy. SX, HY, and YW analyzed the data. HY and DH assisted with the analytic tools. SX and KW wrote the manuscript. All authors contributed to the article and approved the submitted version.This work was funded by the National Key Research and Development Program of China (2016YFC1402205), National Natural Science Foundation of China (41977192), Natural Science Foundation of Ningbo (2021 J060 and 2017A610302), Fundamental Research Funds for the Provincial Universities of Zhejiang (SJLY2022001), Zhejiang Provincial Top Discipline of Biological Engineering (ZS2012006), and K.C. Wong Magna Fund in Ningbo University.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Recycled powder (RP) is a by-product of preparing recycled aggregates from construction waste through debris removal, step-by-step crushing, screening, and mechanical strengthening. It is a fine powder with a particle size of less than 75 μm. Reasonable use of RP can increase the utilization rate of construction waste and reduce dust pollution. This study introduces the current research status of RP. It describes the source of RP; the activation mode of activity; the effect on several aspects, such as early performance and mechanical properties of cement-based materials; and its mechanism of action in light of the research and development. Moreover, the linear regression analysis method was used to obtain the mathematical model between the content of RP and the performance of cement-based materials. The correlation degree between the content of RP and the performance of cement-based materials was obtained based on the gray relation analysis method. It was concluded that the change of the content of RP had the most significant influence on the compressive strength of foamed concrete over 28 d. Finally, some feasible suggestions and prospects for RP are provided. With the rapid development of the economy, the ecological environment, natural resources, and other problems have become increasingly prominent. According to the estimation of relevant industry associations, China’s annual waste production has exceeded 2 billion tons in recent years. As a result, China’s annual production scale of waste reached 2.8 billion tons in 2020. It is expected to reach 7.3 billion tons in 2030, with construction waste already accounting for 40% to 50% of total waste . ConstruIn the 1980s, Buck pointed out the use of concrete waste from construction waste to prepare recycled aggregates for the green recycling of construction waste. This idea was quickly recognized, and research on the green recycling of construction waste continues today . HoweverCurrently, there are two main methods of resource utilization of construction waste: (1) preparation of recycled concrete, recycled bricks, and other construction materials. For example, Wu  et al. u2, and the results of the study showed that 10% to 15% of the cement can be replaced by the same mass of RP in concrete. However, this untreated RP will reduce the performance of the concrete. Cwirzen 2 produceIn addition, curing time impacts the compressive strength of concrete, and prolonging the curing time can alleviate the negative impact of RP on the compressive strength of cement-based materials. RP’s adverse effects on cement-based materials can be mitigated through methods such as improving the RP’s fineness and heat treating the RP.The research on the flexural strength of cement-based materials by domestic and foreign scholars mainly focuses on cement mortar, and the research variables include the amount, ratio, and fineness of RP. Regarding the effect of RP content on the flexural strength of cement mortar, the research conclusions of domestic scholars are the same ,47,88,89Splitting tensile strength is a measure of the tensile properties of concrete. The incorporation of RP adversely affects the splitting tensile strength of concrete, and the greater the amount of incorporation, the more obvious it is. Feng , Fang 9 and Xue In order to quantify the effect of the content of RP on the performance of cement-based materials, this paper further conducts data analysis based on previous experimental data. Among the many variables, a linear relationship was found between RP replacement ratios and the effects on four factors: the fluidity of cement mortar, the 28 d compressive strength of concrete and mortar, the 28 d compressive strength of foam concrete, and the 28 d flexural strength of cement mortar; the specific data are shown in x/F0, Fx represents the fluidity of cement mortar under different RP replacement ratios, F0 represents the fluidity without RP, and PRP represents the replacement ratios of RP.r represents the relative compressive strength, Cr = Cx/C0, Cx represents the compressive strength at different RP replacement ratios, and C0 represents the compressive strength without RP. The slope of Equation (2) is significantly smaller than that of (3), which means that under the same premise, the adverse effect of the amount of RP on foamed concrete is more evident than on concrete.r represents the relative flexural strength, Rr = Rx/R0, Rx represents the flexural strength under different replacement ratios of RP, R0 represents the flexural strength of cement mortar without RP, and PRP represents the RP replacement ratios.SPSS linear regression analysis was used to obtain the standard regression coefficients between RP and cement mortar content, as shown in Considering that the difference between the standard regression coefficients simulated by SPSS linear regression is too small, the effect is insignificant. Therefore, this paper adopts the second method: the grey relational analysis method. Since there are noticeable differences in the values corresponding to each dosage of RP in the collected data, the optimal value is selected from the indexes corresponding to each dosage of RP for grey relational analysis, as shown in Since the data in Taking the amount of RP as the parent sequence, the relative fluidity of cement mortar, the 28 d relative compressive strength of foamed concrete, the 28 d relative compressive strength of concrete and mortar, and the 28 d relative flexural strength of cement mortar are the characteristic sequences.δmax, and the minimum value δmin in the variance change matrix. The grey relational coefficient is determined according to δ is each element in the difference matrix. The grey relational coefficient was calculated as shown in The absolute value of the difference between the reference sequences and the character sequences is calculated to determine the variance change matrix, the maximum value The following equation calculated the grey correlation, and the relationship between the degree of influence was obtained by ranking the correlations in order of magnitude. The results are shown in The results of the gray correlation analysis and the results of the standard regression coefficients simulated by SPSS linear regression are the same, and the two methods corroborate each other. Therefore, the degree of influence of the amount of RP on the four factors is as follows: 28 d relative compressive strength of foamed concrete > 28 d relative compressive strength of concrete and mortar > 28 d relative flexural strength of cement mortar > relative fluidity of cement mortar. This relationship shows that under that exact dosage of RP, the adverse effect on the 28 d relative compressive strength of foamed concrete is the largest and the adverse effect on the relative fluidity of cement mortar is the least.(1)2 into amorphous SiO2, and then improve the activity of the RP [Increase the fineness of the RP. Increasing the fineness of the RP can increase the specific surface area of the RP, convert the stable α-SiOf the RP ,98. Li ef the RP  believedf the RP ,97,100.(2)3 will decompose into CaO. The decomposition of C-S-H and Ca(OH)2 in the cementitious material forms CaO, which has a high specific surface area and high activity. Generally speaking, the higher the CaO content in the RP, the greater the activity. However, scholars’ optimal heat treatment temperatures are inconsistent and are related to the source and composition of the RP used in the experiment.RP heat treatment. Florea  found th(3)2SO4, NaOH, Ca(OH)2, and NaHCO3 had specific active excitation effects on the RP through net cement paste specimen tests and scanning electron microscope observations. The optimal excitation doses were 3%, 3%, 2.5%, and 2.5%, respectively.Alkali-activated treatment. The RP composition of calcium carbonate, calcium silicate, and silica was measured by EDS, providing a solid basis for alkali chemical excitation . Dong 1 found th(4)2 treatment. Since the RP still has a large amount of calcium oxide, researchers have used CO2 to treat it RP. After carbonization, the strength of the cementitious material is higher than before carbonization. Maintenance with CO2 can improve the performance of the RP products. Li [2, which enhanced not only the physicochemical properties of the RP but also improved the activity of the RP. Cheng [2 allows them to gain strength quickly and have good mechanical properties and durability [COucts. Li  treated P. Cheng  found thrability .(5)Double mixing. RCP, RBP, fly ash, slag, and silica fume blending can improve the composition and promote the volcanic ash reaction of cementitious materials. It is conducive to improving the long-term strength of the concrete and can improve the workability of concrete. Xiao  showed tThe RP has a significant water demand, lower activity than class II fly ash, and poor adaptability to concrete admixtures. In addition, in contrast to cement, the strength of the cement-based material decreases with the increasing content of RP. These shortcomings limit the application of RP in practical engineering, so the activation of the activity of RP is a critical factor in improving the recycling efficiency of recycled construction waste. For this reason, many scholars in China and abroad are looking for ways to enhance the activity of RP. To summarize, here are five ways to activate RP:(1)Regarding construction waste recycling, China has been vigorously promoting waste classification. However, the mechanism of waste concrete recycling is not perfect. At present, all waste is recycled together. The lack of inspection, other classification processes, and construction waste recycling negatively impact efficiency. China should establish construction waste recycling norms and further improve awareness of construction waste classification and recycling.(2)At present, scholars in China and abroad mainly focus on studying the mechanical properties and workability of RP on cement-based materials but focus less on the durability of cement-based materials, especially corrosion resistance, and the need to strengthen the research on durability in the future.(3)Concerning the optimum dose of RP for cement-based materials, the optimum dose obtained varies due to different initial conditions. For example, the type of RP, the fineness of the RP, the method of RP excitation, and the dosing of exciter will affect the optimum dose of RP for cement-based materials. Therefore, further research by researchers is required to make it a complete system.(4)Regarding the activation method of RP, mechanical grinding, further research should be conducted to determine the optimal grinding time for different grinding machinery apparatuses and different types of RP. An industry standard must be developed and would be significant for reducing energy waste and for the industrial production of more efficient RP.(5)Regarding the activation method of alkaline excitation treatment of RP, domestic and foreign scholars currently use single-activator activation, and research on composite-activator activation of RP is relatively scarce. Therefore, domestic and foreign scholars should increase research in this area.(6)Scholars in China and abroad have concentrated on improving the mechanical strength of RP, and very few have studied the use of the low-strength properties of RP itself. For example, Xiao proposed to prepare low-strength foam recycled concrete from recycled raw materials and apply it to the material blocking system of the airport runway safety zone . Scholar(7)Most researchers use the cementitious properties of RP to prepare cementitious materials. However, the cementitious properties of RP are far less than those of cement. Therefore, the performance of the prepared cementitious materials is not satisfactory. For example, it is feasible to combine RP with organic polymer material polyurethane, use quartz sand as coarse aggregate, RP as fine aggregate, polyurethane as cementitious material, and prepare a new material—RP polyurethane composite material.