How to treat the iron tailings of mining solid waste with high value is an urgent problem on a global scale. In recent years, the application of iron tailings in the building materials industry has attracted the attention of many scholars. The conversion of iron tailings into green building materials helps achieve carbon neutrality and high-value utilization of solid waste, and promotes sustainable development. Although iron tailings have been extensively studied as supplementary cementitious materials, the performance of concrete is not ideal due to its low activity. In this study, the hybrid supplementary cementitious materials system was prepared by iron tailings, phosphorus slag, and steel slag, and the effects of supplementary cementitious materials type, iron tailings content, iron tailings grinding time, and supplementary cementitious materials content on concrete performance were studied. The compressive properties, iron tailings properties, pore structure, interfacial transition zone, and element distribution of hydration products of concrete were tested by compressive strength tests, X-ray Diffractometer (XRD), X-ray Photoelectron Spectroscopy (XPS), Mercury Intrusion Porosimetry (MIP), Backscattering Electron Tests (BSE), and Energy Dispersive Spectrometer (EDS). The results show that further grinding improves the iron tailings activity. There is a synergistic mechanism between steel slag and phosphorus slag in the composite supplementary cementitious materials, which overcomes the low activity defect of iron tailings and produces concrete with a compressive strength exceeding 40 MPa. The composite supplementary cementitious materials can optimize the interfacial transition zone of the concrete interface and reduce the calcium–silicon ratio of the hydration products. However, it will deteriorate the pore structure of the concrete matrix, cause part of the concrete matrix to be damaged and lead to a loss of compressive strength, and the loss is acceptable. This work broadens the methods of comprehensive utilization of iron tailings and also provides a reference for a more detailed understanding of the properties of iron tailings-based concrete. The continuous development of mineral resources forms many tailings, which is one of the rich solid waste resources. The accumulation of tailings pollutes the environment and poses a threat to the safety of surrounding people and buildings ,2. Iron 2 and Al2O3 in IOTs, many scholars have tried to prepare supplementary cementitious materials (SCMs) using IOTs 2− ions prevent the conversion of “hexagonal hydrate” to C3AH6, and the early hydration of cement is inhibited [The above results indicate the feasibility of using the synergistic mechanism between SS and PS to compensate for the low activity of IOTs. To compare the compressive performance difference between concrete containing ternary system admixtures and normal concrete and to analyze the reasons for it, the admixture amount of IOTs can be adjusted to 6% and the grinding time is preferably 2 h. nhibited . The 28-2/kg after 2 h of mechanical grinding. As the particle size of IOTs particles became smaller, the material particles started to agglomerate under the effect of van der Waals forces. In this process, the free energy of the particles and the chemical potential energy of the system both decrease, so the material particles undergo an agglomeration phenomenon, and the specific surface area decreases [The specific surface area of IOTs after grinding is shown in ecreases . MechaniThe SEM micrographs of IOTs with different grinding times are shown in For inert silicate minerals such as IOTs, in which Al, Si, and Ca elements are present in the form of oxides, detecting the change of surface binding energy between Al, Si, and Ca elements and O elements can reflect the change pattern of the activity of alumina, silica, and calcium oxide in IOTs . To dete2 decreased, and the activity of IOTs was enhanced. This is because, during the mechanical grinding process, IOTs particles with lattice defects will undergo lattice distortion, increasing the plastic deformation of the particles and deepening the degree of amorphism, resulting in a decrease in the intensity of diffraction peaks [To clarify the activation mechanism of IOTs by mechanical grinding, XRD spectra of IOTs at different grinding times were tested, and the results are shown in on peaks ,53. The There is significant inconsistency between the pore structure test results and the compressive strength test, G0 has better pore structure properties than G1.5 and G2, while the compressive resistance is the opposite. The pore structure is not the only factor that affects the compressive properties of concrete. The ITZ, as the weakest region in concrete, should be of concern. Therefore, the inconsistency between pore structure properties and compressive strength will be further discussed.To quantify the unhydrated particles and porosity near the transition zone at the interface of different concrete specimens, strip segmentation, and threshold segmentation were performed for the area within 100 μm of the aggregate, starting from the surface of the aggregate particles. The porosity and the percentage of the area corresponding to the unhydrated particles were determined for each segment using 5 μm as a section ,56. The To further support the results of the BSE image analysis, EDS line sweeps were performed on the gelatinous material on the outside of the aggregate from the ITZ, and more detailed information on the variation of the gelatinous material along the line element concentration on the outside of the ITZ was obtained by the EDS line scan. The Ca/Si ratio of each specimen is listed in Compared with using IOTs alone as SCMs, there are significant advantages of using SCMs in the compounding system. PS makes up for the low activity of IOTs, and the synergistic mechanism between SS and PS can further enhance the compressive properties of concrete. Changing the fineness of IOTs can improve the compressive properties of concrete thanks to its increased activity.The pores of the ITZ of concrete were optimized after the introduction of composite SCMs. When the dosage is increased by 20% or the grinding time of IOTs is increased, it can reduce the porosity of the ITZ and promote the hydration of the particles within the ITZ, thus reducing the calcium–silica ratio and achieving the purpose of enhancing the ITZ.Composite SCMs can deteriorate the matrix pores of the concrete. The increase in pore volume and the coarsening of pore structure are mainly manifested by the increase in the amount of SCMs or the change in the fineness of IOTs. This degradation will be aggravated by the possibility of inducing matrix damage, which will lead to the loss of concrete strength. However, the strength loss due to matrix pore deterioration is within the acceptable range since concrete mostly suffers from interface damage. Therefore, the recommended value of compound SCMs admixture is 20–30%.The introduction of composite SCMs makes concrete suffer from a common defect, i.e., lower early strength than normal concrete. The mechanism behind this phenomenon and improvement measures will be the focus of subsequent research.In this study, the composite SCMs system was prepared by IOTs-PS-SS, and the effects of the type of SCMs, IOTs admixture, IOTs grinding time, and SCMs admixture on the concrete properties were investigated. The effects of mechanical grinding on the activity of IOTs were explored by XRD and XPS. The compressive strength test, MIP, BSE, and EDS were used to test the compressive properties, pore structure, ITZ, and elemental distribution of hydration products of concrete, which provide a reference for the application of building materials in the full particle size range of IOTs. The main conclusions are as follows:


We found that the presence of the Met allele is associated with better olfactory identification and additional engagement of semantic memory system within the olfactory network, in an allele dosage-dependent manner. This suggests that the Met allele may promote adaptive neural reorganization to augment olfactory capacity.The neurogenetic basis of variability in human olfactory function remains elusive. This study examined olfactory performance and resting-state functional neuroimaging results from healthy volunteers within the context of the  In the context of olfaction, BDNF can facilitate neurogenesis in olfactory bulb4 and olfactory neuroepithelium5, while down-regulated BDNF is associated with apoptotic cell death in olfactory bulb6. An interference of BDNF signaling may impede the ability of mice to distinguish odors7, and up-regulation of BDNF mRNA in the neuroepithelium is associated with restoration of olfactory function after olfactory training8. Collectively, BDNF is a key element for adaptive modulation of the olfactory system at both cellular and behavioral levels.Brain-derived neurotrophic factor (BDNF) is the most abundant neurotrophin in the brain, playing an important role in cognitive functionBDNF val66met polymorphism (rs6265) indicates the substitution of methionine [Met] for valine [Val] at codon 66. The variant Met allele has been shown to interfere with intracellular BDNF-trafficking and decreases activity-dependent BDNF secretion10. Variant Met allele may deleteriously affect activity-dependent BDNF secretion, and subsequently, the tyrosine receptor kinase B signaling, on which the survival of neuroblasts in olfactory bulbs hinges. The disruptive neurogenesis in olfactory bulbs may lead to impaired olfactory function, particularly discrimination11. However, whether the aforementioned findings in the limited basic experimental studies can be translated directly to clinical settings remains relatively unexplored. In fact, several clinical observational reports have presented findings contradictory to the theory as grounded on the basic studies. In one study, otherwise healthy Met carriers presented functional deficits in odor detection threshold, discrimination, and identification12. Conversely, other studies counterintuitively reported that the Met allele decelerates age-related olfactory decline late in life13 and mediates the recovery of olfactory function in female athletes following concussion14. Behavioral studies have suggested that Met carriers may perform better in tasks related to learning and memory16, and better memory can be one adaptive mechanism that underlies the beneficial olfactory outcome of the Met-carrier aged people and the concussed Met-carrier female athlete. It is highly plausible that memory-associated neural systems, e.g., parahippocampus/posterior cingulate cortex (PCC) subserving cross-modal retrieval and recognition/identification of odor memories19 and hippocampus/retrosplenial cortex (RSC) subserving long term and autobiographic memories22, can be further engaged as compensatory and organizational neural mechanisms in patients with defective olfactory performance. Anyhow, researchers have yet to determine whether the presence of the Met allele is associated with neural organization, or whether this neural plasticity has detrimental or protective effects on olfactory capacity.The 24. We aimed to clarify whether BDNF val66met polymorphisms are associated with different neural endophenotypes, which in turn can be associated with different olfactory performances. Our work may provide a better understanding of the discrepancy among animal and human olfactory studies, and sheds light on the hitherto unexplored neural plasticity of BDNF genotype-laden brain organizations.In the current study, we investigated the genetic attributes of brain organization using functional connectivity (FC) analysis of resting-state functional MRI (rs-fMRI) to unveil the intrinsic circuitry of olfactory network (ON). Resting-state neural activity, whether based on inherent neural connections or adaptive rewiring of the neural networks, is prone to genetic modulationBDNF val66met polymorphism and olfactory performance. A total of 47 healthy subjects  from a cohort previously assembled for a Neuroimaging Program of Primary Dysmenorrhea (PDM) (termed as PDM cohort) were included in the sample. That research program oversaw the genotyping of the BDNF val66met polymorphism, measurement of gonadal hormone levels, and acquisition of multimodal neuroimaging including rs-fMRI and structural MRI27. Since the frequency of Met allele in BDNF val66met polymorphism is higher in Asian population (43.6%) than that in Western one (19.9%)28, we take the advantage of this preponderant Met allele distribution  and look into the subtle effects contributed by the Met allele. Subjects in the olfaction cohort were grouped according to genotype: Met/Met (n = 13), Val/Val (n = 13), and Val/Met (n = 21). Olfactory ability  was assessed using the Sniffin’ Sticks test30  attributable mainly to Met/Met vs. Val/Val  and Met allele dosage-dependent effects  and , based on a meta-analysis of olfactory activation fMRI studies34. We performed whole-brain seed-based analysis of rs-fMRI to identify brain regions exhibiting genotypic differences in intrinsic connectivity for olfactory perception. Age and gonadal hormonal levels  were regressed out as nuisances. Between-group differences in ON connectivity were observed only between Met/Met vs. Val/Val groups. No significant finding was observed in other pairwise comparisons . The ON in the Met/Met group presented an additional spatial dimension spanning the inferior temporal gyrus , middle temporal gyrus , PCC (BA23) and RSC , somatosensory , and gustatory  areas  comparisons. Thus, the observed Met advantage may be ON specific.We then sought to verify whether the observed genotype-related engagement of memory/multi-sensory systems in the ON was generalizable to the overall PDM cohort as a plausible representation of the population. We conducted the same (as olfaction cohort) image processing procedure on the PDM cohort . A comparison of the ON in Met/Met (n = 32) and Val/Val groups (n = 40) revealed that increased intrinsic connectivity in the Met/Met group confluently involved the RSC, PCC, precuneus and cuneus  subserve semantic memory35, critical for the naming of specific odors37. They also constitute the posterior component of the default mode network (DMN), which subserves self-referential processing38. The multiple sensory systems identified in the olfactory cohort may be indicative of the assimilation of memory process. The PCC/RSC were preponderant among the identified substrates of ON. The neural organization as revealed in Met carriers functionally mirrors the potential engagement of semantic process39, which can be a possible mechanism of better identification of odors as compared to Val/Val subjects.This study unveiled that the Met allele may shape intrinsic connections within the ON, in an allele dosage-dependent manner, and that these effects encompass memory-associated brain areas leading to superior odor-identification performance in healthy subjects. Many identified areas are important neural substrates of ON 40. Contrary to the conventional belief that the Met allele impairs cognitive and perceptual function9, it appears that the Met allele may produce a more resourceful network configuration capable of augmenting cognitive performance. Note that this may explain the counterintuitive observation in which the Met allele appears to counteract age-related olfactory decline13 and prognosticate better olfactory function in concussed female athletes14.We argue that despite an inherent deficiency in the availability of BDNF (in response to rapid depolarization), the Met allele may promote neuroplastic processes, including the gradual formation, fine-tuning, and stabilization involved in sculpting a neural organization capable of augmenting olfactory function12, while we took the advantage of higher allele frequency in the Taiwanese population and were able to decipher the genotype-specific brain organization and respective olfactory performance of BDNF val66met polymorphisms. This highlights the importance of the ethnic factor in the context of different genotype distributions in future studies of genetic neuroimaging and behavioral studies28. Other attributing factors include different gender and age distributions.Many factors can be attributed for the incoherent findings between the study of Tonacci et al. and our current study. Tonacci et al. combined the homozygous and heterozygous Met-carrier people  for statistical analysesOur additional examination of the bilateral V1-seeded FCs implicated that the observed Met-advantage neural resilience may be olfactory domain-specific. It can be of interest for future studies to examine whether such Met-advantage neuroplasticity can occur in other sensory modalities.PDM cohort (n = 145) was three times the size of the olfactory cohort (n = 47), thus the analytic results of PDM  may yield the most stable and robust neural dynamics . On the contrary, the results of the smaller-sized olfactory cohort  may be influenced by the co-engagement of other brain regions (or processes) contextualizing the diversity of individual olfactory experiences. Such individual variations can be vulnerable to averaging process.42.The genotype–phenotype interactions are not of simple linear dynamics and can be substantially affected by gene–gene or gene–brain interaction. Although the current study did not demonstrate a significant correlation between the odor-identification performance and neural network FCs, it should be borne in mind that the brain imaging changes can be more sensitive to genetic influences than the behavioral presentationsP = 0.005 approach for our study of relatively small sample size. Such an approach has been adopted by neuroimaging society43. The engaged brain regions surviving the stringent uncorrected P = 0.001 approach would be additionally marked in the Supplementary Table In order not to miss subtle and insightful information that can be valuable for further hypothetical construction and scientific exploration, we therefore opted for a relatively liberal uncorrected BDNF genotype-specific neural organization is due to inherent gene-imprinting or long-term neuroplastic processes. Nevertheless, our novel findings shed light on the assessment of clinical symptoms and the prediction of outcomes pertaining to olfactory dysfunction in various clinical settings  as well as the tailoring of treatment strategies to specific patients.The limited sample size and uneven gender distribution in the current study precluded the analysis of gender differences. This cross-sectional study was unable to address the commencement or temporal evolution of neurogenetic plasticity. It remains to be determined whether such Neuroimaging Program of Primary Dysmenorrhea (PDM), a portion of which has previously been published45. The survey in that program included BDNF val66met genotyping, measurements of gonadal hormone levels, and multimodal neuroimaging studies including rs-fMRI and structural MRI. Participants with physical or neurological disorders and/or MRI contraindications were excluded from the study. We also excluded subjects presenting head motion exceeding 2 mm or 2 degrees during MRI preprocessing. The final PDM cohort consisted of 145 individuals . Genotype distribution in the PDM cohort did not deviate from the Hardy–Weinberg equilibrium , thereby verifying conformity with the distribution of the general population. Genotype information in the current study was used only for grouping purposes. A subset of participants  from the PDM cohort was randomly recruited to undergo assessment of olfactory function. Note that we had originally aimed to recruit participants for the olfaction cohort with a balanced distribution of genotypes ; however, this goal could not be achieved under the conditions imposed by the COVID-19 pandemic. All subjects were right-handed, as confirmed using the Edinburgh Inventory46. All experiment procedures were conducted in accordance with the Declaration of Helsinki and were approved by the local ethics committee of Taipei Veterans General Hospital, and informed consent was provided by every participant.The subjects enrolled in this study were healthy control participants recruited from our 48. The olfactory threshold for n-butanol was assessed using the adaptive staircase procedure with a three-alternative forced-choice presentation. The odor discrimination task employed 16 triplets of sticks, two of which contained the same odorant with the third containing an odd odorant. The sticks were randomly presented to the participants, who were then required to select the odd one. Odor identification involved 16 common odors, which were identified from a list of descriptors (four for each odor)30. The scores in each subtest were summed up to create a composite TDI (threshold-discrimination-identification) score. Nasal conditions and emotional states have been shown to influence olfactory performance; therefore, we also had the participants complete the Sino-Nasal Outcome Test (SNOT-22)49, Beck Depression Inventory (BDI-II)50, and Beck Anxiety Inventory (BAI)51 questionnaires. No significant differences were observed between the three genotype groups in terms of SNOT-22, BDI-II, or BAI scores . The olfactory exam comprised three subtests: odor detection threshold (T), odor discrimination (D), and odor identification (I)est SNOT-249, Beck27. Briefly, whole blood was collected in 4 mL EDTA tubes and stored at 4 °C. DNA was extracted using the Puregene kit in accordance with manufacturer guidelines . Commercial TaqMan single-nucleotide polymorphism assays  were used for genotyping. Amplification was performed via the polymerase chain reaction. Fluorescence measurements were performed using the ABI HT7900 . Allele calling was performed using the SDS 2.2 software package (Applied Biosystems). Two technicians blinded to the subjects’ personal information assigned genotypes independently.All of the participants in the PDM cohort were subjected to genotyping53; therefore, individual serum hormone levels were regressed out as covariates of non-interest during image processing. Hormone-related data were obtained from blood samples drawn from females during the peri-ovulatory phase , and from all participants on the day they underwent MR scanning. The serum concentrations of estradiol, progesterone, and testosterone were measured using a commercialized assay kit .Inter-subject gonadal hormone variation could conceivably affect the resting-state FC2; in-plane matrix size = 224 × 256 × 192; in-plane resolution = 1 mm). Rs-fMRI images were obtained using a T2*-weighted gradient-echo sequence . Head cushions and earplugs were respectively provided to reduce head motion and noise. Participants remained awake throughout the scanning session in a resting-state .All participants in the PDM and olfaction cohorts were scanned using a 3.0 Tesla MR scanner  equipped with a 12-channel head coil. MR images were acquired from female participants during the peri-ovulatory phase. High-resolution T1-weighted 3-dimensional structural images were acquired  within a Matlab framework . All functional images were subjected to slice timing and realignment for head-motion correction. T1-weighted images from each individual were coregistered to the mean functional image and segmented into gray matter, white matter and cerebrospinal fluid (CSF) signals using the DARTEL Toolbox55. We then conducted the nonlinear transformation of individual images to the Montreal Neurological Institute (MNI) space. The Friston 24-parameter model was used to minimize confounding effects due to head motion56. Other sources of noise were regressed out by removing white matter and CSF signals. Note that we opted not to perform global signal regression, as this is a controversial practice in studies on FC57. Functional images were re-sampled to an isotropic voxel size of 3 × 3 × 3 mm3 and normalized to a customized DARTEL template. The images were then smoothed using a 3D Gaussian kernel of 6 mm full-width at half-maximum. After removing linear trends from the resulting time series, temporal band-pass filtering (0.01–0.1 Hz) was performed to extract low-frequency oscillations associated with spontaneous neuronal activity58.Images were preprocessed using the DPARSF 4.5 Toolbox 34. Similar seed-based FC analyses were conducted on the bilateral V1 as seeded at MNI coordinates  and , respectively36, to verify whether the neuroplastic changes could be olfactory domain-specific. Following the extraction of mean time-series activity from each seed region, seed-based FC maps were generated for group analysis. Each FC map at the individual level was then converted into a z-map using Fisher’s r-to-z transformation for second-level group analysis.Bilateral piriform cortices with a 5-mm radius were selected as anatomical seed areas in the ON. The seeds for ON were centered at MNI coordinates  and , based on a meta-analysis of fMRI-activation during olfactory task performanceP < 0.05. In whole-brain imaging analysis, covariates  were regressed out as nuisances. Post hoc between-group comparison of genotype was also performed in both cohorts. The threshold for significance was first set at an uncorrected voxel level of P = 0.005, and then at a second corrected cluster level of P = 0.05 to estimate family-wise error (FWE). To test for BDNF val66met Met allele dosage-dependent effects, we constructed a linear regression model using the val66met genotype coded according to the number of Met alleles  as the independent variable, and odor identification scores or FC strength as dependent variables. Age as well as levels of estrogen, progesterone, and testosterone were also set as covariates. Bonferroni correction was used to control for type I error attributable to multiple comparisons; therefore, the level of significance was adjusted according to the number of brain areas examined. Consequently, the significance of Met-allele dosage effects on FC in the olfaction cohort in the second experiment was P = 0.006  was used for the between-group analysis of behavioral and functional imaging data. The Bonferroni method was used for post hoc behavioral analysis with the level of significance set at Supplementary Tables.


Neoadjuvant chemoradiation followed by esophagectomy has been established as the first-line treatment for locally advanced esophageal cancer. Postoperative enteral nutrition has been widely used to improve perioperative outcomes. However, whether to implement preoperative nutritional intervention during neoadjuvant therapy is yet to be verified by prospective studies.POINT trial is a multicenter, open-labeled, randomized controlled trial. A total of 244 patients with surgically resectable esophageal cancer are randomly assigned to nutritional therapy group (arm A) or control group (arm B) with a 2:1 ratio. Both groups receive neoadjuvant chemotherapy with concurrent radiotherapy based on the CROSS regimen followed by minimally invasive esophagectomy. The primary endpoint is the rate of nutrition and immune-related complications after surgery. Secondary endpoints include completion rate of neoadjuvant chemoradiation and related adverse events, rate of pathological complete response, perioperative outcomes, nutritional status, overall survival, progression-free survival and quality of life.This trial aims to verify whether immunonutrition during neoadjuvant chemoradiation can reduce the rate of complications and improve perioperative outcomes. Frequent communication and monitoring are essential for a multicenter investigator-initiated trial.Trial registration: ClinicalTrials.gov: NCT04513418. The trial was prospectively registered on 14 August 2020, https://www.clinicaltrials.gov/ct2/show/NCT04513418.The online version contains supplementary material available at 10.1186/s12885-022-09721-y. Esophageal cancer ranks the sixth in mortality and the seventh in incidence among the malignancies worldwide in 2020 according to the latest report of cancer epidemiology . AlthougPostoperative nutrition have proved to be effective in improving outcomes after esophagectomy , 7. HoweTo answer this question, a systematic review and meta-analysis was conducted by our group . The pooThis prospective RCT will evaluate the effects of preoperative enteral immunonutrition on esophageal cancer patients undergoing neoadjuvant chemoradiation. The purpose of this study is to determine whether immunonutrition supply during neoadjuvant therapy can improve the rate of complications and other perioperative outcomes.This is a prospective, open-labeled trial in which every eligible patient is randomly assigned to nutritional therapy group (arm A) or control group (arm B) with a 2:1 allocation ratio. Figure To investigate the effects of enteral immunonutrition therapy during neoadjuvant chemoradiation on postoperative outcomes, a total of 244 patients with resectable esophageal cancer will be recruited from 8 high-volume tertiary hospitals in China. Written informed consent is obtained from each potential participant by the doctors in the participating centers.Histologically confirmed esophageal cancer2N0M0 with high-risk lesions  / cT1b-2 N + M0 / cT3-4aN0-3M0 with the need of neoadjuvant therapy before radical esophagectomyStaging as cTTolerance with oral intake (at least fluid diet)Ages from 18 to 75 yearsEastern Cooperative Oncology Group (ECOG) performance status (PS) ≤ 22 before recruitmentBody Mass Index (BMI) ≥ 18.5 kg/mPatient’s approval and written informed consentExpected survival time less than 6 monthsComplete dysphagiaPregnant or breast-feeding womenUnable to obey the interventions because of any reasonsSerious co-morbidities  in patients who cannot tolerate neoadjuvant therapy and/or surgeryHistory of previous thoracic or abdominal surgeryHistory of other malignant tumor (previous or current)Patients in the interventional group receive 600 ml  immune-enhanced enteral nutritional emulsion Rui Neng®  enriched with ω-3 fatty acids and ribonucleotides per day during the neoadjuvant chemoradiation, given by oral intake, nasogastric feeding tube or jejunostomy. Meanwhile, oral intake is encouraged to reach 25–30 kcal/kg through regular diet. Nutrition assessment and consultation is provided to improve adherence to the interventions. Allergy or intolerance to the nutritional emulsion leading to < 60% of the programmed dose lasting for ≥ 7 days will be regarded as drop out.Patients in the control group are encouraged to intake 25–30 kcal/kg through regular diet without supplemental nutritional support before esophagectomy. Nutrition assessment and consultation is provided to optimize the diet structure of the patients.2). Radiotherapy with a total dose of 41.4 Gy is delivered in 23 fractions, 5 days per week.Both groups receive neoadjuvant chemotherapy with concurrent radiotherapy based on the CROSS regimen . ChemothAfter 4–6 weeks of neoadjuvant chemoradiation, participants will be reevaluated for any contraindications and receive minimally invasive esophagectomy (MIE) if appropriate. MIE is defined as thoracoscopic and/or laparoscopic two-incision (Ivor-Lewis) or three-incision (McKeown) esophagectomy with radical lymphadenectomy. A minimum of 15 resected LNs are recommended. The detailed approach is chosen by surgeons based on the patients’ conditions and the centers’ customs.The primary outcome is the rate of nutrition and immune-related complications up to 30 days after surgery. These include gastrointestinal complications , metabolic complications  and infectious complications .Neoadjuvant therapy measures: completion rate of neoadjuvant chemoradiation, adverse events during neoadjuvant chemoradiation, rate of pathological complete response (pCR).Peri-operative measures: blood loss, operation time, rate of surgery-related complications , length of hospital stay, hospitalization costs.Nutrition and immune-related changes measured from the beginning of neoadjuvant chemoradiation to 6 months after surgery: weight loss, Scored Patient-Generated Subjective Global Assessment (PG-SGA score), white blood cells, hemoglobin, albumin, C-reactive protein, TNF-α, interleukins, IgA, IgG, IgM, fasting blood-glucose.Survival and recurrence: 30-day and 90-day mortality, overall survival (OS) (time from the date of randomization to the day of death or last follow-up), progression-free survival (PFS) .Quality of life (QoL): European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core-30 (QLQ-C30) and Oesophageal-18 (QLQ-OES18) scored at randomization, before surgery, 1, 3, 6 month(s) and 1, 3, 5 year(s) after surgery.The secondary endpoints include the following outcomes:α) of 0.05 and a power of test (1-β) of 0.80. Considering an estimated drop rate of 15%, the minimum sample size of this study is 244 patients, 162 cases in the interventional group and 82 in the control group.The power and sample size calculation was based on the hypothesis that pre-operative immunonutrition during the neoadjuvant therapy can reduce postoperative nutrition and immune-related complications after esophagectomy. According to the previously published articles  and our All the esophageal cancer patients in the outpatient and inpatient service are screened for eligibility. Recruiting announcements are also published on the website of the participating center to promote recruitment.After signing the informed consent, every eligible participant is randomized into nutritional therapy group or control group (ratio 2:1) based on a computer-generated random number stratified by institution. Sequentially numbered, opaque, sealed envelopes are distributed to all the study sites by the sponsor to conceal the sequence until interventions are assigned. The allocation sequence is generated by a statistician (JL). The enrollment and assignment of participants are implemented by each study site.This is an open-labeled study, so trial participants and care providers are not blinded. However, outcome assessors will be masked with assignment to interventions.The time schedule of enrolment, interventions, assessments and follow-ups is summarized in Additional file For the sake of eligibility screen, medical history, physical examination, demographic information, upper gastrointestinal endoscopy with tissue biopsy, thoracic and abdominal computed tomography (CT), and ultrasonography of abdominal organs as well as superficial lymph nodes (LNs) are routinely assessed before any treatment. After enrolment, nutritional assessments  are performed prior to neoadjuvant chemoradiation along with QoL evaluation (EORTC QLQ-C30 and QLQ-OES18 questionnaires) and laboratory tests .After 4–6 weeks of neoadjuvant chemoradiation, participants are reevaluated for the clinical response and any contraindications to esophagectomy. Physical examination, thoracic and abdominal CT scan, ultrasonography of abdomen and superficial LNs, nutritional assessments, laboratory tests and QoL evaluations are recorded.The first 3 follow-ups are performed 1 month, 3 months and 6 months after surgery, including physical examination, nutritional assessments, laboratory tests, CT scan and QoL evaluations. Long-term follow-ups are performed 1 year, 3 years and 5 years after surgery, including physical examination, nutritional and QoL assessments as well as CT scan and other examinations for detecting recurrence. Telephone interview will be supplied to promote completion of follow-up.All the adverse events (AE) and complications will be recorded through the study period, whether caused by neoadjuvant chemoradiation, nutritional intervention or surgery. Serious adverse events (SAE) should be reported to the principal investigator and sponsor within 24 h. Clinical trial insurance is purchased for every participant to compensate those who suffer harm from trial participation.Peripheral blood and tissue samples are collected for future translational research. Blood samples are collected in two 5 ml EDTA tubes before the start of neoadjuvant treatment and at the time of pre-operative evaluation, respectively. Tissue samples are collected before treatment (if available) and during the radical surgery, respectively.https://h6world.cn). To protect confidentiality, only authorized and trained investigators will have access to the data of enrolled patients. Any protocol amendments will be reviewed by the ethical committee and communicated to the participating centers after approval. Auditing will be performed every 6 months until the end of the trial.All data collected by the participating sites will be recorded in an electronic data capture (EDC) system  and compared using Wilcoxon rank-sum test. Time-to-event data will be estimated by Kaplan–Meier method and analyzed by log-rank test as well as Cox proportional hazard model.Data will be analyzed according to the ‘intention to treat’ principle. The statistical analyses will be conducted by using R software . For the primary endpoint, Pearson’s Chi-squared test or Fisher’s exact test will be used to compare the complication rate between the two groups. Regarding secondary outcomes, categorical variables will be presented as number (percentage) and analyzed as the primary endpoint. Normally distributed continuous variables will be presented as mean ± standard deviation (SD) and compared using Student’s P < 0.05 is considered to be statistically significant. Interim analysis will be conducted when 50% of the estimated patients are recruited. Missing data will be dealt with pairwise deletion.Subgroup analyses will be performed by stratifying sex, age, BMI, region, ECOG PS, tumor stage, histology and surgical procedure. This study was approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Ruijin Hospital (RJ 2019–198) on 24 September 2019 and registered on ClinicalTrials.gov (NCT04513418) before recruitment. The current protocol version is Version 2.0 (November 2020). The recruitment was started on 10 November 2020. The POINT trial is still at the stage of recruiting as 36 patients have been recruited until 14 March 2022. The results of primary and secondary outcomes will be published after the recruitment and follow-up.Esophageal cancer is a type of malignant tumor with high disease burden, especially in East Asia . The treHowever, several practical and operational limitations exist when performing this multicenter RCT. Firstly, the compliance and retention of participants may be unsatisfactory due to the characteristics of nutritional intervention. The oral intake and tolerance with enteral nutritional emulsion may vary with the progression of disease. Secondly, confounding factors should never be neglected as the surgical procedures and techniques play a critical role in postoperative outcomes. Randomization and subgroup analyses may relieve the bias to a certain extent. Thirdly, multicenter participation may add to difficulties in long-term follow-up since this is an investigator-initiated trial (IIT). Therefore, frequent communications and monitoring are of great importance during the conduction of this trial. Routine follow-up and MDT care will also help improve the compliance of patients.Additional file1:Table S1. Time schedule of enrolment, interventions, and assessments.


The responsible use of existing antimicrobials is essential in reducing the threat posed by antimicrobial resistance (AMR). With the introduction of restrictions during the COVID-19 pandemic, a substantial reduction in face-to-face appointments in general practice was observed. To understand if this shift in healthcare provision has impacted on prescribing practices, we investigated antibiotic prescribing for upper respiratory tract infections (URTI) consultationsWe conducted an interrupted time-series analysis using patient-level primary care data to assess the impact of the COVID-19 pandemic on consultations and antibiotic prescribing for URTI in England.P < 0.001) after national lockdown measures in March 2020, with increases mostly sustained to May 2022.We estimated an increase of 105.7 antibiotic items per 1000 URTI consultations (95% CI: 65.6–145.8; Overuse of antibiotics is known to be a driver of resistance and it is essential that efforts to reduce inappropriate prescribing continue subsequent to the COVID-19 pandemic. Further work should examine drivers of increased antibiotic prescribing for URTI to inform the development of targeted antibiotic stewardship interventions. Our study used non-identified EHR data, contributed by practices using EMIS Web clinical software. Data included: year and month of birth ; sex; symptoms; diagnosis; drug code; drug name; date of issue; practice location (geographic region); and date of consultation. Remote  and face-to-face consultations were included.IQVIA Medical Research Data (IMRD) contain non-identifiable patient electronic health records (EHRs), collected from general practices.9 Patients prescribed anti-tuberculosis and anti-leprotic antibiotics on the same date as their URTI consultation were excluded from the analysis.We included patients who were diagnosed with an URTI, based on diagnosis and symptom codes, between 1 April 2014 and 31 May 2022. Patients were considered to have received an antibiotic for their URTI if a prescription for an antibiotic was made on the same date as their URTI consultation. Antibiotics were defined using the Anatomical Therapeutic Chemical (ATC) Classification System code J01 .URTI consultation rates were calculated using numbers of registered patients as the denominator and antibiotic prescribing rates were calculated using numbers of URTI consultations as the denominator. Continuous variables were described by median, IQR, minimum and maximum values. Categorical variables were described by the number and proportion of patients in each category.auto.arima function in the forecast package in R (version 4.1.3). The final models were selected using Akaike’s information criterion (AIC) and contained no evidence of residual autocorrelation. Data points were divided into pre-pandemic and pandemic periods, using 23 March 2020 as the cut-point to align with the first national lockdown in England.Interrupted time-series analysis (ITSA) was used to estimate changes in levels (rates) and trends in antibiotic prescribing over time. Regression models with autoregressive integrated moving average (ARIMA) errors were fitted, using the Analyses were conducted on the entire patient population of interest and for specific subgroups of age, sex and geographic region.https://www.iqvia.com/locations/united-kingdom/information-for-members-of-the-public/medical-research-data).The use of IMRD for the purpose of medical and public health research and for supplying the data to external researchers for scientifically approved studies under data-sharing agreements has been approved by the NHS Health Research Authority (NHS Research Ethics Committee ref 18/LO/0441) (Our study protocol was approved by an independent scientific review committee (SRC) on 30 June 2022 (SRC ref no. 22SRC025). In addition, a combined academic, risk assessment and ethics (CARE) form submitted to the LSHTM MSc Research Ethics Committee was approved on 1 June 2022 (LSHTM MSc Ethics ref. 27304).JAC-AMR Online). The median age for patients with URTI was 28 years .We identified a total of 518 859 patients with at least one URTI consultation in our study period, with 262 851 (50.7%) patients receiving an antibiotic for at least one of these consultations  antibiotic items prescribed to patients on the same day as their URTI consultation. Consultation rates for URTI showed a steady decrease of 43.5% in the pre-pandemic period from a peak of 24.1 consultations per 1000 registered patients in December 2014 to 13.6 consultations per 1000 registered patients in December 2019. There was a yearly seasonal pattern in the URTI consultation rates, with the peaks in winter and troughs in summer. Consultation rates dropped from 9.6 consultations per 1000 registered patients in February 2020 to 2.3 consultations per 1000 registered patients in April 2020, and remained at similar levels, with the absence of usual seasonal inclines, until March 2021, at which point consultation rates increased Figure .P < 0.001)—a 27% increase compared with the predicted value in April 2020, had the pre-pandemic trend continued  observed may be due to the prioritization of patients with more severe disease. However, the persistence in increased antibiotic prescribing rates for URTI consultations up to May 2022 suggests that there may be a sustained change in antibiotic prescribing. With an estimated 4.95 million deaths associated with antibiotic-resistant bacteria in 2019,13 and overuse of antibiotics known to be a driver of resistance,14–16 it is imperative that AMR and antimicrobial stewardship remain a global priority.It must be noted that total quantity of antibiotics prescribed for respiratory infections in primary care has reduced subsequent to the COVID-19 pandemic,6 This is also consistent with the finding that antibiotic prescribing rate is higher in remote consultations than in face-to-face settings.17Diagnostic uncertainties arising as a consequence of conducting clinical assessments remotely may have resulted in prescribers being more likely to prescribe antibiotics for URTI. This was suspected to be the case in the early phase of the pandemic, where the number of antibiotic prescriptions was 6.7% higher than expected given the substantial decrease in consultations.4 Additional studies are required to understand the impact of COVID-19 on prescribing for other infections. We were also unable to conduct stratified analyses by consultation setting and believe that this needs to be further explored. Though we have presented analyses by several subgroups we recognize that further work is required to investigate the impact of comorbidities and deprivation on antibiotic prescribing during the COVID-19 pandemic. In addition, the high rate of prescribing in those aged 12–17 years requires further investigation.We acknowledge that our study has several limitations, including that we have only investigated URTI. We focused on URTI due to previous studies identifying higher levels of inappropriate prescribing for this group of infections compared with others.The observed persistent increase in antibiotic prescribing for URTI in England post-COVID-19 is concerning and we recommend that other countries consider conducting similar analyses to assess the impact of the pandemic on antibiotic prescribing. Future studies should consider investigating consultation setting on prescribing rates, and patient and prescriber attitudes.dlad012_Supplementary_DataClick here for additional data file.


The prognosis of patients under existing neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy requires improvement. Whereas programmed cell death 1 (PD-1) inhibitors have shown promising response in advanced esophageal cancer, they have not been used in the perioperative treatment of resectable locally advanced esophageal cancer. Whether immunotherapy can be incorporated into neoadjuvant therapy has became a challenging question for researchers.We present a case of a 65-year-old male who had a history of progressive dysphagia for approximately 1 month. He underwent pertinent studies including computed tomography (CT)，gastroscopy，and pathological biopsy resulting in a diagnosis of medium-low differentiated squamous carcinoma of the thoracic segment of the esophagus (cT2N2M0 stage III). After 4 cycles of neoadjuvant chemotherapy combined with immunotherapy, gastroscopy showed the lesion in the esophagus was no longer present. Subsequently, the patient received thoracoscopic radical resection of esophageal cancer and achieved a pathological complete response (pCR) in postoperative pathological evaluation. During the whole treatment, no adverse effect was recorded and to date no evidence of recurrence has been recorded.Our report suggest that neoadjuvant chemotherapy combined with immunotherapy not only improve the R0 resection and pCR rate in patients with resectable locally advanced esophageal cancer, but also the adverse effects are within the control range. However, the selection of therapeutic strategy, predictors of response to treatment, and interval time between neoadjuvant treatment and surgery still await more reliable evidence-based studies with large prospective samples.The online version contains supplementary material available at 10.1186/s12957-022-02732-w. Esophageal cancer is the seventh most common cancer worldwide, and has the sixth highest mortality rate among all malignancies . EsophagImmune checkpoints enhance the tumor-killing function of immune cells by relieving the body's inhibitory effect on immune cells. Many clinical trials have been initiated to explore the immunotherapy of esophageal cancer , and immNeoadjuvant therapy refers to certain treatments that are given before radical treatment. It is used to improve the surgical R0 resection rate by reducing the tumor volume, size, or number of lymph nodes, and to reduce the recurrence rate by eliminating micrometastasis , 9. In rNeoadjuvant immunotherapy can induce a stronger immunological effect on tumor cells at an early stage of cancer by inducing T cell expansion with less impaired T-cell function compared with that induced by postoperative adjuvant immunotherapy –16. In rTo protect patient's privacy, important patient information is withheld in the following description. The patient is a 65-year-old male with a 5-year history of previous coronary artery disease, who was implanted with a stent in 2016, 2017, and 2019, respectively, and has been taking aspirin, ticagrelor, and atorvastatin postoperatively. The patient denied a history of smoking and alcohol consumption. He was admitted to a hospital after suffering from progressive dysphagia for about 1 month, and was subjected to a gastroscopy, which showed an irregular bulge in the esophageal wall at 22~26 cm from the incisor, occupying 50% of the intestinal lumen Fig. A, B takeAlthough neoadjuvant chemotherapy or chemoradiotherapy combined with surgery helps to improve resection rate and survival in patients with locally advanced esophageal cancer, surgical R0 resection rate remains poor and most patients present with a recurrence pattern dominated by distant metastases. According to Shapiro et al., this recurrence pattern might result from insufficient intensity of systemic therapy . TherefoBased on the case report, our article raises following questions that remain to be addressed.Firstly, identification of metastatic lymph nodes. For patients diagnosed as locally advanced esophageal carcinoma without distant metastasis, the surgical approach and the potential application of neoadjuvant therapy are dependent on preoperative stage, especially N stage. However, 11~56% of lymph nodes were reported to falsely diagnosed as negative for metastasis . TraditiSecondly, the new-emerging “neoadjuvant immunotherapy”, whether should it be used in combination with chemotherapy or chemoradiotherapy. Researches comparing two current and standard neoadjuvant therapy “chemotherapy and neoadjuvant chemoradiotherapy” in resectable locally advanced esophageal carcinoma have revealed no convincing evidence and unified conclusion –25. For Thirdly, selection of predictors for response to neoadjuvant immunotherapy. Some patients might exist as neoadjuvant therapy nonresponders, leading to tumor progression and delaying optimal treatment. Consequently, it is vital to screen the responding population with predictors. For example, for neoadjuvant chemotherapy, serum IgG level was found to be a satisfactory predictor . For immFinally, the optimal time interval between neoadjuvant therapy and surgery is also concerned. In clinical trials, the standard time to surgery (TTS) after completed neoadjuvant chemoradiotherapy is 4–6 weeks. However, due to administration reasons or being not suitable for surgery, a significant number of patients underwent prolonged TTS after neoadjuvant therapy. Kuo has focused on such an issue concerning survival between standard TTS and prolonged TTS, and has detected no significant difference . For theIn resectable locally advanced esophageal cancer, neoadjuvant chemotherapy or chemoradiotherapy combined with surgery has been used as the standard treatment; however, its therapeutic efficacy still needs to be improved. Although neoadjuvant immunotherapy is still at the stage of exploration in small samples, the available clinical data show that its efficacy is significant and its safety and adverse effects are within the control range. In future, neoadjuvant immunotherapy is expected to provide a new treatment strategy for patients with locally advanced esophageal cancer. In addition, based on clinical trial of large prospective samples, the selection of therapeutic strategy, predictors of response to treatment, and interval time between neoadjuvant treatment and surgery will be the essential research directions of neoadjuvant therapy.Additional file 1.Additional file 2.


The present study explored the degradation law and service life prediction of tunnel lining concrete with different mineral admixtures under coupled actions of sulfate attack (SA) and drying–wetting (DW) cycles. The deterioration resistance coefficient (DRC) of compressive strength and influence coefficients of sulfate concentration, mineral admixture content, water/binder (w/b) ratio, and curing regime on DRC were studied. After that, a new service life prediction model based on damage mechanics was developed and analyzed. Results show that, by increasing the DW cycles, the DRC first increases and then decreases. DRCs of Ordinary Portland cement (OPC), fly ash (FA), and ground granulated blast-furnace slag (GGBS) concrete linearly decrease with the increase of sulfate concentration, while the silica fume (SF) concrete displays a two-stage process; by increasing the admixture content, the DRCs of FA and GGBS concrete exhibit two distinct stages, while the SF concrete depicts a three-stage process; increasing the w/b ratio linearly decreases the DRC; the DRC of curing regime was sequenced as standard curing (SC) > fog curing (FC) > water curing (WC) > same condition curing (SCC). Based on the experimental results, the service life prediction model is applied and validated. The validation results show that the proposed model can accurately predict the lifetime of concrete with different mix proportions. Furthermore, it is found that the mineral admixture can effectively improve the lifetime of concrete, and the composite mineral admixture is more effective than a single mineral admixture in improving the lifetime of concrete. Sulfate ions widely exist in groundwater, seawater, sulfate soil, and salt lakes. The external sulfate attack (SA) has become one of the main factors that cause degradation and shortening of the service life of concrete structures ,2. SA isCement-based composites subjected to SA have been paid much attention since the 1960s. SA proceeds as sulfate ions enter the porous concrete and react with cement hydration products to form products such as ettringite, gypsum, or thaumasite. All of these mineral products can lead to expansion, cracking, and degradation of concrete ,22,23. SFurther, for a given concrete structure, its anticipated service life is dependent on material properties, environmental conditions, and maintenance practices . The serThe main objective of this paper is to investigate the degradation law and service life prediction of the tunnel lining concrete with different mix proportions under SA and DW cycles. First, the effects of mix proportions on DRC under SA and DW cycles are studied, and the degradation law is analyzed. Then, the effects of influential factors such as sulfate concentration, mineral admixture content, w/b ratio, and curing regime on DRC are investigated. Influence coefficients of different influential factors are analyzed. After that, a new service life prediction model based on damage mechanics is developed and validated, and the proposed model is employed to predict the lifetime of concrete with different mix proportions.In this study, Ordinary Portland cement (OPC) conforming to GB 175-2007  having t2SO4 was used as the SA source. The mix proportions and relevant compressive strength of the concrete are given in Seven tunnel lining concrete mixtures with a constant w/b ratio of 0.41 were designed for studying the DRC and degradation law under the coupled actions of SA and DW cycles. As per GB/T 50082-2009 , a 5% NaInfluential factors such as sulfate concentration, mineral admixture content, w/b ratio, and curing regime were considered. The test design of different influential factors is shown in 2SO4 solution for 15 h with a temperature of 25–30 °C  and 1 (fully disturbed state). Here, D can be expressed asConsidering the concept of one-dimensional degradation law as proposed ,70, the According to the test results in the present study , the relFor the concrete with a given mix proportion, the slope of deterioration function is assumed to be a function related to the number of DW cycles, Equation (17) can be rewritten as:Integration of Equation (18) leads toA and B are constants determined by the mix proportions and the corrosion environment.Experimental results indicate that the compressive strength degradation conforms to parabolic law under combined actions of SA and DW cycles. Similar trends could also be found in previous works ,64,65,66By substituting the expressions given in Equation (20) into Equation (19)The boundary condition is as follows: when It is evident that the degradation law of Equation (21) is the same as the fitting functions listed in m times. Hence, the corrosion time of concrete in a sulfate environment can be defined as t; m is the parameter related to the deterioration rate of the concrete in the real sulfate environment.Let us assume that the concrete subjected to sulfate environment for one year is equivalent to the DW cycles in a laboratory sulfate environment for t; According to the practice of Glasser et al. , the serm could be obtained by the mechanical test of the real existing concrete under sulfate environment. The flowchart of the service life prediction is summarized in In this paper, we define the lifetime of concrete in the case of corrosion as the time when the initial strength decreases to 50% , namely m was obtained by assuming the compressive strength of OPC concrete reduced by 50% after 100 years’ exposure. The w/b ratios of all the concrete were assumed to be 0.41, and the sulfate concentration was assumed to be 5%. The results are given in An application of the proposed prediction model was conducted on the concrete listed in Considering the coupled effects of SA and DW cycles, the DRC of the tunnel lining concrete with different mineral admixtures was investigated by experiments. The influence of sulfate concentration, mineral admixture content, w/b ratio, and curing regime on DRC was studied. The degradation law of the concrete was analyzed, and a new service life prediction model based on one-dimensional degradation law was developed. The main conclusions are summarized as follows:(1) The concrete without any mineral admixtures (100% OPC concrete) has the most aggressive influence on the(2) The influence coefficients of the OPC, FA, and GGBS concrete are linearly decreased with the increase of sulfate concentration, while the concrete with addition SF exhibits a first increase and a later decrease. Additionally, the results indicate that the addition of SF in concrete displays a more effective improvement than FA and GGBS to enhance the sulfate resistance with the increase of sulfate concentration.(3) For the concrete with different FA and GGBS contents, the influence coefficients of(4) The influence coefficient of the w/b ratio ((5) The concrete under standard curing has the maximum(6) The proposed service life prediction model was verified to be reliable. Additionally, it is suggested that the mineral admixtures can effectively improve the lifetime of the concrete. The composite mineral admixture has a more effective influence on the enhancement of concrete lifetime than a single mineral admixture.


B. anthracis, 10–12 h for Y. pestis, and 16 h for F. tularensis). Ready-to-use reagents for this assay may add a level of preparedness. We examined the option of freezing pre-prepared MAPt agar plates and thawing them upon need. Our results show that adequate minimal inhibitory concentration (MIC) values are obtained with the use of thawed 6- and 12-month frozen agar plates. The ability to store MAPt micro-agar plates at −70 °C for a year, together with all other reagents required for MAPt, holds a great advantage for bioterror preparedness.There is an urgent need for rapid antibiotic susceptibility tests to improve clinical treatment and to support antibiotic stewardship, especially concerning the emergence of multi-drug-resistant bacteria. Nowadays this need is even more profound due to progress in synthetic biology procedures that may facilitate the malicious preparation of engineered antibiotic-resistant pathogens. We recently described a novel, rapid, simple, specific, and sensitive method named a Micro-Agar-PCR-test (MAPt) and showed its performance on clinical as well as environmental samples. The method does not require any isolation or purification steps and is applicable to a wide range of bacterial concentrations, thus allowing a short time to respond within a bioterror event (5–7 h for  Antibiotic resistance is a major concern in the clinic. Rapid antibiotic susceptibility tests (ASTs) may assure proper treatment and lifesaving in intensive care settings. This issue is more profound regarding bio-threat agents, mainly due to public anxiety and more importantly, in light of potential malicious intensions to engineer pathogens carrying antibiotic resistance. Preparedness means that will offer decision-making personnel prompt proper antibiotic treatment options are essential for prophylactic treatment of exposed individuals before symptoms appear and disease spread, and to prevent mortality among morbid individuals.2–5 × 109 cfu/mL) [Bacillus anthracis, Yersinia pestis and Francisella tularensis against ciprofloxacin and doxycycline, the recommended first-line antibiotic treatment [B. anthracis, 10–12 h for Y. pestis, and 16 h for F. tularensis), thus providing the ability to deliver antibiotic susceptibility profiling before the onset of sever morbidity [Recently we have published papers ,2 descrireatment ,4,5. AdeA great benefit of an assay is the ability to store all essential components for long periods and to avoid the need to prepare fresh reagents. In the case of MAPt, all reagents are stored at −20 °C; nevertheless, the MAPt agar plates may be stored at 4 °C for only 2 months. The ability to freeze the plates and thaw them before use holds a great advantage. However, to the best of our knowledge, agar plates are known to be sensitive to freezing and, upon thawing, they lose their structure and firmness. One way to overcome this structure destruction is to apply pressure on the agar plate ,7; howevB. anthracis as the model bacteria to examine the option to use thawed frozen MAPt plates. Fast-growing bacteria are most challenging regarding rapid AST as the outcome of their infection without proper treatment can be fatal in no time. MAPt plates were prepared and stored as described in the Materials and Methods. The plastic bag sealed plates were frozen at −70 °C. As a preliminary experiment, we thawed plates at room temperature after 6 months and determined MIC values for B. anthracis to ciprofloxacin and doxycycline as described previously [B. anthracis to ciprofloxacin and doxycycline were determined and compared to the values obtained from fresh plates and to the standard microdilution test. The assay was performed on two bacterial concentrations, ~104 cfu/mL and ~105 cfu/mL, for each tested antibiotic. The MIC values obtained were 0.125 µg/mL for ciprofloxacin and 0.016 µg/mL for doxycycline at both tested bacteria concentrations  according to the manufacturer’s guidelines. Agar dilution was conducted essentially as defined in CLSI standard M07 . After aTested samples (in duplicates) of 10 microliters were plated in different wells of the MAPt plates containing different concentrations of the tested antibiotics. The MAPt plates were incubated at 37 °C for 6 h. Then, the bacteria were obtained from the MAPt plate with 150 μL of PBS. 100 μL of the recovered bacteria was added to 100 μL of Triton buffer  and the samples were heated for 30 min at 100 °C to sterilize the sample and extract the DNA. A sample of 5 μL was evaluated by qPCR using a 7500 Real-Time PCR system .PL3_F: AAAGCTACAAACTCTGAAATTTGTAAATTG.PL3_R: CAACGATGATTGGAGATAGAGTATTCTTT.Tqpro_PL3: FAM-AACAGTACGTTTCACTGGAGCAAAATCAA-BHQ-1.The qPCR reactions were performed in 30 μL volumes containing 2.3 μL of 20 mg/mL bovine serum albumin , 15.05 μL SensiFAST Probe Lo-ROX Mix , 3.05 μL forward primer (5 pmol/μL), 3.05 μL reverse primer (5 pmol/μL) and 1.55 μL TaqMan probe (5 pmol/μL), and 5 μL of DNA extract. The primers and probes used were ,11:PL3_FThe PCR thermal conditions were: 3 min at 60 °C followed by 40 cycles of 15 s at 95 °C and 35 s at 60 °C.−ΔCt where ΔCt is the difference between the Ct of sampled bacteria compared to the Ct of the untreated control sample. A 10-fold variation between the antibiotic-treated and untreated samples is reflected by a ΔCt = 3.3 (log210), in an efficient PCR. The MIC was determined as the lowest antibiotic concentration that reduced growth to ΔCt ≥ 3.3, which correlated with the lack of visible growth by the standard AST.Bacterial quantification by qPCR was estimated using the Ct value, which was evaluated by the 7500 real-time PCR system Sequence Detection Software (version 1.4). The relative change in bacterial growth between an untreated control and antibiotic-treated sample (designated as FC) was calculated by the equation FC = 25–1 × 106 cfu/mL suspended in CAMHB was added at a 1:1 volume to a 96-well plate  containing duplicates of two-fold serial dilutions of ciprofloxacin  or doxycycline  in CAMHB at a final volume of 0.1 mL. Bacteria grown in CAMHB without the addition of the antibiotics served as growth controls in each assay. The 96-well plate was incubated at 37 °C for 20 h. MIC values were defined as the lowest antibiotic concentration that no growth was shown by visual inspection.Standard broth microdilution was conducted in cation-adjusted Mueller–Hinton broth  according to the CLSI guidelines . An inocA patent application (IL270342) for the described antibiotic susceptibility test (MAPt) was filed by the Israel Institute for Biological Research.


Since the early 1990s, many studies were conducted to utilize waste tires as a replacement for natural coarse and fine aggregates in concrete, known as rubberized concrete or rubber-concrete. In this paper, an experimental study was performed on the strength properties of concrete containing fine-rubber particles as a replacement of fine aggregate, using destructive and non-destructive tests. Ultrasonic pulse velocity (UPV) tests were used to evaluate the strength property of rubber-concrete as a non-destructive test. Compressive and splitting tensile strengths were determined for four different volume contents of fine-rubber particles and exponential equations were proposed for the relationship between compressive, splitting tensile strength and the UPV of rubber-concrete, respectively. With the limited conditions in this paper, it found that UPV tests could also be used to estimate the compressive and tensile strengths of rubber-concrete, that are used in other types of concrete. Over the years, the treatment of waste tires has been one of the huge environmental concerns in many countries. In the research field of concrete, research has been conducted regarding the waste tire as a replacement for natural aggregates in concrete, known as rubberized concrete or rubber-concrete. A number of studies show that the mechanical properties of rubber-concrete, such as compressive and tensile strengths, can be used for certain specified engineering applications ,2,3. To 2) were different for each replacement level of GGBS. The relationship between the compressive strength and UPV of RCC can be used to estimate the strength of concrete at any age and for all replacement levels of GGBS mixed in RCC.Rao et al.  presentsDemirboga et al.  reportedTurgut  presenteKewalramani et al.  reportedFawzy et al.  presenteGregori et al.  predicteMohammed et al.  investigA number of works were carried out to evaluate the relationship between UPV values and strength for various types of concrete. However, there were not many investigations to find the relationship between UPV values and the strength of rubber-concrete at this time. In this study, the mechanical properties of concrete containing fine-rubber particles are investigated, using destructive and non-destructive tests for four different contents of fine-rubber particles varying with temperature. The result of this study intends to estimate the strength properties of rubber-concrete using non-destructive test, and will be provided for use for structural applications of rubber-concrete.In this paper, an experimental program was designed to evaluate strength properties of concrete containing fine-rubber particles as a replacement for fine aggregate. Destructive testing and UPV, as non-destructive testing methods, were conducted for hardened concrete under room and high temperatures at 14, 28, and 56 day curing time .The cement used in this study was an ordinary Portland cement (type I/II in Korea), which met the Korean standards KSL5201 with a specific gravity of 3.15. The used coarse aggregate has a 19 mm maximum size of crushed stone with a specific gravity of 2.64. The fine aggregate has a specific gravity of 2.56 and a fineness modulus of 2.42 of natural sand. The used waste tires’ rubber-particles, as a replacement for fine aggregate in this study, were manufactured from automobile tires by mechanical shredding. The used rubber particle has an average of 1.0 mm in size, and has a specific gravity of 0.83. The gradation curve of fine-rubber particles in this study was determined based on the KS F 2502 method, and the gradation curves of fine-rubber particles are shown in The plain and rubber-concrete specimens were made by a rotary mixer with the following stages: coarse and fine aggregates were mixed for approximately 1 min, and then cement and fine-rubber particles were added in the mixer and mixed for an additional 2~3 min. Mixing continued and then about 50% of the total water was added. Finally, the remaining water was added, and the mixing continued for an additional 4~5 min. In this study, 0%, 10%, 20% and 30% of fine-rubber particle contents were used as a replacement for fine aggregate in concrete, respectively. The details of the mix numbers and mix proportions for the specimens are shown in Concrete specimens were made using a plastic mold of 100 mm in diameter and 200 mm in height. The casting of specimens both in plain concrete and rubber-concrete were made in a laboratory at room temperature. The used specimens were demolded approximately 24 h after their casting, and then cured in a water tank until the time of testing with an average temperature of 20 ± 1.5 °C. A total of 108 specimens of plain concrete and rubber-concrete were made for UPV test, as well as compressive and splitting tensile tests.To evaluate the strength properties of concrete containing fine-rubber particles, compression, splitting tension and ultrasonic pulse velocity tests were carried out for hardened concrete specimens at 14, 28 and 56 days. A total of 54 concrete specimens of plain concrete and rubber-concrete were used for the compression test, in accordance with the Korean standards KSF 2405 (2009). The loading control in a universal testing machine (UTM) was applied at a rate of 0.02 mm/sec with a preload of about 200 N. The peak load and the load–axial displacement in the UTM were recorded during the test using an acquisition system. The compressive strength of each specimen was evaluated at 14, 28 and 56 days, as shown in The test result is based on the average of three cylindrical specimens tested in each mix. Compressive strengths of the cylindrical specimens were evaluated for ages of 14, 28 and 56 days under room and high temperatures. For each specimen, a stress–strain curve was measured, and a typical stress–strain curve of concrete with different replacement for fine-rubber particles for 28 days is shown in T80%) and the area under the stress–strain curve up to the peak stress (T100%). Thus, the toughness index, iT, is expressed as follows:In general, toughness of the material can be calculated by measuring the area under the typical stress–strain curve, up to 80% of the ultimate stress in the post-peak region . In otheThe toughness index of rubber-concrete obtained in this study is presented in The average compressive strengths of rubber-concrete for curing time and rubber particle content are presented with standard deviations in brackets as shown in The average compressive strengths of plain and rubber-concrete for high temperatures are presented with standard deviations in brackets, as shown in The average splitting tensile strength for curing time and rubber particle content is shown in The average splitting tensile strength of rubber-concrete for high temperatures is also shown in In order to find the effect of rubber particles on the strength of rubber-concrete, the relationship between compressive and splitting tensile strength was investigated. The ratio of splitting tensile strength to compressive strength for rubber concrete showed a similar value to that of plain concrete. At the age of 28 days, the ratio was 16.14, 16.20, and 15.96% for 10, 20, and 30% of rubber particle replacement for fine aggregate, respectively. The ratio was 16.57, 15.80, and 16.32% at 56 days, respectively. The relationship between compressive and splitting tensile strength after being exposed to high temperature was also investigated. There was no significant difference compared to plain concrete for room and high temperatures. The ratio at 200 °C was 16.15, 16.44, and 15.68% for 10, 20, and 30% of rubber particle replacement for fine aggregate, respectively. The ratio was slightly decreased for 400 °C and 800 °C.The UPV test was carried out to measure the velocity of wave transmission for specimens of plain concrete and rubber-concrete at 14, 28 and 56 days. The UPV test was measured at a very small deformation of specimens, while strength was measured at the failure state of specimens.The average UPV values of rubber-concrete for curing time and contents of rubber particles are shown in The average UPV measurements of plain and rubber-concrete exposed to 0, 200, 400 and 800 °C are shown in CF is compressive strength, A and B are empirical parameters determined by the regression analysis and pV is the ultrasonic pulse velocity. A correlation between compressive strength and a UPV measurement is shown in Until now, a number of researchers have developed theoretical models for the estimation of relationship between the UPV measurement and the destructive test of compressive strength. It is believed that UPV measurement can also be correlated to compressive and tensile strengths. However, this relationship can be affected by many factors, such as types of aggregates, W/C ratios, curing time, specimen sizes and the testing methods used. Therefore, the UPV value can also be used to estimate compressive and tensile strengths of rubber-concrete ,17,18. I2 value was found to be 0.74.The best curve-fitting equation is plotted in FS is the splitting tensile strength. The best curve-fitting equation is plotted in 2 value is found to be 0.79.A correlation of splitting tensile strength and UPV measurement is shown in 2) obtained in this study are relatively low compared to other different concretes, as shown in 2 of 0.7 or higher to be reasonable analysis [It was found that the coefficients of determination  at 28 days. To verify this result, further investigation is needed under various factors such as types and sizes of rubber, water-cement ratios, curing time, replacement ratios of rubber particles, and so on;Rubber-concrete showed a large reduction in compressive and splitting tensile strengths after being exposed to 800 °C compared to that at room temperature. Further detailed investigations are also needed between temperatures of 400 and 800 °C to verify this result;An exponential relationship between the UPV measurement and the strength of rubber-concrete was proposed. It is concluded that UPV measurements can also estimate the strength of rubber-concrete. However, further investigation is needed under various factors considered in concrete.Based on the experimental and analytical results of concrete containing fine-rubber particles in this study, the following conclusions were made:


P < 0.05). Besides, two different sources of Se supplementation both greatly improved redox status with higher levels of T-AOC, SOD, and CAT (P < 0.05), while less content of MDA (P < 0.05), and reduced protein expression of cleaved-caspase-3 (P < 0.05) to mitigate cell apoptosis. Furthermore, the key proteins related to p38/JNK pathway including p38, p-p38, JNK, and p-JNK were apparently reduced in the groups with both of SeY and Sel-Met (P < 0.05). Interestingly we found that the changes induced by SeY supplementation in cell viability, selenoprotein transcriptome, antioxidative capacity, and anti-apoptosis were comprehensively greater compared with same levels addition of Sel-Met in PEMCs (P < 0.05). In conclusion, both SeY and Sel-Met promoted cell viability and attenuated cell apoptosis by regulating the selenoprotein expression and antioxidative capacity via p38/JNK signaling pathway in PMEC, but SeY has more efficient benefits than that of Sel-Met.Comprehensive studies have been conducted to compare the effect of organic and inorganic selenium previously, but there is still limited knowledge about the difference between organic selenium (Se) from varied sources despite the widely use of organic Se in both animal and human being nutrient additives. In the present study, we systemically compared the effect of two different types of organic Se including selenium yeast (SeY) and selenium methionine (Sel-Met) on cell viability, selenoprotein transcriptome, and antioxidant status in porcine mammary epithelial cells (PMECs) and the results indicated that appropriate addition of SeY and Sel-Met both significantly promoted cell viability and up-regulated the mRNA expression of most selenopreoteins including DIOs, GPXs, and TrxRs family et al. ( Lactating sows showed higher nutrition and energy demands due to the extensive metabolism in mammary glands to produce milk, associated with adaption of a whole animal body system. It has been reported that 632 genes related to amino acids, fatty acids, and glucose metabolism were differentially expressed in livers during lactation . IncreasIn recent decades, antioxidants either from nature or artificial synthesis have been widely accepted and used to improve animal production. This beneficial effect is attributed to their capacity of reactive oxygen species (ROS) detoxication to maintain dynamic redox balance , 8. Se iin vitro model by evaluating cell viability, gene transcriptome of selenoproteins, which are the main forms of Se in mammals, and antioxidant status, with the purpose to provide theoretical foundations for organic Se application in lactating sow diets.Based on those study results, various forms of Se were added in diets with the purpose to improve animal systemic redox status and consequently enhance lactating performance. In general, Se was added in animal diets in two different forms, which are inorganic salts mainly represented as sodium selenite, and organic selenium mainly represented as selenium methionine (Sel-Met) and selenium yeast (SeY). Comprehensive studies have been conducted to evaluate the relative efficiency of different types of Se on animal performance and achieved a common understanding that organic Se has an overall advantage in absorption rate , antioxi3 fragments with sterile scissors and washed repeatedly with D-Hanks solution to wash away blood cells and other connective tissue. Then the tissue fragments were digested with collagenase II at 37°C and 5% CO2 for 1 h. The isolated cells were cultured in DMED/F12 medium supplemented with 10% fetal bovine serum, and the medium was changed every 24 h. Additionally, fluorescence-activated cell sorting (FACS) analysis of cytokeratin expression was used to verify the purity of mammary epithelial cells at more than 90%. In the present study, isolated cells were incubated at 37°C, 5% CO2 and cultured in a complete medium according to the formula of Jaeger et al.  into 0.5 mL 10 mM Tris-HCl (Sigma-Aldrich) buffer. Dissolve 40 mg selenium yeast  in the prepared protease solution and mix well. The samples were ultrasonic 25 s with 80% amplitude on ice and cleaned with ultra-pure water. The extraction power was 30 W and the samples were run for 15 min. The obtained sample was centrifuged at 14,000 rpm for 3 min, and the supernatant was taken. The precipitation was cleaned and mixed with ultrapure water until resuspension, and the supernatant was centrifuged again at 14,000 rpm for 3 min to obtain the supernatant. The concentration of selenium in the sample was determined by inductively coupled plasma mass spectrometry (ICP-MS) .A total of 12 mg of Sel-Met were dissolved in 10 L DMED/F12 to prepare 1.2 ppm stock solution. The original solution was added to 5, 3.75, 2.5, 1.25, and 0 mL volumes of DMED/F12 to prepare the working solution at concentrations of 0, 0.3, 0.6, 0.9, and 1.2 ppm, respectively.2 for 48 h. Then, selenium yeast  and selenium methionine  were successively added to the 96-well plate at concentration gradients of 0, 0.3, 0.6, 0.9, and 1.2 ppm, respectively. At 24 h post-treatment 20 μL, CCK-8 was added to each well, incubated for 4 h at 37°C, and then measured using a microplate reader at the wavelength of 450 nm.Cell viability was tested using the CCK-8 assay  according to the manufacturer's instruction. Briefly, PMECs were seeded into 96-well microplates at 200 μL/well with 2 ×104 cells/mL and were cultured in complete medium at 37°C 5% CO4 cells/mL and were cultured in complete medium at 37°C, 5% CO2 for 48 h. Then, the cells were treated with various levels of SeY and Sel-Met  for 24 h. After that, total RNA was extracted from PMECs using TRIZOL , according to the manufacturer's instructions. The quality and quantity of RNA were analyzed by Agilent Bioanalyzer 2100 using an RNA 6000 Labchip kit. Potential DNA contamination of the extraction was eliminated using the DNA-free kit , and the RNA quality was verified by both agarose gel (1%) electrophoresis, and spectrometry (A260/A280). First-strand cDNA synthesis was performed by using a Prime Script RT reagent kit with gDNA eraser . The cDNA was synthesized from 1 μg total RNA using Super Script III reverse transcriptase according to the manufacturer's instructions. The mRNA levels of 25 selenoprotein genes were analyzed by qPCR using the SYBR Green PCR Master Mix according to the manufacturer's instructions . Primers for the 25 selenoprotein genes were referenced from the study of Zhao et al. . The Western blot analysis was done according to the procedures described in our previous study , malondialdehyde (MDA), catalase (CAT), and the total antioxidant capacity (T-AOC) of cells. The antioxidant capacity of cells was determined using the kit of Nanjing JianCheng Institute of Biological Engineering, and the detection method was according to the instructions of the kit.PMECs were seeded into 6-well plates at 2 mL/well with 5 ×10https://www.cloudtutu.com). The P-value < 0.05 was used as the criterion to judge the significance of the difference.The data of CCK-8, PCR, Western blot, and antioxidant status were analyzed by one-way ANOVA, LSD multiple comparison, and Pearson correlation analysis using SPSS 22.0 software in the present study. The establishment of PCA and heatmap models was performed on the Tutools platform (P < 0.05). At the increased concentrations of 0.9 ppm SeY still led to greater cell viability, but Sel-Met had no affect (P > 0.05), while at 1.2 ppm SeY was not different from the control and Sel-Met treated cells had lower viability (P < 0.05).As shown in P < 0.05), and there was no significant difference between SeY and Sel-Met. When Se concentration was increased up to 0.9 and 1.2 ppm, the supplementation of both forms of Se lead to higher mRNA expression of DIO1, DIO2, and DIO3 (P < 0.05), but SeY groups showed higher mRNA expression levels of DIO1 and DIO2 compared with those with Sel-Met at the same concentration (P < 0.05). The PCA ( The PCA  diagram P < 0.05). For Sel-Met group, the GPX1 mRNA expression level of different supplemental levels was higher than that of the control group (P < 0.05), but lower than that of the SeY group (P < 0.05). The mRNA expression levels of GPX2 and GPX4 were similar in the Sel-Met group and the SeY group at 0.3 and 0.6 ppm. In particular, 1.2 ppm Sel-Met inhibited GPX4 expression in PMECs (P < 0.05). At 0.6 ppm, GPX6 mRNA level in the Sel-Met group was higher than that in the control group, except that the mRNA expression levels of other supplemental levels were the same as that in the control group (P < 0.05). Combined with heat map (P < 0.05).heat map  observatheat map  that botheat map  (P < 0.0P > 0.05), but TrxR1 and TrxR2 mRNA expression were different. TrxR1 mRNA expression in SeY groups was significantly higher than that in the control group (P < 0.05). Sel-Met significantly increased TrxR1 mRNA expression at 0.3 and 0.6 ppm, while it was similar to the control group at 0.9 and 1.2 ppm. TrxR2 mRNA expression was significantly increased in 0.9 and 1.2 ppm SeY groups (P < 0.05), while there was no significant change in the Sel-Met group (P < 0.05).Observe et group . In the et group . The heaet group . Westernet group , but theP < 0.05). However, Sel-Met did not affect the mRNA expression of SeIH (P > 0.05) from 0.3 to 0.9 ppm, and lowered (P < 0.05) the mRNA expression of SeIH when added at 1.2 ppm. The mRNA expression of SelR, SelW, and SPS2 increased significantly after adding 0.6 and 0.9 ppm Sel-Met (P < 0.05). At 1.2 ppm, Sel-Met increased the mRNA expression of SelW and SPS2 (P < 0.05) but had no effect on SelR (P > 0.05). At the same amount of addition, the expression of SelH, SelR, SelW, SPS2 in Sel-Met cells was the same as that of SeY or lower than that of SeY (P < 0.05). With the increase of SeY and Sel-Met levels from 0.3 to 1.2 ppm, the mRNA expression levels of Sell, SelK, and SelM were higher than those in the control group (P < 0.05). The expression of SelN at 0.9 and 1.2 ppm was significantly higher than that in the control group. Except for the same expression of Sell at 1.2 ppm, the effect of the SeY group was better than the Sel-Met group (P < 0.05). In the PCA diagram  and compared with Sel-Met, the groups with SeY addition had significantly higher (P < 0.05) T-AOC, SOD, and CAT. In contrast, the MDA levels are significantly lower (P < 0.05) for both groups supplemented with selenium addition compared with the control. Furthermore, the MDA levels are significantly higher (P < 0.05) with Sel-Met compared to SeY.As can be seen in P < 0.05) than Sel-Met. The abundance of Bcl-2 was significantly higher (P < 0.05) with both Se sources compared to the control, with SeY being higher (P < 0.05) than Sel-Met.To further explore the interaction between selenoproteins, correlation analysis was conducted. As shown in 2SeO3, Sel-Met, and selenite containing Se compounds all showed positive effects on cell viability in various cells including human immature dendritic cells, human lens epithelial cells , thioredoxin reductase family (TrxR), and deiodinase family (DIOs), as well as SelH, SelI, SelM, SelK, etc. , 49. Thein vitro . For insin vitro . Stolwijin vitro  showed tin vitro  also foud muscle . Furtherd muscle . Dietaryd muscle . In the 2 in pregnant Wistar rats than Se/Zinc supplementation , both of which belong to mitogen-activated protein kinases (MAPKs) are involved in the mediation of cellular apoptosis induced by oxidative stress . Yeo et y models . A studyy models . In the via p38/JNK signaling pathway in PMECs, but SeY comprehensively exhibited more efficient benefit than that of Sel-Met. These findings provide a reference for scientific utilization of organic Se and enrich the theoretical research for further investigations exploring more potential nutritional regulation of Se in humans being healthy and animal production.Based on the results of the present study, we summarized that both SeY and Sel-Met promoted cell viability and attenuated cell apoptosis by regulating the selenoprotein expression and antioxidative capacity The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal study was reviewed and approved by South China Agricultural University.FC, SZ, and WG designed the experiment and conducted the final proofreading. CW drafted the manuscript, carried out the experiment, and performed the analysis of all data. All authors have read and agreed to the published version of the manuscript.This research was funded by the General Program of the Natural Science Foundation of Guangdong Province (2021A1515010944).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.


Placement of ventriculoperitoneal (VP) shunt is an important treatment for pediatric hydrocephalus. Although prolonged perioperative antibiotic prophylaxis has theoretically no benefit in reducing device-associated infections, duration of antibiotic prophylaxis for VP shunt placement in pediatrics is not well established. As a part of antimicrobial stewardship program (ASP), our ASP team recommended to stop perioperative antibiotic prophylaxis for sterile medical placement within 48 hours following surgery in April 2017.Our aim of this study was to evaluate rate of VP shunt-associated infections following shunt placement between children received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis.Children aged 15 years old or younger who underwent VP shunt insertion between April 2014 and November 2021 were enrolled at Tokyo Metropolitan Children's Medical Center. Children with co-existing infection at time of surgery were excluded. Rates of VP shunt-associated infections following 1 month and 6 months of post-surgical periods were compared between children who received < 48 hours and ≧ 48 hours of perioperative antibiotic prophylaxis.A total of 110 children were identified. Among them, 11 cases with VP shunt-associated meningitis and 15 cases with other infections were excluded. Girl ratio was 44%. Median age was 4.5 months old (IQR 8-40). Numbers of children with cefazolin and vancomycin-contained regimen were 83 (98.8%) and 1 (1.2%), respectively. Numbers of children who received perioperative antibiotic prophylaxis for < 48 hours and ≧ 48 hours were 43 (51.2%) and 41 (48.8%), respectively. Incidence of VP shunt-associated infections for 1 month of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 4.65% (2/43) and 12.2% (5/41), respectively. (P=0.211)　Incidence of VP shunt-associated infections for 6 months of post-surgical period in < 48 hours and ≧ 48 hours antibiotic prophylaxis groups were 11.6% (5/43) and 12.2% (5/41), respectively. (P=0.936).Shorter duration of < 48 hours of perioperative antibiotic prophylaxis did not increase rates of VP shunt-associated infections among children in short and long terms.All Authors: No reported disclosures.


Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition that is known to involve multiple organs and was first described as an entity in 2003. It is characterized by lesions with a dense lymphoplasmacytic infiltrate, IgG4-positive plasma cells, storiform fibrosis, and frequently elevated serum IgG4 levels. Organs that are commonly involved include the pancreas, biliary tree, salivary glands, periorbital tissues, kidneys, retroperitoneum, lungs, pleura, thyroid, aorta, and lymph nodes. Rarer manifestations of IgG4-RD include central nervous system (CNS) involvement, prostatitis, mastitis, midline destructive disease, and nasopharyngeal disease. In this report, we discuss an atypical case of a young woman with laryngeal subglottic involvement leading to stenosis and airway obstruction, which was ultimately successfully managed with systemic immunosuppression.  Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition that causes fibroinflammatory lesions, which can affect multiple organs and was first identified as a distinct entity in 2003 . It is cRarer manifestations of IgG4-RD include CNS involvement, prostatitis, mastitis, midline destructive disease , and nasopharyngeal disease. The condition can mimic malignancy, infection, and other inflammatory diseases, including ANCA-associated vasculitis and Sjogren's syndrome, and it is not uncommon for it to be misdiagnosed initially . PrimaryHere, we describe a case of a young woman presenting with laryngeal subglottic involvement leading to stenosis and airway obstruction. It is important to closely follow individuals with suspected IgG4-RD, often with a multidisciplinary approach, because the formal diagnosis can be delayed if tissue sampling is a challenge. This patient is a 30-year-old woman who presented to laryngology clinic in 2017 after she was unable to be intubated for elective sinonasal surgery at an outside facility due to subglottic stenosis. Prior to that initial visit, she had been experiencing shortness of breath over the past year and was responsive to a few courses of oral glucocorticoids as well as montelukast. Upon presentation to laryngology clinic, the patient complained of nasal obstruction, crusting, and nosebleeds in addition to difficulty in breathing. Flexible laryngoscopy revealed subglottic stenosis. Rheumatology evaluation was requested due to this constellation of symptoms and a family history of autoimmune disease. Initial rheumatologic differential diagnoses included ANCA-associated vasculitis, IgG4-related disease, sarcoidosis, and relapsing polychondritis. Laboratory workup revealed slightly elevated IgG4 subclass at 151 mg/dL , slightly elevated ALT but was otherwise normal, including basic metabolic panel, complete blood count, and serum protein electrophoresis  vasculitis or other organ involvement of IgG4-RD. Her first endoscopic airway operation  provided relief. Pathology of the laryngeal and subglottic tissues showed a small focus of chronic inflammation with stromal fibrosis/hyalinization and a few IgG4 cells present. Due to the limited size of the sample and only the presence of a small number of IgG4 cells, the findings were not conclusive for IgG4-RD. She underwent subsequent endoscopic procedures six months and again 17 months later. In Feb 2018, she underwent a repeat direct microlaryngoscopy with steroid injection due to recurrent respiratory symptoms, after which she had mild improvement. A repeat subglottic tissue biopsy was negative for IgG4 staining. In a discussion between the patient, her otolaryngologist, and rheumatologist, a decision was made to not start her on any systemic therapy. In the meantime, she was also found to have microhematuria. A cystoscopy done in October 2017 was unremarkable. She was then seen by nephrology, who found a few dysmorphic RBCs on urinalysis and proceeded with a kidney biopsy in March 2018, which was normal and negative for IgG4 staining. It was noted on a 2019 CT abdomen/pelvis that she had some urothelial thickening of the renal collecting system, which could be due to retroperitoneal fibrosis, which can be seen in the setting of IgG-RD. She then had repeat CT imaging of the chest, abdomen, and pelvis in July 2020, which revealed some scattered benign-appearing pulmonary nodules, but was otherwise unremarkable. She was then treated with serial awake, office intralesional steroid injections. Despite some improvement, her symptoms recurred, along with 60% stenosis. At that time, it was decided that the patient should begin systemic glucocorticoid therapy because she responded to local treatment for a shorter period before recurrence compared to other patients, which suggested the possibility of systemic disease. She was started on a taper of prednisone beginning at 40mg; however, she could not tolerate higher doses of prednisone due to side effects of irritability and insomnia; therefore, a reduced dose of 20mg daily was given for two months. After a follow-up visit with rheumatology, she was increased to 40mg daily for a month. This led to improvement in both nasal and laryngotracheal symptoms. A CT scan of her neck at that time showed left eccentric submucosal thickening of the proximal trachea, 22mm below the level of the glottis and centered just below the cricoid ring. In October 2020, she underwent a repeat microlaryngoscopy and bronchoscopy with a larger excisional biopsy. This time, the biopsy showed dense subepithelial storiform fibrosis and chronic inflammation with increased IgG4 positive plasma cells (33 per high power field at 40x) with less than 50% IgG4/IgG (Figure On review of the literature, there have been only a few case reports of IgG4-RD involvement in larynx and trachea. Specifically, there have been four cases reported to our knowledge of subglottic involvement, as seen in our patient -6. A hanThe treatment of IgG4-RD can be multimodal depending on the area involved . The firWhile laryngotracheal involvement in IgG4-RD is rare, our knowledge of this entity is in its infancy, and, thus, it may be under-recognized. It took nearly three years of follow-up and three biopsies to confidently characterize this patient’s disease. This case exemplifies the need for ongoing follow-up in patients with suspicion of systemic disease. This is particularly true if the presentation is in a location in which it is challenging to obtain a large tissue sample.