To validate this approach, heat-stress time-kill experiments were performed with both culturable and VBNC cells. We developed a comprehensive experimental setup and demonstrated the applicability of this VBNC–MIC assay for testing the tolerance of 12 strains of 4 important bacterial species  in the VBNC state to eight important antimicrobials including four different antibiotics. We confirmed that bacteria in the VBNC state were resistant to all tested antibiotics  and additionally insensitive to disinfectants  and preservatives (bronopol and sodium azide). These data emphasize the need for further research regarding the characteristics of bacterial pathogens in the VBNC state and present the advantages and high-throughput capabilities of ATP determinations to investigate tolerance of VBNC pathogens to antimicrobials. The presented method should be helpful in order to identify appropriate countermeasures, treatments, or disinfectants when confronted with bacterial pathogens in the VBNC state.Many bacteria enter the viable but non-culturable (VBNC) state to maximize resources and increase their tolerance to harmful conditions to cope with environmental stress, which has been described for a plethora of important human and foodborne pathogens. VBNC pathogens can potentially present a serious risk to human health as they are invisible to routine microbiological culture-based methods. Of high importance is the increased tolerance to antibiotics or disinfectant measures while in the VBNC state. The greatest remaining challenge for such investigations is the lack of an appropriate, cost-effective multi-species screening method due to experimental constraints. In this study, we investigated if  Bacteria are exposed to environments with constantly changing conditions. To cope with these environmental stresses, many bacteria enter a viable but non-culturable (VBNC) state that results in higher tolerances to harmful conditions . The VBNEmerging bacterial resistance to antibiotics has become a global environmental problem. In contrast to culturable cells, where antibiotic resistance involves specific resistance genes, resistance of VBNC cells is essentially believed to result from a non-specific stress reaction that slows metabolic activity and thereby minimizes the consequences of otherwise unimpaired antibiotic binding . ResearcVibrio vulnificus are protected against a wide variety of stresses by resuscitating the VBNC cells following stress removal. However, from over 100 species known to enter the VBNC state, only a small number of pathogens have been successfully resuscitated , which is the lowest concentration of an antimicrobial that prevents visible growth of a microorganism   , EGDe  broth supplemented with yeast extract in a shaking incubator. 600 of 0.6. This ensured that cells were in a logarithmic growth phase. Subsequently, each well, which contained a serially diluted antimicrobial (dilution 1:2), was inoculated with 5 × 105 CFU/ml of the respective bacterial cells. After bacterial inoculation, the 96-well microtiter plates  were measured at 610 nm wavelength in a TECAN F100 microplate reader  to monitor any possible interference by the compounds at the given wavelength. The microtiter plates were then incubated for 24 h at 30°C for Pseudomonas strains and at 37°C for all other strains. Afterward bacterial growth was assessed by measuring absorbance at 610 nm. The MIC was defined as the lowest concentration of the antimicrobial where no bacterial growth could be measured after 24 h. Results are displayed as mean MIC, including upper and lower limits, of at least three experiments performed on different days.Minimum inhibitory concentrations of the respective antimicrobial compounds were calculated by applying the serial twofold dilution microtiter plate method in BHI medium. In order to create a constant cell status for each experiment, 1 ml aliquots of the respective overnight cultures were transferred into 9 ml of fresh BHI medium and incubated until it reached an OD600: 0.6) was centrifuged for 5 min at 8,000 ×g. The pellet was resuspended in 1 ml of the respective treatment conditions (g and pellets washed with 1 ml of 1× phosphate buffer solution (PBS). Cells were resuspended in 1 ml BHI medium and maintained at their respective incubation temperature.Induction and confirmation of the VBNC state was performed according to nditions  and incunditions . After i5 RLU for de novo ATP production within 24 h, which is an empirical value derived from the previous publication, to make sure that sufficient cells entered the VBNC cells with regard to further experiments. Testing culturability after 24 h also served as a control in order to exclude possible regrowth of remaining culturable cells in the respective samples. Culturability testing was performed by plating 10 μl of the culture onto a tryptone soya agar (TSA) plate and overnight incubation at 37°C.To confirm VBNC induction, culturability and ATP production were tested directly and 24 h after resuspending cells in fresh BHI medium . CorrespTM Microbial Cell Viability Assay . Therefore, 100 μl of bacterial culture was mixed with 100 μl luciferase reagent and incubated for 10 min at RT in the dark. Luminescence was recorded in relative light units (RLUs) using the Tecan F100 microplate reader . BHI medium was used as negative control.To investigate the metabolic activity of non-culturable cells, ATP was quantified using the BacTiter-GloL. monocytogenes EGDe, ScottA, QC1, and MFPT3; Escherichia coli BW, ATCC, and JW; B. cereus KSS and ATCC; Pseudomonas aeruginosa ATCC, K71, and K73) were exposed to different combinations of non-ionic detergents and inorganic salts for 1 h  could be killed by incubation at 90°C for 15 min (To determine the minimum ATP inhibitory concentration (MAIC), respective VBNC induction conditions for each bacterial species had to be determined by preceding screening . In prin for 1 h . After ir 15 min .de novo ATP generation had to be evaluated for each strain individually. For this purpose, three different cell concentrations of each strain  as well as three different incubation temperatures  were tested. To exclude ATP production by regrown cells or resuscitation, 10 μl of each individual sample was plated onto TSA plates. All tests were done in triplicates. Conditions leading to the maximum de novo ATP production were used for further experiments.In addition to the preceding screening, the optimal induction conditions for each strain and the subsequent incubation conditions for optimal de novo ATP production as an indicator of overall bactericidal effect of a defined stress. In these experiments, the CFU/ml of a L. monocytogenes EGDe culture was measured over a period of 180 min when exposed to three different incubation temperatures . The plate count results of the culturable cells were compared to the de novo ATP production of VBNC cells after 24 h incubation in BHI medium. This was done in triplicates.After setting the optimal framework conditions, a series of temperature-dependent time-kill experiments were conducted to evaluate g) and washed once with PBS to remove the induction solution, before resuspending the bacterial pellet in fresh BHI medium . In order to make sure that the cells are really in the VBNC state, a part of the VBNC suspension was aliquoted into a separate vial and subsequently heated at 90°C for 15 min to kill all cells reliably to serve as a (negative) control. Subsequently, 10 μl of each cell suspension was plated onto TSA plates, to check for remaining culturable cells or resuscitation, and the initial ATP concentration in each suspension was measured to determine the background level released from suspended cells . Therefore, 100 μl of the bacterial sample was removed from the respective wells, centrifuged at 8,000 ×g for 5 min, washed with PBS twice, and diluted 1:100. Then 1.5 μl of SYTO 9 dye and 1.5 μl of propidium iodide were added to the sample, followed by vortexing and 15 min incubation in the dark. After incubation, cells were trapped with a 0.2-μm polycarbonate membrane filter , which were subsequently placed between a slide and a coverslip and used for fluorescence microscopy. Viable cells with intact membranes will appear green by fluorescent SYTO 9, which permeates intact or damaged plasma membrane, while propidium iodide can only permeate damaged and disrupted plasma membranes and competes with SYTO 9 for DNA-binding sites. Therefore, cells with intact membranes show green fluorescence while cells with damaged membranes appear with red fluorescence. Those were considered to be dead. Pictures were taken with the Zeiss Observer Z1 inverted widefield microscope and ZEN 2012 (blue edition) software .To investigate if cell membranes of non-culturable bacteria remained intact after exposure to the respective antimicrobial treatment, we used the LIVE/DEADL. monocytogenes EGDe, ScottA, QC1, and MFPT3; Escherichia coli BW, ATCC, and JW; B. cereus KSS and ATCC; and Pseudomonas aeruginosa ATCC, K71, and K73) had to be evaluated by a preceding screening, as described by de novo ATP over a level of 105 RLU within 24 h without regaining their culturability, and could be killed by incubation at 90°C for 15 min  was found. In the case of the VBNC cells, While the results of the time-kill heat stress experiment indicate that this method could be used for such semi-quantitative analysis, the focus of this study was to use it as a qualitative Yes/No screening method comparable to classic microbiological MIC testing.L. monocytogenes EGDe in the “normal” culturable state as well as the VBNC state was performed (VBNC–MIC assay). In the case of the VBNC cells, de novo ATP production in the presence of the respective stress was measured after 24 h of incubation and the cellular status was determined with the BacLight viability assay  and antibiotic ampicillin (Amp) on ty assay .BacLight viability assay. At BK concentrations where de novo ATP production exceeded 105 RLU, the majority of the cells appeared bright green, indicating intact cell membranes and overall cell viability . In contrast, the MIC for culturable cells was 1 mg/l. These results were confirmed with the BacLight assay, where VBNC cells appeared bright green, even at 1,000 mg/l . As there were no significant differences between the different strains of the respective bacterial species, for clarity purposes only exemplary results for one representative strain per bacterial species are depicted in Results clearly show that VBNC pathogens were resistant to all the antibiotics used, while culturable cells completely lost their culturability during overnight incubation in the presence of Amp, imipenem, ciprofloxacin, and gentamicin.The MIC and MAIC were also determined for two quaternary ammonium compounds (QACs) [BK and trioctylmethylammonium (TOMA) chloride] and two preservatives (bronopol and sodium azide). As there were no significant differences between the different strains of the respective bacterial species only exemplary results for one representative strain per bacterial species are depicted in Indeed, VBNC pathogens were much more tolerant to BK and TOMA chloride as well as to the preservatives bronopol and sodium azide.L. monocytogenes as a representative example, it is up to 220 times more tolerant to QACs compared to its culturable form. While the averaged MIC for culturable cells was 6.9 mg/l, VBNC L. monocytogenes survived until a mean concentration of 381.3 mg/l. Similar results were obtained for TOMA chloride. In addition, the MIC and MAIC of the preservatives bronopol and sodium azide were tested. While the mean MIC concentration of bronopol on culturable L. monocytogenes was 59.5 mg/l, VBNC cells were only inactivated using a concentration exceeding 700 mg/l. Moreover, they were resistant to sodium azide, the second preservative tested. Related results were obtained for E. coli, B. cereus, and P. aeruginosa, where VBNC cells were distinctly more tolerant than culturable cells. Further information regarding differences within each species detailed test results and statistics can be taken from Taking The VBNC state is a unique survival strategy adopted by many bacteria in response to adverse environmental conditions. However, the VBNC state is a major problem when it involves pathogens, where they can evade culture-based standard detection methods and tolerate higher antibiotic and disinfectant concentrations . It is tde novo ATP production. ATP measurements have been successfully and routinely performed for the detection or confirmation of viable bacterial cells, including those in the VBNC state, for more than a decade  with a subsequent 24 h incubation at the respective optimal growth temperature of each strain.In order to develop this novel VBNC–MIC screening approach, we induced the VBNC state in 12 different bacterial strains through a combinational effect of non-ionic detergents and salts. For the VBNC–MIC assay to work, it is essential that the cells in the VBNC state are still metabolically active to produce enough ATP L. monocytogenes EGDe in the culturable as well as in the VBNC state were compared. While V. vulnificus to 50°C stress, we suspected that yet higher stress would eventually inactivate VBNC cells. Indeed, our results show that the course of the time-kill curves of VBNC bacteria under temperature stress was very similar to those of culturable cells. Although the use of RLUs as a quantitative measure is in this case not completely applicable, we could see semi-quantitative correlations to the course of culturable cells that confirmed that this method is reliable to answer binary-based questions. As confirmation, we double-checked the outcome with BacLight fluorescence staining and obtained corresponding results, which validated 105 RLU as a reliable cut-off to distinguish between viable and dead cells. Consequently, the new VBNC–MIC approach can be used in a straightforward way to compare the tolerance of cells in the VBNC state to those in the culturable state to a defined stress. While the results of the time-kill heat stress experiments indicate that this method could be used for a semi-quantitative analysis, the focus of this study was to use it as a qualitative Yes/No screening method comparable to classic microbiological MIC testing.The overall reliability of the VBNC–MIC approach was confirmed by a series of time-kill experiments, where the effect of three different incubation temperatures  within 3 h on L. monocytogenes strains, three E. coli strains, two B. cereus strains, and three P. aeruginosa strains in the exponential phase of growth and in the VBNC state, to antibiotics and antimicrobials, was tested by MAIC determination. This variety of strains and species, with a range of susceptibilities to antimicrobials in the culturable state, was used to analyze different responses of their VBNC counterparts to antimicrobial stress.With this VBNC–MIC approach, the susceptibility of four different V. vulnificus or utilized more complex experimental setups using RT-qPCR or fluorescence-activated cell sorting (FACS), the results obtained in this study using the VBNC–MIC assay corroborate previous results and demonstrate the complete ineffectiveness of antibiotics to bacterial cells in the VBNC state  and an ionic liquid  . QACs haSimilar to BK and TOMA chloride, 12 strains in the VBNC state demonstrated higher tolerance to the preservatives bronopol  and sodium azide  compared to respective culturable cells . Again, This observed tolerance of bacterial cells in the VBNC state is a serious concern for human health. Cleaning and disinfection strategies are currently adapted to culturable bacteria and in light of this study are not now seen to be sufficient as a proper intervention against VBNC pathogens. From our point of view, these results have significant implications for microbiologists in all fields, especially in the context of detection, intervention, and chemotherapy when confronted with VBNC pathogens. The results show that the VBNC–MIC approach is suitable for high-throughput susceptibility screening of bacterial cells in the VBNC state. This information can be used for further research and to provide a better understanding of the underlying mechanisms regarding VBNC resistance and tolerance.All datasets generated for this study are included in the manuscript and/or the CR, PM, AW, BS, and PR conceived and designed the experiments. CR and PM performed the experiments. CR, PM, AW, and DS analyzed the data and wrote the manuscript. BS provided the bacterial strains.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.


Penetration testing has been used to measure material properties for over fifty years. Currently, it is under-utilised as a contemporary scientific and engineering tool for investigating the condition of pipes whose inner surface has been exposed to chemical attack. We describe the design, development and calibration of a portable probe which uses a penetrative strain gauge load cell to measure where the semi-solid surface starts and stops within a pipe. We also describe the results of field tests of the probe in concrete sewers, affected by internal corrosion, where the probe proved to be a fast and reliable method for collecting pipe profile information. The results indicate significant benefit in the use of penetrometers to perform concrete sewer condition assessment. Penetration testing for characterising materials is a proven technology in a variety of contexts, including soils , frozen To define chemical attack, we take the engineering point of view that the interaction between the chemicals and the pipe must be destructive, in that the result of this interaction must have resulted in pipe deterioration and/or loss of durability . For exaNon-contact testing is a valuable tool for inspecting the internal profile of a pipe, but the information it provides is not necessarily complete. In the context of sewers, a variety of tests have been operationalised  to augmThis paper is structured as follows. In Following in the footsteps of others , our peIn terms of the size constraints of our application context, we intended for our penetrometer to be able to work in concrete sewer pipes, with the smallest target internal pipe diameter being 225 mm with an associated external pipe diameter of 295 mm. As an aside, these pipes can corrode reasonably quickly, various studies have discovered that up to 4.7 mm/year is possible . ConseqWith the latter two advised requirements of rigidity and velocity, we agree that high rigidity and constant velocity penetration minimise measurement inaccuracies that arise from the storage and release of energy during penetration and inertial forces caused by sudden penetration velocity changes. Constant-velocity penetration (1 mm per second) avoids the rate-dependence associated with creep deformation, assuming a homogeneous material, which is not always the case in concrete sewer pipes.We now describe the materials, sensing and actuator components used by the penetrator. Our design was strongly influenced by the harsh requirements of the proposed operating environment, and less influenced by design standards for penetrometers in other domains . To traThe penetrometer measures force using four strain gauges in a Wheatstone bridge configuration within a S-shaped block of material, an off-the-shelf Shenlan LCS 550 10 kg load cell (P2), which has a resolution of ±5 g. The change in resistance of the strain gauge provides an electrical value change proportional to the load placed on the cell which is then amplified (the HX711) and scaled into a usable range see . Given tThe penetrometer measures distance using an off-the-shelf Hall-effect sensor (A3144E) which detects three magnets in close proximity on the underside of the drive gear which provides the constant velocity see , all witThe protraction actuator is driven by a lead-screw nut which is coupled to a waterproof servo motor  via a paDesigned to operate within the two main dimensions of concrete sewers, our penetrometers were mounted onto two different rigs: one for measuring the surface profile in vertical concrete sewer pipes, and one for measuring the surface profile in horizontal concrete sewer pipes. The vertical rig consisted of a long extendible block see  which waWe firstly bench tested our penetrometer with respect to its ability to measure height, force, and materials, before taking our penetrometers into a concrete sewer system and trialling them against horizontal sections of pipes. In order to benchmark our penetrometer against height, we waterjet cut out a piece of aluminium (as our ground truth) in four step increments of 5 mm, using the left half of the SolidWorks profile shown in It is evident from The concrete paver is longer than the aluminium ground truth because we also cut six different test angles into the concrete (from 10–35 degrees). Concrete sewers generally do not have perfectly horizontal surfaces, so we wanted to determine whether there were any changes in velocity for our penetrometer that might impact our measurements, but more importantly, if our device could withstand slipping around off the rough surface of a concrete sewerage pipe.The penetrometer handled the rough angled concrete surfaces reasonably well, as shown in We next proceeded to investigate our penetrometer’s ability to measure force. We applied five weights, from 50 to 250 g, across three levels of protraction height  and record the results in To determine the penetrometer’s ability to distinguish between materials, we recorded the amount of force required to indent materials that we were advised were similar to corroded concrete, BluTack and modelling clay. We also wanted to determine the degree to which our penetrometer could profile corroded surfaces with different layers, so we constructed samples with BluTack and modelling clay in different orders. We benchmarked our penetrometer see  against As expected, and evident from the slope of load versus displacement curves, (a) shows that the Instron more easily penetrates 10 mm BluTack (lower black line) as opposed to 10 mm modelling clay (higher red line). For example, at a depth of 6 mm the load recorded for BluTack is about 7.5 N and at a similar penetration depth for clay the load value is closer to 8.5 N. With layers (b), it is difficult to identify a smooth transition from BluTack to Clay (Black Line), we believe that these materials are behaving as a single composite, potentially due to the confinement effect. On the other hand, there is a clear transition from Clay to BluTack (Red Line) where the slope flattens after 10 mm of penetration depth. Consequently, we believe that our penetrometer can detect layering, with early flattening indicating a transition from harder to softer materials and vice versa. Note that for both tests we set the Instron to push all the way through to concrete, which the Instron identified at 20 N when the curve goes towards vertical. To be completely sure, we set the stopping criteria of the penetrometer at 50 N, as seen in the previous graphs on step and angle tests.There were similarities between the data collected by the penetrometer and the Instron. The load versus displacement curves by the penetrometer were very similar to the Instron curves, and the trend was also similar between the layered data. There are some differences in the graphs, due to differences in the experimental set-up between the Instron and the penetrometer. The initial position of the Instron probe was extremely close to the surface of the test samples, pointing down, whereas the position of the penetrometer was about 7.5 mm away from the test samples, pointing up. The effect on the data is that penetration takes some time to occur, thus the curves are scaled lower.Having characterised our penetrometer in the laboratory, we then took our devices into a concrete sewer in conjunction with operational personnel using standard access procedures. We operated our devices on multiple horizontal runs with pipe diameters from 225 mm through to 525 mm, on 100 m sections of sewer in the suburbs of Bacchus Marsh and Keysborough. Samples were taken at 1 m, an example of the Keysborough run is shown in This run is interesting to sewer maintenance practitioners for several reasons. There are two points where corrosion exceeds 15 mm, and there is a fair amount of corrosion over 5 mm. Also, the maximum amount of time required to take an individual sample was 30 s.These pipes were over 50 years old and had exposed aggregate, visually suggesting that some concrete corrosion has occurred. Experimentally, we have observed that degradation at times can be localised down to small segments of pipe, hence we would expect a probing regime to operate on a regular basis  which will support the use of analytical models of the service life of systems of pipes.A penetrometer for profiling the inner surface of pipes has been designed and two example systems have been road tested in the context of corroded concrete sewer pipes. We expect that penetrometer-based condition assessment, coupled with traditional visual inspection, will find practical applicability in a range of different concrete pipe environments.We have identified significant scope for improving the serviceability and operation of the proposed system including ruggedisation, projected life-cycle testing, explosive environmental certification, facilitation of a larger range of pipe sizes and tilting of the sensor to allow different test points away from the object to be measured.


Vaccines against viral infections have been proposed to reduce prescribing of antibiotics and thereby help control resistant bacterial infections. However, by combining published data sources, we predict that pediatric live attenuated influenza vaccination in England and Wales will not substantially reduce antibiotic consumption or adverse health outcomes associated with antibiotic resistance. Antibiotic use drives the spread of antibiotic resistance. A considerable proportion of antibiotic prescriptions are prescribed unnecessarily for conditions that are either self-limiting or nonbacterial in etiology  for 2–16-year-old children  consultations and some GP consultations lead to antibiotic prescriptions. Our age-stratified analysis focused on community antibiotic use as the driver of resistance, because hospitalizations for influenza are rare relative to GP consultations  or 42% (unmatched-year) efficacy among 2–16-year-olds  prescriptions per 1,000 person-years  across tAlthough 0.8% is a small decrease in antibiotic use, it might appreciably improve the cost-effectiveness of pediatric LAIV if the healthcare costs of resistance are substantial enough . We estiOur estimates for the foreseeable reduction in antibiotic prescribing from the LAIV program in England and Wales might seem surprisingly low, given that sore throat, cough, and sinusitis together account for 53% of all inappropriate prescribing, which in turn accounts for at least 9%–23% of all prescribing in England . One explanation is that our estimate, derived from statistical attribution of antibiotic prescriptions to influenza circulation during 1995–2009  to a 6% increase (United States) in antibiotic prescriptions over the 4-month period following vaccination, whereas estimates of the effect over entire populations  range from 11.3 fewer prescriptions per 1,000 person-years in Ontario, Canada, to 3.9 fewer in South Africa and Senegal . This vaThe adverse health outcome estimates that we adopt (Our framework estimates the effect of influenza vaccination on antibiotic resistance by using the relationship between influenza circulation and antibiotic use in England and Wales, and can be adapted to other settings for which this relationship can be quantified. An alternative approach would be to correlate LAIV uptake, rather than influenza circulation, directly with antibiotic use. Challenges with that approach include appropriately controlling for confounding factors in the relationship between vaccine uptake and antibiotic use and quantifying herd immunity. However, consistent with our approach, UK-specific empirical estimates have suggested little or no effect of LAIV uptake on prescribing: a self-controlled case-series study found that 2–4-year-old LAIV recipients took 13.5% fewer amoxicillin courses in the 6 months after vaccination (Additional information regarding effect of pediatric influenza vaccination on antibiotic resistance, England and Wales.


Some research studies carried out in the last few years have proved the ability of AAC to replace ordinary Portland cement concrete in different structural applications including the construction of beams and panels. On the contrary, few experimental results concerning the structural effectiveness of fiber-reinforced AAC are currently available. The present paper presents the results of an experimental program carried out to investigate the flexural behavior of full-scale AAC beams reinforced with conventional steel rebars, in combination with fibers uniformly spread within the concrete matrix. The experimental study included two beams containing 25 kg/m3 (0.3% in volume) of high-strength steel fibers and two beams reinforced with 3 kg/m3 (0.3% in volume) of synthetic fibers. A reference beam not containing fibers was also tested. The discussion of the experimental results focuses on some aspects significant for the structural behavior at ultimate limit states (ULS) and serviceability limit states (SLS). The discussion includes considerations on the flexural capacity and ductility of the test specimens. About the behavior at the SLS, the influence of fiber addition on the tension stiffening mechanism is discussed, together with the evolution of post-cracking stiffness and of the mean crack spacing. The latter is compared with the analytical predictions provided by different formulations developed over the past 40 years and adopted by European standards.Alkali-activated concrete (AAC) is an alternative concrete typology whose innovative feature, compared to ordinary concrete, is represented by the use of fly ash as a total replacement of Portland cement. Fly ash combined with an alkaline solution and cured at high temperature reacts to form a geopolymeric binder. The growing interest in using AACs for structural applications comes from the need of reducing the global demand of Portland cement, whose production is responsible for about 9% of global anthropogenic CO Yost et al. (2013) ,9 carrieIt is well known that ordinary concrete exhibits brittle behavior because of its low uniaxial tensile strength and mode-I fracture energy. The addition of fibers randomly spread within the concrete matrix is a well acknowledged methodology to improve the tensile strength and toughness of concrete ,13,14,15The improvement of the tensile behavior of concrete due to the use of fibers can be exploited to enhance the ultimate and the serviceability performance of different kinds of structures . SeveralThe results of an experimental research performed on full-scale reinforced AAC beams subjected to flexure are herein presented. This study aimed at evaluating the effectiveness of ACC as a structural material in view of its use for the construction of typical pre-cast elements such as ducts, manholes, beams, columns, and roof elements. The experimental program included ACC beams not containing fibers and beams made with ACC reinforced either with steel (rigid) or polymeric (deformed) fibers. The paper will describe and discuss the test results by referring to both the ultimate (ULS) and the serviceability (SLS) loading conditions. Particular attention will be devoted to the analysis of the tension stiffening effect, as well as to the prediction of crack spacing and width according to the analytical models available from different European structural codes and pre-standards. s,long = 402 mm2) bottom deformed rebars, resulting in a longitudinal steel ratio (ρl) of 0.43% (concrete clear cover = 26 mm). In the middle portion of the element , no stirrups and reinforcement bars in compression were provided to promote a flexural collapse governed by concrete crushing. In the remaining portions of the beam, two Ø12 mm bars were provided in the compression zone and closed stirrups (Ø6 mm@75 mm) were placed to prevent shear failure. The main properties of the beams are summarized in A total of five beams were cast and tested in the laboratory of structural engineering of the University of Brescia. As shown in After casting, beams and companion samples for material characterization were left in the wooden molders for 2 days (rest period). At the end of the rest stage, all the specimens were demolded, wrapped with a polyethylene sheet to prevent moisture loss and, finally, they were placed in a climate chamber to undertake curing. During the curing process, the ambient temperature was increased up to 60 °C and then kept constant for 24 h. More details about the adopted curing method are described in .Steel fiber-reinforced alkali-activated concrete (SFRAAC) and polymeric fiber-reinforced alkali-activated concrete (PFRAAC) were used to cast the specimens SFRAAC-1 and 2 and PFRAAC-1 and 2, respectively. A single control beam made with AAC was cast.f) of 30 mm and a diameter (df) of 0.35 mm (aspect ratio Lf/df = 85.7), and synthetic embossed macro-fibers with a length of 54 mm and a diameter of 0.80 mm (aspect ratio Lf/df = 67.5), were added to the mixture in two different contents  corresponding to a volume fraction (Vf) of 0.3%. The fiber tensile strength was 2200 MPa  and 585 MPa, respectively, for steel and synthetic fibers.High-strength hook-ended steel fibers, with a length (L3), sand 0–4 mm (615 kg/m3), and class F fly ash (472 kg/m3) mixed with an alkaline solution composed of 8 M sodium hydroxide (48 kg/m3) and sodium silicate (119 kg/m3). The chemical composition of the fly ash is reported in 2 to Na2O ratio) that characterizes the activator solution was found to be 1.99. Extra water (35 kg/m3) was added at the end of mixing just to promote suitable workability. The resulting volumetric mass density (2430 kg/m3) of the hardened material was comparable to that of ordinary concrete.The mixture used for casting the AAC beam consisted of coarse aggregate 4–10 mm , whereas the remaining part was mixed after the addition of the liquid components . This procedure led to an improved material workability as it allowed an enhanced fiber distribution and prevention of any fiber-balling phenomenon. The volumetric mass density of the hardened material resulted 2455 kg/mThe mixtures were all characterized by a liquid to fly ash ratio of 0.43, an alkaline solution to fly ash ratio of 0.35, and by a sodium silicate to sodium hydroxide ratio equal to 2.5. The alkaline solution (mixing of sodium silicate and sodium hydroxide) had the same composition and chemical properties of that used in a previous work . It has A series of tests were carried out to characterize the mechanical properties of the three materials used in the present research investigation. cm) (see To determine the average cube compressive strength (Rcm) see , uniaxiam), determined according to EN 12390-13 [cm) and of the corresponding strain (εcm). All the cylinders were tested after 28 days from the casting date. The results show that all the elastic moduli were lower than that  typically exhibited by a traditional OPC-based concrete. As observed by others [cm) obtained from the tests on cylinders were about 40–70% higher than the corresponding values reported by the Eurocode 2 [Uniaxial compressive tests on cylinders  were carried out under displacement control in order to determine the Young’s modulus and the compressive stress–strain constitutive law of the materials. 12390-13 , as welly others ,21,27, sy others . It alsot e.g., ~ GPa typi3) tested to characterize the tensile post-cracking behavior of the materials. Tests were carried out according to EN 14651-5 [L and the residual flexural tensile strengths fR,1, fR,2, fR,3, fR4, corresponding, respectively, to CMOD values of 0.5, 1.5, 2.5, and 3.5 mm. As usually observed for OPC concretes, the response of the AAC material not containing fibers was characterized by a significant reduction of the tensile resistance after cracking  due to the low mode-I fracture energy. Unlike AAC, the material containing steel fibers exhibited a significantly higher post-cracking strength in correspondence of the CMOD values 0.5 mm and 2.5 mm, which are representative of the serviceability and ultimate conditions according fib Model 2010 (MC2010) [ 14651-5 , which r(MC2010) . Becausey) of 535 MPa, an ultimate strength (ftu) of 646 MPa, and an ultimate tensile strain of about 13%. The longitudinal deformed rebars (B450 C according to Eurocode 2 ) were meThe total load–midspan deflection (δ) curves of the five test beams are depicted in All beams exhibited the same initial elastic stiffness and similar first cracking loads that preceded the onset of the cracked stage. The kink point at the end of the second branch marks off the limit between the cracked stage and the plastic stage. In the plastic stage , the applied load tended to slowly increase up to the maximum value.max = 130 kN) slightly before the final collapse. The latter occurred in the middle portion of the beam through concrete crushing  of the beams reinforced with steel and synthetic fibers (l = 0.43%) made the contribution of fibers more significant in governing the structural response of the beams. Because of their ability of enhancing concrete toughness in compression, fibers were able to avoid a sudden and brittle crushing of concrete. Moreover, compared to the reference beam, all fiber-reinforced beams experienced a more ductile behavior after yielding, and the final collapse was due to the tensile rupture of the longitudinal reinforcement. In fact, the improved steel-to-AAC interfacial bond [The maximum capacity . The strain localization appeared to be more pronounced in the beams containing fibers, where it was promoted by the higher post-cracking tensile strength of the material  that generally involved one of the three monitored sections in which the ultimate mechanism took place  over the depth (h-x) of the cross-section. Based on the previous assumptions, by also supposing that tensile reinforcement is yielded (reasonable assumption considering the low reinforcement ratio selected), the resisting moment  can be calculated as follows:Ftuf = R3f/3 is the tensile strength of fiber-reinforced concrete; R3kf is the residual flexural strength at a crack mouth opening displacement (CMOD) of 2.5 mm  is obtained: cmf is the cylindrical compressive strength of concrete, as reported in R,max,expM). On the contrary, the predicted bending moments related to beams containing steel fibers were basically equal or slightly higher (+2%) than the experimental ones. The analytical model confirmed the minor contribution provided by fibers to the flexural resistance of the beams. However, the simplified cross-sectional model proved to be able to well predict the resistance of all the AAC beams tested in this research study, in contrast to what is stated in [In order to predict the flexural resistance of the test beams, the simplified rectangular stress-block model schematized in 5 mm see ; h = 500tated in .u) and the yielding (Øy) curvature (μØ = Øu/Øy), as well as the ratio between the ultimate (δu) and the yielding (δy) midspan deflections (μδ = δu/δy). Irrespective of the ductility index considered, FRAAC beams resulted to be more ductile than the reference specimen. When considering the ductility in terms of curvature, the average ductility of the SFRAAC beams appears to be higher than that observed for the specimen containing synthetic fibers. Contrariwise, whether the ductility is assessed by the index, which better represents the overall response of the specimen instead of the behavior of the single local cross-section, the ductility of the beams containing synthetic fibers results to be the highest. In fact, once strain localization occurred, the lower post-cracking resistance of concrete reinforced with synthetic fibers allowed to delay the rebar failure, thus promoting a higher ductility (+60%) than that exhibited by the SFRAAC specimens. It seems that, in flexural elements with low reinforcement ratios, synthetic deformed fibers are able to postpone (compared to steel fibers) the strain localization at the rebar level; in addition, their influence on the compression chord, even though less pronounced compared to steel fibers, allows anyway a progressive and controlled decay of the compression chord resistance. The combination of these two effects is beneficial in terms of overall structural ductility . However, this trend should be cautiously evaluated by testing different longitudinal reinforcement ratios.cr = 1.7 mm. Considering that the materials used in the present investigation had basically the same peak tensile flexural strength (fL)  see , similarsmε is the mean tensile strain in the reinforcement; cmε is the mean tensile strain in concrete between cracks; and rmS is the mean crack spacing. A reasonable prediction of crack width necessarily requires the estimation of the crack spacing parameter.Crack control is one of the main features that must be considered in designing concrete members under service loading conditions. To estimate the mean crack width (w) in a concrete member, the following general equation can be used: The results of the tests performed herein allowed to calculate the crack spacing as the mean distance between cracks, namely the distance between the point loads  divided by the number of cracks detected in the constant bending moment region. p ≈ 80 kN) of the maximum capacity. The attainment of a constant crack spacing represents the onset of the so-called stabilized cracking stage. The crack spacing detected in the stabilized cracking stage for the fiber-reinforced beams was similar or slightly lower (−10%) than that presented by the reference beam not containing fibers. On the contrary, for vertical deflections ranging from first cracking (δcr = 1.7 mm) to 7.5 mm, the crack spacing of the reference beam resulted to be the lowest, together with that presented by beam PFRAAC-1. This result appears to be in contrast to what is reported by other authors [As usually observed in OPC concrete members, the mean crack spacing tended to decrease with increasing vertical deflection and then stabilized at a minimum value (stabilizing cracking stage). The crack spacing became almost constant at a deflection of about 8 mm, which corresponded to a vertical load equal to 60% ;k2 = coefficient regarding stress distribution in the cross-section (=0.125 for flexure);Ø = longitudinal rebar diameter; andeffρ = effective reinforcement ratio.In 1990, the updated version of the same European code (CEB-FIP Model Code 1990 ) propose1k and 2k can be assumed equal to 0.8 (deformed bars) and 0.5 (members in flexure), respectively. The Eurocode 2 released in 2003 [The first version of the Eurocode 2 published in 1991  reported in 2003  re-intros,max) according to the following relation:ctmf is the mean tensile strength of concrete  , which mf/dfL) ≤ 1, which includes the fiber aspect ratio f/dfL. Despite the fact that this formulation was initially meant only for elements reinforced with steel fibers, it will be here applied also to the specimens containing synthetic fibers. Note that in the previous equation, the effect of fibers was considered by the factor 50/(The latest model for predicting the crack spacing in fiber-reinforced concrete elements was reported by the MC2010 (2013) . The latFtsmf = 0.45 fR1m, which is related to the residual strength of concrete (R1mf) corresponding to a crack width (CMOD) of 0.5 mm significant for serviceability loading conditions [It is seen that the ability of fibers to reduce the crack spacing is considered by the term nditions . The diagrams of Regarding the AAC beam a, a goodp ≥ 85 kN). When considering the specimens containing synthetic fibers, the prediction of RILEM TC 162-TDF (2003)   and MC20F (2003) c appeareF (2003) b tended max = 130 kN) of the reference beam. The resulting relative variation of midspan deflections will be here referred to as Δ0.30 (p = 40 kN), Δ0.45 (p = 58 kN), and Δ0.70 (p = 90 kN) (The effect of fibers on tension stiffening can be highlighted by comparing midspan deflection of the fiber reinforced concrete beams see  with tho= 90 kN) . As showThis enhanced post-cracking stiffness, related to low level of strains in the rebars (for the same load levels), is a key factor determining a decrease of the crack widths in flexure, confirming several findings in the literature . Experimental results on full-scale beams made of AAC under flexure were presented and discussed in this paper, focusing on the structural response and fiber influence on the global and local behavior.It was observed that the post-cracking response of FRAACs is the most influencing parameter for the structural behavior of beams herein discussed. For this particular geometry and longitudinal steel ratio, fibers promoted enhancements both at SLS and ULS conditions.-lρ = 0.44%), the presence of fibers affected the structural failure mode by promoting a collapse due to rebar rupture; on the contrary, the reference element without fibers (AAC) experienced a classical failure due to concrete crushing.For the studied element geometry and longitudinal reinforcement ratio . Conversely, the lower post-cracking strength observed in polymeric fibers tended to delay, in terms of midspan deformation, the final rebar collapse, resulting in a greater overall ductility (in terms of displacement), also possible thanks to the fiber ability to effectively promote a progressive decay of the concrete in compression.-Elements reinforced with steel fibers developed the lowest number of cracks at ULS, due to the strain localization, which might have caused a limited (not full) development of crack spacing.-The crack stabilizing stage for elements reinforced with fibers took place at a higher load level compared to non-fibrous elements; at the crack stabilizing stage, a good agreement between analytical and experimental crack spacing values was observed.-At SLS conditions, despite AAC beams experiencing a greater elastic modulus, fibers promoted an enhancement of the post-cracking stiffness with a consequent reduction of the midspan displacement and crack widths; a tension stiffening effect was seen to be more noticeable in elements reinforced with steel fibers where post-cracking strengths were greater.Based on the results herein presented and discussed, the main following conclusions can be drawn:


Cerclage wires or cables are commonly being used in hip reconstruction procedures like primary  or revision arthroplasty. Local or distant migration of a broken cable or wire is a complication that might lead to devastating situations depending on the route of migration.  We report a case of a 40-year-old female who underwent bilateral total hip arthroplasty surgery due to bilateral developmental hip dysplasia. Trochanteric osteotomy was needed in her right hip to advance trochanter major distally. Trochanteric fixation was achieved by a cerclage cable system. Four years after the surgery, the patient referred to the hospital with a prominence and pain in her right inguinal area. Radiographies revealed medial migration of a broken trochanteric cable part. The possible route of the cable was through medial adductor muscles, posterior to the femoral neurovascular bundle and anterior to the sciatic nerve. Both migrated and remaining parts of the cable were extracted under general anesthesia.  Broken cables should be followed carefully due to their sharpness and possible serious complications secondary to distant migration. Extraction might be inevitable in case of a close relation with neurovascular structures. Cerclage cables have been used widely in fixation of fractures and osteotomies during reconstruction procedures. Even if it is rare, local or distant migration of broken cables can be experienced. While broken cables might cause localized symptoms like soft tissue irritation and pain, other serious complications might occur due to distant migration. In this case report, we report a broken trochanteric cable part which migrated medially to a subcutaneous place in the inguinal area and caused a prominence with pain. To our knowledge, no similar route for a broken cable was reported in the literature.A 40-year-old female patient presented with pain and decreased range of motion in her both hips. She was unable to maintain her daily activities. Radiographies revealed bilateral osteoarthritis of the hip, secondary to developmental hip dysplasia, and the patient underwent bilateral total hip arthroplasty . In her Trochanteric osteotomy is one of the important parts of a lateral approach in high hip arthroplasty or revision . BesidesAll trochanteric fixation methods have their own advantages and disadvantages. Monofilament wires produce less debris compared to the multifilament cable constructs, but kinking of the wires decreases their strength and makes them vulnerable to wire breakage, trochanteric nonunion, or migration . These dMultifilament cables are another option for trochanteric fixation, and their mechanical properties are found to be superior compared to the wires in some biomechanical and clinical studies , 5. TheiCable grip systems are preferred mostly due to their superior mechanical properties like better resistance to fatigue and higher yield and breaking strength , 7. But Another important but rare complication of these constructs is hardware migration. Some cases have been reported in the literature related to cable or wire failure and their local and distant migration –11, but After failure, broken parts of the implants can migrate locally or distantly. Local migration to subcutaneous place might cause local irritation around the area of surgery. Broken implant or debris might migrate to intra-articular place and lead to loosening or implant wear. In some cases, distant migration can occur and serious complications like vessel, ureter, rectum, vagina, and uterus injuries might take place. Migrations happen usually through soft tissues, but some cases through the circulation system also have been reported, causing cardiopulmonary problems and even death , 13, 14.In our case, medial migration of the cable part and its possible route between sciatic nerve and femoral neurovascular bundle were the distinctive features. To our knowledge, no similar route for a broken cable is reported. Fortunately, it reached subcutaneous tissue and caused only mild clinic symptoms.When cables are used as a fixation device, a closer follow-up of the patients might be needed if the cable is broken and prone to migration. To predict or prevent possible distant migration in asymptomatic cases, a couple of factors should be considered. Age and activity of the patient; size, shape, sharpness, and bluntness of the broken cable; and possible relation to important anatomic structures are important to decide for prophylactic surgical extraction. When possible arterial, venous, or nervous system and organ injuries due to this immigration are considered, true early diagnosis and early treatment of these migrations are essential.


This research expands efforts to understand differences in NIH funding associated with the self-identified race and ethnicity of applicants. We collected data from 2,397 NIH Biographical Sketches submitted between FY 2003 and 2006 as part of new NIH R01 Type 1 applications to obtain detailed information on the applicants’ training and scholarly activities, including publications. Using these data, we examined the association between an NIH R01 applicant’s race or ethnicity and the probability of receiving an R01 award. The applicant’s publication history as reported in the NIH biographical sketch and the associated bibliometrics narrowed the black/white funding gap for new and experienced investigators in explanatory models. We found that black applicants reported fewer papers on their Biosketches, had fewer citations, and those that were reported appeared in journals with lower impact factors. Incorporating these measures in our models explained a substantial portion of the black/white funding gap. Although these predictors influence the funding gap, they do not fully address race/ethnicity differences in receiving a priority score. The National Institute of Health (NIH) has worked to characterize reasons for the underrepresentation of certain racial and ethnic groups within the population of Principal Investigators with NIH research grants. Earlier studies documented attrition rates for different groups transitioning through important career stages from high school to faculty attainment . StudiesTo receive NIH funding, grant applications are peer-reviewed to evaluate the significance, innovation, and approach of the proposed research along with the investigator(s) and the research environment. The NIH application consists of several parts: the research plan, the biographical sketches of key personnel, and the budget. Assigned reviewers provide a preliminary score for each application. The most meritorious applications  are discussed in detail and provided a final priority  score. NIH Institutes and Centers determine which highly meritorious applications are ultimately funded based on budgets and scientific priorities . In our The current study fills in the missing data by using information from biographical sketches (Biosketches) that accompany each NIH grant application. As before, we approached the data with the null hypothesis that information contained in the application determined the probability of an application receiving a priority score and receiving funding. If this is an accurate depiction of the peer review process, then incorporating previously unexplored measures about the investigator from the Biosketch, including his or her academic record, has the potential to explain more of the observed black/white funding gap. In the event that the additional data do not explain the observed gap, and in the absence of other factors, bias in the peer review process remains an open possibility.We randomly sampled 600 applications for each of the self-identified race/ethnicity categories  from grant proposals submitted between FY 2003 and FY 2006 that had been included in the original sample of 83,188 first-time (Type 1) R01 grant applications from PhD investigators at US institutions , 11. OurAs part of the application process, an NIH principal investigator included a Biosketch that lists information, in up to four pages, on education and training, positions and honors, selected peer-reviewed publications, and research support. Information from these 2,397 Biosketches was manually entered into a data collection instrument that coded the following information: academic rank of the applicant at the time of application, undergraduate degrees, PhD degrees, postdoctoral positions, publications, scholarly awards and advisory panel experience, and prior grants. Details of data collection and classification are described in the supplemental material, but we provide an overview of items collected here. Altogether, over one million data items were entered or created from the 2,397 Biosketches.Information on bachelor’s and doctoral degree institution was previously available for US-trained PhDs, but missing for foreign-trained students . InformaWe identified 1,302 predoctoral and postdoctoral fellowships on applicant Biosketches as well as 170 traineeships and 220 diversity-related fellowships and scholarships. In addition, we incorporated data from IMPAC II on T32 predoctoral traineeships, T32 postdoctoral traineeships, F31 fellowships, and F32 fellowships, including diversity fellowships , for theWe attempted to identify PhD and postdoctoral advisors from multiple sources, but found that few Biosketches identified PhD or postdoctoral advisors. We had limited success in identifying PhD or postdoctoral advisors by using the last author’s name from the applicant’s publications during the time they were doctoral students or postdoctoral researchers. For the subset of applicants for whom we could identify advisors’ names from other sources, only 56% of the last authors listed on their doctoral and postdoctoral publications were the applicant’s advisors. Thus, our analysis could not control for doctoral and postdoctoral advisors.Biosketch data allowed us to identify the academic rank, affiliation, and professional service of the applicant at the time the application was submitted. Applicants were associated with 3,107 advisory panels, 2,005 professional society memberships, and 121 leadership positions.Each peer-reviewed publication listed on the Biosketch was assigned to the application and used to build the bibliographic record for the application. Nearly 54,000 publications were identified on the Biosketches, and the majority of these publications were matched to bibliographic information from the Clarivate Analytics Web of Science and Journal Citation Reports by article title, journal title, volume, and author names. Publications were assigned to undergraduate, graduate, postdoctoral, and independent researcher career stages using the dates of degree receipt and postdoctoral appointments. For each publication, we collected bibliometric data such as the number of times cited, the number of self-citations, the narrow and broad journal subject category, the impact factor of the journal, the number of coauthors, and the author position of the applicant.Not all scientific fields have the same publication and citation patterns, so we used field-normalized measures based on the journal subject category of the publication. Citations to a given publication over the first two years were compared to citations to papers in journals in a similar Web of Science journal subject category during the same two years. The publication was then assigned a field-normalized quartile rank in the publication distribution. We identified the percentage of the applicant’s publications that were published in each quartile of the field. In addition, we identified the percentage of papers that were uncited and the percentage of papers where the applicant was either first or last author. We also identified the three most frequent last authors and the three most frequent coauthors, regardless of the order of appearance in the list of authors, on the papers published by the applicant and listed on the Biosketch. We then created bibliometric measures similar to those used for the author’s publications based on the publications of the last authors and coauthors. These bibliometric measures serve as proxies for the professional networks of the applicants.An indicator of prior NIH Grants was an important explanatory variable in previous studies –4. We enWe analyzed the probability of receiving an R01 award using probit models to evaluate whether different combinations of Biosketch data explained the funding gap. Our analysis was built on a main model that included controls for age, gender, foreign PhD, and race/ethnicity, and progressed through eight models that added sets of explanatory variables for academic rank, grants, scholarly honors, publications and associated bibliometrics, coauthor publications, journal field, and a full model  of the NIH funding gap. Many variables included in the analysis are endogenous to the process of obtaining additional NIH funding. Thus, we begin our analysis by only including the exogenous variables in the main model. Education variables will also be exogenous to the NIH funding process, whereas training, positions and honors, publications, and prior research support are all endogenous to the NIH funding process. As a result we estimate multiple specifications in order to examine how the race/ethnicity coefficients change as these endogenous variables are added to the model. Since we are examining differences in NIH funding for multiple race/ethnicity categories, all p-values are adjusted for multiple comparisons using the Bonferroni correction.The Biosketch data features improved measures of publications and associated bibliometrics. Other than our previous works –4 that mScience (impact factor 34.66 in 2015) is given more weight than a publication in Human Biology (impact factor .88 in 2015). Journal impact factors have been criticized because citation distributions of papers in journals are highly skewed [Use of the journal impact factor to evaluate individual publications is controversial , 19. HowAfter establishing the main results that include publications and bibliometrics, we conduct a number of robustness tests to gain a better understanding of the factors contributing to the race/ethnicity gap in NIH funding. Our analysis examines whether race/ethnicity gaps differ between New and Experienced Investigators, those with MD/PhD and PhD degrees, and the funding rank of the institution. NIH has long recognized that new investigators are less-likely to receive NIH research awards than experienced investigators . NIH polOur previous analysis examined whether the black/white funding gap differed for MDs and MD/PhDs . We founIn addition, our previous analysis also showed that the NIH funding rank of an institution explained a significant share of the race/ethnicity funding gap . The NIHWe then used our model to examine the effect of a counterfactual policy experiment designed to increase publications. We considered a mentoring intervention that provides feedback and professional development for black investigators related to the publication process. This type of intervention increased the number and quality of publications in a randomized controlled trial for female economists . We assuWe also used the timing of publications to identify when black and white researchers’ careers diverged. Finally, the black/white funding gap consists of two parts: the probability of receiving a priority score, and then conditional on the score, the probability of receiving funding. We examined whether our measures of publications narrowed the race/ethnicity gap in receiving a priority score.When we added the logarithm of the sum of the journal impact factors and controls for first and last authorship, the funding gap falls from -13.3 ppt (p < .001) to -9.5 ppt (p < .001). A one percent increase in the sum of the journal impact factors increases the probability of NIH funding by 6.7 ppt (p < .001). Likewise a one percent increase in the percentage of first authored publications increases the probability by 9.1 ppt (p < .05) . Field nWe separately analyzed the effect of training variables on the probability of receiving an NIH R01 award. Building on the main model, we progressed through nine models that added sets of explanatory variables for each stage of training: undergraduate, predoctoral, receipt of PhD, postdoctoral, and pre and postdoctoral fellowships , and when all training variables are entered into the model, the black/white funding gap is only slightly smaller at -12.3 ppt (p < .001). The final specification limits the analysis to US citizens in order to evaluate the impact of NIH training, and the black/white gap falls to -11.9 ppt (p < .001). These results indicated that bibliometric measures better explain the black/white funding gap when compared to training measures.Given the importance of publication and bibliometric measures for explaining the funding gap, we used a method developed by Gelbach  to estimNext we compare the main model to the full model in the bottom panel of Table D in The new and experienced investigator estimates must be interpreted with care. It is important to note that our sample contains almost all of the black investigators who submitted applications between 2003 and 2006, and this is the maximum possible sample size. When we split the sample into new and experienced investigators, the standard errors became larger, making it more likely to commit a Type 2 error . There are 150 more black new investigators than experienced investigators, but the p-value for new investigators is much larger than for experienced investigators, suggesting that the remaining variation is sample noise. Since there are a smaller number of black experienced investigators, we would expect to have less precise estimates resulting in larger standard errors and p-values for experienced compared to new investigators. The smaller p-value for experienced investigators contradicts this intuition.We observed considerable evidence that the factors associated with new investigator funding differ from those associated with experienced investigator funding . In partWe partitioned our data into MD/PhDs and MDs as well as Top 100, and 101+ NIH funded institutions to see whether Biosketch publications narrowed the race/ethnicity funding gap in these subsamples. In our previous studies we included measures of publications and citations, but these variables did not fully explain the black/white funding gap. As discussed above, publications were identified in the previous study using a name-matching algorithm, a standard approach for assigning publications to applicants. However, this resulted in an undercount of publications. Estimates in Why do bibliometric measures based on the journal impact factor have better explanatory power than citation counts of an individual’s publication record? Journals are observed on the Biosketch, and citations are not. Furthermore, review panel members are likely to be familiar with the impact factors of journals in their fields. Reviewers appear to be using their understanding of the journal impact factor as a proxy for the quality of the publication, despite warnings to avoid this attribution .Unlike our previous studies, publications and the associated bibliometrics explained a significant portion of the black/white funding gap, suggesting the need to explore factors that may help us understand the differences in publication-related metrics. Figs Our analysis has shown that publications explain about half of the black/white funding gap. Figs We conducted the same thought experiment for new investigators, and the gap nearly closes: 98% (4.2 ppt) of the predicted funding gap is explained by race/ethnicity differences in publications and associated bibliometrics, and that gap was not significantly different from zero (p = .94). For the experienced investigator sample, 36% (3 ppt) of the predicted black/white funding gap is explained by race/ethnicity differences in publications, bibliometrics, and Type 2 awards, but the gap was not significant (p = .22). In all cases, the difference between the white and black investigators’ probability of R01 awards evaluated at the means of R01 awardees are not significantly different. It is important to note that in the case of new and experienced investigators, the confidence intervals are wide given the smaller sample size. However, our sample contains almost all of the black investigators that applied for funding from 2003 to 2006.Our previous study found that proposals that were resubmitted were more likely to be funded and that black investigators were less likely to resubmit proposals . We estiWe examined whether an applicant attended a top 100 NIH funded bachelor’s, doctoral and postdoctoral institution as well as a top 100 NIH ranked employer. We examined differences in publications and citations by career stage as well in Our previous analysis indicated that the probability of receiving a priority score on grant applications differed significantly by race/ethnicity. This is seen for the full sample, as well as for new and experienced investigators  measures by race/ethnicity, R01 award status and investigator experience. Regardless of award status, black investigators publish fewer papers, are cited less often, and publish in lower impact journals than whites. Table G. Average of Productivity Measures by Race/Ethnicity for Experienced Investigators, NIH R01 Awardees and Non-awardees. Table G lists average productivity (publication and bibliometric) measures by race/ethnicity, R01 award status and investigator experience. Regardless of award status, black investigators publish fewer papers, are cited less often, and publish in lower impact journals than whites.This appendix describes the processes used to select the sample used in the study, develop the data collection instrument, conduct data entry using IMPAC II application images for the sample, and ensure the accuracy of the data through standardized data cleaning and quality assurances procedures. (DOCX)Click here for additional data file.


We are reporting a case of a 63-year-old Chinese female who presented to therheumatology clinic with positive antinuclear antibody and unintentional weightloss along with lymphadenopathy. Further workup revealed eosinophilia, elevatedanti–double stranded DNA, serum protein, and serum IgG4 (immunoglobulin G4). Thepatient was diagnosed with systemic lupus erythematosus. Due to the raised IgG4level along with eosinophilia and diffuse lymphadenopathy, IgG4-related systemicdisease was suspected. It was confirmed with IgG4 staining on lymph node biopsy.Our case is presenting the fact that systemic lupus erythematosus andIgG4-related disease can be present in the same patient with multipleoverlapping features making accurate diagnosis challenging. Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a variableclinical presentation and can affect any part of the body. IgG4 (immunoglobulinG4)-related disease (IgG4-RD) is a systemic fibroinflammatory disease with proteanmanifestations involving virtually any organ in the body. Hallmarks of IgG4-relateddisease are lymphoplasmacytic tissue infiltration, fibrosis (often in storiformpattern), obliterative phlebitis, and elevated serum IgG4 concentration. Treatmentmainly involves use of steroids and immunosuppressive agents. We are reporting acase of a 63-year-old female presenting with joint pains, fatigue, unintentionalweight loss along with lymphadenopathy with an unusual overlap of SLE andIgG4-RD.A 63-year-old Chinese female presented to rheumatology clinic with positiveantinuclear antibody 1:80 homogeneous pattern, severe fatigue, hair loss, jointpains for approximately last 3 years, unintentional weight loss of 24 pounds  in last 8 months, and lymphadenopathy. Her joint pains arelocalized to bilateral hands, elbows, shoulders, hips, and knees. Of all the jointsher hands hurt her the most. Joint pains are associated with intermittent swellingand early morning stiffness lasting at least for 30 minutes. Her symptoms were worseduring winter and cold weather. She is unable to do her activities of daily livinglike holding a coffee mug, eating with a spoon, opening bottles, and so on.She was evaluated for underlying malignancy in the setting of generalizedlymphadenopathy and significant unintentional weight loss. Her past medical historywas significant for hypertension, thyroid nodule status post ultrasound-guided fineneedle aspiration cytology consistent with benign follicular colloidal nodule andbilateral carpal tunnel syndrome on electromyography status post nerve release.3 2000 international units. Family historywas significant for cancer in paternal grandmother and hypertension andhypercholesteremia in mother. She is an ex-smoker with 30 pack-year smoking historyand quit smoking 2 years ago.Her medications include benazepril-hydrochlorothiazide 20 mg–12.5 mg, diclofenacpotassium 50 mg PRN, vitamin DPhysical examination was positive for thin, cachectic female with palpable posteriorcervical, supraclavicular, and bilateral axillary lymphadenopathy. Tenderness wasfelt in multiple proximal inter phalangeal joints of bilateral hands with mildsynovitis. Diffuse thinning of hair on scalp was noted.Further review of records showed intermittent eosinophilia on the complete bloodcount. Subsequent work-up showed elevated anti–double stranded DNA 1:40 byimmunofluorescence assay , elevated IgG4 level of 452 mg/dL , elevated serum protein 9.7 g/dL, serum globulin 7.1 g/dL, serumprotein electrophoresis showing polyclonal increase in the gamma region with noM-spike, and erythrocyte sedimentation rate of 67 mm/h.Other testing was negative for smith antibody, ribonuclear protein antibody,anti-SSA, anti-SSB, rheumatoid factor, anti-cyclic citrullinated peptide,anti-phospholipid antibody panel, anti-neutrophilic cytoplasmic antibody withmyeloperoxidase, and proteinase 3 antibody. C3 and C4 levels within normal limits.Urinalysis and renal function were normal. Infection workup was negative forhepatitis, HIV, tuberculosis (quantiferon gold), syphilis (rapid plasma reagin), andcoccidiomycosis. Peripheral blood flow cytometry showed no flow cytometric evidenceof monoclonality, acute leukemia, or lymphoproliferative disorder.A computed tomography scan of the neck, chest, abdomen, and pelvis with and withoutcontrast showed prominent cervical , axillarAge-specific cancer screening was negative for malignancy including pap smear,colonoscopy, and bilateral screening mammogram.Ultrasound-guided fine needle aspiration cytology of bilateral axillary lymph nodeswas negative for malignancy with abundant plasma cells and positive IgG4 staining and 3.She was diagnosed with overlapping syndrome of IgG4 related disease and SLE. She wasstarted on 10 mg prednisone and 200 mg plaquenil daily, which significantly improvedher symptoms. Her prednisone was tapered slowly and completely discontinued in 5months. She is currently on maintenance plaquenil 200 mg daily back to her usualstate. She gained weight, and her other symptoms of fatigue, hair loss, joint pains,and lymphadenopathy completely resolved. Her repeat anti–double stranded DNA, IgG4,and eosinophil levels were within normal limits .1SLE is a chronic autoimmune disease with a variable clinical presentation and canaffect any part of the body. The most common presentation is a mixture of symptomsaffecting the skin, musculoskeletal system, hematologic, and fatigue along withpositive serologies. The diagnosis of SLE should be based on a combination ofclinical and immunologic findings as described in Our patient satisfied 4 criteria with at least 1 clinical and 1 immunologic criteriaas mentioned in the case presentation and was labelled as SLE.3 Serum IgG4 levels are elevatedin approximately 60% of patients. Up to 40% of patients with IgG4-RD have aperipheral eosinophilia and elevated IgE levels.3 Our patient had elevation ofIgG4 level and peripheral blood eosinophilia. Her IgE level was not checked.IgG4-RD is a systemic fibroinflammatory disease with protean manifestations involvingvirtually any organ in the body. Hallmark of IgG4-RDs are lymphoplasmacytic tissueinfiltration, fibrosis (often in storiform pattern), obliterative phlebitis, andelevated serum IgG4 concentration. Most commonly seen in middle-aged and olderpeople; mean age from 59 to 68 years and more common in men (70% to 80%).IgG4 is an antibody that has a very unique structure and function. It is the leastabundant antibody and comprises less than 5% of antibody in human class. Generally,IgG4 level in human body remains always stable in normal condition.4Autoimmunity is one of the commonest triggers for IgG4-RD with key role of T helper-2cell (Th2) cell involvement in the pathophysiology. Th2 cells overexpressinterleukins 4, 5, 10, and 13 as well as transforming growth factor-β, whichresulted in increased eosinophils as well elevated IgG4 and IgE concentrations. Italso contributes to activation of fibroblasts leading to fibrosis.IgG4-related systemic disease can involve pancreas, biliary tree, salivary glands,periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, prostate, breast,thyroid gland, pericardium, and skin.5 proposed a set of criteria for the diagnosis of systemic IgG4-RD designed tobe used independently of the predominant organ: (1) serum IgG4 concentration >135mg/dL and (2) >40% of IgG+ plasma cells being IgG4+ and >10 cells/high-poweredfield of biopsy sample. Validation of these criteria needs to be tested further byconducting international multidisciplinary collaboration with an expert panel. Ourpatient had elevated serum IgG4 level along with abundant IgG4-positive plasma cellson the biopsy.The diagnostic approach of IgG4-related systemic disease should be based on acombination of clinical evaluation, laboratory parameters, imaging, and biopsyresults. Initially proposed criteria were centered on specific organs rather thansystemic IgG4-RD. In 2011, Umehara et al6 first described a form of IgG4-RD as sclerosing pancreatitis in 1961. It waslater termed as autoimmune pancreatitis. Since then, IgG4-RD has been described innearly every organ system. Enlargement of organ is the key finding for clinicalsuspicion of IgG4-RD. Organomegaly is detected either through physical examinationor in incidental finding on diagnostic imaging.7 Symptoms related to specificorgans can be also the primary features like abdominal pain, respiratory symptoms,diarrhea, and pruritis.7Lymphadenopathy is seen in 25% patients approximately.4 In laboratory tests, mild tomoderate eosinophilia is present in one third patients.4 Computed tomography and magnetic resonance imaging findings are veryimportant to support the diagnosis of IgG4-RD. Due to heterogeneous characteristicsof IgG4-RD signs and symptoms, diagnosis is very challenging.Sarles et al8The main therapeutic option in IgG4-RD is glucocorticoids. Based on diseasepresentation, immunosuppressive drugs are also being used. In 90% reported cases,azathioprine was used as an immunosuppressive agent. Anecdotal data and multiplecase reports mention the use of other immunosuppressive agents such ascyclophosphamide methotrexate, mycophenolate mofetil, and tacrolimus. Biologicagents (Rituximab) and surgery are also available options to treat depending on thesymptoms and clinical findings. Because of rarity of the disease, no randomizedcontrolled trails have been conducted and most of the treatment options are derivedfrom individual experience, case reports, and case series.We report an unusual case of overlap of SLE without any kidney involvement andIgG4-RD. Review of the literature shows only one case describing an overlap ofIgG4-RD and lupus nephritis. Our case highlights that these 2 diseases can overlapin some patients, which was never reported in the past.


Thoracic aortic aneurysm is a typically silent disease characterized by a lethal natural history. Since the discovery of the familial nature of thoracic aortic aneurysm and dissection (TAAD) almost 2 decades ago, our understanding of the genetics of this disorder has undergone a transformative amplification. To date, at least 37 TAAD-causing genes have been identified and an estimated 30% of the patients with familial nonsyndromic TAAD harbor a pathogenic mutation in one of these genes. In this review, we present our yearly update summarizing the genes associated with TAAD and the ensuing clinical implications for surgical intervention. Molecular genetics will continue to bolster this burgeoning catalog of culprit genes, enabling the provision of personalized aortic care. This review presents an annual update to the article “Genes Associated with Thoracic Aortic Aneurysm and Dissection: Update and Clinical Implications” originally published in 2017 and updated in 2018 in AORTA.Thoracic aortic aneurysm (TAA) affects 1% of the general populationReport of inherited TAAD in the 1990sROBO4mutation was identified, including two variants that segregated with disease among two affected families.ROBO4is well expressed in vascular endothelial cells and plays a role in endothelial barrier function.ROBO4variants lead to the disruption of endothelial performance at a cellular level, thus altering vascular permeability, the authors cultured human aortic endothelial cells and either silencedROBO4or expressedROBO4variants. They confirmed thatROBO4abnormalities did indeed induce endothelial barrier dysfunction. Lastly, the authors created homozygousROBO4knockout mice and a knock-in mouse with anROBO4splice donor site mutation; the affected mice presented with a mix of aortic valve dysfunction (BAV and/or aortic regurgitation or stenosis) and AscAA, confirming their suspicion that a heterozygous mutation inROBO4can lead to a nonsyndromic presentation of BAV/AscAA.During 2018, several important studies were published that have enhanced our understanding of the pathogenesis of TAAD. Gould et alLTBP1, amongst other genes.LTBP1was considered the likely culprit given its relationship to TGF-β. In addition to TAA, the affected individuals displayed additional features of Marfan syndrome (MFS) and Loeys-Dietz syndrome, even though none of them met the criteria for diagnosis.Latent transforming growth factor binding proteins (LTBP), a family of extracellular matrix glycoproteins, have been shown to play a significant role in TGF-β regulation.LTBP3) gene have been associated with TAAD in a WES study of 271 individuals from unrelated families with heritable thoracic aortic disease (multiple affected family members) without a known genetic etiology for aortopathy.LTBP3in a second family were identified. Sequencing of 338 additional individuals with non-syndromic TAAD found nine additional heterozygousLTBP3rare variants. The authors also demonstrated thatLTBP3knockout mice manifested enlarged aortic roots and ascending aortas compared with wild type mice. These findings demonstrate that individuals withLTPB3are at increased risk for TAAD, in addition to the already established risk for skeletal and dental abnormalities.Mutations of the latent TGF-β binding protein-3 (ARIH1) have been observed in patients with early-onset or familial TAAD.AR1H1encodes a protein of the LINC (linker of nucleoskeleton and cytoskeleton), a protein complex essential for anchoring myocyte nuclei to the cytoskeleton.Rare mutations in the Parkin-like E3 ubiquitin ligase Ariadne-1  gene have been associated with TAAD. Shalata et al have identified an additionalMYLKmissense mutation in a single pedigree.Numerous mutations of the myosin light chain kinase (RAP1GDS1gene and known to be involved in the contraction of vascular smooth muscle cell (VSMC).+/−mouse model, since the complete knockout (SmgGDS−/−) was embryologically lethal, they observed that the downregulation of SmgGDS was causing “pathological phenotype changes in VSMC” via the angiotensin-II pathway.+/−, the mice had less aortic growth and fewer aortic ruptures, suggesting that SmgGDS could be used as a biomarker or a therapeutic agent.Insights to the pathogenesis of TAAD are as important as identifying TAAD variants. Nogi et alAdvances in 2018 have increased our understanding of the pathogenesis of TAAD. The number of genes with genetic variants or mutations associated with TAAD has increased from 29 in our original 2017 reportWe will continue to report annual updates regarding the “TAA genetic dictionary” with updates to the Table and Figure below and provide suggested surgical intervention criteria for each identified mutation.


Streptomycetes) are no longer viable options. In addition to discovery platforms, a concept of an ideal antibiotic should be postulated, to act as a blueprint for future drugs, and to aid researchers, pharmaceutical companies, and relevant stakeholders in selecting lead compounds. Based on 150 references, the aim of this review is to summarize current advances regarding the challenges of antibiotic drug discovery and the specific attributes of an ideal antibacterial drug .The emergence and spread of antibiotic-resistant pathogens is a major public health issue, which requires global action of an intersectoral nature. Multidrug-resistant (MDR) pathogens—especially “ESKAPE” bacteria—can withstand lethal doses of antibiotics with various chemical structures and mechanisms of action. Pharmaceutical companies are increasingly turning away from participating in the development of new antibiotics, due to the regulatory environment and the financial risks. There is an urgent need for innovation in antibiotic research, as classical discovery platforms (e.g., mining soil  Enterobacteriaceae) [in vitro [Enterococcus faecium, S: Staphylococcus aureus or recently Stenotrophomonas maltophilia, K: Klebsiella pneumoniae or recently C: Clostridioides difficile, A: Acinetobacter baumannii, P: Pseudomonas aeruginosa, E: Enterobacter spp., or recently Enterobacteriaceae) receive the most attention, when it comes to identification and screening of novel compounds [A. baumannii and K. pneumoniae) leave physicians with very few options that are left for treating their patients [The discovery and clinical use of antibiotics may be considered to be one the greatest achievements in the history of medicine . The emeriaceae) ,9. Multiriaceae) ,11. The in vitro ,13. Majoin vitro ,15,16,17in vitro . From thompounds ,19,20,21ompounds . In addipatients ,24.In the 21st century, it is becoming obvious that the pace of antibiotic drug discovery cannot keep up with the continuous and detrimental changes in resistance trends . In the 10 × 20 Initiative of the US Food and Drug Administration  and the New Drugs 4 Bad Bugs (ND4BB) programme from the Innovative Medicine Initiative (IMI) of the European Medicines Agency (EMA), antibiotic development is largely in the hands of smaller startup biotechnology companies with specific interest in an antibiotic class or infectious disease [Pharmaceutical companies are increasingly turning away from participating in the development of new antibiotics, with large firms like Novartis, AstraZeneca, Sanofi, Bristol-Myers Squibb, and Allergan dropping their antimicrobial research programmes. There are several economic considerations that may explain this phenomenon . The cos disease ,41,42. I disease ,44. In TThe Waksman-platform has dominated the field of antibiotic discovery for almost 40 years, but after overmining soil bacteria, and the continuous re-discovery of already known compounds, this platform was abandoned by pharmaceutical companies ,51. TherIn addition to discovery platforms, a concept of an ideal antibiotic should be postulated, to act as a blueprint for future drugs . The intMycoplasma/Ureaplasma ssp. , ell wall ) and L-fell wall ,80,81) bell wall . These dell wall . Therefoell wall . The proell wall ,86. The ell wall . Some anell wall ,88,89.Pseudomonas aeruginosa) usually lose their susceptibilities to these drugs [The penetration barrier of Gram-negative cell wall is an important obstacle for antimicrobial development . The outse drugs ,96. The se drugs ,98. Thesse drugs ,99. The +/Na+-gradient-dependent efflux transporters ; secondly, reacting with multiple targets ensures that drug resistance may not develop through single-step mutations  and target modification  [This ideal molecule should be highly reactive, forming an irreversible, covalent bond on multiple, unrelated targets, leading to bacterial cell death . This isistance) ,100. An istance) .a. ≤ 5 hydrogen bond donors, b. ≤ 5 hydrogen bond acceptors, c. molecular mass <500 Da, d. octanol-water partition coefficient (clogP) < 5) assumed that the most commercially successful, orally administered molecules are relatively small and moderately lipophilic [In addition to the interactions of the molecule with the target microorganisms during therapy, these compounds must meet a set of pre-determined set of physico-chemical characteristics that a lead compounds should possess in order to become a drug candidate . Based opophilic ,107. Howpophilic . To furtpophilic .Chlamydia spp., Rickettsia spp., Coxiella spp., Mycobacterium tuberculosis and leprae) and facultative  intracellular bacteria [Tissue penetration of the molecule should be adequate to attain therapeutic concentrations in all parts of the body, including peripheral areas, and in infected sites that are hard-to-reach and that have specific physico-chemical characteristics  ,110. Addbacteria ,112,113.bacteria ,116,117.Compared to other drugs, antibiotics are effective in concentrations that are two to four magnitudes higher than other molecules affecting distinct molecular targets in the human body . This caethionamide, isoniazid, pyrazinamide and the metronidazole-like drugs . This drug belongs to the 5-nitroimidazole group drugs, together with its derivatives, tinidazole, ornidazole, ronidazole and secnidazole. Moreover, these compounds can be considered as the primary lead compounds for nitazoxanide (and its active metabolite tizoxanide), which are broad-spectrum antiparasitic agents [Helicobacter pylori, and it represents the gold standard in drug therapy for anaerobic infections [Mobiluncus curtisii and the genera Actinomyces, Bifidobacterium, Lactobacillus and Propionibacterium) having intrinsic non-susceptibility, the resistance to this drug is <1% worldwide [The question arises as to whether the ideal antibiotic can only be a theoretical concept or is it realistic to identify and design such molecules. Surprisingly, there are a few drugs in current clinical use that have similar characteristics to this model, namely ke drugs .. Metronmulation . In addic agents . Metronifections ,127,128.orldwide ,130,131.orldwide . The resMycobacterium tuberculosis complex. Generally, INH and PYR are part of the first-line treatment regimen for TB, together with rifampicin and ethambutol, while ETH  is usually considered as a second-line drug, useful in drug-resistant TB [Mycobacterium-specific enzyme: ETH requires activation by EthA (a flavin mono-oxygenase) and INH is activated by KatG , while PYR is converted to its active form by the PZase/nicotinamidase, encoded by the pncA gene [Ethionamide (ETH), isoniazid (INH), and pyrazinamide (PYR) are all drugs that are relevant for the treatment of the stant TB ,134. Allstant TB ,134. ThencA gene ,138,139.ncA gene ,138,139.ncA gene . NeverthncA gene ,138,139.Prontosil) would have been excluded, as the active compound sulfanilamide becomes available only after in vivo metabolism [It seems no surprise that all the above-mentioned drugs  are listtabolism . Similartabolism ,145,146.The growing number of antibiotic-resistant pathogens is increasingly threatening the efficacy of healthcare institutions worldwide. Antibiotic discovery needs to be re-energized, to rival the threat of the post-antibiotic era . The attRealistically, producing a molecule that possesses all the listed properties above is very unlikely; therefore, the usefulness of this model is to aim towards specific features from the list, based on the pathogen, site of infection, administration route, and the targeted patient population during drug development. As a matter of fact, the best possible scenario would be to modify and/or functionalize existing antibiotics to attain more of the mentioned properties. Although there are some alternative approaches in development for combating infectious diseases , it is unreasonable to believe that they will replace antibiotics anytime soon . Therefo