This study aimed to clarify the clinical features of and evaluate the treatment efficacy for IgG4-related thyroiditis.Fourteen IgG4-related thyroiditis patients and 42 randomly matched IgG4-related disease (IgG4-RD) patients without thyroiditis in a prospective cohort at the Peking Union Medical College Hospital (PUMCH) were enrolled from 2011 to 2019. Patient demographics, clinical characteristics, laboratory parameters and treatment efficacy were analysed.P = 0.019, P = 0.022, P = 0.004, and P = 0.006, respectively) and more single-organ involvement (P = 0.011). After treatment, the symptoms were relieved, while the size of the thyroid gland did not change significantly, and levothyroxine as a supplemental therapy was still needed.The prevalence of IgG4-related thyroiditis in our cohort was 2.0%. The average patient age was 42.8 ± 14.9 years, and the male: female ratio was 1:1. Goiter , hard thyroid  and neck compression  were the most prevalent onset symptoms observed. IgG4-related thyroiditis was characterized by asymmetric diffuse thyroid enlargement on ultrasound. Thirteen (92.9%) patients had hypothyroidism, and all patients had significantly elevated circulating thyroid antibodies. Compared with patients without thyroiditis, patients with IgG4-related thyroiditis had less submandibular gland involvement and lacrimal gland involvement and lower serum IgG4 and T-IgE levels (IgG4-related thyroiditis is a distinct subtype of IgG4-RD characterized by positive circulating thyroid antibodies and a high rate of hypothyroidism. Although compression symptoms could be relieved with treatment, the thyroid size did not change significantly, and the damage to thyroid function was often irreversible.The online version contains supplementary material available at 10.1186/s13023-021-01942-x. IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disorder , 2. IgG4As one of the less commonly involved organs of IgG4-RD, IgG4-related thyroiditis mainly includes Hashimoto’s thyroiditis (HT) and Riedel’s thyroiditis (RT) , 11. AwaCurrently, the clinical manifestations and pathological features of IgG4-related thyroiditis have been studied . HoweverIn our prospective cohort study of IgG4-RD carried out in the Peking Union Medical College Hospital , 710 IgG4-related disease patients fulfilling the 2011 comprehensive diagnostic criteria were enrolled from January 2011 to November 2019. The diagnosis of IgG4-RD was based on the following criteria: (1) a clinical examination showing characteristic diffuse/localized swelling or masses within single or multiple organs; (2) an elevated serum IgG4 concentration (> 135 mg/dL); and (3) a histopathologic examination showing (a) marked lymphocytic and plasma cell infiltration and fibrosis or (b) infiltration of IgG4+ plasma cells (a ratio of IgG4+ /IgG+ cells > 40% and > 10 IgG4+ plasma cells per high-power field) [A patient was diagnosed with IgG4-related thyroiditis if he/she fulfilled the diagnostic criteria and had a hard thyroid enlarged in size confirmed by a physical examination and imaging. A hard thyroid was defined as hardness of the thyroid between the forehead and the tip of the nose on the physical examination. Neck compression was based on the patient's chief complaint and the tracheal compression sign by an imaging examination (X-ray or CT scan) due to increased thyroid volume.According to Zhang and Stone’s review, IgG4-RD consists of two distinct and overlapping subsets: the proliferative type and the fibrotic type [This study was conducted in compliance with the Declaration of Helsinki and was approved by the Ethics Committee of Peking Union Medical College Hospital (No. S-442). All patients signed written informed consent forms.The thyroid lobes were scanned separately, and a transverse scan of the entire thyroid lobe and half of the isthmus was performed through a single sweep from the superior border to the inferior border. The longitudinal, transverse and coronal boundaries of the thyroid lobes were measured, and the volume was calculated with built-in software .Patient data, including age, sex, disease duration, history of allergies, treatment strategy, onset of symptoms, organs affected, and follow-up time, were collected. The IgG4-related disease Responder Index  and Physician Global Assessment (PGA) at baseline and each follow-up were evaluated [Treatment response was assessed by evaluating the changes in symptoms, size and hardness of the thyroid gland, thyroid function, and IgG4-RD RI scores . ClinicaP-value ≤ 0.05 was considered statistically significant.Statistical analyses were performed using IBM SPSS Statistics version 24.0 software . Data are reported as the mean ± standard deviation or the median and range (interquartile range or min–max). Normally distributed data between two groups were analysed using independent samples t-tests or paired samples t-tests, and one-way analysis of variance was used to compare groups. Categorical data were analysed using the chi-square test or Fisher’s exact tests, while non-normally distributed data were analysed using the rank-sum test. A two-tailed Among the 710 IgG4-RD patients, 14 (7 men and 7 women) were diagnosed with IgG4-related thyroiditis. The demographic features of patients with IgG4-related thyroiditis are shown in Table Of the 14 patients with thyroiditis, 6 (42.8%) were diagnosed with definite IgG4-RD, and 8 (57.1%) were diagnosed with possible IgG4-RD. Pathological diagnosis was performed in 8 patients; among them, 7 underwent thyroid biopsies, and 1 underwent a liver biopsy. The representative pathological features of the thyroid of 1 patient are shown in Fig. Symptoms of IgG4-related thyroiditis at baseline are shown in Table In addition to the thyroid, other affected organs were as follows: lymph node 28.5%), nasal sinus (14.3%), pituitary (14.3%), pancreas (7.1%), submandibular gland (7.1%), lacrimal gland (7.1%), lung (7.1%), kidney (7.1%) and periaortitis/periarteritis (7.1%)  had hypothyroidism, and only 1 (7.1%) patient had normal thyroid function. All patients had significantly elevated levels of thyroid autoantibodies, including Tg-Abs (3172 ± 1516 IU/ml) and TPO-Abs (475 ± 159 IU/ml).Of the patients with IgG4-related thyroiditis, the mean ESR and hsCRP levels were 27 (14–36) mm/h and 2.06 (0.33–3.99) mg/L, respectively. The mean serum IgG, IgG4 and T-IgE levels were 23.56 ± 8.14 g/L, 4750 (2503–8505) mg/L and 100.3 (16.4–175.0) KU/L, respectively. There was no significant difference between male and female patients in laboratory parameters.3 (right lobe) and 46.95 ± 26.66 cm3 (left lobe), with maximum volumes of 143.89 cm3 (right lobe) and 80.51 cm3 (left lobe) in one patient. Thyroid cystic nodules were found in 5 patients (36.3%). Four patients (30.8%) had cervical lymph node swelling. Colour Doppler flow imaging (CDFI) demonstrated increased blood flow signals in the thyroid glands of 6 (46.2%) patients.Thirteen (92.8%) patients with IgG4-related thyroiditis underwent thyroid ultrasound scans. The results revealed asymmetric diffuse enlargement of thyroids, decreased echogenicity and uneven echogenicity in all patients. The average volumes of the thyroid glands were 71.62 ± 42.73 cmCharacteristic imaging findings of IgG4-related thyroiditis are shown in Fig. P = 0.022, P = 0.010, P < 0.001, P < 0.001, and P = 0.011, respectively; Table Compared to IgG4-RD patients without thyroiditis, patients with thyroiditis were younger at disease onset and had fewer organs involved, a lower IgG4-RD RI, a lower PGA, and more single-organ involvement , lower levels of serum IgG4 and IgG3, and lower levels of T-IgE   P = 0.01, lower lEleven patients had thyroid enlargement at disease onset, and three patients had thyroid enlargement during disease progression. Comparisons of onset symptoms between IgG4-RD patients with and without thyroiditis are shown in Additional file P = 0.036, P < 0.001, respectively; Table In 2010, Li  divided The individual clinical manifestations, treatment strategy and response are listed in Table P < 0.001), and the mean PGA decreased from 4.4 ± 2.4 to 2.1 ± 1.0 (P < 0.001). The mean serum IgG levels decreased from 20.50 ± 7.38 g/L to 14.63 ± 7.32 mg/L (P < 0.001), the mean serum IgG4 levels decreased from 6530  mg/L to 2924 (551–5810) mg/L (P = 0.004), and the mean ESR decreased from 27 (14–36) mm/h to 16 (7–14) mm/h (P = 0.017). There were no significant changes in CRP, Tg-Ag or TPO-Ag after treatment .Twelve patients were followed up for more than 6 months. At month 6, 11 (91.6%) patients had alleviation of neck compression, with the thyroid glands becoming softer according to the physical examination. The mean IgG4-RD RI decreased from 5.2 ± 3.6 to 1.6 ± 0.9 (3 and 61.10 ± 40.38 cm3 (P = 0.911) for the right lobe and 55.04 ± 24.31 cm3 and 38.21 ± 26.11 cm3 (P = 0.777) for the left lobe, respectively. One patient’s thyroid gland returned to a normal size after 15 months of treatment.Nine patients were followed up for more than 12 months. At month 12, all patients still needed levothyroxine as a supplemental treatment, and none of them achieved a normal thyroid gland size. During the follow-up, patients still had thyroid gland enlargement confirmed by ultrasonography after 23.3 ± 17.3 months of treatment. The mean volumes of the gland before treatment and at the last follow-up were 85.10 ± 39.81 cmIgG4-related sclerosing thyroiditis is part of the IgG4-RD spectrum, with a 2.0% prevalence in our cohort. Common symptoms of IgG4-related sclerosing thyroiditis were goiter, hard thyroid and neck compression. Most patients had irreversible hypothyroidism and needed long-term thyroxine replacement therapy. After treatment with GCs, symptoms recovered faster than changes in thyroid size on ultrasound. In addition, patients with IgG4-related thyroiditis were younger at disease onset, had fewer organs involved, a lower IgG4-RD RI and PGA and a lower frequency of submandibular gland, lacrimal gland and pancreas involvement, but they more single-organ involvement than those without thyroiditis.IgG4-related thyroiditis was initially thought to include a wide spectrum of thyroid diseases, such as HT and RT. In 2009, based upon the immunostaining pattern of IgG4 on surgically removed thyroid specimens, Li et al. demonstrated a male predominance in patients with IgG4 thyroiditis, younger age at disease onset, elevated IgG4 concentrations, high levels of thyroid autoantibodies, diffuse low sonographic echogenicity of the thyroid and rapid development of subclinical hypothyroidism . ConsistIt has been proposed that IgG4-RD might be divided into two distinct but overlapping subclasses according to the clinicopathological characteristics of patients: proliferative and fibrotic . PatientAt present, there is no standard treatment for IgG4-related thyroiditis. GCs are the first choice, with levothyroxine supplementation for hypothyroidism and surgical excision of the thyroid for compression , 26–28. It is worth noting that although most patients are treated with GCs and/or IMs, long-term levothyroxine replacement is still needed due to the irreversible impairment of thyroid function. In an early pathological study of IgG4-related thyroiditis, the IgG4 thyroiditis group demonstrated thyroid-specific histological features, including the presence of small thyroid follicles, marked follicular cell degeneration, and increased giant cell/histiocyte infiltration. The severity of the IgG4 thyroiditis group was much worse than that of the non-IgG4 thyroiditis group  and may This study had some limitations. First, the follow-up time was relatively short, and the sample size was relatively small because IgG4-related thyroiditis is rare. Second, the ultrasonography results were not confirmed by another independent researcher. Third, not all patients in this cohort underwent a thyroid biopsy.Our study indicates more single-organ involvement and lower serum IgG4 and IgE levels in IgG4-related thyroiditis than those without thyroid involvement, which is a distinct subtype of IgG4-RD and mostly resembles IgG4-RD of the fibrotic type. Goiter, hard thyroid and neck compression were the most prevalent onset symptoms observed. A low female to male ratio, the presence of circulating thyroid antibodies and a higher rate of hypothyroidism are characteristics of IgG4-related thyroiditis. Ultrasound revealed primarily asymmetric diffuse thyroid enlargement. Patient symptoms were relieved with GC therapy, but the size of the thyroid did not change significantly, and levothyroxine as a supplemental therapy was still needed.Additional file 1. Comparison of IgG4-related thyroiditis with/without thyroid enlargement as initial symptom.


Introduction: Antibiotics are commonly prescribed in primary care for acute respiratory tract complaints (aRTCs), often inappropriately. Social marketing interventions could improve prescribing in such settings. We evaluate the impact of a social marketing intervention on general practitioners’ (GPs’) antibiotic prescribing for aRTCs in Malta. Methods: Changes in GPs’ antibiotic prescribing were monitored over two surveillance periods between 2015 and 2018. Primary outcome: change in antibiotic prescription for aRTCs. Secondary outcomes: change in antibiotic prescription: (i) for immediate use, (ii) for delayed antibiotic prescription, (iii) by diagnosis, and (iv) by antibiotic class. Data were analysed using clustered analysis and interrupted time series analysis (ITSA). Results: Of 33 participating GPs, 18 successfully completed the study. Although clustered analyses showed a significant 3% decrease in overall antibiotic prescription (p = 0.024), ITSA showed no significant change overall (p = 0.264). Antibiotic prescription decreased significantly for the common cold (p < 0.001), otitis media (p = 0.044), and sinusitis (p = 0.004), but increased for pharyngitis (p = 0.015). Conclusions: The intervention resulted in modest improvements in GPs’ antibiotic prescribing. A more top-down approach will likely be required for future initiatives to be successful in this setting, focusing on diagnostic and prescribing support like rapid diagnostic testing, prescribing guidelines, and standardised delayed antibiotic prescriptions. Antibiotics are cost-effective, life-saving medicines that have contributed to an extended life expectancy . The rapAntibiotic consumption is a key driver of ABR , particuMalta, a southern European country, has had consistently high antibiotic consumption rates ,14,15,16Improving the quality of antibiotic prescribing in primary care is cornerstone to control ABR. Changing GPs’ prescribing behaviour could have far-reaching consequences, impacting not only their practices, but also patients’ beliefs and attitudes towards antibiotics. However, changing prescribing behaviour is complex and largely influenced by context and cultural norms . Educatin = 1606) were excluded, rendering 5455 eligible aRTC cases. For analysis of antibiotic prescribing by diagnosis, a further 159 patients with secondary diagnoses were excluded , had more years of clinical practice (p = 0.004) and higher pre-intervention antibiotic prescribing rates (p = 0.000) (GP characteristics were similar pre- and post-intervention . However= 0.000) .p = 0.016). Of these, 343 (15.9%) and 285 (32.0%) prescriptions were delayed antibiotic prescriptions (DAPs) at pre- and post-intervention respectively, resulting in a significant increase in the proportion of DAPs prescribed post-intervention (p = 0.001). The rest were antibiotics prescribed for immediate use. This included 1809 (84.1%) before and 605 (68.0%) after the intervention; also a significant decrease post-intervention (p = 0.001).Overall antibiotic prescription for aRTC patients decreased significantly post-intervention from 2152 (45.8%) to 890 (37.7%) (n = 1260 (40.8%) vs n = 890 (37.7%)) (p = 0.024). Interrupted time series analysis (ITSA) however showed no significant change in antibiotic prescription, both directly after the intervention and 1 year later (p = 0.264). Immediately post-intervention, there was a non-significant increase in antibiotic prescription of 1.86% (p = 0.633). This was followed by a non-significant decrease in the antibiotic prescription trend (relative to the pre-intervention trend) of 0.35% per month (p = 0.371). Following the intervention, antibiotic prescription decreased non-significantly at a rate of 0.53% per month (p = 0.182)  .n = 967 (76.8%) vs n = 605 (68.0%)) (p = 0.002). ITSA however showed no significant change in antibiotic prescription for immediate use directly after or 1-year post-intervention (p = 0.349). Immediately post-intervention, there was a non-significant decrease in antibiotic prescription of 6.84% (p = 0.126). This was followed by a non-significant increase in the antibiotic prescription trend of antibiotics for immediate use (relative to the pre-intervention trend) of 0.14% per month (p = 0.771). Following the intervention, antibiotic prescription for immediate use decreased non-significantly at a rate of 0.08% per month (p = 0.867)  .n = 293 (23.3%) vs 285 (32.0%)) (p = 0.002) when analysed using before-and-after clustered analysis. Once again, ITSA showed no significant change in DAP directly after or 1-year post-intervention (p = 0.349). Immediately post-intervention, there was a non-significant increase in DAP of 6.84% (p = 0.126). This was followed by a non-significant decrease in the DAP trend (relative to the pre-intervention trend) of 0.14% per month (p = 0.771). Following the intervention, DAP increased non-significantly at a rate of 0.08% per month (p = 0.867) (Significantly more DAPs were prescribed post-intervention (rvention . DAP inc= 0.867) .p < 0.001). A significant decrease in antibiotic prescribing was also observed for otitis media (p = 0.044) and sinusitis (p = 0.004). Notably, antibiotic prescribing for pharyngitis increased significantly post-intervention (p = 0.015)  .p = 0.021). Concurrently, use of 2 other antibiotic classes decreased for this indication. Prescription of other β-lactam antibacterials (J01D) decreased significantly post-intervention for sinusitis (p = 0.001) and bronchitis (p = 0.040). Although macrolide use decreased significantly for influenza (p = 0.032), its use increased significantly for pharyngitis (p = 0.046)  decreased significantly post-intervention for the common cold (= 0.046) .p < 0.001). Prescription of tetracyclines (J01A) and β-lactam antibacterials, penicillins (J01C) however, increased significantly post-intervention from 0.7% to 2.2% (p = 0.002) and 46.8% to 53.3% (p = 0.032), respectively (The most commonly prescribed antibiotic class (both pre- and post-intervention) was β-lactam antibacterials, penicillins (J01C), with co-amoxiclav constituting the majority of prescriptions. Macrolides (J01F) were the second most commonly prescribed antibiotic class, with clarithromycin and azithromycin being the most favoured antibiotics. Other β-lactam antibacterials (J01D) were also among the top 3 most commonly prescribed antibiotics pre- and post-intervention although less often prescribed. Clustered analysis showed that prescription of other β-lactam antibacterials (J01D) decreased significantly post-intervention from 19.2% to 13.1%  decreased significantly post-intervention for sinusitis and bronchitis, macrolide (J01F) use for pharyngitis increased significantly.Multifaceted interventions coupled with behaviour change theories can successfully improve antibiotic prescribing . In our Changing clinicians’ antibiotic prescribing behaviour is challenging, particularly since prescribing culture is shaped by numerous factors including clinical, cultural, economic, and social factors ,30. MaltIn such cultural backgrounds, it is more likely that broad-spectrum antibiotics are used  as shownRapid POCTs could help decrease antibiotic prescribing rates by reducing GP uncertainty. They could also lessen the risk that GPs succumb to patient pressure by supporting their decision not to prescribe antibiotics ,49. IndeRapid, low-cost diagnostic tests are still largely unavailable in Malta despite their potential in reducing unnecessary antibiotic prescribing ,51. FutuDAP can also address uncertainty ,53,54,55In our study, older and more experienced GPs with higher antibiotic prescribing rates, dropped out of the study during or shortly after the intervention. GP age (>60 years) was previously identified as a significant predictor of higher antibiotic prescribing . It is tIn Malta, GPs typically lack information and therefore appreciate information provided to them by pharmaceutical representatives, although they acknowledge that information may be biased . AcademiTo our knowledge this is the second study that evaluates the impact of a SM intervention to change GPs’ antibiotic prescribing in a Mediterranean setting. Moreover, it is the first time that a rigorous study design has been applied in Malta to monitor and change antibiotic prescribing patterns for aRTCs in primary care. The study involved detailed antibiotic prescribing surveillance conducted over 24 months, generating unique data.Every study, however, needs to be seen in the context of its limitations. Firstly, during or shortly after the intervention, 15 GPs who had significantly higher antibiotic prescribing rates pre-intervention dropped out of the study and did not contribute to our post-intervention data collection. This reduced our sample size and could explain a lack of significant results when using ITSA. It also makes interpretation of the intervention results challenging as it appears that GPs who remained in the study were more willing and motivated to change their antibiotic prescribing practices. Nevertheless, despite GPs’ higher motivation and engagement, only some improvement in their antibiotic prescribing practices was observed. Moreover, not all GPs participated in the intervention to the same extent. Their varying exposure could have inevitably impacted their antibiotic prescribing post-intervention. Finally, due to the study’s small GP cohort and lack of national antibiotic prescribing data, it was neither possible to tailor intervention components to GPs’ individual stage of behaviour change, nor assign a control group for comparison. In addition, the study’s multifaceted design did not allow us to measure the effect of each individual component to determine which intervention had the largest impact on GPs’ antibiotic prescribing.This 4-year quasi experimental study was conducted in primary care practices across Malta between 2014 and 2018 . BrieflyIn 2014, during the pre-intervention phase, 370 GPs and 34 GP trainees were invited to participate in a 1-year antibiotic prescribing surveillance study (May 2015 to April 2016). Ultimately, 30 GPs and 3 GP trainees participated. Following completion, GPs were invited to extend participation in an intervention and subsequent 1-year post-intervention surveillance study (May 2017 to April 2018). Although 24 GPs extended participation and partook in the intervention, 18 GPs reported cases during both the pre- and post-intervention phases, allowing for pre-/post-intervention comparative analyses .Identical data collection methods and tools were used during the pre- and post-intervention phases . GPs colThe intervention comprised 5 components: (i) patient booklets; (ii) waiting room posters; (iii) national antibiotic prescribing guidelines; (iv) DAP pads; and (v) GP educational sessions. GPs received certificates for their participation, which they could have used for CME accreditation. Regular contact (via email and text message) was maintained with GPs throughout, to address queries, provide encouragement, and maintain engagement.Patient booklets were developed based on needs identified during the pre-intervention phase and were informed by the team’s subject-area knowledge and evidence-informed guidelines. They were designed with a medical illustrator and underwent several revisions following team discussions and feedback from three medical professionals and five members of the public. The 6-page booklet included information in both national languages  on the pathogenesis of RTIs, appropriate antibiotic use, the effect antibiotic use has on the body, and ABR . A set oAll participating GPs received a package of patient education materials, relative to their practice size. They were asked to put up posters at their clinics and encouraged to use and distribute patient booklets during consultations with aRTC patients who both received and did not receive an antibiotic prescription. GPs could request more materials if necessary.Both soft and hard copies of the updated national antibiotic guidelines were shared with GPs. GPs also received standardised DAP pads  coupled GPs were invited to attend 4 interactive educational sessions, delivered both in-person and live online. Topics encompassed: (i) antibiotic use and resistance from a global and local perspective; (ii) introduction to the latest national antibiotic prescribing guidelines; (iii) principles of prudent antibiotic prescribing; and (iv) patient communication skills training. The 2-h sessions were held by local experts on antibiotic use and resistance, antibiotic pharmacology, and patient communication, on weekdays after 8pm. All sessions were recorded, allowing GPs to view the sessions at their own convenience via an online educational platform.Key process indicators for all five intervention components are presented in All patients suffering from aRTCs  were considered cases. Cases reported outside the pre-determined surveillance weeks, who received non-oral antibiotics, had incomplete reporting sheets, were diagnosed with pneumonia, or follow-up cases, were not included. Further, all cases reported by the 15 GP ‘non-completers’, were excluded from all primary and secondary outcome analyses to enable pre- and post-intervention comparison. To analyse the change in prescription of immediate versus delayed antibiotics, and antibiotic class pre- and post-intervention, analysis was further restricted to patients who received an antibiotic prescription. Finally, to analyse the change in antibiotic prescribing by diagnosis, patients who received any secondary diagnoses were excluded.The primary outcome of interest was change in antibiotic prescription  among GP ‘completers’. Secondary outcomes included change in: (i) the proportion of antibiotic prescriptions for immediate use; (ii) the proportion of DAPs; (iii) antibiotic prescribing by diagnosis; and (iv) antibiotic prescribing by antibiotic class.p-values < 0.05 were considered significant. Data were input in Excel® 2010  and statistical analyses were performed using STATA® version 15.1 .The WHO’s 2017 Anatomical Therapeutic Chemical (ATC) classification system was used to classify antibiotics . DescripIn this novel study we show that a SM intervention can, to some extent, positively change GPs’ antibiotic prescribing for aRTCs. Our intervention utilised a voluntary behaviour change approach, yet despite being delivered to GPs who were already highly motivated to change, ITSA showed no significant impact on their antibiotic prescribing behaviour. In cultural backgrounds that are more resistant to change, competing drivers may be too strong, especially in a fully autonomous private GP set up like in Malta. Subsequently, a more coercive top-down approach may have had a greater impact. Moreover, the lack of a national antibiotic prescribing surveillance system (and consequent lack of accountability) poses limitations; its set-up needs urgent attention.Several other actions should be taken to improve GPs’ antibiotic prescribing in Malta. Increasing the availability and use of rapid POCTs is highly recommended to provide GPs with a greater sense of clarity and certainty, particularly since antibiotic use for pharyngitis increased post-intervention. With strong political will and stakeholder engagement, we believe that POCTs can limit unnecessary antibiotic prescribing. We also believe that formalising and standardising DAP could help reduce unnecessary antibiotic consumption and change public perceptions about the need for immediate antibiotics for aRTCs. Academic detailing could also provide GPs with evidence-based information on guideline-concordant antibiotic use and give them the opportunity to reflect upon their own antibiotic prescribing. This strategy should be well-accepted in Malta as GPs tend to be rather receptive towards information shared to them by pharmaceutical representatives. Future studies should focus on changing antibiotic prescribing practices for specific indications such as tonsillitis, bronchitis, pharyngitis, common cold and influenza, to achieve better guideline-concordance and further reduce unnecessary and premature antibiotic prescribing for aRTCs.


The magnitude of microbiota perturbations after exposure to antibiotics varies among individuals. It has been suggested that the composition of pre-treatment microbiota underpins personalized responses to antibiotics. However, this hypothesis has not been directly tested in humans. In this high-throughput amplicon study, we analyzed 16S ribosomal RNA gene sequences of 260 stool samples collected twice weekly from 39 patients with acute leukemia during their ~ 4 weeks of hospitalization for chemotherapy while they received multiple antibiotics.Despite heavy and sustained antibiotic pressure, microbial communities in samples from the same patient remained more similar to one another than to those from other patients. Principal component mixed effect regression using microbiota and granular antibiotic exposure data showed that microbiota departures from baseline depend on the composition of the pre-treatment microbiota. Penalized generalized estimating equations identified 6 taxa within pre-treatment microbiota that predicted the extent of antibiotic-induced perturbations.Our results indicate that specific species in pre-treatment microbiota determine personalized microbiota responses to antibiotics in humans. Thus, precision interventions targeting pre-treatment microbiota may prevent antibiotic-induced dysbiosis and its adverse clinical consequences.Video abstractThe online version contains supplementary material available at 10.1186/s40168-021-01170-2. Clostridioides difficile infection [Antibiotics represent a major cause of perturbation experienced by microbial communities in the body. The typical progression of the compositional states of microbiota after antibiotic-induced perturbations includes departure from baseline phase 1) followed by post-antibiotic reorganization (phase 2) , light and sustained , heavy and brief , or heavy and sustained . We studied patients with acute myeloid leukemia (AML) receiving inpatient chemotherapy, a prototype setting for heavy sustained antibiotic exposure. These patients receive multiple antibiotics over several weeks of hospitalization. Initially, patients receive antibiotics to prevent infections. However, most patients develop a fever despite prophylaxis . At the High-throughput amplicon sequencing of longitudinal stool samples collected from hospitalized patients with AML coupled with granular antibiotic exposure data uniquely positioned us to measure the dependency of microbiota perturbations on the microbiota’s baseline state. We find that the composition of pre-treatment microbiota is a major determinant of the magnitude of microbiota departure from baseline. We identify pre-treatment taxa that stabilize or destabilize the microbiota. These findings offer a mechanistic explanation for individualized responses to antibiotics and introduce novel targets for precision interventions to prevent antibiotic-induced dysbiosis and its adverse clinical consequences.ClinicalTrials.gov: NCT03316456) approved by the University of Minnesota Institutional Review Board. An expected ~ 4 weeks of hospitalization was required. No other inclusion or exclusion criteria were used. Clinical and supportive care followed our standard institutional algorithm. Deviations per the treating physicians’ discretion were permitted. Our antibiotic stewardship recommends acyclovir for viral, an azole for fungal, and levofloxacin for bacterial prophylaxis for the duration of neutropenia. Bacterial prophylaxis is continued until development of neutropenic fever or first neutrophil rise above 1 × 109/L, whichever occurs first. Cefepime is our recommended empiric frontline antibiotic for neutropenic fever. When oral intake decreases to < 60% of the lower limit of estimated energy and protein needs for 7 days, we generally initiate parenteral nutrition.We enrolled hospitalized adult patients with newly diagnosed or relapsed/refractory AML to a prospective, biorepository protocol  between hospital admission and day 28 of chemotherapy or discharge (whichever occurred first). Collections were independent of clinical factors. Stool samples were collected in 95% ethanol-filled sterile tubes and stored at – 80 °C. Antibiotic exposure data were collected from electronic medical records for the following classes of antibacterial antibiotics: fluoroquinolones, 3rd or higher generation cephalosporins, piperacillin-tazobactam, carbapenems, metronidazole, oral vancomycin, and intravenous vancomycin.DNA was extracted using the DNeasy PowerSoil DNA isolation kit . The V4 hypervariable region of the 16S rRNA gene was amplified on an Illumina MiSeq platform (2 × 300 paired-end mode) by the University of Minnesota Genomics Center . Sequenc0 to 2 × 106 copies/μL) of the mixture of synthetic DNA fragments containing each target gene sequence were also included in the analysis to generate standard curves. Specific target amplification (STA) was done with 14 PCR cycles to increase the target DNA molecule prior to MFQPCR as previously described [Remaining DNA from a subset of samples was used for microfluidic qPCR (MFQPCR) to quantify various antibiotic-resistance genes (ARGs) including those for beta-lactams, quinolones, and vancomycin resistance as previously described . BioMarkescribed . Sample escribed . All samphyloseq, vegan, lme4, and PGEE in R. Linear discriminant analysis (LDA) coupled with effect size measurements (LEfSe) using patient number as “subject” was used to find taxa that differed significantly  between the two groups [All analyses were performed using custom scripts and packages o groups . OTU abuo groups . A pseudo groups . We usedo groups . Other v0 + 1 × 2−1 + 1 × 2−2 + 1 × 2−3 + 0 × 2−4 + 0 × 2−5 + 0 × 2−6 = 0.875. With this decay factor, exposure on a given day receives twice as much weight than exposure on the previous day. A smaller decay factor would make the differences between the weights smaller. We ran Procrustes analysis [We quantified the “antibiotic history” of each sample using the time series of exposures to 7 major classes of antibacterial antibiotics between hospital admission and the day the sample was collected. The antibiotic classes considered were fluoroquinolones, third or higher generation cephalosporins, metronidazole, piperacillin-tazobactam, intravenous vancomycin , oral vancomycin, and carbapenems. For a given day, if a given antibiotic was used, it was coded 1 and otherwise, zero. Day 0 was defined as the first day of chemotherapy. Next, we applied a decaying average function to the time series of 0s and 1s for each antibiotic class to achieve a single numerical value summarizing exposure history for the given sample and antibiotic. As an example, if levofloxacin was used on days 1–3 for a patient admitted on day − 1 (1 day before starting chemotherapy), the time series for levofloxacin for a sample collected on day 5 of chemotherapy from this patient would be , indicating that the antibiotic was not used on days − 1, 0 (first day of chemotherapy), and 4, but was used on days 1, 2, and 3. With a decay factor of 2, the levofloxacin history for this sample would be quantified and summarized as 0 × 2analysis   of antibiotic history for each non-baseline sample, the top microbiota PCs for baseline microbiota, use of parenteral nutrition, interval from baseline, baseline Shannon index, and sample read depth. Patient ID was a random effect. −3 for shrunken coefficients is conventionally used to exclude variables from the model. Variables that remain in the final model are important predictors of the outcome variable, regardless of the specific value of their regression coefficients. The original model included 133 features: clr abundances of the OTUs collapsed at genus level (121 features) at baseline, decay averaged antibiotic histories (7 features representing 7 antibiotic classes), age, sex, body mass index, use of parenteral nutrition , baseline Shannon index, sample depth, and interval from baseline (days). Patient ID was a random effect. Fourfold cross validation (function CVfit) was used to estimate the optimal value of the tuning parameter, which was then used to build the final model (function PGEE). A first-order autoregressive correlation structure  was assumed. PGEE produces a consistent and asymptotically normal estimator even if the assumed correlation structure is misspecified. p < 0.05 was used to define statistical significance.While principal component regression allows us to understand the association between baseline microbiota and Δm after adjusting for covariates, it does not identify specific pre-treatment taxa that made the largest contribution to Δm. We implemented penalized GEE to analyze longitudinal data with many covariates . The maiEnterococcus , they only explained a small proportion of the variance . Median Aitchison distance between samples from the same patient was significantly smaller than median distance between samples from different patients  of antibiotic history for each non-baseline sample and the top PCs of the microbiota for the baseline sample from the same individual as predictors of Δm. This approach eliminates the problem of multicollinearity because the PCs are orthogonal. We included the first PC of the microbiota and the first PC of antibiotic history as predictors in the model. In addition, use of parenteral nutrition , interval from baseline (days), baseline Shannon index, and sample read depth were included as fixed effect covariates and patient ID as a random effect. The model was powerful, with a Pearson’s correlation coefficient comparing observed vs. predicted Δm values of 0.82  predicted larger Δm values, and one taxon (Bacteroides) predicted smaller Δm values  case 1 with a relatively high abundance of Bacteroides in the baseline sample (34%) and (ii) case 2 with no Bacteroides in the baseline sample. As expected from PGEE results and with Bacteroides predicted to protect against change from baseline, subsequent samples from case 1 were less different from baseline (Aitchison distances 25.7–36.0) compared to subsequent samples from case 2 relative to baseline (Aitchison distances 30.2–56.8). This is also demonstrated in the PCA plot  method, which is suitable for longitudinal high-throughput data analysis , 34. Feaues Fig. , we choslot Fig. .Fig. 4BIn post hoc exploratory analysis . Examples of quorum sensing mechanisms that could contribute to differential response to antibiotics include autoinducers of efflux pumps and biofilm formation [Salmonella typhimurium [We identified 6 pre-treatment taxa predictive of the magnitude of microbiota perturbation from baseline. the host . Specifithe host , potentiompounds . Whetherathogens . A microormation . Bacteroormation . In addiormation , which mhimurium .Enterococcus spp. and Escherichia coli has been reported [Enterococcus, Streptococcus, Staphylococcus, and some Proteobacteria [Considering the two phases of microbiota response to antibiotics, our study focused on phase 1, where the microbiota is perturbed under active antibiotic pressure. We included the characteristics of the antibiotic insult and baseline microbiota as the main potential determinants of phase 1 in our analysis. Although sex, age, and mode of nutrition were adjusted for, the role of other host factors such as genetics and immunity in phase 1 need to be evaluated in future research. Other potentially important variables include the specific type(s) of chemotherapy and proton pump inhibitors (PPIs). Chemotherapeutic regimens commonly used for patients with AML are not known to significantly alter gut microbiota, although an expansion of reported . In othebacteria , 53. We In conclusion, knowledge about pre-treatment microbiota can be used to predict the magnitude of antibiotic-induced perturbations and lead to personalized precision therapeutics. We identified specific taxa in the pre-treatment microbiota that may predict the extent of antibiotic perturbation. Our findings lead to hypothesis generation for testing and validation in future studies. Mechanisms by which specific taxa in gut microbiota communicate with other members of this complex community to regulate stability, resistance, and resilience is a subject of intense investigation. Quorum sensing and horizontal transfer of ARGs are two possible mechanisms. Our preliminary results on ARGs suggest potentially important ARGs with dynamics that could influence microbiota response to antibiotics over time. Finally, the patient population in this study was one with aggressive cancer receiving chemotherapy in a nosocomial setting and with altered nutrition. The extent to which our findings may be generalized to other clinical settings with antibiotic exposure remains to be determined.Additional file 1: Figure S1 Taxonomic distribution in baseline and non-baseline samples. (a) Mean relative abundance of the most abundant taxa are shown. The top 15 taxa in each group were used to generate the plot. (b) Linear discriminant analysis Effect Size using an LDA score threshold of 3.0 and p value threshold of 0.05. The deepest level of taxonomy was genus (g), and taxa unclassifiable at the genus level are shown at family (f) or order (o) level. Figure S2 Procrustes analysis correlating microbiota composition with antibiotic history. (a) Decay factor 2.0. (b) Decay factor 1.5. (c) Decay factor 1.1. Figure S3. Principal component mixed effect regression. The first PC of microbiota for the baseline sample, first PC of antibiotic history for the non-baseline sample, baseline Shannon diversity, read depth of the non-baseline sample, use of parenteral nutrition  before the non-baseline sample, and the time interval in days between the two samples were included as fixed effect predictors of Aitchison distance between the two samples. Patient ID was a random effect. Model performance was defined as the Pearson’s correlation coefficient (r) comparing observed vs. predicted values of the outcome variable. Different values of the decay factor were used in the two panels. PC: principal component. Table S1 Microfluidic quantitative PCR of antibiotic resistance genes.


Cervical spine injuries (CSI) are rare in trauma patients, at about 9.2–16.5/100,000 inhabitants in Scandinavia and Canada, and the annual incidence of CSI surgeries in Norway is around 3.0/100,000 inhabitants. However, despite their rarity, the incidence of CSI has increased, thereby assuming an increasing need for surgery. Outside of Scandinavia, no data about the incidence of CSI and subsequent surgeries exist. Therefore, this study aimed to analyse CSI epidemiology and surgery in a German city with a Level I trauma centre both to understand the injury and improve needs–based planning.This retrospective, monocentre study included all patients who presented with CSI from 2012–2017 at a university hospital with a Level I trauma centre in a major German city and had permanent residency within the city. Based on the assumption that the patients represented all CSI injuries in the city, as they were treated at the only available Level I trauma centre, the annual incidence of surgeries and neurologic deficits due to CSI were calculated.A total of 465 patients with 609 CSI were identified. Of these patients, 61 both received surgery and resided in the city . The incidence of CSI surgeries was calculated as 3.24/100,000 person years . Neurologic deficits occurred in 0.64/100,000 person years. The incidence of both surgeries and neurologic deficits showed no significant changes over the 6-year study period.Compared to Scandinavia, an increasing annual incidence for CSI surgeries and neurologic deficits were found. For long-term demand planning with adaptability to demographic changes, cross-regional studies including long-term follow-up are necessary. In Scan< 0.001) . Another< 0.001) .The age distribution and gender ratio of CSI have also changed. In 1992, the mean age of patients with CSI was 20–29 years in the UK . In the Of all CSI, 18–33.5% require surgery , 7, 13. This retrospective, monocentre study included all patients who presented with and received surgical treatment for traumatic CSI at the Level I trauma centre between January 2012 and December 2017. The centre is in the only maximum medical care hospital in the city that has departments of orthopaedic and trauma surgery and neurosurgery. The inclusion criteria were as follows: one or more injuries in the upper and/or subaxial cervical spine, which were assured via X-ray, computed tomography, or magnetic resonance imaging; a recent trauma; and permanent residency in the city of Bonn. The upper cervical spine was defined as the levels C0–C2 and the subaxial cervical spine was defined as the levels C3 to C7. Patients with residence outside of the city and without an osseous or ligamentous CSI, adequate trauma history, or surgical treatment were excluded. Adequate trauma was defined as follows: (1) a traffic accident with a change of velocity of at least 30 km/h that included motor vehicles, motorcycles, bicycles, scooters, and/or pedestrians; (2) a fall, including falls from a height of at least 1 m and staircase falls; and (3) low-energy trauma with a direct impact to the head, including falls from a height of less than 1 m and sports accidents. Patients with an isolated spinal cord injury but without an osseous or ligamentous injury, pathologic fractures, or osteoporotic insufficiency fractures were also excluded.The regional trauma network included one university hospital, which was a maximum medical care hospital with a Level I trauma centre. The network also included four hospitals with a Level III trauma centre and four hospitals with a Level IV trauma centre. As per regulations within and between the regional trauma networks, patients were transferred to the closest available and most appropriate trauma centre. Besides the hospital included in the present study, the nearest maximum medical care hospitals with Level I trauma centres were at a distance of 30 km, 32 km, 54 km, and 80 km. Due to potential overlap of the rural catchment area, only patients with residency in the city of Bonn were selected and included.p < 0.05.Age, gender, localization of the injury, neurologic deficits, method of admission , length of hospital stay in our institution, and treatment were documented from the patient records. Based on the assumption that all patients with severe CSI, such as those with neurologic deficits or an indication for surgery, presented and were treated at the only available centre in the city, the annual incidence of traumatic CSI with neurologic deficits and those necessitating surgery was calculated using the number of inhabitants of the city of Bonn. Descriptive statistical analysis was performed using SPSS Statistics, Version 25.0 . The level of significance was defined at The study was approved by the local ethics committee of the University Hospital Bonn  and performed in accordance with the ethical standards of the institutional and national research committee and the 1964 Helsinki declaration and its later amendments.Between January 2012 and December 2017, a total of 465 patients with 609 CSI were treated at the university hospital, 130 of whom had permanent residence within the city. Of the 130 patients with a mean age of 67.5 ± 20.4 years, 61 received surgery (46.9%), while 58 received conservative treatment (44.6%) with a cervical collar for an average of 6 weeks, and 11 did not need a specific treatment (8.5%), because their injury had no risk for instability or non-union. The incidence of CSI surgeries was calculated by means of the 61 patients who received surgical treatment.p > 0.05). However, the elderly, especially patients with an age of > 60 years, suffered more often from CSI and had a higher risk for CSI necessitating surgery with patients between 61 and 80 years representing the group at highest risk .Table p > 0.05).On average, 10.2 patients in the city of Bonn suffered from CSI that were treated surgically each year. With an average number of 314,000 citizens, this resulted in an incidence of 3.24/100,000 person years for traumatic CSI receiving surgery. No significant changes in the incidence of CSI surgeries were observed during the study period  as well as that of those who received surgery (68.1 years) were higher than the findings of previous studies, in which the mean age and median were between 54 and 56 years 7.5 years. The higIn the USA, 33.5% of all CSI are treated with surgery, 17.2% of which receive an open stabilisation . In Norwp < 0.05) than their colleagues in the Netherlands who decided upon surgery in only 58.1% [The slightly higher demand for CSI surgeries in the present study as compared to the study in Norway may have been due to a lower threshold for surgery as a treatment for CSI in Germany. An international comparison showed that German spine surgeons chose surgery in 94.2% of CSI patients and significantly more often  identified in the present study, with 12 of the 130 patients suffering from neurologic deficits, the rate could be assumed to be < 9.2%. In 1996, Hu et al. found a rate of 77% for CSI without neurologic deficits , while F0 identifStudies in the USA found a mean length of hospital stay of 8.63 days  and 9.6 This study was the first to calculate the incidence of surgeries as well as neurologic deficits due to CSI in a major German city. The limitations of the study were that only patients with a permanent residence within the city and who were treated in the only available local university hospital were included. Hence, the stated incidence can only be considered an estimation. Patients that only visited the city or worked in the city but had residency outside of the city were not included. Because of overlapping rural catchment areas with neighbouring Level I trauma centres and maximum medical care hospitals, the overall incidence of CSI surgeries in Bonn may have been underestimated. Additionally, injuries that were treated on an outpatient basis or in peripheral hospitals and classified as stable, thereby necessitating no or conservative therapy, could not be detected.Furthermore, patients who died in the preclinical phase due to trauma and therefore never received hospital treatment could not be detected. Post-mortem studies have shown that 21–24% of patients who die at the site of the accident have CSI with spinal cord injuries . In a reBased on calculations in a German city, the annual need for surgeries to treat CSI and the concurrent neurologic deficits were assessed, providing insights into the local supply situation for care research. While both rates showed no significant changes over a six-year study period, the incidence of CSI surgeries as well as the mean age and rate of women was higher in Germany compared to other studies. For long-term demand planning with adaptability to demographic changes, further cross-regional or register studies including long-term follow-up are necessary.


BackgroundLaparoscopic closed cystectomy of the hepatic hydatid cyst (HHC) is increasingly being performed as it has improved postoperative recovery and reduced morbidity. However, laparoscopic closed cystectomy of HHC is difficult when located in segments VI, VII, and VIII. This study aimed to assess the laparoscopic closed cystectomy feasibility of the HHC when cysts are located at the difficult access site.MethodologySeven patients out of 13 patients of HHC treated laparoscopically in the surgery department from 2014 to 2018 were included. These patients had cysts located in segments VI, VII, and VIII of the liver. All patients received perioperative albendazole, underwent ultrasonography (USG) and contrast-enhanced computed tomography for diagnosis. We noted the demographic character of all the patients, cyst’s location, cyst size, type of the cyst, mean operative time, intraoperative and postoperative complications, duration of the hospital stay, and recurrence of the cyst. ResultsAll patients underwent laparoscopic closed cystectomy of HHC. One patient had a conversion to open procedure, and one patient had an additional thoracoscopic approach added. The mean operative time was 191.86 minutes. There were no intraoperative complications. One patient had developed a surgical site infection, and three had a minor bile leak postoperatively. The hospital stay’s mean duration was four days, and there was no recurrence in the 21 months follow-up.ConclusionThe laparoscopic closed cystectomy of HHC located at segments VI, VII, and VIII is feasible, safe, and cost-effective. A thorough preoperative evaluation, preparation, and radiological planning of the procedure should be done. Echinococcus. Hydatid disease is common in Asian countries. Although any part of the body can be affected, the liver is the most frequent organ involved. Symptoms of hepatic hydatid cyst (HHC) develop due to the adjacent structures’ compression, from the cyst’s rupture into the bile duct, pleural space, or peritoneal cavity. Patients may develop jaundice, cholangitis, or septicemia if there is an intraperitoneal rupture [Hydatid disease is caused by the parasite  rupture .Treatment of HHC involves medical, percutaneous, and surgical methods. Surgical treatments can be open methods or minimally invasive procedures. Percutaneous approaches include percutaneous aspiration-injection-reaspiration (PAIR) and its modifications. Surgical excision of the cyst is the definitive management with open surgical techniques in use at various centers. Minimally invasive surgical approaches include laparoscopic approaches. Recently there are many reports published on the laparoscopic management of the HHC. However, there is always the fear of anaphylactic shock due to the cyst contents’ spillage during the procedure . Early rLaparoscopic closed cystectomy of the HHC is a promising approach with minimum morbidity and mortality. However, the anatomical location of the cysts plays a significant role in the laparoscopic treatment of HHC. The lesions located anteriorly, inferiorly, or on the right lateral aspect of the liver and superficial ones are easy to deal with laparoscopically. However, areas such as posterior and posterosuperior aspects of the liver are relatively critical and inaccessible areas, precluding their easy access laparoscopically. According to Couinaud’s liver segments, segments VI, VII, and VIII are challenging to access laparoscopically and often need conversion to open access like laparotomy or even thoraco-laparotomy, which increases morbidity and mortality. Here we present our experience of laparoscopic closed cystectomy of HHC located in the segments VI, VII, and VIII, with possible tips to deal with such cases.A retrospective study included 13 patients of HHC treated laparoscopically in the department of general surgery over five years, from 2014 to 2018. Among them, seven cases of HHC located in segments VI, VII, and VIII were included in the study. All these seven patients underwent laparoscopic closed cystectomy successfully. This study intends to describe the feasibility of these seven patients’ laparoscopic treatments having posteriorly or posterosuperior located HHC. All the patients were symptomatic  of the abdomen. Confirmation of the diagnosis and segmental localization was done using the contrast-enhanced computed tomography (CECT) scan of the abdomen. Preoperatively all patients had received albendazole 15 mg/kg/day for three weeks and continued for one month postoperatively.All the patients were operated on under thoracic epidural and general inhalational anesthesia with endotracheal intubation. The patient’s position was supine with the head high and right side up. The monitor trolley was at the right shoulder. The operating surgeon and the camera assistant were on the left side, whereas the scrub nurse was on the patient’s right side.Pneumoperitoneum was created by an open technique using a 10 mm trocar placed 4 cm to 5 cm above the umbilicus in the midline. Laparoscopy was done to confirm the diagnosis and the position of the cyst. Another 10 mm trocar in the epigastric region 2 cm to 3 cm below xiphisternum, one 10 mm trocar at the right subcostal region in the mid-clavicular line, and one 5 mm trocar in the anterior axillary line were placed. A standard laparoscopy set consisting of a 10 mm 30 degrees telescope and a harmonic scalpel was used in all cases. In all seven cases, the cyst’s location was the posterior and posterosuperior aspect of the right lobe of the liver. The cyst had dense adhesions with the diaphragm. Adhesiolysis was done using bipolar diathermy/ harmonic shear , whereas two were male 20%). Among seven cases, six had solitary cysts, whereas one had multiple (three) cysts. In five patients, a closed cystectomy of a hydatid cyst was performed laparoscopically. One patient required thoracoscopic assistance in addition to laparoscopy. One patient required open conversion as there were multiple cysts, two of which were deep-seated  . HoweverThere exist various minimally invasive procedures like laparoscopy and robotics. Laparoscopy itself has various modifications. The main fear in laparoscopy was the spillage, inadequate clearance, and anaphylaxis. However, it is documented to be safe, feasible, and beneficial ,11. LapaThe main difficulties that arise in the hydatid cyst’s laparoscopic management are accessing the posteriorly located cysts and the evacuation of the particulate contents. There are various methods adopted for the evacuation of the cyst, which include the use of the Palanivelu hydatid system, large transparent beveled cannula, perforator-grinder-aspirator apparatus, liposuction cannula, and perfore-aspirator ,15-17. KVarious reports in the literature suggest that the recurrence rate was 1-22% following open surgery [The laparoscopic closed cystectomy of segments VI, VII, and VIII HHC cyst is feasible, safe, and cost-effective. Thorough preoperative evaluation, preparation, and radiological planning of the procedure should be done. Adequate access with well-positioned ports (with/without thoracoscopy) should be used. Early and wide bore suction decompression of cyst contents should be done. Moreover, finally, experienced laparoscopic surgeons with adequate expertise may be required.


We find that the volume of guest molecules affects the stabilities of large  and small  cages, which are prone to capture C2H6 and CH4, respectively. Mixed double cages  with the mixed guest molecules have the highest stability and fusion energy. The triangular triple cages exhibit superior stability because of the three shared faces, and the triangular mixed triple cages  structure with the mixed guest molecules shows the highest stability and fusion energy in the triple-cage fusion process. These results can provide theoretical insights into the growth mechanism of hydrates with other mono/mixed guest molecules for further development and application of these substances.Owing to a stable and porous cage structure, natural gas hydrates can store abundant methane and serve as a potentially natural gas resource. However, the microscopic mechanism of how hydrate crystalline grows has not been fully explored, especially for the structure containing different guest molecules. Hence, we adopt density functional theory (DFT) to investigate the fusion process of structure I hydrates with CH Due to the wide distribution in permafrost layers and beneath seafloor, this substance has the potential to become an alternative source to fulfill the growing need for nature gas in the global market and solve the energy crisis in the near future ,2,3. Thepressure ,5. Theseolecules ,12,13,14olecules ,16,17, w12) and large cages (51262), play an important role for building double cages and multi-cages. Double cages own three combinations based on two main kinds of mono-cages [4 hydrates, meaning that triangular tri-cages are more stable than linear tri-cages [4, C2H6, and C3H8) [2H6 while sII can only be discovered when the concentration of C2H6 lies in between 2% and 22% [2H6 is essential for the formation of sI hydrates. However, this lacks micro-mechanism study on the stability of sI hydrates with C2H6 and mixed CH4/C2H6 as guest molecules during the nucleation stage. Hence, it is necessary to explore the stabilization and fusion trend of hydrates with CH4/C2H6 guest molecules.It has been revealed that the sI structures growing up gradually from mono-cages to triple cages (tri-cages) is a common process, due to the intermolecular interactions of the cages ,18,19. Mno-cages . Water cri-cages ,22,23,24nd C3H8) . Further and 22% , which i4, pure C2H6, and mixed CH4/C2H6 were selected as guest molecules to explore the fusion process from mono-cages to tri-cages in sI hydrates. We find out that the large cage (51262) is prone to capturing larger volume C2H6 guest molecule based on its suitable pore spaces. Large (51262) and small (512) cages are likely to contain C2H6 and CH4 molecules in the double-cage fusion process, respectively. On the basis of stability energy and fusion energy of double cages, the nucleation process of the double cage is formed by 512 and 51262. The triangular triple-cage structure may be the main form of tri-cages with CH4/C2H6, due to the three sharing faces. The mixed triple cages (tri-LsL) composited by two large cages and one small cage have higher stabilization and fusion energy during the triple-cage fusion process. According to the calculations of related thermodynamic energy, it is obvious that the introduction of an extra 51262 cage help the tri-cage formation based on stable and mixed double cages. The low thermodynamic energy corresponds to stable structure, rendering to search formation mechanism. Consequently, the fusion process from mono-cages to triple cages, following an order of 51262 (L), mixed double cages (Double-Ls), and mixed triple cages (tri-LsL), is thermodynamically favored. The formation micro-mechanism of hydrates with mixed CH4/C2H6 guest molecules is investigated as well, which could provide theoretical guidance for actual hydrate mining.In this study, pure CH−4 and 1.8 × 10−3 bohr in structure optimization, and corresponding root mean square were 3.0 × 10−4 and 1.2 × 10−3 bohr.All calculations were carried out by density functional theory (DFT) with the Gaussian 09 program . The B3Lsta) is applied in this study [sta per H2O molecule (E(sta-p)) is used to compare the relative stabilities of different structures [guest, hydrate are the thermodynamic energy of the single guest molecule, water molecule, and hydrate. The interaction energy (Eint) can reflect the binding strength between guest molecules and water cage structures, which is defined as [water cage represents the energy of water cages without guest molecules. On the other hand, the ability of water cages capturing guest molecules can also incarnate the crystal growth of hydrates. Therefore, the capture energy (Ec) and the capture energy per guest molecules (Ecp) can be expressed as [In order to describe the thermodynamic stabilities of hydrates, the stabilization energy Eint=fusion) was first proposed by Khan [sta(multi-cages), Esta(cage 1) and Esta(cage 2) represent the stabilization energy of multi-cages (double cage or tri-cage), the two parts are divided by multi-cages, respectively. The size of the shared ring is equal to the number of water molecules on the shared face of cage 1 and cage 2. Thus, the more positive Efusion value implies higher stability of multi-cages in the fusion process. On the basis of double-cage fusion, triple-cage fusion was treated as a fusion process of the double cage and mono-cage, which will be further discussed in the results and discussion.To estimate the stabilities of multi-cage structures in the fusion process, the cage fusion energy  takes place. The results are in good consistence with the previous report [int, but the large cage would be the decisive factor for the formation of sI methane hydrate crystals owing to its higher Esta. As for hydrate with C2H6, the large cage is more favored than small cage, referring to both structural and energy factors. The Esta-p of 51262 with C2H6 guest molecule is 53.75 kJ mol−1, which is slightly higher than that of 512 (47.45 kJ mol−1). The 51262 with a Eint of 35.24 kJ mol−1 exhibited a superior interaction between the guest molecule and water cage than the 512 cage (33.76 kJ mol−1). This is most likely due to the large molecular volume of C2H6, which reduces the distance and enhances the interaction between the guest molecule and water cage. On account of these results, a large cage containing a C2H6 guest molecule would play a significant role in the nucleation and growth process of sI hydrate. Hence, regardless of the influence of different guest molecules on the Eint, a large cage is critical for forming the sI hydrate crystal structure. As can be seen from s report , which i12) and large-cage (51262) fusion process: (1) double-small-cage fusion; (2) double-large-cage fusion; (3) mixed-small- and large-cage fusion, which are denoted as Double-s, Double-L, and Double-Ls, respectively. It has been confirmed that if the number of shared rings is greater, the double cages will be more stable [In the growth process of a double-cage hydrate, the cage unit will possibly occur one by one . In addie stable ,20. As ssta-p of the double-cage hydrates with CH4 or C2H6 follow the order of Double-L > Double-Ls > Double-s. Combining with the Esta-p of mono-cages, there is a new sequence for structural stability: Double-L > Double-Ls > 51262 > Double-s > 512, which indicates an advantageous trend for the growth of sI hydrate. What’s more, further evidence shown in 2H6 guest molecule has advantages in stabilizing hydrates. Since two different guest molecules are placed in the double cage, Double-Ls can be divided into two types: Double-Ls-C1C2 (Ls-C1C2) and Double-Ls-C2C1 (Ls-C2C1), in which the large cage contains CH4, small cage contains C2H6 for Ls-C1C2, large cage contains C2H6, and small cage contains CH4 for Ls-C2C1, respectively  is an important parameter for judging hydrate structural stability. The Ec of double cages in 4 while Double-L focuses on C2H6  produced by two single cages fusing into one double cage is summarized in 4 or C2H6), the Double-Ls structure displays a thermodynamic advantage for fusion than the other three double-cage structures. In particular, small and large mono-cages containing CH4 are most likely to fuse together with an Efusion value of 155.81 kJ mol−1.The fusion energy  than that of Ls-C1C2 (150.27 kJ mol−1), indicating that it is more favorable for a large cage to capture C2H6 and a small cage to capture CH4. Compared with single guest component, the Double-s structure with mixed guest molecules CH4/C2H6 shows poor performance in the fusion process, while the Double-L structure exhibits slight superiority. As for the mixed double cage with mixed guest molecules, Double-Ls-C2C1 displays higher potential than others in the double-cage fusion process. The results imply that the mixed double cages exhibit stronger trend than others in the case of fusion. Moreover, Ls-C2C1 has a similar value of Efusion, with Double-Ls containing CH4 as the only guest molecule, which indicates the C2H6 guest molecule has the same potential as a methane hydrate in the double-cage fusion process.Considering the influence of mixed guest molecules, a molecular ratio of CHuest gas . The dou4, C2H6, and CH4/C2H6) on the stability of mixed tri-cages. The formation of sI hydrate follows a continuous fusion process of multi-cages. As Double-Ls have higher stability, the third cage reserves two possibilities in forming a triple cage: small-large-small (tri-sLs) and large-small-large (tri-LsL) triple-cage structures. Different from linear tri-cages with two sharing faces, triangular tri-cages possess more stable structural features with three sharing faces . In this4 as guest molecule) are shown in 4 or C2H6, tri-LsL exhibits superior thermodynamic stability to tri-sLs . As for the tri-LsL structures, tri-LsL-C1C2C1 and tri-LsL-C2C1C2 exhibit the worst and the best performance in stability, respectively, which indicates that the small cage is prone to capturing CH4 and the large cage prefers to contain C2H6.The optimized configuration of tri-cage structures  with CH4 in the small cage and C2H6 in large cages, which indicates that the mono-cage-holding guest molecule with a suitable size is the key factor for multi-cage fusion. The interaction between guest molecules and mono-cages plays a critical role in the process of multi-cage fusion. Hence, the triangular tri-cages with guest molecules fitting into cages with proper sizes have the highest stabilization and fusion energy. As a result, our theoretical study could provide a possible mechanism analysis for the fusion of mono-cages to tri-cages with CH4/C2H6.For tri-cages with mixed guest molecules, the E4 and C2H6 and their combination as the guest molecules, in order to analyze the stability of mono-cages and multi-cages and the fusion trend from mono-cages to tri-cages. We get the following conclusions:In gas hydrates, the guest molecules play an important role in supporting the host water cages. There are complex gas components in the environment where gas hydrates are formed. It is of great significance for exploring hydrate formation mechanisms to analyze the influence of different guest molecules on the fusion process, from mono-cages to tri-cages. In this work, we select CH2H6, the interaction between guest molecules and water cages are further improved. The large cage containing C2H6 is the most stable of the mono-cage structures.(1) Small cages have advantages in structure, while energy is the advantage for large cages. According to these results, large cages play significant roles in the second-step formation of sI hydrate. On the basis of larger volumes of C2H6 makes full use of the interaction between the large cage structure and C2H6, which exhibit the optimal stabilization energy. Double-Ls with mixed guest molecules (Ls-C2C1) has the best performance in multi-cage fusion. (2) As for double cages, the large cage has the advantage in structural stability. Double-L with C(3) For the fusion process of double cages to tri-cages, tri-LsL-C2C1C2 exhibits superior properties both in stabilization and fusion energy. This is in full compliance with the rules, that is, appropriate holes of water cages can hold suitable volume of guest molecules. The tri-cage structures with two large cages and one small cage can adapt to different conditions to achieve structural stability in complex mixed guest molecules.Our theoretical calculation results describe the fusion process of mono-cages to tri-cages with the different guest molecules and analyze the impact of different guest molecules on the stability and fusion trend of hydrate cages. This study provides a theoretical basis for exploring the influence of different guest molecules on the stability of hydrates in practical applications.


The structure, mechanical performance and thermal stability of the film were characterized by SEM, FTIR, TGA and tensile strength tests. The optimized composite film was comprised of KGM 1% (w/v), SL 0.2% (w/v), and ε-PL 0.375% (w/v). The tensile strength  and elongation at break  of the KGM/SL/ε-PL composite film was greatly improved compared with that of KGM. Meanwhile, the thermal stability and antibacterial property of film were also enhanced by the presence of SL and ε-PL. In co-culturation mode, the KGM/SL/ε-PL composite film showed good inhibitory effect on Escherichia coli  and Staphylococcus aureus  by determining the inhibition zone diameter. It was revealed that KGM/SL/ε-PL composite film shows enhanced mechanical strength and reliable antibacterial activities and it could be a potential candidate in the field of food packaging.In order to enforce the mechanical strength and antibacterial ability of biofilm and explore the underlying mechanism, sodium lignosulfonate (SL) and ε-polylysine (ε-PL) were introduced to fabricate the composite film of konjac glucomannan (KGM)/SL/ε-PL in the present study. According to our previous method, 1% ( Konjac glucomannan (KGM) is a natural polymer found in konjac tubers showing unique physical and chemical properties because of its large molecular weight and complex chemical structure . CompareIn this work, SL and ε-PL were introduced to improve mechanical strength, antibacterial ability and thermal properties of the KGM film as showed by performing tensile tests, TGA and antibacterial assessment. The structure of the developed films was evaluated by FTIR and SEM analysis. Lignin, as a rich biomass resource of plants, mainly exists in the cell walls of plants which improve the hardness and strength of plant tissues by virtue of the three-dimensional network structure ,12. LignStaphylococcus aureus and Escherichia coli. ε-PL destroyed the cell membrane structure of microorganisms by interruption of cell material, energy and information transmission, and ultimately leading to cell death [ε-PL is a high molecular peptide with antibacterial effect on common bacteria, such as ll death ,27. Therll death ,29. Escherichia coli and Staphylococcus aureus were evaluated by the Oxford Cup test. The excellent performance of KGM/SL/ε-PL composite film was proved, and it could be a potential candidate for food packaging.In this work, SL and ε-PL were introduced to improve the mechanical strength, antibacterial ability and thermal properties of the KGM film. The structure and performance of the film were characterized by SEM, FTIR, TGA and mechanical performance tests. The underlying mechanism of gel formation among KGM, SL and ε-PL was explored, 2CO3 (AR) were purchased from Sinopharm Chemical Reagent Co., Ltd . Deionized water was used in all experiments. Escherichia coli (ATCC 11775) and Staphylococcus aureus (ATCC 27735) were obtained from the School of Food Science, Fujian Agriculture and Forestry University .Konjac glucomannan  was purchased from Yunnan Zhaotong San’ai Organic Konjac Development Co., Ltd. . Both sodium lignosulfonate (SL) and ε-polylysine (ε-PL) were obtained from Shanghai Aladdin Biochemical Technology Co., Ltd . Glycerin and NaAccording to the procedures of preparing KGM solution in our research group, KGM powder (1.00 g) was dissolved into 100 mL deionized water while mechanically stirred for 1 h to and thoroughly swelled to obtain a KGM control solution ,31. The After the addition of 0.10 g SL powder into 100 mL deionized water, the solution was mechanically stirred for 10 min to obtain 0.1% SL solution. Then 1.00 g KGM powder was added into above 0.1% SL solution and was thoroughly swelled with another 1 h agitation to obtain 0.1% mixed KGM/SL solution. When the serial amounts of SL powder 0.20, 0.30, 0.40, and 0.50 g were added to obtain 0.2, 0.3, 0.4, and 0.5% mixed KGM/SL solutions respectively. The solutions were centrifuged at 3000 rpm for 6 min to degas . Each ceAfter the addition of 0.20 g SL and 0.125 g ε-PL powder into 100 mL deionized water respectively, the solution was mechanically stirred for 10 min to obtain 0.2% SL and 0.125% ε-PL solution. Then 1.00 g KGM powder was added into the above solution and was thoroughly swelled with another 1 h agitation to obtain mixed KGM/SL/ε-PL solution with 0.125% ε-PL. When varied the amount of ε-PL powder was as 0.25, 0.375 and 0.50 g to obtain 0.25, 0.375 and 0.5% mixed KGM/SL/ε-PL solutions, respectively. The solutions were centrifuged at 3000 rpm for 6 min to degas. Each centrifuged solution (30 mL) was poured into a petri dish (Φ 90 mm) which was wrapped by plastic with holes to allow water to evaporate. The mixed solution was dried in an oven (50 °C) to obtain intact  KGM/SL/ε-PL composite films. The mechanical strength of all prepared films was evaluated as the method in 2.5. The composite film of KGM/SL/ε-PL with 0.2% SL and 0.375% ε-PL exhibited the strongest mechanical strength and elongation at break, so 0.2% SL and 0.375% ε-PL were chosen as the optimal amount to be used for the following experiment.Those pieces free of defects (mainly no bubbles) were selected for symmetrical divergence by detecting 5 points . The thickness of the films was measured with a spiral micrometer, and the average (accuracy 0.0001 mm) was recorded. The thickness of the film provides the necessary index basis for the subsequent film strength test. A computer-controlled electronic tensile testing machine  was used to determine its tensile strength (TS) and elongation at break (E). Before testing, the sample film strip was placed in a sealed box with a relative stable humidity (50%) at room temperature (25 °C) for 48 h before testing. The longest distance between the upper and lower clamps was 50 mm, and the speed rate was 0.5 mm/s. All experiments were carried out in triplicate and the results were shown as average value ± SD. The tensile strength (TS) referred to the ratio of the maximum tensile tension (F) that the film could withstand before rupturing under the action of the axial tensile force and the product of the width (L) and thickness (D) of the film. The equation for calculating tensile strength was used as follows (1):Here, TS corresponds to the tensile strength (MPa). F indicates the maximum tension (N) that the sample bears when it breaks. L and D are the width (mm) and the thickness of the sample (mm).The calculation equation of elongation at break refers to (2): Here, EB corresponds to the elongation at break (100%). H and h are the length of the sample film before stretching (mm) and the stretched length of the sample film (mm). Finally, Statistical Product and Service Solutions (SPSS) was used to statistically analyze the significance of the experimental results. Different letters indicate significant differences in data.A field emission scanning electron microscope  was used to observe the microstructure of the film surface. Films were immersed in liquid nitrogen, and they were brittle and easily fractured at extremely low temperatures, and the microstructures of their cross-section were observed. Before the scanning electron microscope test, the films were fixed on the silicon wafer by conductive silica gel. Meanwhile, the surface of the film was gold-plated to make it conductive to obtain clear scanned images.The films prepared above were dried and cut into pieces, and then mixed with potassium bromide, milled and pressed into pieces. The infrared spectrum absorption peak of the films was measured by Fourier infrared spectrometer  ,34,35.The thermal properties of films were tested with a thermogravimetric analyzer  in a nitrogen atmosphere with a flow rate of 25 mL/min. The test temperature increased from 25 °C to 800 °C at a heating rate of 10 °C/min, and the thermal curves were recorded .Escherichia coli (ATCC 11775) and Staphylococcus aureus (ATCC 27735) are representative Gram-negative bacteria and Gram-positive bacteria. These two bacteria were used to evaluate the antibacterial properties of the films. Here, we judge whether the bacterial growth is in the logarithmic phase, which is determined by the bacterial growth curve. Use a 96-well culture plate to grow bacteria and count them. The growth curve is drawn with the culture time as the abscissa and the bacterial count as the ordinate. When the bacteria grow logarithmically, it is the logarithmic phase. Bacteria in the logarithmic phase (200 μL of 1 × 103 CFU/mL) with the best vitality were chosen and cultured in the solid agar medium at 37 °C for 24 h. After the injection of a bacterial solution into the medium, the bacterial solution was homogeneously spread and then dried for use later. The films were placed on a clean bench for UV sterilization for 30 min and then were cut into small discs (Φ 15 mm) with a puncher. The discs were carefully pasted on the surface of the plate culture medium. Three pieces of each medium were attached to reduce the salt error. The plate was placed upside down in an incubator . Then the diameters of the inhibition zone were measured and photographed.w/v) and varied SL amounts . From which, it could be observed that as the concentration of SL increased, the initial tensile strength increased and then decreased. We obtained the optimal concentration of SL. The maximum tensile strength is 108.55 ± 8.50 MPa (SL 0.2%), and the minimum is 38.56 ± 6.18 MPa (SL 1.0%) which might be that SL itself has a certain strength due to its rigid network. However, SL lacks flexibility, so that the concentration is too high and the brittleness becomes remarkable, which leads to a decrease in the elongation at the break of the film. In addition, the phenolic hydroxyl and sulfonic acid groups in SL enhance the hydrogen bonding force within the KGM molecular chains, thereby improving the mechanical strength of the original KGM film. At the same time, the electrostatic interaction between cationic polymer ε-PL and anionic polymer SL also further enhances the force between the components of the composite film. The results also confirmed that KGM/SL films with an SL concentration of 0.2% had better mechanical properties than other films with different SL concentrations.The crosslinking of the polymers of the film is shown in It can be informed from The microstructure of the films was observed by SEM . The sur−1, assigned to the stretching of -OH groups. SL in KGM matrix leads to intensity variation of mentioned bands, which could be ascribed to the interaction between the -OH group on the SL surface and the hydroxyl groups of the KGM matrix. Slight modifications in the intensity of some peaks relating to SL are also visible at 1560 cm−1 (C-C stretching of the aromatic skeleton). In the case of KGM/ε-PL blending film, the two main characteristic peaks related to C-H were shifted towards higher wavenumbers (at 1630 cm−1) due to the interaction between -OH and -NH2 with bending vibration in KGM/ε-PL [−1 conforming to the reference [−1 to a lower frequency range may be due to hydrogen bonds among -OH, -SO3H and -NH2 in the films [−1 and 2874 cm−1 in the KGM infrared spectrum represented the stretching vibration absorption peaks of -CH2- [−1 without obvious change could be assigned as the absorption peak of in-plane bending vibration of the alcoholic hydroxyl group.The chemical structure of KGM and KGM composite films was analyzed by FTIR . The speKGM/ε-PL . The abseference . The shihe films . Accordiof -CH2- . The abs2 of ε-PL and -OH of KGM [The thermal behavior of KGM and KGM composite films was assessed by TGA  at a temH of KGM . The intH of KGM .Escherichia coli and Staphylococcus aureus were evaluated by 24 h co-culturation . Meanwhile, different concentration gradients were used to screen the optimal component of KGM/SL and KGM/ε-PL films. By comparing with KGM, it is found that an appropriate SL concentration can increase the tensile strength and elongation at the break of the film. Moreover, the addition of ε-PL significantly increased the elongation at the break of the film. The screening results show that the optimized ratio of KGM/SL/ε-PL film is: KGM 1%, SL 0.2% and ε-PL 0.375%. Finally, the thermal stability of composite film is improved by introducing SL and ε-PL and has the strongest thermal stability under high-temperature pyrolysis conditions. The addition of ε-PL enabled the film to possess the expected antibacterial properties. It has proved that the composite film can be a good candidate for food packaging. Compared with the one-component pure KGM packaging film, the composite film has significantly enhanced mechanical properties, which helps to enhance the protection and applicability of food packaging. Enhanced thermal stability and antibacterial properties also provide the possibility to improve the durability of composite films in food packaging. At the same time, the use of natural biological materials makes the film more biodegradable, which is conducive to environmental protection and sustainable development and shows potential in the field of food green packaging. In addition, the preparation of composite films can be further improved. For example, enhance the fluidity of KGM to reduce bubbles, thereby improving the uniformity of film formation; further research to improve the air permeability, water solubility and oxidation resistance of the composite film; in-depth study of the mechanism of film polymer molecules to produce stronger mechanical performance biodegradable food packaging film.In this study, the tensile properties, thermal stability, and antibacterial properties of the KGM/SL/ε-PL composite film had been significantly improved by introducing SL and ε-PL. The tensile strength of the composite film is significantly increased to 105.97 ± 4.58 MPa (compared to 49.91 ± 5.88 MPa of the KGM film,


The uptake of the cellulitis management plan was 29.1% (37/127). The appropriateness of antibiotic prescribing for cellulitis at Day 1 was similar at baseline  and in the intention-to-treat post-implementation group  . Commencement of the cellulitis management plan resulted in a non-statistically significant increase in antibiotic appropriateness at Day 1 compared to when a cellulitis management plan was not commenced  Evaluation of more real-world strategies to address evidence–practice gaps, such as the appropriateness of antibiotic prescribing for cellulitis, is required.Despite the availability of evidence-based guidelines, antibiotics for cellulitis remain inappropriately prescribed. This evidence–practice gap is more evident in low-resource settings, such as rural hospitals. This implementation study developed and introduced a cellulitis management plan to improve antibiotic prescribing for cellulitis in three health services in regional Australia. Appropriateness of antibiotic prescribing for cellulitis at Day 1 was the primary outcome measure. Adults with ICD-10-AM codes for lower-limb cellulitis admitted as inpatients of the three health services between May and November 2019 (baseline,  Cellulitis is a common condition that consumes health service resources. A retrospective cohort analysis of US hospital admissions in 2014 reported that 9.8% of over 447,000 cellulitis admissions were associated with non-elective readmission within 30 days at an estimated cost of USD 500 million [p ≤ 0.001) [Inappropriate antibiotic choices for cellulitis are a commonly reported outcome internationally. A recent study of antibiotic prescribing for patients admitted with cellulitis to an Irish district general hospital concluded that there was a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis . A study≤ 0.001) . This is≤ 0.001) .These data highlight the need to improve the implementation of evidence-based recommendations for cellulitis care and to ensure that the strategies adopted are suitable for the regional healthcare setting. This study describes the co-production, implementation, and evaluation of a novel cellulitis bundle and management plan intended to influence antibiotic prescribing practices in three regional health services in Victoria, Australia. There were 165 patients included in the baseline and 127 in the post-implementation audit of antibiotic appropriateness. Reasons for exclusion are shown in The two groups were similar in their demographics and clinical parameters at presentation . While tThe number of eligible patients who had a cellulitis management plan initiated, as evidenced by a scanned copy of the cellulitis management plan in the patients’ medical records, was 29.1% (37/127). Antibiotic appropriateness at day 1, day 3, and discharge was similar in the baseline and post-implementation groups . CommencFlucloxacillin and cefazolin were the two most prescribed antibiotics on Day 1 at baseline and post-implementation. There were fewer orders for piperacillin/tazobactam in the post-implementation group and more orders of benzylpenicillin .There were no statistically significant differences between baseline and post-implementation for the secondary outcome measures , nor between those that had the cellulitis management plan commenced and those that did not . The medThe limb elevation plan was the most completed section of the cellulitis management plan , followed by the antibiotic choice  and location of care . Obesity (10) and the presence of a wound (9) were the most common predisposing factors identified in the cellulitis management plan. There were 15 patients who had no predisposing factors marked.Interviews were completed with two Emergency Department physicians, a pharmacist, a wound-care consultant, and a nurse providing parenteral therapies in the home. Pertinent quotes are listed The challenges in creating a resource that was comprehensive and multidisciplinary were evident in the comments around the bulkiness of the cellulitis management plan. Doctors identified more readily with the earlier sections of the cellulitis management plan that supported diagnosis and antibiotic choice. There were mixed views on who should be responsible for completing the cellulitis management plan. Responsibility was described as often defaulting to nurses in similar initiatives. However, the diagnostic and antibiotic choice components of the cellulitis management plan were thought to align with the scope of practice for a doctor. Pharmacists were identified as another profession with potential scope, but not capacity, to initiate the cellulitis management plan. Other initiatives were described where reduced completion rates of paper forms occurred over time, but practice change was sustained.This study observed that a cellulitis management plan did not improve the appropriateness of antibiotic prescribing for cellulitis at day 1, day 3, or discharge when implemented in three regional health services in Australia. The implementation of a cellulitis pathway to improve antibiotic stewardship has been recommended as a practice improvement strategy . There aThe real-world uptake of the cellulitis management plan (29.1%) fell below expectations, despite positive feedback on its usefulness. A New Zealand study reported that documented evidence of the use of their cellulitis pathway (part or full) was present in just 13% of patients . This hiThere are some limitations to the findings of this study. The COVID-19 pandemic decreased hospital activity, and when combined with the low uptake of the cellulitis management plan, the study was underpowered. The small number of cellulitis admissions at the two smaller health services meant that analysis of the data per health service was not feasible. As this was an observational study, the clinical diagnosis and severity of cellulitis could not be verified retrospectively, and clinical cure of cellulitis was not assessed. Confounding factors included different medical staff in the baseline and post-implementation periods. There is no doubt that this study was implemented in extremely difficult circumstances given the COVID-19 pandemic. Local data suggest a reduction in the utilisation of other established clinical resources, such as sepsis pathways, likely due to a preoccupation with COVID-19 requirements. A different outcome may have been achieved in a different set of circumstances. Antibiotic prescribing behaviours are known to be complex . DespiteThis was a hybrid implementation study intended to test the intervention while also gathering information on its feasibility in a real-world setting .Three Victorian health services located in an Australian Statistical Geography Standard Remoteness Area classification  of innerBundles of care (‘bundles’) are packages of independent evidence-based activities that should be followed for every patient every time . A bundlThe cellulitis management plan was implemented in the three regional health services in February and March 2020. The launch was preceded and accompanied by face-to-face site-specific education sessions for medical, nursing, and allied health staff that explained the various sections of the cellulitis management plan and other communications  coordinated by the site research officers. The primary person responsible for commencing the cellulitis management plan was the admitting medical officer. Completion of the daily review pages was the responsibility of the treating medical team. Completion of the nursing care section  of the daily review pages was the responsibility of the nurse caring for the patient on each shift. Medical, nursing, and allied health staff were requested to provide the patient information leaflet to the patient and discuss the content. In March 2020, the first wave of the COVID-19 pandemic impacted Victorian health services, and all non-critical communications to staff were ceased (including those related to this project). In early October 2020, the cellulitis management plan was relaunched with staff across the three health services through a 4-min educative video and associated prize draw. Embedding was again halted by the second wave of COVID-19 in Victoria. The RE-AIM  framework  was adopPatients presenting to the three health services between 1 May 2019 and 30 November 2019 (baseline) and between 1 March 2020 to 31 October 2020 (post-implementation) who met the inclusion criterion were identified from the Patient Administration System (PAS). The post-implementation data collection was extended compared to the baseline period to try to achieve statistical power given the reduced hospital activity due to the COVID-19 pandemic and low uptake of the cellulitis management plan. The inclusion criterion was adult patients (18 years or over) who were admitted to the hospital  whose episode of care was assigned the ICD-10-AM coding for cellulitis of the lower limb (L03.13 and L03.14). The medical records of all consecutive patients were screened against the exclusion criteria by site research officers. The exclusion criteria included: patients who were not prescribed an antibiotic, intensive care admission during the episode of care, previous admission for cellulitis in the data collection periods, transfer from another hospital, transfer to another hospital, and where review of medical records by the research officers indicated that the condition was not cellulitis.-appropriateness of antibiotic therapy at day 3;-appropriateness of antibiotic therapy upon discharge;-time to first antibiotic dose (TFAD);-duration of antibiotic therapy ; -length of stay;-30-day representation to the same hospital’s Emergency Department with cellulitis;-30-day readmission to the same hospital with cellulitis;-the number of patients who were commenced on a cellulitis management plan; -the fidelity of the cellulitis management plan completion.The primary outcome of this study was the percentage of antibiotic prescriptions assessed as appropriate on day 1 of antibiotic therapy before and after the introduction of the cellulitis management plan. This was chosen as the primary outcome because day 1 is reflective of the initial antibiotic choice and a time point that would capture all patients regardless of their length of stay. Secondary outcome measures determined a priori included:Relevant patient demographics  and representation or readmission information were collected from the PAS. A medical record review confirmed the primary reason for admission or representation. Comorbidities known to be associated with cellulitis  were manAntibiotic prescriptions on the National Inpatient Medication Chart were identified and assessed by the research officers. The name, dose, route, frequency, date/time commenced, and date/time ceased of each antibiotic prescribed for cellulitis were recorded, and duration of therapy was calculated. Day 1 and day 3 of antibiotic therapy were defined as the first and third days that the patient received an antibiotic dose as an inpatient. Any route, dose, or frequency changes of the same antibiotic were considered a new order for the analysis. Single (statim) doses did not contribute to the duration of antibiotic therapy calculations. Copies of discharge prescriptions located in the medical records were accessed and the antibiotic name, dose, and quantity prescribed were recorded.The appropriateness of antibiotic therapy was assessed using the definition from the NAPS . An antiThe time to first antibiotic dose (TFAD) was considered the difference between the triage time at the Emergency Department or Urgent Care Centre and the time that the first antibiotic dose was administered. Reach (uptake) was determined by the number of eligible patients who had a cellulitis management plan initiated as evidenced by a scanned copy of the cellulitis management plan in the patients’ medical records. Fidelity was assessed by viewing the cellulitis management plan in the patients’ medical records and recording which sections were completed as intended.The sample size was calculated based on a dichotomous primary outcome measure with two independent samples (before and after the cellulitis management plan introduction). The following assumptions were applied: α 0.05, β 0.20, baseline rate of inappropriate prescribing of 25% , and 15%t-test (two tailed), Mann–Whitney U, and χ2 tests were used (where appropriate) to compare baseline and post-implementation data, with a p-value less than 0.05 considered statistically significant. For the primary outcome, the full post-implementation sample was compared to the baseline . An analysis of outcomes between those that did and did not commence the cellulitis management plan in the post-implementation period was also undertaken. The Stata statistical package  was used for the analysis.Data from all three sites were pooled for analysis. The data are presented descriptively as mean and range for normally distributed continuous variables  and the number and percentage for categorical variables. Student’s The implementation of the cellulitis management plan was further evaluated through key informant interviews. A pragmatic sample of five health professionals was selected across medical, nursing, and allied health craft groups at site C using only purposive sampling. A larger sample was intended, but health service workforce constraints due to COVID-19 precluded this. Written consent was obtained from all participants. An interview guide with semi-structured interview questions see  was pilo