Background: Bacterial persistence to antibiotics relates to the phenotypic ability to survive lethal concentrations of otherwise bactericidal antibiotics. The quantitative nature of the time–kill assay, which is the sector’s standard for the study of antibiotic bacterial persistence, is an invaluable asset for global, unbiased, and cross-species analyses. Methods: We compiled the results of antibiotic persistence from antibiotic-sensitive bacteria during planktonic growth. The data were extracted from a sample of 187 publications over the last 50 years. The antibiotics used in this compilation were also compared in terms of structural similarity to fluorescent molecules known to accumulate in Escherichia coli. Results: We reviewed in detail data from 54 antibiotics and 36 bacterial species. Persistence varies widely as a function of the type of antibiotic (membrane-active antibiotics admit the fewest), the nature of the growth phase and medium , and the Gram staining of the target organism (persistence is more common in Gram positives). Some antibiotics bear strong structural similarity to fluorophores known to be taken up by E. coli, potentially allowing competitive assays. Some antibiotics also, paradoxically, seem to allow more persisters at higher antibiotic concentrations. Conclusions: We consolidated an actionable knowledge base to support a rational development of antipersister antimicrobials. Persistence is seen as a step on the pathway to antimicrobial resistance, and we found no organisms that failed to exhibit it. Novel antibiotics need to have antipersister activity. Discovery strategies should include persister-specific approaches that could find antibiotics that preferably target the membrane structure and permeability of slow-growing cells. Staphylococcus and Streptococcus spp. after sustained exposure to normally bactericidal concentrations of the recently deployed antibiotic penicillin. They were also able to show that this effective ‘differentiation’ of the cultures into sensitive and resistant cells was purely phenotypic in nature; reinoculation of the survivors showed that they were just as susceptible as they had been in the initial cultures. Bigger  NOT review[ptyp]. The abstracts or titles (if no abstract was available) of a total of 9047 results up to 30 April 2020 were screened for the keywords (in any order): in vitro, persister, bacteria and (proportion or incidence or measure). This was carried out with a grep bash routine in Linux and iterative manual screening of selected papers. At this point, it became apparent that the great majority (over 90%) of publications (dating back to 1946 in PubMed) from the initial search were not relevant to this data compilation. They had vaguely used the terms ‘persistence’ or ‘persister’ for chronic infections and/or to denote certain pharmacokinetic properties of antibiotics and other medications under investigation. Publications on eukaryotic microorganisms (yeasts)  and Arc)  were alA selection of 847 primary publications deemed relevant to the theme of antibiotic bacterial persisters were manually surveyed for quantitative data from work carried out in planktonic cultures. Numerical data were finally extracted from 187 articles ,333,334 https://www.r-project.org/). The hierarchical dendrogram and heatmap of the palette of 47 fluorophores were scripted with R’s dendextend and ggplot’s heatmap.2 packages. The hclust function of dendextend produced hierarchical clusters from a Tanimoto similarity matrix derived as follows: cheminformatic  fingerprints of 47 fluorophores were derived from their InChl notation using the Patterned algorithm within the RDkit (www.rdkit.org/) nodes in KNIME (http://knime.org/) [Plotting and statistical analyses were carried out using R (me.org/) ,335; a TThe fitting of the time–kill data was carried out as implemented in R’s ggplot loess  method. Local fitting uses the distance of data in the neighborhood of each dependent variable (time) to weight the least squares of the independent variable (count of cells of persisters after each time point of incubation). The size of the neighborhood is controlled by the ggplot’s span parameter in geom_smooth or stat_smooth. The default span applied here uses tricubic weighting ^3)^3) .E. faecium leading the table of antibiotic persisters. The most tested antibiotics  had similar persister levels of 0.12–0.16%. Lipopeptides (membrane-active compounds) were similarly represented but with half the levels of persisters, 0.05%. Two of the fluoroquinolones (ciprofloxacin and ofloxacin) and gentamicin exemplified here the Eagle effect, where higher concentrations of antibiotic can be less cytotoxic. This serves as a reminder of the need for optimization of bacteria–antibiotic concentration combinations before the surviving cells from time–kill assays can be interpreted as persisters. The cell wall of Gram-positive bacteria seems to give them an advantage point to tolerate bactericidal concentrations of antibiotics. Since most antibiotics are bactericidal against rapidly growing bacteria, not against slow-growing organisms, the activity seen by lipopeptides producing low levels of persister cells is encouraging. To this extent, we point at the strategy offered by fluorescence-based screening with a validated palette of fluorophores known to be accumulated in E. coli. The need for discovery platforms for antipersister antimicrobials cannot be overstated [Bacteria can tolerate lethal concentrations of antibiotics with cells that are slow growers in an otherwise rapidly proliferating population. Deploying different mechanisms, bacteria undergoing growth-limiting conditions can also survive—in higher proportions (30-fold difference)—the presence of antibiotics. Species represented here are those clinically considered of high priority, usually those with a high incidence of antibiotic resistance , with erstated ,23,337.


Rapid antigen test (RAT) is a practical test to detect the presence of Group A beta hemolytic streptococcus antigens in throat swab samples. The aim of this study is to investigate the changes in the empiric antibiotic prescribing behavior of 10 family physicians in Kırıkkale Province after using RAT in 2017.  RAT test practice started in Family Medicine in February 2017. Family Medicine Information System (FMIS) includes clinical and prescription records of 10 family physicians, providing health service to approximately 35,000 residents in Kırıkkale. The numbers of antibiotics prescribed by the physicians according to the ICD-10 codes (including upper respiratory tract infections) in February, March, and April of 2015, 2016, 2017 were determined. The number and group of antibiotics prescribed by the family physicians with the determined diagnosis and time periods were specified in the FMIS and recorded. Antibiotic prescription behaviors of family physicians do not show a significant difference between 2015 and 2016. There was a dramatic and significant decrease in the number of prescribed antibiotics in 2017 compared to 2015 and 2016 (P < 0.05). This study shows that there has been a significant decrease in antibiotic prescription in 10 Family Medicine departments in 2017 in comparison to February, March, and April 2015 and 2016. The use of RAT resulted in a decrease in antibiotic prescription rates in 2017. In recent years, the maximum utility of drugs in medicine and minimization of its problems that may occur is an important issue on the agenda. The World Health Organization described rational drug use (RDU) in 1985. RDU is a set of rules that require the drugs to be taken at the most cost-effective way to meet the needs of the patient and the society at the appropriate time in accordance with the clinical needs. In order to eliminate the problems that arise due to the use of drugs, RDU should become widespread. All health workers, drug-related units, and citizens, especially physicians, have a significant responsibility [1]. The selection of appropriate medicine according to the diagnosis of the patient, prescription, follow-up of the treatment, informing the patient, training the medical staff have a key role for physicians on account of RDU. The physicians working in primary health care institutions have a special position and role in the implementation of RDU. Physicians, especially for antibiotics, should prevent excessive and incorrect medicine usage, economic losses, and adverse effects, and more importantly, for the reduction of antimicrobial resistance, should establish a correct diagnosis with the approaches in the context of RDU [2]. One of the microorganisms that cause disease in the upper respiratory tract is group A beta hemolytic streptococci (GAS). This bacterium is the cause of acute tonsillopharyngitis. Because of the large number of microorganisms that form acute tonsillopharyngitis , this group of disease is the most common antibiotic prescribed misdiagnosis group. Rapid diagnosis and treatment are important in bacterial tonsillopharyngitis because of the possibility to cause complications in the course of the disease, especially in primary care . Rapid antigen test (RAT) is used to diagnose GAS infections, which are among the agents of acute tonsillopharyngitis and cause serious side effects and complications [5]. In addition, antigen tests have been developed (such as influenza A and streptococcus pneumoniae) in order to enable rapid and accurate diagnosis against some microorganisms . RAT is a practical test for detecting the presence of GAS antigen. Its sensitivity is partly low, but its specificity is very high. For clinical symptoms and infection, the positivity of RAT used to diagnose GAS is suitable for antibiotic prescription [8]. Antibiotics are among the most widely used drugs in Turkey, as in many countries. GAS should be treated with the appropriate antibiotic and dosage in the context of RDU since the irrational use of antibiotics result in the development of rapid resistance and leads to increase in complications and prolonged disease process .The aim of this study is to compare the pharmacological data of 2017 with 2015 and 2016. In fact, Ministry of Health enacted the obligation of RAT procedure in 2017.This is a retrospective study of pediatric and adult patients admitted to outpatient clinics of ten family medicine units in which approximately 35,000 patients are registered in Kırıkkale Province. Our study was approved by Ankara Yıldırım Beyazıt University Yenimahalle Training and Research Hospital Clinical Research Ethics Committee (No: 2017/04). RAT application to avoid unnecessary use of antibiotics and to provide pharmacoeconomic efficiency started in family medicine units in February 2017 in Turkey. Therefore, Provincial Public Health Directorates distributed RATs to family physicians after giving RAT practice and evaluation training, in January 2017. When the use of RAT is required, the RAT outcome is entered into the Family Medicine Information System. If the result is positive, an antibiotic prescription is appropriate. If the result is negative, prescribing antibiotics is not suggested. The lists of patients who were diagnosed with International Classification of Diseases-10 (ICD-10 code) were accessed by entering the Family Medicine Information System (FMIS) from physicians’ computers in ten family medicine departments. The antibiotic names on the prescription pages of patients were found and noted in February, March, and April in 2015, 2016, and 2017. For 2017, both RAT-positive (+) and RAT-negative (–) results were recorded together with prescribed antibiotics. The age and sex of patients were also recorded.RAT is the detection of carbohydrate antigen in the cell wall by using the enzyme immunoassay method. RAT has started to be used to make empirical antibiotic prescriptions suitable for rational medicine usage and pharmacoeconomically efficient. Primarily, the Ministry of Health trained the family physicians about the application and interpretation of the test. These tests were TOYO-brand in vitro diagnostic tests for the detection of group A beta-hemolytic streptococci (GAS). The regulation of FMIS, which is used by every physician, including the appropriate diagnostic criteria, was arranged simultaneously with the distribution of RAT kits to family physicians. Since the probability of GAS in the 0–3 age group was 0–6%, RAT was not required under 3 years of age. After the examination of the patients who were thought to be related to one of the diagnoses in the ICD-10 codes [11] (Table 1) determined by the Ministry of Health, they were allowed to see the table which was compatible with the modified Centor criteria [12] (Table 2) when the family physicians entered the FMIS together with the ICD code. When upper respiratory tract infections such as acute pharyngitis, acute tonsillitis, and acute tonsillopharyngitis are considered prediagnoses, five parameters in Table 2 are seen when entering into the system with one of this prediagnosis. In the presence of at least two of these parameters, the system warns the physician that the use of RAT is appropriate. Symptomatic treatment is prescribed when the score is 0–1. If the score is 2–3, RAT is applied. RAT (+) is directed to prescribing antibiotics while for RAT (–), symptomatic treatment is suggested. When the score is 4 and above, the system allows for empirical antibiotic prescription. If RAT is (+) and clinical symptoms are favorable to infection, the system allows use antibiotics according to age group. Swallow and throat swab samples were taken from posterior pharynx and tonsils of patients. The tongue should be pressed with abeslang so that the sample is not mixed with saliva. The test was used as indicated by the company. If clinic symptoms are present but the test is negative, throat culture can be taken in children and adolescents. The advantage of the test is that it takes 5 to 10 min to reach the result. It is a test with a specificity of 95% and sensitivity of 70–90%. Descriptive statistics for the obtained data were calculated as numbers and percent frequencies. Differences between years, months, age groups, sexes, antibiotics, and physicians were examined with the Poisson regression model. In statistical evaluations, when P-value was <0.05, the result was accepted significant. SPSS (v. 18) Software was used in the calculations.The differences according to years, months, and sex were investigated for the prescription rates containing antibiotics. There was no significant difference between the months of 2015 and 2016 when family physicians did not use RAT in antibiotic prescriptions. There was a significant difference between the 2015 and 2017 (P < 0.001), and 2016 and 2017 (P < 0.001) in February, March, and April . There was no significant difference in terms of the antibiotic ratios prescribed in 2015, 2016, and 2017 when men and women were compared. The prescribed antibiotic rates did not show a significant change according to sex. Differences between years were evaluated separately in both sexes; the difference between 2015 and 2017 (P < 0.001), and 2016 and 2017 (P < 0.001) were found statistically significant in both women and men. According to these results, it can be said that antibiotic prescription in both women and men in 2017 has decreased considerably when compared to 2015 and 2016. Differences between years were examined in terms of the antibiotic rate prescribed in 0–5, 6–10, 11–15, 16–45, and <45 age groups. According to these results, there was a statistically significant difference in all age groups in 2017 (P < 0.01) . There was no significant difference between 2015 and 2016. The difference between the prescription rate of amoxicillin-clavulanic acid and third-generation cephalosporin (3GC) in 2015 and 2016 and the prescription rate of 2017 was statistically significant (P < 0.05) . The difference between the prescription rate of Azithromycin and Penicillin in 2015 and 2016 and the prescription rate of 2017 was statistically significant (P < 0.01) . The difference between 2015 and 2016 was not significant for amoxicillin-clavulanic acid, 3GC, azithromycin, or penicillin. The difference between the prescription rate of amoxicillin, second-generation cephalosporin, or clarithromycin was not statistically significant. There was a decrease in the rate of antibiotics prescribed, which is not statistically significant, in 2017 from February to April. The amount of RAT (–) is higher than RAT (+), and antibiotics prescribed are more than the sum of them . Antibiotic prescribing rate and RAT results are not different between the months over the year.As in many countries, unnecessary or improper drug usage in Turkey is very high due to nonprescribed drug usage and unnecessary prescriptions. Despite all the studies on RDU, there are several important problems such as increased toxic effects of the drugs, drug resistance, treatment failures due to serious adverse effects, and accrued costs. Especially the irrational use of antibiotics is important because it is an obstacle for the treatment of infections and they are used widely. One of the studies on the rational use of antibiotics is to establish a diagnosis for patients with certain diagnostic criteria in upper respiratory tract infections (URI) by using RAT and prescribing antibiotics if they are necessary. The Ministry of Health provided training for RAT use to primary care physicians in January 2017. Then in February 2017, RAT was performed in the patient groups which were selected according to the modified Centor criteria. In this study, RAT applications were evaluated in 10 family medicine units, which are considered to be a sample of many sections of the society such as city center, town, hospital, or remote area and slum area in order to provide homogenization for the population of 35,000 patients in Kırıkkale Province. The changes in the total antibiotic prescribing numbers of the family physicians, who participated in the study in the months of February, March, April 2015 and 2016 were examined. The effect of using RAT in Spain between January and May was examined in 543 patients aged 14 or older with clinical findings of acute pharyngitis and who were evaluated according to the Centor scoring. There was a significant difference in prescribing antibiotics between the control (281 patients) and study (262 patients) groups; it was 60% in the control group without RAT and reduced to 26.9% in the study group that applied RAT [13]. Madurell et al. [14] showed that for the 276 adult patients with acute pharyngitis who participated in the study, the antibiotic prescription ratio was 85% in the control group, while it was 75% in the study group. The use of RAT was also investigated in terms of complications, antibiotic replacement, and patient satisfaction. It was reported that the side effects, complications, and antibiotic resistance which may develop due to antibiotic use can be prevented by increasing the patient satisfaction, then a decrease in antibiotic prescription can be ensured [15–17]. The selection of family physicians from different residential areas has enabled the provision of homogenization for parameters like the number of patients admitted to the clinic, easy or difficult access to the treatment, expectation levels from the physician . Thus, different socio-cultural and socio-economic patient populations in the same province were included in this study. As the main purpose of the study was to reach the number of antibiotics prescribed, patients were taken into consideration in the same period of disease, with similar diagnosis, short term (1–3 days) of other antibiotics, and the number of antibiotics in this prescription. Efficacy and treatment time were not considered.When the suitability of the indications for drugs prescribed worldwide is examined, it is stated that the rate of antibiotics prescribed based on the RDU principles is significantly low. Diagnosis with acute tonsillopharyngitis is also present among the prescriptions that contain the most problems [20]. In our study, the aim of selecting a topic for patients with URIs is that both the excess of the unnecessary antibiotic prescribing, as well as the fact that a test entity (RAT) that verifies the diagnosis may have an effect on the outcome.It has been mentioned that pharyngitis or tonsillopharyngitis caused by GAS in humans may cause some undesirable conditions when not treated. Although throat culture is considered to be the de gold standard for GAS detection, the result can be reached at the earliest after 24 h. Especially in family medicine policlinics where policlinic services are in a large number, RAT, which is a practical and reliable test, accelerates the diagnosis, provides a great ease by giving results in 5 min [21]. In order to compare the results of throat culture with RAT, throat culture was also requested. Throat culture sampling and evaluation process, which was planned to control the reliability of RAT, was not fully practicable in intensive outpatient settings. While RAT is negative, the result is completely negative in a certain number of patients whose throat culture was requested. This has been evaluated as a result that supports the reliability of RAT. It has been reported that 505 pediatric patients presenting with the complaint of URI; 86% were RAT-negative, 14% were RAT-positive, 84% throat culture-negative and 16% were positive for throat culture. The number of patients who were evaluated as both culture and RAT negative was 84% and the number of patients evaluated as culture and RAT positive was 13%. The number of patients with culture and RAT inconsistency was 3% [22]. Despite the decrease in the number of prescribed antibiotics in 2017 compared to 2015 and 2016, the number of antibiotics prescribed leads to a difference in the number of RAT positive and RAT negative patients, because it is predicted that the antibiotic can be empirically written to the system according to the Modified Centor Score. However, the use of the mentioned scoring method provided a substantial decrease in antibiotic prescriptions compared to 2015 and 2016. It was observed that the trainings for the drug prescribing procedures for physicians as part of RDU in recent years can make a positive impact on the results [23]. Studies on public awareness show that the number of patients demanding antibiotics from physicians reduced. The contribution of education to the whole society, especially to physicians, is evident in this study. Not only the rational use of antibiotics, but also the rational use approach in all other drug groups can be increased by the training of physicians and society [24–26].Feedback from physicians suggests that RAT positively affected the diagnosis of GAS, antibiotic prescribing, and more self-confident behavior in the face of the patient in the case of URIs. The use of RAT in fast and reliable detection of other microorganisms, not only GAS, will support this condition. It has been determined that the results of the use of RAT for Haemophilus Influenzae in Korea in 2011–2012 are similar to those of RAT for GAS [27]. The physicians who participated in our study also agreed that the continuity of RAT applications during the outpatient clinic would be positive for the future. RAT-negative results were higher in 2017 than RAT-positive. This result shows that the decrease in antibiotic prescription in 2017 may be related to the use of RAT. Increased use of RAT indicates that antibiotic prescribing may be further reduced.While developing strategies for health systems, it is important to use the capital allocated to health in a rational way by taking into consideration the increase in treatment options, population growth, and technological developments. When allocating budget for health expenditures, the economic impacts of treatment should be taken into consideration as well as efficiency and safety assessments. Unconsciousness in the use of antibiotics in Turkey is an important problem. This is a burden on health expenditures and is a major problem in the underdeveloped countries, but it also poses a problem in developed countries . Our study reveals the importance of both the use of RAT and the training of physicians and community in the scope of RDU in terms of antibiotic prescribing.To counclude, in our study, there was no significant difference in the number of antibiotic prescriptions in the URIs group between 2015 and 2016, whereas the year 2017 when rapid antigen test (RAT) was used was significantly different. Extending the use of RAT not only for group a streptococcus (GAS) but also for other microorganisms will be important for use as a practical, rapid, and reliable diagnostic method in centers providing intense polyclinic services. More simple methods providing treatment options in a shorter time, which may have better results in terms of sensitivity and specificity in GAS tonsillopharyngitis, should continue to be investigated. The development of advanced diagnostic methods for the differentiation of acute GAS infection from chronic carriage will contribute to the rational use of antibiotics and will provide benefits to the national economy in terms of pharmacoeconomic aspects.


Acoustic emission (AE) has been used extensively for structural health monitoring based on the stress waves generated due to evolution of cracks in concrete structures. A major concern while using AE features is that each of them responds differently to the fractures in concrete structures. To tackle this problem, Mahalanobis—Taguchi system (MTS) is utilized, which fuses the AE feature space to provide comprehensive and reliable degradation indicator with a feature selection method to determine useful features. Further, majority of the existing investigations gave little attention to naturally occurring cracks, which are actually more difficult to detect. In this study, a novel degradation indicator (DI) based on AE features and MTS is proposed to indicate the performance degradation in reinforced concrete beams. The experimental results confirm that the MTS can successfully distinguish between healthy and faulty conditions. To alleviate the noise from the DI obtained through MTS, a noise-removal strategy based on Chebyshev inequality is suggested. The results show that the proposed DI based on AE features and MTS is capable of detecting early stage cracks as well as development of damage in concrete beams. Concrete beams are widely used in construction of buildings, dams, and bridges. Heavy load, aging, disasters like earthquake can cause severe damage to beam in concrete structures. It is crucial to assess the performance deterioration in concrete structures for preventing economic losses and ensuring safe operations. The detection of the fractures is important to examine the damage in concrete structures. This is usually managed through regular visual inspections that is very difficult to perform because of the inaccessible locations where the fractures have taken place. To overcome this problem, many sophisticated monitoring methods have been considered that use direct or indirect measurements from various sensors for diagnosing fractures in concrete structures ,2. TheseThe previous researches exploited numerous features such as rise time, decay time, amplitude, energy, ringing counts, RA and AF, etc. for detecting and classifying fractures in concrete structures. Among these features, it is difficult to exactly define features having greater sensitivity to the crack growth. It may happen that certain features are capable of detecting fractures but fail to recognize incipient cracks. Similarly, features sensitive to incipient cracks might not be effective in predicting crack severity (fractures) during final failure stages. It is further emphasized that not only the diagnosis of early stage cracks but the assessment of degradation in concrete structures over their full lifetime is also important to prevent catastrophic failures.In many cases, machine learning-based classification algorithms necessitate prior knowledge of failure data in order to implement condition monitoring of concrete structures. In real-life scenarios, there is limited access to such datasets which leads to construction of inefficient degradation assessment models.The existing AE features exhibit irregular fluctuations, which make it difficult to determine the time-instants of initial crack occurrence precisely. Further, these features may show nonmonotonic behavior with the increase in degradation severity. This can create false alerts resulting in wrong maintenance decisions.AE is a feasible tool for data-driven real-time monitoring of concrete structures. Waves involved in AE are related to source mechanism that helps to identify the crack from sensor responses. AE is different from other NDT techniques for two reasons. The first is its unique ability to detect the dynamic processes such as crack propagation and debonding in materials associated with the performance degradation of the structures. The second is that the AE signals of the concrete beams under heavy load can effectively characterize and identify cracks in structures. Generally, the AE signals are classified into two types considering the shapes of the waveforms : (1) BurA novel DI showing the time history of the performance degradation of concrete beams is proposed. The DI allows us to observe the development of concrete degradation, beginning from the crack formation till absolute failure of the beams. The DI encompasses wide range of AE features merged by MTS classifier for reflecting the concrete health condition based on the time history of flexural bending test conducted on it. The DI does not require any prior knowledge of failure data for the purpose of degradation assessment.A noise-removal (NR) strategy based on Chebyshev inequality is suggested to process the MD in order to obtain smooth and monotonic DI that tends to increase with the growth in degradation severity.Thus, it becomes a prerequisite to develop an inclusive degradation indicator (DI) that combines the diagnosis capabilities of individual features and contains less noise. A lot of previous works have considered AE features extracted through the flexural test conducted on concrete beams. Most of these works focus on fault classification (minor/intermediate/severe), crack classification (tensile/shear), fracture identification, analyzing load against AE history, etc. Existing literature lacks in building a solid DI for the degradation assessment of the concrete beams over time. To fill this gap and tackle the above challenges, in this paper, Mahalanobis–Taguchi system (MTS) is utilized to fuse the useful AE features and develop the DI . MTS is The remainder of this paper is organized as follows. In Carpinteri et al.  presenteKhatir et al. proposed a method for crack detection by improving the training process of artificial neural network (ANN) parameters by adopting Jaya algorithm . ResultsEbrahimkhanlou et al.  have useAE signals obtained from the concrete structures have special parameters/features that can describe AE events. The AE features considered in this paper are the ones used to characterize AE bursts. Features we have considered are peak amplitude, rise time, decay time, AE counts, and AE energy. These parameters will be collectively referred as AEB features in our study. The AEB features are considered to be good measures for detecting cracks and possess good relation to the concrete structural health condition. Peak amplitude: The voltage that is measured as the highest one in AE waveform is regarded as the peak amplitude.Rise time: It is defined as the time interval between the triggering time and the peak of the AE signal.Decay time: Decay time is opposite to rise time. It is defined as the time when the amplitude decreases from the peak value to the lowest within the set threshold.Counts: AE count is the number of times when the signal crosses the threshold. This feature is also used to measure the strength of the hits and AE activity.Energy: Finally, AE energy is the area measured within the rectified signal envelope.uth observation of the vth reference, m presents the total number of observations, and the total number of features are denoted by n. By definition, it is necessary for every single variable to contribute equally to find out MD. Therefore, the observations in F has to be normalized. It can be normalized using the following equation:σ is the standard deviation. σ can be calculated as:a is the number of healthy observations in the dataset. Finally, MD is calculated using the following equation considering the normalized test feature:C is the correlation matrix for the feature we normalize. One critical issue that arises while calculating MDs is multicollinearity. It occurs if there are profound correlations among the features. It leads to an approximate singular correlation matrix that imposes difficulty to compute MDs. We have used Gram–Schmidt orthogonalization process (GSP) [The first step to implement MTS is to calculate the MDs of the normal observations. In order to do this, features that denote normal condition are defined first. After that, data of all the features presenting normal condition are collected. MDs of all the normal observations are calculated next. Let as assume the constructed feature set be:ss (GSP) ,50,51 toLet us assume j refers to a particular feature we are interested in, we can write: kth observation of the jth feature can be calculated using the following equation:jth feature.Assuming that In the second step, MS is used to calculate the MDs of the abnormal group. MS can be denoted as the zero-point, unit distance and is used as the reference point for the measurement scale. For our implementation, abnormal group consists of feature points associated with the crack formation in the concrete beam. Features extracted from the abnormal condition should also be normalized. They are normalized adopting the mean and standard deviation of the corresponding features in the normal group. The correlation matrix that corresponds to the normal group is used to calculate the MDs of the abnormal condition. MDs of the abnormal condition are supposed to have higher values and a sharp rise in the time-history plot can be observed.m is the number of the abnormal conditions and tMD is the MD of the tth abnormal condition.The third step involves finding out useful features to feed the system. As mentioned earlier, MD itself is enough to build time-history trend for faulty conditions. The problem is that we cannot assure features that we have used, if all of them are useful. Using too many features some of which are not even worth using can make the computation process slower. Therefore, Taguchi method is used to select the useful features for calculating MDs. Useful features are sorted out using OAs and SNRs. In MTS, useful feature determination is performed using a two-level OA. Level one includes the feature we are dealing with, whereas level two excludes the feature we are interested in. SNRs calculated from the abnormal conditions are used as response column for every single combination of OA. Usually, larger-the-better type SNR is used to sort out useful features. It is calculated using the following equation:We have to calculate the effective gain of each feature after computing the SNR. If the gain we calculate is positive, we consider the feature for our system. Otherwise, we exclude the feature while calculating the degradation indicator associated with our concrete crack detection. As the feature points of the increasing timeline would eventually correspond to the abnormal data, we will figure out the potted line is sharply rising giving us insight that crack formation has taken place.The proposed methodology can be divided into two main steps. The first one is the acquisition of raw AE data mining the degradation in concrete. For this purpose, an experimental setup was developed to conduct three-point bending test on concrete beams in the presence of an external load. The second one is building an effective DI by utilizing AEB features and MTS classifier that will help us to assess the performance degradation in concrete beams. These steps have been described into the upcoming sections.The test bed was developed in our laboratory for acquiring AE data. Usually, flexural test is used to evaluate the tensile strength of concrete beam and measure its ability to endure failure caused due to bending. This test is carried out using either three-point bending or center-point bending. Three-point bending is implemented in such a way that half of the total load is applied at every one-third of the concrete beam span length. Thus, the concrete beam experiences maximum stress over its central one-third portion. On the contrary, in center point bending, the entire load is applied at the center of the concrete beam. According to American Society for Testing and Materials (ASTM), the length of the concrete beam should be at least three times greater than its depth . In presAfter the load was applied gradually, cracks were formed in the concrete specimen. The data of the applied load and corresponding displacement was carefully recorded. This helps to validate the output results by comparing the load and displacement curves with the AE features acquired during the failure history of concrete specimen. Step 1.The AE signals were collected in real time from the experimental setup designed for implementing three-point bending tests on the reinforced concrete beam.Step 2.The AEB features discussed in Step 3.MDs of the normal observations were calculated. For this, features that denote normal condition were defined first. After that, data of all the features presenting normal condition were collected. MDs of all the normal observations were calculated next.Step 4.MS was used to calculate the MDs of the abnormal group. For our implementation, abnormal group consisted of feature points associated with the fracture formation in the concrete beam. Features extracted from the abnormal condition were normalized. They were normalized adopting the mean and standard deviation of the corresponding features in the normal group. The correlation matrix that corresponded to the normal group was used to calculate the MDs of the abnormal condition.Step 5.Taguchi method was used to select the useful features for calculating the MDs for the final plot. Useful features were sorted out using OAs and SNRs. The SNRs obtained from the abnormal MDs representing fractures in the concrete were used as the response column for each combination of OA.Step 6.The MD was processed using the NR strategy to remove noise and obtain a monotonic DI. The suggested NR strategy was implemented as follows:N denotes the MD values estimated for normal or healthy conditions, nμ and nσ denote the mean and standard deviation, respectively, of dataset N, and P denotes the probability of the elements in data N deviating nε away from the mean nμ. Let us assume that the threshold set for incipient crack detection is nμ + nε where nε = 3nσ, then the Chebyshev inequality states that no more than 89% (=1 − 1/32) of the values in N are more than 3 standard deviations away from the mean value. Thus, an accuracy of 89% can be achieved in discriminating the faulty MD values from the healthy ones.First, the NR approach utilizes Chebyshev inequality to define threshold limits for declaring the beginning of degradation in concrete beams. Mathematically, the Chebyshev inequality is given as iMD, Second, the MD values below the threshold are set to zero and the MD deviations above the threshold are added successively over time to form the desired DI. Let The proposed DI for performance degradation assessment of concrete structures was constructed into the following steps:The analyses in this paper were carried out using the MATLAB software. The proposed technique discussed in A plot of the MTS for the concrete’s failure history is presented in The paper proposes an approach combining AEB features and MTS to build a novel DI for assessing performance degradation of concrete beams. First, the raw AE signals are acquired from the test bed where the concrete beam is subjected to a three-point bending test. Second, five features, namely, peak amplitude, rise time, decay time, AE counts, and AE energy are extracted to form the feature space. These features are supplied to the MD classifier which distinguishes the damage conditions from the healthy ones. Third, the usefulness of the extracted features is determined through Taguchi’s robust engineering method using OAs and SNR. The SNRs obtained from the abnormal MDs representing fractures in the concrete beam are used as the response for each combination of OA. Rise time, decay time, and AE counts are selected in the process as better features due to their positive gain. Finally, MDs are calculated with the sorted-out features and the final MD plot is filtered to remove noise and build a reliable DI for the concrete beam. The new DI can effectively trend the degradation in concrete beam over its time history. The DI could successfully highlight the time when the premature cracks occur and also, the time when failure took place. The proposed method is industry friendly in the sense that it depends only on the healthy data and does not require any previous information of the failure data. Our upcoming work will be to use hybrid feature space and machine learning algorithms, both supervised and unsupervised, for crack detection and crack type classification in real concrete structures.


Consequently, inaccurate diagnostics affect treatment choice, preventing bacterial clearance and potentially selecting for antibiotic resistance. This leads to prolonged, ineffective treatment.Bacterial biofilms are known to have high antibiotic tolerance which directly affects clearance of bacterial infections in people with cystic fibrosis (CF). Current antibiotic susceptibility testing methods are either based on planktonic cells or do not reflect the complexity of biofilms ex vivo lung biofilm model to study antibiotic tolerance and virulence of Pseudomonas aeruginosa. Sections of pig bronchiole were dissected, prepared and infected with clinical isolates of P. aeruginosa and incubated in artificial sputum media to form biofilms, as previously described. Then, lung-associated biofilms were challenged with antibiotics, at therapeutically relevant concentrations, before their bacterial load and virulence were quantified and detected, respectively.In this study, we use an The results demonstrated minimal effect on the bacterial load with therapeutically relevant concentrations of ciprofloxacin and meropenem, with the latter causing an increased production of proteases and pyocyanin. A combination of meropenem and tobramycin did not show any additional decrease in bacterial load but demonstrated a slight decrease in total proteases and pyocyanin production.P. aeruginosa showed high levels of antibiotic tolerance, with minimal effect on bacterial load and increased proteases production, which could negatively affect lung function. Thus, the ex vivo lung model has the potential to be effectively used in larger studies of antibiotic tolerance in in vivo-like biofilms, and show how sub optimal antibiotic treatment of biofilms may potentially contribute to exacerbations and eventual lung failure. We demonstrate a realistic model for understanding antibiotic resistance and tolerance in biofilms clinically and for molecules screening in anti-biofilm drug development.In this initial study of six clinical isolates of  CFTR) gene, which encodes a chloride channel (Cystic fibrosis (CF) is a genetic disease in which people have decreased mucociliary clearance in the respiratory tract, due to mutations in the cystic fibrosis transmembrane conductance regulator  methods, despite these being based on planktonic cells . The curractions . All theractions . Also, tfections , and mayex vivo pig lung biofilm model (EVPL)  or sensitive (meropenem) by standard planktonic MIC testing. Tobramycin was chosen as it is clinically combined with meropenem. The results demonstrated an increased antibiotic tolerance in the EVPL model at concentrations >25-fold the reported sputum concentrations when tested in Mueller-Hinton broth, which even further increased when tested in artificial sputum media. We also investigated the effect of exposure to antibiotics on bacterial virulence. Exposure to antibiotics showed an increased production of total proteases, which may have a role in lung damage. Normalized proteases/cfu and pyocyanin/cfu demonstrated an increased production of these virulence factors per cell. Current clinical prognosis in CF is alarming and creates an urgent need to develop effective anti-biofilm agents. Thus, we propose a unique approach to predict the true clinical effect of antibiotic treatments on bacterial clearance and associated virulence factors in CF using the EVPL model.In this study, we employed a previously developed l (EVPL)  for antiPseudomonas aeruginosa isolates were used in this study, selected from a set of 44 isolates from a single sputum sample as they showed a range of phenotypes in in vitro assays  and ciprofloxacin (Thermo Fisher) were two-fold serially diluted in MHB (256–0.0156 μg/mL), to a final volume of 50 μL in a 96-well plate (Corning). 50 μL of the diluted bacterial suspension  was added to all wells and incubated for 18 h at 37°C before the minimum inhibitory concentrations were determined.Minimum inhibitory concentrations were performed according to the EUCAST guidelines . Briefly600.Minimum biofilm eradication and inhibitory concentrations  were performed using Calgary device (peg lids biofilm assay) according to TM 5G homogenizer  for 40 s at 4.0 m/sec. Biofilm homogenate was transferred to 96-well plates, serially diluted 10-fold and plated on LB agar plates for calculating the bacterial load.Dissection and infection of pig lungs were performed as described in Harrison et al. . BrieflyFor assessing the effect of different media, replicate infected tissues were treated with antibiotics by transferring the washed infected tissues to 48-well plates containing 300 μL of either MHB or ASM containing ciprofloxacin (Thermo Fisher), meropenem (Sigma), tobramycin (Thermo Fisher) or combination therapy at the specified concentrations and incubated at 37°C for 24 h. Antibiotic-treated tissues were then washed, homogenized and plated as previously described.2) in a 2 mL tube and incubated for 15 min at 37°C with shaking at 170 rpm. Then, 500 μL of 10% trichloroacetic acid were added as a stopping solution, and tubes were centrifuged at 13,000 rpm for 1 min at room temperature. 200 μL of the supernatant were transferred into a clean 96-well plate and the absorbance was measured at 400 nm. PBS was used as a negative control and a standard curve using proteinase K  and the familywise error rate correction for multiple comparisons.All data were analyzed by ANOVA to test for the main effect and interactions of different lung, strains and antibiotic treatments using RStudio v1.1.463 . Unpaired P. aeruginosa strains were resistant to ciprofloxacin (MIC 2 μg/mL) and sensitive to meropenem (MIC ≤ 0.25 μg/mL) by standard antibiotic susceptibility testing using the broth dilution method; PA14 was sensitive to both antibiotics  = 749.5, p < 0.001] and meropenem treatment  on bacterial load, the magnitude of which was strain dependent  for ciprofloxacin but strain independent for meropenem  despite the differences in MICs and MBECs.The effect of antibiotics on the bacterial load was first tested by transferring bronchiole sections containing developed biofilms to MHB (standard medium for microdilution assays) containing antibiotics. This allowed to directly compare the inhibitory effect of these antibiotics in EVPL versus in standard diagnostics assays, without the effect of the medium or any physiological differences induced by CF lung mucus. Treatment with ciprofloxacin at 32-fold MIC (8–16-fold MBEC) resulted in a 1–2 log decrease in bacterial load across all tested clinical strains . HoweverF = 9.04, p < 0.01], antibiotic treatment , and a medium × antibiotic interaction F = 5.56, p < 0.05.To investigate the effect of the environment on antibiotic tolerance, the bacterial load of the clinical isolate SED 43 was compared with and without ciprofloxacin or meropenem in MHB and ASM: a chemically defined medium which mimics the chemistry of chronically infected CF sputum . As showP. aeruginosa strains, PA14 and three clinical isolates  were assessed for the production of two readily quantifiable and well-studied virulence factors, proteases and pyocyanin in the lung tissues homogenate and surrounding ASM, separately, in the presence and absence of antibiotics. In this work, we compared our results to P. aeruginosa infected untreated tissues and all data were normalized to uninfected untreated tissues to show the effects that are due to antibiotics’ exposure. The ASM surrounding tissue sections at the end of antibiotic exposure remained visibly clear, suggesting that bacterial cells did not detach from the biofilm or grow in the surrounding ASM at appreciable rates. Total proteases and pyocyanin were shown to be mainly released from the biofilm into the ASM, with a similar pattern in the tissues  = 6.798, p < 0.01] and meropenem treatment  on proteases production in the tissues, and the effect of meropenem did not differ between strains . In the surrounding ASM, similar effects were observed with strain  and meropenem treatment . Total pyocyanin produced in the tissues and ASM was also significantly different between strains , and the effect of meropenem significantly differed between strains .ANOVA showed a significant effect of strain  and , and production of pyocyanin  and .ANOVA analysis showed a significant effect of antibiotic treatment on the amount of protease/cfu [tissue P. aeruginosa infections are characterized by the mucoid phenotype, which can adversely affect the individuals’ pulmonary function increasing mortality rates. Therefore, oral and nebulized ciprofloxacin and colistin, respectively, are administered at early infection stages to reduce the risk of chronic infection and during chronic infections to eradicate P. aeruginosa (max of 2.3 μg/mL in sputum (In CF, chronic ruginosa . Un-clearuginosa . Pharmacn sputum . The admn sputum . Intraven sputum .P. aeruginosa strains using current diagnostic methods and our previously developed EVPL biofilm model. The increase in bacterial resistance profile with the 1 day biofilm Calgary device in comparison to standard MIC had been previously reported (in vivo biofilms. Exposure to ciprofloxacin and meropenem at concentrations higher than MBEC values and reported sputum concentrations led to a decrease of bacterial load by only 1–2 logs (P. aeruginosa biofilms in the EVPL model, with such high concentrations, may be closer to the in vivo effect of these antibiotic treatments, demonstrating the need to employ CF representative diagnostics to better reflect on the antibiotics’ inhibitory effect.In this study, we compared the antibiotic susceptibility of selected reported . However1–2 logs , which m1–2 logs . The faiP. aeruginosa strains, when assessed in ASM compared with planktonic-based MIC in LB medium. P. aeruginosa in ASM. Therefore, we believe it is a more accurate model to show the effect of antibiotic treatment in CF is by testing for antibiotic susceptibility in ASM rather than general laboratory medium. This was alarmingly poorer than in MHB (ex vivo lung model using a small set of isolates. Future work can usefully assess the antibiotic sensitivity profiles of biofilms of a much wider range of isolates in this model and develop this model to a high throughput method that can be easily translated into the clinic taking advantage of its low cost.Antibiotic tolerance was also affected by the use of different media. Besides the difference in planktonic and biofilm based models, n in MHB . As we hin vivo effect of exposure to different antibiotics, in ASM, on the virulence of P. aeruginosa to understand the clinical implications of chosen antibiotics. We focused on two main virulence factors of P. aeruginosa: proteases and pyocyanin production. Production of proteases is triggered by the quorum sensing system to degrade vital host proteins and antibodies. In CF lungs, proteases have been shown to cause a severe inflammatory response leading to pulmonary damage (P. aeruginosa is protected from these reactive oxygen species by its own catalases (P. aeruginosa following Calgary biofilm susceptibility testing did not show any production of pyochelin, pyoverdine or pyocyanin (P. aeruginosa infection in CF and shows the effect different antibiotic treatments supporting the need for anti-virulence drugs.The work also indicated the potential y damage , and wery damage . Pyocyany damage . P. aeruatalases . Previouatalases , similaryocyanin , but folyocyanin . The incin vivo, giving misleading results. The current gap in clinical outcomes and standard susceptibility testing results is a very clear evidence. Our results, taken from an ex vivo animal tissue model using host-mimicking growth medium are consistent with increased antibiotic tolerance in in vivo biofilms. It is possible that current antibiotic prescribing could not only fail to eradicate biofilm load, but also worsen lung conditions by increasing expression of virulence factors by surviving bacteria, which requires immediate action to help eradicate biofilm infections. Thus, further work with clinical samples will be required to determine the effect of antibiotic treatment on bacterial load, lung function, and possibly exacerbations. It is also important to assess the role of mucoidy and alginate production with antibiotic treatments.Bacteria causing biofilm infections are often assessed for their antibiotic resistance profile using standard planktonic MIC methods or simple biofilm platforms such as the Calgary device. These do not represent the environment bacteria inhabit This manuscript has been released as a pre-print at bioRxiv .Raw data will be made available by corresponding author without undue reservation.Ethical review and approval was not required for this work because all pig lungs were post-consumer waste from a commercial abattoir.MH and FH contributed to the concept of the study. MH designed, performed, and analyzed experiments as well as wrote the manuscript. NH helped in designing and performing some of the virulence assay experiments. ES performed pilot work. All authors revised and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Urinary tract infections are one of the most common reasons for prescribing antibiotics in primary care. Current guidelines recommend fosfomycin, nitrofurantoin, or trimethoprim - sulfamethoxazol as empiric first line antimicrobial agents in uncomplicated infections. However, there is evidence that the use of fluoroquinolones, which are no longer recommended, is still inappropriate high. We determined antibiotic prescription patterns, quality and factors affecting antibiotic prescriptions in urinary tract infections in primary care in Switzerland.From June 2017 to August 2018, we conducted a cross-sectional study in patients suffering from a urinary tract infection (UTI). Patient and general practitioners characteristics as well as antibiotic prescribing patterns were analysed.Antibiotic prescribing patterns in 1.352 consecutively recruited patients, treated in 163 practices could be analysed. In 950 (84.7%) patients with an uncomplicated UTI the prescriptions were according to current guidelines and therefore rated as appropriate. Fluoroquinolones were prescribed in 13.8% and therefore rated as inappropriate. In multivariable analysis, the age of the general practitioner was associated with increasing odds of prescribing a not guideline recommended antibiotic therapy.We found a high degree of guideline conform antibiotic prescriptions in patients with an uncomplicated urinary tract infection in primary care in Switzerland. However, there is still a substantial use of fluoroquinolones in empiric therapy. Escherichia coli (E. coli) are known and the estimated susceptibility is over 80%. Despite the fact, that the overall usage of antibiotics in Switzerland is low compared to other European countries [Clostridium difficile associated diarrhoea) and both the US Food and Drug Administration and the European Medicines Agency released warnings and called for a more restrictive FC use [Antibiotic overuse and inappropriate use are associated with the emergence of resistant pathogens . The majountries , there iountries . Due to ountries , 6, 9. Fe FC use , 11.In this study, we determined the prescribing patterns and the quality of antibiotic prescribing in ambulatory UTI and report factors associated with appropriate or inappropriate antibiotic prescribing.We conducted a cross-sectional study between June 2017 and August 2018 in primary care practices in Switzerland to evaluate resistance patterns as well as treatment patterns in patients with lower UTI (cystitis). Details of the study design, as well as recruitment procedure are reported elsewhere . In thisP ≤ 0.2 in univariable analysis, were considered together. Stepwise backward elimination was used to develop final multivariable models with best fit for the outcome of interest. Results of regression analyses were presented as odds ratio (OR) ). ICC was also reported in multivariable analysis. For all tests, P ≤ 0.05 was considered statistically significant. According to ESAC [https://www.R-project.org).Summary statistics were reported as means , and number  as appropriate. Antibiotic prescription patterns were compared between complicated UTI (cUTI) and uUTI using independent sample Student’s t test and chi-square or Fisher’s test, as appropriate. Prescription of FC means prescription of at least one out of ciprofloxacin, levofloxacin, moxifloxacin, or norfloxacin. Univariable and multivariable regression analyses were performed to assess GP and patient determinants associated with the quality of antibiotic prescribing. The results of the “walk-in” clinic were only excluded when analyzing GP characteristics in univariable and multivariable regression analyses, due to the fact that different GPs were on duty and we could not match prescribing patterns with a single physician. In 13 patients, final diagnosis (cUTI or uUTI) was missing; hence, these patients were excluded for regression analysis, but still included in the overall analysis. Multilevel logistic models, with GP as first level clustering variable, were performed for the prescription of guideline antibiotics or for guideline adherent treatment of uUTI, versus any other antibiotics, and separately, for the prescription of fluoroquinolone versus guideline antibiotics. The mixed models with random effects (GP), were specified as follows: “Antibiotic prescription / treatment ~ Fixed Effects (X) + random effects of intercept (GP)” where X = GP characteristics: sex, age, years of experience in practice, type and location of practice, work time percentage, affiliation to a medical network, language ; patient characteristics: age, sex, history of UTI, antibiotic exposure within the last 3 months, inpatient treatment within the last 6 months, travel history within the last 12 months, reason for the initial encounter, type of UTI. In univariable analysis, every fixed effect (X) was considered separately in a single model. In multivariable analysis, instead, relevant effects, that is predictors with . 94.9% of the patients were female and the mean age was 54 years (Table ).One thousand three hundred fifty-two patients were recruited by 161 GPs and the two large “walk-in” practices. Basic characteristics of the conducting GPs are described in Table rs Table .Table 1n = 34) or analgesic drugs (n = 22). Regarding the choice of antimicrobial agents, fosfomycin (44.7%), TMP/SMX (25.8%), and nitrofurantoin (14.5%) were most often prescribed in uUTI, resulting in a guideline conform empiric antibiotic therapy in 84.7%. Including patients with standby treatment and no antibiotic treatment, we found a guideline adherent approach in 85.8% in uUTI. According to the ESAC definitions for treatment in uUTI, the overall percentage of females receiving any systemic antibiotic therapy (92.7%) and the percentage of receiving a recommended antibiotic therapy (84.7%) were within the desired range. In contrast, the prescription rate of FC in all uUTI patients (13.8%) was above the desired range (< 5%), resulting in an evidence-performance gap of 8.8%  patients were treated with one antimicrobial agent, 8 patients (0.6%) with two or more antimicrobial agents. One hundred three patients (7.6%) did not receive any antibiotic. Of these, 47.6% received at least one drug for symptomatic therapy, mainly phytotherapeutics n = 4 or analPanel part A shows the relative prescriptions rates of recommended antimicrobials in female patients with an uncomplicated urinary tract infection in Switzerland. Panel part B shows the relative prescriptions rates of Quinolone prescriptions.p = < 0.001). In contrast, fosfomycin and TMP/SMX were more often prescribed in uUTI  (Table 2).In patients with cUTI 92,3% were treated with antibiotics, most often ciprofloxacin (44.5%), TMP/SMX (15.1%) and fosfomycin (14.3%) were prescribed. Ciprofloxacin was more often prescribed in cUTI compared to uUTI  or a guideline adherent treatment .Results of uni- and multivariable analyses for guideline recommended treatments of uUTI are reported in Table p < 0.001) and the sex of the patient   were additionally identified as significant determinants associated with reduced odds of prescribing fosfomycin, nitrofurantoin or TMP/SMX. In addition, the age of the GP and the diagnosis of a cUTI were significant associated with increased odds  of prescribing any FC antibiotic in multivariable analysis. Particular noteworthy are the relative high intra-cluster correlation coefficient (ICC) in multivariable analysis   in cUTI and increasing age of the GP in uUTI  were associated with higher odds of prescribing a FC in multivariable analysis  and the circumstance, that the reason for the initial encounter was not the suspicion for an UTI , as determinants associated with higher odds for withhold of a recommended antibiotic therapy  , every sary care , there iary care –22, and ary care , 24. Thiary care . A contiary care , 27, andIn contrast to uUTI there is no common consensus on the definition of cUTI . A varieIt is worth mentioning, that we observed in all of our calculations a major ICC. Thus, a quite large amount of variation in prescribing patterns in the individual GP must be due to additional (unmeasured) GP, practice, or patient characteristics. Patient and/or GP preferences, prior microbial results, patient allergies,  guidelines, or even missing guidelines in the case of cUTI, might be possible factors.A significant proportion of the patients was not treated with any antimicrobial agent. The use of anti-inflammatory and/or analgesic drugs , 32, or This study has some limitations. First, we are unaware of the reason regarding the choice of antimicrobial therapy. The personal history of a resistant microorganism, or an allergy or intolerance to a first line antibiotic are potential reasons for the use of an alternative antimicrobial agent. However, although it is unlikely that these factors make a treatment with any of the first line antibiotics impossible, we cannot rule out, that the choice of another antimicrobial agent than the first line antibiotics was the correct clinical approach in some cases. Second, we are unaware of coexisting complaints of the patients at the time of encounter. Although rare, a second infection, which need an antibiotic coverage, could influence the GPs decision of the antibiotic regime towards a FC.We could show that there is a very high degree of guideline recommended antibiotic use in the empiric therapy of uUTI in primary care in Switzerland. However, the use of FC in the empirical therapy of uUTI is still inadequate high and should consequently be addressed by multifaceted interventions.Additional file 1. Table 1 – Overview of prescribed antibiotics stratified by region. Table 2a – Logistic regression analysis for antibiotics prescriptions. Table 2b: Regression analysis identifying GP and patient characteristics as predictor for prescribing any quinolone antibiotic (vs. recommended). Table 2c: Regression analysis identifying GP and patient characteristics affecting GP antibiotic prescribing patterns. Table 2d: Logistic regression analysis for no antibiotics prescription.


MET oncogenic addiction. Here, the efficacy of ABN401, a MET inhibitor, was investigated using histopathologic and genetic analyses in MET-addicted cancer cell lines and xenograft models. ABN401 was highly selective for 571 kinases, and it inhibited c-MET activity and its downstream signaling pathway. We performed pharmacokinetic profiling of ABN401 and defined the dose and treatment duration of ABN401 required to inhibit c-MET phosphorylation in xenograft models. The results show that the efficacy of ABN401 is associated with MET status and they highlight the importance of determining the cut-off values. The results suggest that clinical trials need to establish the characteristics of each sample and their correlations with the efficacy of MET inhibitors.The receptor tyrosine kinase c-MET regulates processes essential for tissue remodeling and mammalian development. The dysregulation of c-MET signaling plays a role in tumorigenesis. The aberrant activation of c-MET, such as that caused by gene amplification or mutations, is associated with many cancers. c-MET is therefore an attractive therapeutic target, and inhibitors are being tested in clinical trials. However, inappropriate patient selection criteria, such as low amplification or expression level cut-off values, have led to the failure of clinical trials. To include patients who respond to MET inhibitors, the selection criteria must include  MET is amplified and/or mutated and/or HGF is overexpressed in cancers  was expressed as the median tumor volume ± standard error of the mean (SEM) in the different groups of mice. The T/C value (%) is an indicator of tumor response to treatment and a commonly used antitumor activity endpoint. The TGI (%) values, which were obtained on the last day of treatment and were compared with the vehicle group, were calculated as follows: 1 − (Ti − T0)/(Ci − C0) × 100%. Ti and Ci are the mean tumor volumes of the treatment and control groups on the measurement day; T0 and C0 are the mean tumor volumes of the treatment and control groups on day 0.For efficacy studies in PDX mouse models, five primary gastric cancer , two NSCLC (LU2503 and LU5381), and one hepatocellular carcinoma (LI0612) xenograft models were established by implanting fresh surgical tumor tissues into immunodeficient mice. The tumors from stock mice bearing human primary tumors were harvested, dissected into fragments, and inoculated into female BALB/c-nude mice. Each mouse was implanted subcutaneously at the right flank with a tumor fragment  were purchased from Vital River Laboratory Animal Technology Co., Ltd., and beagle dogs  were purchased from Beijing Marshall Biotechnology Co., Ltd. The rats and dogs were maintained in air-conditioned animal quarters with alternating 12 h light/dark cycles at a RT of 20–26 °C and a relative humidity of 40–70% before and during the trial. All procedures involving the care and handling of the rats and dogs followed the guidelines of the Pharmaron Institutional Animal Care and Use Committee . PK studies were designed to characterize the single-dose intravenous and oral PK profiles of ABN401 in rats and dogs. ABN401 was administered intravenously at 5 mg/kg and orally at 5, 20, and 50 mg/kg in the rats, and 2 mg/kg intravenously and 2, 5, and 10 mg/kg orally in the dogs. The formulation was freshly prepared on the day of dosing. For all intravenous studies, dosing solutions were prepared using the required volume of 5% DMSO/45% PEG400 in 50% distilled water, whereas 20% PEG400 in 0.1 M sodium acetate buffer (pH 4) was used to prepare oral formulations. The formulated samples were stirred at RT for at least 10 min prior to and during dosing. For the assessment of plasma drug concentrations, blood samples were collected at 5, 15, 30, 60, 120, 240, 480, and 1440 min post-dose from each rat and dog. Liquid chromatography, coupled with tandem mass spectrometry (LC-MS/MS), was used to quantify ABN401 in plasma samples from rats and dogs. To assess the PK of ABN401 in the cynomolgus monkey, ABN401 was administered once orally in capsule form at doses of 0, 1, 5, and 10 mg/kg, and 1 mg/kg was administered once intravenously. Blood samples were collected from the cephalic vein or the femoral vein prior to administration and at 0.5, 1, 2, 4, 8, 12, and 24 h after administration in the control group which received vehicle and in the orally treated groups. In the intravenous administration group, blood was collected from the cephalic vein or the femoral vein prior to administration and at 0.083, 0.25, 0.5, 1, 2, 4, 8, and 24 h after administration. The concentrations of ABN401 in the blood were analyzed according to a bioanalytical method [KIT Analytical Procedure: AP_ABN401-NCPP_CBA02 (V1.00)]. All procedures involving the care and handling of the monkeys followed the guidelines of the KIT-Institutional Animal Care and Use Committee (No. MN117002).The plasma concentration–time profiles of ABN401 were analyzed using a non-compartmental method in Phoenix WinNonlin v6.1 . The linear log trapezoidal algorithm weighting, 1/Y × Y, was used for parameter calculation. The mean PK parameters were calculated in individual animals from each treatment group. Concentrations below the lower limit of quantification (BLLOQ) were excluded from the calculation of PK parameters. The mean values of the PK parameters were calculated using Microsoft Excel.To analyze the PK/pharmacodynamics (PD) of ABN401 in plasma and tumors, tumor-bearing mice were treated with ABN401 at a dose of 10 or 30 mg/kg. At several time points , the plasma and tumor samples were collected, and an aliquot (50 μL) of the mouse plasma was mixed with a 4-fold volume (200 μL) of acetonitrile, containing an internal standard , and was vortexed for 5 min for the quantification of ABN401 in the plasma. For the quantification of ABN401 in the tumor tissues, the wet weight of tissues was measured, and the sample was vortexed with a 9-fold volume of acetonitrile containing the internal standard for 5 min. In this dilution, the density of tissues was assumed to be unity. The mixture was then centrifuged at 4 °C for 5 min at 13,200 rpm . The supernatant was collected, and an aliquot was analyzed for ABN401 by LC/MS/MS. To assess the PD of ABN401 in the tumors, the harvested samples were homogenized in liquid nitrogen and then lysed in 1 mL cell lysis buffer  containing a protease inhibitor cocktail  and PhosSTOP . The extracted proteins were subjected to Western blotting and IHC. Bands representing total MET and phosho-MET (Y1234/5 and Y1349) were quantified using Amersham Imager 600 software . The phospho-MET to total MET ratio was calculated at two doses and several time points. The baseline value (100%) was based on the vehicle.t-test or one-way ANOVA was used for multiple comparisons. * p < 0.05, ** p < 0.01, and *** p < 0.001 were considered statistically significant. Statistical analyses were performed using SSPS 16.0, GraphPad Prism 8.4 software, and Microsoft Excel. In vitro assay and in vivo xenograft data were expressed as the mean ± standard deviation (SD), whereas PDX data were presented as the mean ± SEM.Student’s MET-addicted cancers and shows a favorable PK profile. The testing of ABN401 in clinical trials may be improved by establishing guidelines for patient selection and determining the effective dosage and treatment durations of ABN401 required to inhibit c-MET activity. ABN401 is currently being tested in a phase I/II study, and its safety, pharmcokinetics, pharmacodynamics, antitumor activity, and exploratory biomarker tests are being examined in advanced solid tumors (NCT04052971). In particular, the clinical trial included exploratory studies that isolate ctDNA (cell-free DNA) from CTCs (Circulating tumor cells) obtained from patient blood using a sorting machine (liquid biopsy), to check MET copy number, its expression level, and mutations. Through these studies, we are exploring the best method to select patients who will respond optimally to the MET inhibitor, ABN401.ABN401 is a potent and highly selective MET inhibitor in


Reinforcing steel corrosion, caused by chloride ingress into concrete, is the leading cause of reinforced concrete deterioration. One of the main findings in the literature for reducing chloride ingress is the improvement of the durability characteristics of concrete by the addition of supplementary cementitious materials (SCMs) and/or chemical agents to concrete mixtures. In this study, standard ASTM tests—such as rapid chloride permeability (RCPT), bulk diffusion and sorptivity tests—were used to measure concrete properties such as porosity, sorptivity, salt diffusion, and permeability. Eight different mixtures, prepared with different SCMs and corrosion inhibitors, were tested. Apparent and effective chloride diffusion coefficients were calculated using bound chloride isotherms and time-dependent decrease in diffusion. Diffusion coefficients decreased with time, especially with the addition of SCMs and corrosion inhibitors. The apparent diffusion coefficient calculated using the error function was slightly lower than the effective diffusion coefficient; however, there was a linear trend between the two. The formation factor was found to correlate with the effective diffusion coefficient. The results of the laboratory tests were compared and benchmarked to their counterparts in the marine exposure site in the Arabian Gulf in order to identify laboratory key tests to predict concrete durability. The overall performance of concrete containing SCMs, especially fly ash, were the best among the other mixtures in the laboratory and the field. Concrete service life is often predicted by modeling the chloride ingress into the concrete. Once the chloride content at the depth of the reinforcing steel has been reached, corrosion is initiated in the model.Corrosion of reinforcing steel is the most common cause of reinforced concrete deterioration ,2. WhileThe diffusion coefficient in Equation (1) accounts for the rate at which chloride ions can diffuse through the concrete pores. The concrete diffusion coefficient is a function of the chloride diffusion in pore solution with infinite dilution, the total porosity, and the porosity connectivity and tortuosity. The effective diffusion coefficient is the diffusion coefficient separated from the effects of chloride binding. Due to alumina hydration products in the concrete, part of the diffused chloride is bound by the formation of complex salts such as Friedel’s salt or Kuzel’s salt. Some portion of the chlorides are also bound through physical adsorption on C-S-H . ChloridWhile the literature is full of data on the concrete apparent diffusion coefficient for different mixtures, there is scant data on the effective chloride diffusion coefficient in concrete after chloride binding has been separated ,11.One of the best ways to protect concrete reinforcing steel from corrosion and increase the service life is to reduce the concrete porosity and permeability ,12,13. CF can be calculated using Equation (2)ρ0 is the concrete resistivity (Ω·m), ρ is the pore solution resistivity (Ω·m), D is the chloride diffusion constant in an infinitely dilute solution taken to be 2.032 × 10−9 for Cl¯ at 25 °C, and D0 is the concrete effective diffusion coefficient (9)http://ciks.cbt.nist.gov/poresolncalc.html) and cementitious material composition shown in Rapid chloride permeability results are shown in As shown in 3.In terms of density, it was shown that the CNI mixture exhibited the highest bulk and dry densities at values of 2.33 and 2.21 g/mAs illustrated in 2 value of 0.8, was found between the formation factor and sorptivitity coefficients as shown in A good linear correlation, with average R3A and the reduction of pH level that caused release of chloride [As illustrated in chloride . CNI recchloride .SC illustrated the highest overall chloride profile along its depth during the first 35 days of ponding . SC had On the other hand, the chemical additives seemed to have a minimal overall effect on the chloride profile during the first 35 days of ponding. However, their effect was more pronounced after the six-month ponding with great improvement in the profile, especially the caltite then MCI .The effect of the addition of SCMs and chemical additives seemed to be more significant with the passage of time as illustrated by the six-month ponding results.sC, diffusion coefficients, aD, and 28D, for the concrete bulk diffusion experiments. SC mixture showed the highest decrease, after six months, in the diffusion coefficient which indicated a much slower transfer of chlorides into the concrete. Moreover, the addition of the chemical additives seemed to have a significant effect on the diffusion coefficient which decreased by 55%, 54%, and 73% in the cases of MCI, CNI, and caltite mixtures respectively. In terms of the surface concentration, SC mixture was shown to have the highest surface concentration which could be attributed to its considerably higher binding capacity and initial rate of absorption, while type V concrete exhibited the lowest in the six-month ponding. The lower capacity of V mixture to bind chlorides indicated that the penetration of chlorides might be easier in this mixture, which in turn can be detrimental to its durability in longer exposure periods.aD and 28D was small. The higher values on average of the effective diffusion coefficient was most likely because it was a 28-day value instead of an average of the diffusion coefficient between 28 and 63 days and chloride binding was explicitly accounted for. Use of the simplified Equation (5) to calculate the concrete diffusion coefficient from 35-day ponding tests for service life modeling may give similar results. While large electrical potentials have been shown to cause microstructural changes to the concrete and the proportion of large harmful pores [Considering the expected level of error in chloride profile and binding measurements, the maximum 23% difference between ul pores , it is nul pores , limitinThe highest formation factor was recorded for FA then SC, SF, I, and V . This wa28D, versus measured concrete electrical properties was performed in order to determine the ability of commonly used concrete quality control methods to predict the concrete durability. A comparison of the concrete effective diffusion coefficient, There was good agreement among the experiments of absorption, void ratio, sorptivity, and bulk diffusion because the void ratio influenced greatly the sorptivity and bulk diffusion. Although SC mixture recorded the lowest void ratio, its absorption and sorptivity was relatively high for the same days of curing. This could be explained by the need of SC mixture to absorb water for more hydration, according to the literature, especially when the slag percentage exceeded 40% ,62. NeveThe mixtures were ranked according to their overall performance using pairwise comparison method for all of the tests. There was good agreement between the laboratory and field outcomes. Besides the samples made with corrosion inhibitors, the formation factor was able to predict the relative field performance of the concrete mixtures. The performance of corrosion inhibitors materials, however, was improved in the field which might be attributed to their better performance at larger depth due to decrease of leaching out and better formation and blending. Future work to quantify the formation factor of the mixtures containing corrosion inhibitors through pore solution extraction is needed.The absorption, void ratio, and the binding capacity tests along with formation factor could be indicative, as short term tests, of the long term performance of the different mixtures since their results predicted the field performance.Apparent diffusion coefficient calculated from concrete bulk diffusion tests using the error function and the effective diffusion coefficient at 28 days were similar. This implies that the simple approach used with the error function provides a good index of concrete quality.A good correlation was found between the concrete formation factor and effective diffusion coefficient as predicted by theory. Because the effective diffusion coefficient is a fit value that involves the use of several other parameters—such as chloride surface concentration, chloride binding isotherm, and concrete chloride profile—some error in the values was expected.The laboratory and field results showed that the cementitious materials outperformed the corrosion inhibitors. The use of SCMs provided the largest benefit in reducing chloride diffusion. The corrosion inhibitors showed better performance in the field, especially at larger depths, and after six months of exposure in the laboratory which could be attributed to the effectiveness of corrosion inhibitors at larger depths and leaching out decrease overtime.FA and SC mixtures performed the best compared to the other mixtures for the conducted experimental program in the laboratory and in the field, whereas I and V mixtures delivered the least quality performance as expected.Formation factor predicted the relative performance of concrete mixture in the field. The formation factor could be used as a reasonable surrogate for the effective diffusion coefficient in service life modeling and concrete durability applications. Since the formation factor can be estimated quickly and at a low cost, it could be used more frequently to measure durability than currently used tests. More work on the effect of curing on formation factor is needed.Absorption and binding capacity tests along with the formation factor could be indicative of long-term performance of concrete mixtures since their results agreed with the performance of the concrete in the marine exposure site.Based on this study, the following conclusions can be drawn:


MET alterations in solid tumors and the immune microenvironment remains elusive. Formalin-fixed, paraffin-embedded samples of 21 patients with solid tumors harboring MET alterations were used for immunohistochemical staining. Extracted RNA was analyzed with the NanoString nCounter human PanCancer immune profiling panel . Patients were diagnosed with lung (n = 10), breast (n = 5), genitourinary (n = 3) or colorectal cancer (n = 3). Eleven had a MET missense mutation, four had an exon 14 splice site mutation and six had MET amplification. CD6, CCL19, CD40LG, XCR1, MAGEA1, ATM and CCL19 genes were significantly differentially expressed in MET-altered cancers. MET alterations may have a role in various solid tumors as potential therapeutic targets and combination therapy candidates with immune checkpoint inhibitors.The implication of  MET is a receptor for growth signals that keeps cells alive and healthy. However, some tumors have changes in MET that allow for uncontrollable cell growth. Patients with MET-altered tumors may benefit from treatments targeting this gene, but eventually they become resistant to the treatments. Thus, there is a need to identify additional therapies for this patient population. The authors tested immune gene expression in tumors with MET alterations to determine if these patients would benefit from a new class of treatments called immunotherapies and found that patients with and without MET changes had differences in immune gene expression. MET gene were first identified in hereditary papillary renal carcinoma. Subsequent studies identified similar alterations in sporadic renal carcinoma, non-small-cell lung cancer (NSCLC), breast cancer, colorectal cancer, gastric cancer, head and neck squamous cell carcinoma and other solid tumors . CD. CDMET aMET-altered cancers and those with MET wild-type cancers. Differential immune gene expression in patients with MET-altered tumors suggests these patients may benefit from treatment with immune-targeting therapies. Notably, the authors' study entailed a small sample size of patients with different cancer types, and additional work is needed to evaluate expression of these immune genes in a larger prospective cohort. Additionally, the authors' study examined gene expression from biopsies taken at diagnosis. Immune gene expression may fluctuate through the course of a patient's treatment. Thus, a longitudinal study of immune gene expression in MET-mutated cancers could be performed in the future to better inform the potential of immune-targeting therapies in this population; however, access to longitudinal samples from solid tumors for research purposes is limited.In this study, the authors identified differential immune gene expression between patients with MET-altered tumors is important because aberrant MET activity has been observed in a wide variety of solid tumors, including NSCLC and breast and ovarian cancer [MET alterations in primary tumors commonly entail missense mutations or exon 14 skipping mutations, whereas in colorectal and NSCLC patients, MET amplification has been identified as a mechanism of acquired resistance following treatment with EGFR tyrosine kinase inhibitors [MET exon 14 skipping mutations, which the authors have identified in both NSCLC and SCLC patients, cause deletion of the juxtamembrane domain containing the casitas B-lineage lymphoma E3-ubiquitin ligase binding site, leading to a decrease in the turnover of the resulting aberrant MET protein and prolonged signal activation [MET, such as crizotinib, cabozantinib, capmatinib and tepotinib, are effective in treating NSCLC patients with a MET exon 14 skipping mutation [MET alterations early at initial diagnosis to improve patient response and survival through treatment with targeted therapy. Furthermore, a phase II trial of tepotinib has recently shown favorable results with a durable duration of response in MET-altered tumors [MET-directed targeted therapies in various solid tumors that harbor MET amplifications or increases in MET gene copy number [MET dependence of various solid tumors may be the key to developing novel MET therapeutics [Identification of differential gene expression in n cancer . MET althibitors ,25. MET tivation ,26. Sevemutation . For exad tumors . Capmatiy number . Identifapeutics .MET expression. For example, expression of MET has been implicated in activating myeloid-derived suppressor cells to suppress the immune system by hepatocyte growth factor secretion in mesenchymal stem cells [MET overexpression in breast cancer-associated adipose tissue composed of mesenchymal stem cells has also been correlated with recurrence and a potential role in tumorigenesis [MET activation and amplification directly correlate with PD-L1 expression, and treatment of EGFR-resistant cells with a MET inhibitor has been shown to decrease PD-L1 protein and gene expression [MET expression is able to activate CD4+ T cells and can induce tumor cell killing in natural killer/T-cell lymphoma cell lines, in which MET elicits an anti-tumor immune response by increasing the activation of T cells and reducing the synthesis of TGF-beta [MET-driven tumors.Multiple studies have demonstrated a link between immune phenotypes and em cells . MET oveigenesis . In addipression . IFN-γ hpression ,35, whicpression ,31; indepression ,37. Precpression ,31. Prevpression . AdditioTGF-beta . OverallMET-altered patients. In fact, chemokine receptors such as CCL19 and XCR1, alongside c-MET, have been shown to be overexpressed in mesenchymal stem cells [in vitro and in vivo by chimeric antigen receptor (CAR) T-cell therapy in lung adenocarcinoma cells, where the lung adenocarcinoma cells were effectively destroyed by IFN-γ secretion due to MAGEA1 inhibition [et al. reported that treatment of MET-expressing malignant mesothelioma cells with MET-retargeted CAR T cells was associated with significant IFN-γ release and tumor cell destruction [et al. showed that CAR T-cell therapy was tolerated and evoked an inflammatory response within metastatic breast cancer patients [Identification of several differentially expressed chemokine receptors and CT antigens suggests a heterogeneous tumor immune microenvironment in em cells ,41. CT aem cells . MAGEA1,em cells ,44. Its em cells ,46. CT ahibition . Thayapatruction . This sutruction . A clinipatients . Severalpatients ,51, and MET alterations who may benefit from immunotherapy or CAR T-cell therapy for several malignant solid tumors. The role of MET in a number of immune evasion mechanisms and upregulation of anti-cancer immunity receptors, such as PD-L1, must be clinically evaluated in combination therapy studies with immune checkpoint inhibitors. The nCounter technology  may serve as a reliable tool for assessing mRNA expression levels in FFPE tissue to determine clinically relevant immune markers associated with immune response or resistance.Chemokine receptors and CT antigens could be utilized as co-stimulatory and co-inhibitory markers to identify patients with MET mutations have been identified in a wide variety of solid tumors.MET-altered tumors remain relatively unexplored.The efficacy of immunotherapies and the immune landscape of MET alterations and identified changes in immune gene expression, including upregulation of CD6 and CD1A, in patients with MET-altered tumors.The authors examined immune gene expression of patient tumor samples with and without MET-altered patient population.Future studies are needed to examine the impact of immunotherapy treatment in the Click here for additional data file.