It is shown that the quasi-static tensile strength of mortar is higher than that of concrete since coarse aggregates weaken the interface bonding strength of the latter. Numerical results confirmed that the plane stress hypothesis lead to a lower value tensile strength for the cylindrical specimens. With the increase of strain rates, dynamic tensile strengths of concrete and mortar significantly increase, and their failure patterns change form a single crack to multiple cracks and even fragment. Furthermore, a relationship between the dynamic increase factor and strain rate was established by using a linear fitting algorithm, which can be conveniently used to calculate the dynamic increase factor of concrete-like materials in engineering applications.As concrete and mortar materials widely used in structural engineering may suffer dynamic loadings, studies on their mechanical properties under different strain rates are of great importance. In this paper, based on splitting tests of Brazilian discs, the tensile strength and failure pattern of concrete and mortar were investigated under quasi-static and dynamic loadings with a strain rate of 1–200 s The dynamic increase factor (DIF), defined as a ratio of the dynamic compressive/tensile strength to its quasi-static counterpart, has been widely adopted to evaluate the strain rate effect of concrete-like materials8. Here, it is worth noting that the increase of compressive strength with strain-rate is mainly due to inertial effects. Compared with dynamic compressive strength, dynamic tensile strength is harder to measure and the DIF trend is more complicated. Thus, there is still lack of an accurate formula for the estimation of DIF of concrete-like materials under dynamic tensile loading. Especially, when the strain rate is in the range of 1–200 s−1, DIF is difficult to be accurately determined10 since it is rapidly increasing and appears obviously higher than that at a lower strain rate  splitting tests are convenient to prepare, and experiments are easily performed with high accuracy of results. In addition, the strengths within a wide range of strain rates can be obtained by dynamic splitting tests with SPHB. Therefore, BD splitting tests have become the most common indirect tensile testing method for concrete-like materials13. In the BD tests, pressure is applied on a disc specimen along its radial direction, which generates tensile stress at the direction vertical to loading, causing the specimen failure. Taking inertial and strain rate effects into account, DIF obtained from dynamic splitting tests may overestimate the dynamic strength of concrete-like materials and cause potential security problems of structures subjected to earthquakes, blasting and hard impact6. Previous results show that, when the ratio of thickness to diameter for a BD specimen is equal to 0.5, the inertial effect can be minimized and DIF is mainly contributed by the real strain rate effect17.In the last few decades, a series of methods have been developed to test the static and dynamic tensile strengths of concrete materials. Among these popular testing methods , splitting tensile tests are normally carried out with the split Hopkinson pressure bar (SHPB)19. However, the compressive stress concentration near the loading platen has a significant influence on the results of BD tests. Therefore, it is necessary to investigate the stress distribution and failure process of a specimen under impact loading. To solve this problem, different loading methods were developed to reduce the stress concentration and ensure the crack initiation point located at the center of BD specimens21. Three different failure modes  of BD specimens under splitting loading were also summarized22. Additionally, closed full-field solutions of stress- and displacement-fields in BD specimens with different loading conditions were obtained, based on the two-dimensional elastic theory with an assumption of concrete-like materials being linearly elastic and homogeneous24.During dynamic splitting tension, the start-split location and failure pattern of specimens are main factors that affect the reliability of tests. Generally speaking, experimental results are valid only when an initial crack occurs at the center of a specimen and propagates along the loading diameter direction25. Thus, it is necessary to conduct further investigation to highlight their different failure modes and dynamic tensile strengths under various strain rates.Concrete and mortar, as two typical concrete-like materials, are widely used in engineering structures. However, most of previous studies were mainly focused on the dynamic tensile strength of concrete. Since mortar is prepared without coarse aggregates, its mechanical properties, failure pattern and DIF are significantly different from concrete, especially for tensile strength. There is still lack of a reliable relationship between the DIF and strain rate for mortar materials that are usually used to glue bricks together or as surface binders between metope and groundIn this paper, the tensile strength and failure pattern of concrete and mortar were investigated under quasi-static and dynamic loadings based on splitting BD tests. The paper is organized as follows. In the section Methods, the experimental methods are introduced, including preparation of specimens and principles of compressive, quasi-static and dynamic splitting tests. Then, the failure mode and tensile strength under quasi-static and dynamic splitting tests are discussed in Results and Discussion, with the relationship between the DIF and strain rate. Finally, a brief summary is given in Conclusions.D = 70 mm and thickness H = 30 mm, D = 70 mm and H = 55 mm, respectively. Concrete was prepared in the weight proportion of 0.40:1.00:1.12:2.28 (water: cement: sand: coarse aggregate), while that of mortar was 0.58:1.00:3.03 (water: cement: sand). In preparation, crushed limestones were chosen as coarse aggregates, and fine aggregates were river sands. The sizes of coarse aggregates were smaller than 7.50 mm, with the apparent density, stacking density and porosity of 2.60 g·cm−3, 1.70 g·cm−3 and 37%, respectively. The sizes of sands were smaller than 2.36 mm, with the apparent density, stacking density and porosity of 2.55 g·cm−3, 1.45 g·cm−3 and 35%. Cement was chosen as the ordinary portland cement (OPC 32.5). In addition, to obtain quasi-static compressive strengths that are usually applied in the classification of concrete and mortar, three standard concrete and mortar specimens were cast in the shape of a block with dimensions of 150 × 150 × 150 mm3 and 70.7 × 70.7 × 70.7 mm3, respectively. These specimens were de-molded after 48 h, and then moist-cured in a standard curing room with temperature of 20 ± 2 °C and relative humidity of 95%. The prepared BD specimens are shown in Fig. To study the influence of specimen size on dynamic splitting strength, both concrete and mortar BD specimens were cast in steel molds with two different sizes: diameter −3, respectively. The compressive strengths were tested with the MTS testing machine, according to the standards for evaluation of concrete strengths . For cube specimens, the compressive strength fc can be obtained byFc and Ac are the failure load and cross-sectional area of a specimen. As a result, the average compressive strengths of three concrete and mortar specimens are 34.50 and 25.60 MPa; while their Young’s moduli are 30.32 and 27.45 GPa, respectively.Before compression, the densities of concrete and mortar specimens were tested, and their average values are 2.40 and 2.02 g·cmin-situ measurement of displacement and strain in BD specimens with a commercial software .The quasi-static BD tests were also carried out on the MTS testing machine (C45.105) with a load-sensing transducer , according to the standards for evaluation of concrete strengths (GB/T 50081-2002). The loading rate was 0.1 mm/min, and it took several minutes before load reached the maximum value . Here, two different loading methods (concentrated line loading and 20° arc loading with bearing strips), as illustrated in Fig. P is applied to a BD specimen, stresses at a point on the specimen, as shown in Fig. 26T in the x and y directions; H and D are the thickness and diameter; T to two loading points; and Based on the plane-stress hypothesis, when a concentrate line load x direction and a tensile stress in the y direction27, and the compressive stress It can be inferred that, at the center point of BD, there is a compressive stress in the 29 and flattened BD tests30, were developed. It is shown that 20° arc loading with bearing strips is an effective method. Here, the effect of two loading methods on the tensile strength was firstly studied with mortar BD specimens. Specimens, M-L-1 and M-L-2 , were tested with a load rate of 0.1 mm/min by concentrated line loading and 20° arc loading with bearing strips, respectively. As shown in Fig. In splitting tensile tests, there is significant stress concentration near the positions where force is applied through the concentrated line loading, which results in failure of concrete specimens. Thus, to reduce the stress concentration at loading positions, several new loading methods, such as arc loading with bearing strips31, the stress and particle velocity of a longitudinal stress wave in the SHPB tests can be accurately determined from its associated strain measured by strain gauges, and since both incident and transmission bars are slender rods, it satisfies the plane section assumption. The impact of a striker bar on the free end of an incident bar induces a longitudinal compressive wave propagating in both directions  on incident and transmitted ends of the specimen can be calculated byE, D0 and A are the elasticity modulus, diameter and cross-sectional area of two bars, respectively.The dynamic forces  calculated by Eq. −1. Thus,To the best of our knowledge, there are still no studies on the effects of factors such as types and sizes of aggregates on DIF. With the size increase of aggregates, the density of concrete increases, and a larger specimen is necessary to ensure its isotropy, both of which will have obvious effect on the DIF. In addition, these factors may increase the inertial effect of a specimen in dynamic splitting tests, and lead to a higher dynamic tensile strength and DIF. Thus, the influence of strength on DIF needs further investigation.The quasi-static tensile strength of mortar is higher than that of concrete because coarse aggregates weaken the interface bonding strength. Simulation results show that the maximum tensile stress is at the central point on side surfaces, and the minimum tensile stress is at the central point of a cylinder. Thus, it is confirmed that the calculation based on plan stress hypothesis leads to a lower tensile strength.A macrocrack finally leads to fracture of a mortar specimen when tensile strain reaches a certain value. The strain maps obtained with a DIC technique show that macrocracks nucleate between 0.002 and 0.02.With the increase of strain rate, the dynamic tensile strength of concrete and mortar BD specimens significantly increases, and their failure patterns change form a single crack to multiple cracks and even fragment. For three failure modes, there is a center crack before multiple cracks and wedge fragment, which implies that failure of BD specimens is indeed caused by the tensile stress at the center in dynamic splitting tests.−1. They can be conveniently applied to determine the dynamic tensile strengths and to calculate the DIFs of concrete and mortar materials.Two fitted equations are proposed for the strain rate in the range of 1–200 sIn this paper, the tensile strength and failure pattern of concrete and mortar were investigated under quasi-static and dynamic loadings based on splitting BD tests. The main conclusions can be drawn as follows:Supplementary information


Since 2001 the UNAIDS Secretariat has retained the responsibility for monitoring progress towards global commitments on HIV/AIDS. Key critical characteristics of the reporting system were assessed for the reporting period from 2004 to 2014 and analyses were undertaken of response rates and core indicator performance. Country submission rates ranged from 102 (53%) Member States in 2004 to 186 (96%) in 2012. There was great variance in response rates for specific indicators, with the highest response rates for treatment-related indicators. The Global AIDS reporting system has improved substantially over time and has provided key trend data on responses to the HIV epidemic, serving as the global accountability mechanism and providing reference data on the global AIDS response. It will be critical that reporting systems continue to evolve to support the monitoring of the Sustainable Development Goals, in view of ending the AIDS epidemic as a public health threat by 2030.The online version of this article (doi:10.1007/s10461-016-1662-9) contains supplementary material, which is available to authorized users. Targets were set to address a range of development issues, ranging from education to food security and health. However, mechanisms for developing and implementing appropriate plans of action and for monitoring progress towards the targets were not established and results often fell far short of target levels. A significant change came with the UN World Summit for Children in 1990 when Jim Grant, then UNICEF (The United Nations Children’s Fund) Executive Director, along with colleagues and social activists set in motion the implementation and monitoring processes to instigate momentum behind the Summit’s Declaration: countries established national programs and conducted surveys using recognized, standardized indicators in an unprecedented way. The importance of ongoing follow-up and monitoring of UN commitments was shown to make critical differences in establishing national ownership, global financial support and overall accountability.Setting targets in international development became commonplace in the 1960s, the first In 2000, 189 nations made a promise to free people from extreme poverty and to address a set of social and health concerns in the United Nations Millennium Declaration. This pledge evolved into the eight Millennium Development Goals (MDGs), of which MDG 6 is “Combat HIV/AIDS, malaria and other diseases” , from key populations at higher risk of HIV, such as sex workers , men who have sex with men (MSM) , and people who inject drugs ; and indicators based on programme data, such as prevention of mother to child transmission (GARPR indicator 3.1) and HIV treatment—antiretroviral therapy (GARPR indicator 4.1); and lastly policy related questions from the National Commitments and Policy Instrument (NCPI). The indicator data were reported every second year until the 2011 reporting period, when the frequency was changed to annual progress reporting . In addition to their programmatic relevance, these seven indicators have stayed the most consistent over time (except for indicator 2.1), and were considered most representative of different epidemiological contexts.These analyses provide a summary of the performance of seven key indicators for Global AIDS reporting over time (2006 until 2015 reporting). The seven assessed indicators cut across the different key areas in the reporting system: Updated guidelines on the construction of the indicators have been made available in advance of each reporting round. These guidelines describe in detail the full indicator specifications and data collection methods to ensure consistent data across countries. They also provide guidance on the analysis of the indicator data for country use.The indicator set has evolved over time . In 2002 a series of core indicators were developed and were grouped in four broad categories: (i) national commitment and action; (ii) national knowledge and behavior; (iii) national impact; and (iv) global commitment. This structure was kept until the 2012 reporting when they were restructured around ten targets and elimination commitments based on the 2011 UN Political Declaration on HIV and AIDS . The 201The resulting strategic AIDS information system, referred to as the UNGASS Reporting System between 2003 and 2011 and the GARPR system since 2011, has been predicated on the submission of Country Progress Reports, including indicator data, biennially between 2004 and 2011 and annually since 2012.Key characteristics of the Global AIDS reporting system over time are summarized below. The important issue of data sharing and transparency is summarized in text box no 1.In preparations for the first round of Global AIDS reporting in 2004, the UNAIDS Secretariat used the technical expertise of its Monitoring and Evaluation Reference Group (MERG), which included representatives from international agencies, national governments, civil society and academia, to select a concise set of existing indicators most relevant to the key components of a national HIV response and key epidemiological data. The MERG has continued to provide oversight over the system, leading reviews and proposing changes, e.g. when new programmes were introduced, such as interventions for the prevention of mother to child HIV transmission (PMTCT).In order to reduce the reporting burden for countries, and facilitate global and regional work, the UNAIDS secretariat, through its global, regional and country offices, has worked closely with other reporting systems, such as the WHO health sector response reporting and the European Centre for Disease Prevention and Control (ECDC) Dublin Declaration reporting in Europe and Central Asia to streamline reporting processes through joint reporting and harmonization of indicators.Monitoring and Evaluation Adviser, the staff function was expanded in 2011 to Strategic information Adviser, with greater focus on analysis and programmatic advice. In addition to this technical staff support, direct financial assistance was provided to “kick-start” the reporting process in low- and middle-income countries. Over time, this financial support was reduced as countries’ monitoring and reporting systems became increasingly self-sustaining. Furthermore each round has been supported by training workshops for international and national staff, initially as regional face-to-face workshops and then during the last four reporting rounds in most regions as web-based seminars.In 2004, UNAIDS deployed technical field staff, who were mandated to support the development of systems for the production, analysis, interpretation and reporting of data on national HIV responses. They have been instrumental in assisting the country-based process and training country staff in the preparation and submission of Country Progress Reports. Initially called Guidelines on Global AIDS reporting have been regularly disseminated by UNAIDS prior to the country reporting deadlines. These guidelines recommend that each country conduct data needs assessments; develop data collation and reporting plans; establish data processing procedures ; conduct data vetting and data triangulation workshops to obtain consensus on the values to be reported. It was recommended that this process should involve a wide range of stakeholders including representatives from relevant government departments, civil society organizations and non-governmental organisations (NGOs), and international agencies (where applicable).UNAIDS communications and advocacy strategies at country level have proven to be important and have targeted three different audiences associated with reporting: political leaders, government and partner agency technical staff, and civil society. Each reporting round has started with a letter to Member States missions in Geneva and New York that explains the upcoming reporting, followed up with a more technical note to national monitoring and strategic information staff, usually based at Ministries of Health (MoH) or at National AIDS Councils/Commissions (NACs). Civil society was a driving force behind the 2001 DoC and has continued to be a very active and important partner at global, regional and national level .UNAIDS Secretariat staff, together with colleagues from WHO and UNICEF and other international organisations, worked together with national staff to ensure the availability of high quality data. The Country Progress Reports received by the UNAIDS Secretariat are systematically checked for calculation errors, illogical values, and missing data fields. In many countries where UNAIDS staff are deployed this data quality assurance occurs first at country level, then moves up to regional level and finally at global level. When issues are detected, they are discussed and resolved with technical staff from the relevant country allowing continued country ownership of the data. Additional feedback is provided to countries on request to allow for further improvements in country M&E systems.As part of data processing at the UNAIDS Secretariat level, key international agencies involved in global reporting on AIDS , UNICEF, WHO) reconcile data in an effort to improve data accuracy and reduce discrepancies in reported figures at the global level.The performance of the Global AIDS reporting indicators has been reviewed after each round of reporting and revised in response to technical issues, as well as new programmatic developments. As a result, reporting has continued to improve in both comprehensiveness and quality and, due to the active involvement of country representatives, has become more responsive to country needs . In 2010As per its mandate, UNAIDS supports annually the United Nations Secretary General in reporting to the General Assembly on progress towards the global targets. In addition, progress reporting has also been used to assess achievements against the MDG 6 target. Since 2003, to inform World AIDS Day (1st of December) activities or international AIDS conferences, UNAIDS has published reports in every reporting round. These reports serve as reference documents for many institutions, holding governments accountable for progress against global targets. Similarly, UNAIDS produces regional reports and analysis, such as through the AIDS data-hub in Asia Pacific , servingThe reporting rate increased from 53% (52 Member States) in the 2004 round to a maximum of 96% (186 Member States) in the 2012 round and 92% (180 Member States) in the 2015 round , sex workers: condom use (GARPR indicator 1.8), men who have sex with men: condom use (GARPR indicator 1.12), people who inject drugs: prevention programmes (GARPR indicator 2.1), prevention of mother to child transmission (GARPR indicator 3.1), antiretroviral therapy (GARPR indicator 4.1), and the National Commitments and Policy Instrument (NCPI) are presented in Fig. Reporting rates increased rapidly 2006–2008 for indicators based on general population survey data (1.1) and key population survey data (1.8 and 1.12), most probably reflecting the roll-out of many general population surveys [such as Demographic and Health Survey (DHS)] and key population surveys [such as Integrated HIV Bio-Behavioral Surveillance (IBBS)]. For the indicator on condom use among men who have sex with men increasing reporting rates were seen until 2012, reaching close to 50%.Indicator 2.1 measuring prevention programmes for people who inject drugs was revised from being based on selected survey data to a programmatic indicator in the 2012 reporting round, , therefore only reporting rates from 2012 onwards are available. This change was a result of the broader review of the UNGASS reporting system that occurred in 2010. The rationale behind the change was that programme data when reliable and informative showed a better picture of coverage and that it was easier to follow over time than survey based indicators.Generally the programmatic indicators prevention of mother to child transmission (3.1) and antiretroviral therapy coverage (4.1) have had higher response rates than the survey based indicators, reaching maximum reporting rates of 70%.In the 2015 reporting round, the language in the online reporting tool, used for countries to report the data on all indicators, was modified to indicate whether new data was available for each indicator, with a note to not enter indicator data that had been reported in previous years. Before the 2015 reporting round, countries were only asked whether data was available for the indicator, and previously reported data could be repeatedly reported (e.g. survey based data that are not collected every year). The decrease seen in the 2015 reporting round can most probably be explained by this. This change was introduced to reduce the burden for countries and to avoid repeated entry of the same data, which was leading to inappropriate interpretations in earlier years.The NCPI response rates increased from 46 to 90% in 2012, with a slight decrease in 2014, more details about the development of the NCPI over time can be found in Torres et al. .The Global AIDS reporting system has substantially improved over time and has provided key trend data on responses to the AIDS epidemic at global, regional and country level, serving as the global accountability mechanism and reference data for the global AIDS response.Using data from the Global AIDS reporting system, it was recently reported that the MDG 6 on AIDS, “to halt and start to reverse the AIDS epidemic” has been achieved and that the goal of having 15 million people living with HIV on ART before the end of 2015 was reached nine months in advance of the target date . This siIn addition to the key characteristics of the Global AIDS Reporting system that have already been presented, multiple lessons have been learned as the global AIDS monitoring system evolved and improved. These lessons have provided insights as to specific factors that have contributed to building the Global AIDS Reporting System into a robust and sustainable strategic information system.The indicators in the indicator set have clearly been linked to targets contained in the political declarations, trying to keep the indicators to a limited set, but at the same time covering the larger spectrum of the AIDS response. The MERG, including key actors in the AIDS response, has served as the reference group whose role was to assure that the system has been standards based and responsive to the changing epidemic and response. User-friendly reporting guidance updated for each round, technical workshops, field adviser support, and financial support when needed have been other crucial components in building the system.The locus of control of the system has been at the country level, having national authorities leading the reporting process. The “three ones” highlighting the importance of having ONE M&E system as one of the three ones, the other two “ONEs” being One agreed HIV/AIDS Action Framework and One National AIDS Coordinating Authority was very important to get all partners to agree to harmonize indicators and work together with national authorities . FurtherAs described, the Global AIDS Reporting System is built on a strong national ownership of reporting and is based on a broad consultative process across both government sectors and civil society. The development of the reporting system has required a combination of high-level political commitment and extensive technical collaboration between various elements of the UN system, national governments, bilateral and multilateral development agencies and civil society.The continuous work to improve the system and change it when scientific or programmatic breakthroughs have led to new areas of work has also been important to keep the system up to date and relevant.As shown above in text box 1 the data collected at global level has been shared as broadly as possible in reports and online, and through inclusion in other organisations’ databases. The over 35,000 annual individual visits to AIDSInfo illustrate broad need to access HIV data. The largest funding agents of the global AIDS response, the Global Fund and PEPFAR (Presidents Emergency Plan for AIDS Relief), use the country fact sheets and AIDSinfo data as part of their reference materials for grant applications, analysis, reports and data validation, comparing with their own programme data sets. A recently conducted survey on AIDSinfo (n = 347) showed that respondents use its data for the purposes of studies, research, HIV programming, advocacy, general knowledge and media reporting. The majority of UNAIDS publications reference the HIV related data collected through Global AIDS Reporting System. While sub-national level data is becoming increasingly available, UNAIDS has taken on the responsibility to also publish those data, which make data more meaningful for intervention design and HIV programming.Both nationally and internationally, the Global AIDS Reporting has been viewed as more than just a reporting exercise to the UN General Assembly. The ultimate goal of the Global AIDS Reporting System has always been for national governments and their civil society partners to establish accountability mechanisms and to strategically use the data to inform their National Strategic Plans and guide more effective and sustainable responses to the HIV epidemic. The process has therefore emphasized country ownership of data and the onus of data collection, cleaning, validation, and aggregation rests with each reporting country.The Global AIDS reporting process has important spin-offs in that it has catalyzed the development of national monitoring systems in many countries  and has The indicators on AIDS spending and the policy environment have also been shown to be important components, which are missing in many other international reporting systems. The AIDS Spending indicator has made it possible to track how funds are spent at the national level and where the funds originate to help national decision-makers monitor whether funding allocations are in line with the specific country needs and help donors determine the return on their investment. The policy environment is monitored through the National Commitments and Policy Instrument (NCPI), the most comprehensive standardized global questionnaire available to assess the national policy, strategy, legal and programme implementation environment for the HIV response .Furthermore, Global AIDS Reporting has been described as a non-binding legal instrument, which demonstrates that the use of a non-binding instrument can be remarkably effective in galvanizing increasingly deep commitments, action, reporting compliance and ultimately accountability for results .The AIDS epidemic and the response are changing rapidly and the monitoring system must evolve with the changing context and environment.The work to end the AIDS epidemic is primarily led at country level and the global monitoring and harmonization processes can exist only if they support country leadership and action. Therefore, a global monitoring system must facilitate national efforts, and avoid adding too much of a burden on national systems. High quality global data is essential for global accountability and tracking of the epidemic. Balancing between globally significant indicators, and those that focus on national programmatic accountability can be a trade-off, and it is important that there be an ongoing dialogue to balance the needs of global and national interests. Further, some indicators might be of different relevance in e.g. low-income countries and high-income countries, adding to the complexity of trying to maintain one global, yet nationally relevant monitoring framework.The launch of the MDGs and the UNGASS reporting system encouraged partners at global, regional and national level to build M&E systems and improve them over time. The last decade has seen increased commitments and spending on HIV M&E, as well as improved M&E capacity . HoweverSome areas have proven to be more challenging than others to monitor, e.g. hard to reach populations, such as sex workers, men who have sex with men and people who inject drugs .Many countries are improving both the collection and the use of data at the subnational level to better understand the epidemic and the response. Such data will help all stakeholders to better understand the geographic distribution of HIV epidemics and the responses at community level . For a fThe Global AIDS reporting system will be critical in supporting the post-2015 monitoring of the AIDS response through the Sustainable Development Goals in view of ending the AIDS epidemic as a public health threat by 2030. Many of the challenges, obstacles and biases that arose during the evolution of the monitoring systems for the AIDS response were not unique to the AIDS epidemic. However, it was among the first monitoring frameworks in health to showcase how political, social, financial, behavioral, and service delivery indicators can complement each other. While governments often may resist external pressures for implementing such mechanisms, the Global AIDS Response Progress Reporting has demonstrated that the information that is produced can remain of high quality, even with decreasing external support, once it has proven its added value in accountability. Such mechanisms may arise in new areas of health delivery, driven by current crises, , and as the global community moves into new areas of health services, including Universal Health Coverage, Non Communicable Diseases, antibiotic resistance, etc. AIDS progress reporting can help in understanding the need for integration between different monitoring systems, data sources, and the ongoing dialogue that must be generated between different sector experts.Appendix (UNGASS and GARPR Indicators Summary table) (XLSX 21 kb)Below is the link to the electronic supplementary material.


EGFR T790M mutation are both associated with acquired resistance (AR) to epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) in advanced non-small cell lung cancer (NSCLC). We characterized the frequency, underlying molecular mechanisms, and subsequent treatment for AR in MET overexpressing NSCLC patients with or without the T790M mutation. The study participants were 207 patients with advanced NSCLC and AR to EGFR-TKIs. The percentages of MET-, T790M- and MET/T790M-positive patients were 20.3% (42/207), 34.8% (72/207) and 6.8% (14/207), respectively. The disease control rate was 100% (5/5) for five patients with MET overexpression who received EGFR-TKIs plus a MET inhibitor. Among the MET/T790M-positive patients, seven received EGFR-TKIs plus a MET inhibitor and four received a T790M inhibitor, but no response was observed. The median post-progression survival (PPS) was 14.1, 24.5, and 10.7 months for MET-overexpressing, T790M-positive and MET/T790M-positive patients, respectively (P=0.044). c-Met, p-Met, ERBB3, and p-ERBB3 were highly expressed in MET-positive and MET/T790M-positive patients, but were poorly expressed in T790M-positive patients. EGFR, p-EGFR, AKT, p-AKT, MAPK, and p-MAPK were highly expressed in all three groups. These results suggest that MET/T790M-positive patients are at higher risk of AR to EGFR-TKIs, and have a worse PPS than patients with only MET overexpression or the T790M mutation alone. Clinical trials are needed to determine the best treatment for patients with both MET overexpression and the EGFR T790M mutation.MET overexpression and the  EGFR-activating mutations, such as the exon 19 deletion and the L858R point mutation [EGFR (the T790M second-site mutation) or bypass signaling caused by MET overexpression [Epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), gefitinib, erlotinib, and afatinib,are effective therapeutic agents against non-small cell lung cancer (NSCLC) with pression , 3.Several strategies have been developed to overcome T790M-mediated resistance, including treatment with afatinib in combination with cetuximab, and mutant-selective EGFR-TKIs, such as CO1686 and AZD9291 . Mutant-MET gene amplification, protein overexpression, activating point mutations, and induction of its ligand, hepatocyte growth factor (HGF) [MET amplification and MET 14 exon skipping are relatively uncommon phenomena. Amplification of the MET oncogene has been reported in approximately 5–22% of patients with AR to EGFR-TKIs [EGFR mutant patients with AR in combination with MET amplification or MET overexpression [MET pathway activation is another mechanism of AR to EGFR-TKIs. The MET pathway can be activated in several ways, such as or (HGF) , 8. Receor (HGF) –13. HoweGFR-TKIs . It has GFR-TKIs . A new Mpression .EGFR T790M mutation are both important mechanisms of AR, it is important to consider MET status with or without T790M when designing clinical trials and managing clinical practice. The present study characterizes the frequency, efficacy, and molecular mechanisms of NSCLC in patients with AR and MET overexpression, with or without the EGFR T790M mutation.Since MET overexpression and the EGFR T790M mutation patients was 34.8% (72/207), the percentage of MET/T790M positive patients was 6.8% (14/207), and the percentage of patients with additional resistance mechanisms was 6.3% (13/207). In total, 66 of the 207 (34.1%) patients had no evidence of any resistance mechanism, for which we tested in our study. The percentages of each of the resistance mechanisms are shown in Figure From January 2013 to October 2015, 207 advanced NSCLC patients with AR to gefitinib or erlotinib were prospectively enrolled in the study . The perEGFR mutation (the 19 deletion or the L858 mutation), and EGFR-TKI (gefitinib or erlotinib) were included. No differences were found in clinicopathological or molecular characteristics among the three groups. Among the 42 MET overexpression patients, 4 received EGFR-TKIs plus crizotinib, 1 received axitinib, 24 enrolled in an INC280 clinical trial (NCT01610336), 1 enrolled in a volitinib clinical trial (NCT02374645), 1 continued erlotinib, 5 received chemotherapy and the other 6 patients were lost to follow-up. Among the 72 T790M positive patients, 13 enrolled in an avitinib clinical trial (NCT02274337), 2 enrolled in an AZD9291 clinical trial (NCT02094261), 2 received AZD9291 in clinical practice, 1 received afatinib, 8 continued erlotinib or gefitinib, 33 had chemotherapy and the other 13 patients were lost to follow-up. Among the 14 MET/T790M positive patients, 7 patients received EGFR-TKIs plus a MET inhibitor and the other 7 received chemotherapy.The 128 patients with MET overexpression and/or T790M mutations were divided into three groups: a MET-protein overexpression group (n = 42), a T790M-positive group (n = 72), and a MET/T790M positive group (n = 14). The baseline clinicopathological and molecular characteristics of the three groups are listed in Table EGFR T790M mutation in a liver lesion. This patient achieved a mixed response: PR in the lung lesions, but a Disease Progression (PD) in the liver lesions.Five patients from the MET overexpression group showed good response to EGFR-TKIs plus the MET inhibitor. One of these patients received a multikinase inhibitor, axitinib. Partial response (PR) was achieved in 80% (4/5) of the patients, one patient attained Stable Disease (SD) and all received significant clinical benefit. The longest PFS of the five patients was 7.7 months. Notably, one patient had MET overexpression in a lung lesion and an Seven patients with MET/T790M coexistence received EGFR-TKIs plus a MET inhibitor, with six patients receiving first generation EGFR-TKI (gefitinib) plus a MET inhibitor, and the other patient receiving a second generation EGFR-TKI (afatinib plus a MET inhibitor). None of these treatments resulted in a response or clinical benefit. Only one patient achieved SD and PFS of 5.7 months. The other four MET/T790M positive patients received a T790M inhibitor only (avitinib) with no response. Only one patient had a longer PFS of 8.3 months .Post-progression survival (PPS) was measured from the time of EGFR-TKI failure to death. The median PPS of patients with MET protein overexpression, T790M positive, and MET/T790M positive were 14.1 , 24.5 months , and 10.7 , respectively  or T790M inhibitor only. Although the frequency of MET/T790M positive patients is low (6.8%), the absolute number is large enough that more attention should be paid to this patient group. It is therefore important to consider MET status with or without the T790M mutation when managing clinical practice and designing future clinical trials.MET amplification or MET overexpression [MET amplification responded to a combination of EGFR-TKIs and MET-TKIs, but were resistant to each agent given alone [Patients with MET overexpression that occurred after AR to EGFR-TKIs achieved a good response to EGFR-TKIs plus a MET inhibitor. Three out of four cases achieved PR and one attained a stable disease state, consistent with previous studies. Engelman et al.  reportedpression . Preclinen alone .EGFR mutations associated with the 19 deletion, T790M mutation, and MET amplification. These cells were resistant to erlotinib and an irreversible EGFR inhibitor, CL-387785, but sensitive to the multi kinase inhibitor, XL880. Nakagawa et al. [in vivo models of intrinsic resistance to reversible EGFR-TKIs with EGFRs involving the 19 deletion or the L858 and T790M mutations, as well as MET amplification. All of these studies found that targeting EGFR or MET alone did not produce significant tumor regression. However, a combination of a mutant-selective EGFR-TKI (a T790M inhibitor) and MET-TKI optimized both antitumor efficacy and safety. Nakagawa et al. [There is currently no clinical data on an effective therapy for patients with MET/T790M coexistence, although some preclinical investigations have recently been conducted to develop possible therapies. Bean  reporteda et al. , Xu et aa et al. , and Nana et al.  establisa et al.  combineda et al.  combinedTo further investigate the molecular mechanisms of different responses to MET and T790M inhibitors, we selected nine cases from each group to characterize important markers of protein expression in the MET and EGFR signaling pathways. MET protein overexpression patients had markers of both EGFR and MET signaling activity. This is consistent with the clinical efficacy of first generation EGFR-TKIs combined with a MET inhibitor for the control of tumor growth in these patients. However, both EGFR and MET signaling pathways were also active in patients with MET/T790M coexistence, which might explain the clinical observations that the first generation EGFR-TKIs combined with a MET inhibitor or T790M inhibitor only were not efficacious. It might be useful to enroll MET/T790M positive patients in different clinical trials according to the markers for AR. If EGFR, p-EGFR, MET, p-MET, HGF, ERBB3, and p-ERBB3 are positive, and both the EGFR and MET signaling pathways are active, they could be enrolled in clinical trials of EGFR-TKIs (first or next generation) plus a MET inhibitor. If EGFR, p-EGFR, and T790M are positive, and only the EGFR signaling pathway is active, clinical trials involving the next generation EGFR-TKIs only (T790M inhibitor) would be recommended. In addition, if EGFR, p-EGFR, T790M, MET, p-MET, HGF, ERBB3, and p-ERBB3 are positive, and both the EGFR and MET signal pathways are active, the patients could be enrolled in clinical trials of the next generation EGFR-TKIs (T790M inhibitor) plus a MET inhibitor .MET amplification is higher than previously reported, with 27.1% positive patients, including 6.8% patients with the T790M mutation. Past studies reported this incidence at approximately 5–22% of AR patients detected by FISH [The majority of studies have shown that the frequency of the T790M mutation in Asian populations is 40-50% , 15, 28. by FISH , 14, 15. by FISH . Ji et a by FISH  reported by FISH . One rea by FISH , so moreThe ultimate purpose of this study was to optimize treatment decisions for AR patients. We emphasized the status of two major resistance mechanisms involving MET and T790M. Both MET and T790M patients can be selectively treated, and personalized treatment strategies are available for specific types of resistance. The incidence of MET and T790M-positive patients directly reflects those who have a chance to receive the MET or T790M inhibitors. However, patients with alterations in both pathways have a worse prognosis compared with patients with only one mechanism. Consequently, it is important to design prospective clinical trials to explore treatments and overcome resistance for these MET/T790M positive patients. A major limitation of this study was that a selective EGFR-TKI (T790M) combined with a MET tyrosine kinase inhibitor was not used to treat MET/T790M positive patients. In addition, unknown mechanisms of resistance were identified in 34.1% of AR patients. It is therefore necessary that future studies include comprehensive next-generation sequencing-based mutation profiling as well as protein and gene expression analyses to identify novel mechanisms of AR.EGFR mutations (the 19 deletion or the L858 mutation) at Guangdong Lung Cancer Institute (GLCI) Guangdong General Hospital (GGH). The study design is shown in EGFR mutations (including T790M), as well as mutations in KRAS, ALK, and HER2. The 128 patients with MET overexpression and/or T790M mutation were divided into three groups: MET positive, T790M positive, and MET/T790M positive. Patients with MET protein overexpression were screened in the MET inhibitor clinical trial. Patients who were T790M positive were screened in the T790M inhibitor (such as AZD9291) clinical trial. Other patients received standard chemotherapy. c-MET, p-MET, EGFR, p-EGFR, receptor tyrosine-protein kinase erbB-3 (ERBB3), p-ERBB3, protein kinase B (AKT), p-AKT, mitogen-activated protein kinase (MAPK), and p-MAPK, which are important markers in MET and EGFR signaling pathways, were detected by immunohistochemistry (IHC). The Institutional Review Board of GLCI of GGH approved this study, and all patients provided specimens with written informed consent. Objective responses were assessed every 6–8 weeks according to the Response Evaluation Criteria in Solid Tumors (RECIST1.1). Progression-free survival (PFS) was measured from the time of treatment with the EGFR-TKI plus MET inhibitor or T790M inhibitor to disease progression. Post-progression survival (PPS) was measured from the time of EGFR-TKI failure to death.We prospectively screened consecutive patients from January 2013 to October 2015 for EGFR exons 18–21 and KRAS exons 2–3  according to the manufacturer's instructions. ARMS detected exon 19 deletions, L858R mutations, T790M mutations, L861Q mutations, S768I mutations, G719X mutations, and exon 20 insertions [The ARMS method was used to evaluate ALK probe  were performed on 4 mm thick paraffin embedded sections. Samples were defined as FISH positive if more than 15% of scored tumor cells had split anaplastic lymphoma kinase (ALK) 50 and 30 probe signals or isolated 30 signals [Interphase molecular cytogenetic studies using a commercially available  signals  . The dilutions of c-Met, p-Met, HGF, EGFR, p-EGFR, ERBB3, p-ERBB3, AKT, p-AKT, MAPK, and p-MAPK antibodies were 1:300, 1:160, 1:40, 1:100, 1:1600, 1:250, 1:900, 1:500, 1:100, 1:100, and 1:400, respectively. MET-positive (protein overexpression) was defined as ≥ 50% tumor cells with high intensity staining Figure . HGF, EGThe chi-square test was used to compare qualitative variables, and those with an expected frequency of < 5 were analyzed using Fisher's exact test. A value of P<0.05 was statistically significant. Kaplan–Meier curves were used to estimate PPS and OS. Data analyses were conducted using SPSS for Windows software .MET/T790M positive patients might be more susceptible to AR to EGFR-TKIs, with a worse PPS than patients with only MET overexpression or the T790M mutation alone. Both MET and EGFR signaling pathways are active in these patients, and first generation EGFR-TKIs combined with MET inhibitors or T790M inhibitors alone were not efficacious for these patients. Novel treatment strategies and clinical trials are therefore needed for MET/T790M positive patients.


Ground granulated blast furnace slag is widely used as a mineral admixture to replace partial Portland cement in the concrete industry. As the amount of slag increases, the late-age compressive strength of concrete mixtures increases. However, after an optimum point, any further increase in slag does not improve the late-age compressive strength. This optimum replacement ratio of slag is a crucial factor for its efficient use in the concrete industry. This paper proposes a numerical procedure to analyze the optimum usage of slag for the compressive strength of concrete. This numerical procedure starts with a blended hydration model that simulates cement hydration, slag reaction, and interactions between cement hydration and slag reaction. The amount of calcium silicate hydrate (CSH) is calculated considering the contributions from cement hydration and slag reaction. Then, by using the CSH contents, the compressive strength of the slag-blended concrete is evaluated. Finally, based on the parameter analysis of the compressive strength development of concrete with different slag inclusions, the optimum usage of slag in concrete mixtures is determined to be approximately 40% of the total binder content. The proposed model is verified through experimental results of the compressive strength of slag-blended concrete with different water-to-binder ratios and different slag inclusions. Slag is a by-product obtained during steel manufacturing and is commonly used in concrete because it improves durability and reduces porosity by improving the interface with the aggregate. Economic and ecologic benefits in the form of energy-savings and resource-conserving properties can also be achieved using slag-blended cement ,2.et al. [et al. [Compressive strength is the most important engineering property of concrete. To ensure progress in construction and safety in engineering practices, we aim to develop understanding on the strength development of concrete. Many experimental investigations have been conducted on the strength development of slag-blended concrete. The strength development of slag-blended concrete closely relates to the water-to-binder ratio, slag replacement ratio, and curing conditions. Beushausen et al.  found th [et al.  found th [et al.  systematetc.) as regards Portland cement, Papadakis [To theoretically deduce the optimum usage of slag, models for compressive strength development of slag-blended concrete are necessary. Compared with abundant experimental studies ,4,5, theapadakis ,7 proposapadakis ,7 does napadakis ,9 evaluaapadakis . In addiapadakis . Using aapadakis  evaluateapadakis ,7,8,9,10apadakis ,7,8,9,10To overcome the weaknesses of the current research ,7,8,9,10The innovations of this research are as follows. First, the proposed numerical procedure is valid for concrete with various mixing proportions, such as different water-to-binder ratios or different slag replacement ratios. The dependences of cement and slag reactivity on concrete mixing proportions and curing conditions are clarified; Second, the proposed numerical procedure is valid for both early-age concrete and late-age concrete. Evolutions of concrete properties are expressed as functions of reaction degrees of cement and slag; Third, the proposed numerical procedure evaluates the macro properties, such as the compressive strength of concrete, by using the microstructures of concrete such as the CSH content and phase volume fraction. The physical meanings of parameters in the proposed model are much clearer than those used in the artificial neural network model .i of cement, as shown in Equations (1-1) and (1-2) below:i = 1, 2, 3, and 4) represents the reaction degree of the cement mineral compounds C3S, C2S, C3A, and C4AF, respectively; α is the degree of cement hydration and can be calculated from the weight fraction of mineral compound Tomosawa  proposedB and C are the coefficients determining this factor; B controls the rate of the initial shell formation, and C controls the rate of the initial shell decay.The reaction coefficient The effective diffusion coefficient of water is affected by the tortuosity of the gel pores as well as the radii of the gel pores in the hydrate. This phenomenon can be described as a function of the degree of hydration and is expressed as follows:In addition, free water in the capillary pores is depleted as hydration of cement minerals progresses. Some water is bound in the gel pores, and this water is not available for further hydration, an effect that must be taken into consideration in every step of the progress of the hydration. Therefore, the amount of water in the capillary pores, The effect of temperature on these reaction coefficients is assumed to follow Arrhenius’s law as shown in Equations (5)–(8):On the basis of the degree of reaction of the mineral compounds of cement , the parThe hydration rate of slag depends on the amount of calcium hydroxide in the hydrating cement-slag blends and the reaction degree of the mineral admixtures ,11,12,13The influence of temperature on the slag reaction is originally considered by the Arrhenius law as follows:eratures ,14.et al. [Based on analysis of the experimental results of the amount of chemically bound water, adiabatic temperature rise, and temperature measurement of small quasi-adiabatic blocks, Maekawa et al.  stated tUsing the hydration degree of cement, reaction degree of slag, and stoichiometry of the reaction of slag , the amoIn Equation (10), 2 in the slag As proposed by Papadakis ,7, for sequation ,7 and thWhen slag is incorporated into concrete, two possible reasons may be adopted to explain the change in the hydration process. One is the chemical reaction of amorphous phases in slag, and the other is the influence of slag on the hydration of cement. In the current paper, the new model that is originally proposed can describe the reaction of slag. The influence of slag on the hydration of cement is originally considered through the amount of capillary water (Equation (11)) and the dilution effect (Equation (4)) . Hence, et al. [Iyoda et al.  investigFor each curing temperature, 5, 20 and 40 °C, the reaction coefficients of slag, As shown in The flow chart of modeling is summarized in As reported by Papadakis ,7, the c4fc(t)=A1et al. [2/g, the maximum size of the coarse aggregate is 20 mm, and the fineness modulus of the fine aggregate is 2.96. The chemical compositions of cement and slag are shown in The experimental results of Cheng et al.  are usedA1 for a water-to-binder ratio of 0.7, 0.5, and 0.35 are 52.39, 61.54, and 55.37, respectively. The values of A2 for a water-to-binder ratio of 0.7, 0.5, and 0.35 are 9.81, 12.04, and 4.47, respectively.Using the blended cement hydration model, the amount of CSH can be calculated and is shown in 1A increases from 52.39 to 61.54. Alternately, for high strength concrete (water-to-binder ratio of 0.35), the strength of concrete relates to three phases of concrete, i.e., the ITZ phase, bulk paste matrix phase, and aggregate phase. Due to the contribution of the aggregate to the compressive strength, the ratio of the strength of the ITZ to the sum of the other two phases (bulk paste matrix paste plus aggregate phase) will decrease. Thus, when the water-to-cement ratio decreases from 0.5 to 0.3, the strength coefficient 1A also decreases from 61.54 to 55.37.At the macroscopic level, concrete is a composite material consisting of discrete aggregates dispersed in a continuous cement paste matrix. The bonding region or interfacial transition zone (ITZ) in concrete between the matrix and aggregate is a critical component of mechanical performance . For ordX-axis intercept of the strength development function increases correspondingly. This agrees with Brooks et al.’s study [X-axis intercept of the strength development function will increase. Neville [’s study  on the s Neville  also repA summary regarding the determination of optimum slag content is as follows: First, using experimental results on the reaction degree of slag, the reaction coefficients of the slag reaction model are calibrated; Second, using experimental results on the compressive strength, the strength development coefficients of slag-blended concrete are calibrated; Third, parameter analysis of the compressive strength development of Portland cement concrete and slag-blended concrete is performed. By comparing the strength development of slag-blended concrete with that of Portland cement concrete, the optimum slag content can be analyzed.This paper has proposed a numerical procedure to analyze the optimum usage of slag for the compressive strength of concrete. The conclusions are summarized as follows.First, we proposed a blended hydration model that simulates cement hydration, slag reaction, interactions between cement hydration and slag reaction, and phase volume fraction evolution of cement–slag blends. The amount of calcium silicate hydrate (CSH), which is closely related to the compressive strength of concrete, is calculated considering the contributions from both cement hydration and slag reaction.Second, by using a linear equation for the compressive strength and CSH content, the development of the strength of slag-blended concrete is evaluated. Given a certain age, with an increase in the water-to-binder ratio, the compressive strength of concrete will decrease. The proposed model can reproduce the strength crossover phenomenon between the control Portland cement concrete and slag-blended concrete. The early-age strength of slag-blended concrete is lower than that of the control concrete. However, at a late age, for concrete containing 10%, 20%, and 40% slag, the compressive strength of slag-blended concrete can surpass that of the control concrete. With an increase in the slag content and the water-to-binder ratio, the starting age of the compressive strength development will be retarded.Third, based on parameter analysis, the ratio of the compressive strength between slag-blended concrete and Portland cement concrete is calculated. For concrete with different water-to-binder ratios, at the late age of 360 days, the optimum slag content is approximately 40% of the total binder content. Before this optimum point, the compressive strength of concrete mixtures containing slag increases as the amount of slag increases. After an optimum point, any further increase in slag inclusion does not improve the compressive strength.


Antibiotic resistance, a consequence of antibiotic use, is a threat to health, with severe consequences for resource constrained settings. If determinants for human antibiotic use in India, a lower middle income country, with one of the highest antibiotic consumption in the world could be understood, interventions could be developed, having implications for similar settings. Year wise data for India, for potential determinants and antibiotic consumption, was sourced from publicly available databases for the years 2000–2010. Data was analyzed using Partial Least Squares regression and correlation between determinants and antibiotic consumption was evaluated, formulating ‘Predictors’ and ‘Prediction models’. The ‘prediction model’ with the statistically most significant predictors (root mean square errors of prediction for train set-377.0 and test set-297.0) formulated from a combination of Health infrastructure + Surface transport infrastructure (HISTI), predicted antibiotic consumption within 95% confidence interval and estimated an antibiotic consumption of 11.6 standard units/person  for India for 2014. The HISTI model may become useful in predicting antibiotic consumption for countries/regions having circumstances and data similar to India, but without resources to measure actual data of antibiotic consumption. In 2015,the World Health Assembly endorsed a global action plan (GAP) on ‘antimicrobial resistance’, with special emphasis on ‘antibiotic resistance’ and all countries were invited to prepare national action plans by May 20173. The United Nations general assembly passed a resolution in September 2016, whereby tackling antimicrobial resistance has been placed as the topmost agenda for all nations of the world2.Antibiotic resistance has become a critical threat to health globally, with most severe consequences for people and settings with constrained resources3. Few countries, except for some high and higher middle income countries have, however, at present the capability of monitoring their antibiotic consumption. India, a lower middle income country with close to one fifth of the total global population, has been reported as a country with one of the highest human antibiotic consumption in the world  annually as against 10 billion units in China and 6.8 billion units in the US)4. A high antibiotic consumption is likely to result in increased development and dissemination of antibiotic resistance, so if the determinants for human antibiotic use in India could be understood, interventions could be more easily developed to address them.Recognized key drivers for development and dissemination of antibiotic resistance are antibiotic use in both human and animal health sectors and the antibiotic residues in the environment14. In case of India, such studies on antibiotics are mostly related to antibiotic use in hospitals or community or focus on specific disease18. As nationwide studies on factors determining human antibiotic consumption are lacking for India, it was of interest to explore the determinants for antibiotic consumption for India. Further, India being a medium human development index country (human development index-HDI rank 131 amongst188 countries)19, it was considered that such a study could also have implications for countries with proximate HDI and similar settings.A range of determinants governing human antibiotic use or health seeking behaviour in various countries/regions, such as social, demographic, economic, climatic, educational, cultural and health care related, have been reported or discussed in literature20 and partial least squares (PLS) regression21 are presented in Table The various primary determinants along with their combinations (summary of primary determinants within categories) termed as derived determinants that were used to build the prediction model for antibiotic consumption in India using the ‘R’ statistical language platform22 was very close to zero .In case of several determinants the loading valueThe equation Equation  for the The estimates for antibiotic consumption in India for the years 2011–2014 are presented in Table 4. A two component model named ‘HISTI’ that includes the derived determinants, ‘Health Infrastructure’ and ‘Surface Transport Infrastructure’, had the least Root mean square error of prediction, and emerged as the best predictor for antibiotic consumption in India. For the analyses we used antibiotic sales data4 termed as consumption data. It might however be, an overestimation of actual consumption data, caused e.g. by patient non-compliance due to adverse effects of treatment or a recovery from symptoms (e.g. Cizman 2003)23. We have however in this paper used the term consumption as is commonly done when approximating sales data for consumption23.This study investigated the determinants of human antibiotic consumption for India using PLS regression analysis. It is, to our knowledge, the first attempt to explore determinants of human antibiotic consumption at the country level for India, one of the highest consumers of antibiotics for humans in the world26.Our model also estimated an increasing trend until 2014, till which time data on involved determinants was available for analysis. The HISTI model includes health infrastructure and surface transport infrastructure as determinants for antibiotic consumption and one or both of these components are likely to increase further in the developing economy of India and therefore for some time to come the HISTI model may remain applicable in predicting antibiotic consumption in India. This may become important e.g. for planning of policies for health care, management of antibiotic use, management of antibiotic resistance and management of antibiotic residues in the environment. The model may also become useful in settings similar to India, where information regarding these determinants is available at the country/state/province/region level.Human antibiotic consumption in India increased by more than 40% between 2000 and 2010 and it was suggested that antibiotic consumption is likely to increase further with the progress of the Indian economy28. In a study analyzing determinants of out-patient antibiotic use in 17 European countries (2000–2005), the factors that appeared to be significant were population income, demographic structure, density of general practitioners and their remuneration method29. Data from 19 European countries from 1999–2007 were further assessed together with a number of factors describing countries in terms of agriculture, culture, climate, demography, disease burden, education, healthcare organization and socioeconomics13. In this analysis, relative humidity, healthcare expenditure proportion to gross domestic product, feelings of distrust, proportion of population aged 65 years and above and availability of treatment guidelines as well as a higher proportion of the population describing themselves as religious were found to be associated with higher total antibiotic use. Factors giving lower use of antibiotics were, restrictions on marketing activities towards prescribers, lower population density, lower number of antibiotics available in the market, educational attainment and higher degree of atheism13. A recent review of studies on factors influencing antibiotic use in Europe, identified factors such as cultural determinants, a range of patient-related factors like illness perception, health-seeking behaviour, previous experience, antibiotic awareness, drug perception, diagnosis labeling, work ethos, perception of practitioners, and practitioner-related factors such as management of respiratory tract infections, initial training, antibiotic awareness, legal issues and practice context5. A study from China showed that it was mainly the economic factors that determined antibiotic use in China14.Various studies have previously evaluated determinants for antibiotic use. In Europe, in two early studies, cultural and economic factors were described to govern self-medication with antibiotics26 facilitates antibiotic use; without it even if diseases in need of antibiotics are prevalent but if facilities are not there to give access to antibiotics, antibiotics will not be utilized. Further, without proper surface transport infrastructure outreach of antibiotics (access) and also of health personnel will be adversely affected. This is in line with a discussion paper by Mavalankar (2016)30 and must be understood in the context of India, a vast country where health care and educated health care providers are predominantly available in cities. For the large rural population, rail and road networks facilitate access to healthcare. For a continental country and a growing economy for a long time to come, until saturation is reached, these determinants- health and transport infrastructure- are likely to continue to influence antibiotic consumption in India.In our study, demographic factors such as total population, population density and age of the population, economic factors such as gross domestic product (GDP), gross national income (GNI), healthcare expenditure, poverty level, health related factors like life expectancy, infant mortality rate, vaccination rate, infectious disease burden and climatic factors such as temperature and rainfall, did not appear to have influence on antibiotic consumption in India as much as health infrastructure and surface transport infrastructure. This appears logical as health infrastructure-health systems32, however, in countries/regions, where waterways are also used in a major way for passenger and freight transport, they should also be included as a component of surface transport as a determinant in analysis.Our analysis has, to the best of our knowledge, for the first time brought out health infrastructure and transport infrastructure as the determinants governing antibiotic consumption for a country. Both of these were earlier not considered for evaluation, the way we used them in our analysis, particularly transport infrastructure. In India, for transport infrastructure, we considered road and rail transport, as most of the (more than 95%) freight and passenger transportation occurs using road and railwayset al.33 which suggests that there is an association between physician density and healthcare consumption. Further, Filippini et al.10 found that in Switzerland an increase in the number of physicians at cantonal level caused an increase in the cantonal per capita antibiotic sales. A study from the U.S. also reports that number of physicians and clinics per capita were drivers of antibiotic prescribing rate34, which is in line with our finding that health infrastructure is a determinant governing antibiotic consumption.Our study confirms that provider/prescriber induced demand commonly termed as supplier induced demand plays a role in determining antibiotic consumption, this is in line with the systematic review by Leonard 4. Thus, there is every likelihood that antibiotic consumption per capita is likely to increase in India for some time to come25. As antibiotic use increases, the likelihood of quantitative and qualitative increase in antibiotic resistance in bacteria in India is also likely26. Further, increase in antibiotic consumption will also cause increase in antibiotic residues and resistance in the environment. It is important that countries such as India, areprepared to tackle the problems associated with increasing antibiotic use mentioned earlier and this is a point to be considered for the ‘National Action Plans’ being set up in all such countries following the GAP of 20153.Although our analyses projects an increase in antibiotic consumption in India, from 10.7 units/person in 2010 to 11.6 units/person in 2014, compared to some countries in Europe, the use is still comparatively low, e.g. in 2010 France used 23.1 units/personet al.14 state that besides being useful for estimating and forecasting antibiotic consumption, various exposure models using potential determinants of antibiotic consumption may become useful in estimating environmental residue concentrations of antibiotics in regions where environmental concentration are largely unmonitored. They further suggest designing of spatially resolved models, as antibiotic consumption data are generally available at country level, but determinants may be available at sub-national level also. As has been demonstrated by us by elaborating the antibiotic consumption for the constituent states of India  was greater than the number of observations for the dependent variable. In this case, too, ordinary least square regression in its usual form would have been unable to find a unique set of regression coefficients that minimize the sum of the squared errors. Hence, we built the prediction model by using Partial Least Squares (PLS) regression to avoid over-fitting and to remove highly correlated determinants. PLS regression is a method for constructing predictive models when the independent factors are many and highly collinearPLS regression finds components that simultaneously summarize variation of the determinants while being optimally correlated with the response variable. For a univariate response (in this case antibiotic consumption), each iteration of the algorithm used by PLS regression assesses the relationship between the determinants X (independent variables) and response Y (dependent variable). The predictor data are then orthogonally projected onto the direction (a vector of weights) to generate scores T and U . The scores are then used to generate loadings P and Q, which measure the correlation of the score vector to the original determinants and response. At the end of each iteration, the determinants and the response are “deflated” by subtracting the current estimate of the determinants and response structure, respectively. The new deflated determinants and response information are then used to generate the next set of weights, scores, and loadings.40. Our study appears to be the first using PLS regression for predicting antibiotic consumption.PLS regression is a method which is suitable either where there are many correlated independent variables or where the number of independent variables are much more than the number of observations for the dependent variable and has earlier been used in a variety of studies such as chemical, microbiological, metabolomics, pharmaceutical and health systems studies looking at patient safety and patient engagement42. For all the determinants, we have used publicly available data, which makes our method and analysis potentially useful for others and other countries also for predicting their future antibiotic consumption, where similar datasets for determinants are available. Further, the suggested model/methodology might also become useful in estimating antibiotic consumption in situations where access to actual antibiotic consumption data is difficult to obtain or is not available.The strength of our study is that we have used several determinants per year and have used a method recommended for such data, PLS regressionData for all the determinants for the years 2000–2010 was extracted from relevant publicly available reliable sources’ like the World Bank, the World Health Organization and the Government of India. There can always be limitations in relation to data collection and management techniques of such data, but those data are on the other hand the best or only reliable and valid data available. The methods of their collection are described in official publications of these renowned organizations.43. The data we have used is reported to cover about 95% of sales4. This means that probably our predictions give figures for antibiotic consumption 5% lower than actual. Further, we also did not include any patient perceived factors like inappropriate treatment protocols, corruption etc., which in one questionnaire study was considered as having higher barriers than distance44. Besides human use, antibiotics are also used in animal therapy, prophylaxis and growth promotion, however we could not include that in our current study. It would have been useful to compare our predicted values of human antibiotic consumption with the actual national pharmaceutical sales data values to understand the veracity of our model. However, financial constraints did not allow us to purchase such data for the years 2011–2014 or for the Indian states.A limitation of our study is that, as we used a data in which so called standard units are used, we could not convert the data to DDDs (Defined Daily Doses), prescription or packages as the data was only available to us at an aggregated level. We could thus not use the WHO recommended system of using ATC  and DDD for presenting drug utilization data19 (HDI rank-131/188) and also a lower middle income country, the prediction model formulated in this study may also become useful in predicting antibiotic consumption in other low and lower middle income countries having circumstances similar to India, but without access to actual measurements of antibiotic consumption, particularly because many such countries could have data on their health and transport infrastructure.A model combining health infrastructure and surface transport infrastructure, the HISTI model, was developed using PLS regression and R statistical platform for predicting human antibiotic consumption in India. As one or both these components are likely to increase further in the developing economy of India, for some time to come the HISTI model may have its utility in predicting human antibiotic consumption for India. India being a medium human development index countryWe have only analyzed human consumption data in this paper, it will be interesting to find out determinants for animal consumption and also for total  antibiotic consumption for India.45 and ‘Swatch Bharat’46 (clean India) campaign coming in to practice, it is possible that both optimization of antibiotic use is underway in India, and also infectious disease burden is coming down. Social initiatives like Indian Initiative for Management of Antibiotic Resistance47, Chennai declaration48, and Jaipur declaration49 might also contribute to optimization of antibiotic use by increasing awareness among the public as well as health care providers. Stricter enforcement of prescription only drugs, specifically antibiotics, and prescribing protocols and guidelines may also help in optimization of antibiotic use. Studies in which such factors are included should be undertaken in future.With new antibiotic policies including the national action plan14. In addition, several India specific potential determinants were added for evaluation. For example, in India besides allopathic (western) medical practitioners, there are also AYUSH  practitioners, who also prescribe antibiotics. Therefore, the practitioners, hospitals and healthcare based on AYUSH were also taken into account, i.e. in our analysis, the determinant Total number of hospitals was derived by summing up number of allopathic hospitals and number of AYUSH hospitals; Total number of hospital beds included number of beds in both allopathic and AYUSH based hospitals; Total number of professionals included allopathic medical practitioners, dental surgeons and registered practitioners under AYUSH systems; Total number of providers included the total number of general nursing midwives, auxiliary nursing midwives, health visitors and health supervisors; a combined determinant “Total number of professionals and providers” included the total number of professionals and the total number of providers. Some ‘Derived Determinants’ combining (summarizing) primary determinants within the same category  was sourced from Van Boekel et al.4. Antibiotic sales data available at this source was used as a proxy for human antibiotic consumption. According to these statistics the antibiotic consumption in India increased from 7,413 standard units per 1000 population in 2000 to 10,608 standard units per 1000 population in 2010. The consumption figures for intermediate years were  2001-7,031, 2002-7,392, 2003-7,564, 2004-7,371, 2005-7,721, 2006-8,926, 2007-9,160, 2008-9,460, 2009-10,152 standard units per 1000 population. All the data were inputted in MS Excel for further analysis. In some instances, when data was missing for a particular year for a variable, the missing data was imputed using the forecast function of MS Excel in which the values of the determinant for previous years was used to predict the missing value.The determinants evaluated for governing human antibiotic use in India are shown in Table At the time of analysis, for some states and union territories of India, data for more than one category of determinants was not available. These states and union territories were not included in the analysis presented in Table In this paper we have used data available for relevant independent variables, to build a regression model that could predict antibiotic consumption in the future. For this we attempted to establish relationships between the studied independent variables Table  and the 20. The prediction model was built using PLS regression. A leave-one-out cross validation was used to build a robust model. The data was divided into training set (75% of the available data) and test set (remaining 25% of the data). The training set is a subset of the original data which is used to discover potentially predictive relationship, while the test set is the remaining part of the original data which is used to assess the strength and utility of a predictive relationship. Both the sets, training and test, were created using random sampling technique to minimize any bias.All the analysis was performed using the R statistical language platform22.A model was built on the training set and was validated on the test set. The inclusion of a determinant in the prediction model was decided on the basis of combined evaluation of variable importance in projection (VIP) score Table  and loadVariable importance in projection (VIP) scores reflect the relative importance of each X variable (independent variable) for each X variate in the prediction model. .VIP coefficients thus represent the importance of each X variable (independent variable) in fitting both the X- and Y-variates , since the Y-variates (antibiotic consumption) are predicted from the X-variates . VIP allows to classify the X-variables  and the R code is shown in online Supplementary material.The datasets analysed during the current study are publicly available at sources mentioned in the paper.Supplementary information


Lx (polydactyly-luxate syndrome) in the rat is determined by deletion of a conserved intronic sequence of the Plzf (Promyelocytic leukemia zinc finger protein) gene. In addition, Plzf is a prominent candidate gene for quantitative trait loci (QTLs) associated with cardiac hypertrophy and fibrosis in the spontaneously hypertensive rat (SHR). In the current study, we tested the effects of Plzf gene targeting in the SHR using TALENs (transcription activator-like effector nucleases). SHR ova were microinjected with constructs pTAL438/439 coding for a sequence-specific endonuclease that binds to target sequence in the first coding exon of the Plzf gene. Out of 43 animals born after microinjection, we detected a single male founder. Sequence analysis revealed a deletion of G that resulted in frame shift mutation starting in codon 31 and causing a premature stop codon at position of amino acid 58. The Plzftm1Ipcv allele is semi-lethal since approximately 95% of newborn homozygous animals died perinatally. All homozygous animals exhibited manifestations of a caudal regression syndrome including tail anomalies and serious size reduction and deformities of long bones, and oligo- or polydactyly on the hindlimbs. The heterozygous animals only exhibited the tail anomalies. Impaired development of the urinary tract was also revealed: one homozygous and one heterozygous rat exhibited a vesico-ureteric reflux with enormous dilatation of ureters and renal pelvis. In the homozygote, this was combined with a hypoplastic kidney. These results provide evidence for the important role of Plzf gene during development of the caudal part of a body—column vertebrae, hindlimbs and urinary system in the rat.Recently, it has been found that spontaneous mutation  Lx (polydactyly-luxate syndrome) was originally detected and fixed in the PD/Cub (polydactylous) inbred strain and transferred to genetic backgrounds of the BN-Lx (Brown Norway) and SHR-Lx (spontaneously hypertensive rat) congenic strains [lu (Green's luxoid) spontaneous mutation as a nonsense point mutation in the Plzf (Promyelocytic leukemia zinc finger protein) gene [lu and Lx genes, respectively, Plzf was an obvious candidate for the Lx mutation. Sequence and fine mapping analyses revealed deletion of a conserved intronic sequence of the Plzf gene to be responsible for the Lx phenotype [Deletions of the chromosomal region 11q23 are known in human resulting in a phenotype including mental retardation, craniofacial dysmorphism, microcephaly and short stature. Within the chromosomal region 11q23, the promyelocytic leukaemia zinc finger (PLZF) gene encodes a DNA sequence-specific transcriptional repressor OMIM 176797). A similar mutation also exists in animal models. In Wistar outbred rats, spontaneous mutation in) gene  and conshenotype . PLZF is797. A siLx progenitors, and in SHR-Lx minimal congenic strain, identified Plzf as a candidate gene predisposing the SHR to left ventricular hypertrophy and cardiac interstitial fibrosis [Plzf-/- mice are protected against cardiac hypertrophy induced by angiotensin II [Plzf gene in the SHR to study the effect of Plzf knockout on cardiac hypertrophy and fibrosis. Surprisingly, we found that, contrary to the mouse, over 95% of Plzf-/- homozygotes die shortly after birth. All homozygous animals exhibited manifestations of a caudal regression syndrome including tail anomalies and serious reduction deformities of long bones, and oligo- or polydactyly on the hindlimbs. Impaired development of the urinary tract was also found. The heterozygous animals only exhibited the tail anomalies.Recently, linkage analyses in BXH/HXB recombinant inbred (RI) strains, derived from SHR and BN-fibrosis ,8. In adensin II . In the Plzf-/- homozygotes  growth retardation of Plzf-/- fetuses (mean body weight 1716±35 mg) and Plzf+/- fetuses (mean body weight 1674±37 mg), when compared to Plzf+/+ animals (body weight 1831±35 mg). All wild-type rats were without a visible malformation  ossification of long bones (stylopod and zeugopod) were present in 100% of rats .Among the heterozygous fetuses, only 18% exhibited signs of the caudal regression syndrome. We recorded malformation of the tail (bending of the tip) and strong reduction of tail vertebrae from a normal number 27 to 16–17. In these animals, the distal portion of the tail was only formed by soft tissues . One PlzPlzf-/- rat, which survived till the age of 10 days and externally exhibited serious manifestations of the caudal regression syndrome. Its body weight was only 10.1 g, while the weight of its wild-type siblings was nearly double . Caudal part of the body of this animal was hypoplastic and both lower extremities had markedly reduced length of the stylopod and zeugopod (We examined a zeugopod . The lowzeugopod . The endzeugopod  and the The left kidney was markedly hypoplastic and much less perfused than the right one . Both kiPlzf-/- deficient rats. The significant decrease in body weight (growth retardation) was already found before birth, not only in Plzf-/- rats, but also in the heterozygous Plzf+/- animals. The growth retardation is known to be associated with inborn defects. About one-third of the variations in birth weight are determined by genetic variables in human [In the present study, a caudal regression syndrome and significant decrease of body weight were found in the in human .The syndrome of caudal regression is well known in humans, being characterized by varying degrees of developmental disorders of the caudal half of the body . The external malformations can be associated with developmental disorders of internal organs, such as renal agenesis and dysplasia, vesicoureteral reflux (VUR) including hydronephrosis and dilated ureters, ectopic ureters, fused kidneys, absent bladder, rectovaginal and rectourethral fistulae, transposition of external genitalia, hypospadias, urethral atresia etc. .All homozygous rats in the present study exhibited typical external features of the caudal regression syndrome. Only a portion of heterozygous animals presented externally a “miniform” of the syndrome (reduction of tail vertebrae). However, serious developmental disorder of the urinary tract occurred in one homozygous and one heterozygous rat: they exhibited VUR. The inherited VUR is a complex genetic developmental disorder caused by anomalous development of the urinary tract  ,13. The Plzf knock-out rats is not completely consistent with the observed phenotypes of the Plzf-/- and luxoid mouse [Plzf are viable, the rats die shortly after birth as a result of the urinary tract abnormalities. Hind limb abnormality was more pronounced compared the the Plzf-/- mice, when the frequency of missing digit I is less than 40% in the mouse [Lx mutation [Phenotype of the id mouse ,4. Most he mouse , but 60%he mouse , which whe mouse . In genemutation  than thePlzf-deficient mouse and rat strains.In humans, a rare biallelic mutation of the PLZF gene was described. Observed malformations included bilateral absence of thumbs, aplasia or hypoplasia of ulna, delayed ossification, cleft palate, micropenis, cryptorchidism, short stature, microcephaly, and mental retardation. No renal malformations were reported . This huPlzf deficient rats are affected by the impaired development of the caudal half of the body—caudal regression syndrome, which may also include an inherited anomaly of the urinary tract. The latter anomaly causes the vesico-ureteric reflux with reflux nephropathy, which can progressively lead to renal failure and perinatal death.Based on the present data, we can conclude that the Plzf gene by TALEN method in a highly inbred strain of SHR (SHR/OlaIpcv) that has been brother x sister mated for well over 140 generations. SHR harboring KO mutation in the Plzf gene were derived by microinjections of fertilized ova with pTAL438/439 constructs (see next section). The adult rats were sacrified by cervical dyslocation and the rats from prenatal and perinatal studies were sacrified by decapitation. The rats were housed in an air-conditioned animal facility and allowed free access to standard diet and water. All experiments were performed in agreement with the Animal Protection Law of the Czech Republic and were approved by the Ethics Committee of the Institute of Physiology, Czech Academy of Sciences, Prague (Permit Number: 66/2014).We targeted the Plzf gene. pTAL438 construct was targeting sequence 5´ GCA AGG CCA ATC AGA T 3´, followed by spacer 5´ GCG ACT GGC CGG GAC TTT GTG CG 3´ and by sequence 5´ CCA CCA TGA TGA CCA CAT 3´ recognized by pTAL439  using BigDye Terminator v1.1 Cycle Sequencing Kit and ABI PRISM 310 Genetic Analyzer . For genotyping the offspring of the founder, we took the advantage of the induced mutation (c.91delG) that resulted in the absence of a (CC's_GG) sequence recognized by the NciI restriction enzyme. Therefore, amplification of genomic DNA  with subsequent cleavage by NciI yielded 65 bp and 159 bp fragments for wild-type allele, 224 bp uncleaved product for the targeted allele  was purchased from Abcam . Monoclonal mouse α-tubulin (B-5-2-1) was from Sigma-Aldrich . Membranes were incubated overnight at 4°C with antibodies at final dilution 1:5000 (PLZF) or 1:15000 (α-tubulin), secondary HRP-conjugated antibody was from GE Healthcare Bio-Sciences , and signal was detected using ECL Prime chemiluminiscent detection kit  and Hyperfilm ECL. Developed hyperfilms were scanned and densitometry performed in ImageJ. We made 4 technical replicates and used normalized average of PLZF/control protein density as an estimate of expression level of PLZF in each rat. Theoretical molecular weight of unmodified PLZF is 74 kDa. We observed signal consistently at slightly more than 80 kDa, in skeletal muscle there can also be a genuine minor isoform of approximately 60 kDa (absent in null homozygotes). In liver there is a cross-reacting protein of approximately 100 kDa, which most probably does not represent a PLZF isoform, since there is no evidence in mammalian genomes/transcriptomes of such larger coding sequence.Plzf-/-, 17 Plzf+/-, and 11 Plzf+/+ rats were investigated.The animals were mated overnight. The day, when a sperm was present in a vulva early morning was determined as the first day of pregnancy corresponding to the first day of embryonic development. We totally harvested 37 fetuses at embryonic day (ED) 20–21. After the harvesting, each fetus was weighed, and a sample of tissue was taken from its external ear for determination of its genotype. 9 The native fetuses were examined under stereo-loupe  to detect external malformations. The gross malformations of the internal organs were evaluated after opening the thoracic and abdominal cavities. The organs exhibiting pathological changes were fixed in Bouin-Hollande fluid for 7–10 days, routinely histologically processed, and 8μm thick sections were stained by alcian blue-haematoxylin-eosin. For detection of skeletal anomalies, the specimens were fixed in graded series of ethanol (70–96%), and alcian blue-alizarin red skeletal staining was performed.Plzf-/- rat and its 2 wild-type siblings were investigated. The external and internal examinations and further processing of the specimens were made in a similar way as in the prenatal study.A 10-day-old Plzf-/-, Plzf+/- and Plzf+/+ genotypes were analyzed by one away ANOVA with adjustments for multiple comparisons by Holm Sidak testing. Statistical significance was defined as P<0.05.Body weight data are expressed as means ± S.E.M. Differences between animals with