Different types of waste ceramics (apart from recycled concrete) are the most popular materials for the production of waste aggregates as possible substitutes for natural ones. The aim of this research was to analyse the efficiency of different aggregate mixes composed of waste and natural materials focusing on two waste ceramic aggregates, which were prepared concrete mixes based on specifically composed aggregates  waste ceramic aggregate, and dense, kaolin-based (white) waste ceramic aggregate). All aggregates were thoroughly tested before utilisation for concrete mix creation. Altogether, four blends of aggregates were prepared in order to prepare concrete mixes using a simplex experiment design. The mixes were then modified by adding various amounts of crimped steel fibre. Such properties of hardened steel fibre-reinforced concrete (SFRC) such as density, compressive strength, shear strength, ultrasound propagation velocity, dynamic modulus of elasticity, and limit of proportionality during flexural testing were of special interest. Tests were conducted according to European and Japanese standards. The achieved fibre-reinforced concretes were characterised by satisfactory strength characteristics, thereby enabling the substitution of traditional reinforcement. Strength classes according to the  A growing research effort exists globally to successfully harness different ceramic wastes in the construction industry ,2,3, resfV). Altogether, 16 mixes of concrete were cast in order to test the properties of the concretes in a hardened state.The research programme was divided into two stages. The first stage covered the testing of the geometrical and mechanical properties of the waste and natural aggregates. The second stage covered property testing of concretes made on the basis of the waste and natural aggregates that were tested during the first stage. Analysis of the possible replacement of natural aggregates by waste ceramic aggregates was subsequently conducted. Specific mixtures of both waste ceramic and natural aggregates were proposed for concrete production. The obtained four mixes were subsequently modified by the addition of steel fibres, which were added in volumes ranging from 0.5% to 1.5%  and American (ASTM C305) standards. The achieved grading of all three aggregates was very similar see . All thrdm  within tThe aggregates were thoroughly tested according to the European standards EN 933-1, EN 1097-1,-3,-6, and EN 1367-1. Properties such as density, absorbability, freezing–thawing resistance, and abrasion resistance were of special interest. The Los Angeles abrasion test was utilised as the most common test method to indicate aggregate toughness and abrasion characteristics. Granulometric and other tested properties of the aggregates are presented in Portland Cement CEM I 42.5 N-NA compliant with the EN 197-1:2000 standard was used as a binder for concrete mix creation. Tap water meeting the requirements of the EN 1008:2002 standard and high-performance, commercially available superplasticiser were added during the last stage of the mix preparation. Based on previous experience with the aggregates in question , four diCrimped, copper-coated steel fibres were chosen as fibre reinforcement see . This kiX—red ceramic waste; Y—natural aggregate; Z—white ceramic waste. Due to the different specific gravity values of red ceramic waste, white ceramic waste, and natural aggregate, the materials were dosed by volume. The specific property of the mixture design was that the sum of the volume of all three ingredients was always equal to 100%. In this case, the three aggregates played the roles of the ingredients. The utilised design is described in detail in An ordinary integral simplex design   was utilThe object of the experiment was considered to be a complex composite material. The internal structure of the material was unavailable (for unknown reasons) to observers, with only the “input” and “output” parameters known to observers ,23. All All specimens were tested after 28 days of curing  in a temperature of 20 °C ± 0.5 °C. After curing, specimens were measured, weighed, and dried to avoid problems during the ultrasound velocity test . The cal3 for composites based solely on the red ceramic waste aggregate to values over 2.350 kg/dm3 for composites based solely on the natural aggregate. The composite created using only the white ceramic waste aggregate was characterised by a density of 2.117 kg/dm3. These results are presented in X-axis represents the proportion of red ceramic in the concrete aggregate mix, the Y-axis represents the natural aggregate proportion, and the Z-axis represents the white ceramic proportion. Density graph lines can be seen within the triangle, representing the fractions of the aggregates. The densities of all the concrete mixes with the addition of steel fibre . The velocity was influenced by the aggregate  and the addition of steel fibre. The highest velocity was associated with no-fibre, white ceramic concrete (just over 5 km/s) and the lowest velocity was observed with the no-fibre, red ceramic concrete . In theory, the addition of steel fibre should increase the ultrasonic pulse velocity, but the extra entrapped air effectively contradicted this process. All of the tested SFRCs were characterised by an ultrasonic pulse velocity ranging between the values achieved by the concretes with no fibre. Once the velocities were determined for all of the concretes in question, general ideas about their quality and uniformity could be attained. The velocity of the ultrasonic pulse was used to classify the quality of the tested concretes [V > 4.5 km/s, 4.5 km/s > V > 3.5 km/s, and 3.5 km/s > V > 3.0 km/s, of velocity which was associated with concrete quality . Results below 3.0 km/s were recognised as unsatisfactory. Tested concretes covering the whole range of possible results demonstrated the significant impact of aggregates and fibre addition on the properties and qualities of cement composites. Before destructive testing, all specimens were used to measure the ultrasonic pulse velocity  was then calculated, as described by Neville [ρ is the density of hardened concrete (kg/m3) and V is the ultrasonic pulse velocity (m/s).The value of the dynamic modulus of elasticity  relationship. Specimens were considered to be ultimately destroyed after achieving a CMOD equal to 4 mm. Exemplary registered load–CMOD diagrams are presented in LOPf of a particular concrete and all four residual strengths, i.e., R1, fR2, fR3f, and R4.f The achieved values of LOPf are presented in The load–CMOD diagrams were used to define the limit of proportionality The last tested property was shear strength, which is very important in the case of SFRC because it differentiates these materials significantly from ordinary concretes. The achieved results of shear strength are presented in R1f, R2f, R3f, R4f) associated with particular CMOD values  are not feasible for the direct design of an SFRC mix. There is general agreement among the global SFRC research community that the first residual strength R1f is important in terms of service conditions, whereas the third residual strength R3f is recognised as a key factor for the assessment of ultimate conditions. The “fib Bulletin 55, Model Code 2010” proposed the utilisation of the first and third residual strengths to calculate both the serviceability limit state (SLS) and the ultimate limit state (USL). Basically, the ratio R3f/R1f was defined to describe the relationship between the behaviour of SFRC at ULS and SLS [Four residual strengths  and post-cracking softening or hardening behaviour, which was described by a letter symbol from a to d directly referring to the R3f/R1f ratio. Letter a represents the strongest softening and letter d represents the strongest hardening [The proposed ardening .When the fibre reinforcement was efficient enough, substitution of traditional bar and stirrup reinforcement was enabled. Two following conditions were fulfilled simultaneously to pass the substitution threshold:Calculated values of the above factors for tested concretes are presented in The achieved strength classes and enabled traditional reinforcement substitutions allowed for the utilisation of the tested concretes for structural applications. The wise use of different blends of ceramic waste and natural aggregates to shape the properties of cast concretes is possible. The proposed approach toward ceramic waste aggregates merged the advantages of internal curing and fibre reinforcement and was proven to be efficient.It is possible to cast composites based on multiple waste aggregates;A blend of waste ceramic aggregates achieved a greater flexural strength of a cement composite than ordinary natural sand;The highest compressive strength was achieved using only natural aggregates;The compressive strength of the tested concretes was significantly influenced by the composition of the aggregate mix, as evidenced by the concrete with 1.5% fibre composition, whereby the values ranged from 17.5 MPa to 85.3 MPa;It is possible to partially or fully substitute natural aggregates with white or red ceramic wastes;fib Model Code 2010;The composites created on the basis of the white and red ceramic wastes are characterised by satisfactory mechanical properties, allowing for the assignment of standard strength classes according to both the EN and The research programme should be continued using greater specimens, focusing on more complicated mechanical characteristics  of composites to enable full-scale modelling.The following conclusions can be drawn from the research described in this paper:


Pulmonary side effects are well known, including lung fibrosis, in elderly patients treated with long-term nitrofurantoin to prevent urinary tract infections and secondary renal injury. However, pulmonary side effects have only been reported rarely in paediatric cases, despite nitrofurantoin being a first line prophylactic treatment of recurrent childhood urinary tract infection.A 6-year-old girl was admitted to the hospital with dyspnea, general fatigue, loss of appetite and need for nasal oxygen treatment after long-term nitrofurantoin treatment. A computed tomography scan of the chest showed lung fibrosis. A biopsy confirmed this diagnosis. We suspected the fibrosis to be caused by the nitrofurantoin treatment. Thorough examinations reveal no other explanations. Nitrofurantoin was discontinued and the girl was treated with methylprednisolone. After 17 month a new scan and lung function test showed total regression of the lung fibrosis.This case underlines that risk of severe side effects should be taken in to account before initiation of long-term nitrofurantoin treatment in children. Nitrofurantoin has been a first line antibiotic choice in prophylactic treatment of childhood urinary tract infection. Pulmonary toxicity causing irreversible pulmonary fibrosis is a well-known side effect of long-term nitrofurantoin treatment and other biological treatments in adults and elderly -4. HowevWe report a case of a 6-year-old girl who developed dyspnea and interim need for nasal oxygen treatment due to pulmonary fibrosis manifesting after 2 years of nitrofurantoin treatment.The 6-year-old girl was admitted to the hospital with dyspnea, general fatigue and loss of appetite developing during approximately 1 month. At admission, oxygen desaturation was 80–90% before nasal oxygen treatment.Daily and continuous treatment with oral nitrofurantoin  in combination with solifenacin (tablets) had been initiated 2 years prior to the admission to prevent recurrent urinary tract infections. She presented no other medical history.Initial blood samples revealed liver affection , but otherwise biochemical parameters were unaffected. Multiple PCR analyses detected no microorganisms in samples from the upper respiratory tract. A computed tomography scan of the chest showed bilateral multilobar parenchymal infiltrates, ground glass opacity, interstitial changes, and enlarged hilar lymph nodes however only discrete signs of lung fibrosis with no honeycomb change, subpleural cysts or traction bronchiectasis  was started at the day of admission. Nitrofurantoin and solifenacin were discontinued. After 3 days, treatment was changed to prednisolone tablets (20 mg/kg twice a day).A bronchoscopy performed after 2 months of treatment due to ongoing respiratory symptomes and revealed structurally normal airways. However, microbiological analyses showed pneumocystis jirovecii in a broncho-alveolar lavage sample taken during the procedure. The infection was successfully treated with tablets of sulfametoxazol and trimetoprim (400 mg + 80 mg) three times a day for 3 weeks. It is difficult to be certain about the onset of pneumocystis jirovecii lung infection; however, this infection is most likely a consequence of immunosuppression due to steroid treatment or less likely secondary to the chronic lung changes.After 2 months, prednisolone was withdrawn over a period of 25 days. However, a following synacthen test showed tertiary adrenal insufficiency and hydrocortisone replacement therapy was initiated.1/FCV-ratio unaffected). Following tests showed normalization of all parameters    and forced expiratory volume in 1 s (FEV1) , but no bronchial obstruction (FEVue) Fig. . 17 montNitrofurantoin is an antibiotic medicament often used in the treatment of recurrent urinary tract infections as the urinary excretion rate is high. Recent studies have questioned the efficacy of antibiotics in the prevention of recurrent urinary tract infections and secondary renal injury in children . In a reIn Denmark, the national paediatric society recently changed the national clinical guideline: Prophylactic antibiotics should only be prescribed by specialists and after treatment of relevant risk factors . The recThe American Academy of Pediatrics  recommends “prompt” initiation of antibiotic treatment in case of symptoms rather than prophylactic antibiotic  of recurDifferent pathophysiological mechanisms have been suggested to cause the pulmonary toxitcity of long-term nitrofurantoin treatment. One leading theory is that oxidative stress by the production of free radicals might injure the lung tissue, as nitrofurantoin in its active form is highly reactive. In vivo studies showed reduced injury in tissue incubated with nitrofurantoin in combination with antioxidants compared to nitrofurantoin alone. Hypersensitivity to nitrofurantoin and thereby cytokine-initiated inflammation is another possible explanation. However, hypersensitivity is more likely to cause acute reactions after short-time nitrofurantoin treatment .In this case, a 6-year-old girl developed pulmonary fibrosis after 2 years of nitrofurantoin treatment preventing recurrent urinary tract infections. Thorough clinical examinations and paraclinical testing revealed no infection or other causes of the fibrosis at the time of admission. Discontinuation of nitrofurantoin and treatment of high-dose steroids resulted in full regression of the fibrosis and normalization of pulmonary symptoms and lung function. We conclude that the most probable cause to reversible lung fibrosis was the pulmonary toxicity of treatment with long-term nitrofurantoin. Whether or not the pneumocystis jirovecii infection verified in the lungs 2 months later had been ongoing for longer time is unknown, however if present at baseline and during steroid treatment it would have been expected to be associated with worsening of lung function.This case shows that the well-known side effect of long-term nitrofurantoin treatment in elderly also may be a rare paediatric risk factor. Clinicians should consider alternative options when planning prophylactic treatment of recurrent urinary tract infections in children.


Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aimed to validate maternal and newborn indicators to inform measurement of coverage and quality of care. This paper reports validation of reported antibiotic coverage by exit survey of mothers for hospitalized newborns with clinically-defined infections, including sepsis, meningitis, and pneumonia.An estimated 30 million neonates require inpatient care annually, many with life-threatening infections. Appropriate antibiotic management is crucial, yet there is no routine measurement of coverage. The EN-BIRTH study was conducted in five hospitals in Bangladesh, Nepal, and Tanzania (July 2017–July 2018). Neonates were included based on case definitions to focus on term/near-term, clinically-defined infection syndromes , excluding major congenital abnormalities. Clinical management was abstracted from hospital inpatient case notes (verification) which was considered as the gold standard against which to validate accuracy of women’s report. Exit surveys were conducted using questions similar to The Demographic and Health Surveys (DHS) approach for coverage of childhood pneumonia treatment. We compared survey-report to case note verified, pooled across the five sites using random effects meta-analysis.n = 910), 98.8% (95% CI: 97.8–99.5%) correctly reported their baby was admitted to a neonatal ward. Only 47.1% (30.1–64.5%) reported their baby’s diagnosis in terms of sepsis, meningitis, or pneumonia. Around three-quarters of women reported their baby received an injection whilst in hospital, but 12.3% reported the correct antibiotic name. Only 10.6% of the babies had a blood culture and less than 1% had a lumbar puncture.A total of 1015 inpatient neonates admitted in the five hospitals met inclusion criteria with clinically-defined infection syndromes. According to case note verification, 96.7% received an injectable antibiotic, although only 14.5% of them received the recommended course of at least 7 days. Among women surveyed (Women’s report during exit survey consistently underestimated the denominator (reporting the baby had an infection), and even more so the numerator (reporting known injectable antibiotics). Admission to the neonatal ward was accurately reported and may have potential as a contact point indicator for use in household surveys, similar to institutional births. Strengthening capacity and use of laboratory diagnostics including blood culture are essential to promote appropriate use of antibiotics. To track quality of neonatal infection management, we recommend using inpatient records to measure specifics, requiring more research on standardised inpatient records.The online version contains supplementary material available at 10.1186/s12884-020-03424-7. Infections, including sepsis, pneumonia and meningitis, account for one-third of all newborn deaths globally , 2. MoreEarly appropriate management of neonatal infections is critical for newborn survival. The World Health Organization (WHO) recommends inpatient management of infections among newborns with injectable antibiotics . Early aEvery Newborn Action Plan (ENAP) identified a set of core and additional indicators to be measured globally to monitor and track the progress of newborn health. A multi-partner ENAP measurement improvement roadmap was developed to validate these indicators [Accurate data are crucial to track progress towards the SDGs and the global vision to end all preventable maternal and newborn mortality as well as stillbirths. The dicators . The proEvery Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. Blood culture remains the gold standard diagnosis, even though this may be negative in more than half of cases where skilled clinicians are confident of the diagnosis . Many LMICs still depend on population-based surveys such as The Demographic and Health Surveys (DHS) Program and Multiple Indicator Cluster Surveys (MICS) to report coverage for health care use including for management of childhood illnesses , 25. OneDespite increasing opportunities to improve measurement in routine facility-based information systems, there has been little research on coverage validity for newborn care. This is an important opportunity, given that ~ 80% of the world’s births are now in facilities  coverageAs yet, no published studies have assessed the validity of survey report for clinically-defined neonatal infections, to inform the use of surveys to collect coverage data on this important aspect of universal health coverage, or explored feasibility for capture in facility data systems.‘Informing measurement of coverage and quality of maternal and newborn care’, and focuses on injectable antibiotic treatment of clinically-defined neonatal infections  amongst inpatients, addressing the following objectives:VALIDATION of women’s report through exit survey to determine the accuracy/validity forDenominator options: The following denominator options were assessed-Option d1- Reported the baby was admitted to newborn wardOption d2- Reported the baby was admitted and had any infectionOption d3- Reported the baby was admitted and had any one of the clinically-defined infection syndromes. i.e. sepsis, pneumonia, meningitisNumerator options: The following numerator options were assessed-Option n1- Reported the baby received any injection/antibioticOption n2- Reported the baby received any injection/antibiotic and reported the antibiotic nameQUALITY GAP ANALYSES for injectable antibiotic use to assess the gaps in coverage, quality and measurement from case note verification.BARRIERS AND ENABLERS to understand the barriers and enablers of documentation practices from qualitative interviews.This paper is part of a supplement based on the EN-BIRTH multi-country validation study, The EN-BIRTH study was conducted in five referral hospitals: Maternal and Child Health Training Institute (MCHTI), Azimpur and Kushtia General Hospital in Bangladesh (BD), Pokhara Academy Health Sciences in Nepal (NP), and Muhimbili National Hospital and Temeke District Hospital in Tanzania (TZ)  conceptual framework , 39. We All babies aged ≤28 days at admission, weighing > 1500 grammes (g) at admission or discharge, or gestational age > 32 weeks, receiving inpatient management for clinically-defined infections, i.e. sepsis, pneumonia, meningitis were included for analysis in this paper. Babies with an obvious major congenital abnormality, neonatal encephalopathy (“severe asphyxia”) were excluded at recruitment. All inclusion and exclusion criteria were based on the data abstracted from hospital inpatient records.Results are reported in accordance with STROBE Statement checklists for observational studies .We reported the antibiotic coverage among newborns treated for clinically-defined infections for the following scenarios based on the hospital inpatient case note verification: any injectable antibiotic, any WHO recommended injectable antibiotic, any recommended injectable antibiotic for 2 days, any recommended injectable antibiotic for 7 days. Survey-reported antibiotic coverage was reported for two questions: general- reported any injection or antibiotic was given, and specific- reported the name of a specific antibiotic. We used descriptive statistics to report all point prevalence estimates with 95% confidence intervals. We reported all estimates separately for each of the five facilities, as well as pooled estimates through random effect models with heterogeneity statistics  server was used to store and manage data. We used Stata (version 14) for conducting all quantitative analysis. NVivo 12 software was used to manage qualitative data during analysis.A total of 1015 cases were selected based on the inclusion and exclusion criteria (from 1523 recruited), among which 409 newborns were from Bangladesh, 344 were from Nepal, and 262 were from Tanzania. Among 1015 eligible cases, 910 women (primary caregivers of the newborns) were successfully interviewed, 57 women were lost to follow up, and 48 women did not consent to participate in the study. Figure Background characteristics, clinical history and results of physical examination of the newborns on admission as recorded in the hospital inpatient case notes are shown in Table Additional file Table Overall, 74.7% 55.3–90.1%) of women could report their baby received any antibiotics/injections during their hospital stay: more than 80% in Azimpur BD, Temeke TZ and Muhimbili TZ; whereas only 58.1% in Kushtia BD and 46.8% in Pokhara NP  of women could report the specific name of an antibiotic. 35.2% of women in Kushtia BD and 25.0% of women in Pokhara NP mentioned that they did not know or remember the specific name of the antibiotic. The sensitivity of reporting the name of the specific antibiotic was only 12.7%.Table Table Figure Enabler – awareness regarding the importance case note records: The health workers, i.e. doctors and nurses responsible for inpatient management of sick newborns, were aware of the importance of documentation in the inpatient case notes and medical record keeping. They acknowledged its importance for reviewing the patient’s condition and taking clinical decisions, communicating and coordinating within the clinical team , and preparing discharge certificates.Enabler – source of information for service reports: The health services providers, especially the nurses, regularly used case notes as a source of information for preparing different services reports (daily/monthly reports) and disease-specific registries.Barrier – case note design and lack of standardization: The case notes had a basic structure outlining some key components . The design of the case notes varied substantially across countries, and it did not prioritize any standardized documentation of key clinical care elements. Consequently, the documentation practice was dependent on the preference and performance of the clinical service providers, leading to unstandardized documentation of details. The majority of the health service providers felt the need for specific training related to documentation of inpatient care.Barrier – lack of coordination and duplication with other registers: In addition to case notes, nurses had to maintain other administrative registers such as drugs log, logistic requisition, etc. which also include various patient-related information  leading to duplication of efforts and documentations. One of the nurses from Bangladesh said:We identified the following key themes regarding documentation practices in hospital inpatient case notes:“There are too many registers to fill up. Information related to neonatal infection is recorded into the admission book, patient case file, and monthly summary sheet. To do so in a proper way, it needs a considerable amount of time.”- Health worker, BDBarrier – clinical workload and documentation responsibilities: In addition to the clinical duties, the doctors and nurses were separately responsible for filling-in different sections of the case notes. The majority of the health workers felt that their clinical workload was overwhelming and affected the quality of case note documentation.This analysis, as part of EN-BIRTH study, is the first to validate potential coverage indicator measurement for antibiotic treatment of neonatal infections in hospitalised patients. Based on more than 1000 cases in five hospitals in Bangladesh, Nepal and Tanzania, we validated women’s report during exit survey against information abstracted from hospital inpatient case notes . Given oMaternal report of newborn admission in the inpatient ward had high sensitivity, but specific diagnosis or classifications were poorly reported, with high “Don’t knows”. Infections are a subset of the total neonatal admissions, varying by context and especially by level of facility, with reports between 6 and 68% of all neonatal admissions –49. UsinMore detailed questions to try to identify denominators of clinical diagnosis were asked in two ways , and both of these performed poorly in survey report. Around half of the women could correctly report whether their baby had any infection, and only around one-third could report any specific infection syndromes . Moreover, there were wide variations among different hospitals regarding the accuracy of women’s report on the second  (17.1–75.4%) and the last option . These findings are consistent with the previous studies which reported the challenges of identifying clinical symptoms through household surveys , 27, 50.The numerators assessed involved questions regarding the use of injectable antibiotics. For use of any antibiotic, the sensitivity was 75.9%, with wide variation between the five participating hospitals. In terms of mothers’ knowledge regarding which antibiotic was given, sensitivity was only 12.7%. This was reasonably consistent across all hospitals. During hospital stay, a sick newborn may require different kinds of injectable drugs in addition to antibiotics . TherefoHospital records are another potential data source for tracking injectable antibiotic use, and could be linked to a “contact” point indicator in surveys to assess effective coverage . We founAntibiotic stewardship is an imperative in every country, and neonates are especially vulnerable to antimicrobial-resistant pathogens and more likely to die if infected . There wIn the EN-BIRTH study, verification of hospital inpatient case notes revealed that almost all (97%) newborns admitted in the hospital for clinically-defined infections received injectable antibiotics. However, very few (< 2%) had laboratory-confirmed evidence of any infection in Bangladesh and Tanzania. Importantly, in Nepal, there was a much higher rate of blood culture. Most likely this has happened as a result of the ongoing quality improvement initiatives in Nepal. Diagnostic tests are vital for managing newborns with infections , 67. It Our study has strengths, notably the large sample size and multi-country sites with standardised tools and training and a custom-built android tablet-based application that was designed specifically for this study . Data abIt is also important to acknowledge limitations. Observations of the clinical practices in the selected hospitals and especially timed observations of antibiotic administered for neonatal infections were not feasible, and hence we used inpatient case notes as the gold standard to assess the validity of women’s report through the exit survey. Whilst this is the most commonly used gold standard in many validation studies, It is widely recognised that case note documentation has gaps, even in well-resourced settings . ValiditSurvey report consistently underestimated the coverage of injectable antibiotics for treating newborns with infection, and had low sensitivity for both the numerator and denominator, hence we recommend this indicator not be added to population-based surveys. However, the high sensitivity of a “contact” point indicator of admission to a neonatal unit, at least amongst those admitted, holds promise for tracking coverage of small and sick newborn care. More investment and research on hospital inpatient records for newborns is crucial to enable linked data on content and quality of care. We particularly recommend improving the design of inpatient registers and case notes to address the identified gaps in measurements of quality of care. Strengthening capacities to do blood cultures and lumbar punctures is important in the short term, and in the longer term novel bedside diagnostics for bacterial and viral neonatal infections could be transformative and also to improve antibiotic stewardship and address AMR.Additional file 1. EN-BIRTH study data collection dates by site and time elapsed between birth and exit survey.Additional file 2. Ethical approval of local institutional review boards, EN-BIRTH study.Additional file 3. STROBE Statement—Checklist of items that should be included in reports of observational studies.Additional file 4. EN-BIRTH study background characteristics of the mothers of the newborns, exit interview survey (n = 910 mothers).Additional file 5. Neonatal infection individual-level validation two-way tables, EN-BIRTH study, Neonatal infection dataset .Additional file 6. Neonatal infection indicator individual-level validation results, EN-BIRTH study, Neonatal infection dataset .


MET-positive case that benefited from crizotinib and cabozantinib treatment.Lung cancer is a leading cause of cancer-related mortality worldwide. Currently, targeted therapy has proved highly efficient in the treatment of advanced non-small cell lung cancer (NSCLC). Mesenchymal-epithelial transition factor (MET) is considered a validated molecular target in NSCLC. Given the low incidence of MET exon 14 skipping mutation, the planning of precision treatment for patients is a clinical problem that needs to be solved. In this report, we present a A 77-year-old patient was diagnosed with lung adenocarcinoma in our hospital. Positron emission tomography-computed tomography (PET-CT) showed a right upper lobe mass , right hilar enlarged lymph nodes, and multiple bone and left adrenal metastases (c-T3N1M1c).MET exon 14 mutation  was examined using the lung puncture sample by next generation sequencing. Therefore, the patient was diagnosed with late-stage lung adenocarcinoma with MET exon14 skipping gene mutation.Crizotinib was given as the first-line treatment from August 2019. Considering the resistance of crizotinib, cabozantinib was given for second-line treatment.Crizotinib was administered (250 mg bid) for 8 months, and her disease achieved partial regression (PR) and progression-free survival (PFS), which lasted for 8 months. The patient also reached PR after the second-line treatment with cabozantinib, and is currently under follow-up, with an overall survival (OS) of >12 months.MET exon 14 skipping mutation is rare in clinical practices, MET-TKIs (tyrosine kinase inhibitors) treatment can boost curative effects and improve prognosis of patients with advanced lung adenocarcinoma. This case report supports a rationale for the treatment of lung adenocarcinoma patients with a MET exon 14 skipping mutation and provides alternative treatment options for these types of NSCLC patients.As  In pulmonary sarcomatoid carcinoma (PSC), a rare type of NSCLC, the mutation rate is as high as 31.8%. As an independent indicator of poor prognosis, MET exon 14 skipping mutation is more common in elderly, man, and advanced NSCLC patients,–13 with various types and forms of mutation. MET-TKIs (tyrosine kinase inhibitors), such as crizotinib, capmatinib, and tepotinib were proved effective treatment for NSCLC patients from clinical trials. However, there is no clinical data of cabozantinib used in NSCLC patients with MET exon14 skipping mutation. In this report, we present a case with MET exon14 skipping mutation which benefited from cabozantinib treatment after the disease progressed of treatment with crizotinib in the real world.Lung cancer is a malignant tumor with the highest mortality in the world, with a 5-year survival rate of only 15%. Non-small cell lung cancer (NSCLC) accounts for 85% of lung cancer. As patients with advanced NSCLC are deprived of the possibility of surgery, targeted therapies offer a chance for patients with driver gene alteration to prolong survival. Mesenchymal-epithelial transition factor (MET) has been in the spotlight in the recent years as a promising novel targeted therapy of NSCLC. Abnormal activation of the 2MET exon 14 mutation  and TP53 mutation , PD-L1 tumor proportion score (TPS) 18.34%. As the patient had severe backache, she took 20 mg of OxyContin twice a day. The first-line targeted therapy was conducted with crizotinib (250 mg bid), and grade I diarrhea was observed. The patient reached partial regression (PR) after 2 courses of treatment. With symptomatic treatment such as ibandronate for bone protection and nutritional support, the symptoms of backache and fatigue were alleviated, allowing the patient to gradually reduce and stop the intake of OxyContin. On April 2, 2020, chest CT showed that the right upper lobe mass was larger than before while magnetic resonance imaging (MRI) identified multiple metastases in kidneys, suggesting progression disease (PD). The first-line treatment had a progression-free survival (PFS) of 8 months  showed a right upper lobe mass , right hilar enlarged lymph nodes and multiple bone, and left adrenal metastases c-T3N1M1c)  (TPS ≥ 1%) while the level of tumor mutational burden (TMB) expression was generally low. Among 24 patients with MET exon 14 skipping mutation who received immunotherapy, the objective response rate (ORR) was 17%, and the median PFS was only 1.9 months.Chemotherapy is not an ideal treatment for NSCLC patients with MET exon 14 skipping mutation, including multi-targeted drugs  and selective targeted drugs . Crizotinib was originally a small molecule TKIs developed for c-MET. PROFILE 1001 study analyzed 18 patients with MET exon 14 skipping mutation, whose ORR reached 44% after treatment with crizotinib. A prospective study included 69 patients treated with crizotinib, whose ORR reached 32%, PFS reached 7.3 months, and duration of response (DoR) reached 9.1 months, with common adverse reactions such as grade I–II edema, visual impairment, and diarrhea. Cabozantinib is a multi-kinase inhibitor of MET, VEGFR2, AXL, Tie2, KIT, FLT3, and RET. Cabozantinib can not only serve as anti-tumor angiogenesis, but also combine with the inactive conformation of the ATP domain of the MET gene, with an inhibitory effect on the secondary mutation of MET. Common adverse reactions include diarrhea, fatigue, high blood pressure, hand-foot syndrome. Klempner reported a patient with liver, brain metastases, and MET exon 14 skipping mutation. First-line crizotinib induced remission of lung lesions, progression of intracranial lesions, and grade IV liver damage. In the second-line, the intracranial lesions disappeared with cabozantinib while the lung lesions continued to shrink, and liver transaminase returned to normal. It is suggested that cabozantinib may become a replacement of crizotinib in case of drug resistance. Recent researches show that MET inhibitors  have great advantages in efficacy. Savolitinib was used in the treatment of 41 NSCLC patients with MET exon 14 skipping mutation (PSC excluded), whose had an ORR of 48.8%, disease control rate (DCR) of 95.1%, and PFS of 9.7 months. The GEOMETRY mono-1 study showed that when capmatinib was used in the treatment of stage IIIb or stage IV NSCLC patients with MET exon 14 skipping mutation, there were 28 newly-treated patients who had an ORR of 67.9%, DCR of 96.4%, and PFS of 9.69 months, and there were 69 treated patients who had an ORR of 40.6%, DCR of 78.3%, and PFS of 5.42 months. The VISION study showed that patients with MET 14 exon skipping mutation, when treated with teponitinib, had an ORR of about 46.5%, DCR of 65.7%, and DoR of 11.1 months. With the deepening research of precision treatment, more patients will be able to achieve long-term survival.Targeted therapy is the first choice for the treatment of NSCLC patients with MET exon 14 skipping mutation. The patient taking first-line treatment of crizotinib had significantly improved PR, and PFS of up to 8 months, consistent with previous studies. Meanwhile, symptoms like backache and fatigue were alleviated, analgesic was reduced and terminated, and her physical condition was improved. After the progression, the genetic test of the second biopsy reexamination still showed MET exon 14 skipping mutation, with the second-line treatment with cabozantinib as the first choice to improve the curative effects. Clinicians also observed the side effects and the overall tolerance of the patient. The toxicity of the targeted therapy in this case was generally tolerated, and with individualized symptomatic and supportive treatment, these factors were the key to the prolonged survival. MET 14 exon skipping mutation is a unique molecular subtype of NSCLC, featuring rarity and poor prognosis. Chemotherapy is not effective while immunotherapy needs further verification. In the era of precision treatment, targeted therapy brings breakthroughs and improves prognosis. However, limited availability of new drugs, individual differences in the types of MET exon 14 skipping mutations, and drug resistance are posing challenges to clinical practices, which requires further studies in the future.This case demonstrates that targeted therapy has proved an ideal choice for patient suffering from advanced lung adenocarcinoma with 4MET exon 14 skipping mutation, MET-TKI can significantly improve the prognosis. The patient taking targeted therapy showed reduction of lung lesions, relief of the symptoms, improved quality of life, and prolonged survival.For patients with Conceptualization: Hong-Hao Xue, Ruo-Yan Qin, Xiao-Yan Guo.Data curation: Cheng-Hua Lu.Formal analysis: Hui-Yong Zhang.Investigation: Ling-Yue Zhang.Methodology: Ling-Shuang Liu, Hui-Yong Zhang, Ling-Yue Zhang.Project administration: Hong-Hao Xue.Resources: Cheng-Hua Lu, Xin-Bei Yuan.Software: Xiao-Yan Guo.Validation: Xiao-Yan Guo.Visualization: Xin-Bei Yuan.Writing – original draft: Ruo-Yan Qin.Writing – review & editing: Hong-Hao Xue.


IgG4 subclass antibodies are expressed in alternative Th2 environments featuring high IL-10 expression, including several solid tumors such as melanoma. To induce tolerance, allergen immunotherapy mediates antibody class switching from pro-inflammatory IgE to anti-inflammatory IgG4. We previously reported that IgG4 drives allergic M2 macrophages toward tolerogenic states. Here we assessed the roles of IgG4 and macrophage activation in colorectal cancer (CRC).In this observer-blinded, case-control study, we analyzed total circulating serum IgE, IgG1 and IgG4 levels in CRC (n = 38) patients with  or without  metastasis, and in healthy donors (n = 21). Primary cultures of circulating monocyte-derived macrophages from healthy controls and CRC patients were further evaluated in their responses to stimulation with IgG1 or IgG4.p = .0247 and p = .0009, respectively) in CRC patients.We found higher absolute serum levels of IgG4 in patients with CRC. IgG4 enabled polarization of macrophages derived from CRC patients and healthy controls into alternatively-activated tolerogenic M2b phenotypes. IgG4-stimulated M2 macrophages were characterized by lower surface CD206, CD163, CD14, and CD11b expression and higher CCL-1, IL-10, and IL-6 production. IgG4 was less potent that IgG1 in triggering antibody-dependent cell-mediated phagocytosis (ADCP) of cancer cells. Further, higher z-normalized IgG4/-IgE sera level ratios correlated with the presence of metastasis (High IgG4 in CRC synergizes with macrophages in shaping an immunosuppressive microenvironment and impairs anti-cancer effector cell functions. The shift of serum IgG4/IgE ratios toward enhanced tolerance induction in metastatic disease indicates a role for high IgG4 in disease progression and poor prognostic outcome. Furthermore, accumulation of IgE directed to cancer tissues can contribute to anti-tumor inflammation stimulated by highly-expressed cancer antigens form tumor-associated molecular patterns (TAMPs), facilitating IgE cross-linking and thereby triggering release of cytotoxic macrophage and mast cell-derived mediators, such as TNF-α. Both effector and immune-stimulating functions can induce anti-tumor effector cell activation .7Immunoglobulin E (IgE) induces a strong activation of Fc epsilon receptors (FŒRs) and can activate cytotoxic innate effector cells, such as eosinophils, monocytes, macrophages, and mast cells. These functions are widely established in allergic inflammation. In cancer, besides the debated roles of mast cells, regs) or regulatory B cells (Bregs), which are reported to actively suppress immune responses. They create an immunomodulatory microenvironment by production of immunosuppressive mediators, such as IL-10. IL-10 on the one hand indirectly downregulates IgE production, 8 while on the other hand it accelerates IL-4 mediated isotype switch toward IgG4 production by B cells .9 IL-10 is therefore critical in tipping the balance toward a low IgE/IgG4 ratio. This is well known in the context of IgE-mediated allergy, where allergen immunotherapy typically shifts the response toward IgG4 production, a process known to be associated with immune tolerance toward the allergen. In contrast to IgE, IgG4 induces the weakest activation of FcγRs on effector cells out of all immunoglobulins, and it is the only IgG subclass/isotype which does not activate the complement system .10 Previous studies in melanoma11 and preliminary findings in CRC indicate that IgG4 is expressed in cancer tissues .13 Irregular serum IgG4 levels and concurrent diagnosis of IgG4-related diseases have been reported in several cancer types .14–18 Abundant IgG4+ plasma cell infiltrates were described in pancreatic cancer tissues19 and IgG4 was found to be the dominant IgG subclass in both serum and tumor tissue of patients with thyroid carcinoma, 21 where IgG4+ plasma cells were associated with unfavorable prognostic aspects, such as multi-focality. Further, in gastric cancer, higher numbers of IgG4-positive cells in tumor tissues were associated with disease progression and poor prognostic outcomes .22A significant portion of tumor-infiltrating lymphocytes, however, have been identified as regulatory T cells  subtype M2a, which is prominent in IgE-mediated allergy, is repolarized to an immune-regulatory (“type II activated”) phenotype M2b in the presence of IgG4 .23 It is known that M2 macrophages may create a pro-tumorigenic microenvironment24–26 which correlates with angiogenesis, 28 survival and proliferation of tumor cells .27 However, the macrophage subtype responsible for these modulatory signals has not been defined consistently. In line with the AllergoOncology concept , we transferred and adapted our experiments with alternatively differentiated macrophages from the allergy field into oncology. Here we evaluated whether IgG4, previously reported to be overexpressed in melanoma and other cancers with poor outcomes, can stimulate M2a and M2b macrophages to adapt immunosuppressive states and to enhance production of IL-10 and other immunomodulatory mediators. We asked whether IgG4 can support a pro-tumorigenic microenvironment by driving TAMs into immune-modulating phenotypes and by disruption of antibody-dependent cell-mediated cytotoxicity (ADCC) and phagocytosis (ADCP). We furthermore aimed to assess whether these findings could be confirmed and correlated with disease progression in colorectal cancer (CRC) and, potentially, in other cancer cohorts.In cancer tissues, approximately 50% of infiltrating immune cells have been identified as macrophages, often polarized to the alternatively-activated “M2” phenotype .The study was conducted between 2016 and 2018 at the Department of General Surgery, St. Vincent Hospital Vienna (“Barmherzige Schwestern Wien”), Austria, after approval by the hospital’s Ethics Committee Board (Nr. 201604_EK01). The participants were either in hospital for an elective colonoscopy (controls) or for staging and/or surgery in recently diagnosed colorectal cancer (CRC patients) with (=TxNxM1) and without (=TxNxM0) systemic metastasis at initial diagnosis. Clinical characteristics , laboratory parameters, and follow-up data  were obtained from surgical and pathological records. The blood samples were rapidly sent to our research lab for analysis by a blinded study member (RB).Non-CRC patients with normal colonoscopy (=controls) (n = 15);CRC patients (n = 30):without systemic metastasis at initial diagnosis (=TxNxM0) (n = 20);with systemic metastasis at initial diagnosis (=TxNxM1) (n = 10)In total, 66 patients (N = 66) were recruited at the in-patient ward of the Department of General Surgery, St. Vincent Hospital Vienna, Austria. Blood samples were obtained after gaining written informed consent and rapidly analyzed in a blinded manner as described above. Six (n = 6) patients were excluded due to flaws in blood sampling or pre-analysis. One patient (n = 1), classified as M0 upon inclusion and diagnosed with peritoneal cancerosis during surgery, was excluded from further analysis, as systemic metastasis had not been established at initial diagnosis and mode of metastasis, i.e. local versus hematogenic, was unclear. Nine (n = 9) patients were excluded from the analyses because of IgE-mediated allergy and five (n = 5) patients had insufficient viable PBMCs in serum for consequent analyses. Thus, forty-five (n = 45) patients  were eligible for analyses:• age between 18 and 85 years• recent initial CRC diagnosis, without any preceding or neo-adjuvant therapy (CRC patients)• normal colonoscopy during the last month (controls)• adequate German language skills• signed declaration of consent• innate or acquired immune deficiencies• ongoing potentially immune-modulating therapies• active infectious or inflammatory (bowel) disease• any other kind of malignancy in patient history• previously diagnosed IgG4-associated disease and/or known serum IgG4 elevation.29 Filter sets were from Chroma TechnologyCorp . Images were processed using Java image processing program Fiji software. IgG4 positive expression on CRC tumor samples were evaluated by HistoQuest software  .30For immunostaining protocols, were prepared paraffin blocks from 13 CRC patients using the resection tissues. The 13 CRC patients derived specimens do not overlap with the recruited study population investigated in any other protocol. Serial 4-μm sections were on a microtome (Leica) cut from CRC tumor samples previously fixed in buffered 3.9% formalin and paraffin-embedded. Sections were deparaffinated in Xylene for 20 minutes and rehydrated by serial incubations in alcohol. Heat-induced antigen retrieval was performed in a pressure steam cooker with Tris-EDTA buffer, pH 9 during 15 min. Permeabilization was done with PBS 0.2% Tween20 for 15 min, and blocking with 5% FCS in PBS, for 30 min at RT. For immunohistochemistry method, DAKO EnVision+, Peroxidase system  anti-mouse was used. Sections were counterstained with hematoxylin for nuclear visualization. Alternatively, a fluorescent triple staining was performed using: 1) mouse anti-human IgG4 clone HP6025 1:500 (Genway Biotech); 2) rabbit anti-human CD38 clone EPR4106 dilution 1:100 (Abcam); 3) goat anti-human CD68 clone C-18: sc-7082 dilution 1:100 (Santa Cruz Biotechnology). The secondary antibody used were: 1) donkey anti-mouse IgG AF568 (Abcam); 2) donkey anti-rabbit IgG AF488 (Abcam); 3) donkey anti-goat IgG AF647 (Abcam). Samples were counterstained with DAPI (1:1000 dilution) and mounted in Moviol (Sigma-Aldrich). TissueFAXS , a fully automated multi-channel immunofluorescence tissue analysis system was used for the acquisition of diseased specimen. For acquisition, the 20x/0.5 or the 40x/1.3-oil objectives were used  .Human peripheral blood was obtained by venipuncture using coated with lithium heparin  vacuum tubes CAT serum separator clot activator  or coated with lithium heparin  and then transferred in 2 ml tubes. In both the procedures the samples were allowed to clot for at least 30 min at room temperature in an upright position and were then centrifuged at 1800xg for 10 min. Serum was recovered and stored in fresh 1.5 ml tubes at −20°C. Serum levels of total of IgG1, IgG4, and IgE were determined on a BNII nephelometer . The measured concentrations of total sera IgG1, IgG4, and IgE were normalized using a z-normalization formula for each class separately.We obtained three values: z-normalized IgG1 (zIgG1) values, z-normalized IgG4 (zIgG4) values, and z-normalized IgE (zIgE) values.Then, we hypothesized that the zIgG4 values could correlate positively with the metastatic stage of CRC and zIgE values could correlate negatively with the metastatic stage of CRC. To demonstrated that we created the zIgG4/-zIgE ratio that could include both the characteristics. As controls, zIgG1/-zIgE ratios were used.23 Briefly, PBMCs were isolated by Ficoll-Paque  (density 1.077 g/ml) gradient centrifugation . The white layer of PBMCs was recovered and washed 3 times in RPMI 1640. After the last wash the cells were resuspended and seeded in 6 well plates  at a concentration of 2 × 106 cells/ml, 3.5 ml/well. After 2 hours, non-adherent cells were washed away 2 times and adherent cells (monocytes) were maintained in RPMI 1640 with 10% heat-inactivated FBS, and 1% of P/S (cRPMI), supplemented with 20 ng/ml rh-M-CSF for 7–9 days. Half of the medium was refreshed every 2–3 days. Purity of monocyte cells was assessed after 3 days of culture by multicolor staining of CD3, CD11b, and CD86, using the SYTOX™ Green Ready Flow™ Reagent  to exclude dead cells23(data not shown).Peripheral blood mononuclear cells (PBMCs) were obtained from lithium heparin samples and monocyte cells were purified from the other cells by plastic adhesion method as previously described .in vitro culture with 20 ng/ml rh-M-CSF. Macrophages were then detached using ice-cold PBS−Ca-Mg supplemented with 2.5 mM EDTA (PBS/EDTA) pH 8.0 and allowed to recover in cRPMI. To mimic the creation of IgG1 or IgG4-related immune complexes (ICs) we used plate-bound human myeloma IgG1 (mIgG1) or IgG4 (mIgG4)  as described in previous study .23 Briefly, a 96 well plate  was coated with mIgG1 or mIgG4 antibodies, 5 µg/well in HBSS (50 µg/ml), at 37°C, 5% CO2, 95% humidity for 1 h, and then washed twice with 200 µl of cRPMI. Then, macrophages were seeded in the wells coated or not with ICs at a cell concentration of 1.5 × 105 cells/ml. To polarize the cells in M2a macrophages were used cRPMI supplemented with 20 ng/ml rh-M-CSF, 20 ng/ml rh-IL-4, and 20 ng/ml rh-IL-13.Adherent monocytes acquired the mature macrophage characteristics after 7–9 days of TM Software version 10.3 . Several FlowJo plugins were used to improve the Flow cytometer data analyses. First, the FlowAI plugin was used to identify anomalous events and clean the data by removing them. Second, the DownSample plugin was used to reduce the number of events necessary for the representation of all the parameters datasets in a two-dimensional space to 9.000 events. Finally, a machine learning algorithm uniform manifold approximation and projection (UMAP) was used for dimensionality reduction by using the UMAP plugin. For the characterization of each parameter the geometric mean fluorescence intensity (MFI) values that were calculated for each fluorochrome were used. The z‐normalization of MFI for each staining antibody and each donor was performed for M2a, M2a + IgG1, and M2a + IgG4.23 .After 72 h, M2a cells incubated with or without IgG1- or IgG4-ICs were detached using ice-cold PBS/EDTA and washed twice with cell staining buffer , for surface marker phenotypization. Then, cells were incubated with a multicolor staining mix of monoclonal antibodies against CD14, CD86, CD11b, CD163, and CD206 or their isotype controls  diluted 1:100 in staining buffer for 30 min at 4°C followed by 2x washing with staining buffer. Samples were acquired by FACS Canto II  and analyzed with the FlowJoSupernatants from M2a cells either incubated on IgG1- or IgG4-IC-coated plates or not (see above) were collected after 72 h and IL-10, IL-6, and TNFα were analyzed by ELISA , IL-12p70 by ELISA , and CCL1 by ELISA , following the supplier’s instructions. The z‐normalization of the concentration for each cytokine/chemokine and each donor was performed for M2a, M2a + IgG1, and M2a + IgG4.2 atmosphere .31The human epidermal epithelial carcinoma cell line A431 (ATCC CRL-1555), and the human colon adenocarcinoma cell line CaCo2/TC7 (ATCC HTB-37) were maintained in high glucose DMEM (4500 g/l glucose). The medium for CaCo2/TC7 was supplemented with 20% heat-inactivated FBS, 2 mM L-glutamine, 1 mM NEAA and 1 mM of P/S (cDMEM_CaCo2). The medium for A431 is similar to cDMEM_CaCo2 with the exception of 10% heat-inactivated FBS, and 4 mM L-glutamine (cDMEM_A431); the human colon adenocarcinoma cell line HT-29 (ATCC HTB-38), and the human myelomonocytic cell line U937 (ATCC CRL-1593.2) were maintained in RPMI 1640, supplemented with 10% heat-inactivated FBS, 1 mM of P/S, and 1 mM NEAA (cRPMI). All the cell lines were incubated at 37°C in 5% CO6 cell/ml) with 1 µl of 5 mM CFSE each ml for 20 min at 37°C and kept protected from light  APC  at 4°C after the killing assay. The anti-FcαRI (CD89) APC used for the staining of monocytic cells was labeling only the effector cells and not the tumor target cells  to assess live vs. dead status of the cells. Without washing, the cells were stained with anti-FcαRI (CD89) APC  at RT for 15 minutes. After that 0.5 ml of cell staining buffer  was used to wash the cells and then the cell pellet was resuspended in 200 µl of cell staining buffer and then the samples were acquired using an FACS CANTO II flow cytometer .31The CFSE-labeled tumor target cell lines in the 24 well plate, were incubated with 20 µg/ml of cetuximab derived anti-hEGFR-IgG1 or -IgG4 subclasses/isotypes , (or myeloma mIgG1 and mIgG4 as control) and with U937 monocytic cells at a cell concentration of 3.5 × 10TM Software version 10.3 . FlowAI plugin was used to identify anomalous events and clean the data by removing them. We designed a gate strategy  were analyzed with the FlowJoP > .05, # P < .1, * P < .05, ** P < .01, *** P < .001, **** P < .0001.The graphs and the statistical analyses were performed with GraphPad Prism version 8.4.0 for Macintosh  and with R software (R version 3.6.2.). Validation of data from surface marker expression and cytokines/chemokines concentrations was done by repeated‐measures one‐way ANOVA and Tukey multiple comparison post‐hoc test. The level of statistical significance is defined as n.s. (not significant) Shapiro-Wilk test was used to test normality on the natural logarithm of laboratory data before applying Pearson’s correlation coefficient test with zIgG4/-zIgE and zIgG1/-zIgE.0: AUC = AUC0; AUC0 = AUC with chance level (AUC = 0.5) .32 One-way ANOVA was applied for comparison of the zIgG4/-zIgE ratio between groups. All statistical results with a p-value <0.05 were considered significant.The Youden index and the AUC were calculated using receiver operating characteristic (ROC) analysis to determine an optimal cutoff value for the zIgG4/-zIgE ratio to discriminate between metastatic and non-metastatic patients using a binormal method. We classified the donors regarding the presence of metastases including in the non-metastatic donors also the healthy donors: non-metastatic donors (class = 0), donors with metastases (class = 1). Then, we use a R script and the R package “ROCit” to derive all the parameters. A script in R was written to obtain all the statistical values and the graphs. The level of statistical significance was evaluated using the z-test: null hypotheses H2p) = 0.14, equating to a large effect. After exclusion of participants from calculations due to the reasons stated above (see “Study Population”), we had 45 participants across the three groups. In this case, the study is sensitive to effects of partial eta-squared (η2p) = 0.19; thus, the number of patients analyzed in the CRC group are able to describe statistically significant large effects .33We aimed at 80% power  considering a one-way between-subjects ANOVA across three groups. Our calculations showed that the suggested number of participants was N = 60 and the study would be sensitive to effects of partial eta-squared (ηp = .01109) (p = .02474), and also significantly higher compared to patients with primary disease (p = .0009433)  . On the  .01109) . The z-n0009433) . Compari0009433) .Figure 3p = 5.19081e-06). We also determined that, the area under the ROC curves (AUC) was 0.83438, the False Positive Rate (FPR) was 30% and the True Positive Rate (TPR) was 83%. On the contrary, the best cutoff value for the total serum zIgG1/-zIgE level, used as control, to predict the presence of metastases was 2.92326 (p = .04461). The area under the ROC curves (AUC) was 0.69702, the FPR was 50% and the TPR was 83%.Receiver operating characteristics (ROC) analysis was performed to determine the cutoff value of total serum zIgG4/-zIgE levels that can be used to predict the metastases in diagnosed tumor patients . ROC anaImmunohistochemical staining of CRC cancer tissues were evaluated by the TissueFAXS methodology. We found that IgG4 was mainly expressed in tumor stroma amongst all investigated tumor samples . IF staiMacrophages stimulated with IgG4 displayed M2b-like phenotype surface markers and cytokine production characteristicsex vivo with antibodies of different subclasses. Upon treatment of M2a cells with mIgG4, we applied dimensionality reduction to represent the shape of all events in two dimensions of the cell surface markers mentioned above. The obtained patterns differed from treatments between mIgG1 and mIgG1 stimulation   resembleU937 cell line: tumor cell line interaction when stimulated with immunotherapeutic IgG1 or IgG4 subclassin vitro stimulation of human U937 monocytic cells. Dependent on the IgG1 or IgG4 subclass, and directly correlating with the EGFR expression levels in the tested cell lines (A431 ≫ HT29 > CaCo2), the α-EGFR therapeutic anti-tumor antibody cetuximab displayed different capacity to trigger phagocytosis of tumor cells by human monocytes , particularly in chronic inflammation, can lead to reactive oxygen species-derived DNA-damage, resulting in tumor promotion. Anti-inflammatory cytokines  support tumor expansion via immune evasion, with the invasive properties being promoted by both anti-inflammatory, that is epithelial-mesenchymal transition being enabled by TGF-ß, and pro-inflammatory cytokines, which are also involved in angiogenesis and metastasis. IL-8 and other chemokines are involved in tumor cell migration. Serum IL-6 or IL-10 are discussed as potential markers of tumorigenesis stages and tumor-associated prognosis .3 While initially M1 macrophages can inhibit tumor growth, later M2-like macrophages create a favorable pro-tumorigenic microenvironment and are a source of high levels of immunosuppressive cytokines such as IL-10 .25 Importantly, IL-10 plays a role in enhancing IgG4 production on site. In healthy volunteer, and patient groups with primary or metastatic CRC, IgG4-stimulated M2 macrophages manifested lower surface CD206, CD163, and CD14 expression and higher CCL-1, IL-10, and IL-6 production, in an isotype-specific manner  which recruit monocytes from the periphery to the tumor site. Monocytes differentiate into TAMs with capacity to secrete pro- and also anti-inflammatory mediators depending on their differentiation states .c manner , a profi37 The potential effector functions of therapeutic antibodies may be a consideration in the design of therapeutic agents including potentially checkpoint inhibitor agents such as anti-PD1 IgG4 antibodies Nivolumab or Pembrozilumab .39The release of immune-modulating IgG4 antibodies from the tumor stroma may promote a tolerogenic microenvironment by disruption of TAM mediated anti-tumor mechanisms, such as ADCC and ADCP. To assess whether exogenous IgG4 antibodies could similarly modify the effector response of macrophages, we used two isotype variants of the anti-EGFR therapeutic anti-tumor antibody cetuximab, both with the same variable regions, but with γ1 or γ4 constant domains. IgG4  was less40 may trigger effector cell activation and release of mast cell-derived mediators, such as TNF-α. This can drive innate effector cell responses which can contribute to anti-tumor inflammation. The promising research on the role of IgE in cancer has led to the establishment of the emerging field of AllergoOncology, investigating multifaceted functions of IgE in cancer . Interestingly, IgE may reprogram monocytes and macrophages toward cytotoxic functions, 41 and the first therapeutic application of tumor-specific IgE antibody MOv18 in ovarian cancer patients is presently ongoing in a registered clinical trial (NCT02546921).In contrast to IgG4, IgE cross-linking on densely displayed, overexpressed tumor antigens forming TAMPsOverall, we provide evidence for a detrimental role of IgG4 in CRC from combined in vitro and patient-derived phenotypic and functional evaluations. We report here that: i) elevated IgG4-expressing cells occur especially in close vicinity to macrophages in CRC tissue; ii) higher levels of IgG4/-IgE ratios were found in metastatic compared to primary CRC disease, iii) in macrophages derived from healthy volunteers and different CRC patient groups, IgG4 stimulation could induce an immunoregulatory M2b-like macrophage phenotype, and iv) tumor antigen-specific IgG4 showed impaired antibody-mediated phagocytosis of tumor cells compared with IgG1. Taken together our findings support a role for IgG4 in impairing macrophage activation which may have clinical relevance in CRC. The fact that macrophages in CRC patients have the same polarization plasticity as those macrophages from healthy donors, gives hope that it may be possible to immunologically manipulate and potentially diminish the tumor-promoting functions of IgG4 in the future.At this point, we cannot clearly extrapolate our findings to other tumor entities. While in preliminary studies, we found abundance of IgG4+ infiltrating cells in bladder, kidney and prostate cancers, our retrospective analyses of available samples from these cancer cohorts allowed for identification of similar trends . These studies must therefore be repeated in larger patient cohorts with a sufficient sample size.IgG4 is highly expressed in CRC and drives M2a macrophages to a tolerogenic M2b-like phenotype. Our data indicate that the presence of IgG4 in CRC can shape an immunosuppressive microenvironment, resulting in cancer progression and poor prognostic outcomes. Total serum zIgG4/-zIgE ratio might prove a useful indicator of a metastatic CRC stage.Click here for additional data file.


Until the 1980s, anti-drug education campaigns in the UK were rare. This article examines the reasons behind a policy shift that led to the introduction of mass media drug education in the mid 1980s. It focuses on two campaigns. ‘Heroin Screws You Up’ ran in England, and ‘Choose Life Not Drugs’ ran in Scotland. The campaigns were different in tone, with ‘Heroin Screws You Up’ making use of fear and ‘shock horror’ tactics, whereas ‘Choose Life Not Drugs’ attempted to deliver a more positive health message. ‘Heroin Screws You Up’ was criticised by many experts for its stigmatising approach. ‘Choose Life Not Drugs’ was more favourably received, but both campaigns ran into difficulties with the wider public. The messages of these campaigns were appropriated and deliberately subverted by some audiences. This historical policy analysis points towards a complex and nuanced relationship between drug education campaigns and their audiences, which raises wider questions about health education and its ‘publics’. Grange Hill, released a song titled ‘Just say no’. The single reached number five in the charts and remained in the Top 100 for five weeks. It delivered a clear anti-drug use message, telling listeners to ‘just say no’ to drugs. The song built on a recent storyline in which one of the characters, Zammo McGuire, became addicted to heroin. ‘Just say no’ also echoed American First Lady Nancy Reagan's campaign of the same name, and an anti-drug use TV advertisement made by the Scottish Health Education Group in 1985. The premise of such ‘just say no’ messages was that telling children and young people about the dangers of drugs would dissuade them from substance use. Like other health education programmes during the 1980s, the intention behind drug education was to increase knowledge about drugs, provoke behaviour change and encourage individuals to make healthier choices. The use of such campaigns to prevent drug use was, however, controversial. Health educators and experts on drug use had long advised against mass drug education efforts, for fear that these would have the opposite effect. Many authorities believed that drug education campaigns would provide information about drugs to young people that they were previously unaware of, increasing the likelihood that they would take drugs. Concerns about the so-called ‘boomerang effect’ meant that there were very few anti-drug campaigns in Britain until the 1980s  initially asked the HEC if they would run an anti-heroin campaign. The HEC were reluctant, as a specific education campaign to tackle drug use went against the advice of health educators and drug experts. The HEC also wanted time to gather information and to develop materials, as well as additional resources, but the government demanded swift action . InsteadIn the absence of a full archival record, the strategy behind ‘Heroin Screws You Up’ can be gleaned from what was said about it at the time and from the materials themselves. A report on the campaign stated that it was intended to ‘prevent further increases in the prevalence of drug misuse, and ultimately to reduce its incidence, especially where heroin is concerned’ . AccordiThe ‘Heroin Screws You Up’ campaign consisted of two short TV films, a series of press and magazine advertisements, a poster and a leaflet for parents. It ran from April 1985 to March 1986, and it cost £2 million. The magazine and newspaper advertisements were mostly black and white. This meant that they were cheaper to reproduce, but the monotone colouring also exaggerated the dark message of the advertisements and the dangerousness of heroin. The advertisements featured a mixture of male and female protagonists, all were young, and all were white. Each one of the different images had a similar look, but a slightly different emphasis, presumably designed to reach different audiences. Many of the images focused on the physical and mental consequences of heroin use. In ‘Your mind isn't the only thing heroin damages’ the viewer is confronted with a black and white image of a young man seated in a hunched over position. He appears to be pale, sweaty, dirty and has spots on his skin. Superimposed on top of the image are seven text labels. These catalogue the physical effects of injecting drug use and addiction to heroin, including skin infections, blood diseases, liver complaints and ‘mental problems.’ The text underneath the image offers a narrative of progressive decline and loss of control, from use to sickness and addiction. Similar tropes were at work in other images from the campaign. In ‘At first he was sure he'd never become a heroin addict. Now he's not sure he'll ever be anything else’ we find another pale and gaunt young man, this time seated on a chair with his hand on his head in a seemingly distraught manner. The text underneath states that ‘Take heroin and before long you'll start looking ill, losing weight and feeling like death. So if you're offered heroin, you know what to say. Heroin screws you up.’  This mesThe theme of loss of control and progressive decline intersected with other tropes in ‘How much is heroin likely to cost you’. The advertisement features a succession of images of the same young woman, moving from left to right across the page. In the first image she appears healthy and confident, with her hand on her hip and looking directly into the camera. In the second image, she is standing but looking downwards. In the third image, the woman is seated on a chair, her hair appears to be greasy and she has dark circles around her eyes. In the final image she is seated on the floor, hunched over with a hand pulling at her hair. Superimposed on top of each image is a short text label indicating what heroin will cost the user: ‘It'll cost you your friends’, ‘Your looks’, ‘Your possessions’ and ‘Your health’. The text underneath the image echoes the narrative of progressive decline, but also emphasises the price of heroin use in relation to the loss of possessions, as well as the danger to health. ‘How much will heroin cost you’, and ‘Skin care by heroin’ were clearly targeted at young women, denoted by the images of women and the fact that unlike the ones targeted at young men, these advertisements placed greater emphasis on the risk heroin use posed to physical appearance, an issue presumably thought to be of more appeal to women. The gendered dimensions of this campaign also sat alongside an emphasis on the effect heroin might have on a teenagers’ possessions and their ability to acquire new ones. Such tactics were representative of the place of the teenager (itself a relatively new construction) in a burgeoning consumer society.The dark tone of the campaign and its consumerist framing influenced the ways in which it was received. The campaign was evaluated for the DHSS and the COI by two commercial market research companies. One agency carried out a quantitative study. They surveyed 700 young people aged between 13 and 20, both before and after the campaign. The agency found that 95% of respondents had heard of the campaign. Moreover, the survey suggested that there was significant change after the campaign in relation to awareness about the health risks associated with heroin use. Respondents reported being less likely to take heroin if offered it by a friend after having seen the campaign. This was the case with even with those deemed most ‘at risk’. The campaign appeared to have reached its target group, but the reception of its message was more problematic. The survey noted an increased belief that death was an inevitable consequence of heroin usage . This waA qualitative study, based on focus groups and in-depth interviews, dug more deeply into the attitudes, beliefs and behaviours of the target audience. This also found high levels of recall of the campaign and its message, especially with those thought to be most ‘at risk’ from using heroin. The evaluators asserted that the campaign had fostered and reinforced negative attitudes and beliefs about heroin misuse across the sample. They also pointed to an apparent increased confidence amongst what the report called heroin ‘rejectors’ by providing them with more information about the downsides of using the drug. However, the report also sounded notes of caution. Some of those most ‘at risk’  were less likely to say that heroin was more dangerous than cannabis after the campaign than before it. The authors also felt that ‘the current commercials and press advertisements show signs of wear out: if young people become bored with the executions, they may begin to become more resistant to and react against the message.’ The effects of the campaign were likely to be short-term, and ‘long-term effects might be less favourable unless future activity is handled with care and is both sensitive and responsive to the changing attitudes amongst young people’ .Notwithstanding these warnings, the campaign's paymasters appeared happy with the results. Health minister Whitney pointed to the high levels of recall amongst respondents and the suggestion that attitudes towards heroin were more cautious amongst some young people after the campaign as a sign of its success. He asserted that although unrealistic claims for the effect of the campaign should not be made, the results were ‘encouraging’ . Yet theIt is impossible to know if the ‘Heroin Screws You Up’ campaign led to an increase in drug use, but there is evidence to suggest that some young people deliberately appropriated the campaign and its imagery. There were numerous accounts of teenagers taking the poster or the magazine and newspaper advertisements and putting them up on their bedroom walls, not in support of the message, but in an ironic commentary on it , p. 137.The multiple meanings of drug education messages was not confined to the ‘Heroin Screws You Up Campaign’. Although the Scottish Health Education Group's (SHEG) 1984–85 campaign, ‘Choose Life Not Drugs’, was very different in tone, its public reception was also problematic. SHEG were instructed to mount an anti-drug use campaign by the Scottish Office, and although they were reluctant to do so, they agreed as long as it could be located within their existing work which promoted positive health . The camThe SHEG campaign material was an explicit rejection of the ‘shock horror’ tactics deployed in ‘Heroin Screws You Up’. The difference in tone between the campaigns was not a reflection of the different health systems in Scotland and England, but rather a result of the fact that health educators ran the ‘Choose Life’ campaign, whereas the ‘Heroin Screws You Up’ campaign was designed by a professional advertising agency at the behest of the COI. Given the fact that the ‘Choose Life’ campaign was designed by health educators it is no surprise that it was received more warmly by health educators than the ‘Heroin Screws You Up’ campaign. ‘Choose Life’ was even praised at a World Conference on Health Education in 1985 , p. 212.Trainspotting, the central character, Mark Renton, a heroin user, delivers a soliloquy on the hollowness of ‘choosing life’ and how he chose not to choose life, but chose heroin instead. Irvine Welsh, the author of the book, deliberately inverted the ‘choose life not drugs’ message of the 1985 campaign to say precisely the opposite. In the 2017 film sequel, Trainspotting 2, Renton even says as much when a new character asks him what ‘choose life’ means: He says, ‘"Choose life" was a well-meaning slogan from a 1980s antidrug campaign. And we used to add things to it’ (Indeed, the ‘choose life’ slogan already had another set of connotations. ‘Choose life’ was emblazoned across numerous t-shirts throughout the 1980s. These were launched in 1983 by the fashion designer Katherine Hamnett. She said that ‘Choose life’ was inspired by a Buddhist expression, and was one of number of political messages put on t-shirts by Hamnett, but the ‘Choose life’ t-shirts were particularly popular – especially after they were worn by pop group Wham. A more direct inversion of the ‘choose life’ message in relation to drugs appeared a few years after the campaign. In the 1993 book, and 1996 film, s to it’ .a]n aged and healthy friend, acquaintance or relative – an “Uncle Norman” – who has smoked heavily for years, eats a diet rich in cream cakes and chips and/or drinks ‘like a fish’ is a real or imagined part of many social networks … A single Uncle Norman, it seems, may be worth an entire volume of medical statistics and several million pounds of official advertising’ (Renton, of course, was not alone in choosing not to choose life. Indeed, large sections of the public appeared to be reluctant to make the healthy choices that they were being exhorted, encouraged or cajoled towards. A key piece of research was conducted in South Wales in the mid-1980s. In an evaluation of a health promotion campaign intended to inform the public about the risks of developing heart disease, researchers found that beliefs about heart disease and risk were made up of a mixture of official messages interwoven with ideas derived from the mass media and the experiences of friends and family. Indeed, these were crucial to how people understood risk and thus how they responded to health education campaigns. The team noted that: ‘[rtising’ . Uncle Nrtising’ .Other research at the time and since called into question the language of choice in such settings. Were unhealthy behaviours really choices? If so, what factors shaped them? Looking at why the public continued to make unhealthy choices exposed a range of reasons, both individual and structural. In a now classic study of young mothers who smoked, sociologist Hilary Graham found that for the women she spoke to, smoking was a way of coping with poverty and the demands of motherhood . SmokingConsidering the role of social, political and environmental structures in shaping individual behaviours highlights the importance of placing drug education campaigns and the response to these in context. This historical policy analysis has pointed to the contested origins of the ‘Heroin Screws You Up’ and ‘Choose Life Not Drugs’ campaigns. Both were introduced primarily as a reaction to rising heroin use and the need to be seen to take action. Health educators and experts on drug use were largely against these campaigns. Many of their fears were realised in the reception of the campaigns. This was especially the case with ‘Heroin Screws You Up’, where the ‘shock and horror’ approach added to the stigmatisation of drugs and drug users. Although the ‘Choose Life Not Drugs’ campaign was more positive in tone, and somewhat more in line with the views of health educators at the time, the ambivalent reaction of some audiences pointed to a wider disconnect between the message and those supposed to be receiving it. Indeed, the re-appropriation of imagery and text from both campaigns and its re-purposing in a variety of ways denotes a dynamic relationship between public health messages and their ‘publics’ . Such pu‘Heroin Screws You Up’ and ‘Choose Life’ may not have ‘worked’ in the sense that they failed to achieve lasting behaviour change or prevented many young people from using drugs, but they ‘worked’ as a way to demonstrate to a wider public that the government was taking action to deal with drug use. This narrative could be turned on its head by some viewers, and the campaigns also ‘worked’ as a way to voice teenage rebellion. This was then further appropriated by fashion designers, novelists and film makers. Not all of this was foreseen by health educators at the time, but they did caution against such efforts for fear that these would backfire. Politicians ignored expert advice as they had other objectives in mind. This was not necessarily ‘wrong’, as policymakers must balance a range of issues and interests, but it does highlight a distinction between expert advice and policy objectives. In the wake of the Covid-19 pandemic, the relationship between politicians, policy makers, experts and health education messaging has come in for renewed scrutiny. This historical analysis thus serves as a useful reminder not only that mass media health education campaigns are fraught with difficulty, but also that these can throw light on a broader set of issues about values, the role of experts in policy making and practice, and the complex relations between government and the governed.I have no competing interests.


Propionibacterium acnes. Even though the rate of infections in patients undergoing total shoulder arthroplasty is increasing, effective diagnostic tests and the precautions taken during the surgery are not yet adequate. This systematic review aims to evaluate the effectiveness of antimicrobial prophylaxis in PJI in shoulder replacement and to provide health workers with the best approach to the use of antimicrobial agents based on currently available clinical evidence.One of the most common bacteria responsible for most Periprosthetic joint infection (PJI) is a systematic review of the literature was carried out in accordance with the PRISMA Statement. Studies concerning the effectiveness of antimicrobial prophylaxis in the prevention of PJI in patients undergoing shoulder replacement were included.Seven studies were included in the final analysis because they were considered valid. A total of 3272 patients underwent a surgical procedure, most of which were males. The male population has a greater presence of hair, therefore a greater risk of P. acnes. in surface cultures. Patients were assessed at an average follow-up period of 20 months ranging from 9 weeks to 53 months.The optimal perioperative antimicrobial regimen is controversial. The clinical guidelines recommend the use of only one antibiotic as prophylaxis but considering the increase in the rates of antibiotic-resistant infections, the question arises whether antibiotic prophylaxis should be extended for adequate coverage. Shoulder arthroplasty performed on the male population must be carefully checked after surgery for the possible presence of P. Acnes. Given the high success rate, total shoulder arthroplasty has become an effective surgical procedure for glenohumeral osteoarthritis. However, periprosthetic joint infection (PJI) still remains a devastating complication that negatively affects the overall outcome –6. FurthPropionibacterium acnes (P. acnes), Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus .–25.19–25P. Acnes are microorganisms that populate the shoulder area where they found their natural site not only in superficial tissues but also in deep ones [P. Acnes has been demonstrated in 30 consecutive series of 30 patients undergoing primary shoulder arthroplasty. In fact, the hair of male gender in the shoulder area are known as important factors in colonization. The result expressed by the analyzed swabs showed that the male gender with the presence of hair is significantly correlated to the positive presence of P. acnes in the superficial area. Contrary in the female gender, there are no superficial or profound positives in P. acnes cultures [eep ones . In the eep ones . Moreovecultures .Staphylococcus aureus [The reduction of the surgical site infection rate is possible through the standardized administration of prophylactic antimicrobials, particularly in arthroplasty surgery. Due to its broad-spectrum, the use of cephalosporin is an unscientific approach to avoid shoulder PJI . Furthers aureus . Clindams aureus , 28.This systematic review showed that the optimal perioperative antimicrobial regimen is controversial. Although the use of antibiotic prophylaxis with a single drug is recommended by clinical guidelines, the increase in antibiotic-resistant infections may suggest that the choice to increase prophylactic antibiotic regimens may not be correct, improving the risk of expanding bacterial resistance.The efficacy of the combination of Cefazolin and Clindamycin was studied. These drugs lead to potential damage such as acute postoperative renal damage and Clostridium infection and, therefore, the risk-benefit ratio must be carefully evaluated before performing a large-scale operation . HoweverThe purpose of the preoperative administration of antimicrobials is to allow adequate tissue concentrations capable of eliminating the organisms that could occur before surgery. Therefore, the timing of administration and their dosage must be carefully studied to improve the effectiveness of prophylaxis. Single-shot antibiotic prophylaxis is normally sufficient to prevent the onset of bacteria but is not always capable of controlling P. Acnes . No majoPropionibacterium acnes, before the incision [For the prevention of PJI, the administration of preoperative antibiotic prophylaxis seems to be more effective than normal sterilization to minimize bacterial contamination, in particular from incision . Althougincision . The recincision .This systematic review has a limitation represented by the small sample size of the included studies. Therefore, it is essential to define the concept of this contamination for the use of the necessary sterilization techniques to be used in the pre-operative phase . Even thPropionibacterium acnes in the axillary region and, therefore, its presence must be carefully controlled in the post-operative phase of shoulder arthroplasty.There is a lack of consensus in the administration of preoperative antibiotics to prevent infection in shoulder arthroplasty surgery. In this systematic review, we found that the optimal perioperative antimicrobial regimen is controversial. The clinical guidelines recommend the use of only one antibiotic as prophylaxis but considering the increase in the rates of antibiotic-resistant infections, the question arises whether antibiotic prophylaxis should be extended for adequate coverage. Moreover, our results suggest that the male population is more likely to have a higher concentration of Further research is needed to find more effective techniques for the prevention of PJIs, to define the preparation of the surgical site in order to minimize the possibility of contamination and identify adequate antibiotic prophylaxis taking into account the risks and benefits of individual drugs.


Although HIV became known during the decade of the 1980’s, it was not until 1987 that the WHO launched the Global Program on AIDS to raise awareness, generate evidence-based policies, and provide technical and financial support to conduct research, promote NGO participation, and promote the rights of people living with HIV. It was then also that robust educational and prevention initiatives began to take place. At this time, a Columbia University study, led by Dr. Lynn Tepper, a gerontologist, initiated a study to see if the older population fully understood the disease and the practice of prevention behaviors, as they were not a specific target for AIDS education and prevention. This led to the establishment of the AIDS and the Elderly Interest Group, sponsored by GSA, in an attempt to know more about the impact of AIDS in the older population. Part of a symposium sponsored by the HIV, AIDS and Older Adults Interest Group.