Hypertension is a medical condition that often comorbidly exist in patients with type II diabetes. Therefore, it is very important to manage both conditions simultaneously to mitigate the complications and mortality connected with this comorbidity. Hence, this study investigated the antihypertensive and antihyperglycemic effects of combinations of losartan (LOS) with metformin (MET) and/or glibenclamide (GLB) in hypertensive diabetic rats. Hypertensive diabetic state was induced with desoxycorticosterone acetate (DOCA) and streptozotocin (STZ) in adult Wistar rats. The rats were divided into 5 groups (n = 5): control group (group 1), hypertensive diabetic (HD) control (group 2), treatment groups receiving LOS + MET (group 3), LOS + GLB (group 4), and LOS + MET + GLB (group 5). Group 1 comprised healthy rats while groups 2–5 were HD rats. The rats were treated orally once daily for 8 weeks. Fasted blood glucose (FBS) level, haemodynamic parameters, and some biochemical indices were thereafter assessed.P < 0.05) increased following induction by DOCA/STZ. The drug treatment combinations, particularly combination of LOS + MET + GLB, significantly (P < 0.05) reduced the induced hyperglycemia and remarkably decreased systolic blood pressure and heart rate. There was significant (P < 0.05) reduction in raised lactate dehydrogenase and creatinine kinase levels by all drug treatment combinations except LOS + GLB.FBS level and blood pressure measurements were significantly (Our findings suggest that LOS combinations with MET and/or GLB exhibited significant antidiabetic and antihypertensive effects against DOCA/STZ-induced hypertensive diabetic state in rats. Diabetes mellitus (DM) is a chronic endocrine and metabolic disorder that is characterized by elevated blood glucose level generally referred to as hyperglycemia and it is due to deficiency in insulin secretion or action , 2. DM pThe pathogenesis of DM has been reported as multifactorial. There are some evidence largely suggesting the role oxidative damage, inflammation, apoptosis of pancreatic beta cells and prolonged increased levels vasopressin, which is released within the hypothalamic supraoptic nucleus , 11. LonIndeed, hypertension is a major cardiovascular disease that poses health threat to both developed and developing countries with over 40% of cardiovascular mortality resulting from the interplay between genetic and environmental factors . HyperteIn both comorbid cases, DM and hypertension can be managed by dietary modifications, exercise, and lifestyle changes . With thP < 0.05) decrease in the body weight of the HD control at week 4 and week 8 when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB, and LOS + MET + GLB showed decrease in body weight throughout the treatment period, however, LOS + GLB and LOS + MET + GLB had significance (P < 0.05) across week 3 to week 8 when compared with the HD control.Table P < 0.05) increase in FBS level of the HD control across the 2nd hour to 6th hour when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB, and LOS + MET + GLB showed a significant (P < 0.05) decrease in FBS level across the 2nd hour to 6th hour when compared with the HD control.Table P < 0.05) increase in FBS level of the HD control across week 1 to week 8 when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB and LOS + MET + GLB showed significant (P < 0.05) decrease in FBS level across week 1 to week 8 when compared with the HD control.Table P < 0.05) increase in systolic BP of the HD control across week 1 to week 8 when compared with the normal control. Drug treatment with LOS + MET significantly (P < 0.05) decreased systolic BP at weeks 1, 4 and 8 when compared with the HD control. Whereas, treatments with LOS + GLB and LOS + MET + GLB showed significant (P < 0.05) decrease in systolic BP across week 1 to week 8 when compared with the HD control.Table P < 0.05) increase in diastolic BP of the HD control at weeks 1, 2, and 4 only when compared with the normal control. Drug treatments with LOS + MET and LOS + GLB showed significant (P < 0.05) decrease in diastolic BP only at week 4, while LOS + MET + GLB treatment significantly (P < 0.05) decrease in diastolic BP only at weeks 2 and 4 when compared with the HD control.Table P < 0.05) increase in mean arterial pressure of the HD control across week 1 to week 4 when compared with the normal control. Drug treatments with LOS + MET showed significant (P < 0.05) decrease in mean arterial pressure at week 4 only, LOS + GLB at weeks 3 and 4 only while LOS + MET + GLB showed significant (P < 0.05) decrease in mean arterial pressure at weeks 2, 3, and 4 only when compared with the HD control.Table P > 0.05) change in heart rate of the HD control across week 1 to week 8 when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB and LOS + MET + GLB showed non-significant (P > 0.05) change in heart rate across week 1 to week 8 when compared with the HD control.Table P < 0.05) increase in LDH level of the HD control group when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB and LOS + MET + GLB showed significant (P < 0.05) decrease in LDH when compared with the HD control. CK level was significantly (P < 0.05) increased in the HD control group when compared with the normal control. Treatments with LOS + MET, LOS + GLB and LOS + MET + GLB had significant (P < 0.05) decrease in CK when compared with the HD control.The effects of LOS, MET and GLB on cardiac injury markers of DOCA + STZ-induced hypertensive diabetic rats is shown in Fig. P < 0.05) decrease in HDL level of the HD control group when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB and LOS + MET + GLB increased HDL, however, only LOS + MET + GLB treatment showed significant (P < 0.05) increase in HDL when compared with the HD control. LDL level was significantly (P < 0.05) increased in the HD control group when compared with the normal control. Treatments with LOS + MET, LOS + GLB and LOS + MET + GLB significantly (P < 0.05) decreased LDL when compared with the HD control. There was significant (P < 0.05) increase in total cholesterol level of the HD control group when compared with the normal control. Drug treatments with LOS + MET, LOS + GLB and LOS + MET + GLB showed significant (P < 0.05) decrease in total cholesterol when compared with the HD control. Triglyceride level was also significantly (P < 0.05) increased in the HD control group when compared with the normal control. Treatments with LOS + MET, LOS + GLB and LOS + MET + GLB non-significantly (P > 0.05) decreased triglyceride when compared with the HD control.Figure The effects of LOS, MET and GLB on the histology of the pancreas of DOCA + STZ-induced hypertensive diabetic rats is shown in Fig. The finding from this study showed that treatments with LOS + MET, LOS + GLB and LOS + MET + GLB significantly reduced DOCA/STZ-induced increased in body weight. Moreover, DOCA/STZ increased heart rate, systolic blood pressure as well as elevated blood sugar level when compared with controls. However, these changes were normalized by LOS + MET, LOS + GLB and LOS + MET + GLB treatments, respectively. Additionally, treatments with LOS + MET, LOS + GLB and LOS + MET + GLB significantly attenuated DOCA/STZ-induced increased LDH and CK concentrations. We also found that DOCA/STZ exposure caused a significant increase in LDL and total cholesterol levels, which were reduced by LOS + MET, LOS + GLB and LOS + MET + GLB relative to controls. However, treatments with LOS + MET, LOS + GLB and LOS + MET + GLB failed to mitigate DOCA/STZ-induced increased triglyceride levels in the rats relative to DOCA/STZ control. Excitingly, we also found that LOS + MET + GLB protected against DOCA/STZ-induced degeneration of the pancreatic beta cells and myocardial cells of the heart in comparison with DOCA/STZ groups respectively.The DOCA-salt-induced hypertension is a translational neurogenic hypertensive model characterized of human cardiovascular remodeling due to impairment of renin-angiotensin pathway and hypervolemia, in which the kidney reabsorbs excessive sodium and water due to deranged renal sodium handling capacity . It raisDOCA/STZ significantly decrease body weight of HD control rats by 38.8% which is an indication that it interferes with the normal body growth of rats. Drug treatments significantly inhibited the reduction of body weight by 9.5% in LOS + GLB and 14.8% in LOS + MET + GLB but not in LOS + MET. Combinations with GLB had increase in body weight. This revealed that GLB, like every other sulfonylurea antidiabetic agent, is associated with weight gain .Streptozotocin is a well-known diabetogenic agent . UntreatAccording to the American Diabetes Association (ADA) Standards of Medical Care in Diabetes 2019 update, sulfonylureas such as glyburide (glibenclamide) are considered one of the six options for adjunct therapy with MET, the first-line anti-diabetic medication , 43. WhiBlood pressure parameters  were significantly increased in DOCA/STZ rats which was possibly due to hypercholesteremia and oxidative stress-derived vasoconstriction in the animals. In this study, we observed that weekly administration of these drugs led to a dramatic reduction in SBP and HR, although there were no significance changes in DBP and MAP. Of note, it is an indication that the drug combinations can be used for effective management of blood pressure in hypertensive diabetic states, particularly by reducing systolic pressure .As regards the estimation of biomarkers cardiac injury, serum levels of LDH and CK were used as previous described . AccordiPrevious investigations have shown that dyslipidemia increases the risk of development of coronary artery disease and progression of atherosclerotic lesions , 52. DOCHistopathological results showed that hypertensive diabetic state induced by DOCA/STZ profoundly generated tissue damage in the pancreas and heart. This is depicted by the severe necrosis and inflammation of the Islet cells of the pancreas, and hypertrophy of myocardial cells with interstitial macrophage infiltration, evidenced by elevated levels of FBS and HBP parameters respectively. However, several studies have hypothesized that the clinical effects of antidiabetic and antihypertensive agents are based on their ability to repair or prevention damage to Islet cells of the pancreas and hypertrophy of myocardial cells. In this study, the combinational approach therapy with LOS + MET + GLB significantly reduced the DOCA/STZ-induced damages to the pancreas and heart tissues, suggesting pancreatic and myocadiac protective properties. However, marked attenuating effect on tissue damage was evident in LOS combination with both MET and GLB (LOS + MET + GLB) than when the antidiabetics are used singly with LOS.The findings from this study suggest that the combination of losartan, metformin and glibenclamide mitigate DOCA/STZ-induced comorbid states involving hypertension and diabetes via mechanisms associated with decreased fasting blood glucose level, systolic blood pressure and reduced markers of cardiac injury with corresponding decrease in body weight. The study recommends that for effective management of diabetes and hypertension comorbidity, both metformin and glibenclamide in combination with losartan may be a superior approach to prevent complications associated with this comorbidity.Healthy adult male Wistar rats aged 12–15 weeks and weighing between 220 and 280 g were randomly selected for the study. Animals were obtained from the Animal Facility of the Department of Pharmacology, Ambrose Alli University, Ekpoma, Edo State, Nigeria. The animals were acclimatized for 14 days prior to the study, and were fed with standard animal pellets  and clean water ad libitum. Guidelines followed in the handling of animals were in accordance with the ethical standards of the ‘National Institute of Health Guide for the Care and Use of Laboratory Animals’ as adopted by the ethical committee of the Faculty of Pharmacy, University of Benin, Benin City, Nigeria. Ethical approval was obtained prior to the commencement of the experiment .Streptozotocin (STZ) , deoxycorticosterone acetate (DOCA) , losartan potassium , metformin , glibenclamide  and sodium chloride (NaCl)  were used in this study.Type 2 diabetes was induced with a combination of high-fat diet and a single intraperitoneal injection of streptozotocin  in sterile citrate buffer  to fasted male Wistar rats . It is pThe DOCA salt induced hypertension model was used to mimic secondary form of hypertension. Method of uninephrectomy (UNX) was done according to Hemalatha et al., . BrieflyGroup 1: Normal + distilled water (10 ml/kg) Group 2: DOCA + STZ + distilled water (10 ml/kg) (HD control)Group 3: DOCA + STZ + LOS + METGroup 4: DOCA + STZ + LOS + GLBGroup 5: DOCA + STZ + LOS + MET + GLBHD Hypertensive diabetic; LOS Losartan (50 mg/kg); MET Metformin (500 mg/kg); GLB glibenclamide (5 mg/kg)][Drugs were administered orally daily for a period of eight (8) weeks with a weekly measurement of fasting blood sugar (FBS) and blood pressure (BP).Body weight of animals were measured weekly in grams to estimate the effect of the induced diabetes and hypertension on body composition. The weight was measured using a digital electronic weighing balance.Fasting blood sugar (FBS) level was measured using a glucometer (ACCU-CHEK® Active) with compatible blood glucose test strips. FBS level at 2nd, 4th and 6th hours following single drug administration was measured. Afterwards, weekly measurements of FBS for 8 weeks were taken.Blood pressure measurements  were recorded in the conscious rats weekly during daylight (between 8 am and 12 noon) by the same investigator, using a tail-cuff plethysmography , a computerized non-invasive blood pressure system which measures rat’s tail blood pressure by means of volume pressure. The rat was positioned in the animal holder (restrainer) with necessary adjustments made to ensure a restricted animal movement, and leaving the tail outside the holder. The restrainer was then placed in the heating chamber and heated up to 32℃. The basic software setup of the system was calibrated prior to start of measurement. The BP monitoring sensor was placed round the tail root of rats. Following animal movement stability, the data of SBP, DBP, MAP and HR were recorded .Serum cardiac injury markers including creatine kinase (CK) and lactase dehydrogenase (LDH) were assessed spectrophotometrically according to standard manufacturer’s procedure as seen in the assay kits . High density lipoprotein (HDL) and triglyceride (TG) were evaluated using the assay kit’s procedures  and  respectively. Serum total cholesterol was determined using the method described by Trinder , while lTissue sections of the pancreas and the left ventricle of the heart from all the groups were processed for histological examination according to procedures described by Kieman .All data obtained were expressed as Mean ± SEM (standard error of mean), and analyzed by one-way analysis of variance (ANOVA) followed by Tukey’s post hoc test. Analysis was done using GraphPad Prism version 7.0 . P-values < 0.05 were taken as significant. Data were presented in tables and graphs.


Despite the promising results, there have been limited studies focusing on 3D printing with foamed materials, whereas a survey of the existing body of literature indicates a notable absence of endeavors pertaining to the utilization of aerated concrete within the realm of 3D printing, especially geopolymer composites (GP) and hybrid geopolymer composites (HGP). The outcomes delineated in the ensuing discourse are demonstrative for conventionally used materials rather than the additive manufacturing variant. Hence, this work aims to systematically review existing practices and techniques related to producing foamed concrete with 3D printing technology. This analysis also contributes to the establishment of a foundational framework and furnishes a preliminary basis upon which future endeavors aimed at the 3D printing of aerated concrete can be embarked. The findings from the literature analysis justify the desirability of continuing research on this topic, particularly when considering the potential for large-scale industrial implementation. This article provides a comprehensive state of the knowledge on the development of 3D printing techniques for foamed concrete mixtures. By consolidating and analyzing findings from different studies, this article offers insights into the advancements, challenges, and potential applications of foamed concrete in additive manufacturing processes. This, in turn, contributes to the overall understanding and advancement of 3D printing technologies using foamed concrete as a versatile and sustainable construction material. The encouraging results obtained from the analysis further underscore the need for the continued exploration of 3D printing, especially with an eye towards its industrial-scale implementation.Recent years have witnessed a growing global interest in 3D concrete printing technology due to its economic and scientific advantages. The application of foamed concrete, renowned for its exceptional thermal and acoustic insulation properties, not only holds economic attractiveness but also aligns seamlessly with the principles of sustainable development. This study explores various solutions related to 3D printing technology in construction, discussing the design, production, and properties of foamed concrete mixtures. The integration of 3D printing and the potential for automating the entire process offers opportunities to boost productivity and reduce construction costs. Furthermore, the utilization of foamed concrete with its commendable insulation properties will enable a reduction in the usage of materials other than concrete , significantly facilitating the recycling process during building demolition. This, in turn, will lead to the preservation of nonrenewable natural resources and a decrease in CO Expanded concrete (cellular concrete) is a lightweight material that is obtained by introducing and enclosing gas inside a concrete structure. Foam concrete is one of the varieties of expanded concrete, and its name comes from the method of production. A foaming agent is added to the cement mixture, as a result of which, at ambient temperatures, a material with a porous structure is formed, in which the pore volume is at least 20% . Another3 [3 are considered suitable materials for structural applications, but rather, they are used as insulation material [The universality and very good thermal insulation properties of cellular concrete affect its widespread use in low-energy construction, which is part of the sustainable development trend . Cellula3 . Howevermaterial .As research and technology advancements continue, expanded concrete has the potential to play a significant role in the future of construction, enabling the creation of more sustainable, cost-effective, and energy-efficient buildings and infrastructure. From a technical and scientific perspective, these key characteristics contribute to its potential application in emerging technology that is additive manufacturing. Expanded concrete’s unique combination of properties, including reduced density, enhanced thermal insulation, good flowability, high compressive strength, fire resistance, and versatility, positions it as a promising material for large-scale 3D printing. The integration of 3D printing and the potential for automating the entire technological process present an excellent opportunity to enhance productivity and concurrently decrease construction costs. Furthermore, the additive technology may enable control of the geometry of the manufactured structure both globally as the entire body of the building and locally on the cross-section of the wall, enabling the production of solid and foamed areas or with designed air pores. In addition, during the manufacturing process, it is possible to change the composition and thus the properties of the material used; this feature will help facilitate both the structural and insulation requirements. Three-dimensional printing technology allows the creation of buildings or their elements with complex geometry, which previously would not have been profitable due to the need to use conventional methods. Many concrete structures have been built in 3D printing technology, e.g., a two-story building in Dubai by Apis Cor , a commuBuildings erected with the use of 3D printing technology do not need to use additional external insulation, plasterboards, or reinforcement meshes, which not only increase construction costs but also hinder the possible recycling of such a building, as only “clean” concrete waste can be reused. This will save deposits of nonrenewable natural resources. In contrast to conventional construction methods, the utilization of foamed concrete in 3D printing technology allows for the elimination of additional external insulation, gypsum board, or reinforcement meshes. This not only leads to cost reductions in construction but also facilitates the recycling process, as waste from foamed concrete buildings can be reused. The recycling of construction waste plays a pivotal role in combating the escalating global waste issue. Nevertheless, the scientific literature suggests that contaminants from various materials used in construction, such as gypsum, wood, plastic, steel, or glass, can impede the efficiency of the recycling process. The multiplicity of materials generates a very high probability of contamination transferring to the new material. They can reduce the compressive strength of concrete and reduce the modulus of elasticity by 15% compared to the reference sample [The exclusive use of foamed concrete for building houses is expected to contribute to the advancement of the construction materials recycling industry. The absence of a need to segregate different materials enhances the efficiency of the recycling process and allows for the greater utilization of waste in the production of new concrete. Additionally, the growth of the construction sector employing additive manufacturing (3D printing) may serve as a market for materials derived from the recycling of construction waste. In the context of environmental conservation and the reduction of waste accumulation in landfills, the sustainable management of construction waste holds the utmost importance. According to the European Commission (europa.eu) , construThe disparities between conventional concrete designed for 3D printing and foamed concrete necessitate the development of dedicated printing processes and material transport systems, particularly for large-scale applications. Given these distinct material compositions, specialized 3D printing processes and material transport systems are essential for each concrete type. The successful large-scale implementation of 3D printing with foamed concrete relies on addressing several key challenges unique to this material. The foam content and its distribution within the concrete mix shall be meticulously controlled to achieve the desired mechanical properties and printability. As a result, it becomes imperative to customize the material transport system to effectively handle the unique flow properties of the foamed concrete mix, ensuring a seamless and consistent supply to the printhead, which is located on either the robot’s arm or the gantry structure . This adThe basic parameter used to assess the prepared mixture for the possibility of its use in 3D printing includes the ease of pumping continuously without blocking the material inside the nozzle. Therefore, the material must be fluid enough for its transport to run smoothly, but on the other hand, too much fluidity may result in the uncontrolled spilling of the mix out of the nozzle . This is3) than conventional concrete (2400 kg/m3), which is of great importance in the context of building with the use of 3D printing technology [3. In addition to its thermal, mechanical, and acoustic properties, foamed concrete exhibits a resistance to moisture and fungi, making it a suitable material for applications in humid or damp environments. Its low water absorption capacity further enhances its durability and resilience to environmental factors [A significant reduction in the self-weight of the structure can be achieved by using foamed concrete with a lower density  . The higm manner . Furtherm manner . Accordim manner . The larm manner . Most ofm manner ,61,62. Hm manner . The exa(a)A planetary mixer has arms that move called planetary movements, and the mixing trajectory is continuous. The mixing blades are set at such an angle that the mixing efficiency is as high as possible. The resulting material, together with the hardener, is pumped to the foam generator, where the ingredients combine and foam is produced. The pumping takes place continuously, and the resulting foam is transported through a flexible hose to the nozzle .(b)A conical mixer is equipped with two counter-rotating mixers mounted coaxially in the center axis of the device; thanks to which, a homogeneous concrete mix is created. The screw agitator transports the material vertically upwards, thus setting it into rotation. The blades of the second agitator are set on the outside work in the opposite direction to this movement. Such intensive mixing guarantees the accurate distribution of all ingredients and obtains a homogeneous mass. The mixing of the foam with the concrete slurry must occur at lower speeds than the mixing of the concrete material itself; otherwise, the stability of the preformed foam is significantly reduced. In addition, the frequency of feeding the prepared foam to the concrete material is important, as providing all the foam at one time negatively affects the homogeneity of the final material .(c)The cavitation disintegrator is a device that shreds the material in two ways: cavitation and impact. The principal operation of the device is to introduce high-intensity ultrasonic waves into the process medium, which alternately generates high- and low-pressure cycles during which cavitation bubbles are formed. After absorbing enough energy, they implode, and the resulting shear forces cause collisions between solid particles and breaks them into the expected size. The resulting material is homogeneous. The cavitation phenomenon occurs in the profiled grooves located near the impeller. To create zones of low and high pressure inside the tank, it is important to achieve the appropriate rotational speed ,67.(d)Turbulence mixer is the mixer equipped with a vertical shaft, and the tank is in the shape of a cone. The mixture that is produced in this device can be pumped under foam concrete pressure directly to the printing head .Undoubtedly, the key processes in additive manufacturing are mixing and pumping the produced composition into the printhead. Despite the requirements, according to the literature data, devices available on the market can be used to integrate materials  inter alThe pump responsible for transporting the material to the printhead is not in the printing area but far beyond it. The pumping results depend on the parameters of the pump and the diameter of the hose, and the distance that the material must travel, as well as the selected pumping methodology. The pumped material should be stiff enough to not change its shape after building a layer but fluid enough for transport without disturbances. The potential accumulation of material inside the hose makes it necessary to replace it frequently, so it cannot be kept for a relatively long time. On the other hand, the short flexible hose limits the size of the printing field. The mixture should have a low viscosity and a moderate yield strength . The pumAt the Dresden University of Technology, under the CONPrint3D Ultralight Project, research was carried out to produce foamed concrete suitable for 3D printing, and an attempt was made to develop a technique for feeding this material to the printhead. Several concepts were explored, such as (a) manual filling of the printhead reservoir, (b) mixing and pumping (the mixer was directly connected to the foam delivery pump), (c) pumping to the integrated mixing system (the mixer was connected directly to the printhead), and (d) the system where the mixer was placed on the printhead and the supply of raw materials was automated; an important advantage of this concept was the fact that the pumping process did not affect the stability of the produced material in any way . Despite2SO4). Lightcrete 02™ liquid surfactant was used as the foaming agent and foam stabilizer. The investigation revealed that the thermal conductivity of the printed foamed matrices was comparable to that of various other insulation materials, including foamed concrete, expanded clay, cork boards, and porous fly ash-based geopolymers. The selected suspensions exhibited shear yield stress values ranging between 60 and 130 Pa. Remarkably, the diminished yield stress observed in the foamed suspensions did not impede their buildability due to their correspondingly reduced density. [2, Al2O3, and a polycarboxylate ether superplasticizer. The introduction of a protein-based foaming agent facilitated the generation of the requisite foam composition. The examined component exhibited a thermal conductivity of 0.24 W/mK, signifying an improvement exceeding 80% in comparison to the reference material. Furthermore, the compressive and flexural strengths were evaluated at the 28-day mark, registering values of 10.40 MPa and 2.12 MPa, respectively [3 were prepared. The yield strength and viscosity for these materials were higher than for sand-based materials [3, but its strength decreased by 50% compared to the reference material [3. This is related to the dependence of the increase in the heterogeneity of the foams with the decrease in the density of the produced material. The effects of the inhomogeneity and delamination of the foam and base mix negatively affect the printing process [During additive manufacturing with foamed concrete, the mixing process must be carried out in such a way that the disintegration of air pores is as small as possible. Considering the expected low density of the produced material and the low yield strength required for the process, the composition of the mixture is important, in which the required parameters,  will be achieved with a reduced content of technical foam. Scientists have so far studied numerous compositions, focusing on different properties. Inter alia, the research revealed that a blend comprising Portland cement, microsilica, superplasticizer, and fly ash was employed as the binding agent. The authors examined the structural integrity of the layered elements, assessing both the compressive and flexural strength characteristics . Scientidensity. . In a seectively . The expectively . Furtherectively ,67. Reduectively . While eaterials . Anothermaterial . Interesmaterial . Moreove process .The essence of the process of erecting a building using 3D concrete printing technology is the proper selection of the printing parameters, as well as a properly defined path along which the printing head moves. For example, the appropriate design of the tested sample with a truss cross-section allowed saving 46.7% of the material while ensuring 90% of the strength of the tested element. The material used in this study contained expanded clay sand . Employi3 in studies [3, in which 5% of the cement volume was replaced with aluminosilicate [3 and a porosity of 60–70%, it was found that a high proportion of surfactant negatively affects the shape of the printed layer [It has been shown that foam concrete mixtures may achieve good engineering properties. The foam concrete composition with a density of 1100–1580 kg/m studies  was charsilicate . On the ed layer .3). In further research, different amounts of foaming agent and different mixtures were used, but the same mixers were used: a cavitation disintegrator and a turbulence mixer, and it was thanks to the latter that a lower foam concrete density was obtained even when a smaller amount of foaming agent was added. At the same time, the study of water absorption of the tested samples showed that the quality of the pores obtained using a turbulent mixer is better.The team from Technische Univeraität Dresden  carried 3. The thermal conductivity of the tested mix of printable foam concrete is 0.24 W/mK, which is about 85% less than conventional fine-grained concrete (density 2100 kg/m3), which has a thermal conductivity of 1.68 W/mK  [Moreover, analyzing the works of the authors, foam concrete suitable for printing showed low thermal conductivity and relatively high compressive strength above 10 MPa at a density of 980 kg/moncrete) ,76.To obtain a quick setting in the process of printing with conventional concrete, types of cement with shorter setting times are usually selected or accelerating admixtures are used. These solutions can also be applied to foam concrete. However, the use of setting accelerating materials in foam concrete does not always give the same effect as in ordinary concrete . Table 1An increasing problem in the sense of stability and residential opportunities for young people in Poland is the high prices of houses and flats, which results not only from the growing demand but also from the prices of materials and rising labor costs. The possibility of erecting buildings using 3D printing technology will contribute to reducing the demand for human labor, which is today a significant barrier in the construction industry due to rising salaries but, above all, the lack of qualified construction workers . In 2022In addition, the construction industry is responsible for almost 50% of global carbon dioxide emissions and 20–50% of natural resource consumption, most of which is related to significant land exploration, which has a significant impact on the natural environment . TherefoDue to the nature of additive manufacturing technology, concrete mixes intended for printing must meet specific requirements in terms of material properties. The growing interest in concrete 3D printing means that the developed mixes and the printing preparation technology must be repeatedly checked and evaluated very critically. So far, in the construction market, foam concrete has been used as structural material for low-rise buildings or a filler element in skeletal structures. Foamed concrete exhibits valuable characteristics, such as reduced density, enhanced thermal insulation, good flowability, high compressive strength, fire resistance, and versatility, making it an environmentally friendly material with potential applications in sustainable construction. Large-scale 3D printing using foamed concrete offers the advantage of eliminating the need for additional external insulation, plasterboards, or reinforcement meshes during construction, leading to cost reduction and simplifying the recycling process. The ability to control the geometry and composition of the manufactured structure allows for tailored designs that meet both the structural and insulation requirements. Despite the conducted research on this material, one method of preparing a foamed concrete mix for 3D printing has not yet been developed. First, it is necessary to determine the composition and proportions of the composition, which will make it possible to pump and build layers. Addressing challenges unique to foamed concrete, such as precise control of the foam content and distribution, is crucial for achieving the desired mechanical properties and printability. The integration of foamed concrete with 3D printing offers innovative opportunities for construction, enabling the creation of complex geometries with high precision and efficiency. There are two techniques for producing foamed compositions, depending on how the foam is produced and how pores are generated in the mix. Pre-foaming and mixed foaming are ways of introducing foam into a concrete slurry. Air pores may be caused by the addition of chemicals or blowing agents to the mixture. The use of advanced components of the concrete mix makes it possible to control its parameters, such as setting speed, mechanical strength, fire resistance, thermal insulation, and aesthetics. Most of the information available in the literature presents the results of experiments based on the empirical method of material composition design. The methods of foam concrete production in the analyzed research works were the use of foaming agents and pre-foaming. The number of air pores inside the material depends on the foaming agent used and the application technology. The ease of pumping foamed concrete is influenced by the pores formed, and their diameters should not be greater than 1 mm. The ability of foamed concrete to form layers during printing is considered ideal when the size and shape of the layer faithfully reflect the width of the nozzle. The density of the foamed concrete decreases during the curing and drying of the already printed elements. However, as the number of printed layers increases, there is a noticeable tendency to increase the density. Despite the promising results achieved so far by scientists studying foam concrete for 3D printing, it is necessary to conduct further research on this material and the printing process itself. Achieving the desired density and mechanical properties while maintaining printability is a key focus. Notably, the use of specific mixtures and additives has shown promise in achieving high compressive strength and low thermal conductivity, making foamed concrete a viable option for sustainable construction practices. The choice of foaming agent and production method significantly influences the properties of the foamed concrete material. Synthetic foaming agents are often favored for their economic benefits and stability. Mixing techniques, such as the use of a turbulent mixer, have demonstrated improved foam concrete density and quality of the pores. The development and implementation of additive manufacturing with foamed concrete material will undoubtedly contribute to the reduction of global carbon dioxide emissions, the consumption of natural resources, and the reduction of thermal energy consumption. Buildings without reinforcement meshes or additional external insulation are easier to demolish, and the “clean” construction waste will be able to be reused for the construction of other buildings.Overall, additive manufacturing with foamed concrete holds significant potential for revolutionizing construction practices and facilitating the development of eco-friendly and efficient building structures. Further research and advancements in foamed concrete production and 3D printing technologies are crucial to unlock the full potential of this innovative construction material.


Clostridioides difficile is the number one cause of hospital-acquired infections in the United States and one of the CDC's urgent-level pathogen threats. The inflammation caused by pathogenic C. difficile results in diarrhea and pseudomembranous colitis. Patients who undergo clinically successful treatment for this disease commonly experience recurrent infections. Current treatment options can eradicate the vegetative cell form of the bacteria but do not impact the spore form, which is impervious to antibiotics and resists conventional environmental cleaning procedures. Antibiotics used in treating C. difficile infections (CDI) often do not eradicate the pathogen and can prevent regeneration of the microbiome, leaving them vulnerable to recurrent CDI and future infections upon subsequent non-CDI-directed antibiotic therapy. Addressing the management of C. difficile spores in the gastrointestinal (GI) tract is important to make further progress in CDI treatment. Currently, no treatment options focus on reducing GI spores throughout CDI antibiotic therapy. This review focuses on colonization of the GI tract, current treatment options and potential treatment directions emphasizing germinant with antibiotic combinations to prevent recurrent disease. Clostridioidesdifficile and treatment opportunity.Schematic of the infectious life cycle of  Clostridioides difficile is an anaerobic, spore and toxin forming, Gram-positive pathogen that has become the most commonly identified hospital-acquired infection (HAI) in the United States  is ingesting spores through either person-to-person spread via the fecal–oral route, or direct exposure to the contaminated environment . Disruption of CR, which results from antibiotic therapy, allows overgrowth of C. difficile leading to clinical CDI and increased spore shedding. This review will cover C. difficile acquisition and GI tract colonization, limitations and benefits of current treatment options, and potential new treatment directions emphasizing germinant with antibiotic combinations to prevent recurrent disease.ions CDC . The firC. difficile spore is the primary vehicle used to transmit infections between patients. Mature spores are heat and ethanol resistant, not affected by antibiotics, and have an unknown lifespan in the environment, making environmental decontamination difficult. Spore shedding occurs in both clinically infected patients and asymptomatic carriers, which act as a reservoir for the pathogen. Gut carriage is estimated to be around 10% in newly admitted hospital patients , independent of other well-known CDI risk factors such as age, antibiotic use and proton pump inhibitors . In patients with a prior episode, fidaxomicin saw 19.7% of patients experience recurrence compared with 35.5% for vancomycin (P = 0.045). Though relapse rates differed, the primary outcome of clinical cure as assessed by resolution of diarrhea at the end of 10 days of treatment was similar between the two groups , the instillation of healthy donor feces into a patient's GI tract after CDI directed antibiotic therapy, is recommended for patients with multiple rCDI episodes who have failed appropriate antibiotic treatment. Restoring CR with FMT helps reverse the damage caused by multiple rounds of antibiotic treatment, removing the niche that C. difficile (NTCD) spores post-CDI-directed antibiotic therapy. In a phase 2, randomized, double blind, placebo-controlled trial, patients were given differing doses of NTCD strain M3 spores for 7 or 14 days . The adverse effect profile of spore administration was minimal, and often less than that of placebo. It should be noted that the majority of patients treated were not rCDI patients and multiple rCDI patients were excluded from participation. Lastly, this form of CR, which is likely due to resource competition, may be particularly cost effective to produce through culture. The same durability that allows spores to survive in the environment should afford a long shelf life for hospital pharmacies. The results of this trial are encouraging though more information is needed, particularly in multiple rCDI patients.Another promising non-antibiotic treatment being explored, similar to FMT restoration of CR, is oral administration of non-toxigenic C. difficile that are unable to produce spores (Deakin et al. et al. et al. C. difficile spore-cell life cycle.Spore shedding and persistence in the GI tract are the greatest barriers in preventing rCDI. This was partially elucidated in an murine model with genetically modified strains of ex vivo (Darkoh et al. et al. et al. Administering germinants to patients during CDI antibiotic therapy may sufficiently diminish the spore burden to allow CR to regenerate. This approach would leave behind only hyperdormant spores, decrease total antibiotic administration time and may provide a decolonization method for rCDI patients. Additionally, decreased spore shedding in the hospital environment would likely lead to reductions in HAIs. The primary concern with this method is a sudden increase in toxin production and subsequent decline in clinical status. However, understanding that certain antibiotics, such as fidaxomicin and tetracyclines, decrease toxin production, and bezlotoxumab binds toxin B to neutralize its toxigenic effect should mitigate these concerns. In addition to inducing germination, taurocholate, at concentrations as low as 5 mM, has been found to mitigate cytotoxic effects of toxins A and B et al. Additional considerations are the types of germinants that would be needed for transition from spore to vegetative cell. Taurocholate is taken up in the small intestine and recycled in the bile acid pool. Creation of a non-absorbable version of taurocholate would be beneficial to assure that the dose is reaching the colon in significant amounts. Alternatively, inhibitors of the apical sodium-dependent bile acid transporter, responsible for bile acid uptake, have recently been developed to aid insulin responses in type 2 diabetes and prevent itching in primary biliary cholangitis (Hegade et al. et al. et al. in vivo with conventional methods such as sonication, centrifugation or enzyme digestion. However, hyperdormant spores may not germinate in sufficient numbers or in a timely manner to outpace the regeneration of CR.The final consideration in using germination to eradicate spores is hyperdormancy, or spores that do not readily vegetate in response to germinants. This may be due to the spore's outermost layer, the exosporium. The bile acid receptor CspC implicated in initiating germination is hypothesized to be in the spore coat or outer membrane, both located under the exosporium (Kochan Spore shedding and colonization of the GI tract are significant barriers for preventing HAIs and treating rCDI patients. Options to remove toxigenic spores from a patient's GI tract are severely limited and progressive CDI antibiotic usage may prevent re-establishment of CR. FMT has been very successful at preventing rCDI, but its efficacy is removed through subsequent antibiotic treatment. Currently, no therapy exists to address this issue. Turning spores into vegetative cells with germinants for antibiotic targeting is an alternative approach with potential to decrease the prevalence of CDI. Future studies should investigate the effect and safety of germinants with antibiotics in animal models of CDI to determine whether combination therapy has potential benefit.xtaa001_Supplemental_FileClick here for additional data file.


Creep deformation is an important aspect of magnesium phosphate cement (MPC) used as a structural material. In this study, the shrinkage and creep deformation behaviors of three different MPC concretes were observed for 550 days. The mechanical properties, phase composition, pore structure, and microstructure of MPC concretes after shrinkage and creep tests were investigated. The results showed that the shrinkage and creep strains of MPC concretes stabilized in the ranges of −140 to −170 με and −200 to −240 με, respectively. The low water-to-binder ratio and the formation of crystalline struvite were responsible for such low deformation. The creep strain had almost no effect on the phase composition; however, it increased the crystal size of struvite and reduced the porosity, especially the volume of pores with diameters <20 nm and >200 nm. The modification of struvite and densification of microstructure led to an improvement in both compressive strength and splitting tensile strength. Ammoniu4H2PO4)  and pota) [2PO4) ,6,7,8,9 ) [2PO4) ,10,11,12Struvite or k-struvite provides cementitious properties for the MPC system. When compared with ordinary Portland cement (OPC) and other inorganic binders, MPC shows an array of merits because of its unique reaction mechanisms and microstructural characteristics. These include rapid setting ,14, low Despite the recognition of MPC, it still has several important properties that have not been studied adequately, for instance, shrinkage and creep behaviors. Some experimental studies have been conducted on the free shrinkage of MPC materials. MPC develops very low shrinkage at an early age when compared to OPC, as shown by several studies ,16. Li  reportedIn addition to shrinkage, creep is also a particularly important aspect of MPC used as a structural material. Creep is the deformation of concrete under sustained loading, which may lead to an excessive deflection of the concrete structure and even cause severe serviceability problems ,27. MPC In this context, this paper focuses on studying the long-term deformation of MPC concretes, where three MPC concretes with different contents and gradations of coarse aggregates were designed, and their drying shrinkage and creep were monitored for 550 days under natural (indoor) curing conditions. The mechanical strengths, phase composition, pore structure and microstructure of MPC concretes after shrinkage and creep test were investigated to evaluate the influence of creep strain on the mechanical and microstructural properties. This work may be the first experimental study on the creep of MPC concrete, which will provide preliminary knowledge of the long-term deformation of MPC concrete under sustained stress.4H2PO4), and borax decahydrate (Na2B4O7·10H2O). F-class fly ash (FA) obtained from a local coal-fired thermal power station, with a surface area of 3850 cm2/g and a density of 2.80 g/cm3, was incorporated into the binder. The chemical compositions of MPC and FA are shown in Commercial MPC was supplied by Guizhou Linmei Materials Co., Ltd., Guiyang, China. The main components of this cement were dead-burned MgO, ammonium dihydrogen phosphate  until the testing age.ɛst represents shrinkage strain at the age of t (day), Lb = 500 mm represents the effective length of the specimen that eliminates the embedded length of the copper head in the top end, L0 represents the initial length of the specimen (mm) and Lt represents the length measured at the age of t (day) (mm).Three identical prismatic specimens with dimensions of 100 mm × 100 mm × 515 mm were prepared for each mix and used to measure unrestrained shrinkage following GB/T 50082-2009 . These sɛct represents the creep strain of concrete at the age of t (day), ΔLt represents total deformation value at the age of t (day) (mm), ΔL0 represents initial deformation (mm), Lcb represents the gauge length (mm) and ɛst is unrestrained shrinkage strain measured from unloaded companion specimens at the age of t (day).The prism strength of concrete is essential for investigating compressive creep under a certain stress–strength ratio. The compressive strength was measured from 100 mm × 100 mm × 300 mm prisms, as per GB/T 50081-2019 . The creAfter the shrinkage and creep tests, the prismatic specimens were cut into 10 cm cubes for mechanical tests according to GB/T 50081-2019 . The loaFractured samples were collected from the core of the specimens after the mechanical tests. They were soaked in absolute ethanol for 24 h to stop hydration, and then vacuum dried at 40 °C for another 24 h. Subsequently, the samples were ground and sieved to less than 75 μm before X-ray diffraction (XRD) and thermogravimetric (TG) analysis. Block samples with a size of 3–5 mm were selected for scanning electron microscopy (SEM) and mercury intrusion porosimetry (MIP) tests.The XRD test was performed with a Panalytical X-Pert Pro X-ray diffractometer (Netherlands). The continuous scanning mode of 3°/min was used in the 2θ range of 10–80°. The TG test was carried out in a nitrogen atmosphere using a Netzsch TG 209 F3 analyzer (Germany) at a heating rate of 5 °C/min up to 600 °C. The pore structure was characterized by using a Micromeritics’ Autopore IV 9500 instrument (United States). The test pressure was in the range of 0.518 to 32,923.57 psi, corresponding to the pore size range of 348.63 μm to 5.5 nm. The morphology of the fracture surface of selected samples was observed by using ZEISS Gemini 300 scanning electron microscope (Germany). Before the test, the sample was sprayed with gold by Quorum SC7620 sputtering coating instrument (United Kingdom) under vacuum.MPC concrete specimens were placed in a laboratory without constant temperature and relative humidity. The changes in temperature and relative humidity during the test period are shown in Measured strains from unloaded specimens with different aggregate contents and gradation are shown in t(day), –6/°C = 8.4 με/°C is the coefficient of thermal expansion of MPC concrete according to the previous literature [Tt is the daytime temperature at the age of t(day) (°C), and T0 = 15 °C is the initial temperature value. After removing the thermal strain, the shrinkage strain corresponds to the one measured at T0.The strains measured from unloaded specimens included thermal strain, which is attributable to the significant change in temperature. The thermal strain can be calculated using Equation (5).terature , Tt is tCreep strains of MPC concretes with different mix proportions under sustained compression are presented in The final creep strains of MPC concretes stabilized between −200 and −240 με after 550 days. However, the creep strain of OPC concrete with the same strength level generally reaches around −500 με , which iCreep is the result of plastic deformation between hardened cement paste and aggregates, which is introduced by the viscoelasticity of cement paste in concrete and the interlayer slip of hydrated phases . The rolThe mechanical properties of MPC concrete specimens, which had been loaded for 550 days, and of unloaded specimens are shown in It could be observed that the content and graduation of coarse aggregate have a slight influence on the strength. The order of the compressive strength values of shrinkage and creep specimens with different contents and graduation of coarse aggregate was M1 < M2 < M3 a. The sp2), struvite (NH4MgPO4·6H2O), and dittmarite (NH4MgPO4·H2O). Unreacted periclase, identified as MgO, was generally added in excess to ensure the complete reaction of all phosphates; it could act as micro-aggregates and thus restrain the deformation of hydration products. Struvite was founded to be the main crystalline product of MPC, which has cementitious properties and provides excellent mechanical properties for MPC concrete. The minor presence of dittmarite could be from the reaction between MgO and NH4H2PO4 or the dehydration of struvite at a peak hydration temperature higher than 70 °C [D is the crystal size (nm), K = 0.89 is Scherrer constant; λ represents the wavelength of X-ray (nm); β is the half-width of the diffraction peak (rad); θ is the diffraction angle (rad).The XRD patterns of MPC samples after shrinkage and creep tests are shown in an 70 °C . These ran 70 °C , and theThe TG curves and differential (DTG) curves of MPC samples after shrinkage and creep tests are shown in To further clarify the differences in pore structure between shrinkage and creep specimens, the pore size was divided into four categories according to previous studies , i.e., hTypical microstructures of fracture surfaces of selected samples after creep and shrinkage tests are shown in (1)Under natural conditions, temperature changes affected significantly the free shrinkage strain but had less effect on the compressive creep strain. The shrinkage and creep strains of MPC concretes stabilized in the ranges of −140 to −170 με and −200 to −240 με after 550 days, respectively, highlighting the good volume stability of MPC concrete. This can be attributed to the low water-to-cement ratio and the formation of crystalline struvite;(2)The creep strain had almost no effect on the type of hydration products but increased the crystal size and the quantity of hydration product struvite. The microstructure of MPC concrete can be densified under sustained loading, characterized by reduced porosity, particularly in the volume of pores smaller than 20 nm and larger than 200 nm;(3)Compared to shrinkage specimens, the compressive strength and splitting tensile strength of creep specimens were increased by 24.0–25.3% and 16.9–23.1%, respectively. The positive effect of creep on the mechanical strengths of MPC concrete could be due to the modification of the hydration products and densification of the microstructure.This study investigated the shrinkage and creep deformation behaviors of MPC concretes under natural curing conditions, as well as their mechanical properties and microstructural changes after shrinkage and creep tests. The following conclusions can be drawn:


Multicenter clinical trials play an indispensable role for assessing the efficacy of a new intervention or treatment, particularly in Phase II or III studies. Previous studies have shown that these studies often suffer from inadequate reporting of key details related to their design, implementation, and analysis, both in the protocol and final reports. This limitation reduces the practical and scientific value of the findings. Furthermore, the lack of guidance on how to report multicenter features can contribute to poor reporting. Therefore, this study aims to develop guidelines to improve the reporting of multicenter trials, including two Extensions of the CONSORT 2010 and the SPIRIT 2013.The standard methodology for developing health research reporting guidelines involves the following steps: (i) Identifying the need for development and launching the research project; (ii) Preparing the registration and reviewing the literatures; (iii) Proposing the initial Checklists and conducting the Delphi exercise; (iv) Arranging the consensus meeting and formulating the Checklists; (v) Conducting the pilot test and drafting explanatory documents (E&E); (vi) Seeking comments from advisory group and finalizing the guidelines; and (vii) Developing the publication and dissemination strategies.By using the CONSORT and SPIRIT checklists as starting points, the development of extensions specific to multicenter trials can help researchers design and report high-quality clinical research. This, in turn, can facilitate the application of study findings in the current evidence-based healthcare system. Randomized controlled trials (RCTs) are considered the gold standard for evaluating the effectiveness of a new intervention or treatment . MulticePrevious studies have highlighted several problems in multicenter RCTs, including: (i) a lack of criteria for center selection, resulting in poorly performing centers with delayed start-up, unmet target recruitment, and poor data quality, leading to a waste of resources and time , 8; (ii)To address these issues, we have proposed extending the Consolidated Standards of Reporting Trials (CONSORT) Statement and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Statement to address the problems and challenges in multicenter research , 18. TheEthical approval for this study was granted by the Research Ethics Committee (REC) of Hong Kong Baptist University (ref: REC/19–20/0493). The development process  will adhBefore initiating this research, four authors  conducted a literature review of multicenter clinical studies, focusing mainly on review and commentary papers, and discussed the current problems in the reporting and methodology of multicenter designs. This led to the identification of the need for the proposed guidelines . We thenThe working group has registered the proposed two guidelines in the EQUATOR Network , 30 and First, based on the results of the literature reviews, four authors  drafted the initial checklists for the CONSORT and the SPIRIT for multicenter RCTs, respectively. Second, we consulted with five experienced guideline developers from Canada, the United Kingdom, and Australia for revisions . Finally5 + 0.75*N4 + 0.5*N3 + 0.25*N2) / (N5 + N4 + N3 + N2 + N1), where Ni represents the number of respondents who chose specific “i” in the scale of “1 to 5.” Items with a score greater than or equal to 75% should be included. This calculation formula considers both the consensus level and the weight of responses  to the participants.During the meeting, the project leader will introduce each participant and invite a meeting chair. Working group members will give a presentation focusing on the results of the Delphi survey. In regard to the excluded items in the Delphi process, all participants will actively engage in a focused discussion and anonymously vote on the inclusion of each item. If the meeting is conducted offline, participants will be requested to record their choices on paper without providing their signature. On the other hand, if the meeting takes place online, the Zoom voting function will be utilized. This will enable participants to indicate their agreement, disagreement, or abstention from voting regarding the items. The strength of the consensus will be judged using the following scale: (1) Simple Majority – No Consensus (50.1–59% agreement), (2) Majority – Weak Consensus (60–65% agreement), (3) Super Majority – Strong Consensus (66–99% agreement), and (4) Unanimous – 100% agreement . After vIn addition, the following items will be included in the meeting: (i) Review all included items in the Delphi for finalization; (ii) Discuss the possibility of developing a diagram for multicenter trial specifics and, if appropriate, consider its content; (iii) Discuss strategies for producing documents, identify who will be involved in which activities ; discuss authorship if applicable; and (iv) Discuss a dissemination strategy, such as publication, translation, and endorsement of journals if time permits. At the end of the meeting, each expert will be asked to review the checklists again to confirm that their comments were appropriately understood and considered. After the meeting, experts will receive the formulated checklists for signature.To identify practical challenges with any of the included items, pilot testing before or after the consensus meeting will be considered, if applicable. The potential users for testing will include: (i) Graduate students who have studied a clinical trial methodology course in universities; (ii) Authors (such as the first author and/or corresponding author) who have published or registered multicenter RCTs, particularly in recent years; (iii) Researchers or staff from major pharmaceutical companies with experience in conducting multicenter trials. These targeted individuals will be contacted by email  to obtain their comments on the utility and clarity of the items. Feedback from the pilot test will be used to refine the wording and presentation of the checklist. Useful comments will be incorporated into the E&E documents.Based on the above results, our working group will prepare the guideline statements and E&E documents. The main contents will include: (i) A short document of approximately 3,000–4,000 words reporting on the rationale for developing the guideline and the development process; (ii) The checklist tables, which will include the original CONSORT or SPIRIT items, relevant extensions (and new additions) for multicenter RCT specifics, as well as the modified flow diagram (if any); (iii) A detailed justification and explanation of each item in the reporting checklists. The explanatory document will be considerably longer than the guideline statement and will mainly include the rationale for extensions, characteristics of multicenter studies, and the necessity for reporting. Relevant thematic concepts could be reported in We will consult with advisors for the revision and finalization of the guidelines with E&E documents. An advisory group will be established, comprising of 5–7 experts with international reputations from different areas of expertise, including policymakers, methodologists, and editors, among others. At least 1/3 of the members with experience in guideline development will be ensured. Based on the comments from the advisory group, further revisions of the manuscripts will be conducted by the working group members. Then, each author of the manuscripts will review the revisions and provide approval of the final version.To facilitate the dissemination of the guidelines, we will develop publication and promotion strategies. Firstly, we have registered the guidelines in the EQUATOR Network and will keep all relevant information updated. In addition, a dedicated webpage of the Chinese EQUATOR CenterHigh-quality multicenter RCTs can strengthen the external validity of research findings in practice, accelerate drug development, and promote more efficient translation of scientific knowledge. As a result, the number of multicenter trial publications has significantly increased in recent decades. Ensuring that multicenter research is complete, accurate, transparent, and timely is a shared responsibility of all stakeholders involved in the healthcare system. The development of the CONSORT and SPIRIT extensions for multicenter clinical studies aims to identify key information to be included in protocols and final reports, thereby improving the quality of trial design, implementation, and reporting. These extensions can be adopted in conjunction with the original SPIRIT and CONSORT statements, as well as other extensions, to account for variations in study methodology, including different design aspects , interventions (such as non-pharmacologic treatments), outcome measures, and data (such as patient-reported outcomes). We hope that the CONSORT and SPIRIT extensions for multicenter clinical trials will further facilitate the application of study findings in the current evidence-based healthcare system. A timeline outlining the implementation of the study is provided in The conduct of this research project will conform to the appropriate ethical and legal standards regarding informed consent, confidentiality, and data storage. Ethics approval was obtained from the Research Ethics Committee (REC) of Hong Kong Baptist University (ref: REC/19-20/0493).ZB and DM conceived this study. ZB and XZ designed the project, drafted, revised, and finalized the manuscript. ZB, CY, CD, and XZ drafted the initial checklists. DM, YL, and ZB revised and finalized the initial checklists. XZ, CC, NW, CL, JW, and ZB conducted and summarized the results of literature reviews and the Delphi survey. JM, CY, YL, AL, DM, and ZB provided critical comments for this protocol. All authors approved the final version of the manuscript.This work was supported by the Health and Medical Research Fund (Ref: 18192671), the Food and Health Bureau, The Government of the Hong Kong Special Administrative Region, Hong Kong, China; Chinese Medicine Development Fund (No. 20B2/027A), Hong Kong, China; China Center for Evidence Based Traditional Chinese Medicine, CCEBTM (2020YJSZX-5); and Health@InnoHK Initiative Fund of the Hong Kong Special Administrative Region Government (ITC RC/IHK/4/7). The funders had no role in the design of the study, in the collection, analysis, and interpretation of data, nor in the writing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Antibiotic overuse and misuse are common in skilled nursing facilities (SNFs) and are drivers of adverse drug events, antibiotic resistance and Clostridioides difficile infections. CMS requires SNFs to implement antibiotic stewardship programs (ASPs) that include a system for tracking and reporting antibiotic use (AU) and antibiotic-related outcome (ARO) measures. However, there is limited understanding of the maturity of these systems in SNFs.We conducted a descriptive study of AU/ARO tracking and reporting practices in 10 Wisconsin SNFs recruited in the fall of 2022. Key informants in study SNFs were asked to provide de-identified examples of line lists and facility antibiotic reports that included AU/ARO information. Checklists were developed to identify the types and characteristics of the different AU/ARO variables and measures. Document analyses were conducted on the retrieved source documents utilizing these checklists.36 source documents were analyzed including 24 line lists and 12 AU reports . Of the 20 qualifying line lists, 40% were in a format that permitted direct data manipulation . 70% of SNFs employed multiple line lists. 30% of SNFs were unable to provide an aggregate AU report. Although a majority of SNF line lists captured information on antibiotic indication, duration of therapy and ordering prescriber, these variables were frequently omitted from facility AU reports . Information on appropriateness of antibiotic prescriptions and origin of the antibiotic order  were captured less frequently on SNF line lists and, by extension, facility AU reports .A comparison of facility Line Lists versus ReportsSNF staff devote considerable resources to identifying and characterizing antibiotic events. However, this information is not stored in a format that allows data to be reviewed and analyzed easily. Additionally, a significant minority of SNFs do not routinely generate AU/ARO reports and those that do, often omit important information about prescribing practices that could inform facility quality improvement efforts. These findings suggest there is substantial opportunity to improve SNF AU/ARO tracking and reporting practices.Lindsay Taylor, MD, MS, Merck: Grant/Research Support


Accumulating evidence suggests a gain of elusive toxicity in pathogenically mutated PFN1. The prominence of PFN1 aggregates as a pivotal pathological hallmark in PFN1 transgenic rats underscores the crucial involvement of protein aggregation in the initiation and progression of neurodegeneration. Detergent-insoluble materials were extracted from the spinal cords of paralyzed rats afflicted with ALS and were intramuscularly administered to asymptomatic recipient rats expressing mutant PFN1, resulting in an accelerated development of PFN1 inclusions and ALS-like phenotypes. This effect diminished when the extracts derived from wildtype PFN1 transgenic rats were employed, as detergent-insoluble PFN1 was detected exclusively in mutant PFN1 transgenic rats. Consequently, the factor influencing the progression of ALS pathology in recipient rats is likely associated with the presence of detergent-insoluble PFN1 within the extracted materials. Noteworthy is the absence of disease course modification upon administering detergent-insoluble extracts to rats that already displayed PFN1 inclusions, suggesting a seeding rather than augmenting role of such extracts in initiating neuropathological changes. Remarkably, pathogenic PFN1 exhibited an enhanced affinity for the molecular chaperone DNAJB6, leading to the sequestration of DNAJB6 within protein inclusions, thereby depleting its availability for cellular functions. These findings shed light on a novel mechanism that underscores the prion-like characteristics of pathogenic PFN1 in driving neurodegeneration in the context of PFN1-related ALS. PFN1) is a pivotal factor in the etiology of amyotrophic lateral sclerosis (ALS) (Mutation in profilin 1 (is (ALS) , althougis (ALS) . These sis (ALS) . Compellis (ALS) ; howeveris (ALS) . This inProtein aggregation is a prominent pathology detected prior to neurodegeneration in PFN1 transgenic rats , and is via intramuscular administration expedited the onset and advancement of the disease. This acceleration was attributed to the facilitation of PFN1 inclusion formation in recipient rats expressing mutant human PFN1 at a young age. Pathogenic PFN1 displayed a heightened propensity for aggregation and an increased affinity for the molecular chaperone DNAJB6, leading to the sequestration of soluble DNAJB6 within protein inclusions. These findings underscore the important role of PFN1 aggregate formation in initiating ALS-related neurodegeneration.To address the compelling inquiry into the pathomechanisms of ALS, we examined the impact of inoculating PFN1 inclusions on the initiation and progression of neurodegeneration in PFN1 transgenic rats. The inoculation of a specific detergent-insoluble extract from diseased rat spinal cords Animal use was in accord with NIH guidelines and the animal use protocol was approved by the Institutional Animal Care and Use Committees at the University of Central Florida and at Florida International University.PFN1-C71G-V5 transgenic mice were purchased from Jackson laboratory   and were fully broken by sonication as described . The lysThe immunoreactivity of a desired protein was detected with a specific primary antibody that was purchased from a verified resource: mouse monoclonal anti-GAPDH , mouse monoclonal anti-FLAG , mouse monoclonal anti-Myc , rabbit polyclonal antibody against p62 , rabbit anti-DNAJB6 , rabbit anti-ACTG1 , and rabbit anti-PFN1 . Primary antibodies were diluted at 1:1,000 for immunoblotting and were used for immunostaining at the lowest dilutions recommended by the manufacturers.t-tests were used to analyze any differences in immunoblotting density between groups using Graphpad Instat software. A p value <0.05 was considered statistically significant. The data were not assessed for normality and no test for outliers was conducted.Unpaired p < 0.05) and rat survival was shortened by 49 days . By contrast, later injections did not show any significant modification of the disease course though a trend for facilitated disease course was also observed  are expressed in mammalian cells with differentiated expression patterns in the nucleus and the cytoplasm , respectAs pathogenic mutation of PFN1 increased its affinity for DNAJB6 and afforded PFN1 a propensity to aggregation , 4, we aThe initial identification of detergent-insoluble PFN1 as a primary pathological hallmark within PFN1 transgenic rats prompted a hypothesis that the process of PFN1 inclusion formation could potentially play a central role in the early stages of neurodegeneration in PFN1 transgenic rats . SubsequThe effectiveness of intramuscular administration to deliver protein oligomers is exemplified by the intramuscular injection of synthetic alpha-synuclein fibrils and brain homogenates . DetergeThe general propensity for PFN1 mutations to aggregate agrees with ALS severity in patients . Mutant The original contributions presented in the study are included in the article/The animal studies were approved by Institutional Animal Care and Use Committees at the University of Central Florida and at Florida International University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from the owners for the participation of their animals in this study.SC: Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing. TZ: Data curation, Formal analysis, Investigation, Methodology, Writing – review & editing. XX: Data curation, Investigation, Methodology, Writing – review & editing. JZ: Conceptualization, Resources, Writing – review & editing. QC: Conceptualization, Writing – review & editing. HZ: Conceptualization, Funding acquisition, Supervision, Writing – original draft, Writing – review & editing. X-GX: Conceptualization, Funding acquisition, Supervision, Writing – original draft.The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work is supported by the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NS110455 and NS089701 to X-GX and HZ) and NIH/National Institute on Aging (AG064822 to X-GX. and HZ).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.