Drug overdose is one of the top leading causes of accidental death in the U.S., largely due to the opioid epidemic. Although the opioid epidemic is a nationwide issue, it has not affected the nation uniformly.We combined multiple data sources, including emergency medical service response, American Community Survey data, and health facilities datasets to analyze distributions of heroin-related overdose incidents in Cincinnati, Ohio at the census block group level. The Ripley’s K function and the local Moran’s I statistics were performed to examine geographic variation patterns in heroin-related overdose incidents within the study area. Then, conditional cluster maps were plotted to examine a relationship between heroin-related incident rates and sociodemographic characteristics of areas as well as the resources for opioid use disorder treatment.The global spatial analysis indicated that there was a clustered pattern of heroin-related overdose incident rates at every distance across the study area. The univariate local spatial analysis identified 7 hot spot clusters, 27 cold spot clusters, and 1 outlier cluster. Conditional cluster maps showed characteristics of neighborhoods with high heroin overdose rates, such as a higher crime rate, a high percentage of the male, a high poverty level, a lower education level, and a lower income level. The hot spots in the Southwest areas of Cincinnati had longer distances to opioid treatment programs and buprenorphine prescribing physicians than the median, while the hot spots in the South-Central areas of the city had shorter distances to those health resources.Our study showed that the opioid epidemic disproportionately affected Cincinnati. Multi-phased spatial clustering models based on various data sources can be useful to identify areas that require more policy attention and targeted interventions to alleviate high heroin-related overdose rates.The online version contains supplementary material available at 10.1186/s12889-022-13557-3. Drug overdose is one of the top leading causes of accidental death in the U.S., largely due to the opioid epidemic . Since 1Some studies showed opioid-related emergency department visits increased over time , 7. A stGeospatial clustering has been used to analyze the geographic variation of phenomena , such asWe conducted a case study in Cincinnati, Ohio where the opioid epidemic has been a serious issue. Among U.S. states, Ohio had the highest number of opioid-involved overdose deaths per year from 2014 through 2017 . In the The objectives of this study are to 1) demonstrate how various sources of data can be used to analyze spatial patterns of heroin-related overdose incidents and 2) analyze demographic, socioeconomic, and contextual factors associated with the spatial patterns. Using EMS response data, American Community Survey (ACS) data, and health facilities datasets, we built multi-phased spatial clustering models and analyzed distributions of heroin-related overdose incidents at the census block group level in Cincinnati.The rest of the paper is organized as follows. We used the EMS dataset that includes all responses to heroin-related overdose incidents from the Cincinnati Fire Department  between To identify demographic and sociographic characteristics corresponding to the EMS dataset, we utilized the ACS data for 2015 – 2019 . The datIn the next phase, we mapped individual heroin-related incidents to census block groups in Cincinnati using the geocode information and computed the average number of incidents in each census block for five years. The number of incidents was adjusted for the size of the population of a census block group, and finally, heroin-related incidents per 1,000 adult population were used in the analysis. Using the same procedures, we computed the average crime rate per 1,000 adult population in each census block group level. The average heroin-related incidents and crime rate per 1,000 adult population were merged with the ACS, HIFLD, and SAMHSA datasets, which resulted in 22 variables.Using the merged dataset, we first examined the spatial distribution of heroin-related incident rates using the Jenks natural breaks maps. The Jenks natural breaks maps use a nonlinear algorithm to create groups where within-group similarity is maximized, and between-group similarity is minimized . The numWe then performed a multi-phased geospatial analysis to examine geographic variation patterns in heroin-related overdose incidents within the study area. Our objective was to identify the clusters with high incident rates. The spatial clustering was performed at two levels: global and local clustering. The global spatial clustering was conducted using Ripley’s K function that tests if heroin-related overdose incidents occur randomly or are clustered within the whole study area , 30. TheThe Ripley’s K function is a multi-distance spatial clustering method that describes the dispersed patterns of data points. The function is calculated at multiple distances, which shows how point-pattern distributions can change with scale and compares the observed and expected distributions of points around an index point within circles of various areas. Under the complete spatial randomness, the density of points is uniform. If the observed estimate of the K function falls above the theoretically expected envelope, it indicates that the data points are clustered at every distance in the study area. On the other hand, if the observed estimate of the K function is within the envelope, the data points exhibit complete spatial randomness. Furthermore, if the observed estimate of the K function is below the envelope, it means that the data points are dispersed within the area of interest.N is the observed number of points and A is the area of the study region. The estimated K(t) function [Given the locations of all events within a defined study area, the estimated K(t) is the ratio of the number of neighboring events observed within a given distance of each event and the density of events, function  is shownmentclass2pt{minimt is the radius of a test circle, i-th and j-th points, and t  as its reference coordinate system and projecting it to Universal Transverse Mercator (UTM). The pre-processed heroin-related incidents were converted to point pattern objects. With the converted point pattern objects, we performed the Ripley’s K analysis. To calculate confidence intervals for complete spatial randomness of heroin-related incidents within the study area, we conducted a Monte Carlo simulation . Since tSince the global spatial clustering analysis yields only one statistic to describe the overall point pattern across the whole study area, it does not identify where the local clusters or spatial outliers are. To determine which areas are similar or different from the neighboring areas, we performed a local spatial analysis. Local indicators of spatial association (LISA) decompose global indicators into the contributions of individual observations to identify local cluster patterns or spatial outliers . LISA stIn LISA, spatial autocorrelation for each location with its neighbors is evaluated in five categories: high-high, low-low, low–high, high-low, and not significant. Positive spatial autocorrelation is captured in areas close together that have similar values. In this study, an area evaluated as high-high indicates it has high heroin-related overdose incident rates and its neighboring areas also have high heroin-related incident rates (hot spots), whereas an area evaluated as low-low indicates it has low heroin-related overdose incidents rates and its neighboring areas also have low rates (cold spots). On the other hand, negative spatial autocorrelation occurs when dissimilar values are shown between an area and its neighbors .i, the local Moran’s I equation [The local Moran’s I is a widely used LISA statistic which describes spatial clustering of observations in high or low values. For each observation equation  is shownwhere We performed a univariate Local Moran’s I analysis for heroin-related incident rates using a software called GeoDa . After iIn addition, we examined the relationships between heroin-related incident rates and the accessibility to three healthcare facilities, which are hospitals, opioid treatment programs, and buprenorphine prescribing physicians. Examination was completed separately using a queen contiguity-based spatial weights matrix in GeoDa.For all the local spatial methods, we set the statistical significance level to 0.01, and the number of simulations to 9,999 since trying more than 9,999 permutations given a significance level of 0.01 generated identical outcomes.Between January 1, 2015, and December 31, 2020, there were 542,136 incidents in total within the study area, of which 10,917 were heroin-related incidents. After removing the irrelevant and duplicated incidents, we used a total of 8,767 heroin-related incidents within the 280 census block groups in Cincinnati, Ohio. Table Figure Figure The univariate LISA cluster map Fig.  shows foFigure As shown in Fig. Figure Figure This study showed how various data sources can be combined and used to examine the spatial patterns of heroin-related overdose incidents in Cincinnati, Ohio at the census block group level. We used EMS data to examine geographical distributions of heroin-related overdose incidents. This data is useful to understand real-time drug overdose cases that require emergency care. In addition to EMS data, we used ACS data, crime data, and healthcare facility data to understand demographic, socioeconomic, and contextual factors that may be associated with heroin-related incidents.There have been studies that used EMS data to examine geographical patterns of opioid overdose events. Pesarsick et al.  and DworOur spatial analysis showed that the opioid epidemic disproportionately affected Cincinnati. For example, a heroin-related incident rate was concentrated in the Southwest part of the city, while the rate was low on the East side. This geographic disparity has been found for other outcomes related to drug overdose events. According to the City of Cincinnati Community Health Assessment , the souIn addition to the variability in heroin-related incident rates across Cincinnati, our study found demographic and socioeconomic characteristics in areas with high opioid overdose rates , 41, 42.Queensgate, in which the heroin-related incident rate was the highest among all the block groups in Cincinnati, showed distinct characteristics from other hot spots identified in this study. For example, this area had a much lower percentage of the white population and an extremely higher crime rate and male population. Queensgate mostly consists of industrial and commercial warehouses, and almost 100 percent of residents rent their homes. The level of urbanization and residential stability in a city may be an additional risk factor for opioid overdoses and related outcomes. Some studies found that people who rented were at an increased risk of fatal opioid overdose compared to those who owned a house , 45.We also examined the association between the heroin-related incident rates and the access to healthcare resources for opioid use disorder (OUD) treatment such as hospitals, opioid treatment programs, and buprenorphine providers within census block groups. We hypothesized that hot spots have limited access to those facilities, and this was true in some areas. For example, distances from the center of a block group to the closest hospitals, opioid treatment programs, and buprenorphine providers were longer in the southeast area of the city than the average distances to each of the resources. However, contrary to our hypothesis, most of the hot spots had a shorter distance to the resources for OUD treatment compared to the average distances to each of the resources. For example, the south-central area of the city has a high heroin-related overdose incident rate but a shorter distance to the resources. Maxim et al.  found siFindings from geospatial analyses may serve as a basis for developing potential public health strategies that can alleviate high heroin-related overdose rates. For example, we plotted hot zones and cold zones by the accessibility to healthcare facilities to OUD. Hot zones that have limited accessibility to healthcare resources for OUD  would require different approaches than hot zones that have available resources close to the areas. In this study, Southwest areas of the city  in the EMS data may be different from a final diagnosis determined by a physician in a hospital. That means, the heroin-related incident rates captured through the EMS data might be under or overestimated than the actual rate. Also, heroin-related incidents used in this study do not represent the overall incidence rates that occurred in the city. Cases seen in various care settings, neither through the EMS and nor addressed at all, may have different geographical patterns. Another limitation is related to the estimation of a distance to the closet buprenorphine prescribing physicians. We used publicly available treatment locator data to identify buprenorphine prescribing physicians. However, we might not include buprenorphine-waivered clinicians because they did not consent to be on the buprenorphine list and therefore were not shown in the data. In addition, we might have included buprenorphine-waivered providers who were on the buprenorphine list but no longer actively prescribed buprenorphine. Despite these limitations, studying local EMS data is still critical for timely and targeted public health intervention in that it is the first to respond to medical emergencies.Future studies will generalize our multi-phased geospatial analysis to other cities that are highly associated with the heroin overdose epidemic. The current study can be improved by linking EMS data with other related data sources, such as naloxone administration by first responders, to better understand geospatial characteristics of a heroin overdose. In addition, combining spatiotemporal disparities with machine learning models may help identify patterns at varying spatial and temporal scales more accurately.Additional file 1.


We read with interest the article by Horwich et al. about IgG4-producing plasma cells. The aim of the study was to use IgG4-positivity as a differential biomarker for distinct clinical presentations of plasma cell hepatitis before and after liver transplantation. They found a high degree of IgG4-PC infiltration more frequently associated with plasma cell rejection (PCR) than other types of AIH and concluded that IgG4-positivity might serve as a valuable diagnostic tool in the post-LT setting.2 of tissue by using a Computer-Assisted System Technology (newCAST™). The relative proportion of the main cell types was assessed. The results showed an important representation of IgG4+ PCs with a mean value of 5.9% (0.5%–19.8%) of the total number of immune cells in the inflammatory infiltrates found in portal areas (It is very gratifying to see a confirmation of our previous report regarding the presence of IgG4 PCs in plasma cell-rich rejection (PC-rich R) biopsies. Our group identified the cellular profile associated with PC-rich R, and quantified the number of cells per mm.9% 0.5%–9.8% of tde novo autoimmune hepatitis, first described in 1998  gene and the donor carries at least one copy of this gene –6. Some It is clear that rAIH and PC-rich R represent distinctive clinical entities. The results presented in the article by Horwich et al. and the knowledge of the GSTT1 genetic mismatch with subsequent production of anti-GSTT1 antibodies  should facilitate differential diagnoses between PC-rich R and other inflammatory post-transplant pathologies that have been particularly difficult when pre-LT disease was uncertain as mentioned by the authors.


We evaluated antibiotic-prescribing across 111 mental health units in the Veterans’ Health Administration. We found that accurate diagnosis of urinary tract infections is a major area for improvement. Because non–mental-health clinicians were involved in most antibiotic-prescribing decisions, stewardship interventions for mental health patients should have a broad target audience to be effective. It is unclear how frequently antibiotics are used in these settings and whether there are opportunities to improve antibiotic-prescribing.Even though all US hospitals are required to have an antibiotic stewardship program, standard stewardship metrics like the standardized antimicrobial administration ratio do not capture antibiotic use in a hospital’s mental health units.The objective of this study was to describe and evaluate antibiotic use across inpatient mental health units in an integrated healthcare network known as the Veterans’ Health Administration (VHA).The Institutional Review Board of the University of Iowa and the Research & Development Committee of the Iowa City Veterans’ Affairs Health Care System approved this study and waived informed consent.Using the Veterans’ Affairs Informatics and Computing Infrastructure (VINCI), we collected administrative data on all patients admitted to an inpatient mental health ward in VHA between January 1, 2016 and December 31, 2018. This cohort included data from inpatient mental health units across 111 unique medical centers, including 105 medical centers with an acute-care hospital. We excluded substance abuse rehabilitation units and domiciliaries. For each unique facility, antibiotic days of therapy (DOT) and days present were aggregated based on NHSN methodology.Inpatient and postdischarge antibiotics were collected from the bar-coded medication administration records (BCMA) and outpatient medication files, respectively. Antibiotics included all agents and routes of administration listed in the National Healthcare Safety Network’s (NHSN) Antimicrobial Use protocol. The primary review was performed by a postgraduate year 1 pharmacy resident (J.T.). An infectious disease (ID)–trained clinician (D.L. or B.H.) performed a secondary review of all included cases. We monitored the number of cases in which the ID-trained clinician changed the assessment.Manual chart reviews were performed in a subset of the above cohort to assess adherence to standard recommended practices and professional guidelines for cystitis, or urinary tract infections (UTI), skin and soft-tissue infections (SSTIs), and acute respiratory tract infections (ARIs). Admissions with a qualifying ICD-10 code . During the study period, 27,401 (10.9%) patient admissions had antibiotics administered while hospitalized on the mental health unit  The most commonly prescribed agents, as quantified by DOT per 1,000 days-present, were trimethoprim-sulfamethoxazole (10.7), cephalosporins (9.5), tetracyclines (8.8), anti-influenza medications (8.3) and fluoroquinolones (8.0).Table For 101 SSTI cases, a documented history of active intravenous drug use was present in 25 cases (24.8%). In 6 (5.9%) cases with chronic bilateral lower leg skin changes, we found no documented evidence of cellulitis but antibiotics had still been prescribed for these patients. In the remaining 95 cases with infection (39 purulent and 56 nonpurulent), antibiotic selection and duration was guideline concordant in 75 (78.9%) and 86 (90.5%) cases, respectively.The 108 ARI cases included 55 cases (50.9%) of upper respiratory tract infections, 20 cases (18.5%) with pharyngitis, 13 cases (12.0%) of sinusitis, and 20 cases (18.5%) of acute bronchitis, which included 1 case recategorized as an acute exacerbation of chronic obstructive pulmonary disease. In 76 cases (70.4%) an antibiotic was not indicated and not prescribed. In 29 cases (26.9%) an antibiotic was not indicated but had still been prescribed, and in 3 cases (2.8%) an antibiotic was both indicated and prescribed.Antibiotic recommendations were made by emergency department clinicians in 81 (25.3%) of the manually reviewed cases; recommendations were made by internal medicine clinicians in 89 cases (27.8%); and recommendations were made by infectious diseases clinicians in 2 cases (0.6%). At least 1 of these services was involved in 161 (50.3%) of all reviewed cases, including 54 cases (48.7%) with UTI, 70 cases (69.3%) with SSTI, and 37 cases (34.3%) with ARI. When these nonpsychiatric services were involved, we detected no differences in the quality of antibiotic-prescribing for UTIs or SSTIs and less guideline-concordant management for ARI (Supplementary Table 3 online).In this study across 111 inpatient mental health units in the VHA, 1 of every 10 patients was exposed to an antibiotic. In contrast, studies in acute-care hospitals have reported that half of all patients are exposed to an antibiotic. Overall, these findings suggest that UTI is commonly misdiagnosed and therefore represent an optimal target for stewardship efforts. We also identified some opportunities to improve antibiotic-prescribing for SSTIs and ARIs.The most common reason for antibiotic therapy in these inpatient mental health wards was a suspected UTI, but most UTI cases had the documented absence of local genitourinary symptoms or had no documentation suggesting that a clinician inquired about these symptoms. In many cases, the presence of altered mental status appeared to be a driver of antibiotic therapy even though antibiotics are not recommended for bacteriuria in the context of cognitive impairment alone.Our results revealed that emergency department and internal medicine clinicians commonly provided treatment recommendations in mental health patients with suspected infections. Because antibiotic-prescribing was not consistently better when these services were involved, antibiotic stewardship interventions to improve antibiotic prescribing in VHA mental health units must target both mental health clinicians as well as these other physician disciplines. We speculate that a major contributor to the overdiagnosis of UTIs is the seemingly routine performance of urinalyses in admitted patients. More thoughtful ordering and interpretation of urine studies may help mitigate incorrect UTI diagnoses and subsequent unnecessary antibiotic use.Our findings are in line with prior work that has described the frequent misdiagnosis of UTIs.Our study had a few limitations. First, our manual chart reviews were dependent on the quality of the clinicians’ documentation and our ability to ascertain key data elements in the medical record. To minimize the possibility of omission, we had 2 team members review each included case. Second, to assess guideline concordance, we sampled an equal number of cases from each facility regardless of bed size. As a result, antibiotic-prescribing practices at smaller facilities, which contributed less to total national antibiotic use, may have disproportionately influenced our overall assessments of guideline discordance. Third, because we specifically looked for cases coded as a UTI, we may have overlooked asymptomatic cases in which abnormal urine studies were correctly not attributed to a UTI. Finally, our findings may not be generalizable to non-VHA settings.In conclusion, our study measured and evaluated antibiotic-prescribing across inpatient mental health units, which have been overlooked by both antibiotic stewardship metrics and by prior research. Future antibiotic stewardship interventions in mental health units should focus on the accurate diagnosis of UTIs while targeting the different physician disciplines involved in antibiotic decision making for mental health patients.


This study seeks to identify ethnoracial differences in self-reported home health care (HHC) use among older adults. To do so, we examined 8,817 people aged 65 and older from the 2016 wave of the Health and Retirement Study (HRS), a nationally representative survey of older adults in the U.S. The dependent variable was whether HRS participants reported any HHC service use in the past two years. The primary independent variable was ethnoracial grouping, which included non-Hispanic White, non-Hispanic Black, and Hispanic groups. Multivariable logistic regressions stratified by ethnoracial grouping identified correlates of HHC use. We found that HHC use was more prevalent among non-Hispanic Blacks (14.9%) than in non-Hispanic Whites (10.1%) or Hispanics (10.7%). For all ethnoracial groups, increasing age, dementia, activities of daily living impairment, medical comorbidity (except for Hispanics), and hospitalization (in the past two years) were associated with an increased likelihood of HHC use. In addition, we identified ethnoracial differences in the correlates of HHC use. Among non-Hispanic Whites, more formal education and Medicaid insurance were associated with a higher likelihood of using HHC. For non-Hispanic Blacks, residing in rural areas was associated with a decreased likelihood of HHC use, whereas being single and living alone were associated with an increased likelihood of HHC use. This study thereby identified notable ethnoracial differences in the correlates of HHC use among older adults.


Quadratic RSM models yielded R2 equaling 0.90 and 0.94 for compressive strength at 7 days and 28 days, respectively. Similarly, 0.94 and 0.96 for 7-day and 28-day flexural strength and 0.89 for tensile strength. The optimization performed through RSM indicates that 15% MWA and 50% SD yielded higher strength compared to all other mixtures. The predicted optimized data was validated experimentally with an error of less than 5%.Carbon footprint reduction, recompense depletion of natural resources, as well as waste recycling are nowadays focused research directions to achieve sustainability without compromising the concrete strength parameters. Therefore, the purpose of the present study is to utilize different dosages of marble waste aggregates (MWA) and stone dust (SD) as a replacement for coarse and fine aggregate, respectively. The MWA with 10 to 30% coarse aggregate replacement and SD with 40 to 50% fine aggregate replacement were used to evaluate the physical properties (workability and absorption), durability (acid attack resistance), and strength properties  of concrete. Moreover, statistical modeling was also performed using response surface methodology (RSM) to design the experiment, optimize the MWA and SD dosages, and finally validate the experimental results. Increasing MWA substitutions resulted in higher workability, lower absorption, and lower resistance to acid attack as compared with controlled concrete. However, reduced compressive strength, flexural strength, and tensile strength at 7-day and 28-day cured specimens were observed as compared to the controlled specimen. On the other hand, increasing SD content causes a reduction in workability, higher absorption, and lower resistance to acid attack compared with controlled concrete. Similarly, 7-day and 28-day compressive strength, flexural strength, and tensile strength of SD-substituted concrete showed improvement up to 50% replacement and a slight reduction at 60% replacement. However, the strength of SD substituted concrete is higher than controlled concrete. Quadratic models were suggested based on a higher coefficient of determination (R Concrete has been a material of choice for construction purposes for ages . The maiCorrespondingly, the utilization of non-biological and non-degradable waste, such as that from the marble and stone crushing industries, the preeminent consumption led to research on the construction industry waste . The hug3 (674 lb/yd3) and at a 0.5 w/c ratio. The authors concluded that the concrete mix with marble dust maintains greater compressive strength, higher resistance against sodium sulfate, and abrasion resistance, followed by limestone dust and least by the control specimen, respectively. They also established that water permeability was resisted by the specimen, with marble dust replacing 15% of it [The use of waste from the marble industry and crushed concrete recycled aggregate (RA) in self-compacting concrete allows up to 100% replacement. The authors observed increased workability by using marble waste (MW) aggregate. They noted 6% & 5.6% lower compressive strengths at lower water-binder ratios and 31.5% & 7% at the ratio of water-binder as 0.4, respectively, but strain capability rises by using RA and MW aggregates as compared to LS stress-strain curves . Researc5% of it . Singh, 5% of it  conclude5% of it . In this study, marble waste aggregates (MWA) and stone dust (SD) from their respective productions were substantiated as an alternate approach. The source of MWA exists in the marble finishing industries. The estimated reserves of marble and onyx in Pakistan are more than three hundred billion tons. However, due to primitive ways of quarrying and subsequent processing, the marble processing units in Pakistan cause approximately 70% of the raw material to be transformed into solid and sludge waste . SimilarIn the current study, marble waste aggregate (MWA) and stone dust (SD) were used as partial replacements for coarse aggregate and fine aggregate, respectively, for normal strength concrete. The conventional mix design had a mix ratio of 1:2:4 of cement: fine aggregate: coarse aggregate, respectively, and a water to cement ratio of 0.5. Ordinary Portland Cement (OPC) type-I was used and procured from the Cherat cement factory. The physical properties of OPC are given in Fine aggregate (medium coarse size sand) was obtained from the Lawrencepur Attack quarry and its physical properties are presented in The marble waste aggregates (MWA) were obtained from a marble factory and further crushed and sieved to obtain the desired size of marble aggregates equivalent to the standard coarse aggregate size used in mix design . The parThe physical properties of MWA, which are relatable to the coarse aggregate utilized in the present study, are also given in Stone dust (SD) was procured from the aggregate crushing plant, which is the residue left after aggregate production in the crushing plant. The obtained stone dust was used as a replacement for sand in the mix design. The particle size of SD confirmed the standard size of sand, as shown in For the experimental program, two approaches for mix design of concrete were tested. The ACI method of concrete mix design as well as conventional 1:2:4 mix design. The ACI method of mix design  recommenStandard practice for making and curing concrete sampling and casting of cylinders conforming to ASTM C192/C192M-14  was carrThe properties of concrete in fresh form, i.e., workability tests such as the slump test confirming ASTM C143-78 ), the coSlump for the control concrete specimen was selected at 2 inches (50 mm) and verified in the other two types of specimen (MWA and SD samples) as well. To ascertain the workability of fresh concrete, another method is the compaction factor test. The option slump test is suitable for more workable concrete, whereas the compaction factor test is suitable for less workable concrete. The compaction factor workability test, comprising of three steps, dropping the concrete from 8 inches (200 mm) in two hoppers, then collecting it in a cylinder, and yielding the potential energy as the internal work done on the concrete. This free-dropped concrete weight is known as the weight of concrete with partial compaction due to potential energy (height). Then the cylinder is again filled with fresh concrete and either vibrated externally or compacted in three layers utilizing a tamping rod, hence getting standard compaction. This compacted concrete cylinder weight is the weight of fully compacted concrete. The relationship in terms of compaction factor is:For the absorption test, the cast samples were first submerged for a period of 24 h at room temperature (25 to 30 °C) in clean water, then weighed in surface dry condition. After that, the samples in wet condition were put in the oven for 24 h and weighed once again, in compliance with ASTM C642-21 . The perThe compressive strength test was performed in accordance with ASTM C39/C39M-21 , for meaR) is also the measure of flexural strength. Usually, it is 10 to 20% of the compressive strength, depending on the aspect ratio of the specimen’s shape and the volume of coarse aggregate in the mix. An ASTM C78/C78M-22  third poASTM C496-96  was perf2SO4) for 24 h, and after being removed from the solution and washed, the change in various parameters of a specimen, such as weight and appearance of the specimen, the test medium’s appearance, as well as the specimen’s compressive strength, were evaluated. ASTM C1898-20  was perf® software was used, which is commercially available. Among other methods, central composite design (CCD) is the most commonly used RSM design method in the construction industry [For experimental design, modeling, prediction, and optimization, and establishing a relationship between experimental and predicted data, a user-friendly statistical tool is response surface methodology (RSM) ,57,58,59industry  and therIn this study, MWA and SD were considered as input factors (independent variables), and the responses (dependent variables) were selected as strength properties such as the compressive strength (CS), flexural strength (FS), and split tensile strength (TS) of concrete specimens. The aim was to see the effect of MWA and SD on the prediction of CS, FS, and TS.The slump test measures the workability of concrete. The desired slump value for the control specimen was 50 mm. All results were within the range of 50 ± 5 mm . With thWorkability can also be assessed by the compaction factor test, as shown in The average absorption percentages  of sampl2SO4 than the normal aggregate and finer particles of SD in the respective samples [ASTM C1898-20 was performed to ascertain the chemical resistance of the concrete specimens under the anticipated service environment. The solutions became ashy after one day of submersion of the samples. There was some grainy appearance after the removal of samples from the acid, and this appearance was rougher in specimens containing MWA as compared to the control sample, whereas the appearance was unchanged in the case of SD samples . These f samples . 2, quadratic models were suggested for compressive strength, flexural strength, and tensile strength as shown in 1 and X2 = independent variables (MWA and SD), C = interception constant, A1 and A2 = linear coefficients, A3 = interaction coefficient, and A4 and A5 = quadratic coefficients.Statistical analysis in RSM was performed and validated via ANOVA, fit statistics, and proposed models. Based on higher R2), adjusted R2, and predicted R2, as shown in 2 ≥ 0.90) and higher model F-value (>40) indicate that the proposed models are significant and there is a substantial relationship between factors and corresponding responses. The p-value of less than 0.05 also shows that the proposed model terms are significant with more than a 95% confidence level. Similarly, the numerical difference between adjusted R2 and predicted R2 of less than 0.2 , adjusted R2, and predicted R2, as shown in 2 ≥ 0.90) and higher model F-value (>40) indicate that the proposed models are significant and there is a substantial relationship between factors and corresponding responses. The p-value of less than 0.05 also shows that the proposed model terms are significant with more than a 95% confidence level. Similarly, the numerical difference between adjusted R2 and predicted R2 of less than 0.2 , adjusted R2, and predicted R2, as shown in 2 = 0.89) and higher model F-value (>40) indicate that the proposed models are significant and there is a substantial relationship between factors and corresponding responses. The p-value of less than 0.05 also shows that the proposed model terms are significant with more than a 95% confidence level. Similarly, the numerical difference between adjusted R2 and predicted R2 of less than 0.2  can be modified by inserting the constant and coefficient of model terms  and responses . The results  indicateThe marble waste aggregate and stone dust were both obtained from the dump sites of the respective factories free of charge. This saved an overall 15–18% cost for the optimized proportion in the production of concrete compared to the standard aggregates.With the addition of MWA, workability increases (up to slump +12% and compaction factor −2%) attributed to the smooth surface and less absorption of MWA than normally used coarse aggregate. On the other hand, substation of SD causes decreases in workability (up to slump −4% and compaction factor +2%), which is attributed to the finer particles of SD as compared to sand. Similarly, up to 8.4% less absorption in the MWA specimen and 9.8% more absorption than the control specimen were noted.Resistance to chemicals (acid attack) was less prominent in MWA  and SD  as compared to the standard control specimen.With a lower crushing value of MWA of 19.98%, as opposed to 16.98% of standard coarse aggregate, a relatively smoother surface of MWA than standard coarse aggregate, and less water absorption (paste adhesion), the bond of MWA was weaker than standard coarse aggregate, as obviously visible in the fractured samples.Due to better packing of a wide range of particle sizes of SD, i.e., a wider range of particle gradation, and relatively higher specific gravity improved the density of concrete to some extent. In general, the density relates to the durability of concrete in later stages of service life. However, due to the likely increase of more uniform-sized particles beyond optimum content, there was no clear increase observed in strength parameters.Compressive strength was observed to be slightly lower (14% at 7 days and 12% at 28 days) with 30% MWA substitution but significantly enhanced with 50% SD substitutions (39% at 7 days and 31% at 28 days) individually, as compared to the control sample. However, the strength enhancement declines again with additional SD content.Flexural strength was observed to be slightly lower (15% at 7 days and 17% at 28 days) up to 30% MWA substitution but significantly enhanced (42% at 7 days and 39% at 28 days) up to 50% SD substitutions individually, as compared to the control sample.Split tensile strength was observed to be slightly lower (18% at 7 days and 18% at 28 days) up to 30% MWA substitution but significantly enhanced (46% at 7 days and 47% at 28 days) up to 50% SD substitutions individually, as compared to the control sample.For establishing the combined effect of MWA and SD, RSM was applied, and based on contour plots, three sets of MWA and SD substitutions were obtained for comparing compressive strength with the target compressive strength of 3400 psi and 4200 psi at 7 days and 28 days, respectively. The ensuing compressive strength was 3440 psi (7-day) and 4129 psi (28-day) with the 10MWA-45SD combination, 3832 psi (7-day) and 4421 psi (28-day) with the 15MWA-50SD combination, and 3350 psi (7-day) and 4071 psi (28-day) with the 20MWA-50SD combination.2 (>0.80) and a lower p-value (<0.05), and hence the derived equations can be used to predict compressive strength, flexural strength, and tensile strength.A significant relationship between RSM predicted data and experimental results was achieved for compressive strength, flexural strength, and tensile strength. The proposed quadratic models are well fitted due to a higher RMWA of 15% and SD of 50% replacements were obtained as optimized dosages to replace coarse aggregates and fine aggregates, respectively. The predicted optimized data was validated by additional experiments with an error of less than 5%.An encouraging aspect of the research showed that at an early age, the strength development of the optimized mix is significant. It may be attributed to the rougher texture of SD particles and less absorption of MWA, thus leaving water available for hydration as the combined effect of both substitutes created the opportunity for a stronger bond at the initial phases of hydration. It was observed that approximately 70% of the ultimate strength was achieved in the initial 7 days when cured at a curing temperature of 27 °C ± 5 °C.Re-utilization of waste materials and byproducts (such as marble waste aggregate and stone dust), while reducing the consumption of natural aggregates, will lead to achieving sustainability and producing green concrete.The partial substitution of marble waste aggregate (MWA) and stone dust (SD) was used to replace natural coarse and fine aggregates, respectively, in developing normal strength concrete. The concrete specimens were subjected to physical, durability, and strength tests. The following conclusion is drawn from this study.


Background: This study aims to evaluate the antimicrobial prescribing practices in hospital settings in Italy, focusing on the appropriateness of antibiotic use. Methods: This study was carried out through a retrospective review of medical records of patients admitted in three public hospitals located in Campania Region  between 1 January and 31 December 2018. Results: More than one third (34.2%) of patients received at least one inappropriate antibiotic prescription (antibiotic administered and not indicated). Being female, having a >1 Charlson comorbidity index score, and having a longer hospital stay were significant determinants of an inappropriate antibiotic prescription. Instead, patients who had had a non-urgent hospital admission, an infection on hospital admission, and a microbiological culture test during hospital stay were significantly less likely to have an inappropriate prescription. When the antibiotic prescriptions were analyzed, in 26.6% of cases they were not indicated, while among the 687 antibiotic prescriptions with indication, incorrect choice of antibiotics (36.8%) was the most common reason of the inappropriateness. Conclusions: The findings of the study indicate that the inappropriate use of antibiotics continues to be a relevant issue in the hospital setting and specific interventions are needed to encourage a wider utilization of diagnostic tools to practice targeted therapies and to counter the antimicrobial resistance. Antimicrobial resistance (AMR) represents a main health issue worldwide and the World Health Organization (WHO) has defined it as one of the greatest threats to public health due to its epidemiological relevance and economic burden . The growing increase of antibiotic-resistant bacteria, which impairs the effective treatment of related infectious diseases, results in a sequence of negative effects on patients and the community. Indeed, AMR determines an increase in the morbidity, duration, severity, and mortality of infectious diseases, as well as failure of surgical interventions with a consequent rise in healthcare costs due to the duration of hospitalization, frequent diagnostic investigations, and longer and complex antimicrobial treatments . FurtherTo contrast AMR, the WHO has approved a global action on AMR to ensure the successful treatment of infectious diseases through several objectives, such as the improvement of understanding of AMR, the optimization of the use of antimicrobial agents, and the increase in the investments in the research on new antibiotics, diagnostic tools, and vaccines .The latest Italian Antibiotic Use Report has shown that Italy is among the countries with the highest consumption of antibiotics and spread of multi-resistant microorganisms in Europe . This coIt is well known that the non-optimal and inappropriate antibiotic use is one of the main causes of AMR and although most antibiotics are used for treating infections outside hospitals, in the period 2016–2020, hospital consumption of antibiotics showed an increase in Italy . This isSeveral investigations have been conducted to evaluate the prescriptions of antibiotics in the community and hospital settings ,9,10 andTherefore, this study has two main objectives. The first is to evaluate the antimicrobial prescribing practices in hospital settings in Italy, focusing on the appropriateness of antibiotic use, and the second is to investigate which determinants could predict hospital inappropriate antibiotic use.Overall, 723 patients were enrolled in the study, and they had received 936 antibiotic prescriptions for therapeutic reasons. The main demographic and anamnestic characteristics of the study population are described in Escherichia coli (23.4%), Staphylococcus aureus (20.2%), and Klebsiella pneumoniae (11.7%).Respiratory, urinary tracts, and skin and soft tissue were the most common sites of infection, resulting in 40.3%, 21.5%, and 13.1% of all infections, respectively. A microbiological culture test was performed only in 94 patients (13%) and the more frequently isolated microorganisms were Out of all 723 patients who received antibiotics for therapeutic reasons, 510 had received one and 213 more than one antibiotic prescription for a total of 936 antibiotic prescriptions recorded. The groups of antibiotics more frequently prescribed were third generation cephalosporins (26.7%), penicillin (22.5%), fluoroquinolones (17.5%), and carbapenems (10.3%). Overall, more than one third of patients (34.2%) received at least one inappropriate antibiotic prescription (antibiotic administered and not indicated), and 26.7% and 15% of them received two and three inappropriate prescriptions, respectively. p < 0.001), in those who had had an urgent hospital admission , with longer hospital stay , and without an infection on hospital admission , whereas no difference was found for the different wards of hospital stay. Moreover, the following anamnestic characteristics of patients were also associated with receiving inappropriate antibiotic prescription: not having an immunosuppression status , having a chronic medical condition , having a higher Charlson comorbidity index score , and not having a microbiological culture test during hospital stay   . The results of stepwise logistic regression model performed to estimate predictors of inappropriate antibiotics prescribing are shown in Among the selected patients, 226 (31.2%) underwent a surgical procedure and 190 (87.6%) of them had received antibiotic prescriptions for prophylaxis purpose. All 178 patients eligible for the prophylaxis received antibiotics, whereas among the 48 procedures for which the surgical antibiotic prophylaxis (SAP) was not indicated, more than half (52.1%) received antibiotics. Overall, only 56 SAP (24.8%) were appropriate in accordance with indication, choice of the antibiotic, timing, and doses recommended by the guidelines. The antibiotics most frequently used inappropriately were ceftriaxone (17.9%) and ceftazidime (12.1%).This study provides relevant information on hospital antibiotic prescribing practices in Italy, where the levels of antibiotic utilization and spread of multi-resistant microorganisms are higher compared to other European countries. The results could be useful for the development of specific measures to contrast inappropriate antibiotic use and AMR in the hospital setting.This investigation has three key findings. A first key finding was that approximately one third of patients (34.2%) had received inappropriate antibiotic therapies since there was no indication. The comparison of this rate of inappropriateness with previous studies conducted in Italy and in other countries is difficult due to the different study criteria, healthcare setting, and characteristics of the study population. Despite these differences, similar results were found in two previous investigations where 33% of antibiotic prescriptions were not appropriate in a Swiss tertiary care hospital  and 32.7A second key finding was that, when the single antibiotic prescriptions were analyzed, no indication for antibiotic use accounted for about a quarter of the reasons of the inappropriateness. Indeed, 26.6% of the antibiotics used inappropriately were prescribed to patients who did not have any evidence of infectious disease in the medical record. A possible reason is that physicians at the admission or during the hospitalization start antibiotic treatment even if they are unsure of the diagnosis and, therefore, they do not modify the treatment. This is a very unsafe practice because the unnecessary use of antibiotics may generate AMR, while this behavior should be limited given that Italy is one of the European countries where the consumption of antibiotics is higher, and inappropriate practices regarding antibiotic use has been observed both in hospital and in other healthcare settings ,13,30,31The latest Italian Antibiotic Use Report has shown that inappropriate use of antibiotics was between 25% and 30% and the main reasons of inappropriateness were the treatment in the adult population of upper respiratory tract infections and uncomplicated lower urinary tract infections . MoreoveA third key finding was that the results of multivariate logistic regression analysis showed that patients who had an infection on hospital admission and a microbiological culture test during the hospital stay were significantly less likely to receive an inappropriate antibiotic prescription. This result can be explained by the fact that physicians in our sample prescribe antibiotics when they suspect an infection, and they confirmed the infectious diseases and isolates with the microbiological testing. This finding underlines the usefulness of microbiological tests to implement a correct use of antibiotics, even if only 13% of patients with infections had had a test during the hospital stay. In the global action plan on antimicrobial resistance adopted by WHO , a key sIn conclusion, the results of the present study indicate that the inappropriate use of antibiotics continues to be a relevant issue in the hospital setting. Therefore, it is imperative to implement the adherence of physicians to the guidelines on antibiotic use and the participation in ASP in order to improve the appropriateness in antimicrobial prescription and to reduce the use of broad-spectrum antibiotics. Moreover, specific interventions are needed to encourage a wider utilization of diagnostic tools in order to practice targeted therapies and to counter the AMR.For a correct interpretation of the results, some limitations of the study should be considered. First, due to the retrospective study design, data were only retrieved by medical records. Indeed, it is possible that some information, such as medication prescriptions, reasons for the antibiotic use, and information on the patients’ risk profiles, has not been accurately reported in the medical records by the healthcare professionals. Therefore, it cannot be excluded that the rate of appropriateness of antibiotic use may be underestimated due to the lack of information in the medical records and consultation with a physician that did not allow us to clarify the reason of several antibiotic prescriptions with no indication. Second, data were collected only in three hospitals in the Campania region. The characteristics of the hospitals may not be representative of all hospitals in Italy, and this may limit the generalizability of the study findings. Despite these limits, this investigation has several strengths, such as a large sample size and careful data collection for a one-year period in the selected hospitals. Therefore, we are confident that the results of this study are valid and provide important information on antimicrobial prescribing practices for inpatients.This study was carried out through a retrospective review of medical records of patients admitted in three public hospitals located in Campania Region  between 1 January and 31 December 2018. The minimum sample size consisted of 480 subjects, and it was calculated assuming a 30% prevalence of patients who have received inappropriate administration of antibiotics, a 95% confidence interval, and a 5% error. In order to increase the precision of the results, a larger sample of patients was recruited. Before starting the study, the Heads of the selected hospitals were contacted through a letter to obtain the approval to conduct the study and to describe the objectives of the investigation and the methods of collecting the information. After access to medical records was granted, the research team received the medical records in a secure electronic format from the medical records managers of the selected hospitals. Then, all information was reviewed and summarized on a standardized case report form by two authorized investigators not directly involved in patients care who consulted the medical records assuring the anonymity and confidentiality of the collected data. The medical records of patients fulfilling the following inclusion criteria were retrieved: (a) aged 18 years or above; (b) admitted for at least one day in medical or surgical wards; and (c) having received at least one antibiotic prescription for therapeutic reasons during their hospital stay. The following data were collected for each inpatient: age, gender, weight, height, date and diagnosis of hospital admission, ward and length of the hospital stay, hospitalization in the previous 12 months, smoking status, Charlson comorbidity index, type and number of chronic conditions, immunosuppression and nutrition status, previous allergies to antibiotics, clinical infection(s) on admission, microbiological culture test and antibiogram performed during the hospital stay, details about the antibiotic prescriptions , and presence of HAI according to the criteria of the European Centers for Disease Control and Prevention . MoreoveAppropriateness of antibiotic therapies was assessed according to the Guidelines for the implementation of Antimicrobial Stewardship programs and for the local implementation of antibiotic therapy protocols of the Campania region, and the national and international guidelines on the antibiotic treatments and preoperative prophylaxis ,36,37,38The data collection instrument was pretested on a random sample of 25 medical records not included in the final sample, and the necessary changes were made before starting the study.The study protocol was approved by the Ethical Committee of the Teaching Hospital of the University of Campania “Luigi Vanvitelli” .t-test for categorical and continuous variables, respectively. Subsequently, a multivariate stepwise logistic regression analysis was performed, including in the models the variables with a p-value ≤ 0.25 at the bivariate analysis according to Hosmer and Lemeshow’s model building strategy [p values equal to or less than 0.05. The results of multivariate regression analyses were reported as odds ratios (ORs) and 95% confidence intervals (CIs). Statistical analyses were performed using Stata version 15 software  and werestrategy , to inve


The article shows the effectiveness of the use of polymer additives for the production of fine-grained concrete mixtures and concretes based on using coal fly ash, which can be used as working mixtures for a 3D printer. Using mathematical planning of experiments, a set of experimental–statistical models was obtained that describes the influence of mixture composition factors including copolymer additive on the most important properties of ash-containing concrete mixtures and concretes for 3D concrete printing in the presence of a hardening accelerator additive. It is shown that when the dry mixture is mixed in water, the redispersed polymer powders are converted into an adhesive polymer dispersion, which, when the solution cures, creates “rubber bridges” in its pores and at the border with the base. They have high tensile strength and elastically reinforce the cement stone; in addition, they are also capable of not only significantly increasing the adhesion between the layers of the extruded mixture, but also significantly smoothing out such shortcomings of the cement stone as increased brittleness, low ultimate elongation, and a tendency to cracking. The development of such materials makes it possible to rationally use natural raw materials, fuel, electrical energy, utilize production waste, and reduce greenhouse gas emissions. This approach allows solving a number of important environmental, economic, and social problems [Modern construction is developing at a high speed due to the integration of innovative technologies and modern building materials into its process. The construction industry is one of the most resource- and energy-consuming, since the construction of buildings and structures for industrial and civil purposes requires a significant amount of non-renewable resources, the consumption of which increases with the increasing needs of people . Today, problems ,4.The most famous additive technology is the use of 3D printing in the construction process. The essence of this method is the layer-by-layer application of the mixture. With the use of 3D printers, it is possible to provide high-speed robotic construction of objects, including complex shapes, with a minimization of material consumption and labor use.Nowadays, a large amount of materials for 3D printing is used; the main ones are fine-grained concrete mixtures using Portland cement, mineral aggregates and fillers, various chemical additives, and fiber ,6.Building mixtures for 3D printing must have certain properties, in particular: the necessary workability (extrudability); structural strength after a certain time of layer curing; tensile strength at splitting, characterized by adhesion between the layers; as well as design compressive strength.A series of studies indicate the improvement of the properties of mixtures suitable for 3D concrete printing by adding various polymer additives to the cement matrix ,8. TheirDuring mixing in water, redispersed polymer powders are transformed into an adhesive polymer dispersion, which, when the concrete cures, creates “rubber bridges” in its pores and at the interface with the base . They haYi Zhang et al.  investigNowadays, the technology of cement concrete and mortars using industrial wastes, in particular fly ash, has been developed. Fly ash, having a high specific surface area, in addition to a direct chemical interaction with cement, actively affects the physicochemical processes on the surface of distribution “cement paste—aggregate” where the formation of contacts between them begins. For ash-containing mixtures, the impact of RPP is currently not fully investigated.The aim of this work was to develop ash-containing mixtures using redispersed polymer powder, characterized by the required technological properties, as well as structural strength at a certain time after extrusion of the layer, strength, providing adhesion of concrete layers, and compressive strength at an early and a project age.3S—57.10%; C2S—21.27%; C3A—6.87%; C4AF—12.19% (EN 196-2). The specific surface area of the Portland cement was S = 300–320 m2/kg (EN 196-6).The materials used in the research were Portland cement CEM I 42.5R of Cement Plant Dyckerhoff Ukraine and fly ash from Burshtynska thermal power plant , which belongs to type II ash of category B with a residue on a sieve, with a mesh size of 45 μm no more than 25% (class 2) (EN 450-1:2012). The chemical composition of Portland cement and fly ash are given in 2SO4. The redispersed polymer powders are selected among the most popular ones, in particular: vinyl ester of versatile acid (VEOVA), copolymer—vinyl acetate–ethylene (VAE), and polymer of vinyl acetate (PVA), the characteristics of which are given in Quartz sand with fineness modulus 2.1 was used as an aggregate. Chemical additives were: superplasticizer (SP) of polycarboxylate type and hardening accelerator (HA) sodium sulfate NaThe main task in the study of suitability for 3D printer fine-grained concrete mixtures without coarse aggregate DSTU B V.2.7-43-96 (Ukrainian Standart) is to ensure their required shape when extruded from the printer head with the achievement of the specified structural strength, as well as the strength of adhesion between the layers without the formation of cracks and other defects ,20,21. SThe 3D printed sample was cut into four-layer specimens with cross-sectional dimensions of 40 mm × 50 mm × 50 mm. The surfaces of the samples to which the load was applied were additionally smoothed.The workability of concrete mixtures was determined by immersion of a standard cone; the tensile splitting strength and compressive strength were determined according to EN 196-1 at the age of 1, 7, and 28 days. The testing machine FP-100/1 100 kN  was used for testing. Tests for tensile splitting strength were carried out on three samples. The samples were placed in the machine and loaded with cylindrical steel heads at the boundaries of the layers. The load was transferred to the sample at a constant speed of 50 N/s until destruction. Compressive strength was tested on six samples; the load was transferred to the sample at a speed of 500 N/s until destruction. The head of the testing machine was assembled with a hinge to adapt to any possible non-parallel surface.The setting time (curing time) was determined according to EN 196–3 by the time from the moment of mixing to the beginning of setting, at which it becomes impossible to further mold with a 3D printer.To determine the structural strength, a technique is proposed that allows to measure the ultimate load limit on a sample of an extruded concrete layer, at which it begins to deform  Figure .At the first stage of the study, the effects of redispersed polymer powders of different natures were compared. In the mixtures containing cement and quartz sand, a polycarboxylate superplasticizer and a hardening accelerator were added during mixing. The proportion of polymer was 0%, 1.0%, and 2.0% by weight of the dry mix; the W/C ratio was constant at each point (W/C = 0.6). The compositions of the studied mixtures are given in The obtained experimental results are shown in Analyzing the results obtained, it can be concluded that the addition of RPP causes an increase in the workability of the mixture on the immersion of the cone from 8 cm to 10–11.5 cm at a constant water content and polymer content of 1% by weight of the mixture. With a further increase in the amount of RPP to 2%, there is a slight increase in workability to 12–13.5 cm a. The efThe effect of RPP on the structural strength 30 min after mixing the mixture is ambiguous. Vinyl ester of versatic acid significantly reduces structural strength. The effect of polyvinyl acetate is similar; however, the reduction of strength is less significant. At the same time, a positive effect is observed at a medium content (1%) of the vinyl acetate–ethylene copolymer; however, with a further increase in the content of RPP, the structural strength also decreases compared to the sample without polymer powder .Polymer powders have mixed effects on both compressive and splitting strengths at different curing times. According to the results obtained , the addThe tensile splitting strength a at the The effect of RPP on compressive strength b is someThus, it can be concluded that the best results of structural strength and tensile splitting strength, which characterizes the adhesion between the layers, were obtained using a copolymer–vinyl acetate–ethylene; thus, further studies were carried out using this RPP.2 [n rows and m columns, which gives a set of combinations of factors varied relative to some origin or zero (basic) level. The permissible range of the variation of factors (factor space) is selected on the basis of a preliminary study of the object in accordance with the purpose. To simplify the recording of experimental conditions and processing of experimental data, the upper level of factors is coded +1, the lower level −1, and the main level corresponds to 0.In the second stage, algorithmic experiments were performed to study the combined effect of fly ash and vinyl acetate–ethylene copolymer on the properties of concrete suitable for 3D printer according to the three-level two-factor plan B2 . The useib was estimated by finding the experimental value of the t—criterion (it) and comparing it with the table [For the construction of quadratic models, a full factorial experiment was used, which provides for all the possible combinations of factors at three levels. For the technological analysis and selection of significant factors, along with checking the adequacy of the equation, the significance of the regression coefficients was also assessed. The significance of the regression coefficients he table . Regressk factors. The conditions for planning the experiments are given in The results of the experiments were processed using methods of mathematical statistics, obtaining quadratic regression equations in general form for The parameters studied were: the setting time; structural strength 30 min after mixing; compressive strength; and tensile splitting strength at the age of 1, 7, and 28 days.The planning matrix and composition of the mixtures, as well as experimental results are given in During the research, at each point of the plan to evaluate the influence of factors on the properties of concrete, mixtures were prepared according to The water consumption was varied to ensure the necessary workability by immersion of a standard cone of 8–10 cm, which ensured sufficient formability (extrusion) of the mixture. Formability was determined by the ability of the mixture to be squeezed out of the printer’s mouthpiece without cracks and delaminating along the length of the bar.The suitability of the mixtures for molding was determined by the time from the moment of mixing to the beginning of hardening after which further molding on a 3D printer becomes impossible.After statistical processing of the results of the experiments , performY is the calculated value of the studied parameter; iX…jX are independent variables (factors) that can be varied during experiments; 0β, iβ…jβ, iiβ…ijβ are statistical estimates of regression coefficients.General type of equations:The analysis of the coefficients  of the rTo analyze the obtained experimental and statistical models, two-factor graphical dependencies were built, which show the influence of composition factors on the properties of concrete suitable for the 3D printer .The addition of RPP to the mixtures for the 3D printer allows to increase the setting time a or the The obtained results clearly show the negative effect on the tensile splitting strength a and comThe influence of the studied factors on the strength parameters is to some extent linear, as evidenced by the insignificant quadratic coefficients of the regression equations . This is2 emissions and improves the environmental situation. RPP, in turn, increases the plasticity (extrudability) of the mixture, as well as the adhesive strength of the adhesion of the layers, which is important for mixtures used in 3D printers.The purpose of fly ash in construction mixtures and RPP is different; however, their combination gives a positive effect. Fly ash is an active mineral additive that helps to increase the volume of hydrate formations; moreover, the addition of fly ash to cements and concrete leads to a reduction in clinker consumption, which reduces COComparing the analysis of the influence of the studied redispersible polymer powders allows to consider that the best values of the complex of basic properties of mixtures and concretes for a 3D printer are achieved when using copolymer–vinyl acetate–ethylene.Addition of redispersible polymer powder to the fly ash containing concrete mixture increases the tensile splitting strength, which improves the adhesion strength between the layers of the printed mixture.As follows from the nature of the interaction between redispersible polymer powder and cement–ash binder, the increased content of polymer additive has a more positive effect on the tensile splitting strength at a lower cement–ash binder consumption strength increase by 35–40% at 20% CAB consumption and 8–12% at 15% CAB.The use of a redispersible polymer powder with a cement–ash binder content of 180–200 kg/t, along with increased adhesive strength, makes it possible to provide the necessary compressive strength of ash-containing concrete, suitable for printing on a 3D printer.In further research, it is advisable to develop compositions of building mixtures for a 3D printer using other dispersed products of technogenic origin; in addition, to offer technological solutions that take into account the design features of existing 3D printers.


Antibiotic resistance is a global health threat, and there is growing concern on the inappropriate use of antibiotics in the livestock sector especially in low and middle income countries. The purpose of the study was to understand the knowledge, attitudes and practices on antibiotic use and antibiotic resistance of government animal health workers in Timor-Leste.A cross-sectional survey using a census approach was conducted between August 2021 and January 2022 focusing on government animal health workers involved in field work and access to antibiotics. Interviews were face-to-face in the local Tetun language. Descriptive and regression analysis informed by causal diagrams were performed.The study found poor knowledge of antibiotics among participants, with only 8.0% (13/162) able to correctly answer questions on how antibiotics worked. Knowledge of antibiotic resistance was poor as only 29.0% (47/162) of participants had heard of antibiotic resistance and were able to accurately identify that it made antibiotics less effective. Knowledge of antibiotics and knowledge of antibiotic resistance were crudely associated with being a veterinary technician and having university education. Attitude scores were positively influenced by knowledge of antibiotics and antibiotic resistance. Antibiotics were most commonly used in pigs, cattle and buffalo, with oxytetracycline being the most commonly used antibiotics in pigs and chicken. However, most participants reported a lack in supply of this antibiotic  and other antibiotics. Empiric use of antibiotics in sick animals was common, and some participants used antibiotics for parasitic diseases. Less than a fifth of participants reported ever using human antibiotics, and use of antibiotics for growth promotion was uncommon.There is a need to develop Timor-Leste specific treatment guidelines, strengthen veterinary diagnostic support, improve antibiotic procurement, and develop training programs to address knowledge gaps and poor practices found in this study. Antibiotic resistance is a global health threat which has emerged rapidly in recent decades due to the inappropriate use of antibiotics in humans and animals , 2. In l2  is responsible for providing veterinary and animal health services in Timor-Leste , 20. TheThere is no local manufacture of veterinary antibiotics in Timor-Leste . All vetGAHWs in Timor-Leste include veterinarians, veterinary technicians, livestock technicians and extension workers. There are few qualified veterinarians in Timor-Leste  as is thMost veterinary technicians are animal health degree graduates from the national university where the first cohort graduated in 2013 . Many ofIn Timor-Leste, there have been no studies investigating the knowledge, attitudes and practices (KAP) of antibiotic use and antibiotic resistance among GAHWs, although there was a recent study which found very poor knowledge of antibiotics and antibiotic resistance among smallholder pig farmers . In otheA cross-sectional study was conducted among GAHWs between August 2021 and January 2022 in all 13 municipalities of Timor-Leste. The study was undertaken as part of a larger Fleming Fund Country Grant project administered by the Menzies School of Health Research (Menzies) which aims to optimise antimicrobial use across both human and animal health sectors . EligibiVeterinary technicians and livestock technicians who were involved in field work. Field work means being in a role that involves being called out to provide animal health services such as vaccination and treatment on a regular basis.Extension workers, other MAF employees or volunteers with access to antibiotics for work. Access to antibiotics means that antibiotics distributed to the municipal level Livestock and Veterinary Department office are provided to these individuals for use in animals.The size of the target population was estimated to be about 170 based on information obtained from the MAF national office. A census approach was considered logistically feasible and was implemented. Before each municipality was visited, the municipal-level Livestock and Veterinary Department office was contacted by Menzies to provide an exact list of individuals which met the eligibility criteria because information on the daily roles and responsibilities of each staff which informed inclusion or exclusion from the study was not available at the national level. All eligible participants were contacted and invited to participate in the interview 1–2 weeks before the scheduled interview date. Participants that did not live close to the interview venue in each municipality were provided with monetary compensation for their travel expenses.The questionnaire was initially developed in English and translated into Tetun by two authors  who are fluent in both languages. The questionnaire was piloted with five non-government veterinary technicians and refined prior to implementation. The final questionnaire had four sections and 122 questions which were mostly closed-ended, and an English version is available in the The first section focused on the participant's demographic information, use of laboratory services, and observations on farm properties they have visited. The second section assessed the knowledge of GAHWs on antibiotics, antibiotic resistance and antibiotic residues. The third section assessed the attitudes of GAHWs towards antibiotic use, which can be defined as their beliefs about inappropriate antibiotic use and reducing antibiotic use through measures such as vaccination, farm biosecurity and good animal husbandry. The final section collected information on the antibiotic use practices in animals.The interview was conducted face-to-face in the Tetun language by two trained Timorese animal health professionals and took an average of 50 min to complete. Picture aids were used when asking participants about specific antibiotic products to aid recollection. To minimise interview fatigue, the interview was divided into 2 sessions with a short break in between, and both interviewers were consistently assigned to ask the same set of questions throughout the entire study. Almost all the interviews were conducted either in the MAF national or municipal office, except for 6 GAHWs from Dili municipality who were interviewed in the Menzies Office in Dili to allow better flexibility on the interview time.All responses were collected using the REDCap Mobile App on Android tablets as this facilitated offline data collection due to limited internet connectivity in some municipalities. Any additional responses provided by a participant which provided Free-text responses to 14 questions that allowed open-ended responses were classified into categories that were developed retrospectively by five members of the research team. An overall attitude score was created for each participant by assigning a score of 1 to each of the 11 attitude questions that were answered correctly. Binary variables were created for several of the demographic attributes for use in regression analyses: experience was categorised as <10 years/≥10 years, highest education as university/not university and learnt about antibiotics at a training course as yes (MAF or non-MAF training)/no.a priori to explore relationships between several sets of variables: (1) demographic variables and knowledge of how antibiotics work (i.e. identifying that antibiotics kill bacteria but not viruses), (2) demographic variables and knowledge of antibiotic resistance (i.e. correctly identifying that antibiotic resistance reduces the effectiveness of antibiotics) and (3) key knowledge variables and attitude score. A causal diagram was developed for each of the outcome variables of interest. Prior to conducting the analyses, relationships between pairs of explanatory variables were assessed through correlations and cross-tabulations and planned analyses adapted as required. Where appropriate, the causal diagrams were used to inform minimal sufficient adjustment sets of covariates to estimate total and direct effects for each variable of interest. Logistic regression analyses were conducted for binary outcome variables and linear regression analyses for attitude score. The distributions of residuals from all linear regression models were checked for normality. All analyses included municipality as a random effect to account for clustering at this level. All data analyses were conducted using Stata 17.0 . Causal diagram-informed analyses were proposed ata 17.0 .A total of 188 names were provided to Menzies by the various municipal-level Livestock and Veterinary Department offices. Of these, 169 were interviewed giving an overall participation rate of 89.9%. The most common reasons for being unable to participate was having other work commitments. After the interviews were conducted, we identified three participants who did not meet the eligibility criteria and these participants were removed the dataset. Separately, we identified three participants who had met the eligibility criteria, but had never used any antibiotics for work mainly because they had just joined the government animal health workforce and one participant who gave inconsistent responses throughout the interview. These four participants were included in the demographic analysis but excluded from subsequent analyses. Therefore, 166 participants were included in the demographic analyses and 162 participants were included in the knowledge, attitudes and practices analyses. A study flowchart can be found in Participant demographics are summarised in At the time of the survey participants generally thought that current vaccination coverage in the areas they covered for work was low with only 24.7% (41/166) of participants thinking at least 67% chickens were vaccinated for Newcastle Disease and 4.8% (8/166) thinking that at least 67% pigs were vaccinated for Classical Swine Fever. More than half of the participants said that they occasionally observed fencing around farms with chickens and pigs , chickens in cages  and animals in pens . More than half had never observed a locked gate on farms with chickens and pigs , and more than three-quarters of participants had never observed dedicated boots , disinfection of footwear  or visitor sign-in books  on farms that they have visited. Based on comments captured from participants, farms that had higher biosecurity standards such as dedicated books and visitor sign often belonged to agriculture schools, religious organisations, commercial enterprises, or farmer groups supported by the government or aid programmes. Further information on farm observations can be found in Knowledge of antibiotics by position can be found in Almost all participants  were able to correctly identify Medoxy-LA which is a long-acting oxytetracycline injectable and the most commonly used veterinary antibiotic in Timor-Leste . HoweverKnowledge of antibiotic resistance by position is shown in Bobonaro municipality had the highest proportion of GAHWs that had knowledge of how antibiotics worked and knowledge of antibiotic resistance. Oecusse and Ainaro municipalities had the lowest proportion of GAHW that had knowledge of how antibiotics worked and knowledge of antibiotic resistance respectively. The percentages of participants in each municipality who had knowledge of how antibiotics work (i.e. identifying that antibiotics kill bacteria but not viruses) and knowledge of antibiotic resistance are shown in The overall median score for attitudes on antibiotic use among participants was 7 out of 11 (IQR 6−8). Veterinary technicians had a higher median score (median score = 8) compared to the other participants (median score = 7). Participants from Oecusse municipality had the lowest median score (median score = 4), and median attitude scores by municipality are shown in All 162 participants included in analysis reported ever giving antibiotics to animals for work, with most participants stating that they treated at least an average of 11 animals per month in the last 12 months. The key antibiotic use practices by position are detailed in n = 88), fever (n = 59), cough (n = 53), lethargy (n = 53) swelling in body parts (n = 51), inappetence (n = 46) and wounds (n = 46). Some participants also used antibiotics for scabies (n = 20) and gastrointestinal worms (n = 1). Less than one-fifth of participants  did not always give antibiotics to sick animals, and the main reasons were unlikeliness of a bacterial infection or unavailability of antibiotics. Only seven out of these 29 participants reported facing resistance from farmers when they decided not to use antibiotics. Further information on reasons for antibiotic use can be found in Almost all participants  reported ever using antibiotics for treatment of sick animals and slightly less than half  reported ever using antibiotics for disease prevention. Very few participants have ever used antibiotics for growth promotion . In sick animals, the common clinical signs prompting use of antibiotics were diarrhoea (n = 32).Most participants said that veterinary medicines including commonly used antibiotics such as Medoxy-LA  and Pen-Strep  were lacking in supply for work in the last 12 months. Almost a quarter  of participants said that they have ever obtained antibiotics from other sources other than MAF for work purposes, and almost all of them obtained antibiotics from agriculture shops , what the drug label states is effective for the suspected disease , drug availability , what was learnt at a training course , what was learnt at university/high school  and the duration of action . Almost all participants said that they never chose an antibiotic based on laboratory test results  and veterinary antibiotic prescribing guidelines from other countries . Most participants said they never chose an antibiotic based on what is cheaper  and based on trial and error . Further information on antibiotic supply and antibiotic choices can be found in More than half of the participants reported ever giving antibiotics to pigs, cattle, goat, buffalo, dogs and local chickens, and very few participants have ever used antibiotics in broilers and layers. Pigs , cattle  and buffalo  were selected in the top 3 species which participants administered antibiotics to in the last 12 months. Almost all participants  reported using antibiotics in pigs in the last 12 months. The classes of antibiotics that were used were tetracycline, penicillin, aminoglycoside and sulphonamides. The most used antibiotic by participants in pigs was Medoxy-LA . On the other hand, only 58.6% (95/162) of participants used antibiotics in chickens in the last 12 months. Of those participants that had used antibiotics in chickens in the last 12 months, the classes of antibiotics that were used were tetracycline, penicillin, aminoglycoside, sulphonamides and polypeptides. The most used antibiotic by participants in chickens was also Medoxy-LA . Further information on antibiotics use by species can be found in Less than a fifth of participants  reported ever using human antibiotics in animals. Animal species that received human antibiotics from participants were local chickens, fighting cocks, pigs, dogs, cattle and goats. The human antibiotics given were mainly in tablet, capsule or ointment formulations. The common active ingredients were amoxicillin, ampicillin, tetracycline. The common brands mentioned were Super Tetra and Terramycin. The human antibiotics were mainly purchased from human pharmacies and kiosks. Several participants also reported using leftover human antibiotics that they had received for their own use from health centres/posts or hospitals. Further information on use of human antibiotics can be found in Less than 10% of participants reported ever giving antibiotics through water to animals, and such practices were mostly reported in municipalities bordering Indonesia. Chickens followed by pigs were the most mentioned species which were given antibiotics through water. The antibiotic brands that were mentioned contained amoxicillin, enrofloxacin, colistin, oxytetracycline, neomycin, ampicillin, sulphonamides and bacitracin as active ingredients. One participant mentioned giving an injectable formulation of oxytetracycline through water to chickens. Another participant used a poultry specific oral antibiotic in pigs and cattle. Only three participants reported giving antibiotics through feed to animals. While one could not recall the antibiotic given, the other two participants reported giving an injectable formulation of oxytetracycline through feed to pigs and dogs. Further information on use of oral antibiotics can be found in Before using antibiotics, more than three-quarter of participants  always checked the expiry date. When using antibiotics, around one-third of participants  reported ever giving a lower antibiotic dose than required on the label. Among these participants, the most stated reasons for giving a lower antibiotic dose were a sick or weak animal, inaccurate weight estimation and the lack of antibiotic supply. For participants who reported never giving a lower antibiotic dose than required on the label, the majority stated that it was important to adhere to label instructions. Slightly less than one-third of participants  reported ever giving an animal a shorter duration of antibiotic treatment than on the label. Among these participants, the common reasons for giving a shorter duration of antibiotic treatment were early animal recovery, lack of antibiotic supply, inability to revisit a distant farm to administer antibiotics and the farmer had released the animal. For participants who have never given a shorter duration of antibiotic treatment than recommended on the label, nearly all explained that they had to follow dosing instructions.After giving antibiotics, most participants  always advised farmers to wait a few days before selling, slaughtering or eating products from their animals. When asked about what else was communicated to farmers when antibiotics were used, around half of the participants  also told farmers that that there was a possibility that animals might not improve and around a third of participants  advised farmers to implement good animal management. Less than 20% of participants advised farmers to isolate sick animals. None of the participants engaged with farmers on the impact of antimicrobial resistance and diagnostic testing. Most participants  recorded their antibiotic use on a paper-based form supplied by the MAF national office which was later submitted to the office for collation.Less than a quarter of participants  reported that they have ever given farmers antibiotics to inject animals themselves, and only three participants reported that they have ever advised farmers to give antibiotics without first examining the animals themselves. Around half of participants  said they knew farmers who used antibiotics in animals without first speaking with a technician. When asked about the reasons for such a practise among farmers, participants cited poor access to veterinary services, the ability to purchase antibiotics from Indonesia or agriculture shops, and presence of knowledgeable farmers who administer antibiotics based on previous training. Further information on antibiotic prescribing practices can be found in Exploratory analyses of the demographic variables identified that many were highly correlated and cross-tabulations showed some cells with very low frequencies. For example, position and education were highly correlated because all but two veterinary technicians had university education. Consequently, only crude logistic regression analyses were conducted but the causal diagrams informed discussion of the results and they and the rationale behind them are included for interest in Veterinary technicians were more likely than livestock technicians , and those who attended university were more likely than those who did not attend university  to have knowledge of how antibiotics work. A similar pattern was seen for knowledge of antibiotic resistance, where veterinary technicians were more likely than livestock technicians , and those who attended university were more likely than those who did not attend university  to know that antibiotic resistance reduces effectiveness of antibiotics. See Exploratory analyses of some of the key knowledge variables suggested that the proposed causal diagram-based analyses were feasible. However, knowledge of antibiotic resistance was highly correlated with knowledge of antibiotic resistance transmission and antibiotic resistance as serious human and animal health issues. Furthermore, almost all participants knew that samples could be sent to the veterinary laboratory. Therefore, these variables were excluded from the analyses. The full causal diagram is shown in This is the first study describing the knowledge, attitudes and practices of antibiotic use and antibiotic resistance among government animal health workers in Timor-Leste, and one of few studies which explores this in an LMIC. This study found that GAHWs had poor knowledge on antibiotic and antibiotic resistance, but this was better among veterinary technicians and those with university education. Areas where prudent use of antibiotics could be improved were identified.Most veterinary technicians were under 40 years old, while most livestock technicians were 40 years or older. This reflects the more recent introduction of the veterinary technician position employing animal health graduates from the national university which produced graduates only after 2013, compared to the more historical livestock technician position. The increased female representation among veterinary technicians also reflects Timor-Leste's ongoing efforts to achieve gender equality .Knowledge of antibiotics among animal health workers was relatively poor compared to other LMICs. The proportion of participants who correctly identified that antibiotics did not kill or inhibit viruses in this study 59.9%) was lower than Bhutan (76.5%) .9% was l. FurtherKnowledge of antibiotic resistance was poor among GAHWs in Timor-Leste as only 29.0% of participants had heard of antibiotic resistance and were able to accurately identify that it made antibiotics less effective. This was much lower than GAHWs in Bhutan where almost all participants (95.4%) indicated that resistant bacteria are difficult to treat . There wTo address the poor knowledge, future MAF training which GAHW identified as their most common source of knowledge could focus on addressing the identified gaps such as emphasising that antibiotics do not have direct anti-inflammatory or anti-pyretic properties, identification of common veterinary medicines and the concept of antibiotic resistance. Trainings should focus on municipalities such as Oecusse and Ainaro where there is poorer knowledge.Knowledge of antibiotics and knowledge of antibiotic resistance were all crudely associated with being a veterinary technician rather than a livestock technician and having university education. These findings are consistent with a study conducted in Bhutan, where GAHWs with at least university education had better overall scores for knowledge on antibiotics and antibiotic resistance . StudiesThis study found that veterinary technicians (who are younger in age) had a higher median attitude score compared to non-veterinary technicians. This is consistent with a study in India which showed that those under 30 years old had higher attitude scores .Although nearly all participants believed that laboratory results can help with decisions on antibiotics use, this did not translate into practise as sample submission to the laboratory by participants was low, most have never received a laboratory result and almost all participants have never chosen an antibiotic based on laboratory results. Though the reasons for the low sample submission was not investigated in this study, low sample submission to laboratories by animal health workers in other LMICs is often due to limited access to laboratory services , 36, 44.It was positive that the majority of participants believe that the use of vaccines, implementation of farm biosecurity, and practise of good animal husbandry can reduce antibiotic use in Timor-Leste. However, farm observation by participants in this study showed that vaccine coverage is suboptimal and farm biosecurity practices are typically low in smallholder farms, which is in agreement with previous studies –47. AlthThe use of antibiotics for growth promotion, especially those that are medically important is discouraged and banned in many countries –52. AlthIt is worrying that around three-quarters of participants believed that giving a broad spectrum antibiotic was always a better choice than a narrow spectrum antibiotic, which was very similar to a finding in Bhutan where 72% of respondents indicated that broad spectrum antibiotics should be used for any bacterial infection . This isThe positive total effects of knowledge of how antibiotics work, antibiotic resistance and spectrum of antibiotics on attitude score was encouraging as it suggests that efforts to improve knowledge levels of the GAHW population will translate to an improvement in their attitudes towards antibiotic use and hopefully also their practices. However, the direct effect of knowledge of antibiotics was lower and less precisely estimated, suggesting that a deeper level of knowledge including knowledge of antibiotic resistance and spectrum of antibiotics is important to positively influence attitude score.It is of concern that most participants always gave antibiotics to sick animals, where the antibiotics were used empirically to treat any case of diarrhoea, fever, cough or swelling even though the aetiology might not be bacterial. Such a practise was also reported among GAHWs elsewhere  and coulThere were a myriad of factors influencing the choice of antibiotic. Factors such as past experience and availability of drugs which the majority of participants always used to select antibiotics was similar to findings in other LMICs , 44, 59.The lack of supply of antibiotics and other veterinary medicines found in this study was consistent with another report , and simThere was a limited range of antibiotics available to GAHWs, and similar findings have been reported in other LMICs , 59. Thevia water or feed over a prolonged duration increases the selection pressure for resistance especially for gastrointestinal bacteria  Department of Health and Menzies School of Health Research (2020-3841) and Institute Nacional de Saude in Timor-Leste (MS-INS/DE/IX/2020/1411). An information sheet in the Tetun language was provided and verbally explained to all participants prior to the interview. Informed consent was given by the participant via a written signature. Participants were given the right to decline participation or withdraw from the interview at any stage. Actions were taken to ensure confidentiality and anonymity of interview responses.ST, AP, AA, PV, CD, JJ, SD, JY, JF, and TB conceived and designed the study. AP, AA, PV, and CD conducted the field work. ST, TB, AP, SD, AA, CD, and PV analysed the data. ST, AA, TB, and SD prepared the draft manuscript. JY, JF JJ, SD, HS, AP, AA, CD, and PV reviewed and edited the manuscript. All authors have read and approved the final manuscript.This study was supported by the Fleming Fund Country Grant for Timor-Leste (FF/87/493). The Fleming Fund is a UK aid investment programme to tackle antimicrobial resistance in LMICs around the world and is managed by the UK Department of Health and Social Care.Author TB is a working director of Epivet Pty. Ltd. The remaining 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.


Polypharmacy is common in the home health care (HHC) setting. This study examined the prevalence, predictors, and impact of medications associated with geriatric syndromes (MAGS) use on subsequent hospitalization in HHC patients. Data from the HHC electronic medical records, the Outcome and Assessment Information Set (OASIS), and Medicare HHC claims of 6,882 adults ≥ 65 years old receiving HHC from a large, non-profit HH agency in New York State in CY 2019 were used. MAGS use was identified from active medications reconciled during HHC visits and defined as total count and in quartiles. Hospitalization during the HHC episode was operationalized as a time-to-event variable. Regression analyses were conducted to identify predictors of MAGS use, and survival analyses were conducted to examine the association between MAGS use and hospitalization. Nearly all (98%) of the HHC patients used at least one MAGS and 41% of all active medications were MAGS. A higher MAGS count was found among HHC patients who were non-white, community-referred, with more comorbidities, depressive symptoms, and functional limitations. A higher MAGS count was also related to increased risk for hospitalization. Moreover, higher quartiles of MAGS use combined with having ≥10 diagnoses predicted a 2.5-fold increase in hospitalization risk, relative to the lowest quartile of MAGS use and having < 10 diagnoses. In conclusion, over 40% of medications taken by HHC patients are MAGS, which, along with multimorbidity, increased hospitalization risk. HHC clinicians should identify MAGS use to inform deprescribing discussion with patients and their prescribers.