Objectives: MET protein expression has been reported to be in relevance with the survival of NSCLC patients in various studies, yet the results were inconsistent. The purpose of our study set out to determine the prognostic role of both c-MET and p-MET expression among NSCLC that underwent surgical resection.Methods: Data were obtained from retrospective cohort studies by searching on PubMed, Cochrane Library, EMBASE and Web of Science, and a meta-analysis was performed to assess the prognostic role of MET expression among NSCLC.Results: Totally 18 literatures including 5,572 surgically resected NSCLC cases staged I-IV were included for data synthesis. The positive rate of c-MET and p-MET was 1,753/4,315 and 135/1,257. The pooled hazard ratios (HRs) regarding c-MET and p-MET expression for overall survival (OS) was 1.623  and 1.710 , respectively. Subgroup analysis results on Asian , adenocarcinoma  and rabbit polyclonal antibodies  etc. were also indicative.Conclusion: C-MET over-expression among NSCLC patients that underwent surgical resection is a prognostic factor that indicated adverse survival on OS. Whereas, p-met didn't appear to have an impact on the prognosis of NSCLC. The studies are need and the topic could be re-valued by then. BeinMET , 9. WhenMET . P-MET aMET , 12. WheMET , 14. Theoccurred , 16. Prioccurred , 18. In  disease –22. HencTo date literatures has emerged with inconsistent conclusions on the prognostic role of MET among NSCLC. C-MET expression was thought to be a favorable biomarker in various studies –25, yet Two reviewers (GM and YD), respectively, conducted electronic search on PubMed, Cochrane Library, EMBASE, and Web of Science for relevant studies up till July 15th, 2019, with the beginning date unlimited. The search terms were as followed: “MET” or “Mesenchymal Epithelial Transition factor” or “Hepatocyte growth factor receptor” and “Non-small cell lung cancer” or “NSCLC” or “Pulmonary carcinoma” or “lung cancer” and “Prognosis” or “Outcomes” or “Survival.”Eligible studies was required to be in compliance with the following criteria: (1) NSCLC studies, all included participants should be NSCLC patients that underwent surgical resection; (2) MET expression was examined of each resected specimen, with the correlation between MET expression and NSCLC survival been reported; (3) Hazard Ratio (HR) was clearly displayed and feasible for HR synthesis, according to methods described by Parmar et al. , Williamin vitro studies; (3) Case reports; (4). Studies of which survival data  unavailable for further calculations.Articles were omitted from further consideration if: (1). Systematic review or review; (2) Preclinical studies, such as laboratorial or Basic information of each eligible study was extracted as followed: name of first author, publication year, country, demographic characteristics , smoking status, pathology, and tumor stage, antibody applied for MET immunohistochemical (IHC) staining, cut-off value of MET over-expression and reported HRs (representing prognosis) for meta-analysis.The primary data eligible for calculation and results-pooling was hazard ratios (HRs) reported from either multivariate or univariate Cox hazard regression analysis for overall survival (OS). Literatures of eligibility was filtered by two authors (GM and YD) individually, with any discordance being revised and re-assessed.The Newcastle–Ottawa Scale (NOS) criterion was adopted for quality assessment of included studies . The criQ-test and I2 statistic test were performed to value heterogeneity regarding the pooled HRs (I2 < 50% or P > 0.10) whereas random-effect models were applied for calculation in order to minimize potential influence of heterogeneity on pooled results. Apart from random-effect model, sensitivity analysis by leave one out procedures was also processed uncovering the potential source regarding heterogeneity of pooled results . LogHRs reported in the literature were prior used for HR pooling, otherwise HRs with 95% confidential intervals (CIs) were considered for data syntheses. Multivariate analyses data were prior adopted if multivariate and univariate survival analyses were both conducted. Adjusted HRs was used when unadjusted/adjusted HRs both existed. Chi-square based oled HRs . The Manoled HRs  were ado results . Publica results . Publican = 124), case reports (n = 158), irrelevant topic or fundamental observations (n = 807). Totally 62 potential studies of eligibly were obtained and scrutinized. Then 45 of which were omitted owing to the following reasons: 34 studies focused on irrelevant topics such as MET gene expression and alterations, 11 remaining studies whose data were either survival curve or illegible of HR estimation. Two studies conducted by Sun et.al included overlapped patients  in total. Abstracts of each identified publication was discreetly read and screened. Studies were removed due to the reasons as followed: Reviews or systematic review , indicating an adverse impact of c-MET expression on NSCLC prognosis. Heterogeneity was significant (I2 = 85.9) thus random-effect model was adopted  when combining the three related studies, the pooled result for OS  was neither indicative  Regions (Asian/Non-Asian/Japanese/Chinese); (2) Histology (Adenocarcinoma); (3) Antibodies for IHC ; (4) MET evaluation (H-score); and (5) Derived data .P < 0.001, I2 = 83.5%). The pooled HRs via random-effect models from five Japanese studies and five Chinese studies was 1.985  and 2.627 , respectively. With respect to non-Asian patients, the combined HR for OS from four studies was 0.901 , with random-effect model due to its significant heterogeneity .Totally 12 studies were conducted in Asia, and the pooled HR for OS was 2.115 . Fixed-effect model was applied to perform the analysis since heterogeneity was not significant .The prospect of our present study was to examine the prognostic role of MET expression on multiple NSCLC types. Yet only adenocarcinoma was applicable. Altogether five studies focused on pulmonary adenocarcinoma, and the synthesized HR of OS was 2.220 . Among which five studies adopted SP44  antibody, and the pooled HR for survival was 1.031 . In addition, four studies via SP44 examined MET expression by same cut-off value with reference to methods by Spigel et al. (p = 0.892). For the survival analysis of five studies that applied rabbit polyclonal antibodies, the pooled HR was 2.107 . Heterogeneity was not statistically significant  thus fixed-effect model was preferred.IHC was performed in all studies, and antibodies for MET staining varied between studies. As to seven studies that applied rabbit monoclonal antibodies, the combined HR for OS was 1.107 . The remaining five studies were performed by univariate analysis, of which the pooled HR was 1.051 . Heterogeneity was significant among either results . Therefore, random-effect model was adopted for both analyses.Ten studies addressed the prognostic role of MET over-expression among NSCLC by multivariate analysis. The pooled HR on OS was 2.004   . With reion both , 62. Indsistance , 20, 63.sistance , 64. HenPreviously two meta-analysis was published that assessed the impact of MET expression on survival among NSCLC , 65. GuoDue to practical constraints, our meta-analysis has several limitations. Firstly, our several results had significant heterogeneity. Efforts such as sensitive analysis and subgroup analyses were performed on the basis of several aspects but a distinct source was still lacking. Hence we speculate that the existing heterogeneity could be attributed to the inconsistency of baseline characteristics from included literatures such as tumor stage, smoking status, post-operative therapies and IHC methodology involving varied cut-off values and antibody adoption. Tumor stage was highlighted in the protocol of the present study for its relationship with MET positivity, yet we failed to analyze the prognostic role of MET in each individual stage due to lack of original data. Moreover, explanations to the positive results derived from Asian population remains obscure. With respect to IHC, although several recent publications performed their IHC analysis with reference to an anti-MET clinical trial , a standIn conclusion, c-MET over-expression among resected NSCLC patients is a prognostic factor that indicated adverse survival on OS. Yet p-met didn't appear to have an impact on the prognosis of patients with NSCLC. The existing IHC criteria to define MET positivity is inconsistent, which might be a factor to cause heterogeneity. More studies should be conducted to examine the topic, especially studies that focuses on p-MET expression among NSCLC patients. The prognostic role of c-MET/p-MET both among NSCLC could be re-evaluated when added evidence have emerged by then.The datasets generated for this study are available on request to the corresponding author.GM and QZ conceived the study. GM and XL designed the study. GM and YD searched the literature and collected the data and performed the analyses. GM, YD, and WC drafted the manuscript. ZL and GM prepared The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Blast furnace slag (SL) is an amorphous calcium aluminosilicate material that exhibits both pozzolanic and latent hydraulic activities. It has been successfully used to reduce the heat of hydration in mass concrete. However, SL currently available in the market generally experiences pre-treatment to increase its reactivity to be closer to that of portland cement. Therefore, using such pre-treated SL may not be applicable for reducing the heat of hydration in mass concrete. In this work, the adiabatic and semi-adiabatic temperature rise of concretes with 20% and 40% SL (mass replacement of cement) containing calcium sulfate were investigated. Isothermal calorimetry and thermal analysis (TGA) were used to study the hydration kinetics of cement paste at 23 and 50 °C. Results were compared with those with control cement and 20% replacements of silica fume, fly ash, and metakaolin. Results obtained from adiabatic calorimetry and isothermal calorimetry testing showed that the concrete with SL had somewhat higher maximum temperature rise and heat release compared to other materials, regardless of SL replacement levels. However, there was a delay in time to reach maximum temperature with increasing SL replacement level. At 50 °C, a significant acceleration was observed for SL, which is more likely related to the pozzolanic reaction than the hydraulic reaction. Semi-adiabatic calorimetry did not show a greater temperature rise for the SL compared to other materials; the differences in results between semi-adiabatic and adiabatic calorimetry are important and should be noted. Based on these results, it is concluded that the use of blast furnace slag should be carefully considered if used for mass concrete applications. Controlling the temperature rise in concrete structures employing large volumes of concrete (mass concrete) is critical to prevent thermal cracking caused by large temperature differentials between the concrete surface and its interior even without external structural restraint. Large concrete structures like high-rise buildings and hydro-electric power plants contain structural components and foundations with massive concrete sections. The heat of hydration either dissipates from these concrete sections slowly or is not dissipated locally due to the greater thickness of concrete and its low thermal conductivity . This leThere are several ways to control the heat of hydration of concrete. These include cooling the mixing water, cooling the aggregate, using ASTM Type II moderate heat cement or Type IV low-heat cement, keeping cement contents to a minimum level, using supplementary cementitious materials (SCMs), and choosing proper curing methods . Among tTraditionally, SL, which is an amorphous calcium aluminosilicate material, has been considered to exhibit both pozzolanic and latent hydraulic activity . ReactivIt is generally accepted that the use of SL decreases the maximum temperature rise of the concrete. Previous studies have shown that total heat of hydration in isothermal conditions decreases as the SL replacement level increases ,25. The Moreover, the measurements of the heat of hydration in previous research were mostly conducted using either cumulative heat release data under ambient isothermal conditions or semi-adiabatic testing, and not using true adiabatic calorimetry. Tänzer et al.  and ÖzbaA very limited number of studies have utilized true adiabatic testing setups. De Schutter  utilizedThe purpose of this work is to determine whether SL is an effective material for temperature control of a large volume of concrete with lower w/b. For this purpose, the adiabatic temperature rise of concrete containing various SCMs was measured, and compared with the data from semi-adiabatic temperature rise. Isothermal calorimetry analyses were performed at two different temperature conditions (23 °C and 50 °C) in order to investigate the effect of temperature on reaction kinetics of the SCMs in cement paste. The 28-day compressive strength of each concrete cured in 23 °C lime saturated solution was also determined.Cementitious materials used in this study include ASTM Type I ordinary Portland cement (OPC) manufactured by Ssangyong Cement Industrial Co., Ltd. , Grade 80 Blast furnace slag , ASTM Class F fly ash, undensified silica fume, and metakaolin. Chemical compositions of all materials were analyzed using Shimadzu X-ray Fluorescence spectroscopy XRF-1700 . The densities of the materials were measured by Micromeritics AccuPyc II 1340 pycnometer . 3S), dicalcium silicate (C2S), tricalcium aluminate (C3A), and tetracalcium aluminoferrite (C4AF), were identified in the diffraction pattern. Two types of calcium sulfate polymorphs, gypsum and hemihydrate, and periclase were also observed. Blast furnace slag consists of amorphous calcium aluminosilicate and anhydrite. Fly ash contains quartz and mullite and an amorphous band at lower diffraction angles, which is a typical characteristic of low calcium fly ash [Mineralogical analyses of all materials were also performed using Rigaku Ultima IV X-ray diffractometer  with Cu-Kα radiation. Working voltage and current were set to 40 kV and 40 mA, respectively. The scanning 2θ angle was varied from 5° to 70°. The results are shown in  fly ash . Silica Mixture proportions of the concrete used for this work are shown in While the replacement level of SF, MK, and FA was fixed at 20%, two replacement levels (20 and 40%) of SL were investigated. A polycarboxylate-based water reducing admixture (0.2 liquid wt.% of cement) was used to maintain proper workability of concrete . The polycarboxylate admixture was added along with the mixing water. Before mixing, all materials were preconditioned in a laboratory with constant temperature (23 ± 0.5 °C) for a day to minimize temperature differences of each material.For mixing procedure, crushed sand and stone were dry-mixed for 2 min. Cement and SCM were added and dry-mixed for additional 3 min. Water was then added to the dry-mixture, and continuously wet-mixed for 5 min. After mixing, concrete was poured into the containers for adiabatic and semi-adiabatic calorimeter as well as for 10 cm × 20 cm cylindrical molds for the 28-day compressive strength test. Casting of concrete were done using placements of 3 equal layers with 25 times rodding on each layer, in addition to some vibrations using a rubber hammer.The temperature rise of the concrete was measured using an adiabatic calorimeter, Tokyo Riko ACM-120HA . The machine was designed to compensate the heat loss during the measurement, which was achieved by controlling the temperature of the specimen container to be the same as the temperature at the center of the specimen. The schematic diagram for the adiabatic calorimeter setup is shown in Prior to the experiment, the adiabatic calorimeter was stabilized at 20 °C. Four liters of freshly mixed concrete were poured into the container, which was located inside the thermostat. A type T thermocouple was located at the center of the concrete specimen. The temperature rise was measured every 5 min for first the 24 h after the start of measurement and then subsequently was measured every 10 min. The ambient temperature of the laboratory was maintained at 23 ± 0.5 °C.A semi-adiabatic temperature rise measurement was performed for comparison with results from the adiabatic temperature measurement. A custom-made experimental set-up was used. Isothermal calorimetry was used to determine the effect of the SCMs on the hydration of the cement paste. In order to isolate the effect of the SCMs, testing was conducted with cement paste samples similar to This was performed using samples from isothermal calorimetry measurement using a thermogravimetric analyzer . After 7 days of isothermal calorimetry measurement, samples were taken out of the ampoule without stopping the hydration and then ground using mortar and pestle. Approximately 30–40 mg of the sample was placed in the crucible and tested. The temperature was ramped at the rate of 10 °C/min to 1000 °C to quantify the amount of calcium hydroxide that is present in the cement paste mixtures. The calcium hydroxide content was determined based on its mass loss from 380 °C to 460 °C by using the modified tangential method in which the mass loss is evaluated by using the vertical distance between two tangential lines drawn to the mass loss curve . To miniThe 28-day compressive strength of concrete was measured to quantify the effect of SCMs on mechanical properties. After mixing, fresh concrete was poured into 100 mm × 200 mm cylindrical mold to fill 1/3 of its volume. The concrete was rodded 25 times and the mold was vibrated using a rubber hammer. This procedure was repeated until the cylindrical mold was completely filled with concrete. The top of the container was covered with plastic wrap and stored for 24 h. The concrete was demolded after 24-h and immersed in a saturated calcium hydroxide solution at 23 ± 0.5 °C for 27 days. Compressive strength measurement followed ASTM C 39, maintaining the loading rate of 0.2 MPa/s.The adiabatic temperature rise of the concrete with various SCMs is presented in Isothermal calorimetry was performed to investigate the effect of temperature on the reaction kinetics. Isothermal calorimetry results of cementitious paste with various SCMs at 50 °C are shown in Cumulative heat release of cementitious pastes with various SCMs at 50 °C is shown in As these pastes did not use a superplasticizer, a full dispersion of the cement and SCMs is likely not achieved, which may explain the somewhat lower cumulative heat release of the pastes with SF and MK. However, it should be noted that these materials also showed lower maximum temperature in the adiabatic test. In addition, the filler effect, which increases cement degree of hydration in the presence of SCMs ,44, may The amounts of CH consumed by 20% and 40% SL at 23 °C were 2.92% (11.94%–9.02%) and 5.59% (11.94%–6.35%), respectively. The amounts of CH consumed by 20% and 40% SL at 50 °C were 5.81% (13.79%–7.98%) and 10.56% (13.79%–3.23%), respectively. The CH consumption almost doubled as the temperature increased from 23 °C to 50 °C, which is greater than the increase in the cumulative heat release as temperature increases. Since the amount of CH consumed is likely related to the degree of pozzolanic reaction, these results suggest that the pozzolanic reaction of SL is accelerated when curing temperature increases.As mentioned in the Introduction, SL is generally thought to reduce the heat of hydration of concrete, and thus has been used for such applications. However, the results from this work, contrary to some studies ,25,40, sTemperature rise in the core regions of mass concrete is likely to be similar to adiabatic test results , where S4, the slag may be activated at both temperatures. The CaSO4 increases the concentration of sulfate ions in the concrete with SL, which leads to the formation of ettringite at an early age [Temperature and heat analyses obtained from adiabatic calorimeter and isothermal calorimetry data indicate that the concrete with 20% SL replacement had slightly higher heat of hydration than plain concrete at 23 °C and 50 °C. As the SL used in this study contains CaSOarly age ,47. As t4. Then, the effect of calcium sulfate on adiabatic temperature rise of concrete may be evaluated. The effect caused by the amount and type of calcium sulfate  in SL as well as the effect of various pretreatment of SL will also need to be investigated. Moreover, various replacement levels of SL up to 80% should be investigated because generally 65 to 80% is considered as an optimum SL replacement range for mass concrete applications. Such experiments can confirm the findings obtained from this study.In order to conclusively demonstrate some of the above hypotheses, it is necessary to run a series of experiments using SL without CaSOAccording to the results shown in this work, the following conclusions can be drawn. (1)In semi-adiabatic conditions, concrete with SL showed a reduction in the maximum temperature compared to plain concrete. However, in true adiabatic conditions, concrete with SL showed slightly higher maximum temperature than that of plain concrete. This difference is important as it may potentially lead to cracking in mass concrete structures.(2)Cement paste with SL showed greater heat release at ambient temperature (23 °C) and elevated temperature (50 °C) compared to the cement pastes with other SCMs. Temperature enhances both hydration of the cement and pozzolanic reaction of the SCMs.(3)The increased amount of CH consumption in cement paste with SL at the elevated temperature (50 °C) suggests that pozzolanic activity of SL is enhanced at 50 °C.(4)The use of SL (up to 40%) may not help the reduction of the heat of hydration in a large volume of concrete (mass concrete).


Objective: The aim of this study was to describe and characterize the prescription of antibiotics for urinary tract infection (UTI) in general practice in Denmark and to evaluate compliance with current recommendations.Design: National registry-based studySetting: Danish general practicePatients: 267.539 patients who redeemed a prescription for antibiotics with the clinical indication UTI at community pharmacies between July 1st 2012 and June 31st 2013.Main outcome measures: Antibiotics prescribed for 1) acute lower UTI, 2) acute upper UTI and 3) recurrent UTI presented as amount of prescriptions, number of treatments per 1000 inhabitants per day (TID) and defined daily doses per 1000 inhabitants per day (DID).Results: A total of 507.532 prescriptions were issued to 267.539 patients during the one year study period, representing 2.35 DID. Acute lower UTI was the most common reason for prescription of antibiotics (89.5%) followed by recurrent UTI (8.4%). The majority of the prescriptions were issued to people above 60 year old (57.6%). Pivmecillinam was the most commonly prescribed antibiotic in acute lower (45.8%) and acute upper (63.3%) UTI. Trimethroprim was the most commonly prescribed antibiotic in recurrent UTI (45.9%). Prescription of quinolones increased with increasing patient-age (p = <.0001).Conclusion: Compliance with current Danish recommendations was moderately high. Pivmecillinam is the first line antibiotic for the management of acute lower and upper UTI, and trimethroprim is the first line option of recurrent UTI. A high proportion of the antibiotic prescriptions were issued in the elderly population including a relatively high prescription rate of quinolones.Urinary tract infection (UTI) is a common cause for prescription of antibiotics in general practicePoor compliance in general practice with recommendations for first-line treatment of UTI may increase antibiotic resistanceDanish general practitioners are generally compliant with national and regional guidelines for antibiotic treatment of UTIThere is high use of antibiotics in the elderly population including a worrisome high use of broad-spectrum antibiotics, such as Quinolones. Urinary tract infection (UTI) is a common condition in primary care and the associated costs are significant to the patient as well as society ,2. UTI iIn order to improve the use of antibiotics, the prescription of antibiotics for specific conditions must be continuously monitored to effectively implement antimicrobial stewardship programmes. Such antibiotic surveillance systems can provide important sources of information for healthcare professionals and policy makers monitoring progress towards a more prudent use of antibiotics, in turn ensuring adequate patient treatment, and limiting spread of antibiotic resistance ,9.E. Coli isolates from primary health care was 6% for mecillinam, 40% for ampicillin and 33% for sulfonamide [In Denmark, no official national guideline regarding treatment of UTI exists. Doctors are expected to stay updated with regional guidelines and with national recommendations from The Institute for Rational Pharmacotherapy (IRF), a unit under the Danish National Board of Health. The available recommendation from three regions and from IRF can be seen in fonamide .st July 2012 to 31st June 2013, and to evaluate the accordance of issued antibiotic prescriptions with current national and regional guidelines.The aim of this study was to describe and characterize the prescription of antibiotics for urinary tract infections treated in general practice in Denmark between1st 2012 to June 31st 2013 [In Denmark, antibiotics are only available by prescription, and dispensing in the primary care sector is exclusively managed by community pharmacies. We created a database including all Danish citizens who redeemed an antibiotic prescription  at a community pharmacy between July 11st 2013 .33. This registry contains complete information on all prescriptions redeemed by Danish residents at community pharmacies. For each redeemed prescription, the registry contains information on the following variables relevant to this study: provider practice identification number (encrypted), personal security number for each patient (encrypted), type of antibiotic, age, gender and clinical indication.National data on prescription of antibiotic therapy in Denmark was extracted from the Danish National Prescription DatabaseIn primary care, a clinical indication must be entered when prescribing an antibiotic in the electronic prescription system. An option to use the unspecific indication “Infection” is available for all antibiotic types and lastly the general practitioner (GP) may choose to enter a free text indication. Presently these free text indications are automatically coded as “missing” in the electronic prescription system. The available clinical indications are not formally validated such as International Classification of Primary Care (ICPC)-2 codes . We haveth level; chemical substance34.Antibiotic agents were classified according to the Anatomical Therapeutic Chemical (ATC) index , down to 532. All information on patient and prescriber level was encrypted, and to protect against secondary identification, all variables with cell counts less than 6 patients were grouped as “few”.General practice providers were identified by the unique identifiers for general practitioners (GPs) (encrypted), obtained from Statens Serum Institute, to distinguish GP prescriptions from the entire primary care sectorStatistikbanken.dk, a service from the Statistics Danmark, was used to determine population size in total.A dataset consisting of clinical indications and antibiotic prescriptions, issued exclusively by GPs, was created by merging datasets by the unique practice identification numbers .The clinical indications for UTI were grouped and analyzed as acute lower UTI, acute upper UTI and recurrent UTI (including preventive treatment for UTI). Descriptive analyses of prescription of antibiotics were performed such as percentages, cumulated percentages and number of treatments (TID) per 1000 inhabitants per day and Defined Daily Doses (DDD) per 1000 inhabitants per day (DID). DID was calculated as follows: DDD*1000/number of inhabitants (2012)/365. There were 5,580,516 inhabitants by 31st December, 2012.Association between age group and type of antibiotic was assessed with the Chi-Square statistic test.In addition, compliance with current recommendations was assessed by comparing regional and national guidelines as illustrated in All calculations were done in SAS version 9.3 .st of July 2012 to 31st of June 2013. Women accounted for the majority of the prescriptions . Elderly patients were more exposed to antibiotics with 57.6% of the prescriptions  issued to people above 60 years of age, and this exposure increased with more advanced age. Acute lower UTI was the most common indication for prescribing antibiotics . Upper UTI e.g. pyelonephritis was a relatively uncommon clinical indication . Recurrent UTI accounted for 8.4% of prescriptions but 19.6% of DID. See A total of 507.532 prescriptions (2.35 DID) were issued in general practice to 267.539 patients with the indication UTI from 1Pivmecillinam was the most common antibiotic prescribed for acute lower (45.8% of the prescriptions) and upper (63.4% of the prescriptions) UTI. Sulfonamide was the second most common choice in patients with acute lower UTI (27% of the prescriptions), while quinolones were the second most common choice for acute upper UTI (19.7% of the prescriptions). The two most common antibiotics prescribed for recurrent UTI were trimethroprim (45.9% of the prescriptions) and nitrofurantoin (28.8% of the prescriptions) .p = <.0001).Pivmecillinam and sulfonamide were the most commonly prescribed antibiotics in all age groups . The preThe clinical indication “recurrent UTI” was responsible for a larger percentage 19.6% of total DID. The majority of DID (86%) were prescribed for patients who were 60 years or older. nitrofurantoine and trimethroprim accounted for the majority of DID in all age groups, but methenamin was also commonly prescribed for recurrent UTI .This study on 507.532 prescriptions issued to patients with the clinical indication UTI in general practice showed that the most commonly prescribed antibiotics for acute lower UTI were sulfamethizole and pivmecillinam. Pivmeciilinam was also the most commonly prescribed antibiotic for acute upper UTI, while for recurrent UTI, nitrofurantoine and trimethroprim were the preferred choice of antibiotics. This was in accordance with Regional and National guidelines. However, the prescription of quinolones increased with increasing age. Methenamin was commonly used for chronic UTI, although not included in the guidelines. Acute UTI accounted for the majority of issued prescriptions but prevention of recurrent UTI accounted for a substantial amount of DID.Using a national registry-based cohort involving all prescriptions with the clinical indication UTI was an appropriate design to characterize UTI prescriptions. The data are quite likely to reflect the actual use as all data was routinely collected by electronic data capture from all GPs in Denmark. Furthermore, the amount of non-prescribed antibiotic use was negligible as antibiotics are prescription-only drugs an all redeemed prescriptions are included in the data.Of note, it was not mandatory at the time the data for this study was obtained, to assign a precise indication when issuing an antibiotic prescription . First-lAnother weakness of our study is the lack of an officially recognized guideline for treatment of UTI in general practice. Nonetheless, the available guidelines were in relatively good accordance since all of them recommended using pivmecillinam in most cases of acute UTI. However, sulfamethizole remained the drug of choice in the Northern region of Denmark. Recommendations for prevention of acute UTI were not completely consistent either. The two guidelines that mentioned this indication both recommended trimethroprim, but one still recommended nitrofurantoine as the alternative choice and the other recommended pivmecillinam. Also, we were unable to determine if antibiotics treatment was appropriate due to the lack of clinical data in the database. Methenamine was used quite extensively for prevention of UTI in the elderly despite no guidelines mentioning this drug. Little research exists on the use of methenamine for prevention of UTI, but a Cochrane review has shown promising results . The useKobayashi et al performed a database study on outpatient visits regarding UTI from 2002 to 2011 and found that out of 7111 visits, about 80% were treated with antibiotics and almost half of this use was flouroquinolones . The secThe other Nordic countries have different recommendations for prescription of antibiotics for UTI. This may affect both total consumption of antibiotics and resistance rates .The prescription of antibiotics to the elderly population in our study was relatively high. Furthermore, a higher level of second-line agents were used in this patient group. We do not have sufficient clinical data to assess if this antibiotic pattern of use was appropriate, but it is an area that should call for concern. We find it unlikely that the observed steep increase in antibiotic use for UTI with increasing age reflects a correspondingly steep increase in the incidence of UTI with age. Broad-spectrum agents were more often used in the elderly population as well. This may reflect treatment-failure or antibiotic resistance, but it could also be caused by the difficulty in determining the site of infection in an elderly deranged patient, causing doctors to prescribe more broad-spectrum to cover a possible respiratory focus as well ,27. AlsoDanish GPs were generally compliant with national and regional guidelines when prescribing antibiotics for patients with suspected UTI. However, increasing use of broad-spectrum agents with increasing age including a relatively high prescription rate of quinolones should cause concern. Also, extensive use of antibiotics for prevention of UTI in the elderly population could introduce high resistance-rates in nursing-homes and antibiotic-related adverse outcomes in the elderly population . Future


Acute respiratory tract infections (RTI) in children are a common reason for antibiotic prescribing. Clinicians’ prescribing decisions are influenced by perceived parental expectations for antibiotics, however there is evidence that parents actually prefer to avoid antibiotics. This study aimed to investigate the influence of parent-clinician communication on antibiotic prescribing for RTI in children in England.A mixed methods analysis of videoed primary care consultations for children (under 12 years) with acute cough and RTI. Consultations were video-recorded in six general practices in southern England, selected for socio-economic diversity. 56 recordings were transcribed in detail and a subset of recordings and transcripts used to develop a comprehensive interaction-based coding scheme. The scheme was used to examine communication practices between parents and clinicians and how these related to antibiotic or non-antibiotic treatment strategies.Parents’ communication rarely implied an expectation for antibiotics, some explicitly offering a possible viral diagnosis. Clinicians mostly gave, or implied, a viral diagnosis and mainly recommended non-antibiotic treatment strategies. In the minority of cases where parents’ communication behaviours implied they may be seeking antibiotic treatment, antibiotics were not usually prescribed. Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink /bulging ear drums.We found little evidence of a relationship between parents’ communication behaviours and antibiotic prescribing. Rather, where antibiotics were prescribed, this was associated with clinicians’ expressed concerns regarding symptoms and signs. High rates of antibiotic prescribing have led to increased antimicrobial resistance (AMR) , 2 and hAnother key influence on whether antibiotics are prescribed is communication between clinicians and patients or carers , 14. We Studies that found an association between antibiotic prescribing and clinician perception of parental expectations, also showed parents’ actual expectations of antibiotic treatment were not predictive of antibiotic prescribing . When paOur systematic review found few studies examining the relationship between parent-clinician communication and antibiotic prescribing, with none in a UK context and most undertaken over a decade ago . In the Our study aims to build on this earlier work by examining whether these same parental communication patterns can be found in primary care consultations for children with RTI in the UK, and whether they are associated with antibiotic prescribing.The data consisted of primary care consultations for children with RTI that were recorded between May and December 2013. These recordings were made for a previous study and the data collection methods are described in detail elsewhere . The preOur mixed methods CA approach combined qualitative CA-grounded coding of the recorded consultations with subsequent descriptive quantitative analysis , 27. In A first version of the coding scheme was then drafted for testing. The scheme included a codebook with definitions of the codes, coding criteria and clear exemplars. Further focused meetings were then held to test these codes across the original subsample. Consequently, codes were refined or dropped and/or new codes were identified. A randomly selected further 15% subsample were then independently double coded by JS and RB and further amendments and revisions made based on discussions between JS, RB and CC. In the same way, a second and third 15% subsample were independently coded until consensus was reached on the coding scheme. This Four of these types were identified by previous checking and redefining the communication phenomena captured by the code labels ensured a robust coding framework. One researcher (JS) then applied this coding scheme to the whole data set. The frequencies of coded communication behaviours were then examined across the dataset and in relation to treatment recommendations.This paper reports on the distribution of codes for parent problem presentation, diagnoses delivered, and treatments recommended by clinicians and the relationship between these.The 56 video-recorded consultations were for 60 children with RTI , 78% of children were under 5 years and 67% were male Table . The samFive different types of problem presentation by parents were identified and coded Table . Four ofA viral diagnosis was the most common and delivered explicitly using the term “virus” or “viral” in 37 (66%) consultations and implied in a further nine (16%) consultations by terms like “cold’” or described as an unproblematic illness  cases, parents acknowledged the clinicians’ primary treatment recommendation by either nodding or saying just one or two words; in three cases (5%) parents actively accepted the recommendation; in six cases (11%) parents displayed active ‘interactional resistance’; and in the remaining four (7%) cases there was no clear response to the treatment recommendation Table . After rIn the six cases where parents displayed active ‘interactional resistance’, parental responses to the treatment recommendation came in the form of a question. In one case the parent (P13) was responding to a ‘no-antibiotic’ treatment recommendation; in one case the parent (P19) was responding to a recommendation for antibiotic treatment; and in the remaining four cases, parents responding to home care recommendations. In the one case of ‘interactional resistance’ to a ‘no-antibiotic’ treatment recommendation, the parent questioned what to do after the recommended five-day watch and wait period and informed the GP that accessing same day appointments was difficult; a delayed prescription was subsequently issued for use if needed after 5 days , it was similar to the Finnish study (n = 70) and our study population was more diverse than previous studies, which drew patients from predominantly mid to high income populations. This sample provides for a robust qualitative and descriptive analysis but limited the inferential statistical analysis possible. We recruited a diverse range of families from deprived and affluent neighbourhoods and included a large proportion of non-White British ethnicities, although few Asian. In five of the six practices, clinicians had no influence over which consultations were recorded. One practice triaged all patients requesting same day appointments and, while clinician selection cannot be ruled out, these 10 consultations had similar characteristics to the others. The use of oral steroids in 12 cases implies a significant proportion had a relatively severe illness and we captured a representative range of cases. Clinicians with a range of professional experience were recruited, although, since they had to ‘opt-in’ to the study, participating clinicians may differ from those who did not take part.This was the first study in the UK to use videos of real consultations to explore associations between parental communication and antibiotic prescribing for children with RTIs. Although our study was smaller than previous work in the US (Antibiotic prescribing for children with RTI appears to be influenced mainly by clinicians’ reported interpretation of the symptoms and signs, rather than parental communication behaviours. Parental communication behaviours indicating that they may be seeking antibiotics appeared in few consultations and there was no clear relationship between parental communication behaviours and antibiotic prescribing. If antibiotic prescribing for RTI in children is to be improved, then interventions need a broader focus to include issues that may play a larger role, such as clinical uncertainty, safety concerns and external pressures on clinicians , 10, 35.


MAT2A, AHcy, CBS, MTHFR, and MTR in the DL-HMTBA group were significantly higher than those in other Met source groups. Further study showed that the total content of extracellular Met sources was highest in the DL-HMTBA group, followed by DL-MM group, followed by L-Met and DL-Met groups. These results demonstrated that DL-HMTBA mainly affects the transmethylation and remethylation of Met and it can promote the trans-sulfur metabolism of Met when compared with other Met sources. In addition, most DL-HMTBA and a small amount of DL-MM can escape the intestinal first-pass metabolism and then provide more extracellular Met sources than L-Met and DL-Met. Therefore, this study can provide a theoretical basis for the selection of Met sources in livestock.As one of the essential amino acids, methionine (Met) plays an important role in biological events such as methylation and antioxidant properties besides its function in protein synthesis. Different Met sources have been used in animal production, but their effects on Met metabolic pathways are not well understood. In the present study, we investigated the effects of different Met sources butanoic acid (DL-HMTBA), and DL-methionyl-DL-methionine (DL-MM)) on the metabolism of Met in small intestinal porcine epithelial cell line (IPEC-J2) and the contents of extracellular Met sources. The results showed that concentrations of intracellular Met, S-adenosylmethionine (SAM), S-adenosylhomocysteine (SAH), and the ratio of SAM to SAH in the DL-HMTBA group were significantly lower than that in other Met source groups, while the content of 5-methyltetrahydrofolate (5-MTHF) was significantly higher. Moreover, the mRNA levels of Methionine (Met) is the only sulfur-containing essential amino acid, which plays an important role in the normal growth of animals, such as poultry, monogastric animals, and ruminants –3. SynthStudies have shown that different Met sources are different in the intestinal first-pass metabolism. It has been found that only 48% of dietary Met intake was absorbed into the portal blood of piglets . Fang et2 (40%), or tissue protein (29%) [Researches showed that Met used by the gastrointestinal tissues was metabolized into homocysteine (31%), COin (29%) . In addiin (29%) . In animin (29%) ; SAM is in (29%) . The ratin (29%) . Furtherin (29%) . In the in (29%) . Cys canin (29%) . In addiin (29%) . In the in (29%) , 20.It is known that the first-pass intestinal metabolism of Met and DL-HMTBA is subsistent. However, it is unclear whether DL-MM can be provided to parenteral tissues in the form of a complete dipeptide. The metabolism of Met is associated with many important physiological functions; studies have shown that different Met sources (DL-Met and DL-HMTBA) can affect the gene expression of key enzyme in Met metabolism, but whether different Met sources affect the content of corresponding metabolic pathway products is unknown. So, it is necessary to study the effects of different Met sources on the generation of Met metabolites in intestinal metabolism.The small intestinal porcine epithelial cell line (IPEC-J2) is a nontransformed, nontumorigenic small intestinal cell line, which conserves its epithelial nature and maintains its differentiated characteristics and exhibits strong similarities to primary intestinal epithelial cells . TherefoMet, SAM, SAH, MTA, Hcy, Cysta, Cys, GSH, 5-MTHF, VB6, VB9, VB12, LC-MS-grade acetonitrile (ACN), LC-grade methanol (MeOH), formic acid, ascorbic acid, sodium hydroxide (NaOH) 0.1 M, hydrochloric acid (HCl), ammonium acetate (NH4OAc), tris-(2-carboxyethyl)phosphine (TCEP), L-Met, and DL-Met were purchased from Sigma-Aldrich . DL-HMTBA was purchased from Macklin . DL-MM was purchased from Taopu . Homocystine-d8 was purchased from CDN Isotopes . Ultrapure water was obtained from a Millipore-Q water system . Dulbecco's modified Eagle's medium and Ham's F-12 nutrient mixture (DMEM/F12), RPMI-1640 medium, fetal bovine serum (FBS), and penicillin–streptomycin were purchased from Gibco .μg/ml), insulin (10 μg/ml), and penicillin–streptomycin (100IU/ml) at 37°C in 5% CO2-humidified chamber. Medium were refreshed every 24 h.Liver cells were prepared from 7-day-old male pigs, weighing 2.6 kg. The piglet was obtained from the University's breeding farm and killed by an iv injection with pentobarbital-sodium (150 mg/kg body weight). Liver cell preparation was performed with slight modification of the 2-step collagenase perfusion technique originally described by Seglen . Cells w2-humidified chamber. The medium was changed every 2 days. Cells were cultured in serum-free medium for 18 h and then in Met-free medium for 6 h and finally treated with different Met source in the medium for 2 h.IPEC-J2 cell line was a kind gift from Dr. He Qigai . Cells were used between passages 70 and 90. The cells were grown in the DMEM/F12 containing 10% FBS and penicillin–streptomycin (100IU/ml) at 37°C in 5% CO2; membrane pore size 0.4 μm). Briefly, 3 × 105 IPEC-J2 cells in 1.5 mL medium were seeded in the apical chamber that bathed in the basal chamber with 2.6 mL of medium. The changes of transepithelial electrical resistance (TEER) were measured with a Millicell-ERS instrument . Values were corrected for background resistance contributed by the insert membrane and calculated as Ω · cm2.IPEC-J2 cells was seeded onto six-well Transwell system plates  and incubated for 21 d to obtain an integrated cell monolayer. The culture plate inserts consist of two chambers separated by a polycarbonate membrane (growth surface area 4.67 cmμg RNA was used to prepare cDNA using oligo(dT)12-18 as a primer, the cDNA was diluted into 20 times for real-time quantitative PCR (q-PCR), and the samples were run in 10 μL reaction system with SYBR GREEN qPCR mix . Relative mRNA levels of genes were quantified by using a Bio-Rad CFX Connect™ Real-Time PCR Detection System . Following that, gene expression levels were calculated after its normalization to the standard housekeeping gene β-actin using ΔΔCT method. Finally, the mean of the triplicate cycle thresholds (CT) of the target gene was normalized to the mean of triplicate CT of the reference β-actin using the calculation formula “2CTβ-actin −CTtarget  gene” indicating a relative value as a fraction of the target gene. The following primers  according to the manufacturer's instructions and followed by DNase digestion using a DNA-free kit  according to the manufacturer's instructions. A total of 2 shown in  were synμL of cell lysate was transferred to a vial containing 800 μL methanol + 1% FA and vortexed for 10 s and then stored at −20°C for 2 h. The sample was centrifuged at 13000 rpm for 10 min at 4°C and the supernatants were pipetted and filtered through a 0.22-μm filter and placed into vials for LC-MS/MS analysis. The LC-MS/MS analysis was performed using a LCMS-8050 triple quadrupole mass spectrometer  equipped with an LC-30AD system  and SIL-30AD autosampler . Chromatographic separation was performed using gradient elution on a reversed-phase UPLC XSelect HSS T3 1.8 μm, 100 × 2.1 mm I.D. column . The mobile phases were as follows: A, 10 mM ammonium acetate in water and B, 20% (v/v) acetonitrile in methanol. The flow rate was 0.3 mL/min. The gradient employed was as follows: 0.01–1.5 min started at 5% B, 1.5–6 min from 5% to 50% B, 6–6.1 min from 50% to 95% B and hold for 2 min, and 8–9 min from 95% to 5% B and hold for 4 min. The total time was 13 min. The sample temperature in the autosampler was maintained at 4°C, and the injection volume was 1 μL in each run.Cells were lysed in 1 mL TCEP solution and then incubated for 10 min at laboratory temperature and sonicated for 2 × 1 min in a pulse mode. 200 P value < 0.05 and statistically extremely significant at P value < 0.01.All data plots were performed using GraphPad Prism 5.0 . Data were presented as mean ± SEM. Differences between group means were determined by one-way ANOVA using SAS 8.0 software. It was considered statistically significant at Cells were incubated in medium lacking Met for 6 h and then treated with different Met sources for 2 h , D-2-hydroxyacid dehydrogenase (HADH), and hydroxyacid oxidase 1 (HAO1) [ DAO, HADH, and HAO1 in IPEC-J2 cells are significantly lower than those in primary hepatocytes of pigs  . The N-t1 (HAO1) –29. In t of pigs , which i MAT2A was increased in the Met starvation and DL-HMTBA groups, which is the gene encoding for an essential cellular enzyme responsible for SAM biosynthesis [ MAT2A in the Met starvation and DL-HMTBA groups. Beside, SAM is the substrate for transmethylation and aminopropyl transfer of Met. In this study, the intracellular concentrations of SAH, Hcy, and MTA and the ratio of SAM to SAH in the DL-HMTBA group were significantly lower than those in the other Met source groups and the concentration trend was consistent with the intracellular Met content, indicating that different Met sources could regulate the intracellular Met concentration and then affect the Met methylation metabolism.Shiraki et al.  demonstrynthesis . The conynthesis . The pos CBS and there was no significant difference in the mRNA level of CTH among each group. CBS is the gene encoding for an enzyme responsible for catalyzing Hcy to generate Cysta and CTH is responsible for generating Cys from Cysta. Therefore, it is suggested that the changes in gene expression of CBS and CTH may lead to no significant difference in intracellular contents of Cys or GSH in each Met source group. This may be due to the fact that DL-HMTBA has a tendency to promote the trans-sulfur reaction compared with other Met sources to ensure the content of these important substances such as Cys and GSH. Studies have shown that, in comparison to L-Met, DL-HMTBA is preferentially diverted to the transsulfuration pathway, thus leading to a higher mucosal content of Tau in chicken small intestine [In the trans-sulfur reaction of Met, the content of cysta in each treatment group showed the same trend as that of Hcy, which is the substrate of trans-sulfur reaction. However, in the DL-HMTBA group, the concentrations of Cys and GSH, which are the further metabolites of Cysta, were not significantly different from that in other Met source groups. Further studies have found that DL-HMTBA can significantly increase the mRNA level ofntestine . When fentestine , 35. In ntestine  reported MTHFR and MTR in the Met starvation and DL-HMTBA groups were significantly higher than those in other groups, while there was no significant difference among the other three groups. This may be due to the fact that the intracellular Met contents of these two groups were significantly lower than that of the other groups, while the difference of Met content in the other three groups was small. In order to maintain the cell demand for Met, the remethylation of Met in IPEC-J2 cells was increased.In the remethylation process of Met, the concentrations of 5-MTHF in the Met starvation and DL-HMTBA groups were significantly higher than that in the other groups. Correspondingly, the mRNA levels ofIn terms of the contents of Met metabolites and the mRNA levels of metabolic enzymes, DL-HMTBA was significantly different from L-Met, DL-Met, and DL-MM, and there was no significant difference among those three Met sources. These metabolic differences may be caused by the effects of DL-HMTBA on the expression of genes related Met conversion and metabolism. In this study, the ratio of SAM to SAH in the DL-HMTBA group was significantly lower than that of other Met sources, and the ratio of SAM to SAH is an indication of methylation capacity . ChangesIn conclusion, different Met sources are metabolized differently in the IPEC-J2 cells. Compared with L-Met, DL-Met and DL-MM have the same effect on the contents of Met metabolites and the levels of mRNA expression of metabolic enzymes. However, in the DL-HMTBA group, the contents of intracellular Met and methylation related metabolites were lower; at the same time, the ratio of SAM to SAH was significantly lower than that of the other Met source groups, while different Met sources had no significant effect on the contents of Cys and GSH, suggesting that DL-HMTBA can improve the trans-sulfur metabolism of Met to ensure the production of important antioxidants even though it did not generate Met very well. The total content of extracellular Met sources provided by different Met sources was DL-HMTBA > DL-MM > L-Met and DL-Met, respectively. Among them, DL-HMTBA mainly provided the Met sources to the parenteral tissue in the form of DL-HMTBA and DL-MM could be provided in the form of DL-MM and free Met. This study provides novel insights into selection of Met sources in livestock and poultry production.


In the present paper, different types of concrete made by cement substitution with different type of slags have been studied in order to evaluate the properties of these materials. Cement is replaced by slag from different steel mills, both blast furnace and ladle furnace slag. The percentages of slag substitution by cement are 30%, 40% and 50% by weight. Mechanical, physical and environmental properties have been evaluated. Compressive and flexural strength have been analysed as the main mechanical properties. As far as physical properties go, density and porosity tests were be reported and analysed, and from an environmental point of view, a leachate study was performed. It has been found that some kinds of slag (blast furnace slag) are very suitable as substitutes for cement, providing properties above those of the reference concrete, while other types (ladle furnace slag) could be valid for non-structural applications, contributing in both cases to a circular economy.A circular economy is a current tenet that must be implemented in the field of construction. That would imply the study of the possibilities of the use of waste generated, for obtaining materials the used in construction as replacements for the raw material used. One of these possibilities is the substitution of the cement by slag, which contributes to the reduction of cement consumption, decreasing CO A circular economy is a currently accepted tenet, in which the traditional linear economy is transformed into a circular economy, where every activity is conceived as a cycle, where waste materials are considered as potential new resources, instead of by-products to discard.In the field of construction, the challenge is to exploit the possibilities of the waste generated in the building industry as raw materials to be integrated in the same construction cycle. One of the fields where this strategy is feasible is the incorporation of the slag generated during the steel production into concrete production. It has been used in many processes in the cement production and paving industries. It is interesting to focus attention on this problem and to study, thoroughly, all the possibilities that the steel by-product presents. 2 emissions needed for its production. The substitution of the cement by slag provides two clear advantages; the first one is the use of a waste that must be managed in a landfill, and the second one, even more relevant, is the reduction in cement consumption, so the reduction of CONowadays, there is already a lot of research that supports the adequacy of steel slag for the production of cementitious matrices ,3,4,5,6.There are also some studies on the substitutions of cement by ground granulated blast furnace slag (GGBFS) ,18,19,20Less attention has been paid to the substitution of cement by ladle furnace slag (LFS). In previous works, different types of slag have been studied and compared, with a maximum amount of 25% of cement replaced . These sIn this paper, different types of concrete have been elaborated on, in which the cement is replaced by slag from different steel mills, both blast furnace and ladle furnace slag.2. In this work, we will focus on the relationship between the amount of this component in each slag and the mechanical properties. The percentages of slag substitution by cement were 30%, 40% and 50% by weight. The substitution of cement was made in each mix by types of slag from different factories in Spain. According to different studies, it is known that the component with the highest influence over the durability of cementitious mixtures is SiOCompressive and flexural strength were analysed as the main mechanical properties, making a comparison between all of them to evaluate which one provides the best characteristics. Additionally, some of the physical and environmental properties evaluated were included in the present paper. For physical properties, density and porosity test were reported and analysed. For a sake of brevity, other tests made are omitted. From an environmental point of view, a leachate study of the material was carried out, since it was essential, considering that waste material was being put into service. The paper is structured as follows. In ➢Slag 1 (GGBFS): Granulated blast furnace slag ground in ball mill.➢Slag 2 (LFS1): Ladle furnace slag (LFS).➢Slag 3 (LFS2): Ladle furnace slag (LFS).In this work, a 52.5 R Portland cement (PC) is used; this cement was chosen as it is free of any additives; that is to say, composed of clinker between 95%–100% and between 0%–5% of minor components, without other additives that change their composition. The substitutions were made for the different types of slag that are shown below:LFS1 and LFS2 are ladle furnace slag with different origins and composition. Slag 1 (GGBFS) has a particle size <0.063 μm provided by the company, while the LFSs were sieved in the laboratory to obtain equal granulometry from them. This is an important fact to keep in mind, since it would be interesting to see what would happen if the LFS slags were also treated in the same way as the GGBFS, but the companies that provided us with that type of slag did not have the technology to do so. Therefore, it was decided to carry out the study with screened slags to study its results.Three different concrete mixes were designed by substituting 30%, 40% and 50% of the weight of the cement with slag obtained from three different steel mills in Spain.The most characteristic chemical values of these slags are shown in 2, Al2O3) of each of the slags are transcribed on a ternary diagram : Ordinary concrete without slag.Mix 2 (MGGBFS): Concrete with 30%, 40% or 50% cement replaced with processed slag.Mix 3 (MLFS1): Concrete with 30%, 40% or 50% cement replaced with unprocessed slag.Mix 4 (MLFS2): Concrete with 30%, 40% or 50% cement replaced with stainless steel slag.The different concrete mixtures were named as follows:Concrete mixes defined in the preceding section were subject to different tests. The main objective of these tests was to evaluate the effects on the mechanical characteristics , when cement is replaced by slag.Concrete was made with the proportions shown in The different mixture proportion was made according to the EN 12390-2 norm [The densities and porosities of the new materials were studied. They were obtained according to the EN 12390-7 norm .A cubic specimen of 10 cm of edge were used for this test. Two specimens for each type of concrete were tested. The determination of the parameters was made for concrete of more than 28 days of age.The formulation that was used to obtain the parameters is the following:Psum: Weight obtained by the hydrostatic balance (submerged weight), placing the specimen inside. This test piece must be completely saturated with waterPsss (saturated surface dry weight): Obtained by drying the surface water with a damp cloth.Ps (dry weight): It is obtained by drying the test pieces in the oven and checking every 24 hours that the mass loss is not less than 0.2%, at a temperature of 105 ± 5 °C. As indicated in the EN_12390-7 [The parameters are obtained in the following way:In order to obtain the compressive strength of the concrete specimens, we used cubes with edges of 10 cm and an automated press with a 2.000 kN capacity. The specimens were made according to the normative EN 12390-3  and EN 13, made of the same kneaded as for the rest of the trial. That parameter was calculated using the uniform application of centred load. The same type of curing as the compressive test specimens was applied. This test was performed at 28 and 90 days. The prismatic test specimen was subjected to a bending moment by applying a load through upper and lower rollers, registering the maximum applied load calculating the flexural strength by EN-12390-5 [For the flexural strength, tests prismatic specimens were used with dimensions 4 × 4 × 16 cm-12390-5  Finally, the mixtures are subjected to leachate tests. The cement substitution percentage chosen was 30% for every mixture. Additionally, we carried the test out using a 50% slag substitution percentage for GGBFS, since throughout the research, it showed similar behaviour to conventional concrete. Specimens were immersed in 1 litre of distilled water for 2 days. The treatment that was made to the water sample in the laboratory was to sieve the sample with a 0.45 µm filter, and acidify them to pH < 2. Once that process was done, it was introduced into the spectrometer.The results obtained for the physical (density and porosity), mechanical  and environmental (leachate) tests for each of the mixtures and their different substitutions are shown below, making a comparison between the percentages of loss and gains of strength, and the differences between the varieties.In the differently manufactured mixtures, it was observed  that theThe results of the porosity test are shown in the This property is tightly linked to the durability of the concrete. Taking as reference the PC mixture, for the mixtures with GGBFS, we see that it is practically constant for all the substitutions, even decreasing its porosity by 25% in the 50% substitution, with respect to conventional concrete. Regardless of the percentages of cement substitution, it was observed that the mixtures with slag LFS1 had a high porosity, since its porosity increased significantly. We saw in point In short, the GGBFS and LFS2 mixtures’ lower porosity means a better performance in the long run, as this makes it more difficult for external agents to lead to the deterioration of the material, which affects the steel frame, in the case of reinforced elements. The opposite occurs with the LFS1 mixtures; it has a higher porosity, which can lead to the material having a shorter shelf life thanks to external agents that can damage it.Results of mixtures for slag substitution.The results show that in the LFS1 slag there was a lesser strength for day one, but in this case the compressive strength decreased over time. The loss at 90 days with a 50% substitution of cement was of almost 70% of PC’s strength, as shown in With the slag LFS2, it was observed, as in the mixtures with slag LFS1, that there was a decrease of the strength both on day one, and over time. At 90 days and with a 50% replacement of cement, the loss was 40% .The results lead us to think that, for high percentage substitutions, specimens with ladle furnace slag (LFS) substitutions have a higher strength loss compared with conventional concrete than those with blast furnace slag (GGBFS) substitutions. Particularly, the mixtures with LFS1 substitutions showed the worst behaviour at compressive strength tests, obtaining up to a 70% of compressive strength loss, when the cement substitution percentage was 50%.In It is observed how GGBFS slag presents an increase in strength; it provides pozzolanic benefits to the mixture. On the contrary, what occurs in those made with LFS slags has already been observed by other researchers, like Manso ,31. In tWe can conclude that the blast furnace slag (GGBFS) is a good substitute for cement in terms of compressive strength. On the other hand, there is such a loss of strength on the other two ladle furnace slags , that rule out any possibility of using this concrete as structural material. Nevertheless, they could be acceptable, being able to withstand medium-environmental pressure for situations in which the strength needs are lesser.2, means better pozzolanic characteristics in the mixture, and in this case, it was observed that the mixtures with slag LFS1 were those that obtained the worst compressive strength, a cause not only of the greater porosity, and therefore greater amount of voids that weaken the mixture, but the slag also contained less SiO2.Returning to the ternary diagram in A similar study has been made to evaluate the flexure strength. In this case, the results obtained for all the mixtures are shown in Following a similar trend to the previous section, the mixtures made with ladle furnace slag (LFS) obtained worse strength than the mixture without substitution. On the contrary, those made with blast furnace slag (GGBFS) were equal to and even improved the reference concrete.This loss or increase in strength was observed not only at 28 days, but also at 90 days . It alsoThe percentages of loss of flexure strength of each one of the cases are shown in The significance of this study is highlighted in the comparison of the gain or loss of the strength against flexure and compression combined. We will focus on that point in this section.In 2 into the environment.This indicates the feasibility of LFS slag in non-structural elements, valuing a waste as a by-product, reducing the production of cement that generates a large amount of COIn all the investigations where the laws of mechanical behaviour (constitutive models) for materials are established, outcomes are considered a representative volumetric element of the same. It is assumed that the material behaves as a continuous medium; that is, it has the same elastic properties at each point.The results obtained are shown in In general terms, it can be observed how most of the values obtained had a decrease in relation to conventional concrete. The most significant is to see how the amount of chromium in the mixtures with slag, compared with the conventional concrete mixture, decreased.It is significant how one of the most harmful elements in the leachate is chromium, and this element decreases with respect to the master mix. This is interpreted as the encapsulation of the slag being diluted into the cementitious matrix absorbing this metal, without generating any environmental danger when it is used.There are some values which are slightly above those obtained with the reference concrete (PC); however, all these leachate ranges fall within the values allowed by the Code of Federal Regulations (CFR) 40CFR/261.24. According to those maximum values the encapsulation of the slag in the concrete not only does not leach contaminant, but also reduces the leachate of one of the more dangerous components that are measured in the CFR—the Cr, not exceeding the limit of 5 mg/L. →The results lead us to think that, for high percentage substitutions, specimens with ladle furnace slag (LFS) substitutions have a higher strength loss compared with conventional concrete than those with blast furnace slag (GGBFS) substitutions. Particularly, the mixture with LFS1 slag substitutions showed the worst behaviour in compressive strength tests, obtaining up to a 72% of compressive strength loss with a cement substitution percentage of 50%.→On the other hand, specimens with blast furnace slag substitution showed an increase in compressive strength of 10% at 90 days. Mixtures using this type of slag substitution showed a slower hardening process, with a compressive strength reduction at day one, but gaining a compressive strength similar to or even above the conventional concrete after 7 days.→2, the lower the percentage, the lower the strength. As it can be seen in the mixes made with LFS1 and LFS2 slags, the lack of that compound makes them work worse. GGBFSs are the best performers, having twice the amount of that compound, increasing its strength even with respect to conventional concrete. The good pozzolanic activity that contributes to those types of cementitious mixtures was verified.The chemical characteristics of the slag influence the mixtures and strength. It was observed in this study, that for essential components such as SiO→Another characteristic result of this investigation is the difference of compressive and flexural strength among the different mixtures. LFS presents a loss of flexural strength that is the half of the loss of compressive strength. This suggests that they could be used in other fields of civil engineering with lower strength requirements.→Leaching test confirmed that slag does not cause damage to the environment. The results of the leaching tests of concrete mixtures with slag are similar to the results of traditional concrete. Therefore, slag encapsulation into the concrete seems to be a good strategy to manage this waste product, instead of it being deposited in landfills where it will pollute the environment by leaching.According to the results described, we can outline the following conclusions:As a final conclusion, it is clear that blast furnace slag (GGBFS) is suitable for the production of a sustainable concrete, and as a substitute for cement, since it has been proven to bring the same characteristics to the mixture as cement. For the other two types of mixtures with slag (LFS), a non-structural application would be suitable. This would put a value on the residue, avoiding the consumption of raw material and reducing the landfill deposit.Concrete production with slag is a clear example of circular economics, since the steel manufactured, necessary to build structures, generates waste that can be incorporated to the same building cycle.


The benefit of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for treating cancer of the esophagus or the gastroesophageal junction remains controversial. In the present study, we conducted a comprehensive meta-analysis to examine the efficacy of these two management strategies.http://tech.cochrane.org/revman/download). Weighted mean differences, risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration’s risk of bias tool was used to assess the risk of bias. In this comprehensive meta-analysis, we examined the efficiency of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for the treatment of cancer of the esophagus or the gastroesophageal junction as reported in qualified clinical trials.The MEDLINE (PubMed), SinoMed, Embase, and Cochrane Library databases were searched for eligible studies. We searched for the most relevant studies published until the end of September 2017. Data were extracted independently and were analyzed using RevMan statistical software version 5.3 . In terms of secondary outcomes, neoadjuvant chemoradiotherapy significantly increased the rate of R0 resection and pathological complete response as well . However, there were no significant differences in postoperative mortality between the two groups . For the results of postoperative complications, revealed that there was a statistically significant difference between the two groups in the incidence of postoperative complications such as pulmonary, anastomotic leak and cardiovascular complications. The subgroup analysis of patients with esophageal adenocarcinoma or squamous cell carcinoma showed that both esophageal adenocarcinoma and squamous cell carcinoma patients achieved a high rate of R0 resection  and pathological complete response benefit of neoadjuvant chemoradiotherapy .Our findings suggested that compared with neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy should be recommended with a significant long-term survival benefit in patients with cancer of the esophagus or the gastroesophageal junction. In view of the clinical heterogeneity, whether these conclusions are broadly applicable should be further determined. SimilarThe postoperative complications noted in the five included studies should be discussed. In our study, postoperative complications were based on patients undergoing esophageal resection. One study categorized the complications as surgical complications and nonsurgical complications, and provided a detailed definition . AnastomThe number of clinical studies directly comparing neoadjuvant chemotherapy with neoadjuvant chemoradiotherapy is very rare and limited. In 2017, a recently completed systematic review and network meta-analysis of neoadjuvant therapy combined with surgery for patients with resectable esophageal squamous cell carcinoma (ESCC) investigated the effect of the two groups indirectly, showing that neoadjuvant chemoradiotherapy might be the best choice for resectable ESCC because it could increase the radical resection rate and lower the occurrence of complications, thereby prolonging survival time . A studyTo our knowledge, this is an updated meta-analysis to compare the effects of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy interventions followed by surgery for cancer of the esophagus or gastroesophageal junction. However, many of the clinical trials enrolled small numbers of patients, and it is difficult to detect a treatment benefit through these meta-analyses, even if a benefit actually exists. After comprehensively searching the databases, we found six qualified RCTs with a total of 866 patients. With this larger sample size, we were able to perform both an overall analysis for cancer of the esophagus or gastroesophageal junction, perioperative mortality, and postoperative complications and separate subgroup analyses for esophageal adenocarcinoma and squamous cell carcinoma. Previous meta-analyses did not classify and provide detailed descriptions of the complications of the therapies. To date, this meta-analysis included the latest clinical trials, which are currently the direct comparison of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy with a relatively larger sample size and a wider distribution of patients and pathologic types. Moreover, in our analysis of the results, we clarified the postoperative complications into respiratory complications, cardiovascular complications and anastomotic leakage, which other studies lack. To evaluate possible sources of heterogeneity, we also performed a subgroup analysis of different histological types and performed a sensitivity analysis to assess the influence of each study on the overall pooled estimate.Certain limitations of our meta-analysis should be noted. First, the foremost limitation is the scarcity of high-quality, multicenter, large-sample standard RCTs with which to directly compare the two neoadjuvant strategies. Thus, more such trials are needed to verify the outcomes of this meta-analysis. Second, a significant statistical heterogeneity of the primary outcome of postoperative complications and pathological complete response in the squamous cell carcinoma subgroup among the included trials was observed, which may be explained by the clinical diversity among trials, the small subgroup sample sizes, differences in chemotherapy, chemoradiotherapy dose or surgical procedures in the included studies. Additionally, it is understandable that from an Eastern hemisphere perspective squasmous cell carcinoma is far more abundant than adenocarcinoma; it is the opposite in the Western hemisphere, and most of the clinical trials have been performed in the Western hemisphere. In the west, Barratt surveillance results in an abundance of high grade dysplagia, clinical stage 1, and inner stage 2 disease that uncommonly metastasizes to regional lymph noded, and thus has a good prognosis with ablative or surgical therapy without neoadjuvant therapy. These conditions may introduce a publication bias. Moreover, there is no uniformity of the description of the complications, and these trials seldom provided details of the randomized techniques and allocation concealment. These issues may produce selection bias and measurement bias, which may affect the results.In conclusion, neoadjuvant chemoradiotherapy was recommended with a long-term survival benefit in patients with esophagus or gastroesophageal junction cancer. Patients who underwent the treatment of neoadjuvant chemoradiotherapy could achieve a high rate of R0 resection and pathological complete response as well. However, care should be taken because of an increased risk of postoperative complications, especially pulmonary and cardiac complications and anastomotic leak, which were apparent. Future trials should include modern staging methods to facilitate the appropriate stratification of patients and measures for assessing the quality of surgery. In view of the heterogeneity and different follow-up times, whether these conclusions are applicable should be further determined in future studies.S1 File(DOC)Click here for additional data file.S2 File(DOC)Click here for additional data file.


DEPDC5, NPRL2 and NPRL3 genes encoding the GATOR1 complex, a negative regulator of the mTORC1 pathwayTo define the phenotypic and mutational spectrum of epilepsies related to We analyzed clinical and genetic data of 73 novel probands  with epilepsy-related variants in GATOR1-encoding genes and proposed new guidelines for clinical interpretation of GATOR1 variants.The GATOR1 seizure phenotype consisted mostly in focal seizures , with a mean age at onset of 4.4 years, often sleep-related and drug-resistant (54%), and associated with focal cortical dysplasia (20%). Infantile spasms were reported in 10% of the probands. Sudden unexpected death in epilepsy (SUDEP) occurred in 10% of the families. Novel classification framework of all 140 epilepsy-related GATOR1 variants (including the variants of this study) revealed that 68% are loss-of-function pathogenic, 14% are likely pathogenic, 15% are variants of uncertain significance and 3% are likely benign.Our data emphasize the increasingly important role of GATOR1 genes in the pathogenesis of focal epilepsies (>180 probands to date). The GATOR1 phenotypic spectrum ranges from sporadic early-onset epilepsies with cognitive impairment comorbidities to familial focal epilepsies, and SUDEP. We further delineate the GATOR1 phenotype spectrum and provide an updated and critical review of all novel and previously reported GATOR1 epilepsy-related variants, with new guidance for their clinical interpretation.In this study, we report clinical and molecular genetic data of a new series of 73 probands with rare variants in DEPDC5, NPRL2, or NPRL3 variants  were referred from diagnostic epilepsy centers in Belgium, Canada, Denmark, France, Germany, Italy, Switzerland, the Czech Republic, the Netherlands, the United Kingdom and the United States. Genomic DNA was extracted from peripheral blood lymphocytes. Sanger sequencing was used to confirm single-nucleotide variants, and quantitative polymerase chain reaction (PCR) to confirm CNVs. All probands and affected family members underwent detailed clinical examination, including review of the medical files, magnetic resonance imaging (MRI), and electroencephalographic (EEG) investigations when available. Written informed consent was obtained from all patients included in the study.Individuals with https://www.ncbi.nlm.nih.gov/pubmed; accessed September 2017; Table SWe established a list of all epilepsy-related GATOR1 variants reported in 24 original publications from PubMed , NPRL2  and NPRL3 , using the online version of Variant Effect Predictor (VEP) for human GRCh37 (http://grch37.ensembl.org/Homo_sapiens/Tools/VEP).We annotated novel and previously reported variants based on the longest transcripts of http://gnomad.broadinstitute.org/; accessed in July 2017).15Population allele frequencies for each variant were extracted from the Genome Aggregation Database browser  for splice-region variants.We used in silico prediction tools to assess the pathogenicity of variants: M-CAP  for missense variants;DEPDC5, NPRL2, and NPRL3 were extracted from the gnomAD database and annotated using VEP on the transcript of interest. The distribution of the different types of variants  and the proportion of M-CAP predicted deleterious rare missense variants in the gnomAD cohort were then compared with those found in epilepsy subjects: 110 previously published and 73 from the present cohort.Coding and splice altering variants in DEPDC5, NPRL2, and NPRL3 through international networking with diagnostic epilepsy centers. The main clinical features of the 73 probands are presented in Table We assembled a cohort of 73 previously unreported probands with rare variants in All except two cases (screened for research purposes) were referred for epilepsy genetic diagnosis. A known family history of epilepsy was reported in 55% of the probands. The age at epilepsy onset ranged from the first days of life to 16 years (mean: 4.4 years). Thirty percent (22/73) of the probands had early-onset epilepsy (≤1 year), among which focal seizures were reported in 68% (15/22), infantile spasms in 27% (6/22), or a combination of generalized and focal seizures in one proband. In the cohort, the seizure spectrum comprised 36% (26/73) of sleep-related hypermotor seizures, 16% (12/73) of frontal lobe seizures, 32% (23/73) of focal seizures with undetermined origin, and 10% of infantile spasms. Seizures occurred predominantly during sleep in 48% (35/73) of the probands. Interictal epileptiform abnormalities  were detected by EEG or stereoelectroencephalography (SEEG) in 83% (55/66) of the probands, and in up to 90% (18/20) among those affected with SHE. Six other probands (9%) had interictal focal slow waves, while a normal interictal EEG was reported in only five probands (7.5%).Patients were followed up for a period ranging from 8 months to 2 years (for 6 young probands) up to 58 years (>2 years for 67 probands). Seizure outcome was variable, with a rate of resistance to antiepileptic drugs (AEDs) of 54% (38/71), and up to 65% among probands with SHE. Only 11% of probands were seizure-free on the first AED treatment, while four AEDs were tested on average. Among the seizure-free patients on monotherapy, 5/8 received sodium channel–blocking AEDs, which are classical first-line drugs to treat focal epilepsies. Five other probands were treated with a ketogenic diet, in addition to AEDs, with a seizure improvement in two of them.Neuroimaging investigations, including MRI and fluorodeoxyglucose-positron emission tomography (FDG-PET), revealed abnormalities in 38% 27/71) of the probands, among which 24% (17/71) were malformations of cortical development. Focal cortical dysplasia (FCD) was diagnosed or suspected in 20% (14/71) of the probands, a hemispheric cortical dysplasia in 1 proband, hemimegalencephaly in 1 proband, and focal subcortical heterotopia in another proband. Four additional probands showed hippocampal atrophy/sclerosis, and four others had nonspecific brain abnormalities at MRI  or hemimegalencephaly (1 proband). According to the Engel Epilepsy Surgery Outcome Scale, 60% (6/10) of probands have been seizure-free since surgery , while 20% (2/10) were almost seizure-free , 1 had a worthwhile improvement , and 1 had no worthwhile improvement . Histological examinations confirmed FCD type II in six probands  and FCD type I in two probands.Cognitive impairment and/or psychiatric comorbidities were reported in 60% of the probands of this cohort, and in 76% (16/21) if considering only probands with age at onset ≤1 year. Neurocognitive deficits were reported in 44% (30/68) of the probands. Mild or moderate intellectual disability was reported in 20% (14/68) and severe in 6% (4/68); language learning delay was reported in 15% (10/68) and 9% (7/68) had other cognitive disturbances. In the subgroup of probands with age at onset of epilepsy ≤1 year, 20% (4/19) had a severe intellectual disability or global developmental delay, 8 had a mild or moderate intellectual disability, and 7 had normal cognitive function. Psychiatric comorbidities were diagnosed in 43% (28/65) of the probands: oppositional disorder in 12 probands, attention-deficit hyperactivity disorder (ADHD) or attention deficit in 10, autism spectrum disorder (ASD) diagnosis or autistic features in 6, anxiety and/or depression in 5, disinhibited social engagement disorder in 1, and obsessive-compulsive disorder in 1.DEPDC5, >80 in NPRL2, and >100 in NPRL3 in the COSMIC database) have been mentioned in various cancers,17 we examined cancer occurrence in epilepsy probands carrying germline GATOR1 variants. Two probands developed cancer, one developed Hodgkin lymphoma, and one developed breast cancer. We could not conclude about a link between GATOR1 germline variants and increased risk of cancer.Because somatic variants in GATOR1-encoding genes  and eight individuals had a probable SUDEP . Eight SUDEP cases belonged to seven families with multiple affected members in which a pathogenic null variant was identified in DEPDC5 (two SUDEP cases were in the same family) and one carried a pathogenic loss-of-function (LoF) variant in NPRL3 segregating in a large autosomal dominant SHE family  succumbed to sudden unexpected death in epilepsy (SUDEP). SUDEP is a “non-accidental, non-suicidal and non-drowning death in people with epilepsy, unrelated to a documented status epilepticus, in which postmortem examination does not reveal a structural or toxicologic cause of death.”Germline heterozygous variants in GATOR1-encoding genes were identified in 73 unrelated probands by different diagnostic targeted gene panels and by exome sequencing for research purposes in two cases. Variants were inherited in 45 cases and occurred de novo in two probands, while information was not available in the remaining 26 cases. Variants were dominantly inherited from an asymptomatic parent in 64% (29/45) of the probands, illustrating the reduced penetrance of GATOR1 variants.DEPDC5, 3 in NPRL2, and 7 in NPRL3  was previously suggested for DEPDC5 and NPRL3 transcripts with nonsense variants, confirming that haploinsufficiency is the pathogenic mechanism in GATOR1-related disorders.13Overall, 63 distinct variants were identified: 53 in L3 Figs.  and 2. A21 based on the prevalence of GATOR1-related epilepsies, as recently proposed for MYH7-associated cardiomyopathies.22 We estimated the prevalence of genetic focal epilepsies in the population to be 0.32%, a contribution of DEPDC5 gene to genetic focal epilepsy of 9.4%23 and a penetrance of 60%4 and then calculated an allele frequency threshold of 0.03% for likely benign variants  might be deleterious. Because of lack of both functional assays and strong genetic evidence , these variants would be classified as variants of uncertain significance (VUS) according to the ACMG framework. However, because they are rare (or absent) in the control population and found in patients with a phenotype compatible with GATOR1-related focal epilepsy, we asked whether such variants might nevertheless be clinically relevant. We therefore propose a new classification framework specifically adapted to GATOR1 genes, based on gnomAD allele frequencies and in silico pathogenicity predictions Fig. . First, variants . TherefoIn summary, according to this novel classification framework Fig. , six misDEPDC5, 7 in NPRL2, and 9 in NPRL3. Among them, 64% (60/94) were LoF and were classified as pathogenic, 31% (29/94) were missense, 4% (4/94) were splice-region variants, and 1 was an in-frame deletion (p.Phe164del) classified as pathogenic because it segregated in three large FFEVF families1 and was absent in gnomAD  were reported in unrelated cases, indicating mutational hotspots or founder effects  of all cases  compared with NPRL2 (1700 bp) and NPRL3 (2881 bp), and the fact that NPRL2 and NPRL3 have been tested in a lower number of individuals due to their more recent discovery.Overall, 140 distinct GATOR1 variants have been described in 183 epilepsy probands so far. Most variants are LoF (67%), followed by missense 27%), splice-region variants (4%), and in-frame indels (1%). Recurrent GATOR1 pathogenic LoF variants . This result confirms that the hereby proposed classification method is a valuable resource to help discriminate likely pathogenic and likely benign variants identified in GATOR1 genes.We then compared the type of variants among the 140 epilepsy-related GATOR1 variants with those listed in gnomAD. Excluding silent variants, the distribution of GATOR1 variants in gnomAD was 80% missense, 15% splice-region variants, 4% LoF, 1% in-frame indels, and was similar for all three GATOR1 genes Fig. S. This co24 We analyzed the distribution of the 31 missense variants along the different DEPDC5 domains but did not find any significant clustering , structural axis for binding arrangement (SABA) domain, steric hindrance for enhancement of nucleotidase activity (SHEN) domain, DEP domain, and C-terminal domain (CTD).ng Fig. S.DEPDC5, NPRL2, and NPRL3) are collectively the most frequently mutated genes in focal epilepsies, among which DEPDC5 is predominantly found .With over 180 unrelated families described to date, genes of the GATOR1-mTORC1 pathway . Drug resistance in this novel series was observed in half of the probands, and up to 65% in probands with SHE, supporting previous studies based on smaller cohorts of families with SHE/ADNFLE 7 or infantile spasms (4/5)6. Malformations of cortical development (mostly FCD) were reported in 24% of the probands. A good surgery outcome (Engel scores I–II) was achieved in 80% of them. Previous studies also reported favorable surgery outcome in FCD cases with variants in GATOR1 genes, with seizure remission in six individuals and a worthwhile improvement in three others,13 indicating that the presence of a germline GATOR1 variant does not represent a contraindication for surgery. In one patient with an inherited DEPDC5 variant who underwent epilepsy surgery (proband 14), a somatic second-hit variant, in trans configuration, was detected in the DNA extracted from the resected epileptogenic zone, suggesting that a loss-of-function biallelic mutational mechanism in a negative regulator of mTORC1 causes FCD.25 In this study, cognitive impairment and/or psychiatric comorbidities were commonly reported (60% of the probands), although severe cognitive impairment occurred only in early-onset cases, mostly presenting with infantile epileptic spasms. Previous studies also mentioned neuropsychiatric comorbidities in ~36% of the probands with GATOR1 variants  in a patient with ASD and frontal epileptiform discharges but no clinical seizures.27We reviewed the clinical features of all 183 GATOR1 probands reported so far (in the literature and in this study). As the phenotype is similar between individuals carrying variants in DEPDC5, NPRL2, or NPRL3 variants.28 Moreover, in a retrospective SUDEP cohort, DEPDC5 variants were found in ~10% (6/61) of cases.29 Overall, SUDEP cases were reported in 17 families over 183 (9.3%), emphasizing a possible increased risk of SUDEP in individuals with GATOR1 variants when compared with the global incidence of SUDEP of 0.22/1000 individuals/year in children and 1.2/1000 individuals/year in adults with epilepsy.30 The early age at onset of epilepsy, drug resistance, and predominant sleep-related occurrence of seizures observed in GATOR1-mutated patients, are well-recognized SUDEP risk factors.19 However, like SCN1A variants in Dravet syndrome, GATOR1 variants might confer a higher risk for SUDEP by themselves, although the GATOR1-related physiopathological mechanisms of SUDEP remain unknown so far.31 Assessing whether GATOR1 variants increase SUDEP risk via direct effects on cardiorespiratory functions may have profound clinical impact.Here, we reported nine SUDEP cases among the 73 new families; two were part of the same family. Two previous studies have described SUDEP cases among three families with inherited Finally, we attempted to identify genotype–phenotype correlations among the 183 cases and asked whether pathogenic LoF variants might cause a more severe phenotype with FCD, SUDEP, or infantile spasms than likely pathogenic/VUS variants. We reviewed the literature and this study, and found that 28/32 patients with FCD, 15/17 SUDEP families, and 9/11 with infantile spasms had a pathogenic LoF variant  the lack of functional evidence to prove deleterious effect on protein function; (2) the lack of a strong segregation support, and incomplete penetrance (with variants inherited from asymptomatic parents in 64% of the cases); and (3) the absence of recurrent missense variants (except for the p.Arg92Gln variant in NPRL3) as shown for LoF variants . To respond to an important need for diagnostic testing, we adapted the ACMG classification to GATOR1-related epilepsies, to provide an updated variant classification framework for clinical interpretation. Considering that the frequency of a given variant in the general population is to date the most reliable criterion for interpreting its clinical significance, we took advantage of the recent release of gnomAD to classify all epilepsy-related GATOR1 variants using a threshold specifically dedicated to GATOR1-related epilepsies. Our classification framework together with an accurate delineation of the GATOR1 phenotype spectrum will help clinicians and geneticists for the clinical interpretation of GATOR1 variants. While none of the missense/splice-region variants was classified as pathogenic according to our framework, future in vitro functional assays aimed to measure mTORC1 activity should allow to definitively settle on their pathogenicity.The assignment of pathogenicity of LoF variants  is straightforward because haploinsufficiency has been shown to be the pathogenic mechanism.DEPDC5, are key contributors to a broad spectrum of lesional and nonlesional epilepsies, with variable but highly consistent phenotypes. The pathogenic molecular mechanism linked to GATOR1 haploinsufficiency is a hyperactivation of mTORC1 pathway, as shown in human resective brain specimens13 and rodent models.34 However, how this signaling cascade alters neuronal network function, neuronal development, and ultimately leads to seizures remains to be elucidated. While a high rate of drug resistance to traditional AEDs is often reported, this study also points out a favorable epilepsy surgery outcome in some cases. For patients who are not eligible for surgery, alternative therapeutic approaches targeting GATOR1/mTORC1 complexes are urgently needed. Currently available mTORC1 inhibitors, such as rapamycin, represent promising drugs in the treatment of focal epilepsies.35 Yet, selective agonists of GATOR1 could act as antiepileptogenic drugs as well, which could ultimately lead to reduced side effects and a targeted therapy.To conclude, this collaborative study emphasizes that GATOR1 genes of the amino acid–sensing branch of the mTORC1 pathway, especially Supplementary Figure S1Supplementary Figure S2Supplementary Figure S3Supplementary InformationSupplementary Table S1Supplementary Table S2