The influence of selected mineral aggregates on the expansion due to alkali-silica reaction was tested. The content of 60Co and 152Eu activated by neutron radiation in fine and coarse aggregates, as well as in four types of Portland cement, is presented and discussed in respect to the chemical composition and rock origin. Conflicting results were obtained for quartzite coarse aggregate and siliceous river sand that, despite a low content, 60Co and 152Eu exhibited a high susceptibility to alkali-silica reaction in Portland cement concrete. The obtained results facilitate a multicriteria selection of constituents for radiation-shielding concrete.The design of concrete for radiation shielding structures is principally based on the selection of materials of adequate elemental composition and mix proportioning to achieve the long-term durability in nuclear environment. Concrete elements may become radioactive through exposure to neutron radiation from the nuclear reactor. A selection of constituent materials of greatly reduced content of long-lived residual radioisotopes would reduce the volume of low-level waste during plant decommissioning. The objective of this investigation is an assessment of trace elements with a large activation cross section in concrete constituents and simultaneous evaluation of susceptibility of concrete to detrimental alkali-silica reaction. Two isotopes  Biological shielding structures in nuclear power plants are exposed to ionizing radiation during their service life. After such exposure, certain parts of shielding structures may become a source of decay radiation, thus producing the low-level radioactive waste that has to be properly disposed of during the decommissioning of nuclear power plants. Assessment of the activation level of concrete components is required for the proper selection of methods of waste disposal. If the activation criteria were taken into account during construction at the stage of concrete mix design, the amount of radioactive waste could probably be significantly reduced. However, the selection of concrete constituent materials of highly reduced content of long-lived residual radioisotopes will not diminish the essential load-bearing and shielding function of concrete, nor impair its durability.i (Bq/g), i (Bq/g), n is the number of radionuclides in the mixture [According to recommendations of the International Atomic Energy Agency , the mat mixture . When thve waste .60Co, 152Eu and 154Eu [60Co = 0.3 Bq/g, T1/2 = 5.275 years, CL152Eu = 0.3 Bq/g, T1/2 = 13.54 years, and CL154Eu = 0.3 Bq/g, T1/2 = 8.59 years. The profile of isotopes in spent nuclear fuel has been estimated by Gauld and Ryman [60Co and 154Eu accounted for almost 50% of all notable isotopes [The dominant long-lived residual radioisotopes induced in ordinary concrete at the time of decommissioning, which occupy 99–100% of the total residual radioactivity in terms of CL value, are + and Na+) and hydroxyl (OH−) ions present in the concrete pore solution. If, during the concrete design process, the use of low-alkali cement or supplementary cementitious materials [The recognized causes of concrete deterioration in nuclear environment were discussed by ,9,10. Thaterials ,13,14,15aterials  and dam aterials . ASR wasaterials . ASR hasaterials . This phenomenon may have serious implications for the structural integrity and serviceability of nuclear power plants aging  and ther60Co and 152Eu) in principal concrete constituents and evaluate the susceptibility of concrete to detrimental alkali-silica reaction. The range of investigation covered several normal weight and heavyweight rock aggregates and Portland cements as concrete constituents. Using the neutron activation analysis and ASR expansion tests an enhanced evaluation of mineral aggregates is expected to support optimal mix design.In the context of intended nuclear power development in Poland an experimental program was undertaken to improve tools for concrete mix optimization by incorporating new criterion of the content of long-lived residual radioisotopes in concrete constituents. The objective of this investigation is to assess the content of residual radioisotopes of Cobalt and Europium (3), and six siliceous sands, S2–S7, were tested as fine aggregate. Sands S2 and S3 were characterized as natural river sand , and S4–S7 as natural fossil sands . Aggregate representing three main types of rock  and commonly used in concrete technology was selected as coarse aggregate; additionally, a heavy aggregate—baryte—was taken into consideration. The maximum aggregate size of coarse aggregate was 22.4 mm. Description of the aggregate origin and their density are presented in Seven fine aggregates and nine coarse aggregates were selected for analysis. One crushed limestone sand S1  and the fourth one, white cement with low content of iron was chosen (C4). The ordinary cements were from Polish Górażdże (C1), Małogoszcz (C2) and Norwegian Norcem (C3) cement plants, while white cement C4 was from Danish cement plant Aalborg. The chemical composition of cements is presented in 2Oeq (C2) was used for the estimation of the aggregate potential alkali-reactivity tested according to accelerated mortar-bar test method and long-term concrete prism test. The cement fineness, determined using the PN-EN 196-6 [2/kg. The le Chatelier method  was useThe specimens for activation analysis were oven-dried at 105 °C for 24 h and they were ground into a 75 µm-sieve powder. Manual crushing in glazed mortar has been used to avoid any redundant impurities, which could influence the final neutron activation analysis (NAA) results. n, γ)-reaction of the irradiated nuclides, for the quantitative composition analysis of unknown samples. The selective measurement of the radiation of isotopes with different half-lives gives quantitative and qualitative information about the produced radioactive atoms. The NAA is especially capable of residual radioisotope determination in the µg/g concentration range, or below for 30–50 elements, depending on the nuclear properties of the elements of interest, the measurement conditions, the neutron flux, density and, in some cases, the matrix composition. For the elemental analysis, the k0-standardization method was used [2 s−1. The gamma rays emitted from the samples were counted with a high-purity germanium detector (ORTEC PopTop 55195-P HPGe) within iron low-level counting chambers to reduce the room background. The detector was connected to a dual-input ORTEC DSPEC 502 spectrometer and read out by the ORTEC Maestro 7 software. The spectra with 2 × 16 k channels were recorded with the zero-dead time (ZDT) option to accurately account for the different time-dynamics of the isotopes of interest. For spectrum evaluation, HyperLab 2013.1 software was used [The determination of the concentrations of the elements and assessment of residual radioisotopes using neutron activation analysis was performed. Neutron activation analysis using the detection of delayed gamma rays originating from the  accelerated method of investigating the expansion of mortar bar specimens in a 1 M NaOH solution at a temperature of 80 °C, and (b) a method of investigating the expansion of concrete prism specimens in a highly humid environment (RH > 95%) at a temperature of 38 °C . 2Oeq = 0.9 ± 0.1% [In all of the test Portland cement, CEM I with the possibly highest alkali content available on Polish market was selected to satisfy the requirement Na9 ± 0.1% .3 were prepared for each aggregate, which were processed by crushing and sieving to the appropriate gradation. An aggregate-to-cement ratio of 2.15 and water-to-cement ratio (by weight) of 0.47 were maintained. After 24 h in the mould, the mortar bars were stored for the next 24 h in water in 80 ± 1 °C. After that, their initial zero readings were recorded by a digital extensometer before immersion in 1 M NaOH at 80 ± 1 °C. Subsequent measurements were recorded at least 3 times up to 14 days.Three mortar bar specimens 25 × 25 × 285 mm3 with the equivalent of Na2O adjusted to 1.25% of the cement mass, which resulted in 5.25 kg of alkali per 1 m3 of concrete. The fine test aggregate was combined with a non-reactive coarse aggregate. The amphibolite was used as a non-reactive coarse aggregate, the mortar bar expansion after 14 days was 0.04%. The aggregate proportions were 30% of fine aggregate (0÷4 mm) and 70% of coarse aggregate (4÷22.4 mm). After casting prismatic 75 × 75 × 285 mm3 specimens, the specimens were protected from moisture loss and stored in the molds at 20 ± 2 °C for 1 day. Then, the prisms were demolded and stored in high humidity conditions at 38 ± 1 °C. The expansion result is an average of three specimens measured at 7, 28, 56, 90, 180, 270, and 365 days. An expansion limit of 0.040% at the end of the 1-year test was specified. For the long-term expansion test, all concrete prisms were prepared according to the guidelines  adapted The level of risk of alkali-silica reaction depends upon the importance of the concrete structure and the anticipated exposure conditions. In the concrete designed for radiation shields, ASR cannot be tolerated. Given the low-risk tolerance for NPP structures, the class SC4 according to ASTM C1778  as taken3 specimens cut from the mortar bars or concrete prisms. The specimens were retrieved by slicing the bars/prisms using a slow speed diamond saw cooled by mineral oil. The specimens were then dried in an oven at 50 °C for 3 days and vacuum-impregnated with a low-viscosity epoxy.A thorough investigation, using a combination of Scanning Electron Microscopy (SEM) in backscattered mode and Energy Dispersive Spectrometry (EDS), was conducted on pieces of mortar or concrete removed from selected specimens subjected to the conditions of accelerated or long term testing methods. The microstructural analysis was performed on the 25 × 42 × 10 mm2 of active area. The instrument was used uncalibrated. Elements were identified by their respective Mn Kα-lines. Between examinations, the specimens were stored in a vacuum desiccator to protect them from laboratory humidity.Then, the specimens were placed in an oven maintained at 60 ± 2 °C to allow for polymerizing and the hardening of the medium overnight. After that time, a maximum of one millimeter was cut off the top of the specimen to expose a smooth, fresh surface on the face of interest. The cutting was performed using a Buehler slow-speed saw using mineral oil as the working fluid. The exposed specimen surface was lapped using lapping wheels with diamonds of specific sizes impregnated into the soft metal. Then, three wheels of increasingly fine diamond size were used: 45, 30, and 15 µm, respectively. Finally, diamond paste of the fineness 9, 6, 3, 1, and 0.25 µm sizes was spread on the fabric and diluted with an extender to reduce the viscosity of the paste. The each of the specimen surfaces was carefully observed under an optical microscope before proceeding to the next step of polishing. A strip of conductive tape was then attached to each polished sample, after which they were coated with a thin layer (15 ± 5 nm) of carbon for about a minute using the Quorum Q150R sputter coater. Each of the specimens was thoroughly examined using JEOL JSM-6380 LA SEM-EDX in the backscatter mode using an acceleration voltage of 15 kV. The instrument was equipped with a X-Max detector type SDD with 150 mm60Co and 152Eu were found. Radioactive analysis revealed that 60Co and 152Eu were the major dominant long-lived residual radioisotopes and they have been chosen for further analysis. The results of the 60Co and 152Eu isotope contents in analyzed aggregate are presented in 60Co and 152Eu content in cements is presented in In all tested aggregates and cements, the long-lived residual radioisotopes 60Co and 152Eu, more than 15 ppm and 1.5 ppm, accordingly. The lowest values for 60Co and 152Eu concentrations among all coarse aggregates has been found for the limestone L1 aggregate (a sedimentary rock)—0.20 ppm and 0.05 ppm. Comparatively low contents of these isotopes were found in baryte B1 aggregate, 0.77 ppm for 60Co and 0.38 ppm for 152Eu. Fine aggregate contained significantly less 60Co and 152Eu compared to coarse aggregate—more than ten times less. The lowest content of 60Co and 152Eu in fine aggregate was found in limestone sand (S1), respectively, 0.44 ppm and 0.13 ppm. The difference resulting from the origin (composition) of quartz sand is clearly visible. Higher 60Co and 152Eu concentration values were obtained in tests with fossil sand (S4–S7) compared to river sand (S2 and S3)—less than 1.5 ppm 60Co concentration and less than 0.20 ppm 152Eu concentration in river sands in comparison for 2.0 ppm and 0.35 ppm for fossil sands. Among the coarse aggregate, melaphyre M1 (an igneous rock) and greywacke GW1 (a sedimentary rock) aggregates were characterized by the highest content of 60Co and 152Eu analysis content in cements clearly indicate the difference between ordinary Portland cements C1, C2 and C3 (Fe2O3 = 3.11 ± 0.15%) and cement (C4) with reduced iron content (Fe2O3 = 0.30%). The content of 60Co in Portland cements was between 7.9 and 11.3 ppm, while in cement C4, this was only 1.8 ppm, almost ten times less. The content of 152Eu also significantly differed; in cements C1–C3, the content was 0.59 ± 0.03 ppm, and in cement C4, this was 0.25 ppm. The 60Co content in Portland cements (C1–C3) was comparable to the content of this isotope in quartzite coarse aggregate (Q1), 9.02 ppm for 60Co. The results from The results of the accelerated mortar bar expansion after 14 days of testing in 80 °C and 1 M NaOH are presented in The results of the accelerated mortar bar test showed that the lowest expansion was achieved by mortars bar made with barite B1 and limestone L1 aggregate, after 14 days 0.01 and 0.03%, respectively. Granite aggregates (G1 and G2) also did not reveal alkali-silica reaction potential, G1—0.05% and G2—0.08% after 14 days. The mortar bars with quartzites Q1 and Q2, greywacke GW1 and flint F1 aggregates showed very fast expansion; more than 0.1% after 5 days of testing. Quartzite (Q1 and Q2) turned out to be a very reactive coarse aggregate, expansion over 0.36%. All other aggregates: melaphyre M1, greywacke GW1, flint F1 showed susceptibility to alkali-silica reaction . The susceptibility of river sands to ASR is clearly visible among fine aggregate, It was assumed that, if the expansion of the mortar bars after 14 days was much more than 0.3%  or 0.2% , the aggregate was highly susceptible to an alkali-silica reaction. The expansion of granite G1 and G2 and limestone L1, as well as baryte B1 mortar bars, was less than 0.1% after 14 days, so these aggregates were further tested according to long-term prism test at 38 °C and high humidity conditions. The expansion curves for all concretes after a year did not exceed the limit of 0.040%. The highest expansion was characterized by concrete with granite aggregate , then limestone aggregate (L1—0.027%) and the lowest expansion: concrete with baryte (B1—0.026%). The different shape of the curves for each of the examined aggregates is visible. The fastest expansion was shown by concrete with granite G1, unlike concrete with granite G2, which showed the latest beginning of expansion. Up to 90 days, concrete with baryte B1 showed a rapid increase in expansion, but thereafter significant extinction is noticeable. The result of the long-term prism test confirmed observations according to accelerated mortar bar test. The aggregate granite G1 and G2, limestone L1 and baryte B1 were classified as non-reactive (expansion below 0.04% after one year).After the accelerated expansion test mortar bars were selected and the microstructure analysis was performed on polished specimens. The observed damage due to ASR was various depending on the type of aggregate. The evidence of alkali-silica reaction—cracking and microcracking occurred in the specimens containing greywacke GW1, melaphyre M1, flint F1 and quartzite aggregate Q1 and Q2, as well as siliceous sand S2, S3, S4 and S7. The results of the mortar microstructure SEM analysis are consistent with the results of the preceding expansion measurements. In From all analyzed specimens after long-term prism test, only granite G1 showed slight signs of an alkali-silica reaction; 60Co, 152Eu and 154Eu [60Co and 152Eu isotope contents in analyzed aggregate partly coincide with results for Japanese [60Co, 152Eu and 134Cs. Kinno et al. [60Co = 0.1 ppm and 152Eu = 0.004 ppm and limestone (60Co = 0.08 ppm and 152Eu = 0.05 ppm). According to Suzuki et al. [60Co was 3.55 ppm and 152Eu 0.297 ppm. Pai et al. [60Co and 152Eu, in quartzite 0.79 ppm and 0.12 ppm, respectively. Kimura et al. [The dominant long-lived residual radioisotopes induced in concrete, which occupy 99–100% of the total residual radioactivity, are Japanese  and IndiJapanese  researcho et al.  determino et al. . They hao et al.  found thi et al.  made sim60Co and 152Eu isotopes in coarse aggregate from igneous rocks were also relatively high, but they significantly differ from one other. In rock aggregate of plutonic origin (granite) the average concentration of 60Co was 7.5 times lower than in the rock aggregate of volcanic origin (melaphyre), 3 ppm and 22.6 ppm, respectively. Similar results were obtained for 152Eu content, 0.6 ppm for granite and 2.6 ppm for melaphyre. The lowest values of 60Co and 152Eu in all coarse aggregate were achieved for limestone and baryte aggregates. On the other hand, greywacke and flint revealed the highest content of above residual radioisotopes. All these aggregates belong to the group of sedimentary rocks. A more accurate separation of sedimentary rocks into clastic and organogenetic showed that greywacke, which belongs to the clastic group cannot be taken into consideration as an aggregate for low-activation shielding concrete. Pai et al. [60Co and 152Eu in quartzite was accordingly eight and three times lower than in limestone aggregate. The current investigation on coarse aggregate revealed the average content of 60Co and 152Eu in quartzite of 5.7 and 1.0 ppm, respectively, which was higher than the content of such isotopes in limestone and baryte as well as in granite aggregate.The current investigation revealed that the concentrations of the i et al.  showed t60Co and 152Eu were obtained for fine aggregate than in coarse aggregate, which resulted from larger diversity of rock origin of coarse aggregate, Smaller differences in the content of All above results indicated that quartzite could be an appropriate aggregate to be used as constituent material for low-activation concrete for neutron shielding elements. However, in recent research, performed by Šachlová et al.  and JensThe results of the accelerated mortar bar test showed that the highest expansion was achieved by mortar bars made with quartzite (Q1 and Q2) aggregate. They turned out to be a very reactive aggregate, with expansion of over 0.36%. Baryte B1 and limestone L1 aggregates did not show susceptibility to provoking ASR, while all other aggregates— melaphyre M1, greywacke GW1, flint F1—showed susceptibility to alkali-silica reaction. The expansion of the concrete prisms made with baryte B1, limestone L1 and granite G1 and G2 aggregate after one year of exposure in 38 °C was lower than 0.040%. However, granite aggregates G1 showed a trace amount of alkali-silica gel in cracked aggregate grains observed after one year of exposure at 38 °C.The susceptibility of river sands to ASR is clearly visible among fine aggregate. The highest expansion was achieved by mortars made with sand S2 and S3 (0.32% and 0.24%), much higher than the allowable limit of 0.1%. Previous investigation revealed that certain hematite aggregate or impure baryte aggregate may also be highly reactive ,40. 2Oeq. The conducted research has shown that 152Eu content in Portland cements was similar, but the 60Co concentration significantly depending on the Na2Oeq content; 60Co concentration. Additionally, it has been noted that the content of iron oxide in cement clearly influenced the concentration of 152Eu, 152Eu increased with increasing Fe2O3 content in cement.Blended cements, especially fly ash cement, are known to reduce the potential of alkali-silica reaction in concrete ,42, but 152Eu in plutonic rock and volcanic rock as aggregates can be higher than of 60Co. It was also suggested that the use of sedimentary rock as aggregates would reduce the content of 152Eu in biological shielding concrete. As shown in , the con60Co and 152Eu would not be unambiguous. The radiation-induced deterioration of concrete is still not well understood; it is thought to take place mostly at high neutron fluence levels, possibly beyond the threshold level of 1019 n/cm2 [At the decommissioning stage of NPP, the activation level of elements in concrete should be as low as possible to ease necessary waste disposal procedures. Therefore, concrete constituents should contain, as little as possible, the residual radioisotopes with large activation cross section. On the other hand, concrete structures in NPPs and nuclear facilities are directly classified as structures that require the highest level of ASR prevention and no risk due to ASR being currently tolerated (ASTM C1778 ). The ag19 n/cm2 . With thThe following conclusions can be drawn:60Co and 152Eu activated by neutron radiation in natural fine aggregate was lower than in natural coarse aggregate. The average content of 60Co and 152Eu in natural siliceous fine aggregate amounted to 1.71 ± 0.38 ppm and 0.30 ± 0.09 ppm, respectively. It was 8.73 ± 7.98 ppm and 1.05 ± 0.83 ppm in natural coarse aggregate.The concentration of 60Co and 152Eu content was clearly visible in the analyzed natural fine aggregate. Lower concentrations of Cobalt and Europium were present in the river sands, compared to fossil fine aggregate.The influence of the sand origin on the 60Co and 152Eu concentration were found in limestone, both in fine aggregate, at 0.44 ppm and 0.13 ppm, and in coarse aggregate, at 0.20 ppm and 0.05 ppm, respectively.The lowest values of 60Co was proportional to the content of Fe2O3 and the content of 152Eu was proportional to the total content of alkalis.For the considered range of Portland cements CEM I 42.5 R and 52.5 R the content of Quartzite and greywacke aggregates were found to be highly reactive in the alkaline environment of Portland cement concrete.60Co and 152Eu. At the same time, it is suggested to use the cement with the lowest alkali content, both due to the possibility of alkali-silica reaction of the aggregate in concrete, as well as a lower content of 60Co.Due to the high potential of alkali-silica reaction, it is not recommended to use quartzite as a coarse aggregate, as well as siliceous river sand as a fine aggregate for shielding concrete, despite the low contents of 60Co and 152Eu radioisotopes.Limestone with low content of siliceous minerals is good for preventing the alkalisilica reaction and the formation of


Antimicrobial resistance (AMR) is a pressing public health concern . It is eDrug combinations provide an effective strategy to combat antimicrobial resistance . CompareIn this study, we constructed a comprehensive database  focused on antibiotic combinations . This cuMany studies of antibiotic combinations have been reported in PubMed. To obtain high-quality antibiotic combinations, we manually collected literature-reported antibiotic combinations from thousands of studies. Specifically, the keywords “antibiotic (s),” “fractional inhibitory concentration,” “synerg*,” and “combination (s)” were used to retrieve related literature in PubMed, and we finally obtained 6,175 antibiotic combinations from 6,121 publications (Dec. 2021).e.g., LogP, molecular weight, Lipinski’s five rules, We then filtered out duplicate content and 304 unique compounds were obtained. We normalized them into a standard format (PubChem CID) because they are well-known and easily linked to external databases. Simplified Molecular Input Line Entry System (SMILES) of each compound was obtained from PubChem, and we used SMILES to calculate descriptors , which employs Apache (version 2.4.37) and MySQL (version 8.1) as the web and database server, respectively. The website is built with PHP, HTML and CSS and it can be freely accessed at There are six sections  on the ACDB website. A user-family retrieval system for antibiotic combinations was available on the homepage. The retrieval system allows users to find antibiotic combinations of interest to them. The About page contained the overview and motivation of ACDB. The Download page contained many useful datasets. These datasets can be used for AI-based models, and we will cover these usages in detail later. On the Help page, users can learn how to use ACDB. On the Visualization page, users can upload the dose-effect matrix, and then it will be fitted with the Loewe model. Finally, a heatmap and an isosurface will be shown on the webpage. If users have any further questions, they can find our contact information in the Contact page.ACDB aims to help researchers obtain datasets of antibiotic combinations for further applications and analysis. ACDB contains a large amount of data on structure, pharmacology, and well-documented antibiotic combinations, which contribute to the development of combination therapy. In this section, we list some potential applications of ACDB.et al.  between synergistic drug combinations and lipophilicity. Chandrasekaran et al. (Escherichia coli (E. coli) as features to build an AI-based model and subsequently predict new antibiotic combinations (AUC for synergy = 0.79). On the download page, users can obtain the entire chemogenomic data of E. coli in 324 conditions  for each node. Zou et al. (While machine learning models can offer satisfactory outcomes, the mechanisms underlying the synergy effect are still poorly understood. As such, mechanism-driven methods are needed in order to predict antibiotic combinations. Network pharmacology provides a new paradigm to explore intricate relationships between drugs, genes, and diseases . ACDB pru et al.  used theu et al.  can alsoetc. This is one of the important drivers for development of ACDB. Through the “Organism Search” in ACDB, users can obtain a series of species-specific antibiotic combinations and their efficacy. Undoubtedly, ACDB combined with antimicrobial susceptibility testing can help clinicians tailor treatments based on the pathogen microenvironment and the patient’s condition.Pharmacologically, an antibiotic combination may produce synergy effect, additive effect, and antagonism effect . Every aWe introduce a freely available database focusing on antibiotic combinations. To our knowledge, ACDB is currently the only database utilizing this approach. ACDB contains a great number of well-documented drug combinations and structural, physicochemical, pharmacological and chemogenomic data. It should benefit the performance of AI-based models and to explore the mechanism of synergy effects. In future versions, combinations of antibiotics, human-targeted drugs, and plant extracts and more applications will be incorporated into this web-based program.


The neural mechanisms subserving the processing of abstract concepts remain largely debated. Even within the embodiment theoretical framework, most authors suggest that abstract concepts are coded in a linguistic propositional format, although they do not completely deny the role of sensorimotor and emotional experiences in coding it. To our knowledge, only one recent proposal puts forward that the processing of concrete and abstract concepts relies on the same mechanisms, with the only difference being in the complexity of the underlying experiences. In this paper, we performed a meta-analysis using the Activation Likelihood Estimates (ALE) method on 33 functional neuroimaging studies that considered activations related to abstract and concrete concepts. The results suggest that (1) concrete and abstract concepts share the recruitment of the temporo-fronto-parietal circuits normally involved in the interactions with the physical world, (2) processing concrete concepts recruits fronto-parietal areas better than abstract concepts, and (3) abstract concepts recruit Broca’s region more strongly than concrete ones. Based on anatomical and physiological evidence, Broca’s region is not only a linguistic region mainly devoted to speech production, but it is endowed with complex motor representations of different biological effectors. Hence, we propose that the stronger recruitment of this region for abstract concepts is expression of the complex sensorimotor experiences underlying it, rather than evidence of a purely linguistic format of its processing. The embodied approach to language claims that the same neural structures involved in making sensory, motor, and even emotional experiences are also involved in understanding the linguistic material related to those experiences ,11,12,13Abstract concepts have been defined as mental representations referring to entities that are neither purely physical nor spatially constrained . When coAccording to Paivio’s “dual-coding” theory ,39,40, tEven within scholars that contributed to developing the embodied approach to language, abstract concepts remain a topic of great debate. In this respect, Dove  defined Some authors have also stressed the emotional valence of abstract concepts ,47,48,49Another proposal, known as the “Words as Tools” (WAT) approach ,52,53,54As a whole, reviewing the theoretical frameworks proposed to explain how the brain codes abstract concepts unveils that, even among the supporters of embodiment, there is not a unique view for concrete concepts. Moreover, in no case are specific neural substrates and mechanisms considered the only elements necessary and sufficient to process abstract concepts. Aside from and beyond modal aspects, additional amodal aspects and mechanisms are evoked to fully grasp them. As underlined in some recent reviews on this topic ,57,58,59To the best of our knowledge, only one recent proposal  has suggIt is worth noting that, in the philosophical domain, this approach is not completely new and is reminiscent of Locke’s view  on ideasAccording to Locke, words are signs of ideas. In this respect, the author distinguishes proper names  from general words . This latter category includes words expressing simple and complex ideas (as defined above). Thus, the words we define as concrete and abstract are included in the category of general words by Locke. Accordingly, the meanings of general words, both concrete and abstract, are always grounded in the experience they point at. The only difference is that the experience is simpler in the case of concrete words and more complex for abstract words expressing complex ideas.The aim of the present meta-analysis is to assess whether (and to what extent) the processing of concrete and abstract concepts is subserved by the same neural structures. The meta-analytic results will be discussed in light of the hypothesis that abstract concepts are more complex than concrete ones, rather than disentangled from actual experiences.http://www.prisma-statement.org/, accessed on 25 April 2020). PRISMA guidelines suggest following a 27-item checklist and reporting a flow diagram of the literature search and paper inclusion  Statement guidelines  and (fMRI OR PET OR neuroimaging OR brain imaging))”. Only studies written in English and published from January 1990 to April 2020 were included. This preliminary search returned a total of 272 results, and 14 additional studies were identified through other sources i.e. , yieldinThe reported coordinates were extracted and divided into 4 main sets based on our contrasts of interest: (1) main effect of abstractness, (2) main effect of concreteness, (3) abstract > concrete, and (4) concrete > abstract  the main effect of abstractness and (2) the main effect of concreteness was performed in order to show areas of spatial overlay. The clusters in each set were thresholded at p < 0.05 uncorrected and entered into the conjunction analysis, which was thresholded with a p < 0.05 false discovery rate (FDR) correction.We performed analyses for each subset of coordinates through the GingerALE software  using the Activation Likelihood Estimation (ALE) method and non-additive correction to minimize the within-experiment effects as described in Turkeltaub et al. ,98. Ginganalyses ,101,102.The conjunction analysis between concreteness and abstractness revealed extensive clusters in the left temporal lobe, including the middle and inferior temporal gyri, and in the left motor cortex. Significant activations were also found in the right parietal cortex, left inferior frontal gyrus, and prefrontal regions see .The concrete > abstract contrast revealed left parietal , temporal , and posterior (precuneus) activations. Smaller clusters included the left inferior frontal gyrus and the middle cingulate cortex see .The abstract > concrete contrast revealed two major clusters situated on the left inferior frontal gyrus  and middle temporal gyrus. Smaller clusters included the medial frontal cortex and the bilateral temporal poles see .The present meta-analysis included 33 articles published over the last 30 years. We will discuss the results in the following order: (1) common brain activation related to concrete and abstract concepts, (2) brain activation when contrasting concrete > abstract, and finally (3) brain activation when contrasting abstract > concrete.Common activation for concrete and abstract concepts included areas within the frontal lobe in the motor and premotor cortex , areas in the parietal lobe , and areas in the temporal lobe . These results suggest that both concrete and abstract concepts recruit temporo-fronto-parietal circuits normally involved when individuals interact with objects and, more generally, with the environment ,107,108.It turns out that abstract concepts are not such because their meaning is “far from experience”, but rather that the concrete experiences expressed by abstract concepts are similar to those underlying concrete language, although they possibly have a higher complexity that is grounded in different neural systems (multi-systemic), involves different effectors , and evolves dynamically across the lifespan . In keepWhen comparing concrete > abstract concepts, the present meta-analysis showed activation in the temporo-parietal areas , posterior cingulate and parahippocampal gyrus, and precuneus. Activations in these regions have already been found in previous meta-analyses on the matter ,117. In As for mesial activation , these areas were also found by Binder et al. . ClassicFinally, the angular gyrus (AG) has been involved in several functions, including semantic processing, word reading and comprehension, memory retrieval, self-processing, attention and spatial cognition, and social cognition (for a review see ). The acThe abstract > concrete comparison showed activation of the IFG and the middle temporal gyrus. These activations largely overlap with those found by previous meta-analyses ,117,133.In summary, while the meanings of concrete concepts are supposed to be defined by perceptual features and their relation to the physical world, the meanings of abstract concepts are thought to be verbally mediated and emerge from use in sentence contexts .In contrast with the classical view of Broca’s region as a pure linguistic area, several anatomical and neurophysiological findings have clearly demonstrated that the IFG, where Broca’s region lies, is not only endowed with mouth motor representation but also includes hand–arm representation. Potentially all biological effectors are represented in the IFG, both in monkeys as well as in humans ,141,142.It has been put forward that in the phylogenesis, as well as in cultural evolution ,141,149,On the basis of this empirical evidence, we put forward that the prevalent activation of the IFG during the processing of abstract vs. concrete concepts may indicate that the recruitment of this area is related to a re-enactment of actions unchained from the use of specific objects and from specific contexts, rather than due to the understanding of abstract concepts in a purely propositional linguistic format. Put differently, because abstract concepts and their corresponding verbal labels express actions or entities that are dynamic in time and space and may be executed by different effectors and coded in different systems , their cOf note, the findings reported here and the interpretation proposed should be considered in light of a number of limitations. In particular, the meta-analytic power of the present study is intrinsically limited by the amount of available data, especially for the concrete > abstract analysis. Therefore, if sufficiently powered to detect large summary effect sizes, the present study might have failed to detect smaller effects.Overall, the present meta-analysis suggests that abstract concepts and concrete concepts share common neural substrates, including not only areas classically considered semantic hubs but also parieto-frontal structures involved in coding actions. These findings may be interpreted as indirect evidence against the notion of abstract concepts disentangled from sensorimotor experiences. As proposed in a recent review , the sen


Antimicrobial resistance (AMR) is a public health crisis of global proportions. Data is required to understand the local drivers of antimicrobial resistance and support decision-making processes including implementation of appropriate antimicrobial stewardship strategies.To measure antimicrobial usage in hospitals in Ghana.Using the Global Point Prevalence instruments and processes, we conducted point prevalence surveys across AMR surveillance sentinel hospitals in Ghana, between September and December 2019. Hospital records of all inpatients on admission at 0800 hours on a specific day were reviewed for antimicrobial use at the time of the survey. Data on antibiotic use, including indication for use and quality of prescribing were recorded.n = 1591/2897), ranging between 48.4% (n = 266/550) and 67.2% (n = 82/122). The highest prevalence of antibiotic use 89.3% (n = 25/28) was observed in adult ICUs. The average number of antibiotics prescribed per patient was 1.7 (n = 1562/2620), with the majority  administered via the parenteral route. The five most-commonly used antibiotics were metronidazole , cefuroxime , ceftriaxone , amoxicillin/clavulanic acid  and ciprofloxacin . The majority  of antibiotics were prescribed to treat an infection, whilst surgical prophylaxis accounted for 26.1% (n = 684/2620).Overall prevalence of antibiotic use across the sentinel sites was 54.9% (We observed a high use of antibiotics including metronidazole and cephalosporins at the participating hospitals. Most antibiotics were empirically prescribed, with low use of microbiological cultures. High usage of third-generation cephalosporins especially for community-acquired infections offers an opportunity for antibiotic stewardship interventions. Antimicrobial resistance (AMR) is on the increase worldwide.Hitherto, different studies have highlighted high levels of AMRFigurehttp://www.global-pps.com/documents/). All departments and units in the participating hospitals were included in the survey. The survey was conducted between September and December 2019.This was a multicentre observational study. We reviewed the hospital records of all patients on on a ward at 8 o’clock in the morning of the survey according to Global PPS definitions . The Global PPS protocol aligns with the WHO PPS recommendations, is flexible and is ideal for use in LMICs, including Ghana. The Global PPS platform includes an optional freely available internet-based application with form-based user interfaces for data entry. The application checks erroneous data entry, such as double-entry of the same drug. The application also has built-in error and warning checks for data validation as well as real-time analysis tools for feedback and reporting. The Global PPS has worldwide coverage, and the online application permits for direct comparison of antimicrobial use patterns across hospitals from different regions.We used standardized instruments from the Global PPS platform for all data collection activities . For each patient on at least one antimicrobial treatment, the patient-level data included age, gender, patients’ antimicrobial usage and reasons for use, dosage, dosing, route of administration, presence of active community- or healthcare-associated infections, results of routine microbiology tests performed, and the quality of antimicrobial prescribing. Ward data collected included the type of ward, the total number of beds and the number of patients admitted to each ward at the time of the survey.,http://www.global-pps.com/documents/.We classified all drugs administered to treat or prevent infection as anti-infectives. Two major categories were used: antibiotics and ‘other antimicrobials’. The former refers to conventional antibacterial agents for systemic use. The latter include antimycotics and antifungals for systemic use, drugs to treat tuberculosis, antimalarials, and antivirals. A prescription was defined as the use of one antimicrobial by one route of administration. Antibiotic agents were analysed using the WHO Anatomical Therapeutic Chemotherapy (ATC) 5th level classifications.Data collected were entered onto the Global PPS platform but the data remained the property of the hospital. All captured data were anonymized within the database and safeguarded at the University of Antwerp . For analysis, we included hospital-, ward-, and patient-level data from all seven participating hospitals. No data was excluded from any hospital. Data was exported from the online platform into an Excel database and subsequently imported into Statistical Package for the Social Sciences (SPSS version 21) for analysis. Categorical data were reported as the frequency with percentage while continuous data were presented as mean (with standard deviation) or median. Prescribed antibiotics were reported as the number of patients receiving at least one antibiotic per diagnosis. Prevalence of antibiotic use was defined as the number of patients receiving at least one antibiotic divided by the total number of patients on admission at the time of the survey. The patient to antimicrobial prescription ratio was calculated as the total number of patients surveyed divided by the total number of antimicrobial prescriptions.Drug utilization 100% (DU100%) referred to the number of antimicrobials accounting for 100% of drug use. We ranked the drugs by volume of defined daily doses and determined how many antimicrobials accounted for the DU100% segment.The study received approval from the Ethical Review Committees of the Ghana Health Service (GHS-ERC010/05/19), Komfo Anokye Teaching Hospital (CHRPE/AP/523/19), Korle-Bu Teaching Hospital (KBTH/MD/G3/19), and Tamale Teaching Hospital (TTH/R&D/SR/19/129). Informed consent was waived for the conduct of the study.A total of 4387 patient beds were counted on the wards during the survey . The total number of beds ranged from 199 to 1403 with a median bed size of 417 beds (IQR 392–1201). Over the study period, 2897 individual folders and charts of patients admitted to 55 wards were reviewed for the current use of antimicrobials. Of these, 122 (4.2%) patients were from a primary care hospital, 468 (16.2%) from secondary care hospitals, and 2307 (79.6%) from tertiary care hospitals.n = 2620/2875). Overall, 1562/2897 (53.9%) patients on admission received at least one antibiotic for systemic use on the day of the survey. Out of 1562 patients, 39.5% (n = 617) received one antibiotic, the majority  received two antibiotics, 6.3% (n = 99) received three antibiotics, and 0.4% (n = 7) received four antibiotics. The average number of antibiotics per patient was 1 : 1.7 (n = 2620 antibiotics/1562 patients). The median age of patients on antibiotics was 33 years. This varied from 1 day to 104 years (IQR: 22–50 years). The commonest route of antibiotic administration was the parenteral route . Prevalence of antibiotic use varied between sites  and 52.4% (n = 245/468) prevalence of antibiotic use, respectively  Table. The majely Table. In addin = 1367/2620), prophylaxis accounted for 34.1% (n = 893), and 13.7% (n = 360) of the prescribed antibiotics had no documented indications. Figuren = 20.6%, n = 541/2620), cefuroxime , ceftriaxone , amoxicillin/clavulanic acid , and ciprofloxacin . This pattern of antibiotic use varied among different age groups. Among neonates, gentamicin , ampicillin , cloxacillin , cefotaxime  and amikacin  were the most common antibiotics used (TableJAC-AMR Online). Among the adult population, metronidazole , cefuroxime , ceftriaxone , amoxicillin/clavulanic acid  and ciprofloxacin  were the top five antibiotics used.The majority of antibiotic prescriptions were used for treatment of infections , skin and soft tissue  and sepsis , respectively. For respiratory tract infections, the top three antibiotics used were ceftriaxone , azithromycin  and amoxicillin/clavulanic acid . The top three antibiotics for treating skin, soft tissue, bone and joint infections were clindamycin , metronidazole  and ciprofloxacin . The top three antibiotics for treating bloodstream infections and pyrexia of unknown origin were ceftriaxone , gentamicin  and cloxacillin .The majority of antibiotics prescribed for treatment of infections were for community-acquired infections  and hospital-associated infections  Figure. The mosn = 893) of cases. The majority  were for surgical prophylaxis as compared with medical prophylaxis . For all patients who received surgical prophylaxis, 74.7% (n = 511/684) were given for more than 1 day whilst 16.5% (n = 113) received antibiotics for a day and 8.7% (n = 60) had received a single dose. Antibiotics prescribed for medical prophylaxis were mainly for managing newborn risk factors such as very low birth weight and intrauterine growth restrictions . Metronidazole was prescribed more for surgical prophylaxis (36%) than for medical prophylaxis (14%), whilst cotrimoxazole was prescribed mainly for medical prophylaxis (13%).Figure n = 1314) were empirically prescribed. Thirty-eight of the 53 guided antibiotic treatments targeted at least one multidrug-resistant organism. About 5.2% (n = 137) of the antibiotic prescriptions were based on biomarkers, largely full blood counts with elevated white blood cell counts . Overall, 48.2% (n = 1262) of the antibiotic prescriptions had a documented reason in the notes and 46.7% (n = 1226) had a documented stop/review date indicated.TableIn this multicentre study of about 3000 hospitalized patients, one in every two hospitalized patients received at least one antibiotic and over 60% of the prescriptions included ≥2 drugs for a single indication. Approximately half of the antibiotics were used for managing infections, one-third for prophylaxis and about a tenth had no documented indication.,,,,Prevalence rates of antibiotic use in this study are similar to previously published studies from Ghana. In a multicentre PPS conducted in 10 hospitals across Ghana, nearly 61% of patients surveyed were on antibiotics,,,,,,,,,,Point prevalence surveys of antibiotic use, when repeated regularly, provide data on patterns of antibiotic use and serve as a benchmark for antibiotic stewardship activities. Observations from previous multicentre PPS in Ghana,,,In the last 15 years, there has been a steady trickle of papers on AMR in Ghana.Our study has some limitations. Although we noted similarities in the prevalence of antibiotic prescribing within hospitals and between regions, as well as between previously reported PPS, the data may not be representative for most of the country. For instance, private healthcare facilities were not surveyed, and there was low representation from primary hospitals, and the overall rates provided are averages. Our analysis did not control for institutional factors, which may influence antibiotic prescribing patterns. There is the possibility that the quality of data may have been affected by poor record-keeping, leading to possible underestimation of antimicrobial use.On average, one in every two patients in our study received an antibiotic, with relatively high use of metronidazole and cephalosporins, especially for community-acquired infections. Second, the majority of antibiotics were prescribed empirically without culture. There is an urgent need to improve access to bacterial culture and susceptibility testing to inform antibiotic prescribing. Third, documentation of the reason for antibiotic prescription and stop/review dates were uncommon. Findings from this study could be used as benchmarks for quality improvement of antibiotic prescribing. These indicators should be targeted as key interventions, and the effects of such interventions should be measured with repeated point prevalence surveys.dlab087_Supplementary_DataClick here for additional data file.


Glioblastoma is the most common and malignant primary brain tumor, with a median survival of around 14 months. The aggressiveness of glioblastoma is due to intense cell proliferation, angiogenesis, invasiveness, genetic instability, resistance to therapies and high frequency of relapses. These features render glioblastoma almost incurable, considered an extreme therapeutic challenge. In the last few decades, it has been observed a reduced cancer incidence in diabetic patients treated with metformin, an oral hypoglycemic drug. The reported ability of metformin to arrest cancer cell growth in in vitro and in vivo experimental tumor models, have suggested the possibility to reconsider metformin as an anti-cancer add-on therapy, but further investigations about molecular mechanisms and optimal therapeutic regimens are needed. Here, we tested the efficacy of metformin against primary glioblastoma endothelial cells, responsible for tumor angiogenesis, invasiveness and resistance to therapy, reporting promising results and advancing a novel target of metformin, the “sphingolipid rheostat”.n = 10 primary glioblastoma endothelial cells (GECs), by viability and proliferation tests, as MTT and Live/Dead assays, apoptosis tests, as annexin V assay and caspase 3/7 activity, functional tests as tube-like structure formation and migration assay and by mRNA and protein expression performed by quantitative real-time PCR analysis (qRT-PCR) and Western Blot, respectively. Results: Data resulting revealed a time- and μ-dependent ability of MET to decrease cell viability and proliferation, increasing pro-apoptotic mechanisms mediated by caspases 3/7. Also, MET impacted GEC functionality with a significant decrease of angiogenesis and invasiveness potential. Mechanistically, MET was able to interfere with sphingolipid metabolism, weakening the oncopromoter signaling promoted by sphingosine-1-phosphate (S1P) and shifting the balance toward the production of the pro-apoptotic ceramide. Conclusions: These observations ascribed to MET the potential to serve as add-on therapy against glioblastoma, suggesting a repurposing of an old, totally safe and tolerable drug for novel oncology therapeutics.Background: Glioblastoma is the most aggressive primary brain malignancy in adults, with a poor prognosis of about 14 months. Recent evidence ascribed to metformin (MET), an antihyperglycemic drug, the potential to reduce cancer incidence and progression, but the molecular mechanisms underlying these effects need to be better investigated. Methods: Here, we tested the efficacy of MET on  IDH-wild type (here named glioblastoma) is the most malignant and frequent glial tumor in adults, classified as grade IV by World Health Organization (WHO) guidelines [Glioblastoma, idelines .Glioblastoma alone accounts for 12–15% of all primary central nervous system (CNS) tumors and 45.8% of malignant ones . SurvivaThe therapeutic management of patients with newly diagnosed glioblastoma is currently performed according to the Stupp protocol , and conA main feature of glioblastoma is its intense angiogenesis, the formation of novel disorganized blood vessels, which sustain tumor growth and infiltration into surrounding tissues, finally compromising patient’s neurological skills. Angiogenesis is mediated by tumor endothelial cells, called glioblastoma endothelial cells (GECs), which are strictly involved in glioblastoma resistance to therapies, through the modulation of a sensitive balance between anti- and pro-angiogenic factors ,9.In the last few years, several studies have reported a worsened prognosis and a decreased survival in patients affected by both glioblastoma and hyperglycemia . WhetherN,N-dimethylbiguanide, MET), an oral antihyperglycemic drug of the biguanide family, is widely used as the first line of therapy for all patients with type-2 diabetes mellitus (T2DM) [In this context, high glucose and insulin levels have been widely described as adverse prognostic factors in many tumors, as breast, colon and prostate cancer . From ths (T2DM) . Of intes (T2DM) .Several studies performed in different tumor models, including breast, pancreatic, colon, endometrial, ovarian and lung cancer, demonstrated the ability of MET to inhibit tumor cell proliferation, both as monotherapy or in combination with chemo- and radiotherapy ,16,17. TRecent evidence ascribed to MET the ability to also interfere with sphingolipids metabolism and signaling. In particular, in patients suffering from Poly-Cystic Ovary Syndrome (PCOS) and treated with MET, a change in lipidomic signature and metabolism, including glycerolipids, glycerophospholipids, and sphingolipids was observed . The tarWith this aim, we here tested the effect of MET on primary GECs, isolated and purified from patient-derived tumor biopsies. Our results prove for the first time a time- and μ-dependent ability of MET to inhibit cell growth, proliferation, invasiveness, and angiogenesis, adding to previous studies the translational relevance of patient-specific ex-vivo models. Furthermore, PCR and protein analyses indicate the sphingolipid rheostat as a molecular mechanism involved in MET action in GECs, further sustaining the potential use of MET in glioblastoma therapy.n = 10) from patients that underwent surgical resection for newly diagnosed glioblastoma at the Neurosurgery Unit of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico  were included in the study. The clinical and molecular features of patients and respective glioblastoma tissues are provided in 2 incubator.Tissue samples  MET at 5 mM, 10 mM, 20 mM, and 50 mM, (ii) TMZ 200 μM, (iii) TMZ + MET at 5 mM, 10 mM, 20 mM, and 50 mM. We previously identified the optimal concentration of TMZ on GECs in previous studies ,9.3/well) in 96-well plates and cultured for 24 h. Then, culture media were replaced with fresh media containing the specific treatments. Tests were performed in triplicate following 72 h of treatment. At the end of treatment, culture media were replaced with 100 μL of fresh media + 10 μL of MTT (5 mg/mL in D-PBS) and, after 4 h of incubation, the media were removed and cells were lysed with 100 μL of 2-propanol/formic acid  for 10 min. Absorbance was read at 570 nm with a microplate reader.3-−2,5-Diphenyltetrazolium Bromide (MTT) assay was used to assess cell viability as a function of redox potential. GECs and GBM cells were seeded (5 × 104) were seeded into 25 cm2 collagen-coated flask and cultured in basal conditions or with specific treatments. At 24 h, 48 h, and 72 h, GECs were detached by TrypLE Select, stained with Trypan Blue (ThermoFisher) and counted in a Fuchs Rosenthal counting chamber, to evaluate growth rate. An estimation of viable and non-viable cells was performed at the end of treatment (72 h).GECs  cell viability assay by measuring intracellular esterase activity and plasma membrane integrity. To this purpose, GECs were seeded into 24-well plates (2 × 104/well), grown until confluence, and then treated with the specific treatments for 72 h. Then, the mixture of Calcein AM and EthD-1 was prepared following manufacturer’s instruction, and administered to cell cultures. Fluorescence images were acquired with Eclipse Ti-E microscope .Live and dead cells were determined by the LIVE/DEAD3/well) were seeded and cultured in 96-well plate for 24 h. Then, specific treatments were administered together with the detection reagent. Upon loss of membrane integrity, the dye entered the cell and bound to DNA, generating a fluorescent signal. Fluorescence was read with a microplate reader at 8 h, 24 h, 48 h and 72 h after treatments.The assessment of apoptosis was performed using the RealTime-Glo™ Annexin V Apoptosis and Necrosis Assay, a live-cell (non-lytic) real-time (kinetic) assay that measures the exposure of phosphatidylserine (PS) on the outer leaflet of the cell membrane during the apoptotic process. GECs and GBM cells  were seeded and cultured in 96-well plate for 24 h and then submitted to specific treatments. After 72 h, Caspase-Glo® 3/7 Reagent was added as an “add-mix-measure” format resulting in cell lysis, followed by caspase cleavage of the substrate and generation of a “glow-type” luminescent signal, proportional to the amount of caspase activity, produced by luciferase. Luminescence was read with a microplate reader.Caspase 3/7 activity was evaluated by the luminescent assay Caspase-Glo4/well) and cultured in basal condition or with specific treatments. Cord formation was monitored with an inverted Eclipse Ti-E microscope (Nikon Instruments). After 24 h of incubation, five random images were acquired and analyzed with the “Angiogenesis Analyzer” plugin in ImageJ 26.μ-Plate Angiogenesis 96-Well (Ibidi) were coated with 12.5 mg/mL Matrigel , 10 μL/well, at 4 °C. After gentle agitation to ensure complete coating, plates were incubated for 30 min at 37 °C to allow Matrigel solidification. GECs were then seeded  into Ibidi Culture-Inserts (Ibidi). and cultured until 95% confluence was reached. After that, the inserts were removed, and cells were stained with 1 mg/mL Calcein AM (Thermo Fisher Scientific) for 30 min at 37 °C. Then, fresh EndoPM was added in the presence of pharmacological treatments, as previously described. After 24 h, images of GECs that migrated into the cells-free gap were acquired with an inverted Leica DMI6000B widefield microscope at 20× magnifications in five random fields. Cells migrated into the gap were than counted using “Analyze Particles” in ImageJ.GECs were seeded (1 × 105/well) were seeded into 25 cm2 collagen-coated culture flasks. When 90% confluence was reached, or at the end of the above listed treatment, total RNA was extracted following TRI-Reagent protocol and quantified with NanoDrop 1000 Spectrophotometer (Thermo Fisher Scientific). Reverse transcriptase reaction was executed using TranScriba Kit (A&A Biotechnology), loading 1 μg of RNA (A260/A280 > 1.8), according to the manufacturer’s instructions. qRT-PCR was performed using StepOnePlus™ (Thermo Fisher Scientific), 1 μg of cDNA, forward and reverse primers (250 nM each) (−ΔΔCt method.GECs (1 × 10nM each)  and Powe5) were seeded into a 25 cm2 collagen-coated culture flasks precoated with Collagen Bovine Type I and cultured until they reached the appropriate confluence (about 80–90%). Then, cells were lysed with M-PER Protein Extraction Reagent (Thermo Fisher Scientific) in the presence of Halt Protease Inhibitor Cocktail (Thermo Fisher Scientific). Proteins were quantified by the Pierce Detergent Compatible Bradford Assay Kit (Thermo Fisher Scientific). Protein lysates (30 mg) were separated in Bolt 10% Bis-Tris Plus Gels (Thermo Fisher Scientific) in Mini Gel Tank (Thermo Fisher Scientific) and transferred onto nitrocellulose iBlot 2 Transfer Stacks using iBlot 2 Dry Blotting System (Thermo Fisher Scientific). After transfer, the membrane was blocked in Tris-buffered saline/Tween 20 þ 5% milk solution and incubated separately with anti-RAS (Santa Cruz Biotechnology), anti-HIF1a (Thermo Fisher Scientific), anti-BAX (Thermo Fisher Scientific), anti-BCL2 (Thermo Fisher Scientific), anti-SPHK1 (Santa Cruz Biotechnology), anti-S1PR1 (Santa Cruz Biotechnology) and anti-CERS (Abcam), overnight at 4 °C. After incubation with HRP-labeled secondary antibody , protein bands were scanned with SuperSignal West Pico PLUS Chemiluminescent Substrate (Thermo Fisher Scientific) and detected by ChemiDoc XRSþ . Densitometric analysis were performed using ImageJ.GECs . Parameters were compared and analyzed by a one-way analysis of variance. When significant differences were detected, Dunnet post hoc comparisons versus control group were made. Differences were considered statistically significant for The clinical and molecular features of patients and their respective glioblastoma tissues are provided in The assessment of GEC viability by MTT assay showed that the most significant effect of MET manifested at the concentration of 20 mM, with a 50% decrease in viable cells, whereas no appreciable effect was observed with MET at 5 mM and 10 mM. This result was confirmed by the combined treatment with TMZ, which exerted the highest efficacy with MET at 20 mM .To select the best concentration of MET in terms of cytotoxicity, we further increased the concentration to 50 mM, monitoring GEC viability by optical microscope. As seen in In order to confirm this observation, we performed a Live/Dead assay, to optimize the estimation of non-viable cells. The representative images in These preliminary results suggested to us to continue the experiments using the optimal concentration of MET 20 mM, to avoid necrotic events. Therefore, we evaluated MET effect on GEC proliferation. The results A revealeWith the aim of combining the viability data with those relating to the cellular apoptosis, we evaluated the apoptotic mechanism by annexin V and caspase 3/7 activity . The annThe effect of MET alone or in combination with TMZ was also tested on GBM cells, confirming the pro-apoptotic efficacy of MET, especially in combination with TMZ . NotablyIn order to evaluate the impact of MET on angiogenesis, we then performed a tube-like formation assay , which mIn addition, migration assay revealed that the administration of MET, both alone and in combination with TMZ, resulted in a significant decrease of the number of cells migrated into the gap .Finally, with the aim of investigating a potential molecular mechanism underlying the effect of MET, a gene expression screening was performed. The results revealed a down-regulation of proliferative signaling pathways  and anti-apoptotic mediators (Bcl-2), as well an up-regulation of onco-suppressor genes  and pro-apoptotic mediators (Caspases and Bax-family) A,B.In addition, and intriguingly, the evaluation of gene expression of sphingolipid metabolism and signaling revealed that MET treatment induced an up-regulated expression of genes encoding enzymes responsible for ceramide biosynthesis, and a down-regulation of mediators involved in S1P signaling .Gene expression data were confirmed by protein analysis conducted by Western Blot on the key mediators of identified pathways, which support the downregulation of proliferative markers, the upregulation of pro-apoptotic mediators and the suppression of S1P oncopromoter signaling toward a pro-apoptotic one .Several studies performed in the last century demonstrated that MET was able to decrease fasting and post-fasting glucose, insulin resistance and glycated hemoglobin , leadingFurthermore, researchers of our teamwork previously found that MET enhances TMZ effect on TMZ-sensitive cell line (U251) and overcomes TMZ-resistance in T98G GBM cell line. This effect was mediated by the increase of pro-apoptotic mechanisms mediated by Bax family and the reduction of reactive oxygen species (ROS) production . FurtherHowever, the main limit of previous studies may be the use of commercial cell lines, which did not account for the molecular characteristic of individual patients. Here, we tested the effect of MET in patient-specific ex vivo models, suggesting the potential of early prediction of patient response to a combined treatment, thus optimizing the therapeutic approach. Of relevance, we used a peculiar model, the endothelial glioblastoma component, whose contribution in glioblastoma progression and therapy resistance is now clearly established, and under investigation for anti-angiogenic target therapy.Our data demonstrate that MET is able to inhibit GEC proliferation with a time- and dose-dependent trend, suggesting the possibility to adjust the therapeutic administration to optimize safety, tolerability, and patient’s outcome. Furthermore, the proved ability of the optimal dose of MET in promoting cell apoptosis by activating caspases, without producing necrotic events, may imply the specificity against GECs presenting aberrant proliferation. In GBM cells, the ability of MET to decrease cell viability and induce apoptosis was confirmed, but in this case, we observed a higher efficacy of TMZ, which was exacerbated by the combined treatment. These data confirmed the heterogeneity of GBM cell components, whose different response to therapy corroborates the necessity of a multitargeted therapeutic approach.The gene expression screening confirmed the inhibition of proliferative pathways, as those mediated by Akt and MAPK Raf, Ras, Mek-1, and Erk-1, as well the decrease of anti-apoptotic mediators as Bcl-2. These results were concomitant to the up-regulation of caspases, pro-apoptotic mediators, as Bax and Bid, and tumor suppressor genes as p53, p21 an p27.TP53 encodes a transcription factor that is a critical barrier to carcinogenesis. Inactivation of TP53 is the most common mutation in sporadic human cancers, suggesting a strong selection against p53 function during tumorigenesis. p53 is thought to act as a tumor suppressor by serving as a cellular stress sensor. The inheritance of a mutant TP53 allele is observed in Li-Fraumeni syndrome, predisposing patients to early onset of cancer development, further underscoring the role of p53 in tumor suppression [The Ras/RAF/MEK/ERK (MAPK) signaling represent one of the best-characterized pathways in cancer biology, and its hyperactivation is associated to more than 40% of human cancers. The signaling by MAPK promotes cellular overgrowth by turning on proliferative genes, and simultaneously enables cells to overcome metabolic stress by inhibiting AMPK signaling. Mechanistically, upon binding of RTKs or other stimulations, Ras small GTPases are activated by GTP/GDP exchange factors (GEFs), which in turn recruit RAF/MEK complexes to the plasma membrane, and trigger the RAF/MEK/ERK kinase cascade through facilitating RAF/RAF (or KSR), RAF/MEK, and MEK/MEK interactions as well as subsequent phosphorylation . Active pression . Similarpression .Notably, these reported effects of MET were enhanced by the co-administration with TMZ, advancing the promising synergistic anti-cancer activity of MET as add-on therapy.The exploration of scientific literature reporting MET activity disclosed its effect in influencing sphingolipid metabolism, improving oxidative stress status , as wellOur previous studies reported that S1P plays pleiotropic functions in gliomagenesis ,26,49,50In this contest, we found that MET determines the up-regulation of genes coding enzymes that mediate the catabolic process of S1P into sphingosine, the S1P phosphatases, as well as those responsible for Cer production, as the Cer synthases. This effect was accompanied by the simultaneous down-regulation of the enzyme mediating Cer degradation, as the acid ceramidases, and S1P production and signaling, i.e., S1P kinases, and S1P receptors. These data suggest a sphingolipid-related activity of MET, whose anti-proliferative and pro-apoptotic effects may be due to the shift in the sphingolipid rheostat in favor of Cer. Our data are in line with the observations by Hart et al., which demonstrated that MET blocks hypoxia-induced SphK1, whose high expression was found to promote ovarian cancer progression .Overall, our data support MET efficiency as add-on therapy for the treatment of glioblastoma patients, and the rationale for a combined therapeutic approach involving a totally safe and tolerable drug, whose optimal dose needs to be adjusted to obtain the best clinical outcome .IDH-wildtype glioblastoma, starting from the observed overexpression of mitochondrial markers in IDH-wt glioblastomas undergoing oxidative stress (NCT04945148).However, it should be mentioned that the results of some clinical trials consisting in the administration of MET in glioma patients deserve attention for their controversial outcomes. A recent clinical trial assessed MET efficacy as neo-adjuvant compound together with TMZ and hypofractionated accelerated radio-therapy (HART) in 33 patients with glioblastoma. The study confirmed no adverse effects after the use of MET, confirming its safety and tolerability and validating previous results on favorable outcomes of glioblastoma patients, particularly those with low methylation levels of MGMT (NCT02780024) . HoweverTaken together, the results of this study advance novel insights in the potential use of MET in oncology, suggesting a promising translational relevance, which needs further confirmation and correlation with molecular parameters. The identification of predictive biomarkers of therapy response, and the identification responsive glioblastoma subtypes may really impact clinical practice in terms of personalized therapeutic approaches.


Antibiotics are among the most prescribed drugs in the neonatal intensive care unit (NICU), but frequently are used inappropriately exposing preterm neonates to additional harm. Antibiotic stewardship programs (ASP) have demonstrated impact on antibiotic use in the hospital setting, but implementation in neonatal units is challenging. We sought to determine the effects of weekly antibiotic rounds on overall antibiotic consumption in the NICU. Single-center, retrospective observational study. In November 2014, we implemented weekly antibiotic rounds in a 60-bed tertiary-care NICU, led by a pediatric infectious disease physician. Antibiotic therapy decisions were made in collaboration with neonatologists. Data collected included the proportion of patients receiving antibiotics, irrespective of the indication. Multimodal ASP was implemented hospital-wide in 2015. Antibiotic consumption was measured with days of therapy (DOT). Data on costs and in-hospital mortality were obtained from pharmacy and hospital records. From November 2014 to December 2020, we evaluated 13609 neonates admitted to the NICU during rounds. Of those, 3607 (27%) were receiving at least one antibiotic. Overall, the proportion of patients with antibiotics decreased from 31% to 19% during the study period (p< 0.001). In 2017, an outbreak of neonatal necrotizing enterocolitis (NEC) occurred. Specific countermeasures as well as reinforcement of ASP were implemented. Despite Antibiotic usage by DOT increased in 2017 driven by empiric treatment with piperacillin tazobactam in patients with NEC, overall antibiotic consumption decreased from 254.4 DOT/1000 patient days (PD) to 162.4 DOT/1000 PD . Annual costs from antibiotic prescriptions were US&23,161 in 2015 and decreased to US&12.046 in 2020 saving over US&3,800/year (fig 2a). During the study period, we did not observe an increase in crude in-hospital mortality rate . Primary Y axis indicates the proportion of patients with at least one antibiotic prescription during rounds. Secondary Y axis indicates antibiotic consumption by days of therapy metrics.Antibiotic prescription costs and NICU mortality rates during study periodA. Annual antibiotic prescription costs; B. NICU mortality rateWeekly antibiotic rounds led to a significant decrease in antibiotic utilization in our NICU. This strategy is relatively simple and low-cost, saves hospital resources and has a large impact on antibiotic use. Hence, its implementation is encouraged as part of successful antimicrobial stewardship programs. All Authors: No reported disclosures


It is difficult to distinguish between multicentric Castleman’s disease (MCD) and IgG4-related lung disease (IgG4-LD), an IgG4-related disease (IgG4-RD) in the lung.We focused on IL-6, which is elevated in MCD, to distinguish between MCD and IgG4-LD by RNAscope, a highly sensitive RNA in situ method. Six cases of MCD and four cases of IgG4-LD were selected.IL-6 expression was observed in all MCD and IgG4-LD cases except for one IgG4-LD biopsy. IL-6-expressing cells were mainly identified in the stroma. Sites of IL-6 expression were not characteristic and were sparse. IL-6 expression tended to be higher in MCD compared with IgG4-LD. A positive correlation was found between the IL-6 H-score and serum IL-6 level.In all cases of MCD and IgG4-LD, 10 or more IgG4-positive cells were found in one high-power field. All MCD cases were inconsistent with the pathological IgG4-related comprehensive diagnostic criteria, but 2 of 6 cases had an IgG4/IgG ratio greater than 40%. In all IgG4-LD cases, histological features were consistent with the pathological IgG4-RD comprehensive diagnostic criteria. IL-6 expression may help distinguish between MCD and IgG4-LD. In addition, the presence of high IL-6 levels may help elucidate the pathological mechanisms of IgG4-LD.Differences in  IgG4-related disease (IgG4-RD) is characterized by mass lesions, elevated serum IgG4, IgG4-positive lymphoplasmacytic infiltration into affected organs, and fibrosis termed storiform fibrosis. Recently, cases of increased serum IgG4 , 2 and IFurthermore, reports of MCD and IgG4-related lung disease (IgG4-LD), an IgG4-RD and IgG4-related respiratory disease in the lung , both ofThis study was conducted in accordance with the Declaration of Helsinki and was approved by the ethics committee of Shinshu University School of Medicine . At Shinshu University Hospital, Matsumoto, Japan between 2008 and 2020, specimens of IgG4-LD and MCD in lung were selected.Six MCDs were selected, three of which were resected specimens and three of which were biopsy specimens. Four cases of IgG4-LD were selected, two of which were resected specimens and two of which were biopsy specimens. Clinicopathological data were obtained from medical records. Materials used for evaluation were archived formalin-fixed paraffin-embedded tissues. Two pathologists (T.U. and M.I.) re-evaluated the histological features of all specimens.IL-6 mRNA was detected using an RNAscope kit , as previously described [IL-6 expression was quantified on the basis of a five‐grade scoring system recommended by the manufacturer . The H‐score was calculated as: (% of grade 1 cells × 1) + (% of grade 2 cells × 2) + (% of grade 3 cells × 3) + (% of grade 4 cells × 4). The overall H‐score for each patient was calculated on the basis of the H‐score per high‐power field (400× magnification).escribed . IntraceP value less than 0.05 was considered statistically significant.Pearson’s chi-squared test, Wilcoxon rank sum test, and Spearman rank correlation test were analyzed by JMP Statistics software version 13 . A Table Lymphoplasmacytic infiltration was observed in MCD and IgG4-LD Fig. a, d. HowIL-6 mRNA in situ was performed, but one case with MCD was excluded due to negative internal control. IL-6 expression was identified in all MCD and IgG4-LD samples except for one IgG4-LD biopsy  that IL-6 expression is an important factor in MCD and is related to symptoms [IL-6 expression in tissues may be useful for the accurate diagnosis of MCD. Although IL-6 expression was also observed in IgG4-LD, there was a relatively different IL-6 H-score between MCD and IgG4-LD; therefore, expression analysis by RNAscope may be useful for differentiating between MCD and IgG4-LD, especially when serum IL-6 data are not available.Because There have been several reports of increased IgG4-positive plasma cells by the histopathological analysis of clinicopathologigally diagnosed with MCD , 11. In Clinicopathologically, increased IL-6 levels were reported in IgG4-RD  and IL-6The concept of an “MCD-like” subtype of IgG4-RD, which has the characteristics of MCD and IgG4-LD, has been proposed . FurtherIL-6 negative by the RNA in situ method [IL-6 positivity. Another study reported that IL-6 was positive in situ [IL-6 in situ depends on the conditions at the time of staining, including the number of storage years and storage conditions.Several studies have reported IL-6 expression in MCD and IgG4-RD by immunostaining and RNA in situ , 21. Altu method . In deta in situ . HoweverThis study had some limitations. These diseases are rare and the number of MCD and IgG4-LD samples was low in this study; therefore, further case accumulation is desired. IL-6 is secreted by various immunocompetent cells including T/B lymphocytes, monocytes, fibroblasts, and endothelial cells; however, its role and secreting cell type in MCD are unknown . TherefoIL-6 expression, IL-6 was identified in the affected organs of MCD and IgG4-LD; therefore, differentiation between these diseases should be judged by factors other than IL-6. However, the strong expression of IL-6 may be supporting evidence of MCD. Further investigation of elevated IL-6 expression in IgG4-LD might help elucidate the pathophysiology of IgG4-LD.Regardless of the amount of


Background: The goal of the present study was to estimate the prevalence of patient and physician related variables associated with antibiotic prescriptions in patients diagnosed with acute lower and upper respiratory tract infections (ALURTI), treated in general practices (GP) and pediatric practices, in Germany. Methods: The analysis included 1,140,095 adult individuals in 1237 general practices and 309,059 children and adolescents in 236 pediatric practices, from the Disease Analyzer database (IQVIA), who had received at least one diagnosis of an ALURTI between 1 January 2015 and 31 March 2019. We estimated the association between 35 predefined variables and antibiotic prescription using multivariate logistic regression models, separately for general and pediatric practices. The variables included the proportion (as a percentage) of antibiotics or phytopharmaceuticals on all prescriptions per practice, as an indicator of physician prescription preference. Results: The prevalence of antibiotic prescription was higher in patients treated in GP (31.2%) than in pediatric practices (9.1%). In GP, the strongest association with antibiotic prescription was seen in the practice preference for antibiotic use, followed by specific diagnoses , and higher patient age. In pediatric practices, acute sinusitis and bronchitis were the variables with the strongest association, followed by practice preference for antibiotic prescription. The strongest association with the non-prescription of antibiotics was practice preference for phytopharmaceuticals and the specific diagnosis of a viral infection. Conclusion: This study shows a high prevalence of antibiotic prescribing for patients with ALURTI in a primary care setting, especially in adult patients; physician related factors play an important role that should be addressed in interventions to reduce potentially inappropriate antibiotic prescribing. Common colds, defined as acute lower and upper respiratory tract infections (ALURTI), are benign, self-limiting syndromes that include a group of diseases caused by several virus families. The severity and type of symptoms vary depending on the person and the pathogen . ALURTI Although physicians know that ALURTI are primarily caused by viruses, antibiotics are prescribed in many cases . HoweverData from Germany revealed that 40–45% of all outpatient antibiotic prescriptions were written by general practitioners . Many ofThe goal of the present study was to estimate the prevalence of antibiotic use, and patient and physician related variables associated with antibiotic prescriptions in patients diagnosed with ALURTI, treated in general and pediatric practices in Germany.This study was based on data from the IMS Disease Analyzer database (IQVIA), which contains drug prescriptions, diagnoses, and basic medical and demographic data obtained directly, and in an anonymous format from computer systems used in the practices of general practitioners and specialists, including pediatricians . The datThe analysis included patients who had received at least one diagnosis of ALURTI in 1237 general or 236 pediatric practices between January 1, 2015 and March 31, 2019. These diagnoses included: acute nasopharyngitis (J00), acute sinusitis (J01), acute pharyngitis , acute laryngitis and tracheitis (J04), acute upper respiratory infections of multiple and unspecified sites (J06), acute bronchitis , unspecified acute lower respiratory infection (J22), bronchitis not specified as acute or chronic (J40), cough (R05), and viral infection of an unspecified site (B34).The first ALURTI diagnosis documented during this period was defined as the index date. Only patients who had been observed for a period of at least 12 months prior to the index date were included. Patients with a prescription for antibiotics (ATC code: J01) in the 30 days prior to the index date, and patients diagnosed with a bacterial infection  at or in the 30 days prior to the index date, were excluded from the study .The main outcome of the study was the proportion of patients with ALURTI who received an antibiotic prescription on the day of diagnosis. Additionally, we estimated the association between predefined variables and antibiotic prescription. Variables used included age, sex, health insurance coverage, region (West versus East Germany), ALURTI diagnoses by ICD-10 codes, chronic co-diagnoses documented within 12 months prior to or on the index date (diabetes (ICD-10: E10-14)), ischemic heart disease/heart failure , renal failure , cancer (ICD-10: C00-C98), chronic obstructive lung disease (COPD) (ICD-10: J44), asthma (ICD-10: J45)), diagnosis of a bacterial infection within 365–31 days prior to the index date, and the total number of patients per practice and quarter. Finally, two variables were used to consider the extent of the antibiotic and phytopharmaceutical preference of each practice: average proportion of antibiotic prescription on all prescriptions per practice, and average proportion of phytopharmaceutical prescription on all prescriptions per practice within twelve months prior to the index date.The prevalence of antibiotic prescription was calculated as the number of patients with at least one antibiotic prescription on the index date by the number of all patents with ALURTI.p-value was performed, and a p value of <0.001  was considered statistically significant. Furthermore, results were regarded as relevant or not when the odds ratio (OR) was >1.25 or <0.75, respectively. Fitness of the logistic model was checked using the Hosmer–Lemeshow statistic. As a sensitivity analysis, a random effect of practice was estimated.Patients were grouped by those who had received and those who had not received an antibiotic on the index date. Differences in the sample characteristics between those with and those without antibiotic prescriptions were tested using chi-squared tests for categorical variables and Wilcoxon rank sum tests (Mann-Whitney U test) for continuous variables. A multivariate logistic regression model was conducted to study the association between predefined variables and antibiotic prescription. This model was adjusted for all variables previously listed. Since the regression models contained up to 35 variables, a Bonferroni correction for All analyses were performed separately for patients treated by GPs and by pediatricians (children only). Analyses were carried out using SAS version 9.4 .In total, 1,449,154 individuals  were diagnosed with ALURTI between January 2015 and March 2019, and 384,410 (26.5%) of them had received an antibiotic prescription on the day of diagnosis. The prevalence of antibiotic prescription was higher in patients treated in general (31.2%) than in pediatric practices (9.1%). By GPs, the highest antibiotic prescription prevalence was observed in patients with acute or non-specified bronchitis (54–57%), acute sinusitis (52%), and acute pharyngitis (46%) . InteresWhen an antibiotic was prescribed, macrolides were the most common drug class by GPs (34%), followed by cephalosporins (27%), and penicillins (21%). In pediatric practices, cephalosporins (44%) had the highest proportion, followed by a penicillin (29%), and a macrolide (26%).When comparing baseline characteristics of patients who had and who had not received an antibiotic prescription in general practices, patients receiving antibiotics were slightly older (51 vs. 46 years) and were more often diagnosed with an acute or non-specified bronchitis, pharyngitis, sinusitis, laryngitis and tracheitis. Additionally, they had more often chronic co-diagnoses, were more often treated in practices preferring antibiotic therapy, and less likely in practices preferring phytopharmaceuticals . In pediThe results of the multivariate logistic regression model for GPs are displayed in In pediatric practices , the praThis study, conducted in general and pediatric practices in Germany and based on more than one million individuals, resulted in three key findings. First, the recent prevalence of antibiotic prescription in adults with ALURTI was high (31.2%) and associated with age, coded infection diagnosis, and geography. Second, practice-level variables indicating frequent prescription of antibiotics or phytopharmaceuticals had independent associations with antibiotic prescription prevalence, both in general as well as in pediatric practices. Third, antibiotic prescription prevalence among children with ALURTI was low (< 10%) and associated with coded infection diagnosis, cancer as an underlying disease, and practice size in addition to practice preference for antibiotics.Antibiotics are an important therapy option for bacterial infections and can save lives, provided the correct indication, dose, and duration of therapy. However, in the case of an ALURTI, there is usually no indication for an antibiotic prescription since the majority of such infections are of viral origin, and even in cases of bacterial origin, only a minority of patients benefit from antibiotic treatment. According to a systematic review, there is no difference in the outcomes between patients with immediate and delayed antibiotic use . A more Prescribing physician-level factors may be critically affecting antibiotic prescribing for patients with ALURTI. O’Connor et al., for example, identified that a higher number of patients per day resulting in shorter consultations, as well as a doctors’ professional training and their career stage were significant factors . PracticAn interesting finding in our study was the association between practice preference for phytotherapy and lower antibiotic prescribing rates, both in adults and children. There is some evidence that the use of phytopharmaceuticals could contribute to a reduction in the number of inappropriate antibiotic prescriptions for respiratory infections; in a recent study based on the electronic medical records from approximately 234,000 primary care and pediatric patients in Germany, the use of selected phytopharmaceuticals in ALURTI was associated with a reduced need for antibiotic prescriptions in the further course of the disease . ReviewsA strength of this study is the large sample size. This is, however, also the study limitation, as every minor difference becomes highly significant with large patient samples. Further limitations include the lack of several potentially confounding factors, such as disease severity, patients’ sociocultural variables, and patients’ preference of antibiotics. An additional limitation of the present study was the unavailability of possible point-of-care test results as a possible confounder. We could not assess the coding accuracy and consistency. The fact that explored covariates are very general, in line with the registry intention of the database, should be noted.In addition, the study reflects the German healthcare system, and its results may not be generalizable to other countries.In conclusion, we show a relatively high recent prevalence of potentially inappropriate antibiotic prescribing for adult patients with ALURTI in a primary care setting. Practice related factors, including antibiotic preference, seemed to play an important role in prescribing prevalence and should be studied in more detail in order to design interventions to further reduce inappropriate antibiotic use.