We demonstrate that combined treatment with metformin (Met) or its mitochondria-targeted analog, mito-metformin (Mito-Met), and various iron chelators synergistically inhibits proliferation of pancreatic and triple-negative breast cancer cells. Previously, we reported that Met (at millimolar levels) and Mito-Met (at micromolar levels) inhibited pancreatic cancer cell proliferation. Inhibition of mitochondrial complex I and mitochondrial oxidative phosphorylation (OXPHOS) through stimulation of mitochondrial redox signaling was proposed as a key mechanism for decreased cancer cell proliferation. Because of its poor bioavailability, the use of Met as a “stand-alone” antitumor drug has been questioned. Iron chelators such as deferasirox (DFX) and dexrazoxane (DXR) exhibit antiproliferative effects in cancer cells. The potency of Met and Mito-Met was synergistically enhanced in the presence of iron chelators, DFX, N,N'-bis(2-hydroxyphenyl)ethylendiamine-N,N'-diacetic acid (HBED), and deferoxamine (DFO). Met, DXR , and DFO are FDA-approved drugs for treating diabetes, decreasing the incidence and severity of cardiotoxicity following chemotherapy, and mitigating iron toxicity, respectively. Thus, the synergistic antiproliferative effects of Met and Met analogs and iron chelators may have significant clinical relevance in cancer treatment. These findings may have implications in other OXPHOS-mediated cancer therapies. Galega officinalis and an FDA-approved drug, is one of the most widely used antidiabetic drugs (+) were synthesized and characterized . Alt. AltGalecterized . The Mit in vivo .e.g., Met or Mito-Met) will induce synergistic antiproliferative effects in cancer cells. Tumor cells have different levels of hypoxic areas, with the central core exhibiting maximal hypoxia ) dose-dependently decreased the survival fraction of MDA-MB-231 breast cancer cells (not shown).We determined the synergistic antiproliferative effects of the iron chelator, DFX, and Met on breast cancer cells. Triple-negative breast cancer cells, MDA-MB-231, and brain homing breast cancer cells, MDA-MB-231-BR, were treated with Met or DFX alone and together. Cell proliferation was monitored in real time and showed that the combination of DFX and Met inhibits more than additively . Other ileft) and Mito-Met (right) and the iron chelator, HBED, either alone or in combination in pancreatic cancer cells, MiaPaCa-2. At the concentration of the compounds, which had only modest effects when used alone, the combination of Met or Mito-Met with HBED chelator led to stronger antiproliferative effects. Next, we investigated the concentration-dependent effect of the combination of the above compounds on cell proliferation. The cell confluence (as control groups reach 90% confluency) was plotted against the concentrations of the drugs. left) and Mito-Met and HBED (right), alone and in combination. (left) and Mito-Met (right) exert synergistic inhibition of cell proliferation at several concentrations (1–10 μM) of HBED.We monitored the effect of the compounds studied on the proliferation of MiaPaCa-2 pancreatic cancer cells in real time using the IncuCyte Live-Cell Imaging system. left), the number of colonies formed in the presence of Met and HBED was decreased. The survival fraction was calculated and a significant decrease in survival of MiaPaCa-2 cells was obtained, with the strongest and statistically significant inhibition observed when the drugs were combined (right). left and right) shows that Mito-Met and HBED also significantly decreased pancreatic cancer cell colony formation, except that Mito-Met was effective at micromolar concentrations as compared with Met, present at millimolar levels. Mito-Met is nearly 1,000-fod more effective than Met.MiaPaCa-2 cells were treated with Met or Mito-Met in the presence of HBED, and the number of colonies formed was counted. As shown in combined , right. Because iron chelators and Met analogs effectively induced synergistic inhibitory effects on cancer cell proliferation, we tested their effects under these conditions on mitochondrial function , 6B. As 2·–)-specific probe, hydroethidine (HE), was used to detect Mito-Met-induced superoxide generated by inhibiting complex I in MiaPaCa-2 cells , and peroxidase-catalyzed formation of dimers (diethidium [E+-E+]) (The superoxide (O-2 cells  20]. In. In2·–)-[E+-E+]) , 7B. Inc2) [2) on the antiproliferative potency of DFX in MiaPaCa-2 cells. As shown in 2). However, under hypoxic conditions (1% O2), the inhibitory effect on cell proliferation was abolished (2 (It was reported that the effect of iron chelator DFX observed at low oxygen levels is not the same as those obtained under high oxygen levels in human glioblastoma cells . For exa2) . Thus, wbolished . This isished  enhance metastasis of tumors by decreasing ROS . Iron ch+ [Metformin is weakly cationic and targets mitochondria, inhibiting complex I-dependent respiration in cancer cells . However+ . The mit+ . Mito-Me+ .e.g., doxorubicin, cyclophosphamide, and cisplatin or carboplatin) in the treatment of triple-negative breast cancers has previously been reported [in vitro and in vivo prior to being translated to the clinic.Synergism between the iron chelator, DFX, and conventional cytotoxic chemotherapeutics  will not only decrease the tumor proliferation (as discussed in this work) but could potentially protect cardiomyocytes against oxidative damage. Heart problems in doxorubicin-treated cancer patients do not manifest until many years post chemotherapy [Another aspect of Met analogs and iron chelators therapies of cancers is that both Met and DXR have exhibited cardioprotective effects in human and animal studies –49. Thusotherapy –52. Chilotherapy .e.g., Triapine) show promise in cancer therapy, copper chelators such as penicillamine revealed an antitumor effect [Both iron and copper are important for cancer cell proliferation . Whereasr effect . It has r effect , 56. In r effect , and thir effect . Based oMito-Met was synthesized and purified as reported previously . Iron ch2) in Dulbecco’s Modified Eagle Medium  supplemented with 10% fetal bovine serum, 100 units/ml penicillin, and 100 μg/ml streptomycin .Human MiaPaCa-2 pancreatic cancer and wild-type and brain homing MDA-MB-231 breast cancer cells were purchased from ATCC . All cells were kept frozen in liquid nitrogen and were used within 20 passages after thawing. The cells were cultured under standard conditions , as described previously . ChangesFor clonogenic assay, cells were seeded as indicated in six-well plates and treated with Mito-Met or Met for 24 h. The plates were placed within the incubator and the cell culture media changed every 3–4 days until the control (untreated) cells formed sufficiently large clones. The cell survival fractions were calculated as previously reported .e.g., pyruvate/malate for complex I and succinate for complex II. Rotenone, malonate, and antimycin A were used as specific inhibitors of mitochondrial oxygen consumption at complexes I, II, and III, respectively.The mitochondrial function was measured in real time using a Seahorse XF96 Extracellular Flux Analyzer . Assays in intact cells were performed as reported previously . The OCR+, formed from HE reaction with O2·– was prepared by reacting HE with Fremy’s salt [+ , was purchased from Sigma-Aldrich . The dimeric product (E+-E+) was prepared by oxidizing HE with excess ferricyanide [ROS were measured using the probe, HE. A stock solution of HE (20 μM) was prepared in deoxygenated dimethyl sulfoxide and stored in the dark at −80°C until use. Previously, we showed that a global analysis of oxidation products derived from HE provides a better picture of oxidants generated intracellularly. To this end, we characterized the various oxidation products from HE using the appropriate standards , 66. They’s salt . The nonicyanide . All sta18 column.HPLC and liquid chromatography–mass spectrometry (LC–MS/MS) analyses were performed as previously described . Brieflye.g., cell cycle arrest and cell cycle dysregulation, disruption of mitochondrial redox signaling, topoisomerase inhibition and DNA damage, activation of tumor suppressor genes, endoplasmic reticulum stress, and autophagic pathways) are involved [In this study, we report that the combined use of iron chelators, some of which are FDA-approved drugs, and Met analogs synergistically inhibits proliferation of pancreatic and breast cancer cells. Iron chelators previously have been shown to inhibit cancer cell proliferation when combined with conventional cytotoxic chemotherapeutics , 39, 59.involved –64.


There is ongoing debate on the clinical benefits of antibiotic prophylaxis for reducing pelvic infection after miscarriage surgery. We aimed to study the cost-effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in low-income countries.We did an incremental cost-effectiveness analysis using data from 3412 women recruited to the AIMS trial, a randomised, double-blind, placebo-controlled trial designed to evaluate the effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in Malawi, Pakistan, Tanzania, and Uganda. Economic evaluation was done from a health-care-provider perspective on the basis of the outcome of cost per pelvic infection avoided within 2 weeks of surgery. Pelvic infection was broadly defined by the presence of clinical features or the clinically identified need to administer antibiotics. We used non-parametric bootstrapping and multilevel random effects models to estimate incremental mean costs and outcomes. Decision uncertainty was shown via cost-effectiveness acceptability frontiers. The AIMS trial is registered with the ISRCTN registry, number ISRCTN97143849.Between June 2, 2014, and April 26, 2017, 3412 women were assigned to receive either antibiotic prophylaxis (1705 [50%] of 3412) or placebo (1707 [50%] of 3412) in the AIMS trial. 158 (5%) of 3412 women developed pelvic infection within 2 weeks of surgery, of whom 68 (43%) were in the antibiotic prophylaxis group and 90 (57%) in the placebo group. There is 97–98% probability that antibiotic prophylaxis is a cost-effective intervention at expected thresholds of willingness-to-pay per additional pelvic infection avoided. In terms of post-surgery antibiotics, the antibiotic prophylaxis group was US$0·27 (95% CI −0·49 to −0·05) less expensive per woman than the placebo group. A secondary analysis, a sensitivity analysis, and all subgroup analyses supported these findings. Antibiotic prophylaxis, if implemented routinely before miscarriage surgery, could translate to an annual total cost saving of up to $1·4 million across the four participating countries and up to $8·5 million across the two regions of sub-Saharan Africa and south Asia.Antibiotic prophylaxis is more effective and less expensive than no antibiotic prophylaxis. Policy makers in various settings should be confident that antibiotic prophylaxis in miscarriage surgery is cost-effective.UK Medical Research Council, Wellcome Trust, and the UK Department for International Development. Globally, about 210 million pregnancies are estimated to occur annually, 90% of which are in low-income countries.By contrast, sufficient evidence to support the routine use of antibiotic prophylaxis in the surgical management of miscarriage is scarce,In response to this, the Antibiotics In Miscarriage Surgery (AIMS) trial was jointly funded by the UK Medical Research Council, the Wellcome Trust, and the UK Department for International Development, as part of the Joint Global Health Trials Scheme, to evaluate the effectiveness of antibiotic prophylaxis during the surgical management of miscarriage in low-income countries. Here, we use data from the AIMS trial to determine the relative cost-effectiveness of antibiotic prophylaxis compared with placebo in the surgical management of miscarriage based on the outcome of cost per pelvic infection avoided within 2 weeks of surgery.Evidence before the studyIn low-income countries, the surgical removal of miscarriage tissues is the most common method of miscarriage management. To date, national and international guidelines on the surgical management of miscarriage do not recommend the use of prophylactic antibiotics to reduce the risk of pelvic infection. Infections after miscarriage surgery are frequent in low-income settings and have been associated with clinically significant morbidity and mortality implications. A Cochrane review showed no previous high quality evidence of effectiveness, with four small single-centered studies showing no significant benefit from prophylactic antibiotics. The AIMS trial provided evidence on the role of antibiotic prophylaxis in miscarriage surgery.Added value of this studyTo our knowledge, this study is the first to assess the cost-effectiveness of antibiotic prophylaxis relative to placebo in women undergoing surgical management of miscarriage in low-income settings. We find that antibiotic prophylaxis in the surgical management of miscarriage is cost-effective and provides substantial economic and health benefits.Implications of all the available evidenceFor clinicians and policy makers there is now evidence of both clinical and cost-effectiveness. Our interpretation is that this new evidence should result in the recommendation that, in low-resource settings, antibiotic prophylaxis should be administered before miscarriage surgery. Guidelines on the management of miscarriage should be updated on the basis of this evidence.The AIMS trial was a multinational randomised, double-blind, placebo-controlled trial. Detailed information about the trial design and participants can be found in the published trial protocol9 cells per L, with no other recognised cause of infection, or only one of these four clinical features if there was a clinically identified need to administer antibiotics for the treatment of a presumed pelvic infection.The outcome of the AIMS trial was pelvic infections avoided within 2 weeks of surgery. As per trial protocol, pelvic infection was determined in the presence of two or more of the following clinical features: purulent vaginal discharge, pyrexia (>38°C), uterine tenderness on examination, and white cell count of more than 12 × 10Resource use information was collected prospectively via case report forms. Forms were completed on at least one occasion before discharge after surgery, at every contact assessment during the follow-up period, daily whilst an inpatient, and at final assessment. Resource use information was collected from the perspective of the health-care provider and included antibiotics and medications related to pain, allergy, diarrhoea, vomiting, nausea, malaria, and fever as well as inpatient hospital stays, outpatient visits, laboratory examinations, and treatment of complications for which antibiotic prophylaxis could potentially offer a clinical benefit. Such complications were haemorrhage requiring blood transfusion, repeat uterine evacuation, and anaphylaxis. Other rare complications, such as uterine perforations, were not considered as they do not relate to antibiotic prophylaxis and were expected to equally appear in both groups of the trial.We calculated the cost associated with the use of antibiotics and other commonly prescribed medications on the basis of established dosage regimens and patient-specific duration of treatment. Mean unit costs were obtained from the International Drug Price Indicator Guide,To standardise unit costs across countries in cases where data were not available, an index table was used to indicate the relative mean cost of tertiary and secondary inpatient and outpatient hospital services for each country-pair in the study, based on the WHO-CHOICE estimates . This maEvidence suggests that health-care service provision and patient outcomes differ across different hospitals within one country and across countries,We did an incremental cost-effectiveness analysis to compare the costs and outcomes associated with the two groups of the trial. To account for the inherent uncertainty around cost-effectiveness point estimates, we used non-parametric bootstrapping with multilevel models to generate 1000 paired estimates of incremental mean costs and outcomes adjusted for age, marital status, gestational age, previous miscarriage or stillbirth, evidence of induced abortion, HIV status, type of miscarriage surgery, cadre of surgeon , and residential characteristics. We used the bootstrapping results to derive cost-effectiveness acceptability frontiers,The economic evaluation relied on available case analysis since only 74 (2%) of 3412 women were censored at 2 weeks follow-up. Given that group allocation was found to be a predictor of missingness in the AIMS trial data ,34We did subgroup analyses to assess the relative cost-effectiveness of antibiotic prophylaxis for each participating country, for the different types of miscarriage (incomplete and missed miscarriage), for the different types of miscarriage surgery , and for different gestational age groups (<12 weeks and ≥12 weeks). To assess the robustness of the main study findings, we did a sensitivity analysis using published regional unit cost estimates for each participating country .18 We usThe funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.Between June 2, 2014, and April 26, 2017, 3412 women with a median age of 25 years (IQR 18–31) were recruited across Malawi (2145 [63%] of 3412), Pakistan (353 [10%]), Tanzania (210 [6%]), and Uganda (704 [21%]), and were assigned to receive either antibiotic prophylaxis (1705 [50%] of 3412) or placebo (1707 [50%] of 3412). Of the 3412 women recruited, 2876 (84%) were married, 2352 (69%) lived in an urban area, and 2086 (61%) were unemployed or in a housewife role. In terms of residential characteristics, 1060 (31%) women were living in rural areas, 589 (17%) had a flushing toilet, and 772 (23%) had non-shared piped and tapped water. 1262 (37%) of 3412 reported that they had problems getting the food they need sometimes or more often. 696 (21%) of 3412 women had previously had a miscarriage or stillbirth. Further information is available in the 158 (5%) of 3412 women developed pelvic infection within 2 weeks of surgery. Of these women, 68 (43%) were in the antibiotic prophylaxis group and 90 (57%) in the placebo group. The absolute risk difference between antibiotic prophylaxis and placebo per woman was −1·3% . The figure shows the probability of antibiotic prophylaxis being cost-effective across a range of willingness-to-pay values per additional pelvic infection avoided in the main and secondary analyses. Antibiotic prophylaxis has a more than 80% probability of being cost-effective for any willingness-to-pay value below $20 per pelvic infection avoided . Pelvic This study assessed the cost-effectiveness of antibiotic prophylaxis relative to placebo in women undergoing surgical management of miscarriage in low-income settings. The findings show that the provision of antibiotic prophylaxis before miscarriage surgery results in fewer pelvic infections within 2 weeks of surgery and lower costs than the current practice of no antibiotic prophylaxis. Our analysis concluded that there is a 97–98% probability that antibiotic prophylaxis is a cost-effective intervention at expected thresholds of willingness-to-pay per additional pelvic infection avoided. This finding could translate to an annual total cost saving of up to $1·4 million if antibiotic prophylaxis was used routinely before miscarriage surgery across the four participating countries  and a saving of up to $8·5 million across the two regions  of 3412 women were censored at 2 weeks after miscarriage surgery, women in the antibiotic prophylaxis group were more likely to be missing. This finding could be attributed to the small number of women lost to follow-up, or it might indicate better effectiveness for antibiotic prophylaxis, but a worst-case scenario was used for analysis. For this calculation, costs for censored women were multiply imputed assuming the presence of pelvic infection. This analysis concluded that, at expected thresholds of willingness-to-pay per additional pelvic infection avoided, there is 88–89% probability that antibiotic prophylaxis is cost-effective.Current international guidelines recommend the use of prophylactic antibiotics in abortion surgery but not in miscarriage surgery. Our findings lend strong support on the cost-effectiveness of antibiotic prophylaxis before miscarriage surgery. Policy makers in various settings should be confident that providing prophylactic antibiotics in the surgical management of miscarriage is a good use of their restricted health-care budgets. Decision making guidelines on miscarriage management should be updated to reflect the findings of this study and the efficacy evidence from the AIMS trial.Any data requests for the clinical data should be made to the corresponding author of the AIMS clinical paper.


Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disease characterized by elevated serum IgG4 levels with infiltration of IgG4+ plasma cells and severe fibrosis in affected tissues. Recently, idiopathic fibrosing mediastinitis (FM), an extremely rare fibroinflammatory disorder, has been recognized as a form of IgG4-RD. As IgG4-RD can be treated by glucocorticoids, identification of the etiology of FM by surgical biopsy is essential; however, mediastinal biopsy is often difficult. We report 2 cases of IgG4-related FM successfully diagnosed with computed tomography (CT)-guided percutaneous needle biopsy.Case 1 was a 66-year-old woman with elevated serum C-reactive protein without any symptoms and case 2 was 78-year-old woman with abnormal mediastinal contour on chest x-ray. By further work-up, both cases were found to have mediastinitis accompanied by elevated serum IgG4. CT-guided percutaneous needle biopsy revealed massive infiltration of IgG4+plasma cells along with storiform fibrosis.IgG4-related FM.Glucocorticoid therapy.The treatment resulted in significant improvement of the lesions after 3 months.Early recognition and diagnosis of IgG4-related FM is essential because a delay in appropriate treatment initiation leads to progressive fibrosis with irreversible organ damage and poor prognosis. Our cases highlight CT-guided percutaneous needle biopsy as a promising option for histological examination in patients with IgG4-related FM. IgG4-RD frequently involves the pancreas, lacrimal glands, salivary glands, bile duct, kidneys, lungs, and retroperitoneum, but can potentially affect any organ.Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disease characterized by elevated serum IgG4 levels, infiltration of IgG4,3 FM can be classified as idiopathic or secondary based on its etiology, and identification of the etiology is clinically important for selecting the correct treatment. Delay in diagnosis and initiation of appropriate treatment for FM results in irreversible organ damage, which can lead to severe disability and poor prognosis.,3Fibrosing mediastinitis (FM) is one of the rare fibroinflammatory diseases that affects the mediastinum. As IgG4-RD is treatable with glucocorticoids, clinicians should recognize FM and perform a biopsy to identify the etiology. However, surgical biopsy in patients with FM is often difficult if a lesion's location is paravertebral or adjacent to vital organs. Additionally, FM usually affects the elderly, who often have comorbidities.Recently, IgG4-RD has been linked to some cases of “idiopathic” FM, which is now called “IgG4-related FM.”We report 2 cases of IgG4-related FM successfully diagnosed with low-invasive computed-tomography (CT)-guided percutaneous needle biopsy.Ethical approval was waived according to the regulations in Japan. Informed consent were obtained from the patients.22.1TB , antinuclear antibody (ANA), rheumatoid factor (RF), and anti-neutrophil cytoplasmic antibody (ANCA) were negative. C3 and C4 were within the normal range. Serum interleukin-6 (IL-6) level was elevated . Blood cultures did not identify any pathogens. Antibodies to syphilis were negative. Urinalysis showed no proteinuria, hematuria, white blood cells, or casts. Chest x-ray revealed small pleural effusions. A contrast-enhanced CT demonstrated interval enlargement of the mass around the aorta and development of left hydronephrosis  of prednisolone (PSL) as induction therapy. Kidney ultrasound performed 14 days after initiation of therapy revealed improvement of the left hydronephrosis. After 3 months, the levels of serum IgG4 and CRP had decreased to 78 and 0.06 mg/dL, respectively. CT findings also revealed remarkable improvement of the mass around the thoracic aorta and of the hydronephorosis   at a regular checkup without any symptoms in June 2017. CT findings revealed a soft tissue mass involving the aortic root, aortic arch, descending thoracic and abdominal aorta, and left iliac artery. Paraaortic mass lesions were identified adjacent to the thoracic spine. She was admitted to our hospital for further workup. Physical examination revealed a normal blood pressure of 138/88 mmHg and body temperature of 36.6 °C. The findings of ocular, face, neck, lungs, cardiovascular, abdominal, neurological, and skin examinations were normal. Laboratory tests showed elevated serum IgG , IgG4 , and soluble interleukin-2 receptor . Serum immunoglobulin E (IgE) level was within the normal range. Other blood tests including blood count, serum electrolytes, liver enzyme levels, and serum creatinine were within the normal range. The enzyme-linked tuberculosis immunospot assay (ELISPOT) T-SPOT.2.2TB were negative. Urinalysis showed no proteinuria, hematuria, white blood cells, or casts. To confirm the diagnosis, we performed a CT-guided percutaneous needle biopsy of a paravertebral mass. Histological findings revealed dense lymphoplasmacytic infiltration with storiform fibrosis and hyperplastic ectopic germinal center formation  and IgG4 (1170 mg/dL). CT findings revealed soft tissue masses involving the aortic arch, abdominal aorta, and perivertebral thoracic soft tissues Fig. A–C. Retr164 mg/dL3We described 2 cases of IgG4-related FM diagnosed with CT-guided percutaneous needle biopsy. Both cases showed the typical radiological features of FM, histological findings for IgG4-RD, high serum IgG4, and response to glucocorticoid therapy.,3 and that IgG4-related FM is treatable by glucocorticoid therapy, clinicians should recognize IgG4-related FM and perform a biopsy to identify the etiology of FM. Second, CT-guided percutaneous needle biopsy is one option for the pathological diagnosis of IgG4-related FM that is less invasive than surgical biopsy for accessing the mediastinum. Finally, we found hyperplastic ectopic germinal centers consisting of T and B cells and massive infiltration of M2 macrophages, along with storiform fibrosis, in the affected tissues of IgG4-related FM. This suggests that T–B interaction and M2 macrophages may be involved in the pathogenesis of IgG4-related FM, as commonly reported in other sites of IgG4-RD.–10Our cases are noteworthy for several reasons. First, considering that delayed diagnosis and initiation of early appropriate treatment for FM results in irreversible organ damage and potential subsequent severe disability and poor prognosis,,3 It can be asymptomatic and found incidentally on radiological examination, or symptoms such as dyspnea, hemoptysis, dysphagia, and chest pain can occur in cases where the FM mass compresses adjacent organs .,3 FM can be classified as idiopathic or secondary based on its etiology.,3 Secondary FM can follow infections , malignancies (particularly lymphoma and mesothelioma), autoimmune diseases (anti-neutrophil cytoplasmic antibody-associated vasculitis and Behçet disease), and sarcoidosis. It can also develop in response to radiation therapy and drugs . If no clear cause is identified, the disease can be classified as idiopathic. Recent reports suggest that “idiopathic” FM in some patients can be attributed to IgG4-RD.,11–19 We have described 2 cases of “idiopathic” FM that showed extensive IgG4 and IgG4+ plasma cell infiltration along with storiform fibrosis in affected tissues, eventually diagnosed as IgG4-related FM. Both cases were successfully treated with glucocorticoid therapy. Considering that a delay in diagnosis and treatment may cause severe disability and poor prognosis in FM patients,,3 clinicians should consider IgG4-related FM in cases of mediastinal masses to allow early treatment.FM is a rare fibroinflammatory disease.,21 some forms of IgG4-RD, such as IgG4-related retroperitoneal fibrosis, periaortitis, and inflammatory aortic aneurysms, can present with high serum CRP.–24 In this regard, it should be noted that IgG4-related FM can also present with high serum CRP. While the underlying differences between IgG4-RD patients with normal and high CRP remain unclear, Kasashima et al recently reported excessive levels of local and serum IL-6 in patients with IgG4-related inflammatory aortic aneurysms, with alternatively activated (M2) macrophages in the adventitia producing IL-6. In line with these findings, case 1 in the present study showed high serum CRP as well as high serum IL-6. Therefore, high serum CRP in IgG4-related FM may be attributed to excessive local production of IL-6. In terms of other clinical features of published IgG4-related FM cases, the median level of serum IgG4 was 392 mg/dL (range 127–3300 mg/dL), and involvement included retroperitoneal fibrosis , lymph nodes , pancreas , lung , and dacryosialadenitis . Further accumulation of IgG4-related FM cases will help to elucidate the clinical features.We have reviewed all cases previously published as “IgG4-related FM” including our 2 cases Table . A total,6 Consistent with these findings, case 1 in the present study showed massive infiltration of CD163+ M2 macrophages in the area affected by storiform fibrosis associated with IgG4-related FM. This suggests that M2 macrophages are involved in the fibrosis process in IgG4-related FM.While severe fibrosis is one of the important characteristics of IgG4-related FM, the mechanism underlying fibrosis formation is unclear. Recently, several studies reported that M2 macrophages contribute to fibrosis formation by producing CC-chemokine ligand-18 in IgG4-RD.–10 Both of our cases showed hyperplastic ectopic germinal center formation at affected sites (Figs. Recent studies have suggested that follicular helper T cells are involved in ectopic germinal center formation and IgG4-secreting B-cell maturation and differentiation at sites affected by IgG4-RD.The anatomical location of FM often makes it difficult for clinicians to perform a biopsy; however, because IgG4-RD is treatable by glucocorticoid therapy, it is important to first consider the histological diagnosis of IgG4-related FM and to exclude other diseases. In both of our cases, we successfully performed CT-guided percutaneous needle biopsy, and obtained specimens suitable for accurate diagnosis. Considering that IgG4-RD affects elderly patients with frequent comorbidities, and that CT-guided percutaneous biopsy is less invasive than surgical biopsy, CT-guided percutaneous needle biopsy is a useful option for obtaining tissue specimens for diagnosis of IgG4-related FM.,3 Our cases showed dramatic improvement of the lesions with glucocorticoid therapy. The long-term prognosis of IgG4-related FM remains unclear.The prognosis of FM is affected by the enlargement of fibrous masses that compress adjacent organs.4IgG4-related FM should be included in the differential diagnosis when clinicians find fibrosis in the mediastinum. It is important to screen for systemic organ involvement and to measure serum IgG4. CT-guided percutaneous needle biopsy is very useful and effective for an accurate diagnosis.Conceptualization: Satoshi Takanashi.Data curation: Satoshi Takanashi.Writing – original draft: Satoshi Takanashi.Writing – review and editing: Satoshi Takanashi, Mitsuhiro Akiyama, Katsuya Suzuki, Kotaro Otomo, Tsutomu Takeuchi.


Rapid risk and outbreak assessmentsMulti-country outbreak of new Salmonella enterica 11:z41:e,n,z15 infections associated with sesame seedsDate of publication: 14 June 2017http://ecdc.europa.eu/en/publications/Publications/rapid-outbreak-assessment-salmonella-enterica-Greece-14-Jun-2017.pdfIncrease of cholera cases in the Horn of Africa and the Gulf of Aden - risk for EU/EEA citizensDate of publication: 23 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1703Hepatitis A outbreaks in the EU/EEA mostly affecting men who have sex with menDate of publication: 19 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1701Outbreak of Ebola virus disease in Bas Uele province, Democratic Republic of CongoDate of publication: 19 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1699Potential public health risks related to communicable diseases at the WorldPride festival in Madrid, 23 June-2 July 2017Date of publication: 8 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1697Risk related to the use of 'do-it-yourself' CRISPR-associated gene engineering kit comtaminated with pathogenic bacteriaDate of publication: 2 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1692Outbreak of yellow fever in BrazilDate of publication: 14 Aprilhttp://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1675Multidrug-resistant tuberculosis in migrants (MDR TB), multi-country clusterDate of publication: 13 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1673Zika virus disease epidemicDate of publication: 4 Aprilhttp://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1671Technical reportsVaccine-preventable diseases and immunisation: Core competenciesDate of publication: 14 June 2017http://ecdc.europa.eu/en/publications/Publications/VPD%20Competencies%20Training_Short_Technical%20report_final.pdfEuro-GASP external quality assessment (EQA) scheme for Neisseria gonorrhoeae antimicrobial susceptibility testing 2016Date of publication: 7 June 2017http://ecdc.europa.eu/en/publications/Publications/EQA%20Report%202016%20final.pdfA literature review of Training Needs Assessment (TRNA) methodologyDate of publication: 1 June 2017http://ecdc.europa.eu/en/publications/Publications/LR-TRNA_Methodology_25042017_Final.pdfHepatitis B and C testing activities, needs, and priorities in the EU/EEADate of publication: 5 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1706EU Laboratory Capability Monitoring System (EULabCap): report on 2015 survey of EU/EEA country capabilities and capacitiesDate of publication: 28 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1690Immunisation information systems in the EU and EEA - results of a survey on implementation and system characteristicsDate of publication: 26 April 2017http://ecdc.europa.eu/en/publications/Publications/immunisation-systems.pdfCatalogue of interventions addressing vaccine hesitancyDate of publication: 25 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1683Economic evaluations of interventions to prevent healthcare-associated infections - literature reviewDate of publication: 19 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1676Scientific AdviceSystematic review on the diagnosis, treatment, care and prevention of tuberculosis in prison settingsDate of publication: 30 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1707Special reportMonitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia: 2017 progress reportDate of publication: 26 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1688HIV and men who have sex with men: http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1682Continuum of HIV care: http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1685HIV testing: http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1686HIV and migrants: HIV and treatment:http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1684Technical documentSurveillance of healthcare-associated infections and prevention indicators in European intensive care units - HAI-Net ICU protocol version 2.2 Date of publication: 5 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1694Surveillance of surgical site infections and prevention indicators in European hospitals - HAI-Net SSI protocol version 2.2Date of publication: 5 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1695Clostridium difficile infections - surveillance protocol version 2.3European surveillance of Date of publication: 21 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1677Mission reportTechnical mission: HIV, STI and viral hepatitis in Bulgaria. 19-21 September 2016 and 14-15 November 2016Date of publication: 29 May 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1705Surveillance reportsLegionnaires’ disease in Europe, 2015Date of publication: 14 June 2017http://ecdc.europa.eu/en/publications/Publications/Legionnares-disease-europe-2015.pdfMeasles and rubella monitoring, January 2017Date of publication: 24 April 2017http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1679


The European concrete standard EN 206 introduces the k-value concept as one of the three methods allowing the use of granulated blast furnace slag in the design of the freeze-thaw-resistant concrete mix. It is assumed that the freeze-thaw durability of the concrete, whose composition (w/c ratio) has been corrected by adopting a certain k-value, is the same as the freeze-thaw resistance of the reference concrete made with the cement containing no addition (CEM I). This article presents the results of freeze-thaw resistance analysis (modified with the ASTM C666A standard Class XF3) of 24 series of concretes made with a binder containing varied amounts of slag, with a w/b ratio ranging from 0.25 to 0.55. The aim of the study was to estimate the k-value as a parameter defined by the w/b ratio and the slag content in the binder. In this approach, the k-value is determined by trial and error in such a way that the deformation of the concrete specimens containing the slag corresponds to the deformation of the reference concrete. As shown by the analysis, the k-value decreases with increasing slag content in the binder. According to the PN-EN 206 standard, the adoption of appropriate exposure classes and the correct design and manufacture of the concrete mix ensure adequate durability of concrete structures. It is important to use the right type of cement and w/b limiting value. The limit values regarding the composition and the properties of concrete defined in the standard are specified only for Portland cement CEM I, with other cement categories being ignored in this respect. In the case of hydrotechnical and bridge structures, where massive constructions are often found, it is technically and economically essential to use cements containing blast furnace slag addition. The basic technological requirement is to reduce the heat of cement hydration to prevent young concrete from damage as a result of thermal and shrinkage stresses. Such concrete must simultaneously meet a number of requirements regarding water permeability, resistance to chemical agents, and freeze-thaw resistance. Compressive strength is of secondary importance. The use of granulated blast furnace slag, assuming a sufficiently long period of moist curing and good compaction, results in decreased total porosity of hardened concrete. Analysis of the pore size distribution indicates a lower capillary pore volume and a general reduction in the average pore size. This decides about the improvement of the mechanical properties and increased durability of such concretes. the k-value decreases as the amount of GGBS increases;the k-value increases with increasing fineness of GGBS (larger surface area increases GGBS hydraulic activity);k-values are higher in lower strength cements;GGBS concretes are more sensitive to poor curing conditions than concretes without addition;the expansion of GGBS concretes subjected to freeze-thaw cycles is much greater. Concrete expansion is greater even though an increased amount of GGBS can increase the 28-day compressive strength of concrete.Ground granulated blast furnace slag (GGBS) can be a constituent in pre-blended factory-produced cement or a separate component for concrete added directly to the concrete mix. The first solution is recommended, as the quality of the addition as well as its fineness are controlled, which guarantees the production of good quality cement. The PN-EN 206 standard specifies slag as a type II addition and introduces the concept of k-value for GGBS with the application rules the same as for fly ash and silica fume. A k-value of 0.6 is recommended when using the slag along with cements CEM I and CEM II/A. The maximum amount of slag used should meet the recommendation: GGBS/cement ≤1.0 by mass. If a greater amount of GGBS is used, the excess should not be taken into account for the calculation of the water/(cement + k × GGBS) ratio and the minimum cement content. The issue of adding granulated blast furnace slag directly to the concrete was addressed by Sanjuan et al. [According to Sanjuan et al. , the adoIn the case of ordinary and high-performance concrete, the microstructure is the main determinant of mechanical properties, permeability, and durability . The perThe use of mineral additives is known to reduce permeability even when concrete is of a young age . Very tiThe study by Stark and Ludwig  shows thThe key question is whether water-tight, low-permeability concrete requires air-entrainment to achieve good freeze-thaw resistance. The formation of cracks due to frost was explained quite a long time ago. As observed by Powers , upon frA significant number of research papers are devoted to blast furnace cement. Deja  showed tAccording to Peng et al. , air-entThe PN-B-6265: 2004 standard, which is a supplement to the PN-EN 206-1 standard, allows the cements CEM I, CEM II/A-S, CEM II/B-S, CEM III/A, and CEM III/B , CEM II/B-S (28% GGBS), and CEM III/A (53% GGBS),concretes made with cement binders consisting of CEM I and GGBS addition in the range 0 to 60%.The test program included producing two series of non-air-entrained concretes:cements: CEM I 42, 5R HSR NA, CEM II/A-S 42, 5N, CEM II/B-S 32, 5R, CEM III/A 32, 5N, and CEM I 42, 5R NA;GGBS;natural sand 0/2 mm;coarse basalt aggregate, fractions 4/8 and 8/16 mm;plasticizer.The following materials were used in this study:Concrete mixes were prepared in a forced-mix laboratory mixer. First, the solid constituents were dosed and mixed for 60 s, then water and finally plasticizer were added, after which the mix was mixed for 90 s. The concrete testing on the homogeneous mixture included slump to PN-EN 12350-2:2011 and density to PN-EN 12390-7:2011.The concrete mix was compacted on a vibrating table. The specimens were removed from the moulds after 24 h. The freeze-thaw resistance specimens were stored in water (at 20 ± 2 °C) until an age of 7 days and then in dry air  for 21 days. Two beams with dimensions 8 cm × 8 cm × 35 cm were used for freeze-thaw resistance testing according to the modified ASTM C666 method Procedure A. After 28 days of maturing, the specimens were saturated in water for 7 days. Then, the specimens were immersed in water in metal containers, in which they remained all the time during freezing and thawing at high degree of water saturation, corresponding to XF3 exposure class according to PN-EN 206. The tests included 300 freezing cycles at −18 ± 2 °C and thawing at +10 ± 2 °C, taking 3 cycles a day. Once a week, the specimens were removed from the freezing chamber and the degree of deterioration was determined based on observations of their appearance and mass and length measurements. The measurement of linear expansion was possible due to the attachment of metal plugs on the front surfaces of the beams during moulding. The changes in mass and length of the beam specimens after 300 freeze-thaw cycles in water are shown in The freeze-thaw resistance assessment was carried out for non-air-entrained concretes made with cements of different GGBS content  and for concretes made with CEM I cement and GGBS addition (E and F series). concretes with the best freeze-thaw resistance, for which small changes in mass dm and small linear expansion dL were recorded (class 1);a group of concretes with small linear expansion dL but with significant mass losses dm  (class 2);concretes with the lowest freeze-thaw resistance, where both mass loss dm and linear expansion dL were substantial (class 3).Class 1, with the best freeze-thaw resistance, includes high-performance concrete (w/b ratio = 0.35) with a very tight microstructure. The mass change ranges from 0 to 21 g and the linear expansion dL is in the range 0 to 1.12 mm. Class 2 concretes are resistant to internal cracking but susceptible to scaling. Linear expansion dL is in the range 0.14 to 0.99 mm and the mass loss dm = 117–238 g. Class 3 includes non-freeze-thaw resistant concrete with the mass loss dm = 50–556 g and linear expansion dL from 1.60 to 4.83 mm.When the GGBS addition is used, the analysis of pore size distribution indicates a lower capillary pore content and a general reduction in the average pore size. As a result, high pressures are generated that damage the concrete structure. The specimens are frozen in water and the continuous contact with water allows the supply of additional water from the outside and an increase in the degree of saturation. This leads to the ice lens formation and, as a result of cyclic freezing-thawing, to the phenomenon of micro-ice-lens pumping. Passing the critical degree of saturation, even locally, is the major factor in microcrack formation, which, as freeze-thaw cycles continue, leads to the opening of the initially tight structure, taking up an additional amount of water, and as a result, to the failure of the concrete structure. In the early stage of deterioration, the mass of concrete first increases then decreases due to mass losses.The change in mass dm after 300 freeze-thaw cycles depending on the w/b ratio and the slag content is shown in The influence of the w/b and slag content in the binder on the development of internal damage in non-air-entrained concrete was also analyzed . The speThe smaller the w/b ratio, the more resistant the concrete is to internal deterioration. Low GGBS content of 20–30% in the binder does not affect the freeze-thaw resistance. It can be seen that an increase in the amount of GGBS to 40–60% clearly reduces frost resistance. With a given w/b ratio, the increase in the slag content causes greater damage to the concrete. cr = 1.3 mm as the criterion of freeze-thaw resistance of concrete, the critical ratio (w/b)cr for concrete made with cement containing varying slag contents was determined based on cr criterion decreases. Whereas for CEM I Portland cement, the critical w/b value will be about 0.49, for the GGBS cement with a slag content greater than 50%, the (w/b)cr will be about 0.38.Assuming the linear expansion dLThe results obtained allowed for the estimation of the k-values for the GGBS contents in the binder . Once moFrom the presented tests of resistance to internal cracking of non-air-entrained XF3 concretes made with binders containing different slag contents, it appears that high-GGBS addition to concrete reduces its freeze-thaw resistance performance through the linear expansion of concrete specimens. With regard to concrete internal damage, adopting w/b = 0.45 seems safe, provided that the GGBS content is 40% or below.With regard to frost-resistant concrete design, one of the variants adopted in the EN 206 standard is the concept of the coefficient , which takes into account the amount of additive in the design composition of concrete by adjusting the w/c ratio. It is common belief that the coefficient  is determined for type II additive with Portland cement, CEM I, not with ready-to-use cements, such as CEM III/A and CEM III/B. However, a decrease in frost-resistance  is observed when both ready-made cements containing GGBS and more than 40% slag additions are used. The results discussed in this paper confirm the above statement. The fixed value of k = 0.6 is another area of controversy.The paper proposes an approach to determining the k-value. Several series of concretes made with a binder of different GGBS contents were subjected to 300 freeze-thaw cycles and strain curves dL = f (w/b) were determined for each series. By adjusting the curve of the GGBS-containing concretes to the reference curve for Portland cement concretes, the k-values were determined for particular amounts of slag in the binder. The analysis indicates that the k-value decreases with an increase of the GGBS content in the binder. With a slag content of 40% or below in the binder, the k-value is from 0.6 to 1. When the amount of slag in the binder increases over 40%, the k-value is 0.5–0.6. The authors of this study can confirm that the proposed approach to determining the k-value within the context of concrete frost durability is a simple and effective approach.It is important to note that the conclusions formulated here pertain to the materials used in the present study. Further research, which will be necessary to verify the relationships obtained, should include slag-containing cements of different strength classes and those derived from different sources.


We also assessed whether the presence of the vital sign taker creates an arousal effect.Data smoothing of vital signs has been reported in the anesthesia literature, suggesting that clinical staff are biased toward measurements of normal physiology. However, these findings may be partially explained by clinicians interpolating spurious values from noisy signals and by the undersampling of physiological changes by infrequent manual observations. We explored the phenomenon of data smoothing using a method robust to these effects in a large postoperative dataset including respiratory rate, heart rate, and oxygen saturation . We compared manually recorded vital sign data with contemporaneous continuous data recorded from monitoring equipment. We proposed that data smoothing increases differences between vital sign sources as vital sign abnormality increases. The primary assessment method was a mixed-effects model relating continuous-manual differences to vital sign values, adjusting for repeated measurements. We tested the regression slope significance and predicted the continuous-manual difference at clinically important vital sign values. We calculated limits of agreement (LoA) between vital sign sources using the Bland–Altman method, adjusting for repeated measures. Similarly, we assessed whether the vital sign taker affected vital signs, comparing continuous data before and during manual recording.o2 paired measurements for analysis. For the model relating continuous-manual differences to continuous-manual average vital sign values, the regression slope  was 0.04  for respiratory rate, 0.04  for heart rate, and 0.10  for Spo2. For Spo2 measurements of 91%, the model predicted a continuous-manual difference  of −0.88% (−1.17% to −0.60%). The bias (LoA) between measurement sources was −0.74 (−7.80 to 6.32) breaths/min for respiratory rate, −1.13 (−17.4 to 15.1) beats/min for heart rate, and −0.25% (−3.35% to 2.84%) for Spo2. The bias (LoA) between continuous data before and during manual observation was −0.57 (−5.63 to 4.48) breaths/min for respiratory rate, −0.71 (−10.2 to 8.73) beats/min for heart rate, and −0.07% (−2.67% to 2.54%) for Spo2.From 407 study patients, 271 had contemporaneous continuous and manual recordings, allowing 3740 respiratory rate, 3844 heart rate, and 3896 Spo2 measurements, it was not clinically significant. The wide LoAs between continuous and manually recorded vital signs would commonly result in different early warning scores, impacting clinical care. There was no evidence of an arousal effect caused by the vital sign taker.We found no evidence of data smoothing for heart rate and respiratory rate measurements. Although an effect exists for Sp Question: Does a “smoothing effect” exist between manually recorded and electronically recorded vital sign measurements in postoperative care?Findings: Using a mixed-effects model, we found no relationship between continuous-manual differences and continuous-manual average values for heart rate and respiratory rate, and we found a weak  relationship for oxygen saturation.Meaning: We found that clinical staff in a postoperative ward did not “smooth” vital sign values with a bias toward recording more normal readings because the differences between manual and continuous vital sign measurements were not related to the vital sign values.o2)—are often inaccurate.3 Manual calculations of clinical risk scores are also error prone.6 While automated monitoring technology exists, it is mostly confined to high-acuity patients, and manual measurement and documentation of vital signs remain the standard of care in many wards. A potential source of inaccuracy that may exist in the manual vital sign record is data smoothing.7 Clinical staff may be biased toward vital sign values that lie within the assumed limits of normality and record vital sign values that are incorrectly normal— “smoothing” the extremes in the vital sign record. If real, this “smoothing effect”8 may result in lost opportunities for early recognition of physiological deterioration.Manual measurements of the main vital signs—which include respiratory rate, blood pressure, heart rate, temperature, and oxygen saturation  value of the vital sign becomes more extreme. We tested whether differences between continuous and manual vital sign recordings are related to the average value of the 2 vital sign recordings. We also assessed agreement between continuous and manual data. Finally, we investigated whether there is an arousal effect caused by the vital sign taker.15We present a secondary analysis of a large database of postoperative vital sign records to investigate data smoothing of respiratory rate, heart rate, and Sp17This article adheres to the Reporting of Studies Conducted Using Observational Routinely-Collected Health Data statement, an extension of the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.The database for this retrospective analysis was created during the Computer Alerting Monitoring System 2 (CALMS-2) study, which was granted ethical approval  and registered in the International Standard Randomised Controlled Trial Number (ISRCTN) database . This study assessed whether ambulatory physiological monitoring combined with an alerting system improved recognition and outcomes in patients after major surgery.Vital sign data used in the CALMS-2 study were collected in a step-down postoperative ward of the Oxford University Hospitals National Health Service (NHS) Trust, Oxford, between May 2009 and December 2013. Potential participants were screened during preoperative assessment and deemed eligible if they were planned to undergo major upper gastrointestinal surgery. This category was defined as follows: oesophagectomy, oesophagogastrectomy, gastrectomy, Whipple’s operation, liver resection, pancreatectomy, gastric bypass, biliary reconstruction, and splenectomy. Participants were excluded based on the following criteria: participants <16 years of age, pregnant women, participants unable to wear the required monitoring, participants without the capacity to consent, and participants who could not understand written English and for whom no translator could be found. For this secondary analysis, patients who did not receive contemporaneous bedside electronic vital sign monitoring and manual vital sign observations were excluded a priori. Written informed consent was obtained for all subjects.o2 . Respiratory rate was measured by impedance pneumography, heart rate was derived from the electrocardiogram, and Spo2 was measured by pulse oximetry. Clinical staff also made manual measurements of blood pressure and temperature, typically at hourly intervals. After this initial period, these patients then join the other patients on the ward in receiving general-ward-level care, which consists of manual vital sign recording typically at 4-hour intervals. The standard of care for measuring respiratory rate on the ward is by counting chest wall movements, and heart rate and Spo2 measurements were likely to be transposed from the monitor screen. In the CALMS-2 study, ambulatory monitoring of heart rate and Spo2 was undertaken. However, for consistency, we restricted this analysis to manually recorded values that could be compared with contemporaneous values from bedside monitoring.In the step-down ward used in the CALMS-2 study, high-risk patients are admitted after a period of elective intensive care unit stay, while patients with a lower risk of complication are admitted to the ward immediately after surgery. High-risk patients typically receive an increased level of care for the first 2–48 hours of their ward stay, during which time they undergo conventional bedside monitoring, consisting of continuously measured respiratory rate, heart rate, and Sp5 Continuous vital sign data from the bedside monitors were saved directly from the monitor every second. The final dataset obtained for this study consisted of vital sign records of respiratory rate, heart rate, and Spo2 from continuous bedside monitoring equipment and manual vital sign observations.Manual vital sign measurements documented on paper-based bedside charts were double entered into an electronic database. A third researcher reconciled differences with access to the original charts.Manual and continuous vital sign values were compared based on the timestamps taken from paper records and the computer-generated timestamps from the patient monitor. Clinical staff manually recorded blood pressure measurements at the time of observation, and these were also logged in the automatically generated data record. We set the manual observation time for all vital signs to the computer-generated timestamps for blood pressure (while checking that data were correctly matched). This calibration method ensured that the data considered contemporaneous from manual and continuous measurement sources were synchronized, and thus could appropriately be used for comparison.We summarized the number of vital sign measurements included per patient using the sample median and interquartile range.15 We undertook sensitivity analyses by recomputing the primary assessment method for windows of 1–10 minutes.We sampled the continuous data at the time of each manual observation to create paired measurements of continuous and manual vital signs. We sampled the continuous data by extracting the median value of a 5-minute window centered at the time of manual observation. We used this methodology  to summarize the continuous data without the effects of measurement noise or short-term variance while retaining long-term vital sign trends. We included all manual observations with contemporaneous periods of continuous data, allowing patients to provide multiple observations in our analysis. We selected a 5-minute window to reflect clinical practice, in line with previous work.To obtain the differences between the 2 measurement sources, we subtracted the manual vital sign from the continuous vital sign in each measurement pair. We also calculated the average of the continuous and manual vital signs for each measurement pair. We modeled the relationship between the differences and the averages of the measurement recordings using a linear mixed-effects model, with averages as a fixed effect and subject as a random effect to adjust for repeated measurements. We note that there may be factors other than a smoothing effect that could affect the relationship between the continuous-manual difference and the continuous-manual average, notably the accuracy of the continuous monitoring equipment. However, given our use of gold standard monitoring equipment and median filtering to remove transient outliers, the continuous data were likely to be equally reliable over the range of measurement values. Thus, a linear relationship between the continuous-manual difference and the continuous-manual average would be best explained by a clinical bias in the manual data, allowing the smoothing effect to be tested.F test (type III with Kenward–Roger degrees of freedom approximation),18 using a significance of 0.05 to reject the null hypothesis that the regression slope was 0 (no relationship). To assess the clinical significance of the linear relationship, we simulated the mean differences and 95% confidence intervals (CIs) predicted by our model at vital sign values corresponding to important clinical thresholds. We used respiratory rate values of 8 and 24 breaths/min, heart rate values of 40 and 130 beats/min, and an Spo2 value of 91%, which are the maximum National Early Warning Score limits for each vital sign.19The regression slope of the fixed effect in the mixed-effects model represents the increase in the continuous-manual difference for a 1-unit increase in the continuous-manual average. Statistical significance of the regression slope was calculated with an 20 CIs (95%) were calculated for the bias and the LoAs using the method recommended by Bland and Altman.21 Horizontal lines were included on the Bland–Altman plots to show the bias and LoAs. The regression line from the linear mixed-effect model was plotted to visualize the relationship between the differences and the averages.We generated Bland–Altman plots for the continuous and manual vital sign data by plotting the differences between the 2 measures (y-axis) against the averages of the 2 measures (x-axis). The bias was calculated as the mean difference between continuous and manual measurement pairs. Limits of agreement (LoAs) were calculated using a mixed-effects model, including a subject random effect to adjust for repeated measurements.15 to allow comparison. The selection of the continuous data is shown schematically for heart rate in Figure We assessed whether there is an arousal effect caused by the vital sign taker by comparing continuous data before and during the time of manual observation. For the continuous data before the observation, we used the median value of a 15-minute window ending 5 minutes before the time of observation. For the continuous data during the time of observation, we used the median of a 5-minute window, as described in previous paragraphs. These methods replicate those of Taenzer et al,22 We also could not identify the statistical power of the study since previous studies of “the smoothing effect” have not used Bland–Altman analyses (preventing estimation of approximate population regression slopes). We instead provided CIs for all reported outcomes to demonstrate the precision of our results, as recommended by Goodman and Berlin.23We did not perform sample size calculations for this study because it is a retrospective cohort study of an existing dataset—we used all available data, noting that our dataset was larger than those used in most previous analyses of the smoothing effect.o2 from 271 patients (3896 paired measurements). The median (interquartile range) number of observations for each patient was 11 (7–18) respiratory rate, 11 (7–18) heart rate, and 11 (7–19) Spo2 measurements.Patient inclusion is shown in Figure P = .11) for respiratory rate, 0.04  for heart rate, and 0.10  for Spo2  between the continuous-manual difference and the continuous-manual average was 0.04  between the continuous and manual data was −0.74 (−7.80 to 6.32) breaths/min for respiratory rate, −1.13 (−17.4 to 15.1) beats/min for heart rate, and −0.25% (−3.35% to 2.84%) for Spo2  between continuous data before and during manual recording was −0.57 −5.63 to 4.48) breaths/min for respiratory rate, −0.71 (−10.2 to 8.73) beats/min for heart rate, and −0.07% (−2.67% to 2.54%) for Sp.48 breathttp://links.lww.com/AA/C522.Results for the sensitivity analysis of the primary assessment method for different window sizes  are given in Supplemental Digital Content 1, Table 1, o2 were related to the measurement value. However, this relationship was clinically insignificant , which is within the measurement error of most pulse oximeters.24 The LoAs (95% CI) between continuously and manually recorded vital signs were large: 14.1 (13.8–14.4) breaths/min, 32.5 (31.9–33.3) heartbeats/min, and 6.2% (6.1%–6.3%) Spo2 between LoAs, suggesting that these recordings cannot be used interchangeably. We found no evidence of an arousal effect from the vital sign taker. The bias between continuous vital sign values recorded before and during manual observation was less than a single breath, heartbeat, or percentage Spo2.We found no clinically relevant smoothing effect in postoperative care. If vital sign data were smoothed, then manual measurements would be recorded above abnormally low and below abnormally high continuous measurements, causing continuous-manual differences to be related to vital sign values. However, differences between manual and continuous heart rate and respiratory rate measurements were not related to the average values because the regression slope was not significantly different to 0. Differences between manual and continuous measurements of Spt Figure , with mihttp://links.lww.com/AA/C522). As window size was reduced, lessening the effect of median filtering, the differences predicted by the model increased, although only by 1–2 heartbeats or breaths. Increasing the window size does not affect our findings, suggesting that the choice of a 5-minute window  appropriately removes artefact without increasing the sample size beyond what is plausible for bedside measurement. Notably, 4 previous studies found a smoothing effect using automated monitoring signals without temporal averaging, relying on manufacturer settings for artefact removal.12 Sapo et al14 demonstrated that Spo2 values <90% are associated with poor signal quality, suggesting that the effects in these studies may be due to clinicians correctly removing spurious values.Our sensitivity analysis showed that window size affected the relationship between continuous-manual differences and averages but not to a clinically meaningful extent  in Supplemental Digital Content 2, Figure 1, http://links.lww.com/AA/C523.25In contrast to our Sp3 so the high variance in the differences between continuous and manual measurements is perhaps not unexpected. However, as early warning scores commonly include respiratory rate ranges between 2 scores of 4 breaths/min or less,27 these differences would commonly impact clinical care. The LoAs for heart rate and Spo2 were also wide and again would commonly result in different early warning scores. These results are important for those seeking to automate early warning scores,29 which have not been designed for use with continuous data, so patients would clearly alert differently.Manually recorded vital sign measurements varied widely from the continuous measurements. Respiratory rate is difficult to measure clinically,Our study is limited by its single-center design because practices may vary between hospital wards and institutions. There may have been transcription errors in the value or timing of manual vital sign observations. This effect was minimized by double data entry and synchronizing observation times with computer-generated timestamps of blood pressure. One bedside monitoring provider was used in this study, so we could not assess differences between monitors. If we had found a relationship between the continuous-manual differences and averages, then this would have prevented exploration of whether the relationship could be explained by monitor inaccuracy, rather than clinician smoothing. Because there is no clinically significant relationship, this is not a significant issue for our findings. Our results are not influenced by undersampling because the measurement pairs of manual and continuous data sample the same physiology. The strengths of our article are the large dataset used in comparison to previous work and the analysis of 3 different vital signs.10 This may be more pervasive in acute episodes during surgery and may not apply to postoperative wards, where nursing staff are available to measure and document vital signs simultaneously. Further research should investigate the smoothing effect during anesthesia, using the Bland–Altman method of assessing agreement between measurement sources, and comparing manually recorded measures to the median of a continuous window. If confirmed, the effects of the large differences between manually recorded and continuous vital sign measurements on early warning scores require investigation before the measurement and recording of these variables can be safely automated for early warning score computation.We have provided evidence against the existence of a smoothing effect in postoperative care. However, this phenomenon may still exist in the context of anesthesia. It is possible that errors in vital sign documentation increase when clinicians record vital signs from memory after the measurement has been taken.o2 in postoperative care. We found no evidence of an arousal effect caused by the vital sign taker. Differences between manually recorded and continuous measures of respiratory rate, heart rate, and Spo2 were frequently large, suggesting that the methods cannot be used interchangeably.We found no evidence that a clinically significant smoothing effect exists for respiratory rate, heart rate, or SpThe authors thank several individuals for their work on the Computer Alerting Monitoring System 2 study. Breda Lynch, Theresa Saunders, Sarah Vollam, and Deborah Evans conducted data collection; Jacqueline Birks undertook the statistical analysis and assisted in protocol development; and Julie Darbyshire assisted in proof reading. The authors would also like to thank Dr Lei Clifton for her work in preparing the dataset. Furthermore, the study could not have been undertaken without the support of the clinical staff on the upper gastrointestinal ward. The authors would like to thank the participants of the Computer Alerting Monitoring System 2 study for their commitment to research.Breda Lynch, Research Nurse, Oxford University Hospitals NHS Trust, Oxford, United Kingdom; Theresa Saunders, Research Nurse, Oxford University Hospitals NHS Trust, Oxford, United Kingdom; Deborah Evans, Research Nurse, Oxford University Hospitals NHS Trust, Oxford, United Kingdom; Sarah Vollam, Research Nurse, Oxford University Hospitals NHS Trust, Oxford, United Kingdom; Jacqueline Birks, MA, MSc, National Institute for Health Research–Oxford Biomedical Research Centre (NIHR–OXBRC) Senior Medical Statistician, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; Julie Darbyshire, BA, MA, MSc, Critical Care Research Programme Manager, Oxford University Hospitals NHS Trust, Oxford, United Kingdom; and Dr Lei Clifton, BSc, MSc, PhD, Medical Statistician, Centre for Statistics in Medicine, Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.Name: Hamish R. Tomlinson, BE (Hons).Contribution: This author helped conduct the analysis and prepare the manuscript.Name: Marco A. F. Pimentel, PhD.Contribution: This author helped with conception and design of the analysis and drafting the manuscript.Name: Stephen Gerry, MSc.Contribution: This author helped with conception and design of the statistical methodology, and drafting the manuscript.Name: David A. Clifton, PhD.Contribution: This author helped with data acquisition and drafting the manuscript.Name: Lionel Tarassenko, PhD.Contribution: This author helped with conception and design of the analysis, data acquisition, and drafting the manuscript.Name: Peter J. Watkinson, MBChB, MD.Contribution: This author helped with conception and design of the analysis, data acquisition, and drafting the manuscript.This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.


To reduce the cracking caused by shrinkage and avoid the brittle behavior of concrete, MgO expansion agent and steel fibers were used in this paper. Firstly, the effect of MgO and steel fibers on the compressive strength of concrete was compared. The results showed that the compressive strength of steel fibers reinforced concrete (SC) and steel fiber reinforced MgO concrete (SMC) was significantly improved. Compared with ordinary concrete (OC), SMC’s 28 days compressive strength increased by 19.8%. Secondly, the influence of MgO and steel fibers with different contents on the self-volumetric deformation of concrete was compared through the experiment. The results showed that as a result of the hydration expansion of MgO, MC and SMC both showed obvious expansion, and their 190 days expansion was 335  Owing to its high compressive strength, good corrosion resistance, low price, and excellent operating performance, concrete has become the most popular building material all over the world. However, crack is a fatal flaw in concrete, which not only reduces the mechanical properties of concrete, but also provides channels for the intrusion of harmful substances in the outside world. Moreover, cracks accelerate the corrosion and destruction of concrete and seriously affect the durability of concrete, especially in ports and Marine structures.In order to restrain concrete cracking and enhance its durability, researchers have proposed three methods. One is to compensate for shrinkage of cement-based materials during hydration by adding expansion agents, such as CaO-type, MgO-type, and AFt-type expansion agents, which can reduce shrinkage cracks ,2,3,4,5.In the past two decades, some researches have focused on the engineering application of fiber-reinforced concrete and expansive concrete, such as railway sleepers ,17,18, dIn this paper, the authors combined MgO expansion agent with steel fibers. The expansion behavior of MgO is restrained by steel fibers in the hardening process and produces self-pressure, which can significantly improve the cracking load. The large vertical pressure exists at the interface between the cement matrix and steel fibers, which significantly improves the bonding property. Compared with polypropylene (PP) fibers and polyvinyl alcohol (PVA) fibers, steel fibers have a higher modulus of elasticity, and thus have stronger binding capacity, which can significantly improve the bonding property.Owing to the constraints of steel fibers, the expansion and mechanical properties of steel fiber-reinforced MgO concrete (SMC) are quite different from those of MgO concrete (MC). In this paper, self-volumetric deformation experiments and compressive experiments were performed to reveal the expansion property of MC and SMC and the mechanical properties of SMC, which can help us understand SMC better and provide a theoretical basis for further engineering application.Portland cement, fly ash, coarse aggregates, fine aggregates, steel fibers, and polycarboxylate based plasticizer were used as the experimental objects. The details about each material are enumerated below.The cement was produced by Shandong Shan Aluminum Cement Co., Ltd. . The specific model was Shan Lu P.0. 52.5 ordinary Portland cement. The 3 days compressive strength of cement was 33.2 MPa and the 28 days was 59.8 MPa. The initial setting time of cement was 220 min, and the ultimate setting time was approximately 290 min. Fly ash was Class I fly ash produced by Shenhua Huashou Power Co., Ltd. . The sulfur trioxide content of fly ash was 1.2% and the water storage ratio was 74%. Steel fibers were wavy steel fibers produced by Shuanglian Building Materials Co. LTD in Zibo, China and the tensile strength of the steel fibers was 520 MPa. The diameter of the steel fibers was 0.58 mm and the length was 38 mm. The photograph of the wavy steel fibers utilized in the present study is depicted in 2/g. The photograph of MgO in the present study is depicted in MgO expansion agent was produced by Wuhan Sanyuan Special Building Materials co. LTD in Wuhan, China, and its activity was 115 s. The crystal size of MEA was 36.3 nm and the specific surface area was 45.7 mThe mix proportions used in the present study are listed in k is measurement sensitivity of strain gauge; b is temperature correction factor of strain gauge; a is the linear expansion coefficient of concrete; and Type-VWS-10 vibrating wire strain gauges made by Nanjing Gelan Industrial Co., Ltd.  were used. The gauge distance of strain gauge was 100 mm, and the vibrating modulus of the strain gauge, F, was closely related to its length, varying with the length change of the transducer brought about by deformation of concrete . The strFor each mix design, nine cylinders (dimension STM C109 ), at 3 a× 300 mm . The con× 300 mm . All tesIn order to study the effect of the steel fibers and MgO expansion agent on the microstructure of concrete, fractured surfaces of concrete at the age of 30 days were investigated by scanning electron microscope .The process of concrete compression failure is actually the process of crack generation, crack propagation, and crack penetration. In the process of loading, each specimen had experienced the elastic stage, elastic-plastic stage, and failure stage. On the other hand, the failure modes of SC and SMC specimens were obviously brittle. When the specimen approached the peak stress gradually, a small number of small vertical cracks began to appear on the surface of the specimen. After reaching the peak point, the bearing capacity of the specimen decreased more and more slowly, and a large number of discontinuous longitudinal short cracks appeared. Finally, the specimen could not return to the original deformation state and formed an inclined main crack. The angle between the inclined crack surface and the vertical line of the load was 70–80 degrees, and the failure form of steel fibers was pull out failure.For SMC, the 3 days and 7 days compressive strength of concrete increased by 4.23% and 19.8% respectively, to 49.3 MPa and 70.3 MPa. There are two main reasons for the rise in the strength of SMC. First, steel fibers prevent cracks from developing, and delay further damage to concrete. Secondly, the combined use of MgO and steel fibers produces a “superstack” effect and, under the constraint of steel fibers, and the stress of concrete becomes a three-way compression state, which create self-pressure inside the concrete and further increases the strength of the concrete.The strain of concrete with different dosages of steel fibers and MgO, which represents the self-volumetric deformation, is listed in The expansion curve of SMC was similar to that of MC, but the 190 days expansion value of SMC was 16.3% less than that of MC owing to the constraint action of steel fibers, reaching 288 Concrete interface is the weak link of the concrete specimens, and the interface between cement matrix and aggregate directly affects the mechanical properties and durability of concrete ,23,24. SConsidering the defects of MgO expansion agent or steel fibers when used alone, this paper combined MgO expansion agent and steel fibers. On the basis of detailed experiments and theories, the following conclusions can be drawn:(1) After the combined use of MgO expansion agent and steel fibers, the damage pattern of SMC under compression changed significantly compared with OC, and the SMC showed obvious ductile damage. The compressive strength of SMC increased by 19.8%, which was much greater than the simple sum of strength increments of MC (5.79%) and SC (9.54%).(2) Compared with OC, the 190 days shrinkage of SC was reduced by 24.1% owing to the restraint effect of steel fibers. However, the steel fibers cannot completely offset the shrinkage of the concrete, and the 190 days shrinkage of SC still reached 135 (3) According to the SEM test, there were many defects in the interface between cement matrix and aggregate in MC, while SMC had a denser interface and better bond strength, which explained why the compressive strength of SMC was significantly higher than MC.(4) Thanks to the positive results in this study, SMC should be widely used in the basement, bridge deck, and other structures with high requirements for anti-seepage and crack resistance.


The molecular hosts cyclodextrins form inclusion complexes with a wide variety of guests, resulting in complexes with various host:guest stoichiometries. In the case of a series of 19 1,4-naphthoquinolines as guests with either β- or γ-cyclodextrin studied using electrospray mass spectroscopy, in most cases only 1:1 complexes were observed, with 2:1 host:guest complexes observed in just 6 out of 38 host:guest combinations. It is shown that these higher-order complexes were observed only in the case of small (or no) electronically withdrawing substituents, and were much less likely in the case of the larger γ-cyclodextrin host. The size and electronic properties of the substituents involved shows that both steric and electronic factors must be taken into account in predicting which cyclodextrin host:guest stoichiometries will be stable enough to form . It is clear that the prediction of host-guest stoichiometry for a specific host-guest pair is complicated, and involves a subtle interplay of both electronic and steric factors. However, there are definite trends, which can be used to help predict host:guest stoichiometry for a given host-guest pair. Cyclodextrins (CDs), the cyclic oligomers of glucopyranose, are by far the most commonly used organic host compounds for the inclusion of organic guest molecules ,2,3. TheHowever, it remains challenging to predict the stoichiometry of cyclodextrin host:guest inclusion complexes. In a broad sense, consideration of the size of the guest will to some extent help to predict this stoichiometry, as guests that are small relative to the native cyclodextrin host cavity diameter will tend to form 1:2 CD:guest complexes ; those tp-quinone system is quite popular as a part of many natural products -1,4-naphthalenedione) or the parent PAN 1 both in the presence of β-CD are shown in m-CH3, p-CH3, m-ethyl and un-substituted PAN, two of which are shown in m-CH3 and p-CH3). This lack of higher-order complexes in all but six CD:PAN pairs was reproducible and clearly established by these experiments.ESI-MS experiments were performed for all 19 guests in both β- and γ-CD; the results of these experiments in terms of the observation of host:guest inclusion complexes, and their stoichiometry, are presented in 1 and K2 for Equilibria 1 and 2, respectively. The magnitude of the binding (formation) constants K1 and K2 cannot be determined from ESI-MS experiments, only the presence (or absence) of these complexes.In all six cases in which 2:1 host:guest inclusion complexes were observed, 1:1 complexes were also observed to varying relative concentrations. This indicates a stepwise equilibrium formation of these 2:1 complexes, as follows:1 and K1’ (as indicated by Equilibrium 1 above), are needed, for the formation of anilino or quinone complexes, respectively, and also two pairs of 2:1 binding constants, K2 and K2’ (as indicted by Equilibrium 2), for the addition of the second host CD to either the anilino or quinone 1:1 complexes, respectively.The ESI-MS experiments provide direct and unequivocal determination of not only the formation of inclusion complexes but also the varying host:guest ratios (stoichiometries) observed. However, no experimental information is provided by this technique on the nature of these complexes , for example the specific orientation in which all or part of the PAN guest fits inside the CD cavity. In the case of PAN, as shown in 1 is expected to be larger than K1’. This preference of inclusion of the anilino moiety over the quinone end is also supported by our molecular mechanics calculations, as will be discussed in Considering the shape of the PAN guests, as shown in It is observed that the formation of 2:1 complexes is more likely with β-CD (occurs with four PAN derivative guests) than with γ-CD (occurs only with two PAN derivative guests). This makes sense, considering the relative size of these two hosts: γ-CD is much larger than β-CD, so there is more likely to be unfavourable steric interaction between the two hosts in the case of γ-CD, making the encapsulation of the guest by a second host less likely. Furthermore, the cavity of γ-CD is larger than that of β-CD, making it more likely that the guest can be completely encapsulated within a single host cavity. The reason why only certain guests are encapsulated by β- and γ-CD will be discussed in both ends of the guest PAN are encapsulated by a β-CD host.Molecular modeling calculations were performed for all 19 PAN derivatives as guests encapsulated in the β-CD, to estimate the stabilization energy obtained by complexation (which provides an indication of the relative binding constants). Both modes of encapsulation for 1:1 inclusion were examined and compared, i.e., encapsulation of the anilino moiety (anilino complex) vs. encapsulation of the quinone moiety (quinone complex). As can be seen from m-Et, m-Me and p-Me respectively) on the aniline end of the molecule. Those four substituents being very small, they have little steric effect on the stability of the complexation. They also do not cause strong electronic effects, since they are only very weakly electron donating (the electronic effects will be discussed in p-Et group). p-methyl). This figure illlustrates the minimal steric interaction between the CD cavity and the small p-methyl substituent on the anilino ring, and the deep anilino penetration into the CD cavity, in both cases.Since only PAN derivatives 1, 4, 7 and 10 showed a 2:1 complex under ESI conditions, we further investigated the results indicated in p-n-Bu and p-n-Hexyl respectively) did not show a 2:1 complex since the n-butyl and n-hexyl groups are quite bulky and under the energy of the ESI, the complexation on the aniline side of the molecule would be lost.PAN derivatives 5 and 6 , the energy difference between the 1:1 quinone and 1:1 anilino complexes are relatively identical  with ical see . In thispara substituent. Comparing derivatives 16 and 18 (p-Cl and p-Br respectively) shows that the 1:1 anilino complexation for p-Br (derivative 17) is favored. This is due to the inductive effect of the p-Br which forces the nitrogen atom of the aniline group to push its electronic density into the aromatic. This further stabilizes the aniline moiety versus the quinone. Derivatives 8, 12, 13, 14 and 19 , all show the same trend since these groups are electron withdrawing and also force the nitrogen atom to donate its electronic density to the aniline side of the molecule. Derivative 3 (p-OMe) shows the exact opposite effect since it is an electron donating group. The electronic density of this group forces the nitrogen atom to push its electronic density into the quinone group. In this case, the 1:1 quinone complexation will be favored.This leaves PAN derivatives 3, 8, 12, 13, 14, 16, 17, and 19. All of these derivatives have a Thus, when a derivative does not show a 2:1 complexation in the ESI, the absence of these 2:1 complex are explained by a combination steric and electronic effects. Furthermore, the preference for either the 1:1 quinone or 1:1 anilino is correlated by the difference of energy from m and σp substituent constants, which have been determined and tabulated based on the effect of meta or para substitution of a substituent the acid equilibrium constant of benzoic acid 41]. Enerm-methyl, m-ethyl, and p-methyl) and 2 cases for the larger γ-CD (m- and p-methyl). Thus, the specific nature of the PAN derivative, and the effect of the specific substituents, has a major effect on determining the resulting host-guest stoichiometry, as does the size of the host CD cavity. Molecular modeling studies showed that 1:1 complexation most likely involves encapsulation of the aniline rather than the quinone moiety, and indicated large stabilization upon 2:1 complexation. Consideration of the Hammett parameters of the substituents showed that 2:1 host-guest complexes formed only with PAN derivatives with small substituents with negative σm or σp values, i.e., for guests with electron donating substituents. This trend indicates that higher electron density on the aromatic ring encourages complexation by 2 host molecules. However, larger alkyl substituents with negative σm and σp parameters did not yield 2:1 complexes, even for the larger γ-CD host, showing that steric effects in terms of guest size are also highly important. It is clear that the prediction of host-guest stoichiometry for a specific host-guest pair is complicated, and involves a subtle interplay of both electronic and steric factors. However, as demonstrated in this paper, there are trends in terms of the electronic nature of the guest and the size of both the guest and host, which can be used to help predict the expected host:guest stoichiometry for a given host-guest pair.2-[(R-phenyl)amine]-1,4-naphthoquinones (PAN) form host-guest inclusion complexes with both β- and γ-CD, as observed by ESI-MS experiments. For the majority of the 19 PAN derivatives studied in these two CDs, only 1:1 CD:PAN complexes were observed (32 out of 38 host:guest pairs). In six cases, 2:1 host:guest complexes were also observed: 4 cases for β-CD (parent PAN,