The study also showed that the concrete surface had excellent paint absorption despite the use of release agents. The architectural concrete was evenly covered with paint without any problem. There were no difficulties in applying it, e.g., greasy places preventing the concrete from being coated with emulsion. The suitability of the produced release oils for lightweight architectural concrete structures intended for facades was confirmed. The best results were obtained after using formulations O65T35 and O90W10.In the article, unique formulations of biodegradable, non-toxic, edible oil-based release oils were developed and tested on architectural concrete. The produced agents have physicochemical properties similar to diesel fuel, but at the same time, are renewable and biodegradable products. An ultrasound was used to properly combine the liquid phase of edible oil and the liquid phase of glyceryl trioleate and/or water. Based on the PN-B-19305 standard, seven-component configurations were designed and then tested. The wettability of the concrete was determined by contact angle (CA) analysis. After the application of the formulations produced, the architectural concrete still had good wettability. The vapor permeability test showed that the tested release agents did not inhibit water vapor diffusion from the tested samples. The O65G35 (65% unique edible oil formula and 35% glyceryl trioleate) concrete had the best absorption. In this case, the CA was 56° after oil application and 46° before. The new agents did not impair the adhesion of the plaster to concrete. The O90W10 concrete showed the best adhesion of plasters made with it—51.9 kN/m A characteristic feature of concrete as a construction material is the formation of elements of practically any shape. In the case of precast elements, this is performed in suitably prepared molds, usually reusable. In monolithic structures, modular or individual formwork is used, which generally can also be used again. The forming process consists of tightly filling the mold with concrete mix. Once the concrete is placed in the mold, the chemical processes of setting and hardening begin. The cement used as a binder in concrete due to transformations and reactions turns into, among other things, calcium hydroxide, which is the cause of a highly alkaline environment. As a strong alkali, it has corrosive properties which are harmful if they come into contact with the skin, and it also affects the surface reaction between the mold material and the concrete. The hardened concrete will stick firmly to the mold and cause two undesirable effects during demolding—damage to the surface of the molded concrete element or damage to the mold (formwork). Damage to the surface of the concrete generally needs to be repaired for the sake of the structure’s design life. In concretes with expected visual parameters , it may disqualify it entirely and lead to the demolition of the element and reconstruction. The only way to avoid problems remains to use an adequately selected release agent designed to minimize cohesion forces between contacting materials.Sources of knowledge such as ,4,5,6,7 Release agents also are not covered by standard requirements, as in concrete admixtures or concrete additives, for example. However, they can be classified in a collaborative group of products, so-called construction chemicals. In the PN-EN 13,670 standard —executioDiesel oils are often used as release agents. The disadvantages of diesel oils are toxicity related to their composition of harmful aromatic hydrocarbons, flammability (class II), unpleasant smell, and aggressiveness towards the environment. Even more destructive are lubricating oils and used oils that should not be used for these purposes due to their carcinogenic effect. For these reasons, in most industrialized countries with highly ecologically sensitive societies, there have been strong trends toward the search for molding oils that are harmless and compatible with the environment. In response to these trends and demands, unique formulations of biodegradable, non-toxic oils with reduced human and environmental impact were developed in this paper.Release agents can be distinguished in three types: directly applied as oil, in the form of water-oil emulsions, and a gel. Baty and Reynolds  divided Fatty acids can be obtained by modifying vegetable oils such as canola oil, sunflower oil, coconut oil, or soybean oil by separating them into glycerol and the fatty acids themselves. A subsequent combination of these acids with another suitable alcohol gives fatty acid esters, which can then be emulsified in water . Most baBaty and Reynolds  also sugVegetable oil-based release agents have been marketed in Europe for nearly 40 years, and many successful companies have already proved their use. However, initial poor technical performance, low prices of mineral oil-based products, and lack of awareness of the environmental consequences, among other reasons, are responsible for the current minimal market share of this type of oil . In the Biodegradability is one of the stringent environmental requirements that new generation release agents must meet. The ingredients used for the production of biodegradable release agents should absolutely meet strictly defined environmental requirements. For European countries, the most common needs are those adopted in Germany in the 1970s with the “Blue Angel” eco-label regulation. These guidelines have successfully introduced new technologies and are still used to modify lubricant compositions, create modern products with ecotoxicological properties, and limit lubricants’ impact on the environment.Thus far, the classification of release agents has not been developed by the International Organization for Standardization (ISO). The withdrawn standard PN-B-19305 —“ReleaseThe primary outcome of this research is to evaluate the use of biodegradable release oils and their effects on the physical and mechanical properties of light-colored architectural concrete.Release oils tests were conducted on architectural concrete with white CEM I 52.5 R cement with high color purity requirements.–2/g, beginning of binding 140 min, end 170 min; compressive strength after two days 36.0 MPa and after 28 days 56.6 MPa. Loss on ignition 2.1%, whiteness 75%, insoluble residue 0.43%, Cl content 0.06%, SO3 content 3.82%, volume change 0.8 mm [Portland cement CEM I 52.5R, with the following specifications: a specific surface area of 4080 cme 0.8 mm . Tests oe 0.8 mm . Portlan–2, Al2O3, Fe2O3, and CaO . The chemical composition of the quartz sand and the coarse aggregate was obtained using a scanning electron microscope (SEM)—Quanta FEG 250. Quartz sand is characterized by specific gravity equal to 2650 kg/m3, water absorption amounting to 1.2%, and moisture reaching 0.16% [Quartz sand (0–2 mm). The utilized sand is characterized by the following chemical composition: SiOng 0.16% ;–3;Coarse aggregate—natural gravel quartz (2–8 mm) from light sandstone and minerals in gravel grains came from plutonic rocks, i.e., orthoclase and albite, minerals in grains came from sedimentary rocks—calcite, illite dolomite. The bulk density of sand and gravel used was the same, i.e., 2.65 kg/dm–−3 and pH 1–5. By using a polycarboxylic ether-based superplasticizer, a comparable consistency was obtained for all concrete samples.Superplasticizer was used in order to reduce the amount of water used in the production process. It is a highly liquefying agent based on polycarboxylates with a density of 1.06 ± 0.02 g∙cmMaterials used to make the concrete mix:The dry ingredients were slowly mixed in a mixer for 2 min. Then water with superplasticizer was slowly and gradually added to the mixture to achieve a thorough combination and avoid segregation of the mixture components. Mixing was continued for 5 min. The concrete mix was compacted in the molds on a vibrating table at a vibration frequency of 50 Hz to achieve complete compaction without segregation and release of cement laitance. After removing the mold, the samples were stored in water at 20 ± 5 °C for 28 days under laboratory conditions. The made concrete slump test for concrete mixture indicated 12 ± 2 cm, which reflects consistency class S3 .3; coarse aggregate 2–8 mm—1156 kg/m3; quartz sand 0–2 mm—770 kg/m3; superplasticizer—3.3 kg/m3; water—112.2 L/m3; w/c ratio = 0.3.The composition of the light-colored architectural concrete was as follows: Portland cement CEM I 52.5 R—374 kg/m–O65G35—65% bioecobase and 35% bioecobase-o;–O65G33W2—65% bioecobase, 33% bioecobase-o, and 2% water;–O65G31W4—65% bioecobase, 31% bioecobase-o, and 4% water;–O65G29W6—65% bioecobase, 29% bioecobase-o, and 6% water;–O70W30—70% bioecobase and 30% water;–O80W20—80% bioecobase and 20% water;–O90W10—90% bioecobase and 10% water.Following seven release agents configurations were prepared in the study:The method for the preparation of bioecobase and bioecobase-o includes the steps of heating inedible  vegetable oils , preparing a catalytic mixture from methanol and potassium hydroxide, causing a reaction by combining the heated oil with the catalytic mix, resulting in a post-reaction combination.Methods of producing bioecobase, bioecobase-o, and mold release agents are the subject of patent application number P.437754 dated 30-04-2021. The individual components were mixed using a slow-speed mixer for 5 min to combine thoroughly.The general characteristics of the concrete were obtained from tests: volumetric density according to EN 12390-7 standard , compresDensity and viscosity of the release agent: the viscosity coefficient was determined by the Stokes method  at the r3 of 50 mg/dm3 solution were prepared for testing, into which 1 cm3 of inoculum containing more than 107 CFU/cm3 (active cells/cm3) were introduced each. The inoculum used for testing was obtained from municipal wastewater after mechanical treatment. This test determined the decrease in hydrocarbon concentration in a sample containing the test substance in a mineral medium inoculated with microorganisms. The release agent was introduced into the experimental vessels in carbon tetrachloride. The absorption maximum of CH3–CH2 bonds at 2930 cm−1 was determined in the obtained extracts. The concentration of hydrocarbons was determined spectrophotometrically by IR (NICOLET 380 FT IR spectrophotometer) after saponification of the samples by ultrasound and extraction with carbon tetrachloride. The determination of IR absorption was performed after 7 and 21 days of the experiment. The test allows the substance to be classified as readily biodegradable if it achieves, within 28 days, the required level of biodegradation of 70% for the determination of dissolved organic carbon and 60% for the determination of Biochemical Oxygen Demand or CO2 produced.Biodegradability: Biodegradability tests were performed under the conditions described in CEC Method L-33-T-82 ,23. Acco–steel rectangular with dimensions 40 mm × 40 mm × 160 mm;–plastic cubes with dimensions of 100 mm × 100 mm × 100 mm;–wooden furniture board 50 mm × 300 mm × 300 mm.The effect of release agents on concrete surface quality: greasiness of concrete surface, color change of concrete surface, streaking . Influence of the release agents on the mold quality: adhesion—checking the effectiveness of the release agent. According to paragraph 2.3.2 of the PN-B-19305  standardThe molds were thoroughly cleaned, and then their walls were coated with a release agent.w (kg/(m2 s0.5)) due to capillary rise was performed according to PN-EN 1015-18 [3 and were applied onto the sample via micropipette. Five drops were applied to each sample, given the heterogeneity of the material. The measurements were conducted at the temperature approximating 22.5 °C [The effect of release agents on the characteristics and durability of concrete: the water absorption coefficient A 1015-18  standard 22.5 °C . The watThe adhesive strength of the hardened plasters on concrete samples was tested in accordance with EN 1015-12 standard . Adhesio3, compressive strength fc,cube#150 = 75.4 MPa, and flexural strength during bending 8.2 MPa. The mechanical strength values  were obtained after 28 days.The primary characteristics of concrete that are not addressed in this study are volumetric density 2295 kg/m3. Water at a temperature of about 1 °C has a similar density. 2/s. The highest values of both dynamic and kinematic viscosity were characteristic for the preparation of O65G31W4.The tested newly produced agents have a density of 1.0–1.1 g/cmThe results obtained are summarized in The best parameters were obtained for formulation O65G35 because even at a temperature of −14 °C, it remained liquid and did not freeze. Preparations with water admixture froze depending on the amount of this admixture (from 0 to −10 °C).The biodegradability results are shown in The test showed that all the oils obtained can be classified as readily biodegradable because, after 21 days, the level of biodegradation was between 98 and 100%.According to clause 2.3.1 of the PN-B-19305 standard , the greAs shown in According to Section 2.3.2 of PN-B-19305 , the relNo staining, streaking, crystallization, or efflorescence was observed on the surface of the demolded concrete samples for all the mold release agents analyzed. Satisfactorily, the new mold release oils did not cause streaking or yellow stains on the light-colored architectural concrete, which is a very desirable characteristic.The molds were thoroughly cleaned, and then their walls were coated with adhesive, as shown in The test was carried out in accordance with point 3.6.2.1. of the PN-B-19305 standard , which cWe did not observe any problems with the release of samples from the molds or adhesion of concrete to the mold after either 1 h or 24 h of coating the molds with oils. The test showed that the produced release oils fulfilled their function.2). The concrete obtained the highest absorption coefficient at 20% water content. These values are typical for ordinary concrete; they do not deviate from the standard, which indicates the lack of adverse effect of oils on water retention in concrete.It was observed that as the amount of water in the mixture increases, the water absorption coefficient due to capillary rise increases. It differs by a maximum of 7% between the agent without water O65W35 and the highest water content O80W20. Architectural concrete obtained similar coefficient values regardless of the oil used (0.96–1.02 kg/mThe contact angle (CA) analysis was performed on distilled water. Measurements were conducted at approximately 22.5 °C at the time of droplet application .In the case of architectural concrete, which contains plasticizing and hydrophobizing admixtures, the contact angle was higher than ordinary concrete. It is not a disadvantage caused by the oil application but is due to the specific characteristics of this type of concrete, the admixtures used, and the lower w/c ratio. Evidence of this can be seen in the contact angle measurements, which increased by only 2–3° after oil application. Therefore, it can be concluded that the release oils did not increase the wetting angle of the analyzed concrete surfaces.The results of water vapor diffusion over time are shown in The test showed that the tested release agents did not inhibit water vapor diffusion from the tested specimens . After 7The study results are shown in 2. The plasters showed the greatest adhesion to O65G35 concrete. The antiadhesion oils did not adversely affect the adhesion of adhesive mortars to concretes.The mortars showed good adhesion, ranging from 36.3 to 51.9 kN/mThe condition of the samples after applying two coats of white emulsion paint is shown in The plain concrete was evenly coated with paint. There were no difficulties in applying the paint, e.g., greasy spots making it impossible to cover the concrete with emulsion. Excellent paint absorbency was achieved. The generated release agents did not adversely affect the ability to coat the concrete with paint.Analyzing the appearance of the agents, it can be stated that in the case of O65G35, no segregation of components or precipitate was observed, even a few days after production. The color of the agent with 10% water content (O90W10) changed to a more transparent, darker color, similar to natural oils. However, a slight precipitate was observed at the bottom of the container. As the amount of water in the mixture increased, turbidity of the substance was noticed. The individual components of the new agents mixed very well together. However, as time passed, a white precipitate appeared at the bottom of the container for O90W10, O80W20, and O70W30 and a pink residue for the agents with glyceryl trioleate and water. Due to too much segregation of the mold release agent with 30% water content, further studies decided to eliminate it.2/s [The measurements of the η coefficient showed that the agent O65G31W4 had the highest dynamic/kinematic viscosity, while the agent O90W10 had the lowest. For comparison, the kinematic viscosity of rapeseed oil methyl ester at 20 °C is 7 mm2/s . The higIt is crucial that manufacturers or distributors provide information regarding the biodegradability, ecotoxicity, and bioaccumulation of chemical products in Section 12 of the safety data sheets for chemical products  preparedThe analysis on the possibility of obtaining biodegradable release oils with planned operating properties presented by Duncan et al.  showed tAnalyzing mortar adhesion to the concrete surface, no lack of adhesion was observed in all six studied cases. In their article, Brito et al.  tested tSatisfactorily, the new release agents did not cause staining, streaking, crystallization, or efflorescence on the light-colored architectural concrete, which is a very desirable feature. In the article Klovas and Daukšys , the maiBoth 1 h and 24 h after application of the release agent, there were no problems with samples being released from the molds or concrete sticking to the mold. Libessart et al. , in theiw was obtained at 20% water content. These values are typical for normal concrete and do not deviate from the standard, indicating any adverse effect of oils on water retention in concrete.It was observed that as the amount of water in the mixture increases, the water absorption coefficient due to capillary rise increases. It differs by a maximum of 7% between the agent without water O65W35 and the highest water content O80W20. The highest absorption coefficient AThe mold release oils did not seal the structure of the concrete. All CA were lower than 90°, indicating the hydrophilicity of the concrete. The O65G35 concrete had the best wettability. In this case, the contact angle was 56°. For architectural concrete, the contact angle was much higher than for normal concretes or mortars described, for example, in the work of Barnat-Hunek et al. ,43. The Water vapor diffusion is the movement of molecules in a mixture of gases to equalize the vapor concentration. Diffusion allows water vapor to pass through partitions by balancing the partial pressure prevailing on both sides of the partition. The water vapor diffusion test was conducted to see if the new release oils had a negative effect on the flow of water vapor through the concrete specimen. The test showed that the tested release agents did not inhibit water vapor diffusion from the test specimens . The moi2. The plasters showed the highest adhesion to concrete for which O65G35 oil was used in the preparation. The release oils did not adversely affect the adhesion of the mortars to the concretes.The mortars showed good adhesion on which the new formulations were used, ranging from 36.3 to 51.9 kN/mThe architectural concrete was evenly covered with paint. There were no difficulties in applying the paint, e.g., greasy spots that made it impossible to cover the concrete with emulsion. The release agent did not negatively affect the ability to coat the concrete with paint.Studies have shown that higher fatty acids derived from vegetable oils can be used as release oil for steel and plastic molds used to produce light-colored architectural concrete elements, meeting the normative requirements for this type of oil. Formulations have good service properties except for a white precipitate that can be filtered out as needed.In addition, the good rheological properties, resulting from the relatively low viscosity of the oil, have a beneficial effect on the use-values, as it can be applied to steel mold surfaces by typical methods such as dipping, brushing, or spraying, without the need for dilution. Agents with no or 2–4% water content are characterized by a low freezing point (from −14 °C to −7 °C).The newly developed release agents do not seal the concrete, allow moisture to migrate freely, no greasy film is formed on the concrete surface, the adhesive mortar shows good adhesion to the substrate. The high biodegradability of the new release agents was demonstrated, as they are made exclusively from natural substances.Thus, the suitability of the selected molding oil for construction applications in concrete technology was confirmed. The best results were obtained with O65G35 and O90W10 mixtures.


BackgroundThe number of publications is widely used as a measure of academic productivity in the field of orthopaedics. How “productive” a physician is has a great influence on consideration for employment, compensation, and promotions. Predictors of potential high-output researchers would be of value to the orthopaedic department and university leadership for new faculty evaluation.MethodsThe study population included orthopaedic faculty from the top 10 orthopaedic institutions in the United States. Their names and the number of publications at each point in their training  and early career (first five and 10 years following fellowship) along with a total number of publications to date were collected by using PubMed.Resultssr=0.717, P<0.0001). However, no significant correlations were found comparing publications during each stage of training and the first 10 years following fellowship. A moderate positive correlation was found when comparing publications during medical school and residency output .Strong correlations were seen between publications during total training and publications output in the first five years following fellowship (ConclusionsThe data presented here may be utilized by department chairs during the evaluation of faculty and candidates to not interpret the number of publications during training and early career as a gauge of research interest and potential for future publications. Program directors may also use the only moderate correlation between publications in medical school and residency when evaluating applications as support of a more holistic review of applicants to determine research interest. The importance of publications early in one's career in determining successful applications for medical school, residency, and fellowship has been well documented . PublicaConsidering the significant impact of a physician’s publication history on their academic career within orthopaedics, research regarding relationships between publication record during training and early career with future academic productivity is of particular interest to not only orthopaedic leadership but also recruitment and promotion committees. Many times, an orthopaedic surgeon’s prior publication history is translated into their academic potential later in their career. The purpose of this study is to assess if prior publication output during training and early years as an attending correlates with future publication output within orthopaedics.The top 10 academic institutions in the United States for orthopaedics were identified using the US News Health Report Rankings in 2018 . The onlsr, SPSS 26.0; IBM, Chicago, IL, USA) were used to assess the relationships between the number of publications at different points in training and the early years in practice. Strength of the correlation was described using the following guide for the absolute value for sr: 0.00-0.19 “very weak”, 0.20-0.39 “weak”, 0.40-0.59 “moderate”, 0.60-0.79 “strong”, 0.80-1.0 “very strong”. Physicians with multiple fellowships were included in each of their respective fellowships for analysis.Physicians with incomplete data, such as missing graduation years during training, were omitted from data analysis. Spearman’s rank correlation coefficients . The sample included 327 (92%) males and 28 (8%) females.The majority were listed as assistant professor (46%), followed by associate professor (32%), and professor (22%). Years in practice, the total number of publications, and H-indexes all showed positive trends with increasing academic rank Table .The average number of publications during medical school was 0.3+/-3.3 Table . The aveA comparison of academic productivity between the orthopaedic subspecialties including the number of publications and per cent of physicians with no publications at each stage in training is displayed in Table sr=0.717, P<0.0001). However, no significant correlations were found between the number of publications at any stage in training and the number of publications produced in the first 10 years following fellowship. Furthermore, only a weak positive correlation was observed between the number of publications during the first five and first 10 years following fellowship .Spearman rank coefficients showed statistically significant correlations between the number of publications in medical school, residency, fellowship, and the first five years in practice Table . Strong sr=0.401, P<0.0001) and a strong correlation was seen with publications during residency and publications during fellowship .A moderate positive correlation was found when comparing publications during medical school and residency output  by departmental and university leadership. Although an isolated publication number may not accurately represent academic output, it is used as a global assessment for when promotion, dedicated academic time and funding, and institutional value come into question. A strong significant correlation was found between publication output during training with output during the first five years following completion of the fellowship. This finding could suggest that having a previous foundation in research can help an attending be productive earlier in their career. This foundation could come in the form of training/experience in efficient data collection, statistics, or manuscript preparation, along with already established academic collaborations.However, no significant correlation was seen between productivity during training with productivity in the 10 years following fellowship. Furthermore, only a weak correlation was seen between publication output during the first five years and the first 10 years. These results can be important for orthopaedic leadership to take note of. A new attending may not have a strong prior research foundation or may hold other time consuming academic/clinical duties that could lead to lower publication output during their early career. However, this should not always be viewed as them not having an “interest” in research, seeing as they still have the potential to become a high-output researcher later in their career. A major component in consideration for promotion is current research productivity and the potential for future productivity, as measured by the number of peer-reviewed publications. This information may be used by department chairs when evaluating the portfolios of assistant and associate professors for under consideration for promotion. A physician’s lack of early publications during training years should not be used as an indicator of future research productivity potential. This information may also be used when hiring new faculty that may not have produced many publications during their years of training, but demonstrate many other characteristics that align with the institution’s values and criteria for junior faculty.In addition to using by department chairs when evaluating faculty, orthopaedic residency program directors may use this data when evaluating medical students’ applications. In recent years, the number of publications has become increasingly important for medical students as a determinate of successfully matching into an orthopaedic residency program. When selecting applicants to interview, 66% of orthopaedic surgery program directors cited "demonstrated involvement and interest in research" as a factor in applicant selection . In 2018This study was not without limitations; the first being the selection bias of only including orthopaedic surgeons employed by the top 10 institutions. While highly ranked institutions tend to conduct and publish more research, this still represents a limitation in the utility of subspecialty references at other institutions. It was not feasible to collect data for the orthopaedic faculty at every academic centre, so we chose to focus on these institutions where we predicted this type of data would be of greatest utility to department chairs. The other main limitation of this study was that not every journal lists the date of acceptance along with the date of publication, so publication date had to be used when the acceptance date was not available. With the time from initial submission to publication estimated to be 36 weeks, the significant correlations seen between sequential stages in training, such as residency and fellowship, may be influenced by a lag in publication times [This paper provides some useful reference data for residency directors, department chairs by using data obtained from the top 10 orthopaedic institutions. Here we demonstrated that while there is some correlation between the number of publications during training with the number of publications during the first five years following fellowship, this relationship does not hold true for number of publications during the first 10 years following fellowship. Therefore, department chairs should not view the number of publications as a reflection of a new attending's research interest. This information may also be utilized by residency program directors while evaluating medical students’ applications as a reminder to look beyond the number of publications when gauging a potential resident's research interest.


IgG4-Positivity (# IgG4-PC/# pan-IgG-expressing cells) distribution was heterogenous and overlapping . IgG4-Positivity was inversely correlated with corticosteroid use (p < 0.001). IgG4-Positivity ≥0.500 was associated with rapid AST improvement (p = 0.03). The variable IgG4-Positivity of AIH, rAIH and PCR suggests diverse and overlapping immunopathologic mechanisms and that current diagnostic schemes inadequately capture PCH immunopathology. We propose incorporation of IgG4-Positivity to refine current PCH classification and treatment strategies.Autoimmune hepatitis (AIH), post-transplant recurrent AIH (rAIH), and plasma cell-rich rejection (PCR) are clinical diagnoses with the shared histopathologic hallmark of plasma cell hepatitis (PCH). As these histologically and serologically indistinguishable diagnoses are differentiated by clinical context, it remains uncertain whether they represent distinct immunologic phenomena. Improved understanding of immunoglobulin subclass 4-producing plasma cells (IgG4-PC) has brought attention to IgG4 as an immunophenotypic biomarker. To date, degree and clinical significance of IgG4-PC infiltration in PCH remain elusive. This retrospective, single-center study assessed IgG4-PC infiltration in AIH, rAIH, and PCR via standardized immunohistochemistry analysis. Identified cases from 2005 to 2020 ( Plasma cell hepatitis (PCH) is a pathohistological finding characterized by lymphoplasmacytic portal and lobular inflammation with prominent plasma cells and often with the presence of interface hepatitis, perivenulitis and centrilobular necrosis –4. WhilePCH often results in the development of hepatic fibrosis if not promptly and adequately treated with potent immunosuppressants (IS) such as corticosteroids (CS), antimetabolites, and calcineurin inhibitors –16. More.Since histopathological and serological assessment do not distinguish between AIH, rAIH, and PCR, their diagnosis is entirely reliant on clinical context, which is coupled with challenges, perhaps ambiguity , 20–23. PC, the terminally differentiated B cells, play a major role in the regulation of humoral immunity through the production of immunoglobulin (Ig). PC exhibit highly diverse immunomodulatory effects depending on the classes and subclasses of Ig production such as IgG, A, and M as well as IgG1, 2, 3, and 4, respectively . Hence, Prior studies have demonstrated the infiltration of IgG4-PC in the liver tissue of PCR and native-liver AIH, with a PCR subtype demonstrating significant enrichment , 29. ConAll study procedures were approved by the University of Southern California Institutional Review Board (HS-19-00258). The study subjects were identified with the Department of Pathology Database by querying for reports containing “AIH,” “PCR”, or “PCH” from 2005 to 2020. The medical record and histopathological finding of all subjects identified through the database were confirmed to meet the diagnostic criteria of AIH  or PCH (Banff consensus) , 30, 31.The medical records of identified subjects were reviewed to extract relevant demographic and clinical information.n = 47) were retrieved. The hematoxylin-eosin (H&E)-stained pathology slides were first reviewed for adequacy of the tissue as determined by 8 or greater portal tracts and at least 1.5 cm in length. All retrieved samples were deemed adequate by these criteria. For individuals with multiple biopsies with the same diagnosis, the initial biopsy specimen available was used. Cases were evaluated for the following histological characteristics: portal inflammation, interface lobular necro-inflammatory activity, perivenular inflammation and the presence of bridging necrosis. Both activity and fibrosis were assessed on the Metavir histological activity and fibrosis score. Any additional pathological findings were also recorded. The tissue specimens were serially sectioned and applied for immunohistochemical stains using anti-human pan-IgG (RWP49 clone: Leica Biosystems) at 1:1,000 dilution and anti-human IgG4 (MRQ-44 from Cell Marque) at 1:500 dilution. All staining was performed using Bond III Leica Autostainer system at the Human Pathology Core. The representative portal tract of each subject identified by an expert pathologist was used to determine the IgG4-Positivity, which was calculated by the number of IgG4 staining positive PC normalized by the number of pan-IgG staining positive PC in the corresponding portal tract of the serially sectioned slides. Counting was done manually on ×400 of both the IgG and IgG4 cells in that portal tract.The Formalin-Fixed Paraffin-Embedded (FFPE) liver needle core biopsy specimens of all enrolled cases  or frequencies with proportions for the overall cohort and stratified by PCH subtype. Characteristics were compared within the respective non-transplant (tnAIH versus fAIH) and transplant (rAIH versus PCR) groups using Wilcoxon-rank sum and Fisher’s exact tests, as appropriate.Measures of IgG4 were characterized as the presence or absence of IgG4-PC and the proportion of IgG4-PC of all IgG-producing cells, which were compared by PCH subtype. The proportion of IgG4-PC was plotted by PCH subtype and separately categorized in tertiles to accommodate the skewed distribution. Laboratory parameters and therapeutic outcomes were evaluated for their association with increasing tertile of IgG4-Positivity using non-parametric trend tests (Stata nptrend) and markedly high IgG4-Positivity in the post-LT groups (≥0.500 vs. <0.500) using Kruskal-Wallis tests (Stata).p < 0.05. Statistical analysis was conducted using SAS 9.4  and Stata 14.0 .Differences were considered statistically significant at The demographics and clinical characteristics of the study subjects are summarized . There wCalcineurin inhibitor (CNI) and corticosteroids (CS) were the most common IS at biopsy  . Apart fp = 0.01), median total plasma cell count (p = 0.003), severity of lobular inflammation (p = 0.046), and presence of interface hepatitis (p < 0.001) compared to fAIH. In the post-transplant groups, PCR demonstrated higher median number of plasma cells (p < 0.001) and proportion of plasma cells relative to total lymphocyte count (p < 0.001) compared to rAIH. However, the overall histologic similarities among PCH subtypes did not allow for definitive differentiation based on the histopathological assessment with H&E staining.The H&E stained and trichome stained section of liver needle biopsy specimen were reviewed by a liver pathologist for the aforementioned features . In the To investigate whether each PCH disease reflects distinctive or overlapping immuno-pathologies, we further examined the specimen by immunophenotyping of infiltrating PC via immunohistochemical analysis of IgG4 expression. IgG4-PC was identified in 30 cases (64%), while the remaining 17 cases did not exhibit the presence of IgG4-PC . IgG4-PCp = 0.03). In the transplant groups, PCR demonstrated a higher median IgG4-Positivity than rAIH (p = 0.03)  . Five su = 0.03) . No rAIHp = 0.02). This is consistent with the findings seen in other IgG4-RD (p < 0.001). Alternatively, no statistically significant trends were detected between degree of IgG4-Positivity and serum white blood cell count (p = 0.71), serum sodium (p = 0.50), serum creatinine (p = 0.83), ALP (p = 0.39), AST (p = 0.66), ALT (p = 0.64), or total bilirubin (p = 0.70) at time of biopsy (p = 0.14) or elevated ANA titer (≥1:40) (p = 0.78). ASMA positivity decreased by tertile of IgG4-Positivity from 71% to 36% in the lowest to highest tertiles, although this trend did not achieve statistical significance (p = 0.09). The relationship between serum IgG4 level and IgG4-Positivity could not be assessed due to limited data, though prior studies have shown that serum IgG4 concentration does not serve as the surrogate for the degree of IgG4-PC infiltration in the liver  and lobular information (p = 0.005) increased with tertile of IgG4-Positivity but was not significantly associated with presence of moderate or severe fibrosis (p = 0.57).Histologically, higher degree of IgG4-Positivity was associated with severe necro-inflammatory change in the histological assessment . The prop = 0.04) at 7–10 days after treatment initiation. However, no significant difference was found when comparing by diagnosis (p = 0.11) (p = 0.08)  of liver-related serologic tests  of current diagnoses (rAIH and PCR) to IgG4-Positivity strata (<0.500 and ≥0.500) was performed. High IgG4-Positivity (≥0.500), all of which were PCR cases, was associated with greater improvement of AST ( = 0.11) . The % i = 0.08) .In summary, our analysis suggests that the high degree of IgG4-PC proliferation is associated with the histological features of severe inflammation in non- and post-LT setting, as well as more rapid response to IS in the post-LT setting.de novo AIH exists separately from PCR  was only found in PCR cases. This implies that IgG4-PC infiltration to this extent is not a general immune response to a liver allograft, but rather appears to be a unique immunopathological fingerprint of PCR . We alsofrom PCR . Moreovefrom PCR .To date, there remain substantial gaps in understanding the underlying pathophysiology of PCH, which significantly hinders clinical management of PCH diseases. In particular, there is concern as to whether each PCH disease represents a distinctive condition or a cluster of broader, overlapping conditions than current classification schemes. The latter case might, at least in part, be the basis for the variable degree of response to IS among and within the PCH diseases. Current management strategies of PCH entirely rely on the empiric use of a variety of IS, which may result in significant toxicity and morbidity such as, but not limited to, the development of infection and malignancy. While the current empiric management strategy is capable of inducing remission in a large proportion of patients, the prognosis of individuals with PCH remains highly variable. In the non-LT setting, transplant-free survival of AIH is 91% and 70% at 10 and 20 years from the initial diagnosis, respectively, with up to 40% progressing to cirrhosis despite treatment , 34. SimGiven advancement in understanding of IgG4-RD, there has been increasing interest in the involvement of IgG4-PC in liver diseases. The pioneer work examined the liver tissue of autoimmune pancreatitis patients with liver enzyme abnormalities, in which the dense infiltration of IgG4-PC in the liver parenchyma was observed in nearly all cases . Since tIgG4 is known to have a unique immunomodulatory effect distinct from other types Ig . Other t+ (C-X-C chemokine receptor type-5) CXCR5+ T cell, namely Tfh cells, facilitates transdifferentiation of naive B cells to IgG4-PC (+ T cells with a cytotoxic function (CD4+ CTLs), which abundantly express SLAM family member 7 (SLAMF7), granzyme A (GZMA), IL-1β, and TGF-β, is observed in the affected organ of IgG4-RD -4 and IL-10 secreted from CD4 IgG4-PC –45. Acco IgG4-PC . In addi IgG4-RD , 48. TGF+ CTLs. Accordingly, previous studies by others reported that AIH cases with IgG4-PC infiltration were associated with a comparatively rapid response to steroid therapy to the induction of clinical remission (In general, IgG4-RD is known to be highly responsive to glucocorticoid-based IS. This notion coincides with the immunosuppressive properties of IgG4 as well as the anti-inflammatory effect of TGF-β secreted by the CD4emission , 40. Moremission  may servemission , 49, 50.emission . Moreoveemission . These oIn summary, this study is the first to cross-sectionally demonstrate the diversity of the immunophenotypic profile of PCH in the non- and post-transplant setting, in the absence and presence of IS, as defined by IgG4-Positivity—with significant differences across and within disease entities. The highly heterogenous IgG4-Positivity across and within PCH entities indicate that current classification of PCH diseases is insufficient in capturing the immuno-pathophysiology. Hence, we propose refining the PCH classification strategy by incorporating the IgG4-Positivity based stratified categorization, particularly in the post-LT setting; which might inform a immunopathology-specific management strategy and prognostication. Toward this goal, further prospective studies with a larger number of subjects treated with a standardized IS regimen, and long-term follow up, are warranted.


IgG4-related autoimmune cholangitis (IgG4-AIC) is often difficult to distinguish from cholangiocarcinoma (CCA). This study aimed to determine a practical clinical strategy for distinguishing between IgG4-AIC and CCA to avoid unnecessary surgical resection. We retrospectively collected and compared the clinicopathological data between IgG4-AIC and CCA patients, including the clinical, serological, and radiological characteristics, to follow up on these patients to investigate the prognosis. Among the 377 patients who received surgical resection for suspecting CCA at the Sun Yat-Sen Memorial Hospital between June 2004 and June 2014, 14 patients were diagnosed as IgG4-AIC through histochemistry after surgery. Immunohistochemistry revealed that IgG4 was up-regulated in the plasma cells of IgG4-AIC tissues in 13 out of 14 patients. The serum CA19-9 level was significantly lower than in the CCA group. Patients with IgG4-AIC can only see slight or no enhancement under the contrast enhancement CT scan, while there are no signs of ring-like or delayed enhancement that is unique to CCA. Thirteen patients were followed up, and the time was 12 to 92 months. Three of them were regularly treated with prednisone after surgery, and original symptoms disappeared. Our study demonstrated that the combination of imaging with serum CA19-9 could improve the preoperative diagnostic value and reduce the rate of unnecessary resection. IgG4-related autoimmune cholangitis (IgG4-AIC) is defined as an autoimmune disease involving the intro- and extrahepatic biliary tract, which belongs to the manifestation of IgG4-related disease (IgG4-RD) in the biliary tract , 2. AbouCholangiocarcinoma (CCA) is a kind of epithelial malignant tumor derived from various locations within the biliary tract . CCA is Due to plenty of overlapping characteristics between the two diseases, it’s hard to distinguish IgG4-AIC from CCA. IgG4-AIC is often misdiagnosed as a biliary malignant tumor, resulting in unnecessary surgical resection. To enhance the understanding of IgG4-AIC and avoid unnecessary surgery due to misdiagnosis, we have retrospectively collected cases of autoimmune cholangitis undergoing surgery in our hospital. In the present study, clinicopathological characteristics, serological examination, and radiological characteristics were used to describe and compare with CCA, and follow-up was performed to investigate efficacy and prognosis. Objective analyses of these data were performed, thereby increasing the accuracy of diagnosis and reducing unnecessary resection.Between June 2004 and June 2014, 377 patients who were suspected as CCA underwent surgical resection at the Department of Hepato-Pancreato-Biliary Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University . Among these patients, 14 patients were verified as IgG4-AIC histopathologically after surgery, according to the HISORt diagnostic criteria  at the Medical Research Center of Sun Yat-Sen Memorial Hospital. The stained sections were independently evaluated by two investigators who were blind to the clinical data of patients. The immunohistochemical staining sections were first scanned under a light microscope at low magnification (x40), and then five non-overlapping fields were observed at a final magnification of x400 , 14. TheWe have collected the first computer tomography (CT) or magnetic resonance (MR) of patients. CT or MRI scans were evaluated by a single radiologist, who was blind to the diagnosis, and recorded if there were any of the following abnormalities: biliary tract stenosis due to the thickened wall or tumor-like lesions in the bile duct, the dilation of the lumen, the enhancement of lesion, and peripheral lymphadenectasis.Only 13 patients have received complete follow-up. These 13 IgG4-AIC patients have received follow-up for 12–92 months . For each patient, periodic reviews were recorded, including laboratory tests, abdominal ultrasound, CT, or MR scan. The deadline for the follow-up was December 2014.Continuous variables were analyzed using Student’s t-test when the variables were normally distributed, like the age of patients, while the Mann-Whitney U-test was used when data did not follow the normal distribution, including ALT, AST, GGT, ALP, TBIL, CA19-9, CA125, AFP, and CEA. In all statistical analyses, P values were two-sided, and statistical significance was assumed with P<0.05. Statistical analyses were performed using SPSS 18.0 .The immunohistochemistry staining of all bile duct tissues for IgG4 was performed to evaluate the expression of IgG4 (n=53). The stained sections showed that IgG4 was highly expressed in the plasma cells of IgG4-AIC tissues ; the representative images are shown in All IgG4-AIC patients with pathological confirmation (n=14) had specimens. HE staining showed microscopically detectable chronic cholangitis with storiform-arranged fibrosis: plasma cell infiltration , chronic lymphadenitis , seven had bile duct fibrosis ; the representative images are shown in -1, P=0.025), which was observed as obviously elevated in CCA patients. However, there were no significant differences in CA125 (P=0.096) and AFP (P=0.572).The incidence of misdiagnosis of IgG4-AIC is 3.71% (14/377) in our center. The general characteristics of these patients were summarized in The image of IgG4-AIC patients showed that gallbladder wall or bile duct diffused thickened, stenosis of the bile duct, and dilation of the bile duct above the site of biliary obstruction. Out of these 14 patients, 5 exhibited enlarged lymph nodes that were misdiagnosed as lymph nodes metastasis . The most common involvement lesions found by imaging examination were the gallbladder in seven patients , followed by the common bile duct in five , the other intrahepatic bile duct in one , and the common hepatic duct in one . In addition, gallbladder wall thickening was found in seven patients, and four of them also presented thickened common bile duct. Through the enhanced scanning, the lesion was observed to exhibit low-density and no enhancement during the arterial phase in IgG4-AIC patients. By contrast, CCA tissues presented ring-like enhancement around and low-density in the center during the arterial phase, and enhanced area showed centripetal expansion as delayed-enhancement in the portal- and delayed-phase imaging Figure 3Thirteen out of 14 patients had received complete follow-up . The follow-up time was 12 to 92 months . Ten patients presented intermittent abdominal pain after surgery , and seven of them were required to take a pain-killer . Three patients were treated with prednisone (0.6 mg/kg) after surgery, and their symptoms disappeared after treatment and no other organs have been found affected in these patients. Five patients were followed up in the outpatient clinic; new hepatic hilar lesions under CT imaging were found in one patient, intrahepatic diffuse disease through ultrasound examination was found in one patient, and an enlarged right kidney was found in one patient. The above three patients have discovered recurrence within 6 to 12 months after surgery.IgG4-RD is a type of systemic disease that can involve any organ such as the pancreas, lungs, kidney, lymph nodes, and glands, which is characterized by infiltration of IgG4-positive plasma cells, elevated serum IgG4, and good response to the steroid, when it comes to the biliary tract is known as IgG4-AIC –17. On t-1 is less in IgG4-AIC than in CCA 163 from Key Laboratory of Malignant Tumor Molecular Mechanism and Translational Medicine of Guangzhou Bureau of Science and Information Technology; Grant KLB09001 from the Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes; and Grant from Guangdong Science and Technology Department .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


How to prevent the cracking of tunnel lining concrete under a high-temperature and low-humidity environment has gradually become a challenge faced by the engineering community. Actually, the concrete structure will be restrained, which easily leads to cracking. Aiming at this problem, a self-restraint device of concrete specimens was designed in this paper, which aims to more realistically simulate the restrained state of concrete structures during construction. SEM, EDS and XRD detection methods were used to study the macroscopic and microscopic properties of an early-age restrained concrete specimen under a high-temperature and low-humidity environment, and the results were compared with those of a non-restrained concrete specimen. The results show that the change in the internal relative humidity of the concrete was an extremely slow process, and the response rate of the internal humidity of the concrete was much slower than that of the temperature. A cubic curve model was used to fit the measured concrete damage degree with the loading age, and the fitting effect was good. Under the environment of high temperature and low humidity, the loading age from the 0.6th day to the 1st day was the period of a relatively large fluctuation in the concrete temperature and humidity, and the restraint would aggravate the damage of the concrete. The damage degree increased with the increase in the loading age, the microcracks gradually increased and, finally, macrocracks were formed. The restraint effect was to intensify the formation of microcracks, affect the hydration of the cement at the micro level and, finally, increase the risk of concrete cracking perpendicular to the restrained direction at the macro level. The research results may provide guidance for research on the cracking mechanism of tunnel lining concrete constructed under a high-temperature and low-humidity environment. A large number of engineering practices have proved that 80% of concrete structural cracks are mainly caused by the non-load stress generated by the concrete material itself or under the action of environmental temperature and humidity changes . There wOn the other hand, as a multiphase composite material, concrete will produce initial cracks before external load, namely, initial damage , which mIn fact, the concrete structure will be restrained, either restrained by the external rock base , restraiBased on the characteristics of the low thermal expansion coefficient and high strength of Invar alloy , a concrP·O 42.5 common Portland cement was used, which conformed to the Chinese standard GB175-2007. Natural fine aggregate was used. The fineness modulus of sand was 2.65. The coarse aggregate was granite gravel. The continuous gradation was 5 to 25 mm. Polycarboxylate superplasticizer was used, and the water was ordinary tap water. Concrete specimens of C30 target strength grade were prepared according to the Chinese standard JGJ55-2011, and the specific mix proportion of concrete is shown in Invar, as a nickel–iron alloy, has a very low coefficient of thermal expansion and can maintain a fixed length in a wide temperature range. Taking Invar alloy as raw material, a relevant restraint device that meets the experimental conditions was designed and manufactured, as shown in The experimental environment was controlled by a high–low temperature alternating temperature humidity test chamber. The measured temperature range was −20 to 150 °C, and the relative humidity range was 30% to 98%.The digital signal of the transmitter was collected regularly by the inspection instrument and stored by the computer. The experimental environment temperature was set at 50 °C, the relative humidity was set at 30% and the loading time was 7 days. The experiment was carried out after the specimen was ready for pouring. The overall effect of the experiment is shown in In order to ensure the one-dimensional transmission of moisture along the height direction of the specimen, tin foil paper and oil paper were laid on the inner surface and bottom of the restraint device and the non-restrained specimen mold, and a layer of waterproof coating was brushed onto these. For the non-restrained specimen after mold removal and sealing with tin foil wrapping, all specimens were only left on the upper surface in contact with the air.The plastic tubes for placing the sensor with an outer diameter of 20 mm were prepared. Two segments of a 3 mm-wide unconnected annular belt along the outer ring line 2 mm away from the bottom of the tube were cut, and the bottom of the plastic tube was sealed with a plastic sheet. The stainless steel bars with a diameter of 18 mm were prepared and placed in the plastic pipe in advance, and the inner wall of the plastic pipe was kept in close contact with the steel bar. The length of the steel bar exceeded the upper end of the plastic pipe by at least 5 cm for easy removal. The purpose was to ensure that the cement slurry did not penetrate from the bottom hole during the vibration process. The length of the sensor probe was 3 cm, and two O-shaped rubber sealing rings were sleeved at the position of 3 cm. Then, the mixed concrete was poured into the mold and fully vibrated with a vibrating bar. Finally, the plastic tube with a steel bar was slowly inserted into the corresponding position of the concrete specimen. According to the above steps, three plastic pipes were inserted into each concrete specimen, and their depths in the concrete were 1 cm, 3 cm and 5 cm, as shown in The steel bar was slowly pulled out after the pouring was completed for a period of time. The slurry remaining at the bottom of the plastic tube was sucked out with a sponge, and then the sensor was placed in the plastic tube, where the top of the sensor probe was as close as possible to the bottom of the plastic tube. As there was a gap between the outer wall of the sensor and the plastic tube, in order to ensure the accuracy of the collected humidity, a 2 mm-thick O-ring was placed 3 cm above the sensing part of the sensor so that the bottom of the plastic tube formed a sealed space of 3 cm in length. At the same time, the gap between the sensor and the PVC pipe was filled with polymer liquid sealant at the top of the plastic pipe to ensure that the sensor could accurately measure the temperature and humidity at the specified position. Then, the prepared concrete specimens were placed in the environmental test chamber, the environmental temperature was set at 50 °C and the relative humidity was set at 30%. The temperature and humidity were collected, and the data were recorded every 1 min.The principle of ultrasonic flaw detection  was usedIn order to distinguish the temperature and humidity collected by the sensors, the sensor numbered 1 for each specimen was named as temperature sensor T-1-1 and humidity sensor RH-1-1 in this paper, and the sensors numbered 2 and 3 were also named in this way. It can be seen in The relative humidity in the test chamber was set at 30%. The relative humidity measured by the sensor first decreased rapidly, then increased rapidly, and then decreased slowly, with large fluctuations. The main reason was that at the start-up time of the machine, the humidity in the hole was first measured by the sensor. Under the action of high temperature, the wet air evaporated and dissipated, and the relative humidity measured by the sensor decreased rapidly. On the other hand, as the initial stage of concrete pores contained more free water, they were in a state of humidity saturation. Under the action of high temperature, the free water inside the concrete began to evaporate, and the water vapor continued to attach to the sensor, resulting in the relative humidity measured by the sensor remaining at nearly 100% for a period of time. From then, under the continuous action of the high-temperature and low-humidity environment, the relative humidity measured by the sensor gradually decreased. The main reason is that the concrete cement itself had a certain degree of hydration and formed a certain amount of particles. When the free water was gradually isolated by the hydrated particles, and its continuity was destroyed, the vapor pressure in the pore began to be lower than the saturated vapor pressure. While the free water in the pore of the concrete decreased, the capillary water and gel water in the concrete began to evaporate continuously, resulting in the relative humidity measured by the sensor decreasing gradually.As sensors RH-1-1 and RH-2-1 were the closest to the upper surface of the concrete, the relative humidity measured by sensors RH-1-1 and RH-2-1 began to decrease on the 0.65th day and the 0.7th day of the loading age, respectively, and the relative humidity decreased the fastest. Sensors RH-1-2 and RH-2-2 took second place, and sensors RH-1-3 and RH-2-3 were the slowest with the increase in the hole depth. The relative humidity measured by sensors RH-1-1 and RH-2-1 decreased to 53.5% and 58.8%, respectively, on the 7th day of the loading age, and the relative humidity difference between them was 5.3%. It was speculated that the microcracks generated by the restrained concrete specimen caused by the restraint effect accelerated the water loss in the concrete. The relative humidity measured by sensors RH-1-2 and RH-2-2 began to decrease on the 3.10th day and on the 3.25th day of the loading age, respectively. On the 7th day of the loading age, the relative humidity measured by sensors RH-1-2 and RH-2-2 decreased to 94.8% and 95.1%, respectively. For sensors RH-1-3 and RH-2-3, the relative humidity measured on the 7th day of the loading age was still close to 100%. It can be seen that the change in the relative humidity in the concrete was an extremely slow process, and the response rate of the humidity in the concrete was much slower than that of the temperature.The measured data of the propagation time of the restrained concrete specimen (specimen 1) and non-restrained concrete specimen (specimen 2) on the 0th, 1st, 3rd, 5th and 7th days of the loading age were sorted. The damage variable D value of each specimen was calculated by Equation (1), as shown in The relationship between the damage degree D and the loading age t (d) of specimens 1 and 2 was fitted by a cubic curve model . The quaIt can be seen in It can be seen in Chapter 3.1 that when the ambient temperature was 50 °C and the relative humidity was 30%, the relative humidity measured by the sensors RH-1-3 and RH-2-3, whose position depth was 30 mm from the upper surface, was close to 100% on the 7th day of the loading age. In order to make the results more obvious, samples A1 and A2 of specimen 1 The results show that the change in the relative humidity in the concrete was an extremely slow process, and the response rate of the humidity in the concrete was much slower than that of the temperature. The central temperature of the concrete specimen reached the maximum value of 50 °C around the 0.6th day of the loading age, and the central relative humidity of the concrete specimen was almost 100% on the 7th day of the loading age.(b)The restraint increased the damage of the concrete specimens perpendicular to the restrained direction. When the central temperature of the specimen reached 50 °C, that is, at about the 0.6th day of the loading age, the difference in the damage degree between the restrained specimen and the non-restrained specimen began to become obvious, and the damage degree increased with the increase in the loading age. The relationship between the damage degree D and the loading age t (d) was fitted by a cubic curve model, and the quantitative relationship was obtained. The goodness of fit was 99.4%.(c)The restraint intensified the generation and expansion of microcracks in concrete specimens and accelerated the loss of water in the concrete. On the 7th day of the loading age, the relative humidity decreased at the depths of 1 cm, 3 cm and 5 cm of the concrete specimens by 5.3%, 0.3% and 0.01%, respectively, under the restraint.(d)The restraint effect manifested by intensifying the generation of microcracks and affecting the hydration of the cement at the micro level, resulting in a decrease in hydration products, a decrease in the crystallization degree and structural consistency density and, ultimately, an increase in the risk of concrete cracking at the macro level.(e)The loading age from the 0.6th day to the 1st day was the period of a relatively large fluctuation in the concrete temperature and humidity, which might be the key period of concrete damage and microcrack aggravation. Therefore, it is necessary to perform a good job in moisture conservation measures of concrete surfaces at an early age.In this paper, through the combination of macro experiments and micro-SEM, EDS and XRD detection methods, the following main conclusions were obtained for the early-age restrained concrete specimen under the environmental conditions of 50 °C and 30% relative humidity.


DICER1 gene mutations has been proposed.Thyroid cancer dedifferentiation is an unusual observation among young patients and is poorly understood, although a recent correlation to DICER1 sequences, but identified a somatic ETV6-NTRK3 gene fusion and a MET germline variant . MET is an established oncogene known to be overexpressed in thyroid cancer, and this specific alteration was not reported as a single nucleotide polymorphism (SNP), suggestive of a mutation. Both the primary PTC and the metastatic PDTC displayed strong MET immunoreactivity. A validation cohort of 50 PTCs from young patients were analyzed using quantitative real-time PCR, revealing significantly higher MET gene expression in tumors than normal thyroid controls, a finding which was particularly pronounced in BRAF V600E mutated cases. No additional tumors apart from the index case harbored the p.Arg359Gln MET mutation. Transfecting PTC cell lines MDA-T32 and MDA-T41 with a p.Arg359Gln MET plasmid construct revealed no obvious effects on cellular migratory or invasive properties, whereas overexpression of wildtype MET stimulated invasion.A 28-year old patient presented with a sub-centimeter cytology-verified primary papillary thyroid carcinoma (PTC) and a synchronous lateral lymph node metastasis. Following surgery, histopathology confirmed a 9 mm oxyphilic PTC and a synchronous metastasis of poorly differentiated thyroid carcinoma (PDTC). Extensive molecular examinations of both lesions revealed wildtype MET mutation in any way influenced the dedifferentiation of a primary PTC into a PDTC metastasis remains to be established. Moreover, our data corroborate earlier studies, indicating that MET is aberrantly expressed in PTC and may influence the invasive behavior of these tumors.The question of whether the observed The online version contains supplementary material available at 10.1186/s13044-021-00110-4. BRAF) is the most common recurrently mutated gene in PTC, with activating V600E mutations present in 50–70% of adult patients [TERT) promoter mutations, occurring in 10–15% of cases [RAS proto-oncogenes, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) and AKT serine/threonine kinase 1 (AKT1) are generally observed in clinically less worrying PTCs [RET) or neurotrophic receptor tyrosine kinase 1, 2 and 3  genes are dominant [Papillary thyroid carcinoma (PTC) is the most common subtype of thyroid cancer, accounting for approximately 70% of cases . Althougof cases . In contdominant .BRAF, TP53 and the TERT promoter, and several studies support the fact that an accumulation of additional mutations are possible contributors to the dedifferentiation process. In pediatric and adolescent patients however, the occurrence of PDTC is an exceedingly rare event which seems intimately coupled to mutations in the micro-RNA processor DICER1, a tumor suppressor gene also implicated in the development of follicular thyroid carcinoma [If well-differentiated thyroid cancers dedifferentiate into poorly differentiated thyroid carcinoma (PDTC), the clinical prognosis is much worse as current medical treatments exhibit reduced effectiveness . Histoloarcinoma , 15.MET gene encodes the MET tyrosine kinase receptor belonging to the superfamily of heterodimeric receptor tyrosine kinases (RTKs) [MET mutations and gene amplifications are present in a number of malignant tumors, including sporadic and hereditary papillary renal cell carcinoma and colorectal carcinoma [MET gene mutations and fusions have also been reported, including PTCs [RET wildtype familial medullary thyroid carcinoma was recently shown to carry a germline, potentially causative p.Arg417Gln MET mutation [The s (RTKs) . The METs (RTKs) , 18. Actarcinoma –21. In ting PTCs , 22. Mormutation .We describe a 28-year old female (denoted herein as the “index patient”) without previous medical history or family history of thyroid cancer, nor any history suggesting previous radiation exposure. She recently underwent surgery at our department for a cytology-verified sub-centimeter primary PTC with a lateral lymph node metastasis. Histopathology was consistent with a 9 mm primary PTC, but the lymph node metastasis exhibited a predominant morphology suggesting PDTC, as well as a peripheral rim with PTC morphology near the lymph node capsule. Two aspects of this clinical presentation are highly unusually encountered in routine practice: A) young patients often develop PTCs with lymph node metastases, but exceedingly seldom do we encounter dedifferentiation to PDTC in patients < 60 years of age; and B) as the PDTC was observed in the lateral lymph node metastasis adjacent to a remaining rim of PTC, this strongly suggests that the PDTC developed in the metastasis and not in the thyroid gland per se. Therefore, any underlying genetic mechanism leading to dedifferentiation would possibly be identified by parallel sequencing and comparison of data from the primary and metastatic lesion.The histological attributes of the index patient’s tumors are illustrated in Fig. https://evs.gs.washington.edu/EVS/) and the Database of Single Nucleotide Polymorphisms  were used in order to verify the minor allele frequency of the index patient’s MET variant. PolyPhen2 (http://genetics.bwh.harvard.edu/pph2/), “Sorting Intolerant From Tolerant”  and MutationAssessor (http://mutationassessor.org/r3/) were employed to examine if the variant had an impact on the MET protein function. The roles of this specific variant in the somatic setting were analyzed using the Catalogue of Somatic Mutations in Cancer (COSMIC) database (https://cancer.sanger.ac.uk/cosmic).The Exome Variant Server , and standardized protocols used the Ventana automated methodology in clinical routine practice at the Department of Pathology and Cytology, Karolinska University Hospital. The staining was assessed by an experienced endocrine pathologist using light microscopy, in which the level of immunoreactivity and sub-cellular localization was scored for both tumor samples.BRAF and TERT promoter mutational status of these cases have been previously published [MET gene output, clinical parameters were retrieved, including age at diagnosis, date of diagnosis, gender, tumor size, eventual lymph node metastases, eventual distant metastases, BRAF V600E mutation status and TERT promotor mutation status, disease-free survival (endpoints: relapsed/progression or disease-free) and overall survival . DNA and RNA extraction as well as cDNA synthesis was performed using the DNeasy Blood and Tissue kit , miRvana miRNA isolation kit  and High-Capacity cDNA Reverse Transcription Kit  respectively according to the protocols provided by the manufacturers and quantified using NanoDrop ND-100 .We have previously collected fresh-frozen tissues from PTC specimen from 93 selected patients operated at the Karolinska University Hospital between 1987–2005 for inclusion in unrelated projects. For this study, the 50 youngest patients were selected due to the index patient’s young age. These 50 cases were between 15–53 years old at the time of surgery and thus younger than the AJCC staging cutoff age (< 55 years). The ublished . In ordeMET gene mutation was performed in the independent PTC cohort as well as in leukocyte DNA of the index patient. The PCR reaction was performed using Platinum™ II Hot-Start PCR Master Mix (2X) (Thermo-Fisher Scientific), following the manufacturer instructions. Primers for the specific MET region were constructed by using Primer-BLAST (forward primer sequence 5´-TGCTCAGACTTTTCACACAAGA-3’ and reverse primer sequence 5´- GCAGTGCTCATGATTGGGTC-3´). Amplification was accomplished by following a PCR touchdown protocol. Products were purified using Invitrogen ExoSap-IT . Sanger sequencing was performed at the KIGene core facility at Karolinska University Hospital Solna using routine procedures, in order to screen for the specific p.Arg359Gln MET mutation. All chromatograms were visually inspected by two of the authors.Sanger sequencing verification of the n = 50) and histopathologically verified, de-identified normal thyroid tissues (n = 9) were normalized to a reference gene (GAPDH). The following Taqman Gene Expression Assays were used, MET as target gene  and GAPDH  as endogenous control. All specimens, tumor as well as normal, were run in triplicate and a mean value with standard deviation was calculated for each case. The relative expression was calculated using the 2−ΔCT method.We used the 7900HT Fast Real-time PCR system (Applied Biosystems) according to the manufacturer’s instructions. cDNA from PTC samples .Pearson correlation test was used to compare Detailed information regarding the cell lines and the functional experiments are available in a MET gene  was found in both the primary tumor and metastasis. This variant was confirmed as constitutional by Sanger sequencing of germline DNA. No somatic mutational events were noted in any gene interrogated. We thereafter submitted DNA and RNA from both tumors for extended analyses using the Oncomine Childhood Cancer Research Assay, and detected a pathognomonic ETV6-NTRK3 gene fusion in both the primary PTC as well as in the metastatic PDTC. No other cancer-related gene mutations or fusions were noted, including the thyroid cancer related genes BRAF, HRAS, KRAS, NRAS, TERT, TP53 and DICER1.When interrogating DNA from the primary PTC and metastatic PDTC using the Oncomine Solid Tumor Panel, a missense variant in exon 2 of the MET gene variant  was reported in 4 out of 12,214 exomes sequenced, and the minor allele frequency was estimated to 0.03%, well below usual cut-offs for distinction of mutations . Moreover, consulting dbSNP, the variant exhibited a near-identical minor allele frequency of 0.000338 = 0.03%. Moreover, using the PolyPhen2 in silico prediction software, the described variant had an impact score of 0.999, meaning that is highly probable that the variant exhibited a significant consequence for MET protein function. An additional SIFT analysis yielded similar result, with the variant predicted as “damaging” . To highlight the uncertain nature of this variant using in silico analyses, we also added data from MutationAssessor, in which the variant was predicted as having a low functional impact . Moreover, the p.Arg359Gln substitution is also reported in the COSMIC database as COSV59264672. The mutation has been reported in two neuroblastomas, one paraganglioma, as well as in single cases of prostatic adenocarcinoma, pancreatic adenocarcinoma and squamous cell carcinoma of the lung.In the Exome Variant Server, the specific The primary PTC as well as the metastatic lesion (both the PTC rim and the extensive PDTC component) exhibited strong and diffuse MET expression, distinctly stronger than adjacent normal thyroid tissue Fig. D and H.n = 50) are shown in Table BRAF V600E mutation (64%), and a single PTC exhibited the C228T TERT promoter mutation (2%).The clinical characteristics of the PTC validation cohort  (data not shown). BRAF V600E mutated cases presented with significantly higher MET expression than wildtype cases   , distant metastases  or disease-free survival . However, we found a significant correlation between low MET expression and overall survival   Fig. A. There BRAF V600E and TERT promoter mutations. For every incremental increase of T stage, the risk for recurrence increased , independent of other variables. Presence of a TERT promoter mutation was also an independent predictor of disease recurrence . T stage and TERT promoter mutation were also independent predictors of mortality . However, overexpression of MET did not predict recurrence or mortality (p = 0.564 and p = 0.964 respectively) in multivariate analyses.We performed Cox regression analysis to calculate the hazard ratio (HR) for relapse and death with adjustment for covariates Table . CovariaMET mutant plasmids into MDA-T32 and MDA-T41 cells revealed increased expression of pro-MET  protein expression compared to mock transfected controls, as visualized by Western blot analysis. Expressional levels of mature MET (145 kDa) were similar in transfected cells and mock controls , the mutant plasmid conferred higher pro-MET expression than the wildtype MET plasmid . ETV6-NTRK3 is a recurrent fusion gene event in PTC, but is to our knowledge not reported as a genetic aberrancy commonly associated to the development of PDTC in younger patients [TP53, the TERT promoter and DICER1), we therefore studied the occurrence and potential impact of the specific MET alteration and potential dysregulation in an extended cohort of PTCs from young patients. In the validation cohort, the majority of the patients exhibited increased tumoral MET expression compared to normal thyroid tissue, and there was a strong correlation to the presence of BRAF V600E mutations and larger tumor sizes. However, we found no additional p.Arg359Gln MET mutations in the same cohort. Our findings verify previous notions that up-regulation of MET is a common feature in PTCs, and that the index patient mutation is very uncommon, even among younger PTC patients [MET propelled the invasive behavior of the two PTC cell lines. However, given the lack of appropriate animal models, we lack in vivo evidence of this specific MET gene aberration actually influencing thyroid cancer dedifferentiation.The index patient exhibited a rare manifestation of PDTC arising from a metastatic well-differentiated papillary thyroid carcinoma, driven by an patients . As the patients –28. MoreMET variant is not known. A few parameters argues in favor of a true biological role: 1) the exceedingly low frequencies of this specific variant in germline DNA of the general population, 2) the pathogenic status of this variant in the majority of the performed in silico based algorithms, and 3) the known occurrence of somatic p.Arg359Gln MET mutations in various tumors. However, we could not see an augmented effect in the PTC cell lines transfected with mutated MET compared to cells transfected with a wildtype MET sequence only, which could imply that the variant had no clear effect on MET gene function. However, this assumption should also be weighed against the fact that the MET gene status of these BRAF driven cell lines were unknown, in addition to the potential influence of wildtype MET in these cell experiments Since MET is an established oncogene, a gain-of-function phenotype rather than a deleterious effect of our variant could be suspected, which is also supported by the intense MET immunoreactivity in both the primary and metastatic tumor samples in our index patient. Earlier work has shown a selective overexpression of the mutant MET allele in patients with germline MET mutations and papillary renal cell tumors, suggesting that some MET mutations might affect the transcriptional output, possibly through selective gene doubling [MET could most likely act as bona fide gain-of-function mutations [MET gene variant described herein.The functional consequences of the index patient’s doubling . Moreoveutations . Even soMET gene overexpression seems to be a recurrent event in thyroid cancer. We found that 48 (96%) PTC cases in our validation cohort exhibited increased MET mRNA expression compared to normal controls, although none of the cases harbored the same MET mutation as our index patient. Interestingly, Wasenius and co-workers did not find a significant disparity in MET expression between MET mutated and wildtype thyroid carcinomas, suggesting that MET gene expression is regulated in part by mutation-independent mechanisms [MET mRNA levels to clinical parameters in our validation cohort of PTCs, we found a significant correlation between tumor size and MET expression. However, unlike previous studies that suggest that increased MET expression is associated to a higher risk of metastases and poorer outcome, we found no such correlations [MET expression was observed in cases harboring the BRAF V600E mutation in contrast to wildtype cases. There is also a well-known correlation between overexpression of MET in patients treated with BRAF inhibitors, which is attributable to an increased MET signaling which reactivates the PI3K/AKT pathway and thereby circumvents the BRAF inhibitors [MET gene output in BRAF mutated cases without BRAF inhibitor treatment is not known.Interestingly, chanisms . When weelations , 26. Nevhibitors . The mecMET in PTC cell lines was noted, but no stimulatory effects when transfecting PTC cell lines with the specific p.Arg359Gln MET mutation, possibly suggesting that this specific variant did not influence the metastatic properties of the PTC/PDTC in our index patient. However, we did identify an ETV6-NTRK3 gene fusion in both the primary PTC and the metastatic PDTC. Fusion-positive thyroid carcinomas are not seldom clinically aggressive, and are predominantly PTCs, and only rarely PDTCs [ETV6-NTRK3 positive PTCs dedifferentiating into PDTCs are exceedingly rare, but given the negative in vitro results of the index patient MET mutation, one cannot exclude that the transformation into metastatic PDTC was driven solely by the ETV6-NTRK3 fusion in this case. Of course, the combinatory effect of the translocation and the MET mutation could have contributed to the dedifferentiation process, but this remains speculative.A positive influence of invasive behavior when overexpressing ly PDTCs . To our Additional file 1. Supplementary Materials and Methods.Additional file 2. Western blot analysis of transfection experiments.Additional file 3. Wound healing assay MDA-T32.Additional file 4. Would healing assay MDA-T41.Additional file 5. Transwell invasion assay.


MET) amplification may present an additional opportunity for a targeted therapeutic approach, especially considering emerging data in non-small cell lung cancer. In this case, we present a metastatic cholangiocarcinoma patient with high-level MET gene amplification for whom capmatinib, a tyrosine kinase inhibitor with activity against c-MET, provided a partial response after cessation of chemotherapy.Cholangiocarcinoma is a highly morbid gastrointestinal malignancy for which available therapies are limited. Standard of care includes cytotoxic chemotherapies such as gemcitabine, platinum agents, nab-paclitaxel, and fluoropyrimidine analogues. However, tolerability of these regimens varies, and patients who do not tolerate chemotherapy have limited targeted therapies and immunotherapy options. In cholangiocarcinoma, mesenchymal–epithelial transition factor ( The majority of intrahepatic cholangiocarcinoma (iCCA) patients are diagnosed with advanced disease and are not candidates for surgical resection. Though the major focus of treatment involves cytotoxic therapy, performance status may limit the ability for clinicians to offer treatment as the median age at diagnosis is approximately 70 years. CCAs are also highly heterogeneous, often resulting in chemoresistance and poor prognosis.2Cholangiocarcinoma (CCA) constitutes 3% of all gastrointestinal tumors and 15% of all liver cancers while carrying a high mortality rate, accounting for 20% of hepatobiliary cancer deaths.NTRK gene fusions have made them attractive options for patients who cannot receive conventional chemotherapy. The KEYNOTE-158 study led to pembrolizumab approval in microsatellite instability high (MSI-H) solid tumors, and activity was successfully demonstrated in MSI-H CCA.3 However, these only comprise 1.3% of all CCA cases.4 The KEYNOTE-158 study also led to pan-tumor approval of pembrolizumab for patient tumors identified as Tumor Mutational Burden (TMB)-High (TMB ≥ 10 mutations/megabase); however, there were no biliary tract tumors in this study that were found to be TMB-High.5 Studies leading to the approval of larotrectinib6 and entrectinib7 for solid tumors with NTRK fusion alterations also included NTRK fusion-positive CCA patients, though these cases are rare.Comprehensive genomic profiling has become an essential tool for discovering personalized treatment options for advanced cancer patients based on their tumor-specific genomic alterations. Pan-tumor approvals of immunotherapies and targeted therapies for 8 Currently, guidelines include recommendations for use of targeted agents in patients with unresectable and metastatic disease after progression on primary treatment.9 This includes FGFR2 fusions and rearrangements (found in 9–16% of iCCA cases),11IDH1 mutations (16–25%),12 and BRAF V600E mutations (1–6%)  and PIK3CA (4–9%) as well as ROS1 rearrangements (8–9%)  .8,13–15 s (8–9%) .8,15,1617MET gene amplification has been found to be oncogenic and potentially targetable in several solid tumor types including 2% of iCCA cases.16 However, there is limited clinical evidence for c-MET inhibition in MET amplified CCA patients. A phase II study investigated the multikinase inhibitor cabozantinib in pretreated, unselected patients with advanced CCA resulting in limited activity with high toxicity.18 However, one patient considered to have high MET expression  analysis) experienced a prolonged benefit and duration of treatment. In a phase I study, the c-MET inhibitor tivantinib was given in combination with gemcitabine in patients with advanced or metastatic solid tumors including 8 cases of CCA.19 Of the 49 evaluable patients, 39% were strongly positive for MET expression by IHC. Partial response or stable disease was observed in 20% of patients including 1 patient with CCA.The mesenchymal-epithelial transition factor (c-MET) is a receptor tyrosine kinase that activates multiple downstream signaling pathways upon hepatocyte growth factor (HGF) ligand binding and dimerization including phosphatidyl inositol 3-kinase (PI3K)/AKT, mitogen activated protein kinase and others.MET gene amplification resulting in the use of capmatinib, a highly potent and selective inhibitor of the MET receptor.In the following case study, we describe an older male patient with iCCA who was unable to tolerate standard of care cytotoxic therapies. Comprehensive genomic profiling of this patient’s tumor revealed high A 77-year-old man with a history of spinal stenosis presented to the hospital for planned L4-S1 decompression and fusion. Following surgery, he was noted to have become jaundiced, and liver function testing revealed total and direct bilirubin as 6.4 mg/dL and 5.2 mg/dL, respectively. Cross-sectional imaging was obtained and revealed an infiltrative mass in the liver measuring 8.3 cm x 4.8 cm x 5.9 cm with associated intrahepatic biliary dilatation . There wHe underwent endoscopic retrograde cholangiopancreatography (ERCP), and two stents were deployed into his right and left hepatic ducts, respectively. Biliary brushings and CT-guided liver biopsy revealed a poorly differentiated adenocarcinoma supporting a primary diagnosis of iCCA.Upon interview in the oncology clinic, the only pertinent family history reported was his mother, with a history of gastric cancer who was deceased by age 59. The option for genetic testing was discussed but the patient opted to defer. Further history revealed that the patient was a veteran of the Vietnam War having been exposed to Agent Orange. He worked in the oil industry later in life. He was a nonsmoker, drank a moderate amount of alcohol (1–2 standard drinks per day), and had never used recreational drugs. After determining that he was not a surgical candidate, he was started on systemic therapy with gemcitabine, cisplatin, and nab-paclitaxel. Patient experienced best objective response of stable disease on this regimen.TERT promoter and TP53, amplifications of CDK6, CUL4A, and MET, and equivocal amplifications of FGF14 and IRS2. Of the possible targets, MET was considered an appealing option due to the existing literature supporting the use of small molecule tyrosine kinase inhibitors (TKIs) in MET-amplified tumors. After discussing available agents, the patient agreed to an empiric trial of capmatinib, a TKI approved for treatment of non-small cell lung cancers (NSCLC) that exhibit an exon 14 skipping mutation in the MET gene.Over the course of this regimen, treatment delays and dose reductions were necessary due to the treatment-emergent fatigue and thrombocytopenia, with a nadir of 55,000 platelets per microliter. Ultimately, it was decided that these adverse effects were intolerable, and treatment with cytotoxic chemotherapy was discontinued after 8 months since treatment initiation. This prompted comprehensive genomic profiling using FoundationOne®CDx for consideration of alternate targeted therapies. Genomic profiling results from the tumor tissue revealed immunotherapy biomarkers as microsatellite stable with low TMB (5 mut/Mb), mutations in After a four-week treatment holiday to recover from acute toxicities, repeat imaging showed growth of the tumor from 8.9 cm x 7.4 cm x 8.4 cm  to 9.4 cm x 6.9 cm x 9.7 cm . He was MET-amplified iCCA that responded to targeted c-MET inhibition. The patient was diagnosed with an inoperable iCCA and was unable to tolerate conventional cytotoxic chemotherapies. Therefore, he was considered for targeted agents after comprehensive genomic profiling of his tumor. Following initiation of the c-MET inhibitor capmatinib, he enjoyed a partial response and nearly six months of improved quality of life.This case represents an example of a TP53, most of the genomic alterations detected in this patient’s tumor are not common in iCCA, nor are they associated with approved targeted agents in CCA or other solid tumors. However, the MET gene amplification was particularly notable in this case, considering the recent approval of the c-MET tyrosine kinase inhibitor capmatinib for NSCLC patients based on results from the GEOMETRY mono-1 trial.20 This phase 2 trial described the use of capmatinib in NSCLC patients whose tumors harbored MET exon 14 skipping mutations or were MET-amplified. In this study, MET gene copy number (GCN) was assessed in tumor tissue by next generation sequencing. In patients with MET amplification GCN < 10, ORR was 7–12%. However, those with a GCN of 10 or higher showed an ORR of 29% in previously treated patients and 40% in treatment naïve patients with a median duration of response of around 8 months and median progression free survival (PFS) of just over 4 months.One of the difficulties in clinical practice is choosing which molecular aberration to target with subsequent-line therapy once standard of care, guideline-directed treatment becomes unfeasible. With the exception of a mutation in MET gene amplification are not standardized. Studies in multiple malignancies, both clinical and preclinical, define the GCN cutoff at varying levels between 4 and 10.20–22 In this case, MET gene amplification in this patient’s tumor was at a GCN of 23. Despite some categorical uncertainty in the broader medical literature, this GCN was considered to be highly amplified, as defined by the GEOMETRY trial, and was considered an appropriate focus for targeted therapy.It is worth noting that detection methods and cutoffs for high-level versus low-level 23 In addition, MET mutations and amplifications have been associated with drug resistance in multiple cancer types. Therefore, targeting c-MET is of acute scientific and clinical interest in MET-amplified malignancies. Few clinical data exist to support inhibition of c-MET as a standalone therapy, but there is a growing evidence base given the increasing availability of these agents. For example, a 2021 report of results from the AcSé-crizotinib program indicated a role for c-MET inhibition in MET-amplified esophageal and gastric cancers. Nine patients with chemotherapy-refractory tumors having ≥6 MET copies were treated with crizotinib monotherapy demonstrating an ORR of 33.3%, median PFS of 3.2 months, and overall survival of 8.1 months.24A poorer prognosis is evident in numerous cancers, including CCAs, which exhibit high expression of c-MET.MET-amplified tumors. There are currently an abundance of clinical trials studying selective and nonselective c-MET inhibitors alone or in combination with other therapies across many cancers with MET mutations or amplification.17 There are currently no ongoing clinical trials specifically targeting c-MET positive CCA, though these patients may be eligible to enter any trial investigating these agents in all solid tumors. With such limited clinical data available, it is hard to draw firm conclusions about the use of these agents in CCA. More clinical trials investigating c-MET specific targeted therapies in CCA patients with MET-amplification are warranted. Nevertheless, the foundational science supports the role for c-MET inhibition in MET amplified CCA, and this case represents one instance in which a patient benefited from such therapy.Previous and ongoing studies provide some generalizable evidence for the use of c-MET-directed agents in MET gene amplification. Because of strong evidence in MET-amplified NSCLC in the GEOMETRY mono-1 trial, capmatinib was chosen as subsequent-line therapy after the patient was unable to tolerate cytotoxic chemotherapy. He was found to have a partial response and enjoyed six months of improved quality of life before ultimately experiencing complications of progressive disease and enrolling in hospice.Comprehensive genomic profiling is crucial for treatment decisions in patients with metastatic cancers, providing clinicians the information to choose appropriate therapeutic options and enroll patients in clinical trials. This is especially important when considering tumor types where standard of care therapies are limited. In this report, we discussed a patient with advanced CCA who was found to have high-level MET-amplified cholangiocarcinoma in whom cytotoxic therapy is no longer an option. Further, randomized studies should be performed in this population in order to define the role for these agents, which may provide benefit beyond available therapies.This case may indicate that c-MET inhibition is a reasonable consideration in patients with