Pept1) and DNA methyl transferase 3a (DNMT3a), and decreased the DNA methylation level of jejunum Pept1 in offspring (p < 0.05). Maternal MET supplementation significantly raised the ratio of villus height to crypt depth in jejunum and ileum, improved the jejunum lactase activity, up-regulated the mRNA expression of jejunum Pept1, lactase (LCT), DNMT1, DNMT3a, and methylenetetrahydrofolate reductase (MTHFR), and increased the DNA methylation level of jejunum Pept1 in offspring (p < 0.05). However, the ratio of jejunum villus height to crypt depth was higher in BPA + MET treatment compared with CON and BPA treatment (p < 0.05). Meanwhile, there was no difference in the jejunum sucrase activity, the mRNA expression of jejunum Pept1 and DNMT3a, and the DNA methylation level of jejunum Pept1 between CON and BPA + MET treatment. These results indicated that maternal exposure to BPA during gestation might suppress offspring’s intestinal digestion and absorption function, whereas supplementation of MET could counteract these damages, which might be associated with DNA methylation. This study was conducted to explore whether exposure to bisphenol A (BPA) during pregnancy could change intestinal digestion and absorption function in offspring using pigs as a model, and whether methyl donor (MET) could counteract the BPA-induced impacts. Fifty Landrace × Yorkshire sows were divided into four dietary groups throughout gestation: control diet (CON); control diet supplemented with BPA (50 mg/kg); control diet supplemented with MET ; and control diet with BPA and MET supplementation (BPA + MET). Intestine samples were collected from pigs’ offspring at birth and weaning. Maternal BPA exposure during pregnancy significantly reduced the ratio of jejunum villus height to crypt depth, decreased the jejunum sucrase activity, down-regulated the mRNA expression of jejunum peptide transporter 1 ( Bisphenol A (BPA) is a kind of industrial chemical compound widely used in the manufacturing of polycarbonate plastics, such as baby bottles, infant tableware and the epoxy resin lining of beverage or food cans ,2. ExposA growing body of research shows that a broad range of adverse effects induced by BPA are linked to epigenetic modifications, such as DNA methylation ,8. The fIt is interesting that early developmental exposure to BPA can change offspring phenotype, stably altering the epigenome, but is counteracted by maternal MET supplements . Therefon = 13); control diet + BPA (n = 13); control diet + MET (n = 12); and both BPA and MET supplementation in control diet . The control diet was the basal diet during pregnancy . A total of fifty 3–5 parity Landrace × Yorkshire sows were artificially inseminated, then weighed (211.63 ± 2.65 kg), and randomly allocated to four groups at day 1 of gestation. Pregnant sows were fed one of the four diets: control diet   and otheDuring gestation, all sows were individually fed their trial diets two times per day : 2.28 kg/day diet and 2.72 kg/day diet on days 1–90 and days 91 to parturition, respectively. At day 107 of gestation, sows were moved to the farrowing rooms and individually penned. After parturition, all the sows were offered the diet three times per day , starting at 2.0 kg/day, then gradually increasing 1 kg/day until the sixth day ad libitum. Throughout the experiment, all animals were free to access water. The ambient temperature for sows was maintained at 20–25 °C. Heating light and pads were provided for sucking piglets and the temperature was maintained at 26–32 °C, which gradually decreased with the increase of age.When the piglets were born and weaning, researchers recorded the body weight of each, then selected piglets to be slaughtered and sampled according to body weight , and then embedded in transparent paraffin and sliced. All tissue sections (5 μm) were stained with hematoxylin and eosin (HE), and mounted with gum. The slice images were captured at the magnification of 100× using an Olympus BX51 microscope equipped with a DP70 digital camera . Crypt depth (μm) and villus length (μm) were measured with Image-Pro Plus 6.0 software . At least eight pairs of villus and crypt were observed in each slice; the average was the final value.The activity of intestinal lactase, maltase, and sucrase was measured. After thawing, 0.2–0.5 g of mucosa samples was homogenized according to the weight of intestine mucosa (g): volume of physiological saline pre-cooled on ice (mL) = 1:9, and centrifuged at 2500 r/min for 10 min. The supernatant was used to measure activity. Before measurement, a pre-test was necessary for the optimal reaction condition. For instance, the appropriate reaction concentration of samples. The activity of disaccharide was measured strictly in accordance with the manufacturer’s instructions for the kit .260/OD280 ranging 1.8–2.0. The concentration of RNA solution was confirmed by nucleic-acid/protein analyzer (Beckman DU-800) to determine the required amount in the next reverse transcription. After that, cDNA was synthesized with a reverse transcription (RT) kit , according to the manufacturer’s instructions. The cDNA can be stored at −20 °C for later relative quantification by polymerase chain reaction (PCR) or immediately used. Real-time PCR was performed with the synergy brands (SYBR) green mix system  by ABI-7900HT instrument . Ten microliters of mixed system  was used for RT-PCR. Primer sequences were designed by Primer 5.0 and shown in β-actin was shown to be consistent, and was amplified in parallel with the target genes as an inner control. The optimal annealing temperature of each primer and the range of PCR cycles was determined before the formal determination. The correlation coefficients of all the standard curves were >0.99, and the amplification efficiency values were between 90% and 110%. At the end of target gene amplification, researchers performed a melting curve analysis to identify amplification specificity. The mRNA expression of target genes normalized with the house keeping gene β-actin was calculated with the 2Ct−ΔΔ method.Jejunum samples stored in a −80 °C freezer were ground to powder with a mortar, adding liquid nitrogen continually. A 50–100 mg powder sample was put in an eppendorf tube containing 1 mL TRIzol , shaken up and down so as to completely dissolve the powder. Total RNA was extracted with TRIzol. RNA quality was detected by means of electrophoresis with 1.0% agarose gel at low temperature, 80 V for 25 min, observing the picture under ultraviolet light. The strips should be clear and complete without smearing. The absorbance of RNA solution at wavelengths of 260 nm and 280 nm was measured by scanning spectrophotometer ; resulting in optical density (OD)Pept1 gene expression was significantly affected by the BPA and MET supplementation, and in view of its importance for oligopeptides transportation, this study determined the methylation status of the Pept1 promoter regions. The Cytosine-phosphoric acid-Guanine (CpG)-rich sequences for the Pept1 promoter regions were identified using the USCS genome browser, from 2000 bp upstream of the transcriptional start point. Four different EpiTYPER assays  were designed (EpiDesigner), which covered 8, 8, 8 and 13 CpG sites respectively . The primer sequences and the locations relative to the translational start codon for the assays are presented in Pept1 promoter was performed using Sequenom’s MassARRAY EpiTYPER protocol . Genomic DNA was extracted from the newborn piglets’ intestine using a Wizard Genomic DNA Purification Kit , and then bisulfite-treated with the EZ DNA Methylation Kit . Specific PCR was carried out with the bisulfate-modified DNA. The conditions were as follows: 94 °C for four minutes followed by 45 cycles of 94 °C for 20 s, 52–62 °C for 30 s and 72 °C for three minutes. The PCR products were detected on agarose gel before the further analysis. In vitro transcription and RNase cleavage reaction were conducted using the Mass Cleave (hMC) kit. Transcription cleavage products were dispensed onto a 384 element SpectroCHIP bioassay, and the mass spectra were acquired through a MassARRAY mass spectrometer (Sequenom). The spectra were analyzed and the methylation rations were obtained by the EpiTYPER software v.1.0 (Sequenom). Each step of the above operation was performed in strict accordance with the corresponding manufacturer’s instructions.The results of nutrition transporters gene expression measurement showed that ® SPSS® Statistics, New York, NY, USA). Data were tested for normality and homogeneity of variances  and when necessary data were normalized  to achieve ANOVA assumptions. Additionally, Duncan’s multiple range tests were conducted to determine difference among the treatments. All data were expressed as mean and standard error. p < 0.05 was considered statistically significant.Raw data were preliminarily processed with MS Excel, with further data analysis performed by two-way ANOVA using SPSS Statistics 20 (IBMp < 0.05)  .p < 0.05). Maternal MET supplementation significantly increased the jejunum villus height of newborn piglets, and the ratio of jejunum and ileum villus height to crypt depth both in newborn and weaning piglets (p < 0.05). Additionally, the ratio of jejunum villus height to crypt depth in newborn offspring and the ratio of ileum villus height to crypt depth in weaning offspring were significantly influenced by BPA × MET interaction (p < 0.05)  .p < 0.05). Maternal MET supplementation significantly improved the activity of jejunum lactase in both newborn and weaning pigs, and the activity of duodenum and jejunum sucrase in weaning piglets (p < 0.05). The activity of jejunum lactase in newborn and weaning pigs was significantly affected by BPA × MET interaction (p < 0.05)  .Pept1 and SUC in newborn piglets (p < 0.05). Maternal MET supplementation significantly up-regulated the mRNA relative expression of jejunum Pept1, Sglt1 and LCT in newborn offspring and weaning offspring. SUC was only affected at birth (p < 0.05). Compared with the BPA group, the mRNA relative expression of jejunum Pept1 was significantly increased in the BPA + MET group at birth and weaning (p < 0.05)  .Pept1 promoter region (p < 0.05) (p < 0.05), the methylation rates of CpG sites −93 and −721 were significantly influenced by BPA × MET interaction (p < 0.05). Compared with the BPA group, the average methylation of CpG sites at jejunum Pept1 promoter was significantly increased in the BPA + MET group  . WhereasET group .DNMT3a in newborn offspring (p < 0.05). Maternal MET supplementation significantly increased the mRNA relative expression of jejunum DNMT1, DNMT3a and MTHFR in newborn piglets (p < 0.05). Compared with the BPA group, the mRNA relative expression of jejunum DNMT3a was significantly increased in the BPA + MET group at birth (p < 0.05)  .+ and CD25+ cells [This was the first study to focus on the effect of maternal BPA exposure during pregnancy on intestinal digestion and absorption function in offspring. In this study, the ratio of jejunum villus height to crypt depth in newborn and weaning pigs was significantly decreased by maternal BPA exposure. The ratio of villus height to crypt depth reflects the capacity of the small intestine for nutrient digestion and absorption to a certain extent . The pro5+ cells , which w5+ cells ,28. Most5+ cells . SUC mRNA expression. Lactose is the main source of mammalian carbohydrate during lactation, so lactase is the dominant enzyme in the intestine of suckling piglets [In this study, the jejunum sucrose activity in offspring was significantly decreased in response to BPA exposure, which was consistent with the  piglets . HoweverPept1 mRNA level was observed to be significantly decreased in BPA-exposed offspring. Pept1 is located at the brush-border membrane of intestinal epithelial cells and mediates cellular uptake of these oligopeptides by using an inwardly directed H+ gradient across the brush-border membrane [Pept1 gene expression [Consistently, the development of absorption function in the intestine relied greatly on the intestinal nutrient transporter . Increasmembrane . Therefopression .Pept1 promoter region in newborn BPA-pigs was obtained. Researchers found that the CpG sites −1771 and −721, where the methylation rate were decreased, were located in the transcription factor cAMP-response element binding protein (CREB) binding sites, and CpG sites −1544, −1352 and−93 were located in the transcription factor stimulatory protein 1 (SP1) binding sites. Studies have demonstrated the importance of the transcription factors CREB and SP1 in up-regulation of Pept1 expression [Pept1.The functional relevance of reduced methylation at CG-poor regulatory regions is still unclear. Although the related mechanisms remain unclear, this study indicated that Pept1 gene expression decline via hypomethylation modifications was a mechanism by which the maternal BPA was not beneficial for oligopeptides transfer and absorption in offspring. It is known that DNMT3a is one of the DNA methyltransferases, catalyzing the formation of de novo methylation [DNMT3a in BPA-exposed newborn pigs was significantly decreased, which indicated that BPA-induced hypomethylation was likely through decreased DNA methyltransferases. Research has shown that the effects of BPA were manifested in disrupted fetal metabolic programming through hypomethylation modifications via decreased DNMT, even though the concrete mechanisms remain unclear [Recently, a growing number of studies showed changes in gene expression due to BPA, especially the long-term effects but at low does, possibly involving epigenetic pathways . In thispression ,37. Tradpression . Howeverhylation . In this unclear .The intestinal morphology results suggested that MET could induce the increase of the intestinal epithelial cell proliferation as demonstrated by the increased ratio of villus height to crypt depth in MET offspring pigs. A similar study reported that the maternal MET  deficiency during gestation and lactation in rats induced higher intestinal crypt apoptosis and lower villi epithelial cell differentiation in offspring . ConsistPept1 and Sglt1 genes expression in newborn pigs’ jejunum, which were positively correlated with transportation and absorption for oligopeptides and glucose. Studies have shown that the changes of gene expression resulted from MET were closely related to DNA methylation [Pept1 promoter region in newborn pigs. Among the 25 CpG sites tested on the Pept1 promoter region, the methylation rate of eight CpG sites was significantly influenced by MET. The increased CpG site −721 was located in the transcription factor CREB binding sites; CpG sites −1544 and −93 were located in the transcription factor SP1 binding sites. Research has suggested that Pept1 gene expression is mainly regulated by some transcription factor, such as caudal-related homeobox 2 (CDX2), CREB, amino acid response element (AARE) and SP1 [In this study, MET increased the hylation . As expe and SP1 . Recentl and SP1 . DNMT1, DNMT3a, and MTHFR genes in MET newborn pigs in this study further confirmed that the higher Pept1 genes expression might be related to DNA methylation. These results suggested that maternal MET supplementation could promote offspring’s intestinal digestion and absorption function by improving intestinal morphology, increasing disaccharidase activity, and up-regulating the expression of the transporter gene via methylation changes. DNA methylation occurs within the one-carbon metabolism pathway, which is dependent upon several important enzymes. Through an ATP-driven reaction with methionine adenosyltransferase (MAT), a carbon product, methionine, whose methyl groups are derived either from the folate/vitamin B12 pathway or choline/betaine pathway is converted into S-adenosylmethionine (SAM), the cellular direct methyl donor . Then, DPept1 gene expression in offspring of the BPA + MET group were significantly higher. This indicates that MET could counteract the negative effects of BPA on intestinal digestion and absorption function. Moreover, these consequences could still persist until weaning, even if administration was not implemented during lactation. One possible reasonable explanation is epigenetic change, most likely DNA methylation according to a previous study on BPA or MET [Pept1 promoter was significantly increased in the BPA + MET group. However, the specific mechanism by which MET interacts with BPA through the DNA methylation pathway requires further study.It is noteworthy that intestinal morphology, disaccharidase activity and nutrient transporters gene expression in offspring were significantly influenced by the interaction of maternal BPA and MET treatment. Compared with the BPA group, the ratio of jejunum villus height to crypt depth in offspring, the jejunum lactase activity in newborns, the duodenum sucrose activity in weaning pigs, and the A or MET . Once DNIn conclusion, the results of this study indicated that maternal BPA supplementation during gestation might suppress offspring intestinal digestion and absorption function, and MET could counteract the damage, which might be related to the DNA methylation status of specific genes.


Immunoglobulin G4-related disease (IgG4-rd) is characterized by lymphoplasmacytic infiltration and tissue fibrosis. Orbital manifestations of IgG4-rd may include unilateral or bilateral proptosis, cicatricial extraocular muscle myopathy, orbital inflammation and pain which may mimic ophthalmic Graves’ disease.A 25-year-old woman has been referred to the endocrinology clinic, 4 months after delivery, with suspected Graves’ orbitopathy. She has had bronchial asthma and recurrent skin rashes of unknown aetiology for the last 10 years and was treated for dacryoadenitis with steroid containing eye drops 5 years ago. During pregnancy she developed eyelid swelling. After delivery, eyelid redness and retrobulbar pain evolved. Proptosis was demonstrated by Hertel’s exophthalmometry. Orbital magnetic resonance imaging showed enlarged lateral and superior rectus muscles in both orbits. Thyroid function tests were in the normal range and no thyroid stimulating hormone (TSH) receptor autoantibodies were present. The eye muscle involvement pattern raised suspicion, and the high IgG4 level with positive histology of the lacrimal gland confirmed the diagnosis of immunoglobulin G4-related orbitopathy. Rapid improvement was observed following oral methylprednisolone.IgG4-related orbitopathy may mimic Graves’ orbitopathy. Euthyroid patients with no TSH receptor autoantibodies should be evaluated for immunoglobulin G4-related orbitopathy. Once IgG4-related orbitopathy is proven, other manifestations of IgG4-related disease have to be searched for; lifelong follow-up is warranted. The most common orbital disease usually with exophthalmos is Graves’ orbitopathy, which is the extrathyroidal complication of Graves’ thyroid disease . The annBeside detailed ophthalmological examination  laboratory parameters that are necessary to confirm the diagnosis include: measurement of serum thyroid stimulating hormone, free thyroxin, and TSH receptor antibody levels. In euthyreoid Graves’ orbitopathy, TSH receptor antibody level is elevated without thyroid function abnormality. The diagnosis of Graves’ orbitopathy in most patients is obvious; however, exophthalmos can also be present in patients with lymphoproliferative disorders of the orbits, idiopathic orbital inflammatory syndrome, orbital myositis, severe obesity, Cushing’s syndrome, histiocytosis, granulomatosis with polyangitis, and IgG4-related orbitopathy , 3, 4. OA 25-year-old woman presented in the endocrinology clinic, in October 2013, with eyelid swelling, redness and retrobulbar pain with suspected Graves’ orbitopathy after ophthalmological examination, 4 months after delivery  were 24 mm on the right side, and 21 mm on the left side. Visual acuity was 1.0 in both eyes, intraocular pressures were 16 mmHg and 20 mmHg on the right and left sides, respectively. Pupils were isocoric, equal and had normal reaction. Digital retropulsion did not suggest a mass or tumor in the retrobulbar space. Upon examination both the lower and upper eyelids were found to be markedly swollen and a swollen lacrimal gland became visible after the right upper eyelid had been lifted.Orbital MRI showed enlarged lateral and superior rectus muscles, and eyelid oedema and swollen lacrimal gland in both orbits while the typical MRI features of Graves’ orbitopathy  were missing Fig. . Serum lPlaced on oral corticosteroid administration  a rapid improvement in both the eye symptoms and skin rashes was observed within a few days (Fig. IgG4-rd is a recently described and increasingly recognized entity  which marituximab is another therapeutic option [All patients with symptomatic active IgG4-rd require treatment. Glucocorticoids are the first-line agents for remission induction. Following a successful course of induction therapy, certain patients benefit from maintenance therapy. Repeated glucocorticoid courses are indicated in patients who relapse following successful remission induction. Most patients respond to glucocorticoids within several weeks, typically with symptomatic improvement, reduction in the size of masses or enlarged organs, improvement in organ function, and a decrease in serum levels of IgG4 [c option .Neither the natural course nor the prognosis of IgG4-rd is well-understood. Spontaneous improvements can be seen, but the disease often relapses if left untreated. Symptoms respond dramatically to glucocorticoids, but relapses are common following discontinuation of therapy. Significant organ dysfunction may arise from uncontrolled and progressive inflammatory and fibrotic changes in affected tissues. Currently, it is uncertain if there is an increased risk of malignancy in patients with IgG4-rd, however, lymphomas occur more frequently in patients with IgG4-related disease , 16.The prevalence of the disease could be more frequent than it is diagnosed . There iAs far as clinical manifestations are concerned, cutaneous presentations, similar to the present case, may be the first sign of IgG4-rd .The most typical manifestations of IgG4-related orbitopathy are the usually easily detectable dacryoadenitis, swollen eyelid and involvement of extraocular muscles. The external eye muscle involvement pattern on MRI is distinct from Graves’ orbitopathy, where the inferior and medial rectuses are the most frequently involved muscles . In IgG4In our patient, skin symptoms and salivary gland enlargement have also been components of IgG4-rd. Although only the lacrimal gland was biopsied, improvement of the skin and salivary gland lesions after glucicorticoid therapy was indirect evidence of the involvement of these organs. Symptoms which were typical of bronchial asthma may have been caused by IgG4-rd. Possible pulmonary manifestations of this condition are nonspecific interstitial pneumonia, sclerosing mediastinitis, mediastinal or hilar adenopathy, massive pleural effusion, nodular pleural lesions and pulmonary arterial hypertension , 20. DurThe case presented here is rather unique as the patient is a young woman, since IgG4-rd occurs predominantly in elderly men , 12. In IgG4-related orbitopathy may easily be mistaken for Graves’ orbitopathy . All pat


Femoral component malrotation is a common cause of patient dissatisfaction after total knee arthroplasty. The sulcus line (SL) is more accurate than Whiteside’s line as it corrects for variation in the coronal orientation of the groove. The hypothesis is that averaging the SL and posterior condylar axis (PCA) will reduce femoral malrotation.The component was inserted at a position between the SL and PCA in 91 patients. An intraoperative photograph was taken showing the landmarks. These were compared to the component position achieved relative to the surgical epicondylar axis (SEA) on a postoperative CT scan. The component position was compared to the position achieved using the individual landmarks.p < 0.05) for the average position (2/84) when each was compared to the SL (16/84) and PCA (14/84) individually. In 21/84 (25%) of cases, there was more than 4° of divergence between the SL and PCA.Relative to the SEA, the final component position was 0.6° , the coronally corrected SL position was −0.7° , the PCA position was 0.9° . Averaging the landmarks significantly decreased the variance of the component position compared to using the SL and PCA individually. The number of outliers (>3° from SEA) was also significantly less (Averaging the SL and the PCA decreases femoral component malrotation. Femora are frequently asymmetrical in the axial plane. Referencing posterior condyles alone to set rotation is likely to cause high rates of patellofemoral malalignment. Femoral component rotation in total knee arthroplasty (TKA) continues to be a contentious issue. Femoral component malrotation is associated with patella maltracking –7, increThese landmarks have been extensively studied to determine how they relate to each other and to the flexion-extension axis (FEA) of the knee. The SEA has been recommended as a closer approximation of the FEA of the knee than the AEA –15. HoweReferencing the posterior condyles during either mechanical alignment or KA techniques relies on the assumption that the flexion-extension axis of the posterior condyles has a consistent relationship with the axis of rotation of the patella and trochlear groove. There is some research to suggest that on average, the axes are close to parallel , 19. HowA new technique for measuring the rotational alignment of the trochlear groove has recently been developed , 26. TheThe aims of this study were to (i) determine the clinical accuracy of the SL and STAG technique, (ii) assess the benefit obtained by averaging the SL and PCA, and (iii) characterise the relationships between the SL, SEA and posterior condyles.Approval to conduct the study was gained from the local Human Research Ethics Committee.A prospective study of a consecutive series of 91 TKAs was conducted. There were no preoperative exclusion criteria. All operations were performed by one surgeon using a standardised technique. Conventional instruments were used. The distal femoral cut was produced at 6° from the anatomical axis of the femur using an intramedullary rod. The tibial cut was produced perpendicular to the long axis of the tibia using an extramedullary jig.The femoral rotation was determined by averaging the SL and the PCA. The SL was drawn on the distal femur using diathermy after dislocation of the patella and before any bony cuts were made. This was done by carefully palpating the deepest points of the trochlear groove starting at the intercondylar notch and leading anteriorly. The most proximal section of the trochlear groove was not incorporated into the SL as it has been shown to be prone to excessive variability due to arthritic damage, osteophyte formation and anatomical variation , 28. MulThe STAG intramedullary rod was inserted and the STAG block placed over the rod. The block was then orientated to match both the rotational Fig.  and the The PCA was determined with the use of a standard sizing guide. Paddles were placed under the posterior condyles, and an additional 3° of external rotation was added to compensate for the average proximal tibia joint line obliquity. The PCA is defined as 3° of external rotation to the posterior condylar line (PCL). A 3.2-mm drill was used to produce two holes on the distal cut surface which match the rotation of the PCA. In order to report reproducible technique which does not rely on surgeon experience and to allow the calculation of an accurate PCL, no adjustment was made for posterior condylar bone loss.A sizing guide was used which allowed variation in the rotation from the posterior condyles in 1° increments between 0° and 6° of external rotation. The rotation of the SL (STAG pin-holes) and the PCA PCL + 3°) were compared. These landmarks are able to be accurately compared by placing a sizing guide on the distal cut surface of the femur and dialling the rotation between the two sets of pin-holes. Therefore, the rotational angle between the PCA and SL was able to be accurately determined. When they were different, an average position was produced as accurately as possible by altering the rotation of the sizing guide in 1° increments. This average position was marked with a further set of pin-holes, and the 4-in-1 cutting block was inserted into these pin-holes. The prosthesis was therefore inserted in the average position. Therefore, the relationship between the PCA or SL and the actual component position was able to be determined from the photograph. An intraoperative photograph was taken of the three sets of pin-holes using a camera set in the overhead light . Both components have symmetrical posterior condyles.A postoperative computed tomography (CT) scan was performed prior to discharge from hospital. A low-dose scanner (GE Optima 660) produced 1.25 mm slices from the proximal end of the femoral component to the tip of the tibial stem.Measurements were taken of both the intraoperative photographs and the CT scan by two observers (one orthopaedic resident and one orthopaedic surgeon). The first ten cases were measured twice at an interval of 1 week to assess interobserver and intraobserver reliability. Internal rotation was recorded as a negative angle and external rotation as positive. The angles between the three sets of pinholes were measured on the photographs using Adobe Photoshop CS6. The angle between the posterior condyles of the femoral component and the SEA was measured using InteleViewer 4-3-4. The SEA was defined as a line from the most prominent point on the lateral epicondyle to the deepest point of the medial sulcus posterior to the medial epicondyle. Multiple axial slices were referenced when necessary to determine the landmarks. If either observer found that the sulcus was not able to be accurately determined, the scan was excluded. The data was collected using a purpose-designed Excel spreadsheet. Statistical analysis was performed using SPSS (22.0.0.0).calculated mean PCA and SL to SEA)  Table  was measA) Table  was alsoA definition of trochlear condylar divergence (TCD) was developed to identify cases in which the PCL and SL were not perpendicular. This is a measure of femoral rotational asymmetry. A difference of 4° was deemed clinically significant based on the evidence that more than 3° of femoral malrotation is associated with adverse patellofemoral outcomes , 3, 6.Subgroup analysis was performed based on the predominant pattern of arthritis detected on preoperative knee X-rays and intraoperative findings. They were classified as predominantly medial, lateral, patellofemoral or tricompartmental osteoarthritis.Of the 91 cases, one was excluded as the SL could not be clearly delineated. This patient had a patellectomy 30 years prior to TKA and the groove was grossly deformed. Six cases were excluded due to a poorly visible medial epicondylar sulci on the postoperative CT scans, leaving 84 cases for analysis. Slightly, more female  than male  participants were included in the study. More TKAs were conducted on the right side .SL  or the PCA   or the PCA .The SL 0.7° internally rotated to the SEA . The PCL was 2.1° internally rotated . The actual component position achieved was 0.6° externally rotated . The calculated mean PCA and SL was 0.1° externally rotated . There was a significant decrease in variance between the calculated mean PCA and SL to SEA to either the p < 0.05).There was a significant difference between the means for both the SL and PCA when compared to either the actual component position or the calculated mean PCA and SL to SEA (p < 0.05). There was no significant difference between the SEA and the calculated mean PCA and SL to SEA (p > 0.05).There was a significant difference between the means for the SL, PCA and actual component position compared to the SEA  (Table p < 0.05).Outliers were considered to be measurements more than 3° from the SEA. By combining the SL and PCA, the rate of outliers decreased from 19% for the SL, 17% for the PCA to 2% for the calculated mean PCA and SL .Interobserver and intraobserver reliability was excellent for all measurements .The STAG device removes parallax errors which occur when referencing APA . These eThe combination of the SL and PCA produced fewer outliers than predicted by the findings of the 3DCT study suggesting that the intraoperative technique using the STAG is at least as accurate and reproducible as the virtual technique using the CT scans.On average, the SL was slightly internally rotated to the PCA and SEA, and externally rotated to the PCL. Referencing the SL using the STAG device produced a landmark with a narrow range and a level of variability which was similar to the PCA. This is an improvement compared with published results using APA –32 whichThe comparison of the means revealed that the only technique to produce no statistically significant difference from the SEA was the calculated mean PCA and SL to SEA. While this would support the hypothesis that combining the two landmarks is likely to result in a closer average position relative to the SEA, it is the decrease in variability and outliers which is more important. In addition, the size of the difference in the means relative to the SEA was less than 1° for each of the techniques, which may not be clinically significant. It is the size of the potential variation using each technique which is important. This changes from up to 5.5° for the SL and 6.1° for the PCA down to 4.0° for the actual component position and 3.7° for the calculated mean PCA and SL to SEA. Averaging the SL and PCA . When severe trochlear arthritis is present, there are often parallel grooves in the bone surface which allow easy identification of the SL. In knees with lateral arthritis, there was on average 0.9° of internal rotation of the PCA compared to the medial group. This difference was not significant. There was no difference in the SL between medial and lateral groups.Analysis of the relationship between the SL and PCL revealed a high percentage of cases in which the two landmarks were not perpendicular to each other . Overall, there was only a weak negative correlation between the SL and PCL Fig. . The relIn 21 of 84 knees, there was more than 4° of difference between the PCL and SL. We have coined the term trochlear condylar divergence to describe this group. In 19 of these 21 knees, the SL shifted, relative to the SEA, in the opposite direction to the PCL. This suggests an anatomical variation in which the rotational alignment of the SL and the PCL may be linked. The direction of this divergence was not influenced by the diagnosis of medial or lateral osteoarthritis. In two of four knees with lateral arthritis and nine of 14 knees with medial arthritis, the divergence occurred in the opposite direction to that anticipated if the variation was due to posterior condylar bone loss. For example, in nine knees with medial arthritis, the PCL was more than 4° internally rotated to the SL. This is despite posterior condylar cartilage and bone loss tending to externally rotate the PCL. Therefore, if the surgeon in these nine cases had internally rotated the femoral component relative to the PCA in order to compensate for posterior medial condylar bone loss the degree of internal malrotation relative to the SEA and SL would have increased. This would indicate that it is a true anatomical variation rather than the effect of arthritic bone loss. Further studies are planned to assess this variation and determine if it is linked to proximal tibial coronal alignment.These findings are consistent with the findings of Iranpour et al. . This stIranpour et al.  also pubBoth studies by Iranpour and colleagues are quoted by proponents of posterior referencing and kinematic alignment as evidence of a consistent rotational relationship between the posterior condyles and the patellofemoral joint . This coThis is also consistent with several recent studies which measured the relationship between the posterior condyles, the epicondyles and the trochlear groove using a variety of techniques. Jones et al.  used MRIThe results of this study raise concerns regarding any technique which solely references the posterior condyles to determine rotation. Twenty-five percent of femora have more than 4° of rotational asymmetry, and yet our femoral components are symmetrical. Therefore, referencing solely the posterior condyles may produce a well-balanced tibiofemoral joint but change the rotation of the patellofemoral joint relative to its original position. This may be particularly pertinent in cases of kinematic alignment in which the native knee has a combination of proximal tibial varus and external rotation of the SL relative to the PCL. This combination may lead to an exaggerated internal rotation of the trochlear groove of the femoral component relative to the native position.One limitation of this study is that we did not attempt to compensate for posterior condylar bone loss when determining the PCA. This was done to maintain a consistent technique and to avoid subjectivity involved in compensating for bone loss intraoperatively. Nam et al.  determinIntraoperatively, the ability to perfectly average the SL and PCA was limited by the sizing guide which had 1° or 1.5° rotational increments. In cases where the difference between the SL and PCA was less than the 1° the guide was left at the PCA landmark. Therefore, a measurement based on perfect averaging of the angles from the intraoperative photographs was also calculated. This is why there are "actual" and "calculated" measurements for the average of the SL and PCA. The difference between the two results was minor.Further limitations of the study involve the exclusion of several cases due to difficulty finding the medial epicondylar sulcus; however, our exclusion rate is similar to other studies , 22.Due to the lack of preoperative long leg X-rays, data on mechanical alignment or severity of deformity was not available. Preoperative knee X-rays and intraoperative assessment of the location of the arthritis were used to produce subgroup data. There are only 11 cases with predominantly lateral compartment osteoarthritis. The results in this group suggest that combining the two landmarks may be a reliable technique; however, the numbers are too small to draw firm conclusions. Further studies assessing non-arthritic knees are planned.Measurement errors could occur with the identification of the SL and measurement of the intraoperative photographs and the CT scans. However, the very high interobserver and intraobserver reliability makes it unlikely to account for the degree of variation we have identified. Likewise, the measurement error associated with the use of the STAG device was shown to be small (mean 1° for both interobserver and intraobserver measurements) in the previously published cadaver study .A high proportion of femora have axial asymmetry with different rotational alignment of the trochlear groove and posterior condyles. By using a trochlear alignment guide that corrects for the coronal alignment of the trochlear, the rotational alignment of the groove can be more accurately identified during surgery than by using APA. It also allows direct comparison between the anterior and posterior landmarks. Averaging the SL of the trochlear groove and the PCA significantly decreases femoral component malrotation.


Ambulatory antibiotic prescribing contributes to the development of antibiotic resistance and increases societal costs. Here, we estimate the hidden societal cost of antibiotic resistance per antibiotic prescribed in the United States.In an exploratory analysis, we used published data to develop point and range estimates for the hidden societal cost of antibiotic resistance (SCAR) attributable to each ambulatory antibiotic prescription in the United States. We developed four estimation methods that focused on the antibiotic-resistance attributable costs of hospitalization, second-line inpatient antibiotic use, second-line outpatient antibiotic use, and antibiotic stewardship, then summed the estimates across all methods.The total SCAR attributable to each ambulatory antibiotic prescription was estimated to be $13 (range: $3–$95). The greatest contributor to the total SCAR was the cost of hospitalization . The costs of second-line inpatient antibiotic use , second-line outpatient antibiotic use  and antibiotic stewardship . This apperars to be an error.; of the total SCAR) were modest contributors to the total SCAR. Assuming an average antibiotic cost of $20, the total SCAR attributable to each ambulatory antibiotic prescription would increase antibiotic costs by 65 % (range: 15–475 %) if incorporated into antibiotic costs paid by patients or payers.Each ambulatory antibiotic prescription is associated with a hidden SCAR that substantially increases the cost of an antibiotic prescription in the United States. This finding raises concerns regarding the magnitude of misalignment between individual and societal antibiotic costs. Antibiotic resistance is a major public health problem, with more than 2,000,000 infections and 23,000 deaths caused by antibiotic-resistant organisms annually in the United States . Most anThe relationship between ambulatory antibiotic prescribing, antibiotic resistance and increased health care costs is complex and likely influenced by heterogeneity in antibiotic use, bacterial response to antibiotic pressure, geographic distribution of resistance genes, non-human reservoirs of antibiotic resistance and impact of bacterial resistance on clinical outcomes. At a fundamental level, however, the association between ambulatory antibiotic prescribing, antibiotic resistance and increased health care costs implies a downstream societal cost of antibiotic resistance (SCAR) attributable to each ambulatory antibiotic prescription. The SCAR represents a hidden cost that, to our knowledge, has not been estimated at the prescription level and could (1) help quantify the economic burden of antibiotic resistance linked to ambulatory antibiotic prescribing, (2) inform future cost and cost-effectiveness analyses pertaining to ambulatory antibiotic prescribing, and (3) frame policy discussions regarding stewardship efforts.Antibiotic resistance increases societal costs by increasing health care utilization, shifting antibiotic use towards more costly second-line agents, and leading to the development of antibiotic stewardship programs , 2. In tWe developed four methods to estimate the components of the SCAR attributable to each antibiotic prescription, with each method focusing on a different mechanism by which antibiotic resistance increases societal costs. These four methods estimated the incremental costs of antibiotic resistance associated with (1) hospitalization, (2) second-line inpatient antibiotic use, (3) second-line outpatient antibiotic use, and (4) antibiotic stewardship. For all methods, we estimated the total annual incremental SCAR relative to a hypothetical “no antibiotic resistance” base case scenario.Given the complex and poorly understood relationship between ambulatory antibiotic prescribing and increased health care costs and the exploratory nature of this modeling analysis, we assumed that each human ambulatory antibiotic prescription contributed equally to the total incremental costs of antibiotic resistance associated with the four methods mentioned above and widely varied all model parameters in sensitivity analyses. If broad-spectrum antibiotics contribute more than narrow-spectrum antibiotics to the downstream social costs of ambulatory antibiotic prescriptions, this assumption would potentially over-estimate the downstream SCAR for narrow-spectrum antibiotics and under-estimate the downstream SCAR for broad-spectrum agents. To estimate this impact, we performed a secondary sensitivity analysis in which we arbitrarily assumed that broad-spectrum antibiotics were associated with double the impact of narrow-spectrum antibiotics on the total incremental SCAR attributable to each antibiotic prescription. For each method, we estimated the annual SCAR in the U.S. attributable to the specific cost mechanism of interest and then divided this estimate by the annual number of ambulatory antibiotic prescriptions in the U.S.  , after aWe then summed the individual cost components to obtain an estimate for the total SCAR attributable to each ambulatory antibiotic prescription. This approach is conservative because it assumes that all societal costs of antibiotic resistance are captured in these four estimates.Using a previously described approach , we estiBecause this prior study estimated the total incremental societal cost of hospitalization for antibiotic-resistant infections relative to no infections rather than relative to antibiotic-susceptible infections, it potentially overestimates the incremental costs of antibiotic-resistant infections relative to antibiotic-susceptible infections. To correct for this potential overestimate, we assumed that only 35 % (range: 25–45 %) of the total incremental societal costs of hospitalization for antibiotic-resistant infections could be attributable to antibiotic resistance based on estimates of the incremental costs of antibiotic-resistant versus antibiotic-susceptible Staphylococcal and Enterococcal hospital infections , 16.To estimate the SCAR attributable to each antibiotic prescription arising from the incremental cost of second-line inpatient antibiotic use, we assumed that this cost equaled the total annual incremental U.S. cost of antibiotics used, in the inpatient setting, primarily for the treatment of antibiotic-resistant infections  relative to antibiotics used primarily for the treatment of antibiotic-susceptible infections Table  17–21].–21.17–21To estimate the SCAR attributable to each antibiotic prescription arising from the incremental societal costs of second-line outpatient antibiotic use, we assumed this cost was a function of incremental antibiotic costs in the presence versus absence of antibiotic resistance Table . In bothWe assumed that antibiotic resistance caused only an increase in cost per ambulatory antibiotic prescription and not an increase in the number of ambulatory antibiotic prescriptions per patient for a given infection or total duration of antibiotic therapy. This assumption is likely conservative given that ambulatory patients with antibiotic-resistant pathogens may return to clinic more frequently than those with antibiotic-susceptible pathogens and require multiple antibiotic prescriptions .To estimate the SCAR attributable to each antibiotic prescription arising from the incremental societal costs of antibiotic stewardship, we assumed that such costs would not have been incurred in the absence of concern for the potential development of antibiotic resistance and equaled the annual costs of antibiotic stewardship programs incurred by U.S. hospitals Table . Given aWhen we summed the costs of all four components, the SCAR attributable to each ambulatory antibiotic prescription was $13 in the base case and ranged from $3–$95 in sensitivity analyses Table . The greIn the secondary sensitivity analysis in which we assumed that a broad-spectrum antibiotic prescription was associated with double the impact of narrow-spectrum antibiotic prescription on the total incremental SCAR attributable to each ambulatory antibiotic prescription, we estimated that the total downstream SCAR attributable to each ambulatory antibiotic prescription was $9 for a narrow-spectrum antibiotic prescription and $17 for a broad-spectrum antibiotic prescription.Assuming that there are 263 million ambulatory antibiotic prescriptions annually in the United States  and thatThis exploratory analysis quantifies the hidden, but considerable, societal cost of ambulatory antibiotic prescribing. We conservatively estimated that the hidden SCAR attributable to each ambulatory antibiotic prescription is $13 in the base case and substantially increases the societal cost of an antibiotic prescription if incorporated into antibiotic costs paid by patients or payers.This estimate has important implications for patients, clinicians, payers and policy makers. For patients and clinicians, this study further raises the costs of inappropriate antibiotic prescribing for diagnoses such as the common cold, upper respiratory tract infections, and acute bronchitis, for which antibiotics are commonly prescribed , 35 despshould bear this economic burden. Future discussion of the appropriate bearer of this economic burden and the optimal cost allocation mechanism must be informed by an understanding of the magnitude of the economic burden and the likely impact of any cost allocation mechanism on health outcomes. This study did not attempt to quantify all potential downstream costs and benefits of ambulatory antibiotic prescribing but rather one poorly understood downstream cost of ambulatory antibiotic prescribing, namely the costs of antibiotic resistance. In estimating the economic burden of antibiotic resistance associated with ambulatory antibiotic prescribing, this analysis provides one element necessary for an important discussion regarding net costs and benefits of ambulatory antibiotic prescribing.Classically, economists have proposed several solutions to address such a ‘negative externality’—regulation, taxation or permits, all of which have been considered as solutions to ease the economic burden of antibiotic resistance attributable to antibiotic use . These cThis study has several strengths. First, this study employed a novel approach to estimate the hidden SCAR attributable to each ambulatory antibiotic prescription. Second, this study incorporated conservative assumptions that biased the analysis in favor of lower cost estimates. Within the four estimation methods, we focused only on major cost drivers. Further, when summing across the four estimation methods, we assumed that they represented all of the mechanisms by which antibiotic resistance increases societal costs. If there are other material mechanisms by which antibiotic use leads to SCAR, i.e. by leading to increased utilization of outpatient services, then this analysis would result in a conservative estimate of the total SCAR attributable to each ambulatory antibiotic prescription.Our analysis also has limitations. First, in the absence of published data describing the relative impact of human and agricultural antibiotic use on antibiotic resistance in humans, all four estimation methods relied on our estimate of the relative impact of human versus animal antibiotic use on antibiotic resistance costs in humans. Our assumption that each unit weight of antibiotic use in humans and animals equally impacts antibiotic-resistance costs in humans, however, is likely conservative. Second, in the absence of available data allowing us to make reasonable estimates regarding the relative contribution of different antibiotics , we assumed that each human ambulatory antibiotic prescription contributed equally to the total incremental SCAR, which may potentially over-estimate the downstream SCAR for narrow-spectrum antibiotics and under-estimate the downstream SCAR for broad-spectrum antibiotics are greater contributors to the total incremental SCAR than narrow-spectrum antibiotics. Third, in the absence of published data providing further guidance, our four estimation methods did not account for antimicrobial prescribing in long-term inpatient care facilities, potential contribution of inappropriate antibiotic dosing and duration and antibiotic resistance introduced from travel exposures outside of the United States. Fourth, each method had unique limitations. In the second-line inpatient antibiotic cost method, we estimated the SCAR attributable to ambulatory antibiotic prescribing based in part on antibiotics that are predominantly used for treatment of antibiotic resistant infections in the hospital setting . Further, some proportion of second-line antibiotic use may be inappropriate and not reflective of concern for antibiotic resistant infections, which could lead to an overestimate of the SCAR arising from this source. In the second-line outpatient antibiotic cost method, we assumed that ambulatory use of broad-spectrum antibiotics predominantly reflects physician concern for antibiotic resistance when it may also reflect other attitudes towards the value of specific antibiotics. In the antibiotic stewardship cost method, we estimated total U.S. costs of antibiotic stewardship by extrapolating costs of stewardship from a 200-bed community hospital to a national level based on bed size, assuming a linear relationship between bed-size and stewardship costs across all hospitals , 29. FinIn summary, we found that there is a considerable hidden SCAR attributable to each ambulatory antibiotic prescription that would substantially increase the total societal costs of ambulatory antibiotic prescribing if incorporated into costs experienced by payers or patients. The magnitude of the misalignment between antibiotic costs experienced on individual and societal levels reinforces the need to develop and validate innovative strategies to appropriately align individual and societal costs of antibiotic use in an effort to safely reduce total societal costs of antibiotic use.


PET is a promising molecular imaging technique, which provides real-time information on the metabolic behavior of the tracer. The diffusive nature of glioblastoma (GBM) and heterogeneity often make the radiographic detection by FDG-PET inaccurate, and there is no gold standard. FDG-PET often leads to several controversies in making clinical decisions due to their uptake by normal surrounding tissues, and pose a challenge in delineating treatment-induced necrosis, edema, inflammation, and pseudoprogression. Thus, it is imperative to find new criteria independent of conventional morphological diagnosis to demarcate normal and tumor tissues. We have provided proof of concept studies for 11C methionine-PET (MET-PET) imaging of gliomas, along with prognostic and diagnostic significance. MET-PET is not widely used in the United States, though clinical trials from Japan and Germany suggesting the diagnostic ability of MET-PET imaging are superior to FDG-PET imaging for brain tumors. A major impediment is the availability of the onsite cyclotron and isotopic carbon chemistry facilities. In this article, we have provided the scientific rationale and advantages of the use of MET-PET as GBM tracers. We extend our discussion on the expected pitfalls of using MET-PET and ways to overcome them by incorporating a translational component of profiling gene status in the methionine metabolic pathway. This translational correlative component to the MET-PET clinical trials can lead to a better understanding of the existing controversies and can enhance our knowledge for future randomization of GBM patients based on their tumor gene signatures to achieve better prognosis and treatment outcome.The present most common image diagnostic tracer in clinical practice for glioma is  In this article, we offer a rationale for incorporating MET-PET imaging in future large cohorts of brain tumor clinical trials and evaluate its prognostic value over conventional FDG-PET. Methionine uptake by GBM represents a metabolic abnormality that distinguishes cancerous from normal tissues. 11C-Methionine may be a better PET imaging agent than conventionally used 2-deoxy-2-18fluorodeoxyglucose (FDG) because the human body cannot biosynthesize methionine. Though there are a few studies reporting 19F-labeled amino acid and other analogs as tracers for PET imaging, FDG-PET is the widely used imaging modality for brain tumors. Therefore, we have made a comparison of FDG-PET vs. MET-PET in this article.The complex nature of high-grade gliomas [glioblastoma (GBM)] makes radiologic detection inaccurate. It is essential to find new criteria either complementary to or independent of positron emission tomography FDG-PET diagnosis in distinguishing tumor and normal tissues. PET provides the real time metabolic monitoring of molecules and identifying molecules specific to cancer cells can play a crucial role in cancer diagnostics. Previously, through metabolic profiling of gliomas, we have shown that glioblastoma (GBM) cells and glioma stem cells (GSCs) accumulate methionine when compared to normal counter parts. Cellular uptake studies of methionine in GBM, GSC, and normal human astrocytes (NHAs) show a significant uptake of methionine by GBMs and GSCs when compared to NHA . This reMTAP) is a key enzyme essential for the methionine salvage pathway. MTAP catalyzes the cleavage of 5′-methylthioadenosine (MTA) into adenine and 5-methylthioribose-1-phosphate (MTR-1-P). Adenine is then used to generate AMP, whereas MTR-1-P is converted into methionine. In normal mammalian tissues, MTAP recycles purines and methionine consumed during polyamine synthesis. MTAP deficiency has been reported in both liquid and solid tumors, including gliomas . Homozygous deletions of human chromosome 9p21 occur frequently in malignant cell lines and are common in primary gliomas.Methylthioadenosine phosphorylase   , 22. Ourcurrence –31. In s18F-fluorodeoxyglucose (FDG) and 11C-methionine (MET) PET was made. FDG-PET portrayed malignant tumors as hot spots but was not able to delineate the extent of the tumor, whereas MET-PET, regardless of the degree of malignancy, outlined the tumors clearly as areas of increased 11C-methionine accumulation  and is more appropriate for use with high precision radiation techniques /gross target volume (GTV). We hope that this can be achieved through the integration of MET-PET into radiation treatment planning. Differentiating nonspecific postoperative changes in operated patients with GBM, and delineating gross tumor volume precisely, is important for radiation treatment planning. It has been shown that the sensitivity and specificity of MET-PET in differentiating non-tumoral tissue and LGGs are 78 and 87%, respectively , 46. In chniques . A recenwith GBM . One of de novo pathway, also referred to as methionine salvage pathway. In the salvage pathway methionine is converted to SAM, the principal methyl donor and is a substrate for nucleic acids (RNA and DNA) and proteins in biological systems. During methylation, SAM transfers methyl groups and is then converted to S-adenosylhomocysteine (SAH). SAH is further hydrolyzed to homocysteine (Hcy) then metabolized by methylation and trans-sulfuration salvaging methionine. The methionine metabolic pathway is deregulated in response to genetic or environmental stimuli, resulting in depletion of SAM or accumulation of SAH.Normal cells can survive and proliferate without methionine, while cancer cells would not due to the deregulation of various enzymes in methionine metabolic pathway. Exploiting this metabolic vulnerability could lead to better therapeutic intervention in cancers while sparing normal cells. Methionine can alter translational (protein), transcriptional (RNA), and epigenetic (DNA) status of cells. Methionine is the substrate for principle methyl donor S-adenosylmethionine (SAM) and variations in SAM levels can lead to hypo-/hypermethylation of DNA. Schematic methionine metabolic pathway diagram is shown in Figure MAT1A), and its paralog MAT2A catalyze the conversion of methionine to SAM, by recruiting ATP. SAM is the principle methyl donor in cells and regulates RNA, DNA, and protein methylation. SAM is utilized by both de novo and salvage pathways depending on the physiologic or pathologic state of cells. In the salvage pathway, SAM produces polyamines, while generating methylthioadenosine (MTA) as a byproduct. MTA is then phosphorylated by MTA phosphorylase (MTAP), producing 5′-methylthioribose-1-phosphate (MTR-1-P), which then salvage methionine as an end product. Conversely, in the de novo pathway, SAM methylates DNA, RNA, and protein regulated by methyl transferases. SAM, after donating methyl groups, is converted to SAH. SAH is then converted to homocysteine by adenosylhomocysteinase (AHCY), which further salvages methionine. Therefore, the patients should be stratified based on the status of enzymes MAT 1A/2A, MTR1P, MTAP, and AHCY. The chromosomal location of various genes regulating methionine pathway in the genomic context is shown in Figure Biochemically after methionine uptake, methionine enters the methionine metabolic cycle. The initial members of the pathway methionine adenosyl transferase MATA, and itMTAP status could open the door for the potential utility of MET-PET as a diagnostic and prognostic tool for gliomas simultaneously addressing the sensitivity of MET-PET. Some of the key enzymes implicated in the methionine pathway are listed in Table Though mounting evidence for using methionine as a PET tracer for successful diagnostic and treatment planning purpose, we should exercise caution and look for potential pitfalls. To identify the possible failure of MET-PET imaging in a subset of patients, we should equip ourselves with the activity status of key metabolites in methionine pathway. Methionine uptake will be determined primarily by the state of cells . The sensitivity of MET-PET for gliomas including all grades has been estimated in the range 75–95%. Stratifying patients based on MTAP status. In this study, key methionine, metabolic genes should be correlated with methionine uptake. Moving forward with MET-PET imaging trials, patients can be enrolled only in centers with the onsite cyclotron facility which appears to be a limitation. Nevertheless, we anticipate that this trial could change the diagnostic evaluation of gliomas and improve the care for the patients.We have provided the scientific rationale for initiating brain tumor clinical trials with MET-PET imaging for a better prognosis and treatment outcome. A prospective trial would be of great value, randomizing MET-PET and FDG-PET in a uniformly treated patient cohort with balanced KP wrote the manuscript and AC edited the manuscript.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.


The consumption of antibiotics is a major driver in the development of antimicrobial resistance. This study aims to identify the trends and patterns of the total antibiotic consumption in China’s tertiary hospitals from 2011 to 2015 by retrospectively analyzing aggregated monthly surveillance data on antibiotic sales made to 468 hospitals from 28 provinces. Antibiotic consumption was expressed in DDD per 1,000 inhabitants per day (DID). We compared population weighted antibiotic consumption patterns in China with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC). Total antibiotic consumption, including all the specific antibiotic class except for aminoglycoside antibacterials, were significantly increased during the study period from an average of 7.97 DID in 2011 to 10.08 DID in 2015. In 2015, the eastern regions of China consumed the most antibiotics using population denominator while the western regions consumed the most using inpatient denominator. Cephalosporins accounted for 28.6% of total DID, followed by beta-lactam-beta-lactamase inhibitor combinations (20.0%), macrolides (17.4%), and fluoroquinolones (10.5%). Antibiotic in parenteral form accounted for nearly half of all antibiotics. Although over the past few years major efforts had been made to reduce the risks of excessive antibiotic use through antibiotic stewardship, total antibiotic consumption showed a significant upward trend during the study period. A consistent preference for cephalosporins, macrolides, beta-lactam-beta-lactamase inhibitor combinations, as well as parenteral preparations was observed. How antibiotics are used is crucial for reducing the risks of antimicrobial resistance, which is one of the biggest threats to global health, food security, and development today . Joint eThe Chinese government has made significant efforts to improve antibiotic use over the past decade . These eAntimicrobial stewardship in China has brought about a range of changes to antibiotic use. However, given the fragmentation of health care information data, aside from one study conducted in Shanghai , no reliWe retrospectively analyzed aggregated monthly surveillance data on antibiotic sales to 468 hospitals from 28 provinces in China from January 2011 to December 2015. The data was derived from the electronic database of China Medical Economic Information (CMEI). CMEI is one of the largest government-approved information consultation and service platforms, which was designed to collect and analyze hospital medication usage under the administration of the China Pharmacy Association (CPA). The database covers more than 1,000 city-level public hospitals across mainland China. The sales of participating hospitals accounts for approximately 40% of total drug sales at city level public hospitals in China. Hospitals were sampled hierarchically based on geographical and socio-economic factors. We selected 468 tertiary hospitals in 28 provinces on the basis that they each had full records of antibiotic use during the five year study period which accounts for 72.6% of the overall sample hospitals listed in the CMEI.Monthly antibiotic sales records data were extracted from the CMEI electronic database. Hospital information linked to the CMEI including the various types of generic antibiotics, amount of sales, the route of administration, expenditure, and geographical data were collected. Hospital names were concealed so as to protect confidentiality.Data were managed and analyzed in Microsoft Excel 2013. Sales data were extracted according to Anatomical Therapeutic and Chemical (ATC) classification J01  with defined daily dose (DDD) as measurement unit, as recommended by the WHO Collaborating Center for Drug Statistic Methodology . A totalTo make the consumption data available to provide internationally comparable information, we adopted European Surveillance of Antimicrobial Consumption (ESAC) methods that is projected to collect data on antimicrobial consumption in ambulatory care and hospital settings in Europe . The antY: Coverage inhabitants in a given year in province i using census population data;Y′: Coverage inhabitants in a given year in province i using inpatient volume;Pi: Total population in a given year in province i;Qi: Total inpatient volume in total tertiary hospitals in a given year in province i;ni: Number of sample hospitals in province i;Ni: Number of total tertiary hospitals in province i;ni′: Number of total inpatients in tertiary hospitals in province i;Ni′: Number of total inpatients in all hospitals in province i;All the relevant census data for calculating inhabitants were collected from China Health Statistics Yearbook and China Statistics Year Book .Because of different health care systems and data availability, we were not able to distinguish the outpatient and inpatient use of antibiotics sales in the CMEI dataset. Thus, we compared the total antibiotic consumption in China with outpatient consumption in 29 European countries in 2012 when assessing the quality of trends and pattern of antibiotic consumption . It was We adopted the 12 ESAC drug-specific quality indicators to assess the appropriateness of the patterns of total antibiotic use in China . The numTotal antibiotic consumption in general, including all the specific antibiotic classes except for aminoglycoside antibacterials, significantly increased during the study period from an average of 7.97 DID in 2011 to 10.08 DID in 2015 . The proThe regional distribution of antibiotic consumption in China in 2015 was shown in The most frequently used antibiotic class in China were cephalosporins which accounted for 28.6% of total consumption, followed by beta-lactam-beta-lactamase inhibitor combinations with 20.0%, macrolides with 17.4%, and fluoroquinolones with 10.5% .During the study period, cephalosporin consumption consistently increased from 2.46 DID to 2.88 DID, among which second and third generation cephalosprins contributed the most. The same trend was also observed in penicillin, macrolides, and carbapenems. The consumption of beta-lactam-beta-lactamase inhibitor combinations increased the most among all antibiotics classes by 0.66 DID. The consumption of aminoglycoside was the only antibiotic class that did not increase .When exploring antibiotic consumption in different regions of China, we used two different denominators to better reflect the distribution in different regions, that is, population based and inpatient volume based . When usThe number of antibiotics that accounted for 90% of total antibiotic consumption fell from 58 in 2011 to 43 in 2015. Half of these 43 antibiotics in 2015 were cephalosporins, among which 11 were only available in parenteral form .Total parenteral use of antibiotics in China in 2015 accounted for 47.1% of total DID, whereas the expenditure of parenteral antibiotics accounted for 87.0% of total drug expenditure. The proportion of antibiotics used in parenteral form was stable during study time period. The oral antibiotics consumption continuously increased from 4.13 DID in 2010 to 5.20 DID .We compared antibiotic use in China with ESAC data from 2012 . The comThis study is the first to estimate population-based antibiotic consumption at national level in China, using ATC/DDD methodology for international comparison. Our study quantified antibiotic consumption changes over a five year period, giving us the opportunity to benchmark the gaps between antibiotic utilization in China and European countries, which would be informing for healthcare providers, decision-makers, as well as the public.The consumption of antibiotics is a major driver for the development of antimicrobial resistance . As Fig Cephalosporin was the most consumed antibiotic class of total antibiotic consumption which accounted for nearly 30% in China in 2015. This was observed in previous study conducted in other regions of China , as wellCarbapenems were considered as last-line treatment for multi-resistant bacteria. Although the proportion of consumption of carbapenems out of total antibiotic consumption is lower than EU/EEA data (1.5% verses 2.9%) , we stilMoreover, the distribution of antibiotic consumption in China revealed that the eastern regions consumed more antibiotics than the middle and western regions when using census population as denominator. This could be explained by the patient flow between provinces caused by unbalanced healthcare resources allocation. Since the eastern regions are more developed than the central and western regions, the healthcare resources, especially the best ones, are located more in cities like Beijing, Shanghai, and Guangzhou, which brought patients from other regions travelled to these more developed areas for treatment. In addition, this phenomenon may be greater for central regions rather than western regions due to the geographical distance between central and eastern regions is closer. Hence, when we used inpatient volume as denominator to verify the speculation, the result showed that western regions consumed the most antibiotics. Antibiotic consumption in eastern regions decreased while antibiotic consumption in central and western region increased compared with population based consumption. This would further confirmed that there was a large volume of patient flow for healthcare between provinces in China.The number of antibiotics that accounted for 90% of total antibiotic consumption dropped from 58 in 2011 to 43 in 2015. This could be partly because that antibiotics were mandatorily classified into three categories based on the prescription rights of the physicians as part of the stewardship campaign in 2012. This measure made antibiotics harder to be prescribed. Parenteral antibiotics accounted for 40% of the total consumption, but 80% of total expenditure. This proportion was significantly higher than that of Europe of 7% . Since iThis study has several important limitations. First, the hospital participation functions on a voluntarily basis instead of mandatory participation and therefore might not be representative. Second, primary care setting was not included which may cause bias on the pattern of antibiotic consumption since a number of parenteral antimicrobial agents was used in primary care setting. Third, the population denominator used in the study may underestimate antibiotic consumption as it cannot include cross-provincial patient flow as discussed. Finally, as the study analyzed sales data rather than clinical usage, we were unable to determine the appropriateness of antibiotic use at the individual level.This study used aggregated sales records data to analyze the antibiotic consumption in China’s tertiary hospitals over a five year period. Although significant efforts have been made through antibiotic stewardship in the past few years, total antibiotic consumption showed a significant upward trend during the study period. The patterns of antibiotic consumption demonstrated that there was a consistent preference for cephalosporins, macrolides, beta-lactam-beta-lactamase inhibitor combinations, as well as parenteral preparations. More efforts are needed in the future to investigate the quality of antibiotic prescriptions, especially in primary health care settings in order to reduce risks of antimicrobial resistance.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.


Rationale (hypothesis): IgG4-related disease (IgG4-RD) is a pathological entity recently recognized by the medical world that can affect any organ or system. However, there is insufficient data about this disease in medical literature.Aim (objective): A more extensive clarification of the IgG4 molecule, the diversified aspects of IgG4-related disease, and the response of this disease to treatment, will provide a crucial understanding of the immune system and other diseases now known to be associated with IgG4.Methods and results: The MEDLINE online medical database was used, and, after a comprehensive review of medical articles regarding IgG4-RD, published after 2003, using the search words “IgG4- related disease” and “IgG4 molecule”, we have described the clinical, pathological and therapeutic features of IgG4-RD, as well as the presence of the IgG4 molecule in the evolution, diagnosis and management of this syndrome. We characterized the potential disease mechanisms and discussed early observations related to treatment.Discussion: Given the response to immunosuppressive therapy, it is hypothesized that IgG4-related disease is most likely an autoimmune disease. Therefore, IgG4-related disease is a fibro-inflammatory condition that can affect any organ and can lead to the formation of pseudotumoral lesions requiring differential diagnosis with various malignancies. Positive diagnostic criteria are histopathological and require at least two features out of the following three: dense limphoplasmocitary infiltrate, storiform fibrosis, obliterative phlebitis. Damage can be done to a single organ or to multiple tissues or systems that are involved in a synchronous or metachronous way. The clinical expression of the disease varies depending on the organs involved. The histopathological examination is considered the gold standard in obtaining a diagnosis, and the observed morphopathological changes are similar regardless of the affected organ. From this perspective, IgG4-related disease may be compared to sarcoidosis, another multisystemic disease with similar morphopathological changes in any sample of tissue that is involved. The histological criteria are: diffuse lymphoplasmacytic infiltrate, numerous IgG4 positive plasma cells in the examined tissue, storiform fibrosis (resembling the spokes of a cartwheel), eosinophils in mild to moderate quantities, obliterative phlebitis, and pseudotumoral lesions that tend to form in the affected organs [2]. Though initially considered that markedly elevated serum IgG4 levels were essential for diagnosis, it is known now that up to 30% of the patients may have a normal serum concentration despite the histopathological criteria supporting a positive diagnosis [3]. However, many aspects of the disease remain unclear.IgG4-related disease (IgG4-RD) is a pathological entity recently recognized by the medical world that can affect any organ or system. The basics of this condition have begun to be constructed since 2003, when patients with autoimmune pancreatitis have also been observed to have extrapancreatic manifestations [4].Epidemiology of the disease is insufficiently described, but some demographic peculiarities stand out. Most patients are males over 50 years of age with a male/ female ratio of 3/ 1. Here, what should be noted is the discrepancy with other classic autoimmune diseases such as Sjogren's syndrome, systemic lupus erythematosus, primary biliary cirrhosis, which are predominantly found in females. The incidence and prevalence of the disease are not known, because only studies of autoimmune pancreatitis were conducted mainly in Japan. The prevalence is 0.8 cases/ 100,000 inhabitants/ year, accounting for 6% of the total cases of chronic pancreatitis [5]. Therefore, over time, more and more diseases have been included in the spectrum of IgG4-related disease. Considered a variant of Sjogren's syndrome, Mikulicz syndrome consists in the swelling of the submandibular, lacrimal and parotid glands, and is now reclassified as being IgG4-related sialadenitis/ dacryoadenitis [6]. Kuttner tumor is an increase in the volume of submandibular glands in the context of a lithiasis or an infectious etiology, while bilateral damage to the submandibular glands in the absence of a precise etiology should be regarded as pertaining to IgG4-RD [7]. Also, Riedel thyroiditis is now a small part of the many diseases included in the IgG4-RD family. In the initial stages of the disease, the diagnosis is effortless based on classical histopathological criteria, but as the disease progresses and fibrotic tissue replaces the parenchyma, it is troublesome to obtain a definite diagnosis [8]. The affliction of the thoracic aorta in ~10% of the cases is found in IgG4-RD in the form of a chronic sclerosing aorta. The abdominal aorta , pancreas - type 1 autoimmune pancreatitis, biliary tract  may also be involved. Ocular and periorbital tissue may be affected, but the reported frequency appears to be very low due to refraining from performing a biopsy. Eosinophilic angiocentric fibrosis causes pseudotumoral lesions of the eye or upper respiratory tract.Type 1 autoimmune pancreatitis (AIP) is associated with an increased serum IgG4 level and it was the first disease included in the broad spectrum of IgG4- related disease. The assumption that IgG4-RD is a multisystemic disease was raised from the fact that patients with autoimmune pancreatitis also express extrapancreatic manifestations. Fundamentally, IgG4-RD can affect any organ: the pancreas, bile ducts, eyes, salivary glands, lungs, heart, kidneys, skin, aorta, ganglia, meninges, prostate, breast, thyroid, retroperitoneal tissue, etc. [9]. In contrast, for pemphigus vulgaris or idiopathic membranous nephropathy, IgG4 triggers immune-mediated processes that lead to tissue destruction. The histopathological examination performed in these diseases differs substantially from the changes observed in IgG4. The main element is the lymphoplasmacytic infiltrate observed in most cases, with the acknowledgment that in advanced cases of retroperitoneal fibrosis or Riedel thyroiditis, extensive fibrosis virtually replaces the entire parenchyma, and typical changes that support the diagnosis of IgG4 are not found. Lymphocytes are especially CD4-positive T lymphocytes, and the B cells are confined to small cohesive lymphoid aggregates [10]. Eosinophils do not dominate the histopathological picture but justify the patient's allergic history. Many patients have a history of atopy, eczema, asthma, or chronic sinusitis. Besides the abundant cellularity of lymphocytes, plasmocytes and eosinophils, the storiform fibrosis is characterized by short, interlaced, curved collagen beads arranged in a matted and irregularly whorled pattern, which originate from a central point and radiate towards the periphery. Obliterative phlebitis is seen as veins with narrow lumens (sometimes completely stenotic) by the lymphoplasmacytic infiltrate; this process is always found in pancreatic and submandibular salivary glands, but less frequently in the lacrimal glands [2]. The differential diagnosis with a vasculitis is based on the absence of neutrophils, fibrinoid necrosis, or nuclear dust. Histopathological elements that make a diagnosis of IgG4-RD improbable are epithelioid cell granulomas, neutrophil infiltration, giant cells, and necrotic zones [11].Although it has a high concentration in the serum, IgG4 immunoglobulin does not appear to play a central role in the pathophysiology of the disease [12].Most of the plasmocytes are IgG4 positive, a change that can also be found in chronic inflammatory processes. This finding is insufficient to support the diagnosis and should be accompanied by other histopathological findings. A minimal percentage of IgG4-positive plasmocytes for diagnosis has not yet been established, but 30 plasmocytes per high-powered field or an IgG4: total IgG ratio of greater than 40% are suggestive for the diagnosis of IgG4-related disease. A lower cutoff point for IgG4-positive cells is accepted in patients with suggestive pathological findings [3]. For type 1 autoimmune pancreatitis, the sensitivity of serum IgG4 increases depending on the stage of the disease; it should be stated that some studies included patients with type 2 autoimmune pancreatitis with different characteristics at a microscopic level  [13]. No other serum markers have an established role in the diagnosis.Patients with IgG4-RD may have a polyclonal increase in immunoglobulins regarding the IgG4 subclass, a feature that can be useful in reinforcing the diagnosis but is not required to be present or self-sufficient for the diagnosis. A high serum concentration of IgG4 immunoglobulins is found in patients with multiple organ damage. A wrong diagnosis of IgG4-RD is commonly encountered because overestimation is given to the role of serum or tissue IgG4  .Patients with type 1 autoimmune pancreatitis have a clinical presentation similar to that of patients with pancreatic cancer: obstructive jaundice, weight loss, mild abdominal pain. Therefore, the diagnosis was obtained laparoscopically until recently, but with a better understanding of the IgG4-related disease concerning specific imaging changes  a high index of suspicion should be made. A differential diagnosis with primary sclerosing cholangitis is difficult based only on imaging studies and is based on histopathological changes [15].Patients with type 1 autoimmune pancreatitis can have liver damage that includes portal inflammation with or without perihepatitis, obstruction of large bile ducts, portal fibrosis, lobular hepatitis, canalicular cholestasis. The differential diagnosis of autoimmune hepatitis is based on autoantibodies . The gallbladder localization of the disease appears as acalculous cholecystitis, but the discovery is often made after the surgical removal, microscopic examination and staining for IgG4 . Other organs involved can be the pituitary gland, meninges, skin, prostate, pericardium, lymph nodes. Ganglia involvement can be isolated  or generalized; it is important to mention that a lymph node biopsy does not reveal storiform fibrosis commonly found in other locations, and a diagnosis of reactive follicular hyperplasia is usually made, as other diagnoses such as IgG4-RD are not considered. The frequency of localization in various organs is not fully known, as many lesions are asymptomatic such as cutaneous erythematous papular eruptions.The IgG4-related lung disease site comprises the following symptoms: cough, haemoptysis, shortness of breath, pleural effusion, chest pain. Interstitial pneumonia or pseudotumoral inflammatory lesions complete the clinical spectrum. Histologically and radiologically, four types of pulmonary patterns are described: nodular, bronchovascular, interstitial, round ground-glass opacities. Renal disease in IgG4 disease is difficult to distinguish from renal carcinoma. The microscopic examination reveals tubulointerstitial nephritis with diffuse or sometimes localized lymphoplasmacytic infiltration with associated interstitial fibrosis. Clinical features are hematuria, proteinuria, renal failure and other extrarenal manifestations in an overwhelming proportion of cases [17]. The molecule plays a pivotal role in the pathogenesis of diseases such as bullous pemphigus by interacting with desmoglein-1 [18]. Also, in podocytes, the interaction of IgG4 with M-type phospholipase A2 explains the appearance of idiopathic membranous glomerulonephritis. Thrombotic thrombocytopenic purpura is initiated by binding of IgG4 with ADAMTS13  [19]. The definitive role of IgG4 in the disease remains to be established, whether this subclass plays a central role in the pathogenesis of the disease, or is an epiphenomenon in other processes without a direct implication in the pathophysiology of the disease.The pathophysiology of the disease is complex and should start with the description of the IgG4 molecule. IgG4 has a concentration of less than 5% of total IgG immunoglobulins, being the subclass with the most stable interindividual concentration. IgG4 does not activate the classical complement pathway and plays a limited role in the immune process. The production is predominantly controlled by T helper type 2 lymphocytes through secretion of cytokines - interleukins 4 and 13 [20]. IgG4-RD is regarded as both an allergic as well as an autoimmune disorder.Is essential to distinguish IgG4-RD from a lymphoma. Type B lymphomas have a predominantly lymphocytic infiltrate of type B lymphocytes, unlike IgG4-RD where lymphocytes are predominantly T-type. Additional clonal studies are always required for a correct diagnosis. Inflammatory infiltrations adjacent to neoplastic processes are comprised of focal IgG4 positive plasmocytes aggregates, as opposed to their diffuse layout in IgG4-related disease. There is a similarity in the structure of human carbonic anhydrase type II and that secreted by Helicobacter pylori . Patients with autoimmune pancreatitis frequently have antibodies against Helicobacter pylori; thus, these antibodies directed against infectious agents may act as autoantibodies directed against various tissue structures in patients with a genetic predisposition [21].The role of type T and B-lymphocytes is still not fully understood. Finding a CD 4+ cytotoxic T cell remains the main objective in unveiling the main part of the pathophysiology, bearing in mind that these cells are found in the highest concentration within the lesions. This cell population secretes molecules such as interleukine-1, TGF-β or IFN-γ, which play a major role in the fibrosis that characterizes the late stages of the disease. As well, is important to mention that the CD4+ cytotoxic T cells have a molecule on their surface, called SLAMF7, not formerly labeled on T cells, only B cells . One study showed that the prozone effect led to false negative results of IgG4 concentration. The prozone effect is more common in those with active disease, and that is, precisely in patients in whom a correct and rapid diagnosis is crucial to begin the treatment. The concentration of IgG4 is measured by nephelometry; it is carried out by measuring the turbidity in a water sample by passing light through the sample being measured. The amount of light passing through is dependent on the level of aggregates formed by the interaction of the antibodies present in the reagent to the antigens (IgG4) present in the patient sample. If the antigen is present in the solution, the light scatter signal begins to decrease, a phenomenon known as the prozone effect. The prozone effect can be bypassed with the dilution of the sample as to obtain and maintain an antibody level greater than that of the antigen [23].There is contradictory information about a periodic monitoring of serum IgG4 levels to assess the response to treatment. Although there is a decrease in IgG4 concentration after the start of corticosteroid treatment, serum levels remain high in most patients . Only 30% of the cases with persistent elevated IgG4 levels had relapses. Also, 10% of the patients with normal IgG4 levels also experienced recurrences [24]. Other recommendations suggest the treatment should be stopped after 3 months [22]. Corticosteroid therapy is effective but relapses frequently occur. Methotrexate, azathioprine, or mycophenolate mofetil are other agents that can be used but have not been included in clinical trials to study their effectiveness. In patients with a recurrent or refractory disease, rituximab may be used with spectacular results. When rituximab is administered, there is a marked decrease in IgG4 level, with stable concentrations of the other immunoglobulin subclasses, and with clinical remission registered within a few weeks. The effect of rituximab is obtained by lowering the concentration of CD 20 positive B cells that differentiate into IgG4 producing plasmocytes [25]. Patients with longstanding disease, in whom extensive fibrosis has virtually replaced the parenchyma of the affected organ, have a lower rate of response to the glucocorticoid or rituximab treatment.Treatment should be instituted urgently when vital organs are affected, as the disease can evolve to severe organ dysfunction. Not all disorders require immediate treatment. Lymphadenopathy in the disease is often asymptomatic and may persist for decades without clinical consequences. Glucocorticoids are the first line of treatment. The starting dose should be 0.6 mg/ kg of prednisolone for 2-4 weeks, then adjusted to 5 mg/ day over a period of 3-6 months. The treatment can be continued for up to 3 years with a dose of 2.5-5 mg/ day [ Given the response to immunosuppressive therapy, it is hypothesized that IgG4-related disease is most likely an autoimmune disease. Therefore, the IgG4-related disease is a fibro-inflammatory condition that can affect any organ and can lead to the formation of pseudotumoral lesions requiring differential diagnosis with various malignancies. Positive diagnostic criteria are histopathological and require at least two features out of the following three: dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis. IgG4 immunoglobulins weakly bind the complement and are considered to have anti-inflammatory properties. Various autoantibodies have been described in the disease, but their contribution to lesion progression remains to be established. The genetic substrate needs to be properly assessed by clinical studies as well as the possible role of bacteria in pathogenesis through human microbiota studies. Also, it is necessary to identify the target antigens of IgG4 as well as the role of fibroblasts and macrophages in the pathogenesis of the disease. A more thorough insight of the IgG4 immunoglobulin, the distinct aspects of the IgG4-related disease, and the response of this syndrome to treatment, especially B-cell reduction, may return critical understandings of the immune system and other conditions now known to be associated with IgG4.None declared.