Immunoglobulin G4-related disease (IgG4-RD) is known for forming soft tissue mass lesions that may have compressive effects. It is an extremely rare disease that most frequently affects the pancreas causing autoimmune pancreatitis. It can also affect the gallbladder, salivary glands, and lacrimal glands causing respective organ-specific complications. In our report, we describe an IgG4-RD case that affected the spinal cord. A 60-year-old female presented with cervical spinal cord compression caused by IgG4-RD leading to several neurological deficits. Pathological examination of the excisional biopsy of the mass revealed dense lymphoplasmacytic cells infiltration and stromal fibrosis with IgG4 and plasma cells. The patient showed a dramatic response to the administration of systemic steroids with almost resolution of her neurological symptoms. This case highlights the first case in literature for IgG4-RD of the extradural tissue causing spinal compression. Hereby, we also demonstrate the dramatic response of IgG4-RD to the administration of systemic steroids as the patient had no recurrence after 5 years of close follow-up, the longest reported period of follow-up reported in the literature to date. IgG4-related disease (IgG4-RD) is an extremely rare condition that can affect the pancreas, liver, salivary glands, kidneys, lungs, central nervous system (CNS), and the heart. It is diagnosed based on the clinical presentation, hematological data, and histopathological criteria. Very limited data is available about the CNS involvement in IgG4-RD because it is an extremely entity of the disease.The manifestations of IgG4-RD when it affects the CNS depends typically on the location of the sclerotic mass. IgG4-RD have been previously described in the literature as it affected the pituitary gland and manifested as hypophysitis , the menA 60-year-old Caucasian female with medical history of obstructive sleep apnea, seasonal allergies, and osteoarthritis who presented with weakness and numbness in all four extremities for 4 weeks. Initially, she had bilateral burning pain at the tips of her fingers and toes that progressed later to pin-and-needle paresthesia. The paresthesia was associated with low grade fever, bowel and bladder incontinence, and vague dull neck pain. Her home medications are acetaminophen, methocarbamol, and vitamin D supplementation and she is allergic to aspirin, calcium, cortisone meperidine, phenytoin, gabapentin, ibuprofen, naproxen, penicillin, salicylate, and sulfa drugs. She denied alcohol, tobacco, and illicit drug use.She has a past surgical history of 2 caesarian sections, hemorrhoidectomy 31 years ago, and splenectomy after a remote vehicle accident 35 years ago. 5 months prior to this presentation, she underwent decompressive laminectomy for a C1-C5 cervical mass originating from the dorsal part of the cervical epidural space. The pathology report from the resected mass revealed an inflammatory mass with extensive collagenized background and a polymorphous-appearing cell infiltrates with a mixture of small lymphoid cells, plasmacytoid cells, very occasional eosinophils, and neutrophils.At admission, she was alert and oriented and maintaining normal vital signs. Physical examination revealed that her neck was supple without lymphadenopathy but was significant for neck tenderness. CNS examination revealed intact cranial nerves, 3/5 power strength and 2+ reflexes in upper extremities bilaterally, 2/5 strength and 3+ reflexes in lower extremities bilaterally, intact sensation in all four extremities, and no saddle anesthesia. The rest of the physical examination was unremarkable.CBC, serum electrolytes, and blood chemistry were unremarkable. Magnetic resonance imaging (MRI) of the thoracic spine showed T2-diffuse enhancement of extradural soft tissue mass with marked spinal canal stenosis, most prominent at the level of T4-T5 . Whole bA laminectomy of T2 through T6 with excisional biopsy of the epidural mass was performed. The histological examination of the extradural mass chronic inflammatory infiltration composed of lymphocytes, plasma cells, histiocytes, neutrophils, eosinophils, mast cells . It alsoAfter the surgery, the patient was discharged to an acute rehabilitation facility and then home but she continued to have quadriparesis, bowel and bladder incontinence, and limited ambulation due to motor weakness and poor sensation. It was almost 6 weeks until the final pathology report was received that confirmed the diagnosis of IgG4-RD, after which she was started on weekly pulse doses of oral dexamethasone 40 mg split into 4 doses. Due to her corticosteroid allergy, she was pretreated with 50 mg diphenhydramine 30 minutes before the administration of dexamethasone.A dramatic clinical improvement was achieved, particularly in her quadriparesis, after the administration of systemic corticosteroids. She was able to walk with walker within 3-4 months, then independently in about a year. Her hand Fine motor skills have improved tremendously and she is currently able to perform knitting. Her bowel and bladder dysfunction also recovered completely. Over the course of 5 years of close follow up, she was kept on dexamethasone 40 mg weekly preceded with diphenhydramine and she did not experience any disease relapse. Annual follow-up MRI images have shown no disease recurrence and IgG levels remained suppressed for 5 years after the initial diagnosis and treatment, the longest follow-up period for IgG4-RD reported. Serum IgG4 levels in relation to her compliance to Dexamethasone is outlined in IgG4-RD is a rare disease which was first recognized as one of the causes of autoimmune and sclerosing cholangitis . SubsequThe diagnosis of IgG4-RD relies on clinical, hematologic, and histopathologic criteria. These include patients' presentation with characteristic diffuse or localized masses in single or multiple organs, elevated serum IgG4 levels >1.35 g/L, marked fibrosis with lymphocytic and plasmacytic infiltration with positive immunohistochemical staining for IgG4 on histological examination. IgG4+/IgG ratio >40% and >50 IgG4+ plasma cells/high power field are also very suggestive for IgG4-RD on pathological examination .The immunological mechanism of IgG4-related sclerosing disease is not completely understood. The prevailing theory is the one that involves molecular mimicry based on an immune response to self-antigens that results in an increased regulatory T-cell and type 2 T-helper (TH2) cell response that results in persistent inflammation . IgG4 anIgG4-RD has been reported to affect the CNS in literature. The most common CNS manifestation of IgG4-RD is hypertrophic pachymeningitis where it lead to dural hypertrophy (and thickening) which will eventually lead to symptoms such as headaches, cranial nerve dysfunctions, sensory and/or motor symptoms depending to the location, either intracranially or spinally . Meninge17 cases were reported in the literature where IgG4-RD hypertrophic pachymeningitis  was causUnlike other systemic inflammatory diseases such as sarcoidosis or systemic scleroderma, the immunological manifestations of IgG4-RD are reversible with corticosteroids. Once the diagnosis has been made, the disease often dramatically responds to systemic corticosteroids. Some patients may not meet the histopathological criteria for IgG sclerosing disease, yet still, show clinical improvement with glucocorticoids . A dramaCurrently, there is no consensus about the dose or duration of systemic corticosteroid therapy for IgG4-RD. Some physicians treat with systemic steroids temporarily for several months, while some patients in Japan get corticosteroids permanently . We elecTherefore, a single high dose is unlikely to have sustained effect. Overall, the effects of corticosteroid pulses appear to include downregulation of activation of immune cells and proinflammatory cytokine production, leading to reduced expression of adhesion molecules and reduced movement of neutrophils into sites of inflammation. These effects are qualitatively similar to those seen with anti-TNF-alpha therapy . CorticoThough extremely rare, spinal cord compression could be the initial presentation of IgG4-RD. The IgG4-RD disease process can be rapidly ameliorated with systemic corticosteroid use, even in the late stages of the disease. Early diagnosis of this rare IgG4-RD disease entity, extradural spinal cord compression, and early treatment with systemic corticosteroids can decrease the disease mortality and morbidity and improve patients' quality of life .


ANCAs in IgG4-related disease might sustain an underlying vasculitic process. Sir, IgG4-related disease (RD) is a rare and often misdiagnosed systemic disease characterized by diffuse/focal organ enlargement, mass-forming or nodular/thickened lesions in various organs and a prominent infiltration of lymphocytes and IgG4-positive plasmacytes with fibrosis [fibrosis . Substanfibrosis .Hypertrophic pachymeningitis is a very rare manifestation of IgG4-RD. Only four cases of hypertrophic pachymeningitis IgG4-RD with a positive ANCA assay have been described in the literature, and one with pachymeningitis of the spine .Here, we report a case of IgG4-RD involving the dura mater with a hypertrophic pachymeningitis and a positive ANCA assay with aortitis of the aortic arch. We also review the literature in order to provide clinicians with tools for interpreting ANCA positivity in IgG4-RD patients.A 59-year-old woman was referred for an ingravescent headache and neck pain. A gadolinium-enhanced MRI of the brain disclosed a diffuse neoformed meningeal tissue at the level of the foramen magnum, with compression on the bulbo-medullary junction. Therefore, a suboccipital craniectomy and C1 laminectomy was performed, removing part of the tissue.The patient’s serum tested positively for ANCA by both immunofluorescence (cytoplasmic ANCA pattern) and enzyme immunoassay, with specificity for PR3 , with negative microbiological examinations for recent or past infections. Assays for ANA, RF, antibodies to ds DNA, thyroperoxidase and thyroglobulin were negative. The CRP was elevated ; ESR and tests of renal, thyroid and liver function were within the normal ranges.+ and CD8+ lymphocytes, CD138+ plasma cells and CD68+ macrophages/histiocytes. Focally, discrete follicular and microfollicular aggregates of CD20+ lymphocytes and scanty infiltrates of neutrophils were present. The immunohistochemical analysis revealed several IgG4+ plasma cells. No granulomatous or vasculitic features or fibrinoid necrosis of vessel walls could be detected.The histopathological specimens consisted of dense fibrous dura mater tissue, with hypertrophic and chronic inflammatory features. The tissue was characterized by dense inflammatory infiltrates composed of CD3These histopatological findings were consistent with the suspicion of IgG4-related hypertrophic pachymeningitis .18F-fluorodeoxyglucose (18F-FDG) uptake on PET/CT study (Thoracic and abdominal CT with iodinate contrast media excluded the presence of nodules and granulomatous lesions characteristic of parenchymal involvement in AAV, in addition to the presence of pancreatic involvement, retroperitoneal fibrosis or other organ-specific alterations typical of IgG4-RD. However, CT revealed a diffuse enhancement of the posterior wall of the aortic arch as a mural inflammation, with an intense CT study . TreatmeWe identified 11 other reports of patients with IgG4-RD and positive ANCA in the literature; three with hypertrophic pachymeningitis IgG4-RD biopsy proved and positive ANCA, and one with IgG4-RD diagnosed presumptively.et al. [The association between ANCA positivity with aortitis and IgG4-RD could suggest pathophysiological similarities between the two rare diseases. François-Xavier Danlos et al.  assume tet al. , 6. A coet al. , 8. Howeet al. [Our clinical case, in view of the coexistence of periaortitis and hypertrophic pachymeningitis with bioptic IgG4 infiltrates and serum ANCA positivity, seems to confirm this correlation between IgG4-RD and AAV, underlying the possibility of a new overlap syndrome, as postulated in the study by Danlos et al. ; howeverFunding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.Disclosure statement: The authors have declared no conflicts of interest.


Upper respiratory tract infections are the leading cause of misuse of antibiotics, a problem that leads to unnecessary adverse events and antibiotic resistance. Antibiotic prescription in Ecuador was analyzed in order to evaluate the state of antibiotic prescribing for upper respiratory tract infections. Both the appropriateness and adequacy of prescribing was evaluated. Appropriateness represents the percentage of prescriptions that are indicated; adequacy refers to the percentage of patients requiring antibiotics who are treated.The aim of the study is to analyze the appropriateness and adequacy of antibiotic prescription for upper respiratory tract infections in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador. This is a cross-sectional study of patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with upper respiratory tract infection as a primary diagnosis.We included a total of 1393 patients in the analysis. Out of the 1393 patients identified, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%, and 51 required antibiotics, reflecting a real need of antibiotics of 3.7%. Appropriateness: Of these 523 patients who were treated, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. Adequacy: When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%.The results of our study report a 90.25% of inappropriate prescription. The antibiotic prescription, appropriate prescription, and adequate prescription rates show the need for implementation of strategies in order to reduce them. Related aspects regarding prescriber’s behavior and the patient’s expectations should be analyzed.The online version of this article (10.1186/s40360-018-0237-y) contains supplementary material, which is available to authorized users. Appropriate and adequate use of drugs is now one of the most commonly debated topics in public health. According to the WHO, only 50% of all prescribed medications are dispensed or sold in an appropriate way . On the Differences in prescription can be due to both the prescriber and the patient. Studies have shown that factors like gender, multi-morbidity and previous personal experiences can influence prescription , 6. PresA 2016 study by Fleming-Dutra et al. in the United States shows a rate of inappropriate oral antibiotic prescription of about 50% in upper respiratory tract infection (URTI), adjusted by age and diagnostic in adults and children . AnotherA prospective study with 3402 patients with acute cough from 13 European countries analyzed the variation in prescription of antibiotics in primary care. Their results showed a high prescription rate, in all countries included that ranged between 20 and 90% (media of 53%) . AnotherEven though resistance to antibiotics is a natural phenomenon in bacteria, human activities have potentiated its expansion, favoring the appearance of resistant strains. The lack of efficient practices for prevention and control of infections has also contributed to the emergence of new resistances . The inaStaphylococcus aureus, enterococci, and gram-negative bacilli, are associated with an increase in mortality, morbidity, days of hospitalization and health costs [Costelloe, et al. in 2010, demonstrate a strong association between the prescription of antibiotics in primary care and antimicrobial resistance in URTI . It has th costs . The incth costs .Due to the large impact on health, antibiotic prescription in Ecuador was analyzed in order to evaluate if the tendency aligns with the misuse of antibiotics occurring around the world. Defining the scope of the problem will allow for further analysis and policy implementation in the country.The aim of this study was to analyze the appropriateness and adequacy of antibiotic prescription for URTI in the Ambulatory Health Centers of the Ministry of Public Health of Ecuador in the District 17D03 during 2015. The design of this cross-sectional study of the appropriateness and adequacy of antibiotic prescription imitates similar studies from different settings , 17–19 aThe data source for the variables included in this study are the Electronic Health Records (EHR) of all the patients from one Health Center of the Ministry of Public Health in the District 17D03 in Ecuador during 2015 with URTI as a primary diagnosis. This district has been using EHR since 2010. Prescribers enter the information directly into the EHR on a computer during the outpatient appointment. Information was manually extracted from the EHR simultaneously by two peer reviewers, according to the following criteria:Inclusion criteria: Patients 3 months of age and above who required clinical care for URTI in the Ambulatory Health Centers of the Ministry of Public Health in the District 17D03 in 2015.Exclusion criteria: 1) Patients who received clinical care in the ambulatory health centers of the Ministry of Public Health that are not a part of the D1703 district; 2) Patients who received clinical care in ambulatory health centers that are not a part of the Ministry of Public Health in the D1703 district.The International Classification of Disease (ICD) – 10 was used for selection of the diagnosis criteria for URTI, where we considered codes J00-J06, J10, J11, H65, H66 : prescribing antibiotics CG69” by the National Institute for Health and Care Excellence (NICE), considering the lack of a National clinical guideline for URTI in Ecuador. Table The antibiotic prescription rate was defined as the number of antibiotic prescriptions divided by all patients diagnosed with URTI.p value of < 0.25. These variables were: gender of prescriber, hours dedicated to clinical practice and category of health professionals. We excluded patient age, prescriber age and gender of patient due to their lack of statistical significance.The variables included in this study were qualitative dichotomous and categorical variables and quantitative continuous variables, an additional text file of description of variables shows this in more detail  one by one creating an extended model, but did not find anything of significance. In order to choose between the models to be used, we used Akaike’s Information Criteria (AIC). The formula for the final model was:i.levlehp_cate is health professional categorized by type, gender_prescriber is the gender of the prescriber, and hours_clinical is the hours dedicated to clinical practice.Where We used STATA v14 and Microsoft Excel as statistical software.We analyzed adequate dosage of antibiotics based on several clinical Guidelines defined in Table The general characteristics of our sample are described in Table We included 1393 patients that met our inclusion criteria in the analysis that were attended by 21 health professionals . Out of the 1393 patients, 523 were prescribed antibiotics, constituting an antibiotic prescription rate of 37.5%. Of these 523 patients, 51 required an antibiotic, resulting in an appropriate antibiotic prescription rate of 9.75%. The 51 patients in our sample that needed antibiotics represent 3.66% of all patients. When analyzing each individual case, 33 of these 51 patients received an antibiotic, constituting an adequate prescription rate of 64.7%. We then debriefed the data by different diagnosis according to the ICD-10 codes  with a mode of 7 days. The distribution of antibiotic classes used are shown in Fig. –15 days Out of the 523 patients that received antibiotics, 493 (94.3%) were prescribed one antibiotic and 30 (5.7%) were prescribed a combination of antibiotics. The two types of combinations prescribed were ‘Benzathine penicillin + Amoxicillin’ in 26 patients (86.7%) and ‘Benzathine penicillin + Azitromycine’ for 4 patients (13.3%). Neither one of the combinations of antibiotics used can be considered as appropriate prescription.Out of the 337 children that were prescribed antibiotics, 7 received a combination of antibiotics, resulting in 344 antibiotics prescribed in children (single or in combination). Considering weight was reported for all the children included in this study, we were able to calculate the adequate dose for treatment in this group of patients.Amoxicillin was prescribed in 272 (79.06%) times in children , where the group of identified symptoms can reflect other diagnosis, but are classified in this category that leaves an open diagnosis. In this case, patients received antibiotics at a high rate, where it is not appropriate in any case. It seems that the vague definition of this category allows for a lot of variation in treatment prescribed.In Ecuador, all Medical graduates must do a year of training in a rural area in order to be able to practice as a General Practitioner. In North America and Europe, the General Practitioner is being replaced by Family Medicine Doctors, but in Ecuador the General Practitioner is still the most common type of doctor. In our study, when classifying by health professions, Family Medicine Doctors have the lowest odds of prescribing antibiotics. This could be due to the additional years of training that are required to fulfill that degree, giving them the necessary tools to act. The clinical guideline used in this study does not take into consideration psychiatric comorbidities as a parameter for prescription. Even though psychiatric patients tend to have associated comorbidities that are not considered in this study, patients in primary care health centers usually do not have severe psychiatric disorders that could justify an antibiotic prescription due uniquely to their psychiatric condition.A study by Del Fiol et al. , that anOne of the most relevant limitations in our study is the fact that we relied on retrospective information from EHR. The EHR used in this district allows for registration of all possible variables, but health professionals in many occasions fill in only what is relevant to them about the current reason of consultation, leading to possible incomplete records. Even though during the consultation the health professional may not include the patients’ medical history, like history of prematurity, previous hospitalization and some comorbidities, they are able to find this information in the records and can refer to them in order to decide on diagnosis and treatment. This thought process is not contemplated in our analysis, turning it into a limitation for our study and a possible underestimation of appropriate prescription in some cases. Nevertheless, all the variables described in the clinical guidelines were both registered in all patients included and considered for analysis.Another limitation is the lack of a National Clinical Guideline for upper respiratory tract infections, forcing us to use the NICE guideline. NICE Guidelines consider a global context, instead of only local studies, for their recommendations, which is why we considered this guideline to be appropriate for our study. Ecuador’s Minister of Health recommends the use of international guidelines when there is no local guideline provided. NICE guidelines are always taken into consideration when developing national guidelines in Ecuador, which is why we chose this as our reference.Another limitation to our study is that the sample comes from only one health center. This is due to the lack of an EHR that can report the included variables for each patient, which led to having to extract all the data manually.Finding a difference both between health professionals in the amount of antibiotics each prescribe can be helpful when targeting individuals for educational plans about antibiotics. If these variables were analyzed in each health center, the specific health professionals that need educational interventions about the appropriate use of antibiotics can be targeted.In the health center in Ecuador included in the study there is a high rate of inappropriate prescribing of antibiotics; these findings support the need for implementation of strategies to reduce the prescription of antibiotics. Creating this baseline for the whole country instead of one health center could be the first step to realizing the scope of the problem in Ecuador. The antibiotic prescription, appropriate prescription and adequate prescription rates all underscore the need for further research and specific policy analysis and implementation in developing countries. Knowing that inadequate antibiotic prescribing is a problem in this local setting can contribute to an appropriate prescription policy.Additional file 1:“Description of Variables”, shows variables collected for the analysis of appropriateness and adequacy of antibiotic prescription. (DOCX 23 kb)Additional file 2:“Variables considered for the regression model”, shows variables chosen for bivariate logistic regression model. (DOCX 21 kb)


The potential of Fiber Reinforced Polymer (FRP) in the reinforcement of concrete structures has been shown in many studies and practical applications. However, few works have focused systematically on the development of quantitative criteria to measure surface roughness and relate this parameter to the bonding mechanical property. Moreover, some researchers have declared that, if the concrete interface is rougher, the bond performance between FRP and concrete will be increase, However, there is no answer to how rough the surface is. There are limited application standards for engineers to conduct in FRP reinforcement projects. This work evaluated several concrete specimens with three different strengths and six types of interface roughness. A single shear test was conducted to study the influence of surface roughness on the interfacial bonding performance of a carbon fiber-reinforced composite (CFRP)-concrete beam. The results show that, among the six interfaces, a concrete interface with the roughness of 0.44 has the best interfacial bonding performance. An interfacial appearance with the cement mortar almost cleaned away, and almost one fifth of the single coarse aggregate bared will get the best bond performance. Roughness parameters significantly influenced the effective bond length. The effective bond length of the six interfaces experienced an overall decreasing trend as the roughness increased. The bond–slip curves of concrete interfaces with roughness of 0.25–0.44 did not significantly change the rigidity within the brittle region. The rougher the interface was, the shorter the brittle region was. After entering a plasticity stage, the bond–slip curves for the six types of interfaces all declined with different slopes, and the max slip values were 0.04–0.35 mm when debonding failure occurred. The use of Fiber Reinforced Polymer (FRP) materials to strengthen reinforced concrete elements has gained more and more popularity in the last decades, for their relevant properties such as the higher strength to weight ratio and the excellent corrosion resistance. In this strengthening method, the performance of the FRP-to-concrete interface in providing an effective stress transfer is of crucial importance. Indeed, several failure modes in FRP-strengthened RC members are directly caused by interfacial debonding between the FRP and the concrete. Standards from many countries are proposed about how to paste FRP to concrete surface; in more details, surface preparation is the process by which the concrete substrate must be sound, clean, and suitably roughened. This process includes removing the unsound concrete and bond-inhibiting films, strength verification and opening of the pore structure.Some of the most common surface preparation methods are: steel brushing, angle grinding, sand blasting, water–sand mixed spray, high-pressure water spray, and chiseling ,2. The rAs a design level, construction guidance relevant to strengthening projects in different countries have confirmed that interface pre-processing positively influences strengthening behavior ,8. In 19Once the importance of the surface roughness is recognized, the following fundamental issue is the achievement of a uniform, as well as easy and convenient, roughness parameter for engineers to conduct in the project on sites.In this perspective, the present paper describes the results of an experimental program aimed at investigating, from a qualitative view point, the roughness effects on the interface bond performance. Several CFRP-concrete specimens were prepared with six different surface roughness levels, strengthened by CFRP sheets and then tested. Prior to CFRP being pasted, surface roughness was measured by means of Chinese sand-filling method, which proved to be easy and valid. A single shear test was carried out on the CFRP-concrete specimens, and several spaced strain gauges were placed along the CFRP sheet to measure strains.Results show a significant effect about concrete surface roughness on the interfacial bond performance between CFRP and concrete. The failure mode, the effective bond length and the interface law are also affected by the type of the surface roughness.The concrete used in the tests consisted of commercial portland ordinary cement 42.5(P.O 42.5 cement), produced by a plant operated by the Jilin Yatai Group in China. The fly ash was Level I superfine fly ash produced by Lianyungang Power Plant in China. The aggregate was medium sand with a fineness modulus of 2.5 and continuous graded artificial gravel with particle sizes ranging 5–20 mm. The additive was a superplasticizer produced by Hongxiang Building Additive Plant from Shenyang in China, with a water-reducing rate (mass fraction) of 18%. The water was running water appropriate for domestic use. The CFRP was a HICOMA-HITEX series carbon fiber sheet produced by Nanjing Hitech Composites Co., Ltd from Nanjing in China. The adhesive colloid was an epoxy resin AB adhesive, with the bonding resin compounded at a mass ratio of 2:1. The concrete specimen was 80 mm × 80 mm × 200 mm in size. To produce the roughness, a layer of retarder was first gently coated on the bottom surface of the concrete specimen mold to reduce the negative influence of cracks formed as a result of concrete damage during the tests. After the test specimen was cast for 24 h and demolded, a steel brush method was used to form six types of interfaces with different roughness and specific discrimination. This helped distinguish the rough surfaces, but also greatly reduced the discretization influence of the concrete’s surface damage on the test results, as shown in Existing quantitative methods cannot accurately propose specifications from different counties. However, some methods can indirectly determine the interfacial roughness. Specification MC2010  providesδ represents the maximum value of the bump depth of the concrete’s bonding surface. Roughness mula (2) :(2)fi=hδThe bonding area for the test was maxδ was used δ in Formula (2), as shown in There were four trace lines along the bonding length direction, with each trace line having a length of 100 mm. Five equal parts were divided along the length of trace line, and a digital readout micrometer was used to acquire the bump depth value As i–fj  mark the procedure from interface i to interface j. For example, f0–f2 indicates that, before processing, it was interface f0, and, after processing, it was interface f2. The variable f0–f0 indicates the process of removing the floating mortar with abrasive paper after demolding. j, the greater is the value of fi. Interfaces f0–f5 are roughened by 2.1, 2.4, 4.5, 5.2, 7.5, and 10 times, respectively, with f5 being roughened most significantly.In In tests, an electro-hydraulic servo material testing machine was used for loading, with a loading rate of 1 kN/min. In the loading procedure, the load and strain of CFRP sheet near the loading end were synchronously increased. When the load reached 20% of the ultimate bond load, the CFRP sheet began to make slight tearing sounds. When the load continued to increase to 40% of the ultimate bond load, there were discontinuous “snap” sounds as abrupt changes occurred to the CFRP surface strain. This indicated that the CFRP sheet and concrete directly showed the debonding phenomenon. When the load reached 70–80% of ultimate bond load, the debonding sounds were heard more frequently, and this process lasted longer. In the process, some specimens varied in load, however, the variation range was not large. When the load increased to the ultimate bond load, a “snap” was heard and the CFRP debonded from concrete specimens. There was no obvious sign before failure, and the failure was characterized as brittle. After the specimens with six modes of interfaces suffered a single shear failure, they exhibited four failure modes. There are three typical interfaces. Interface a, comprised of the epoxide resin, CFRP sheet and concrete, presents excellent bond performance. Especially when the epoxide resin adhesive penetrates a certain depth through the micro pore of concrete, a new composite is formed combining the epoxide resin and the concrete in this area. Given that the combined epoxide resin and the concrete are jointed together around the coarse aggregate, it is difficult to be broken deep inside the coarse aggregate area, so the slip line is on the surface of the mortar a.As shown in As for Interface c, the roughness of this interface continues to grow, and the majority of the coarse aggregate is fully revealed. Under such circumstance, the roughness degree of the interface shall be even more serious. The height difference of the bordering concave and convex points are seriously irregular. Hence, the bonding resin fails to bond the CFRP and the concrete at the interface, creating the gaps among them. Additionally, the epoxide resin between the convex aggregates is easy to form the cantilever structure, forming the stress concentration, which will greatly decrease the interface bond property. The bond property of Interface c is extremely low, and, as the concrete strength grows, the failure load of the bond is less influential. However, as the aggregate size increases, for the same rough interface, the bond stress is greatly elevated, which is consistent with the mentioned mechanism.Single shear test was done for the specimens of f0–f5. Key parameters are shown in From the key parameters values In The bond–slip relationship is the constitutive property determining the bonding performance at the CFRP-concrete interfaces. CFRP strain distribution data were collected based on single shear tests. The bond–slip relationship for the test was obtained using residual calculations.iτ at the position of the ith strain gauge is:The local bonding stress x, then the slip value iS at the position of the ith strain gauge is:ε0 denotes the strain value for the first strain gauge near the loading end within the bonding area. Because two strain gauges were placed in parallel at the first position, the average value for those two strain gauges was assessed. The variable jε  denotes the strain value for the jth strain gauge along the length direction of CFRP. The variables fE and ft denote the elasticity modulus and thickness of CFRP, respectively.Assuming the interval between strain gauges is ∆The effective bond length is an important parameter when studying the bonding performance of FRP-concrete interfaces. As the bonding length increased, the interface bearing capacity increased, correspondingly. Once it exceeded a certain fixed length d length . Two meted by Le ,16,17, med by Le , measuriAs shown in τm of 4.89 MPa and τs of 0.035 mm. Six kinds of interface curves show the tendency increasing first and decreasing after; the whole curve can be divided into four intervals named: O–A, A–B, B–C, and C–D. In Interval O–A, the interface is in the situation of linear elastic tension. Reaching Point A, the epoxide resin comes into the plastic range, and stress increases slowly in Interval A–B, while slip grows. When Point B is reached, interface bond stress strengthens. Within the B–C range, epoxide resin continues to deform, and the deformation rate is bigger. At Point C, the interface shows the stress slowly increasing, and the epoxide resin deformation is still increasing. At Point D, the interfacial stress reaches zero, epoxide resin is thoroughly fractured, and the CFRP is debonded from the concrete surface. Three interfaces, f0–f3, are basically the same in the stiffness of elasticity area. Such property of these three interfaces can be overall deemed as the same. Interfaces f4–f5 are significantly decreased in stiffness, and the elasticity section is narrowed. Moving into the plastic stage, the bond stress–slip curves of six interfaces are overall declined in different slopes. Ultimately, these interfaces are torn in the slip value scope of 0.04–0.35 mm. It is acquired from the constitutive relation curve that the effective bond length is overall increased in the preliminary stage and decreased in the follow-up stage with the increase of roughness, which demonstrates the conclusion mentioned above.The bonding strength and the ultimate displacement of the interface are not always increased with the increase of interface roughness. However, this condition can be realized within certain limits. In An experimental investigation into the effects of concrete roughness on the bond shear strength of FRP-concrete interface was presented. Several concrete prisms, before strengthening, were prepared according to surface treatments; roughness level was then measured by means of sand filling method. Finally, specimens were subjected to single shear tests.Fifty-four single shear tests were carried out between CFRP and concrete interfaces, and different stress–slip relations of interface under six types of roughness were acquired. Additionally, the influence of roughness carried by the concrete interface on the bonding shear property of FRP-concrete interface was analyzed. The following conclusions are drawn. Different surface preparations can provide different values of bond shear strength; in particular, the roughness value 0.44 measured by Chinese method is the most effective. An interfacial appearance with the cement mortar almost cleaned away, and almost one fifth of the single coarse aggregate bared will get the best bond performance.Concrete surface damage can be greatly decreased when a layer of retarder is first gently coated on the bottom surface of the concrete specimen mold before the roughness processing. In fact, there are still many methods to measure contact, although the Chinese sand-filling method is an easy and efficient way to quantify the uneven surface.It is not the case that the rougher the FRP-concrete interface, the greater its bonding strength and ultimate displacement. The laws governing variability only apply within a certain range.The effective bond length of CFRP-concrete beam interface was significantly enhanced based on the roughness parameter. As roughness increased, the effective bond lengths of six interfaces all experienced an overall decreasing trend. τ–s curves for interfaces with the roughness of 0.25–0.44 did not significantly differ in rigidity within the brittle region. However, the rougher an interface was, the shorter its brittle region was. After entering the brittle region, the bond–slip curves for six types of interfaces all declined with different slopes. The slip values were 0.04–0.35 mm when debonding failure occurred.Among the six interfaces, the interface with the roughness of 0.44 had the best bonding performance. The The present work confirmed again the important effects of roughness on the interface between CFRP and concrete. With only 162 test results, the sample is too small to derive a formula for engineers to use as a standard. Future research should enlarge the sample and propose a formula to calculate the bond strength, effective bond length, etc. The above values can be predicted based on the existing formula. Furthermore, the CFRP-concrete specimens should go through harsh environment such as high temperature, freeze–thaw cycles, seawater and alkaline solution, etc., as many elements in this research remain unchanged.


Background: Overuse of antibiotics may not only increase the burden of antimicrobial resistance, but also accelerate the growth of healthcare expenditures. China has issued a series of policies to improve antibiotic use and reduce the cost of medicine in healthcare institutions. This study aimed to evaluate the trends of antibiotic expenditure in public healthcare institutions in Shandong from 2012 to 2016 and to assess antibiotic expenditure by drug class and the level of healthcare institutions.Methods: We collected data from the centralized bidding procurement (CBP) system in Shandong province between 2012 and 2016. Governmental health facilities including secondary and tertiary hospitals, and urban and rural primary healthcare centers (PHCs) procured antibiotics via this system. Antibiotics were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. Antibiotic expenditure was assessed using total annual expenditure (US dollars) and expenditure per person per year (US dollars).Results: The overall antibiotic expenditure was $717 million in 2016, a 56% increase compared to 2012. Parenteral antibiotics accounted for 84% of the total antibiotic expenditure in 2016. Most of the antibiotics were procured by secondary and tertiary hospitals . The expenditures continuously increased in secondary hospitals, tertiary hospitals, and urban PHCs from 2012 to 2016, while antibiotic procurement decreased in urban PHCs since 2015. The third-generation cephalosporins (J01DD) were among the top five ATC classes of antibiotics in all healthcare institutions. Fluoroquinolones (J01MA) were commonly procured by tertiary hospitals, rural and urban PHCs. The expenditure on carbapenems (J01DH) raised sharply in tertiary hospitals.Conclusions: The overall antibiotic expenditure kept increasing in the public healthcare institutions in Shandong. The trends of increasing expenditure began to decline in 2016, which may be associated with antibiotic stewardship initiatives. The expenditure for expensive and critical important classes of antibiotics increased, therefore it is of importance to develop policies on improving the rational use of antibiotics. Globally, attention is being drawn to antimicrobial resistance (AMR). AMR has posed a serious threat not only to human health but also to economic and social development. In the absence of no effective strategy to control AMR, it is estimated that by 2050, there will be approximately 10 million deaths each year and a cumulative $100 trillion economic burden, caused by resistant infections O'Neill, . AMR is In China, national health expenditure sharply increased from $423 billion  in 2012 to $698 billion in 2016  was established at provincial-level across China, with the purpose of supporting the essential medicine policy, regulating medicine procurement behaviors by health providers and reducing medicine costs  hospitals and 28 specialized hospitals], 368 secondary hospitals , 2,152 PHCs , and 87 other healthcare institutions , that obtained antibiotics via the CBP system in Shandong . From 2012 to 2016, the CAGR was 10.9% for overall antibiotic expenditure, 11.3% for parenteral antibiotic expenditure, and 9.0% for oral antibiotic expenditure. The major portion of expenditure per person per year  was for parenteral antibiotics. With the exception of 2013, antibiotic procurements steadily increased between 2012 and 2016. Expenditure on parenteral formulations kept increasing from 2013 to 2016. Expenditure on oral antibiotics increased from 2012 to 2014, after which it did not change much in the next 2 years , followed by secondary hospitals . Compared to 2012, antibiotic expenditure in secondary and tertiary hospitals increased by 44 and 72% in 2016, respectively. In rural PHCs, antibiotic expenditure rose by 47% from 2012 to 2014, then declined by 10% from 2014 to 2016. Even after a 2.4-fold increase, the expenditure in urban PHCs only accounted for 4% ($22 million/$717 million) of the overall antibiotic expenditure in 2016 . From 2013 to 2016, the expenditure increased yearly in both general and TCM hospitals. With a small proportion of the overall antibiotic expenditure , the expenditure in specialized hospitals reduced by a third in 2016 in comparison to 2015  were always among the top five classes of antibiotics by expenditure. Among the third-generation cephalosporins (J01DD), the one with the greatest expenditure was cefoperazone and beta-lactamase inhibitor (J01DD61) in tertiary hospitals, ceftizoxime (J01DD07) in secondary hospitals and ceftriaxone (J01DD04) in PHCs. Whereas, the top antibiotic by expenditure among the second-generation cephalosporins was cefotiam (J01DC07) in secondary and tertiary hospitals and cefuroxime J01DC02) in PHCs. Expenditure on fluoroquinolones (J01MA) were among the top five in tertiary hospitals and PHCs. Since 2014, carbapenems (J01DH) which showed the fastest-growing expenditure, had replaced the first-generation cephalosporins (J01DB) to become one of the top five ATC antibiotic classes in tertiary hospitals. In secondary hospitals, combinations of penicillin (J01CR) an antibiotic class with the highest expenditure in 2016, almost tripled in expenditure over the 5-year period. Among this class, piperacillin and beta-lactamase inhibitor (J01CR05) led the expenditures in secondary and tertiary hospitals, while amoxicillin and beta-lactamase inhibitor (J01CR02) had the highest expenditure in PHCs. After 2014, the expenditure for almost all antibiotics declined in rural PHCs. On the contrary, all classes of antibiotics in urban PHCs kept increasing in expenditure during the 2012–2016 period, among which, the second-generation cephalosporins (J01DC) and combinations of penicillin (J01CR) were almost tripled in 2016 in comparison to 2012 , followed by beta-lactam antibacterials (J01C) and quinolones (J01M). The third-generation cephalosporins (J01DD) class was among the top five ATC antibiotic classes in all public healthcare institutions from 2012 to 2016. Fluoroquinolones (J01MA) have been in the top five ATC antibiotic classes in tertiary hospitals and PHCs. The rank of carbapenems (J01DH) class was on the rise in tertiary hospitals.Antibiotic stewardship initiatives have helped to decrease both antibiotic consumption and expenditure in the United States, based on the national data reported during 2010 and 2015 (Van Boeckel et al., In accordance with global evidence, about 80% of all antibiotics were consumed in PHCs (Center for Disease Dynamics Economics Policy, Regarding the total medicine expenditure, inconsistent with the findings in the United States where PHCs spent the most for antibiotics, secondary and tertiary hospitals paid more for antibiotics than PHCs in Shandong (Suda et al., Cephalosporins and quinolones were among the top used ATC classes of antibiotics in many countries including China, while at the same time increased rates of bacteria resistance to these antibiotics were reported (Liew et al., This study reported the trends of antibiotic expenditure in a province, covering about one-tenth of the total national population, based on the CBP system. It filled a research gap where previous studies only focused on antibiotic cost data collected from prescriptions. However, several limitations should be acknowledged. Firstly, we cannot calculate expenditure per user as no patient-level data were recorded in the CBP system. Further studies in this field, using data based on a patient-level, such as data from the health insurance system, would be greatly beneficial. Secondly, we did not consider antibiotic expenditure that may have occurred in private pharmacies. Thus, the total antibiotic expenditure at provincial-level may be underestimated. Thirdly, the trends of antibiotic expenditure in public healthcare institutions were evaluated based on years. We suggest that future studies evaluate monthly trends to shed additional light on diagnostic demands within years. Fourth, the increasing number of secondary and tertiary hospitals may impact on the changes in expenditure. Finally, the policies of zero mark-up and medicine cost proportion controlling were issued in recent years. Future studies which evaluate the long-term effect of these policies on antibiotic expenditure are therefore recommended.The overall antibiotic expenditure increased over time in Shandong, China. However, the increase rate of expenditure began to decline in 2016, possibly related to the implementation of antibiotic stewardship initiatives. The expenditure for expensive and critically important classes of antibiotics continued to increase in public healthcare institutions, especially in tertiary hospitals. In addition to controlling the overall expenditure, policies should be developed to improve the rational use of antibiotics in public healthcare institutions.JY and QS designed the study. CW helped to collect and interpret the data. JY analyzed the data and wrote the first draft of the manuscript. QS and XW provided critical comments and revised the manuscript. All authors reviewed 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.


IgG4-related disease (IgG4-RD) is a pathological condition that is characterized by an infiltrate composed of IgG4-positive plasma cells and recently recognized as an immune-mediated condition. It causes tissue throughout the body to become stiff and thickened due to autoimmune reactions that cause fibrosis and scarring. Disease-related changes commonly occur in the salivary glands, bile duct, pancreas, and lungs, but are seldom seen in the small bowel. A diagnosis of IgG4-RD is suspected if a high level of IgG4 is found on a blood test. The ideal diagnostic method is pathological examination, but because the clinical manifestations of IgG4-RD are very diverse and nonspecific, the disease may often go undiagnosed until an unrelated biopsy or resection specimen is obtained. The most common treatment for IgG4-RD is steroid use. However, tapering or stopping steroid administration is seen to result in recurrence in approximately 50% of cases. A complete cure is therefore considered extremely difficult.A 69-year-old man with gastrointestinal obstruction underwent small bowel resection for two lesions. On histopathological examination, the specimen showed features of IgG4-RD. We performed several tests to detect other characteristics of IgG4-RD, but were unable to find any. The patient is being followed up regularly for a year and is being observed for any symptoms of recurrence.We present a case of IgG4-RD wherein the ileum wall was significantly sclerosed, leading to gastrointestinal tract obstruction; therefore, we resected two sections of the ileum. We believe that resection of IgG4-RD lesions can help avoid long-term steroid use in patients, because the surgery completely eliminates the pathological origins of the condition. IgG4-related disease (IgG4-RD) is a pathological condition that is characterized by an infiltrate composed of IgG4-positive plasma cells and recently recognized as an immune-mediated condition that can affect almost any organ . UsuallyWe present a case of IgG4-RD wherein the ileum wall was significantly sclerosed, leading to gastrointestinal tract obstruction, due to which we resected two sections of the ileum.The patient was a 69-year-old man who was a known case of type 2 diabetes mellitus (T2DM). He initially presented with sigmoid colon cancer that progressed to obstructed necrotizing enteritis. He had undergone subtotal colectomy (from the ascending colon to the sigmoid colon) in our department. We had created a stoma at the ascending colon and had closed it 1 year later. During this phase, the patient’s recovery was hampered by nontuberculous mycobacterial infection, for which he underwent treatment with isoniazid, rifampicin, and ethambutol at another hospital; he recovered completely from the infection.He subsequently presented with repeated episodes of gastrointestinal tract obstruction, even after two surgeries. He was then admitted in our department to receive conservative treatment.Two years after the first surgery, his central venous port was infected, for which he underwent treatment with antibiotics  at another hospital. Subsequently, he presented with obstruction of the gastrointestinal tract again. We therefore attempted to try and resolve this problem.Blood tests showed renal dysfunction (serum creatinine level 1.18 mg/dL), anemia (hemoglobin 9.0 g/dL), and a slightly elevated CA19-9 level (46 U/mL). Radiological enteroclysis revealed two stenosed sections of the small bowel Fig. .Fig. 1WeWe continued conservative treatment (using an ileus tube), but his condition did not improve. We then decided to operate to resolve this condition.In the surgery, we recognized two sections of small bowel 30 cm and 53 cm from the terminal ileum seemed to be fibrosed, with extraordinarily thick walls. We resected these sections with a few centimeters margin and anastomosed the remaining bowel using functional end-to-end anastomosis, finally obtaining two specimens Figs. . We alsoAfter the surgery, pathological examination yielded a large number of plasma cells and IgG4-positive cells in the specimen; the ratio of IgG4-positive cells to non-IgG-positive cells was 87% 350/404). We then realized that the specimen showed features of IgG4-RD  to detect signs of IgG4-RD in the pancreas and bile duct, but did not find any. We therefore concluded that there were no findings that suggested IgG4-RD, except for in the small bowel.The patient was discharged to his home on the 39th postoperative day. He has been following up regularly for a year with us and has not shown any symptom of recurrence of IgG4-RD.The primary pathological features of IgG4-RD are swelling around the internal organs, thickened lesions due to infiltration by lymphocytes and IgG4-positive plasma cells, and fibrosis of tissue throughout the body [IgG4-RD rarely affects the small bowel. Several studies describe the common primary locations of the lesions as the salivary glands, bile duct, pancreas, and lung; however, none of these studies describe any cases with lesions in the small bowel .Characteristic diffuse or segmental swollen, massive, nodule, or hypertrophic lesions in single or multiple organsElevated serum IgG4 levels (above 135 mg/dL)Overwhelming infiltration of lymphocytes and plasma cells and sclerosing and infiltration of IgG4-positive plasma cells; the ratio of IgG4/IgG is over 40%, with over 10 IgG4-positive plasma cells seen per HPF.The diagnostic criteria of IgG4-RD are quite clearly defined . There aThe etiology of IgG4-RD seems to be autoimmune, based on the presence of high serum IgG4 levels and infiltration of IgG4-positive plasma cells. The disease is associated with both Th2 and regulatory T cell (Treg) immune responses. Th2 responses are also linked to the development of allergies and bronchial asthma, both of which are conditions that are more prevalent in patients with IgG4-RD .The most commonly used and suitable medication used to treat IgG4-RD is steroids , 9. KamiThis is a very unusual case of IgG4-RD wherein the patient presentation was different, and the signs of the condition were not present in any of the usual locations. Additionally, symptoms of recurrence have not developed even a year after surgery. In this case, the serum IgG4 level was found to be within normal limits. However, we believe that this was only because we checked the IgG4 levels after surgery. This possibly occurred because we resected the lesions that were likely producing the IgG4-positive plasma cells. This suggests that resection of the primary lesion in cases of IgG4-RD decreases the IgG4 level. This hypothesis is also supported by a report by Fujita et al., of a case of IgG4-RD treated using steroids. In this case, prednisolone was used, but resection was not performed. The patient’s symptoms improved, but the number of IgG4-positive cells did not change after remission .In our case, we have determined that if symptoms of recurrence are noted, the best course to follow would be steroid treatment with careful monitoring, keeping in mind the patient’s T2DM and latent nontuberculous mycobacterial infection, because the utility of re-operation is yet unknown.This patient underwent subtotal colectomy for obstructed necrotizing enteritis by sigmoid colon cancer, but it is not related to IgG4-RD. This patient developed gastrointestinal obstruction only because of sclerosis and thickening of the ileum by etiology of IgG4-RD. Resecting the lesion seemed to solve the problem, but recurrence is possible in the future. Therefore, his condition needs to be strictly monitored during follow-ups.We suggest that operation is one of the feasible tactics of treatment of IgG4-RD in a particular situation, such as in a case we are reluctant to use steroid . Xiao et al. reported that among 39 cases of IgG4-related cholangitis, 4 underwent surgery . Among tExperience of additional cases is needed to determine the symptoms and characteristics of IgG4-RD with sclerosing changes in the small bowel, as very few cases have been reported so far. Resection of the lesions of IgG4-RD could be considered to avoid long-term steroid use in patients.


The applicability of the LWGP concrete flume with a 0.5 mm crack width was also evaluated based on the bending strength results. The LWGP5, which has a smaller particle size among LWGPs, filled the smaller pores, thereby reducing the porosity and contributing to the compressive strength gain. Higher volume and weight change ratios for all specimens immersed in MgSO4 solution were found than those immersed in Na2SO4 solution under identical conditions. Flexural loads of all the LWGP concrete flumes with 0.05 mm crack widths were greater than 48.5 kN, as required by the KS code; however, these flexural loads were lower than those of ordinary Portland cement. The applicability was also validated via a flexural test complying with KS.To prevent chemical erosion of concrete and improve chemical resistance, reinforced concrete flumes were manufactured, conforming to the Korean Industrial Standards (KS). Two different sizes of liquid crystal display (LCD) waste glass powder (LWGP) particles were used  with two substitution types with cement in concrete . Changes in compressive strength, pore structure, weight, volume, and strength of the concrete flumes after immersion in two sulfate solutions (i.e., Na In recent years, technological development of concrete materials has enabled the design of enlarged, high-rise, and multi-functional structures and plays a pivotal role in protecting human lives and properties from various disasters. Concrete structures have been designed and constructed to fulfill the same requirements as those of multi-functional structures. However, the durability of concrete structures in a marine condition and in wastewater treatment facilities in severe environments easily deteriorates from chemical erosion and often causes structural problems ,2,3. In Several studies have aimed at incorporating various binders together with cement to prevent chemical erosion of concrete and improve chemical attack resistance. In particular, the incorporation of pozzolanic materials produces a C–S–H phase within the cement matrix, which further densifies the cement matrix. It reduces permeability and improves the durability of concrete by suppressing the pore continuity.Meanwhile, Korea’s investment in the LCD industry is as high as 27 billion USD per year, with a production of over 480,000 panels per month  . The com2 as the main component, which is similar to silica fume (SF), fly ash (FA), and blast furnace slag (BS); these components improve the pozzolanic reactivity. The replacement dosage of cement and the high fineness of the LCD waste glass powder (LWGP) are considered appropriate for durability improvement. Although the substitution of cement with LWGP improves durability as well as mechanical and microstructural properties, the deterministic characteristics of LCD glass powder particles include particle size/surface area and the substitution amount [LCD contains SiOn amount ,16,17,182SO4) and magnesium sulfate (MgSO4) were used as solution for simulation of the sulfate-bearing environments. Changes in compressive strength, volume, and weight caused by chemical erosion were measured and compared. Based on these results, concrete flumes with an improved chemical resistance were fabricated to conform to the Korean Industrial Standards (KS F 4010) [Herein, concrete containing 10% and 20% of LWGP was mixed with ordinary Portland cement (OPC). Sodium sulfate (Na F 4010) . The app2 (69%), Al2O3 (19%), and CaO (10%), was used as the admixture similar to the fly ash used as the concrete binder. In order to minimize the multi-degradation originating from carbonate aggregates  on the specimens [OPC and two different types of LWGP were used as the primary binder in this experimental study. LWGP were prepared by grinding the LCD glass . Table 1pecimens ,21, locapecimens . They weConcrete slump was checked according to KS F 2402  Figure . The molThe concrete specimens shown in 3 volume as a function of the replacement ratios. The water was totally dried out under a 105 °C after the specimens were submerged in an alcoholic solution for a week to halt hydration.Mercury intrusion porosimetry (MIP) using Micromeritics  was implemented to measure the concrete porosity ratio and distribution of the concrete specimens with a 1.0 cm2SO4 and MgSO4 to measure the reduction ratios of the volume, weight, and the changes of the compressive strength at 84 and 182 days. The LWGP concrete specimens cured in water for 28 days were immersed for 182 days. The used sodium sulfate and magnesium sulfate solutions were prepared according to the American Society for Testing and Materials (ASTM) C 1012 standards [The cured specimens at 28 days were immersed in a solution of 5% Natandards . The sol2SO4 and MgSO4 for 182 days to evaluate the resistance to sulfate attack by measuring the weight and volume according to ASTM C 1012 [2SO4 was used. This phenomenon may be caused by the matrix porosity. The sulfate ions that intruded the concrete initially reacted with calcium hydroxide to form ettringite and gypsum, which continuously accumulated within the pores. In turn, the amounts of hydration products caused the dilatation of the concrete and generating an internal stress around the matrix, followed by cracking. The calcium hydroxide depletion induced the decalcification of the hydration products, thereby resulting in a dissolution of the C–S–H gel and a subsequent increase of the matrix porosity [2 because of the pozzolanic reaction obtained from the replacement of the LWGP powder in the concrete. Regardless of the mixture of the LWGP powders, the reduction ratios of the weight and the volume for concretes were smaller when they were immersed in the MgSO4 solution than in the Na2SO4 solution for 182 days. This result can be attributed to the reaction between the Mg2+ ions and the hydrates formed in the matrix. According to Lee [− and Mg2+ ions in the pore water reacted to form magnesium hydroxide (Mg(OH)2) at early exposure periods, as well as the formation of gypsum and ettringite, filling the voids within the matrix . Therefore, the penetration resistance of ions into the concrete substituted by the LWGP increased with exposure duration to MgSO4 solution, which is validated by the time-dependent behavior of concrete deterioration, implying change of the pore structure. The deterioration by sulfates also decreased at the early ages. However, in the long-term periods, the deterioration of concrete exposed to the MgSO4 solution would be accelerated because of an increase of the stress inside the concrete arising from the accumulation of hydrates [2+ ions in the pore solution [4 solution showed a higher value at 182 days of exposure compared with that in the Na2SO4 solution at an identical condition.The LWGP-mixed concrete was immersed in a solution of 10% NaM C 1012 . As showporosity ,29,30. Cporosity , the ratg to Lee , the OH−hydrates ,34. Furtsolution . ConsequThe compressive strengths of the concrete mixed with the LCD powder are shown in Note that the high strengths of concrete at an early age (7 days) were produced when the mean particle diameter of 5 μm with 10% and 20% replacement ratios was used. Similar cases were observed with the mortar test. However, the compressive strengths decreased when the substituting ratio increased to 20%. However, the LWGP12 with large average diameters showed a strength smaller than that of OPC, regardless of the substituting ratios. The LCD cement showed compressive strengths slightly smaller for the diameter of 12 μm; however, the compressive strengths were higher for cement with a 5 μm diameter . This phThe LWGP5 with small average diameters exhibited a higher strength from 7 days, which resulted in a noticeable strength increase at 28 days, showing the influence of diameters on the strength. When made of finer powders and smaller diameters, the LWGP-mixed concrete could result in an active pozzolanic reaction, leading to an increase in both strength and durability.4 solution, leading to a limited strength activation caused by the M–S–H gel formation. The strength reduction trends were similar to those observed with the weight and the volume. The chemical resistance of the concrete exposed to the sea waters and underground waters can be provided by adjusting the replacement ratios.The compressive strengths (KS F 2405 ) for the3 in the volume) were obtained from concrete for the compressive strength. The pore size was divided into four groups: 1) Voids: >10 μm; large capillaries: 0.05–10 μm; medium capillaries: 0.01–0.05 μm; and small capillaries: <0.01 μm [The importance of the pore distribution in the matrix must be expressed. Materials with the same pore size can perform completely differently because of the pore size and dispersion ,37. The <0.01 μm .2 decreased, whereas the gel pores increased by forming the C–S–H gel as the time elapsed. This result led to a pore reduction and a higher strength development [The pore decrease of the concrete containing the LWGP powder is elucidated in elopment . HoweverThe structural behavior of the LWGP concrete flumes was investigated by comparing the flexural loads by OPC and LWGP. Testing was done for 28 days based on various diameters and substituting ratios. The cracks were monitored by strain gauges attached to the lower part of the socket. The flexural loads were identified when cracks with a width of 0.05 mm were found at the end of the section . Table 5The flexural load of the LWGP concrete flumes greater than that of OPC by 3.5% to 6.5% was observed, demonstrating a trend similar to that of the compressive strength of the LWGP5, which was greater than the compressive strength of OPC by 15% to 17%. Load was applied with 1 mm/min according to KS F 4010 to measure the flexural capacities. The flexural capacity of OPC was 65.66 kN, whereas those of the LWGP concrete flumes were 69.92 kN and 67.99 kN for LWGP5-10 and LWGP5-20, respectively. However, the flexural loads of the LWGP concrete flumes decreased to 62.21 kN and 58.56 kN for LWGP12-10 and LWGP12-20, respectively. The KS code defines the flexural load of the reinforced concrete flume when the crack width of 0.05 mm was reached to protect the reinforced concrete flume contacted by polluted waters from erosions of wires and structural damages of the concrete. The ductility of the LWGP concrete flume is also shown in (1)The LWGP yielded large compressive strengths of 23.66 to 28.92 MPa at 28 days. LWGP5 especially resulted in a strength increase greater than those of OPC. By contrast, the strengths of the LWGP12 demonstrated a compressive strength smaller than those of OPC, regardless of the substituted ratios of the LWGP.(2)2 decreased, whereas the gel pores increased by forming the C–S–H gel. This led to pore reduction and a higher strength development.A pore decrease of 25.4% compared with OPC was observed at 28 days when the LWGP5-20 powder was used with concrete. The capillary pores (below 10 μm) related with the ion penetrations were found in the order of OPC (17.79%), LWGP12-10 (16.32%), LWGP12-20 (16.24%), LWGP5-10 (13.79%), and LWGP5-20 (13.27%). The capillary pores occupied by Ca(OH)(3)2SO4 solution for 182 days, whereas those were 6.04% and 4.32% when immersed in the MgSO4 solution. This trend was found to be similar to that of the compressive concrete strength immersed in the sulfate solution.The reduction ratios of the weight and the volume for concretes with the mixture of LWGP powders were smaller than with OPC. The reduction ratios of the weight and the volume of the LWGP5-10 concrete were the lowest as 4.41% and 2.70% when they were immersed in the Na(4)The maximum flexural load of the LWGP concrete flume was the highest at 69.92 kN in the LWGP5-10 contained concrete, while the LWGP10 contained concrete flumes smaller than the OPC concrete flumes. The flexural load of the concrete was generally increased or decreased in proportion to the compressive strength; hence, the tendency similarity was confirmed. Moreover, the opposite case was that the decrease of the flexural load of the concrete flume with LWGP10 also had the same tendency.(5)The flexural loads of all the LWGP concrete flumes with a crack width of 0.05 mm were greater than the 48.5 kN required by the KS code, but smaller than the flexural loads of OPC. The initial cracks were effectively controlled for LWGP5-10 and LWGP12-10 before the critical load.(6)The durability of the conventional reinforced concrete flumes against the sulfate attack resistance was improved by substituting cement by LWGP, thereby extending the use of the new reinforced concrete flumes to the replacement of conventional reinforced concrete flumes. The applicability was also validated by the flexural test complying with KS.This study used the LWGP, an industrial waste material, as an admixture to increase the sulfate attack resistance of concrete flumes. The compressive strength, pore structure, weight, volume, and strength change in two kinds of sulfate solution were measured for the durability evaluation. The LWGP was also mixed with the reinforced concrete flumes, and the performance was evaluated by the bending strength test. The results are as follows.


Background: Pancreatic ductal adenocarcinoma (PDAC) has limited standard of care therapeutic options. While initially received with enthusiasm, results from targeted therapy with small molecule tyrosine kinases inhibitors (TKIs) have been mixed, in part due to poor patient selection and compensatory changes in signaling networks upon blockade of one or more kinase of tumors. Here, we demonstrate that in PDACs otherwise resistant to rational kinase inhibition, Met-directed immuno-positron emission tomography (immunoPET) can identify targets for cell-signaling independent targeted radioligand therapy (RLT). In this study, we use Met-directed immunoPET and RLT in models of human pancreatic cancer that are resistant to Met- and MEK-selective TKIs, despite over-expression of Met and KRAS-pathway activation.Methods: We assessed cell membrane Met levels in human patient samples and pancreatic ductal adenocarcinoma (PDAC) cell lines  using immunofluorescence, flow cytometry and cell-surface biotinylation assays. To determine whether Met expression levels correlate with sensitivity to Met inhibition by tyrosine kinase inhibitors (TKIs), we performed cell viability studies. A Met-directed imaging agent was engineered by labeling Met-specific onartuzumab with zirconium-89 (Zr-89) and its in vivo performance was evaluated in subcutaneous and orthotopic PDAC xenograft models. To assess whether the immunoPET agent would predict for targeted RLT response, onartuzumab was then labeled with lutetium (Lu-177) as the therapeutic radionuclide to generate our [177Lu]Lu-DTPA-onartuzumab RLT agent. [177Lu]Lu-DTPA-onartuzumab was administered at 9.25MBq (250μCi)/20μg in three fractions separated by three days in mice subcutaneously engrafted with BxPC3 (high cell-membrane Met) or MIA PaCa-2 (low cell-membrane Met). Primary endpoints were tumor response and overall survival.Results: Flow cytometry and cell-surface biotinylation studies showed that cell-membrane Met was significantly more abundant in BxPC3, Capan2, and Suit2 when compared with MIA PaCa-2 pancreatic tumor cells. Crizotinib and cabozantinib, TKIs with known activity against Met and other kinases, decreased PDAC cell line viability in vitro. The TKI with the lowest IC50 for Met, capmatinib, had no activity in PDAC lines. No additive effect was detected on cell viability when Met-inhibition was combined with MEK1/2 inhibition. We observed selective tumor uptake of [89Zr]Zr-DFO-onartuzumab in mice subcutaneously and orthotopically engrafted with PDAC lines containing high cell-surface levels of Met , but not in mice engrafted with low cell-surface levels of Met (MIA PaCa-2). Significant tumor growth delay and overall survival benefit were observed in both BxPC3 and MIA PaCa-2 engrafted animals treated with RLT when compared to controls, however, the benefit was more pronounced and more durable in the BxPC3 engrafted animals treated with [177Lu]Lu-DTPA-onartuzumab RLT.Conclusions: Our findings demonstrate that while over-expression of Met is not predictive of Met-directed TKI response, immunoPET can detect Met over-expression in vivo and predicts for therapeutic response to Met-selective RLT. This phenomenon can be exploited for other Met-overexpressing tumor types specifically, and to any differentially overexpressed surface molecule more broadly. The standard of care for patients diagnosed with locally advanced pancreatic cancer is systemic chemotherapy. Still, only a minority <25%) of patients achieve any radiographic response, and the 5-year survival for all patients is <5% 5% of patActivating mutations in the KRAS onocogene are present in >90% of pancreatic adenocarcinoma in vivo. For example, immunohistochemistry (IHC) may overestimate target accessibility because some stained targets are intracellular and unavailable to engage antibody-based therapies in vivo, resulting in a suboptimal selection of patients since antibodies usually target membrane domains of the antigen/receptors. Although TKIs can access intracellular targets, understanding whether their receptors are overexpressed, accessible, and contributing to oncogenesis in vivo may inform not only targeted therapy, but also treatment with biologic agents. A theranostic approach with molecular immunoPET can help begin answering some of these questions Identifying patients with potentially actionable somatic events that would lead to therapeutic response is difficult. While histopathological staining for tumor markers and genomic analysis all play a crucial role toward this end, neither accurately represent marker availability The RTK hepatocyte growth factor (HGF) receptor, Met, is overexpressed in several malignancies, including cancers of the lung, breast, bladder, and pancreas Because Met activates the KRAS pathway, we hypothesized that in cells that overexpress Met, combined blockade of the RAS pathway and Met would yield therapeutic synergy. This rationale was even specifically highlighted in previous reports on the interplay between Met signaling and KRAS mutant cancers While Met expression is not predictive of response to Met targeted TKIs, we posit that detection and targeting of Met may have value as a theranostic tool to identify Met-expressing tumors that may respond to RLT. This opens an avenue in precision medicine where the “actionable mutation” biology (and evolution of resistance mutations/mechanisms) is less relevant as long as a molecular target can be identified and thus, therapeutically targeted.The technology to engineer molecular imaging agents from biologic agents, peptides or small molecules in order to directly visualize both on-target and off-target localization in patients has been available for many years, but remains underutilized clinically, despite having the potential to provide insights into responses to therapy, including TKIs in vivo and yielding better signal to noise for imaging earlier following initial tracer injection. Accordingly, we used this antibody as a scaffold from which to build a Met selective immunoPET and RLT agent. To the best of our knowledge, no one has evaluated onartuzumab in KRAS-activated PDAC for either imaging or radiotherapeutic purposes Onartuzumab is a one-armed humanized monoclonal antibody that binds to the extracellular domain of Met, blocking HGF binding, receptor activation, dimerization, internalization, and limiting degradation or shedding of Met www.cbioportal.org). The datasets were parsed with an in-house MATLAB script to stratify the patient population into two groups (n = 44) containing patients exhibiting Met expression levels in the top or bottom 25-percentile of the entire patient cohort. Survival time for each patient was extracted from the clinical data set, and Kaplan-Meier curves were generated for each group. To explore expression levels of Met in human cancer cell lines, we obtained Affymetrix HG-U133 chip-based microarray data from the Broad-Novartis Cancer Cell Line Encyclopedia (CCLE) website containing Robust Multi-array Average (RMA) normalized mRNA expression data with Affymetrix annotations across 1457 human cancer cell lines Previously published gene expression array datasets of tumors and matched normal tissue from patients were interrogated for differential expression of Met by combining tools from oncomine.org and evaluating original published data 2. Cell lines were authenticated at MSKCC integrated genomics operation core using short tandem repeat analysis, and used within passage number 15. Deidentified patient non-tumor and pancreatic cancer samples were obtained from David M. Rubenstein Center for Pancreatic Cancer Research following institutional review board (IRB) approval.PDAC  cell lines were purchased from ATCC  and were grown according to standard procedures. All media were purchased from the Media Preparation Facility at Memorial Sloan Kettering Cancer Center (MSKCC). All cell lines were mycoplasma free and maintained at 37 °C in a humidified atmosphere at 5% CO6 cells of each PDAC line were harvested, and washed with ice-cold phosphate buffered saline (PBS) three times. Cell pellets were resuspended in FcR block   and incubated for 30 minutes on ice. Cell suspensions were then split into multiple groups, stained with fluorescently labeled onartuzumab (3µg/mL), fluorescently-labeled non-specific IgG (3µg/mL), or incubated without antibody for 30 minutes on ice. Following incubation, cells were washed with ice cold buffer ) three times Onartuzumab was produced and provided by Genentech . Approximately 10 × 102) and 1 mM calcium chloride (CaCl2). Cells were incubated with 0.5 mg/mL of EZ-LINK Sulfo-Biotin (Thermo Fisher Scientific) for 30 min at 4 °C with gentle rotation. The reaction was stopped by washing twice with 100 mM glycine (Thermo Fisher Scientific) in PBS containing 0.5 mM MgCl2 and 1 mM CaCl2. Cells were scraped in RIPA buffer , lysates were centrifuged at 16,000 g for 10 min at 4°C, and supernatants were collected and assayed for protein concentration using the Pierce BCA Protein Assay Kit . A volume of 500 μL of RIPA buffer containing equal amount of proteins was incubated with NeutrAvidin Agarose Resins (Thermo Fisher Scientific) for 2 h at 4 °C with gentle rotation and washed three times with RIPA buffer before suspension in Laemmli buffer.For biotin pull-down assays, cells were washed twice with ice-cold PBS buffer containing 0.5 mM magnesium chloride  and imaged on the Odyssey Infrared Imaging System (LI-COR Biosciences) followed by densitometric analysis.Whole-protein extracts from cells were prepared after cell scraping in RIPA assay buffer, centrifugation, protein quantification, and denaturation in Laemmli buffer as described above. Cell-membrane protein extracts were prepared as previously described. Following electrophoresis and transfer to polyvinylidene difluoride (PVDF) membranes , the blots were incubated in 5% (m/v) BSA in Tris-buffered saline buffer-Tween  and probed with mouse anti β-actin 1:20,000  and rabbit anti-Met 1:1000 . After washing, the membranes were incubated with IRDye89Zr]Zr-DFO-onartuzumab) was achieved in accordance with previously described methods, including conjugation of p-SCN-Bn-DFO , purification, and subsequent radiolabeling 2CO3. p-SCN-Bn-DFO was added in a 6:1 ratio and incubated at 37 ºC for 90 minutes followed by purification via PD-10 column into PBS (pH 7.4). Then, Zr-89 oxalate in oxalic acid (1 M) was neutralized to pH 7.0-7.2, using Na2CO3 (1 M) followed by addition of the appropriate construct in PBS (pH 7.4). The mixture was incubated at room temperature for 60 minutes and monitored using radio-iTLC with silica-gel impregnated glass-microfiber paper strips , using a mobile phase of aqueous solution of EDTA , and analyzed using an AR-2000 . Upon satisfactory radiolabeling, the reaction was quenched by addition of the same EDTA solution (10-20 μL) and the labeled construct was purified using gel-filtration chromatography with 0.9% saline. Radiochemical purity was assessed by radio-iTLC as described above. The Zr-89 used was produced at MSKCC via the 89Y89Zr transmutation reaction on a TR19/9 variable-beam energy cyclotron  Preparation of Zr-89 labeled onartuzumab , resuspended in DMSO, and reacted with onartuzumab at a 10:1 ratio and incubated at 37ºC for 90 minutes. The construct was purified with PD10 column using 200 mM ammonium acetate (pH=5.5) containing 6 mg/mL ascorbic acid buffer for radiolabeling. Lu-177 that was obtained from ITM Isotope Technologies  and was incubated with purified onartuzumab-CHX-A'' conjugate at 37ºC for 60 minutes. Labeling was monitored using radio-iTLC with silica-gel impregnated glass-microfiber paper strips , eluted with a mobile phase of aqueous solution of EDTA . The product was purified using PD10 column equilibrated with 6 mg/mL ascorbic acid in PBS (pH=7) adjusted with 1M Na2CO3. Radiochemical purity was assessed by radio-iTLC as described above.Onartzumab stock buffer was exchanged with PD10 column into PBS and pH adjusted to 8.5 with 1 M NaSupplemental Information.Details of characterization of the bioconjugates and radioconjugates including mass spectrometry analysis, serum stability, and pharmacokinetic profiles are described fully in the 89Zr]Zr-DFO-onartuzumab and [177Lu]Lu-DTPA-onartuzumab was determined using BxPC3, a human pancreatic cancer cell line which highly expresses Met, via a previously reported Lindmo method The immunoreactivity of the [89Zr]Zr-DFO-onartuzumab, cells were incubated with cell culture medium in the presence of 30 μg/mL (303 nM) [89Zr]Zr-DFO-onartuzumab for a total period of 8 h at 37 °C. For the fractionated experiments, 10 μg/mL [89Zr]Zr-DFO-onartuzumab was added every 3 h for a total of 8 h and extracts were collected at 3 h, 6 h and 8 h post-incubation. Control experiments were also performed by incubating the cells with unconjugated Zr-89, including both a fractionated dose (3 × 0.018 MBq/well of Zr-89) and single dose . All samples were measured on a gamma counter calibrated for Zr-89.For the internalization assays with Zr-DFO-onartuzumab  (blocking group), or only [89Zr]Zr-DFO-onartuzumab  via the lateral tail vein. Static scans (n=2) were recorded at the 24 h, 48 h, 72 h, and 120 h with a minimum of 12 million coincident events . Images were recorded on a microPET Focus scanner  as previously described For experiments with the subcutaneous xenograft model, mice (n = 5) were administered either 25-fold mass excess of unlabeled onartuzumab 48 h prior to injection of [89Zr]Zr-DFO-onartuzumab , via tail vein injection and images were acquired at 24 h, and 120 h. Static scans were recorded on an Inveon PET/CT scanner  at the various time points with a minimum of 30 million coincident events . Data sorting, reconstruction, and normalization were performed as previously reported Orthotopically engrafted mice (n = 3) were administered [89Zr]Zr-DFO-onartuzumab was assessed in nu/nu athymic mice subcutaneously engrafted with BxPC3 tumors. Tumor volumes were measured with a Peira TM900  tumor measuring device and the mice were separated into five groups (n=4-5) with similar mean and median tumor volumes before being injected via the lateral tail vein . Biodistribution studies were performed at 1, 24, 48, 72 and 120 h post-injection. In one cohort, blocking was achieved by injecting 25-fold excess mass of unlabeled onartuzumab 48 h prior to [89Zr]Zr-DFO-onartuzumab injection.Biodistribution of [177Lu]Lu-DTPA-onartuzumab were performed in nu/nu athymic mice subcutaneously engrafted with BxPC3 and MIA PaCa-2. Animals were separated in to three groups (n=5) with similar tumor volumes and received [177Lu]Lu-DTPA-onartuzumab via tail vein . Biodistribution studies were performed at 24, 48, and 120 h post-injection.Biodistribution studies of Lu-DTPA-onartuzumab 9.25 MBq(250μCi)/20 μg × 3 fractions (every three days), (3) 20μg onartuzumab × 3 (every three days). Animal tumor size, weight, and survival were monitored and animals were sacrificed if tumor volumes exceded 2000 mm3, or if they lost >20% body weight.Mice were subcutaneously engrafted with either BxPC3 (high Met expressing) or MIA PaCa-2 (low Met expressing) and tumors allowed to grow to ~150mmQuantitations of results were performed with Prism software . An unpaired, two-tailed Student's t-test was used to analyze the data. Survival analysis determined with Mantel-Cox log-rank test. In all cases, a 95% confidence level (P < 0.05) was considered to represent a statistical difference in the data. Graphically, p<0.05 = *, p<0.01= **, p<0.0005 = ***, p<0.0001 = ****, NS: not significant, p >0.05).Figure 1). Using the cancer microarray database Oncomine across matched tumor and normal gene expression datasets, we confirmed amplification of Met in several pancreatic cancer patient datasets (denoted by the first author of the relevant publication) . Analysis of pancreatic cancer data from The Cancer Genome Atlas (TCGA) demonstrates that Met expression is associated with unfavorable survival in patients with pancreatic adenocarcinoma . Immunofluorescence studies in PDAC primary patient samples demonstrated higher expression in tumor tissue when compared with matched normal pancreas tissue .To determine Met expression in tumor vs. normal tissues, we first explored Met expression in a panel of tumor tissues . Together, these findings suggest the importance of Met and its downstream targets in pancreatic cancer. BxPC3, Capan2, and Suit2 pancreatic cancer cells exhibited high Met expression . In contrast, MIA PaCa-2 pancreatic cancer cells demonstrated low expression of cell-membrane Met . Results from flow cytometry with fluorescently-labeled onartuzumab  incubated with the BxPC3, Capan2, Suit2, and MIA PaCa-2 PDAC cell lines were consistent with the expression data from CCLE . Notably, these four cell lines exhibit mutational status common in PDAC including KRAS, TP53, p16/CDKN2A, SMAD4 . While BxPC3 is KRAS wildtype, it harbors an activating BRAF mutation, making it functionally KRAS pathway-activated.Gene expression data from the cancer cell line encyclopedia (CCLE) assessing global Met expression along with its ligand, HGF, and other downstream kinases  supported high Met expression in pancreatic cancer cell lines (Table ). A moderate effect on cell viability was observed when PDAC cell lines were exposed to MEK1/2 inhibition with trametinib; however, no additive cytotoxic effect was observed when trametinib was combined with capmatinib/INC280 .Given that PDAC overexpresses Met, we sought to determine the sensitivity of pancreatic cancer cells to Met-directed kinase inhibition. PDAC cell lines exhibit micromolar sensitivity to kinase inhibitors with activity to several kinases , but are refractory to Met-specific inhibition (capmatinib/INC280) , while serum stability and blood half-life studies suggested that our radioconugates would perform well in vivo . To determine the ability of immunoPET to image Met-overexpressing pancreatic cancers, non-invasive imaging studies were performed in preclinical models of PDAC using [89Zr]Zr-DFO-onartuzumab. BxPC3 and MIA PaCa-2 exhibited the highest and lowest cell membrane Met levels, respectively , and were therefore used for subsequent in vivo experiments. 89Zr-labeled onartuzumab allowed non-invasive tumor imaging in mice subcutaneously engrafted with BxPC3 Figure A. Notably, kidney accumulation was seen, which was comparable to prior studies with [89Zr]Zr-DFO-onartuzumab in other models, with corresponding increase in the group where Met was blocked with an excess of unlabeled antibody   in vivo target engagement in subcutaneously engrafted models. PET images with high contrast were obtained as early as 24h after injection of 89Zr-labeled onartuzumab in BxPC3 tumors, and correspondingly low accumulation was observed in MIA PaCa-2 tumors as predicted . PET SUVmax quantitation across all time points corresponded with in vitro Met expression with higher signal obtained in BxPC3 . To recapitulate some components of the microenvironment in human pancreatic cancer, we evaluated our tracer in an orthotopic setting and similar performance was observed . Biodistribution studies of [89Zr]Zr-DFO-onartuzumab were also performed with varied mass of the antibody to gauge the optimal mass needed to administer before saturating available receptors at the tumor and, therefore, decreasing the tumor uptake and degrading the signal-to-noise. We determined that < 25 μg of antibody would be optimal .Analysis of bioconjugates demonstrated 4.4 DFO and 0.44 DTPA per onartuzumab . Additionally, we observed that Met decreases at the cell membrane after 3h of incubation with 30 μg/mL of onartuzumab. A decrease in cell membrane Met is observed even after 6h of incubation, suggesting that the receptor has yet to cycle back to the membrane within this timeframe. Because onartuzumab binds to the extracellular domain of Met, we hypothesized that onartuzumab administration in a fractionated regimen (in the period of time where Met is being recycled back to the membrane) will increase its membrane targeting efficiency . Indeed, a fractionated dose of onartuzumab (3 × 10 μg/mL) as illustrated in Figure  allowed Met recycling to the plasma membrane after a total incubation time of 6h . Additionally, the amount of radiolabeled onartuzumab associated to cell membrane was higher in BxPC3 cells incubated with a fractionated dose than in cells incubated with a single dose . We observed comparable results in the other PDAC cell lines .Encouraged by our previous studies demonstrating that membrane dynamics need to be considered in imaging and therapy of membrane receptors, we performed in vitro findings, we expected that a fractionated therapeutic protocol would allow for improved PDAC therapy using onartuzumab radiolabeled with the therapeutic radionuclide lutetium-177 (Lu-177). This hypothesis was supported by pilot in vivo therapy study in subcutaneous BxPC3 tumors performed with [177Lu]Lu-DTPA-onartuzumab RLT agent, which demonstrated a modest, but statistically significant decrease in tumor growth and overall survival benefit in the cohort of mice bearing BxPC3 tumors treated with three fractions (1.48 MBq(40μCi)/6.7μg × 3 administered at 3 day intervals) versus a single fraction (4.44 MBq(120μCi) /20μg × 1) (data not shown). These promising results prompted a more rigorous evaluation with subsequent experiments.Premised on our 177Lu]Lu-DTPA-onartuzumab in animals bearing BxPC3 tumors compared with those bearing MIA PaCa-2 tumors . Autoradiographic evaluation of tumors 120h following injection with [177Lu]Lu-DTPA-onartuzumab demonstrated significantly higher activity in BxPC3 tumors, correlating with higher Met expression, and lower Ki-67 staining when compared with MIA PaCa-2 tumors, suggesting proliferative changes resulting from treatment with RLT . Quantitative biodistribution showed rapid accumulation and persistence up to 120h post injection of the construct .Cherenkov imaging, that is, detection of the naturally occurring luminescence of certain radioisotopes, confirmed significantly higher localization of Zr-DFO-onartuzumab, to predict the therapeutic response, that is, tumors with higher SUVmax demonstrated a more durable response to [177Lu]Lu-DTPA-onartuzumab. While the durability of response was more pronounced in the animals treated with [177Lu]Lu-DTPA-onartuzumab harboring BxPC3 tumors, which have high Met expression, animals engrafted with MIA PaCa-2 cells, which have low expression of Met, also exhibited a benefit when treated with our RLT agent. The tumor growth delay and overall survival benefit observed in MIA PaCa-2 cells after administration of a fractionated dose likely reflects a combination of the enhanced permeability and retention effect, non-zero Met expression levels, receptor recycling, and higher radiosensitivity of MIA PaCa-2 compared with BxPC3. Notably, clonogenic assays performed by Souchek et al. and Milanovic et al. determined that MIA PaCa-2 is an order of magnitude more radiosensitive compared to BxPC3  3 and MIAPaCa-2 = 150±68.4 mm3), four animals in the BxPC3 and one animal in the MIA PaCa-2 saline treatment groups demonstrated tumor regression, which represents a limitation of the models used in our study. Since we could not definitively confirm that animals with tumor regression in the treatment arms were primarily due to our treatment, authors decided to include these animals in the final analyses. That said, inclusion of these animals would bias the results against the efficacy of our RLT and the fact that we observed significant local control and survival benefits despite this handicap speaks to the promise of RLT as a modality.Compounded with data demonstrating that PDAC cells respond only modestly to small molecule inhibition alone or in combination with other small molecule inhibitors, we were surprised to observe a significant and durable local response as well as a survival benefit by delivering cytotoxic radionuclides to tumors expressing both high and relatively low surface Met in our animal studies. Of equal importance was the ability of our imaging probe, [in vitro studies demonstrate a relatively short membrane half-life of Met (<8h), and increased membrane Met when incubated with a fractionated dose of the radioligand, the kinetics of this cycling are more challenging to ascertain in vivo. The fact that we observed a local response and overall survival benefit, suggests that our treatment dose and schedule were within a favorable time-frame to engage Met on tumor cell membranes. It is possible that the relatively rapid recycling of the receptor may allow for more available binding for subsequent boluses of RLT, though to what extent the receptor dynamics in vitro mirror those in vivo is unclear. Studies to further characterize this effect as well as defining the mechanisms of RLT resistance are ongoing.Although Met is overexpressed in pancreatic cancer cells, the cell membrane presence of Met is highly dynamic, which contributes to its short membrane half-life in vivo despite Met not being a key driver in this disease by exploiting its overrepresentation on tumor over normal tissues. Moreover, while over-expression of Met does not alone predict for response to anti-Met TKIs, immunoPET can assess in vivo expression, serving as an important companion imaging biomarker that predicts for therapeutic response to radioligand therapy. This strategy can be applied to not only other Met-expressing cancers specifically, but also may present a blueprint applicable to other differentially overexpressed surface tumor markers. In fact, two open Phase I trials listed on clinicaltrials.gov aim to do just that using, HuMab5B1, a monoclonal antibody specific to CA19.9, a well-known serum and tissue biomarker for pancreatic cancer: NCT02687230  and NCT03118349 . While both trials include other CA19.9-positive malignancies, results will provide insights on how immunoPET could inform RLT more broadly.Clearly, deconvoluting the network of signaling cascades involved in oncogenesis of pancreatic and other cancers is crucial to our understanding of the biology that underpins these diseases. Further, it informs the development of targeted small molecule drugs and rational combinations therein. Nevertheless, it is important to highlight that our agent can achieve tumor control and survival benefit Supplementary methods, results, and figures.Click here for additional data file.