Hepatocellular carcinoma (HCC) is among the most lethal cancers. Mounting studies highlighted the essential role of the HGF/c-MET axis in driving HCC tumor progression. Therefore, c-Met is a potential therapeutic target for HCC. However, several concerns remain unresolved in c-Met targeting. First, the status of active c-Met in HCC must be screened to determine patients suitable for therapy. Second, resistance and side effects have been observed frequently when using conventional c-Met inhibitors. Thus, a preclinical system for screening the status of c-Met signaling and identifying efficient and safe anti-HCC agents is urgently required. In this study, immunohistochemical staining of phosphorylated c-Met (Tyr1234) on tissue sections indicated that HCCs with positive c-Met signaling accounted for approximately 46% in 26 cases. Second, many patient-derived HCC cell lines were established and characterized according to motility and c-Met signaling status. Moreover, LZ8, a medicinal peptide purified from the herb Lingzhi, featuring immunomodulatory and anticancer properties, was capable of suppressing cell migration and slightly reducing the survival rate of both c-Met positive and negative HCCs, HCC372, and HCC329, respectively. LZ8 also suppressed the intrahepatic metastasis of HCC329 in SCID mice. On the molecular level, LZ8 suppressed the expression of c-Met and phosphorylation of c-Met, ERK and AKT in HCC372, and suppressed the phosphorylation of JNK, ERK, and AKT in HCC329. According to receptor array screening, the major receptor tyrosine kinase activated in HCC329 was found to be the epidermal growth factor receptor (EGFR). Moreover, tyrosine-phosphorylated EGFR (the active EGFR) was greatly suppressed in HCC329 by LZ8 treatment. In addition, LZ8 blocked HGF-induced cell migration and c-Met-dependent signaling in HepG2. In summary, we designed a preclinical trial using LZ8 to prevent the tumor progression of patient-derived HCCs with c-Met-positive or -negative signaling. Liver cancer is the sixth most common and third most deadly cancer worldwide . HepatocTumor metastasis, one of the most complicated pathological processes is initiated by epithelial mesenchymal transition (EMT), migration and invasion of the primary tumor, followed by intravasation, extravasation, and colonization at the metastatic loci . Within Among the metastatic factors, the scatter factor HGF was highlighted to be involved in the progression of cancer , includiThe binding of HGF to c-Met induces the autophosphorylation of its cytoplasmic domain, followed by the recruitment of upstream regulators, such as Gab, Grb2, and PI3K, that activate downstream mitogen activated protein kinase (MAPK) and AKT signaling –32. In aDuring the past decades, numerous small molecular c-Met inhibitors have been designed for c-Met-based target therapy. Currently, at least 17 c-Met inhibitors, including JNJ-38877605, GEN-203, and ARQ197, are under clinical evaluation . HoweverOne promising anti-HCC agent is the medicinal peptide LZ8 , which is purified from the Chinese herbal drug Ganoderma lucidium . In prevIn this study, we improved the preclinical trials for preventing HCC progression in several aspects. First, to validate the feasibility of c-Met targeting, we screened active c-Met  in HCC tissues. Moreover, using patient-derived HCCs as target cells, we noted that LZ8 can suppress HCC tumor progression, associated with inhibiting the activity of critical signal molecules involved in c-Met- or non-c-Met-dependent pathways.Saccharomyces cerevisiae. Cells expressing LZ8 were disrupted and centrifuged, and the supernatant was passed through molecular sieves to obtain proteins between 10 kDa and 100 kDa large. The filtrate was further purified using Superdex 75 columns  and the purity was determined by HPLC.Human hepatoma cell HepG2 was purchased from the Bioresource Collection and Research Center . HCC tissues were collected during surgery performed at Tzu Chi Hospital with patient’s consents, which have been approved by the Research Ethics Committee in Buddhist Tzu Chi General Hospital (IRB 101–62). The tissues were snap frozen at −80°C before being harvested for Western blotting or sectioning for immunohistochemical analysis. HGF and JNJ-38877605 were obtained from Peprotech  and MedKoo , respectively. SP600125, PD98059, AG1748, and SU5416 were acquired from Calbiochem . Antibodies for c-Met, p-c-Met, phosphorylated JNK (p-JNK), phosphorylated ERK (p-ERK), phosphorylated AKT (p-AKT), phosphorylated paxillin (p-paxillin S178), GAPDH, and ERK were obtained from Santa Cruz Biotechnology, Inc. . LZ8 was purchased from the Yeastern Company  and prepared using recombinant protein technology in a yeast system. Briefly, DNA sequence encoding LZ8 was cloned and expressed in Clinically derived HCC cell lines were established from parts of HCC tissues obtained from surgery with patient’s consents, which have been approved by Buddhist Tzu Chi general hospital Research Ethic Committee (IRB 101–62). All patients signed informed consent forms , a few of which are presented in Immunohistochemistry (IHC) for HGF and p-c-Met was performed according to the standard protocols established by the Research Centre for Hepatology at Tzu Chi Hospital.The cells were cultivated in 24-well plates. After appropriate treatments, the cells were counted with hemocytometer every 24 h for 72 h. The doubling time of cells was calculated using the following equation: Time (h)/Generation, where Time is the time from cell seeding to cell counting and Generation is the generation of cell replication and was equal to log N1-log N0/log2 .HCC cells were harvested by trypsin detachment and washed in ice-cold, phosphate-buffered saline (PBS). After centrifugation and supernatant removal, the cells were fixed using ice-cold 70% ethanol for 24 h. The cells were then washed with PBS and incubated with RNase A  and propidium iodide  at room temperature for 15 min. The red (FL3) fluorescence of the stained cells was analyzed using a Beckman Coulter Gallios flow cytometer. The percentage of cells in the G1, S, and G2/M phases of the cell cycle was analyzed using Kaluza 1.1 software (Beckman Coulter).The cells were cultivated in 24-well plates with a wound healing culture insert until confluence, and then serum starved for 24 h, after which the culture insert was removed. After appropriate treatments of the cells, images were obtained using phase contrast microscopy. Quantitation of cell motility was performed by counting the cells migrating into the blanking area using Image J software.Cells were seeded on a 24-well transwell migration insert  in a complete medium for 24 h. After appropriate treatments, cells that had migrated to the underside of the insert membrane were stained with 0.3% crystal violet. The cells on the topside of the insert membrane were rubbed with a cotton swab. The migrated cells on the underside were imaged using phase contrast microscopy with 200× magnification.Western blots were performed according to our previous study . The ban7 cells were injected subcutaneously into the right flank of the mice, and the signs of tumor development were then monitored daily. Once the subcutaneous (s.c.) tumor reached 1 to 1.5 cm in diameter, it was removed and cut into approximately 1- to 2-mm cubes and implanted in the left liver lobe of the mice. Two to four months after tumor implantation and appropriated treatments, the mice were sacrificed for examining the primary tumor growth on middle liver lobe and secondary tumor foci on left and right lobes. Nodules with diameters exceeding 0.1 to 0.2 cm observed on the left or right lobes were denoted as secondary tumor foci. Intrahepatic metastasis was defined if a minimum of two secondary tumor foci can be observed in the left and/or right liver lobes of a treated mouse. Extrahepatic metastasis was defined by tumors appearing in organs other than the liver, such as the intestine. During animal experiment, which was approved by the Institutional Animal Care and Use Committee at Tzu Chi University (No. 102080), regulations relevant to the care and use of laboratory animals were followed.Orthotropic transplantation was performed for tumor inoculation. Initially, approximately 1 × 10A receptor array kit  capable of simultaneously detecting 49 essential RTKs in phosphorylated form was used for screening the phosphorylated RTK (p-RTK) signaling in HCC329 according to the manufacturer’s protocols. For quantitation, the average signal (pixel density) of the pair of duplicate spots representing each p-RTK was determined using Image J. The average background (from the PBS control spot) was then subtracted from each p-RTK signal. Detailed information of the 49 RTKs is presented in t test was conducted to analyze the differences in band intensities between samples on the Western blot and the differences in cell motility and doubling time between the indicated HCCs. Quantitative data were expressed as mean ± coefficient variation (CV), indicated by the error bars in each figure. Differences in intrahepatic metastasis between various treatments and the reproducibility of the indicated molecules exhibited on IHC tissue section were analyzed using the Fisher Exact V2 test for categorical data.A paired Student’s The status of HGF/c-Met signaling in 26 HCC tissue samples was evaluated by examining the amount of Tyr1234 phosphorylated c-Met  coupled with HGF in the tumor environment. To obtain more specific target cells for personalized therapy, parts of the HCC tissues from each of the 26 HCC cases were used for establishing patient-derived cell lines by feeder layer selection method. Currently, nine patient-derived HCC cell lines  were established and the phenotypes were characterized. HepG2, which is an epithelial and non-motile HCC, was also included for comparison of the HCC phenotypes. According to the morphologies demonstrated under phase contrast microscope , most ofThe statuses of the critical signaling components, including c-Met, ERK, JNK, and AKT, involved in tumor progression , 48 wereRegarding the downstream signaling components, p-JNK was abundant in most of the HCCs, and relatively low in HCC340 and HepG2 . On the It appeared that the correlation of ERK and JNK activations with the status of c-Met signaling differed among the HCCs. As shown in Both HCC372 and HCC329 were further used as target cells for evaluating the potential of LZ8 as an anti-HCC agent. As shown in the cell proliferation assay , LZ8 (0.50: 26.5 nM) suppressed migration of HCC372 by 50%. On the other hand, LZ8 and JNJ suppressed cell migration of HCC329 by 80% and 10%, respectively. Notably, the extent of inhibition by JNJ was higher in HCC372 than in HCC329, a phenomenon that can be attributed to c-Met signaling which was active in HCC372 but not HCC329. In addition, compared with the single LZ8 treatment, a combination of both LZ8 and JNJ didn’t exert enhanced effects in blocking the migration of both HCCs (data not shown). Because the cells were treated with LZ8 in serum-free media in the wound healing assay, whether serum can influence the effect that LZ8 exerted on HCC migration needed to be examined. Thus, we repeated the cell migration assay by using a transwell culture insert, and treated HCC329 and HCC372 with LZ8 in complete media containing 10% serum. As depicted in Further, the effect that LZ8 exerted on the cell migration of both HCCs was examined using the wound healing assay. As demonstrated in We further examined the effect that LZ8 exerted on HCC329 metastasis using a SCID mouse model established previously . HCC329 To investigate the molecular mechanisms by which LZ8 suppresses HCC progression, we examined the influence that LZ8 exerts on the activity of critical signal molecules in HCC329 and HCC372. As shown in vs. that in untreated HCC329 (LZ8/control) was 0.317, far below 1.0. This revealed that p-EGFR was greatly suppressed in HCC329 after LZ8 treatment. In addition, the relative intensities of p-Axl and p-RYK were significantly less than 1.0, whereas those of the other seven p-RTKs were greater than 1.0. On the other hand, we investigated whether blocking the EFGR pathway would affect the signal transduction and cell migration of HCC329. As depicted in Because c-Met signaling is inactive in HCC329, the signaling pathway suppressed by LZ8 for blocking tumor progression of this HCC remained unclear. Thus, the RTK signaling activated in HCC329 was screened using a receptor array, which can simultaneously detect 49 essential RTKs in phosphorylated forms. Among the phosphorylated RTKs, phosphorylated EGFR (p-EGFR) was the most abundant in untreated HCC329 . MoreoveFinally, we investigated whether LZ8 could block HGF-induced c-Met signaling in HepG2. As shown in Target therapies are emerging as the most promising strategy for HCC management. Among the growth-factor-mediated cancer signaling, the HGF/c-Met axis is intimately related to the metastatic transformation of HCC. A prerequisite of c-Met-based target therapy is to identify whether c-Met signaling is active in an individual HCC, an aspect that has not been clarified in previous clinical studies. In our initial screening, p-c-Met (Tyr1234), the active form of c-Met, was positive in 46% of the HCCs tested. Although the sample size was not large enough, this pilot study suggests that large-scale screening of c-Met signaling in HCC is feasible before enrolling patients for c-Met-based target therapy.Another critical concern in the preclinical trials for anti-HCC progression is selecting target cells for studying the efficacy of various HCC antagonists. In this study, numerous patient-derived HCC cells were established and characterized . After tThe status of c-Met signaling in the HCCs was essential for verifying whether patients are suitable for c-Met-based target therapy. This was reflected by that the suppressive effect of JNJ, the typical c-Met inhibitor, exerted on cell migration was much more prominent for HCC372 than for HCC329 . HoweverEffective and safe drugs are required for successful HCC target therapy. Although the usefulness of sorafenib has been demonstrated, developing second line drugs for HCC patients who were resistant to sorafenib are essential. Currently, many potential Chinese-herb-derived anticancer compounds have been explored. For example, Celastrol, extracted from the root of Tripterygiumwilfordii Hook, was found to have anti–prostate cancer properties . MoreoveThe effect that LZ8 exerted on HCC tumor progression can be ascribed to the suppression of critical signaling, either c-Met dependent or c-Met independent, involved in HCC progression. For the c-Met positive HCC372, LZ8 suppressed both the expression of c-Met and phosphorylation of c-Met (Tyr1234) , which aAccording to receptor array screening, we determined that EGFR was the major RTK activated in the c-Met-negative HCC329 . Moreovein vitro [We established the profile of downstream MAPK members, including p-JNK and p-ERK, in the patient-derived HCCs. Because of their essential roles in proliferation, survival, differentiation, and migration, deregulated MAPKs were frequently found to contribute to the development of many cancers, including HCC . Previouin vitro . In the in vitro . TherefoThe suppressive effects of LZ8 on MAPK in both HCC329 and HCC372 also differed substantially. Although phosphorylation of ERK and JNK can be detected in HCC372 , only p-Recently, the roles of p-JNK and p-ERK as prognosis markers of HCC treated with sorafenib have been studied. Compared with ERK activation, JNK activation is more inversely correlated with the therapeutic response to sorafenib, suggesting that JNK activity may be used as a predictive biomarker for response to sorafenib treatment –59. In tvia blocking the c-Met-dependent or the c-Met-independent pathway. Since the safety concern of LZ8 has been certified, whether it can be used as an effective and nontoxic anti-HCC agent is worthy of further investigation in clinical trials.To develop an effective c-Met-based target therapy for preventing HCC progression, we screened c-Met-dependent signaling on HCC tissues. In addition, patient-derived cell lines, either c-Met-positive or c-Met-negative, may be used for testing the efficacy of HCC antagonists in vitro and in vivo. Specifically, LZ8 suppressed the tumor progression of HCC S1 Fig(A) IHC of the indicated molecules coupled with H & E stain was performed on tissue sections of three HCC cases. Green arrows indicate the location of tumor as verified by HCC tumor marker GPC3. The blue rectangle indicates the area that was magnified to 400×. The deep brown staining region revealed the location of indicated molecules in contrast to the light brown negative region. Data were representative of two reproducible experiments. (B) IHC of p-c-Met coupled with H & E stain was performed on tissues from which the indicated HCCs cell lines were derived. Imaging was performed through phase contrast microscopy. The image of negative controls (excluding the primary Ab incubation) was demonstrated in parallel. The area indicated by blue rectangles (100X magnification) was enlarged to 400X magnification. In the IHC of p-c-Met, the deep brown staining region revealed the location of p-c-Met in contrast to the light brown negative region. Data were representative of two reproducible experiments.(TIF)Click here for additional data file.S2 FigHCC372 and HCC329 were cultivated on a migration culture insert for 24 h and treated with LZ8 at indicated concentrations in a medium containing 10% serum for 24 h. Imaging was performed through phase contrast microscopy using 200× magnification. Data were representative of three reproducible experiments.(TIF)Click here for additional data file.S3 FigHCC329 cells were untreated (control) or treated with indicated inhibitors for 48 h (A) or indicated times (B). Wound healing migration analysis (A) and Western blot analysis of p-JNK (B) were performed. In (A), relative migration time was calculated, taking the data of control group as 100%. In (B), GAPDH was included as the loading control. The normalized intensity calculated as p-JNK/GAPDH is shown. Data were representative of three reproducible experiments.(TIF)Click here for additional data file.S4 FigHCC372 cells were treated with JNJ (26.5 nM) or 2 μg/mL LZ8 for 4 h. Western blot of indicated signal molecules was performed using GAPDH as a loading control. Data were representative of three reproducible experiments.(TIF)Click here for additional data file.S1 MaterialsSigned informed consent forms  of 4 HCC patients who agreed to provide their surgical HCC tissues for cell lines establishment in Liver Disease center in TZU CHI hospital Hualein, Taiwan.(PDF)Click here for additional data file.S2 Materialsst) and 4th column are the coordinates referring to the position of each antibody (in duplicate) indicated in the parallel column.This is one of the appendixes in the manufacture’s protocol of Proteome Profile™ Array; R&D system. It provides the detailed information regarding the positions of the antibodies of 49 phosphorylated RTKs (p-RTKs) conjugated on the membrane for detecting the respective p-RTKs. The letters indicated in the most left (1(JPG)Click here for additional data file.S3 MaterialsThe copied certificate of English editing for this paper by a mother tongue English speaker, Dr. Jennifer Sampson in Wallace Academic Editing Company.(PDF)Click here for additional data file.


Environmental and economic factors increasingly encourage higher utility of industrial by-products. The basic objective of this study was to identify alternative source for good quality aggregates which is depleting very fast due to fast pace of construction activities in India. EAF oxidizing slag as a by-product obtained during the process in steel making industry provides great opportunity to utilize it as an alternative to normally available coarse aggregates. The primary aim of this research was to evaluate the physical, mechanical, and durability properties of concrete made with EAF oxidizing slag in addition to supplementary cementing material fly ash. This study presents the experimental investigations carried out on concrete grades of M20 and M30 with three mixes: (i) Mix A, conventional concrete mix with no material substitution, (ii) Mix B, 30% replacement of cement with fly ash, and (iii) Mix C, 30% replacement of cement with fly ash and 50% replacement of coarse aggregate with EAF oxidizing slag. Tests were conducted to determine mechanical and durability properties up to the age of 90 days. The test results concluded that concrete made with EAF oxidizing slag and fly ash (Mix C) had greater strength and durability characteristics when compared to Mix A and Mix B. Based on the overall observations, it could be recommended that EAF oxidizing slag and fly ash could be effectively utilized as coarse aggregate replacement and cement replacement in all concrete applications. Concrete being the largest man made material used on earth is requiring good quality of aggregates in large volumes. The availability of natural coarse aggregate is depleting day by day due to tremendous demand in Indian infrastructure industry. Aggregates are the main ingredient of concrete occupying 70–80% of its volume and exert a significant influence in concrete properties. A need was felt to identify potential alternative source of coarse aggregate to fulfil the future growth aspiration of Indian infrastructure industry .Use of by-products such as slag, dust, or sludge from the metallurgical industries as filler materials in concrete helps to conserve natural resources as an economically positive option.Slag, an industrial by-product of steel and iron smelting operations, must be recycled because it has increased proportionately with the development of the steel industry , 3.Big steel plants in India generate about 29 million of tonnes of waste material annually. Slag reduces porosity and permeability of soil, thus increasing the water logging problem. Since large quantities of these wastes are generated daily, they are considered problematic and hazardous for both the factories and the environment. Problem of disposing this slag is very serious which can be reduced by utilizing steel slag for concrete production .Steel making slag specifically generated from EAFs, BOFs, and BFs during the iron and steel making process has many important and environmental uses. In many applications, due to its unique physical structure, slag outperforms the natural aggregate for which it is used as a replacement . SeveralA very few researches have been performed regarding the utilization of EAF oxidizing slag in concrete. EAF oxidizing slag is an industrial by-product obtained from the steel manufacturing industry. It is produced in large quantities during the steel making operation which utilizes Electric Arc Furnace oxidation process.EAF oxidizing slag has a high specific gravity; it can produce heavy weight concrete if used as an aggregate for structural concrete. Since most heavy weight aggregates are obtained through quarrying, substitute aggregates must be developed for environmental preservation and protection. From this point of view, the use of EAF oxidizing slag as aggregates holds great significance , 31.According to recent studies, an increase in the compressive strength of concrete was reported if EAF oxidizing slag aggregates are used for structural concrete. The use of EAF oxidizing slag as aggregates for structural concrete not only protects the environment but also reduces costs –35. Kim Kim et al. conducted a research on the characteristics of concrete with EAF oxidizing slag as an aggregate and that evaluated the applicability of the slag for reinforced concrete (RC) members. The study performed bond performance between the steel bar and the concrete with EAF oxidizing slag aggregates which were evaluated in order to use this new material in RC members .Kim et al. conducted results and characteristics of EAF oxidizing slag as an aggregate for structural concrete. The experimental results showed that applying EAF oxidizing slag aggregates to PHC piles enhances the compressive strength, saves energy, lowers carbon dioxide emissions, reduces the amount of cement used, and helps to cut costs .This present paper examines EAF oxidizing slag as coarse aggregates contributing to environment and enhancing greater strength.Nowadays, most concrete mixture containing supplementary cementing material fly ash to replace certain amount of cement, thus, is reducing the cost of using Portland cement. Fly ash is the most common supplementary cementing material used in concrete. It has been used successfully to replace Portland cement up to 30% by mass, without adversely affecting the strength and durability of concrete .Several laboratory and field investigations involving concrete containing fly ash had reported to exhibit excellent mechanical and durability properties. The pozzolanic reaction of fly ash is a slow process; its contribution towards the strength development occurs only at later ages .The study was conducted to define and analyse the physical, mechanical, and durability properties of eco-friendly concrete made with 50% EAF oxidizing slag aggregate in addition to 30% fly ash (Mix C) compared with conventional concrete mix (Mix A) and concrete with 30% fly ash (Mix B) of two grades M20 and M30.2 content. The slag is mainly composed of oxides which are similar to the natural rocks and has alkaline properties such as cement products [The slag used in the present investigation was collected from Salem Steel Plant (SSP), Tamil Nadu. The slag had greyish black colour, stone-like appearance, cubical shape, and rough surface texture and more durable than natural aggregate. The roughness and hardness nature of the slag makes it reliable for coarse aggregate. In that study the slag passing through IS Sieve 20 mm was used. EAF oxidizing slag offers high applicability as an aggregate for concrete due to its CaO and SiOproducts . The phyIn this investigation low calcium fly ash obtained from Mettur Thermal Power Plant was used.53 grade ordinary Portland cement conforming to Indian standard codes IS 12269-1987 was used. Locally available river sand conforming to grading zone II of IS: 383-1970 and crushed granite coarse aggregate of maximum size of 20 mm conforming to IS 383-1970 was used in concrete mixes. Potable water and naphthalene based superplasticizer were used in concrete mixes.The mix design of M20 and M30 grade concretes was designed as per IS 10262:2009. The mix proportioning of M20 and M30 grades is shown in Tests were done as per the following codes of Bureau of Indian Standards. The test for compressive strength on cubes (150 × 150 × 150 mm) was measured at 7, 28, and 90 days of curing as per IS: 516-1959 , test fo2/s), Q is the quantity of water absorbed (m3) by the oven-dried specimen in time (t), t is 3600 s, and A is the surface area (m2) of concrete specimen through which water penetrates.Coefficient of water absorption is considered as a measure of permeability of water . This wai is the cumulative water absorption per unit area of inflow surface (m3/m2), S is the sorptivity (m/s1/2), and t is the time elapsed (s). The sorptivity test is shown in Sorptivity is a measure of the capillary forces exerted by the pore structure causing fluids to be drawn into the body of the material . In thisThe water penetration test, which is most commonly used to evaluate the permeability of concrete, is the one specified by BS EN-12390-8:2000 . In thisThe resistance of concrete to salt attack was assessed by Rapid Chloride Permeability Test (RCPT) at 28 and 90 days of water curing in conformity with ASTM C-1202 . Three sμm sieve. 10 g is taken and diluted in distilled water by stirring. The pH value of the solution is noted with a pH meter. The alkalinity test is shown in For the alkalinity test, the concrete cubes after curing were dried in an oven for 24 h at 105°C. After cooling in room temperature, the specimens were broken to separate the mortar from the concrete. The mortar is powdered and sieved in 150 The resistance to sulphate attack was studied by immersing the 28 days cured standard cube specimens (150 × 150 × 150 mm) in a solution containing 7.5% magnesium sulphate for 28, 60, and 90 days. The concentration of the solution was maintained throughout the period by changing the solution periodically. The change in weight during the period of 28, 60, and 90 days was determined [The compressive test is the most important test that can be used to assure the engineering quality in the application of building material. In M20 grade, at the age of 7 days the compressive strength of Mix C progressively increased by 8.69%  and 47% when compared to Mix A and Mix B, respectively. But the strength development of Mix A increased by 35.29% when compared to Mix B at the earlier age. At the age of 28 and 90 days, there is a continuous improvement in the strength performance of all the concrete mixtures. Mix C increased by 11.07%  and 15.2% at 28 days and 11.11% and 12.04% at 90 days  when comThe splitting test is well known indirect test for determining the tensile strength of concrete. In M20 grade, at the age of 7 days the split tensile strength of Mix C progressively increased by 9.75%  and 50% when compared to Mix A and Mix B, respectively. But the strength development of Mix A increased by 36.66% when compared to Mix B at the earlier age. At the age of 28 and 90 days , the splFlexural test is intended to give the flexural strength of concrete in tension. In M20 grade, at the age of 7 days the flexural strength of Mix C progressively increased by 6.25%  and 21.42% when compared to Mix A and Mix B, respectively. At the age of 28 and 90 days, the flexural strength increased in all the concrete mixtures. Mix C increased by 6.89%  and 8.77% at 28 days and 7.8% and 13.1% at 90 days  when comThe coefficient of water absorption is suggested as a measure of permeability of water. Results indicated that there is significant reduction in the coefficient of water absorption which was measured in Mix C (concrete made with EAF oxidizing slag and fly ash) when compared to Mix A and Mix B for both M20 and M30 grade as shown in −6) (m/s0.5) and 4.63 (10−6) (m/s0.5) when compared to Mix A  and Mix B (concrete with fly ash), whereas Mix B showed higher sorption and maximum sorptivity coefficient of 7.02 (10−6) (m/s0.5) and 6.67 (10−6) (m/s0.5) as compared to Mix A and Mix C. At the age of 90 days (−6) (m/s0.5) as compared to Mix A and Mix B and the rate of sorptivity of Mix C dropped by 46% and 42%, respectively. The sorptivity coefficient of Mix B was similar to that of Mix A and the rate of sorptivity dropped by 40% and 36% of M20 and M30 grade of concrete, respectively. From the results, it was observed that Mix C (concrete made with EAFOS aggregate and fly ash) obtained lesser sorption in all the ages when compared to Mix A and Mix B of M20 and M30 grade concrete.The sorptivity test measures capillary suction of concrete when it comes in contact with water. From the results of M20 and M30 grade, at the age of 28 days, Mix C (concrete made with EAFOS aggregate and fly ash) resulted in lesser sorptivity coefficient of 5.65  and Mix B (13.5 mm and 15.7 mm) of M20 and M30 grade concrete, respectively. At the curing of 90 days , lower pRCPT is an electrical indication to measure the ability of concrete to resist the penetration of chloride ions. The results of M20 and M30 grade indicated all the values of Mix A, Mix B, and Mix C obtained were between 100 and 1000 and hence the chloride ion permeability is “very low” as per the code. The important observation is that concrete made with EAF oxidizing slag and fly ash (Mix C) makes it less permeable to chloride ions when compared to Mix A and Mix B .Alkalinity test results indicated that the pH value of concrete made with EAF oxidizing slag and fly ash (Mix C) is within the limits about 12 to 13 and hence the potential for corrosion is low, similar to that of Mix A and Mix B . For sulBased on overall results and observations concrete made with EAF oxidizing slag and fly ash exhibited greater strength and durability characteristics compared to conventional concrete mix considered. Thus EAF oxidizing slag, a logical choice for sustaining the environment, eliminates quarrying of natural aggregates and avoids landfill of slags. It could be recommended for all construction activities in India.


In this paper, not only strongly lacunary ward continuity, but also some other kindsof continuities are investigated in 2-normed spaces.A function  Menger  introducNθ-convergence was introduced in [Nθ-ward continuity and further studied in [Using the main idea in the definition of sequential continuity, many kinds of continuities were introduced and investigated, and not all but some of them are in –13. The duced in  and furtduced in . Stronglduced in  as namedudied in .The aim of this paper is to investigate strongly lacunary ward continuity in 2-normed spaces and prove interesting theorems.N and R will denote the set of all positive integers and the set of all real numbers, respectively. Now we recall the definition of a two-normed space. Let X be a real linear space with dimX > 1 and ||·, ·|| : X × X → R a function. Then  is called a linear 2-normed space if (i) ||x, y|| = 0⇔x and y are linearly dependent, (ii) ||x, y|| = ||y, x||, (iii) ||αx, y|| = |α|||x, y||, and (iv) ||x, y + z|| ≤ ||x, y|| + ||x, z|| for α ∈ R and x, y, z ∈ X. The function ||·, ·|| is called a 2-norm on X. Observe that in any 2-normed space  we have that ||·, ·|| is nonnegative, ||x − z, x − y|| = ||x − z, y − z||, and ||x, y + αx|| = ||x, y|| for all x, y ∈ X, α ∈ R. Throughout this paper by X we will mean a 2-normed space with a two-norm ||·, ·||. As an example of a 2-normed space we may take X = R2 being equipped with the 2-normx1 = , x2 = .Throughout this paper, xn) of points in X is said to converge to a point L of X in the 2-normed space X if limn→∞||xn − L, z|| = 0 for every z ∈ X. This is denoted by limn→∞||xn, z|| = ||L, z||. A sequence (xn) of points in X is said to be a Cauchy sequence with respect to the 2-norm if limn,m→∞||xn − xm, z|| = 0 for every z ∈ X. A sequence of functions (fn) is said to be uniformly convergent to a function f on a subset E of X if for each ε > 0, an integer N can be found such that ||fn(x) − f(x), z|| < ε for n ≥ N and for all x, z ∈ X [θ = (kr) is an increasing sequence of positive integers such that k0 = 0 and hr = kr − kr−1 → ∞ as r → ∞. The intervals determined by θ will be denoted by Ir =  of points in X is called strongly lacunary convergent, or Nθ-convergent to an element L of X ifz ∈ X and it is denoted by Nθ − limk→∞||xk, z|| = ||L, z|| for every z ∈ X [Nθ” instead of “strongly lacunary” and assume that liminfr qr > 1.A sequence  = ||x, z||, ∀x, for each z ∈ X, forms a locally convex topological vector space, and the topology formed by this family of seminorms gives the required topology on X. Since dimX ≥ 2, for each x ∈ X there exists a y ∈ X such that x and y are linearly independent, and hence by (i), py(x) = ||x, y|| ≠ 0. Thus the locally convex topological vector space induced by the set {pz : z ∈ X} of seminorms is Hausdorff so X is a Hausdorff space [The set of seminorms {ff space . In thisE of X is called Nθ-sequentially compact if any sequence of points in E has an Nθ-convergent sequence with an Nθ-limit in E.A subset Nθ-sequentially compact subsets of X is Nθ-sequentially compact, intersection of any Nθ-sequentially compact subsets is Nθ-sequentially compact, any compact subset of X is Nθ-sequentially compact, and any finite subset of X is Nθ-sequentially compact. Sum of Nθ-sequentially compact subsets of X is Nθ-sequentially compact where sum of two subsets A and B is defined as A + B = {a + b : a ∈ A, b ∈ B}.We note that union of two f defined on a subset E of X is said to be strongly lacunary sequentially continuous or Nθ-sequentially continuous at a point x0 of E if (f(xk)) is an Nθ-convergent sequence to f(x0) whenever (xk) is an Nθ-convergent to x0 sequence of points in E. If f is strongly lacunary sequentially continuous at every point of E, then it is said to be strongly lacunary sequentially continuous on E.A function f defined on a subset E of X is lacunary statistically sequentially continuous at a point x0, then (f(xk)) is an Nθ-convergent sequence with Nθ − lim||f(xk), z|| = ||f(x0), z|| for every z ∈ X whenever (xk) is an Nθ-convergent sequence with Nθ − lim||xk, z|| = ||x0, z|| for every z ∈ X. We see that a function f defined on a subset E of X is strongly lacunary sequentially continuous if and only if it preserves strongly lacunary convergent sequences without stating limit of the sequence. We note that sum of two Nθ-sequentially continuous functions at a point x0 of X is Nθ-sequentially continuous at x0, and composite of two Nθ-sequentially continuous functions at a point x0 of X is Nθ-sequentially continuous at x0. In the classical case, that is in the single normed case, it is known that uniform limit of sequentially continuous function is sequentially continuous; now we see that it is also true that not only uniform limit of sequentially continuous function is sequentially continuous, but also uniform limit of Nθ-sequentially continuous function is Nθ-sequentially continuous in 2-normed spaces. Now we give the latter in the following.If a function Nθ-sequentially continuous functions is Nθ-sequentially continuous.Uniform limit of fk) be a uniformly convergent sequence of each term defined on a subset E of X with uniform limit f and let (xk) be any Nθ-convergent sequence of points in E with Nθ − lim||xk, z|| = ||x, z|| for every z ∈ X. Take any ε > 0. By uniform convergence of (fk), there exists an n1 ∈ N such that ||f(x) − fk(x), z|| < ε/3 for k ≥ n1 and every x ∈ E and z ∈ X. Hence,r ≥ n1 and every x ∈ E and z ∈ X. As fn1 is Nθ-sequentially continuous on E, there exists an n2 ∈ N such that, for r ≥ n2,z ∈ X. Now write n0 = max{n1, n2}. Thus for r ≥ n0 we havevk(x) = f(x) − fn1(x) for every k ∈ N. HenceLet ) be any sequence of points in f(A) where xn ∈ A for each positive integer n. Nθ-sequentially compactness of A implies that there is a subsequence (γk) = (xnk) of (xn) with Nθ − limk→∞||γk, z|| = ||l, z|| for every z ∈ E. Write (tk) = (f(γk)). As f is Nθ-sequentially continuous, (f(γk)) is Nθ-sequentially convergent which is a subsequence of the sequence (f(xn)) with Nθ − limk→∞||tk, z|| = ||l, z|| for ∀z ∈ E. This completes the proof of the theorem.Assume that Nθ-quasi-Cauchy sequence.The concept of a quasi-Cauchy sequence in a 2-normed space was studied in . Now we xn) of points in a subset E of X is called Nθ-quasi-Cauchy if (Δxk) is Nθ-convergent to 0, that is,xk = xk+1 − xk.A sequence ) is an Nθ-quasi-Cauchy sequence whenever (xk) is.A function defined on a subset Nθ-ward continuous functions is Nθ-ward continuous, and sum of two Nθ-ward continuous functions is Nθ-ward continuous.We note that a composite of two Nθ-ward continuous image of any Nθ-ward compact subset of X is Nθ-ward compact.f is an Nθ-ward continuous function on a subset E of X and E is a Nθ-ward compact subset of A. Let (f(xn)) be any sequence of points in f(E) where xn ∈ E for each positive integer n. Nθ-ward compactness of E implies that there is a subsequence (γk) = (xnk) of (xn) with Nθ − limk→∞||Δγk, z|| = 0 for every z ∈ E. Write (tk) = (f(γk)). As f is Nθ-ward continuous, (f(γk)) is Nθ-quasi-Cauchy which is a subsequence of the sequence (f(xn)) with Nθ − limk→∞||Δtk, z|| = 0 for ∀z ∈ E. This completes the proof of the theorem.Assume that Nθ-ward continuous image of any compact subset of X is Nθ-ward compact.The proof follows from the preceding theorem.f defined on a subset E of X is sequentially continuous at x0, if for any sequence (xn) of points in E converging to x0, we have (f(xn)) converges to f(x0). f is sequentially continuous on E if it is sequentially continuous at every point of E  ∈ ΔNθ⇒(f(xk)) ∈ ΔNθ,(xk) ∈ ΔNθ⇒(f(xk)) ∈ c,(xk) ∈ c⇒(f(xk)) ∈ c,(xk) ∈ c⇒(f(xk)) ∈ ΔNθ,(xk) ∈ Nθ⇒(f(xk)) ∈ Nθ,(xk) ∈ ΔNθ⇒(f(xn))  is quasi-Cauchy,(xk) ∈ ΔNθ⇒(f(xn)) ∈ Nθ. is Nθ-sequentially continuity of f, and (3) is the ordinary sequential continuity of f. It is easy to see that (2) implies (1), and (1) does not imply (2); and (1) implies (4), and (4) does not imply (1); (2) implies (3), and (3) does not imply (2). (6) implies (1), but (1) does not imply (6) and (7) implies (1), but (1) does not imply (7). Now we give that the implication (1) implies (5), that is, any Nθ-ward continuous function is Nθ-sequentially continuous.We see that (1) is f is Nθ-ward continuous function on a subset E of X, then it is Nθ-sequentially continuous on E.If f is an Nθ-ward continuous function on a subset E of X. Let (xn) be any Nθ-convergent sequence in A with Nθ − limk→∞||xk, z|| = ||x0, z|| for all z ∈ X. Then the sequence x = (xn) defined byNθ-convergent to x0. Hence it is Nθ-quasi-Cauchy sequence. As f is Nθ-ward continuous on E, the transformed sequence (yn) obtained byNθ-quasi-Cauchy. Thus,z ∈ X. It follows from this that the sequence (f(xk)) is Nθ convergent to (f(x0)).Assume that f =  on the 2-normed space R2 with the usual 2-norm.The converse of this theorem is not valid in general, a counterexample can be easily constructed via the function fn) is a sequence of Nθ-ward continuous functions on a subset E of X and (fn) is uniformly convergent to a function f, then f is Nθ-ward continuous on E.If (xk) be any Nθ-quasi-Cauchy sequence of points in E, and let ε be any positive real number. By uniform convergence of (fk), there exists an n1 ∈ N such that ||f(x) − fk(x), z|| < ε/3 for k ≥ n1 and every x ∈ E and z ∈ X. Hence,r ≥ n1 and every x ∈ E and z ∈ X. As fn1 is Nθ-ward continuous on E, there exists an n2 ∈ N such that, for r ≥ n2,z ∈ X. Now write n0 = max{n1, n2}. Thus, for r ≥ n0, we havef preserves Nθ-quasi-Cauchy sequences. This completes the proof of the theorem.Let (n-normed spaces as another further study.In this paper, we investigate strongly lacunary continuity and some other kinds of continuities defined via a lacunary sequence and we prove interesting theorems related to these kinds of continuities. The results in this paper are extensively deeper than existing related results in the literature. We note that the notion of a strongly lacunary quasi-Cauchy sequence coincides with the notion of a strongly lacunary convergent sequence in a complete non-Archimedean 2-normed space, and so the set of strongly lacunary ward continuous functions coincides with the set of strongly lacunary sequentially continuous functions in a complete non-Archimedean 2-normed space (see  for the


Since 1984, when the hypothesis that HIV-causes-AIDS was announced, many scholars have questioned the premise and offered alternative explanations. Thirty years later, competing propositions as well as questioning of the mainstream hypothesis persist, often supported by prominent scientists. This article synthesizes the most salient questions raised, alongside theories proposing non-viral causes for AIDS. The synthesis is organized according to four categories of data believed to support the HIV-AIDS hypothesis: retroviral molecular markers; transmission electron microscopy (EM) images of retroviral particles; efficacy of anti-retroviral drugs; and epidemiological data. Despite three decades of concerted investments in the mainstream hypothesis, the lingering questions and challenges synthesized herein offer public health professionals an opportunity to reflect on their assumptions and practices regarding HIV/AIDS.“The HIV/AIDS hypothesis is one hell of a mistake”, wrote Kary Mullis in 1996  . Becausen (JAMA) .Celia Farber’s book, Serious Adverse Events: An Uncensored History of AIDS  – an exp… patients with repeatedly reactive screening tests for HTLV-III/LAV antibody … in whom antibody is also identified by the use of supplemental tests  should be considered both infected and infective Finally, in 1987, CDC adopted a non-qualified claim that antibodies signify active infection and/or illness: “The presence of antibody indicates current infection, though many infected persons may have minimal or no clinical evidence of disease for years” According to critics, a definitive answer regarding which protein–antigens are specific to HIV and HIV alone can only come from successful virus isolation and purification. Isolating and purifying “would be required to verify that all of these proteins actually originate from HIV particles” .The expression “viral load” refers to the quantity of virus found in HIV-infected blood. According to the mainstream perspective, information on viral load helps monitor the infection’s progress, “decide when to start treatment, and determine whether or not … HIV medications are working” .The technique for measuring viral load is known as RNA PCR – ribonucleic acid polymerase chain reaction . MainstrDespite its enhanced specificity, many mainstream scientists and practitioners recommend caution when using PCR for screening or diagnosing infection . For insPCR technology evolved quickly since it was introduced in 1983 . AlthougKary Mullis … is thoroughly convinced that HIV is not the cause of AIDS. With regard to the viral-load tests, which attempt to use PCR for counting viruses, Mullis has stated: “Quantitative PCR is an oxymoron.” PCR is intended to identify substances qualitatively, but by its very nature is unsuited for estimating numbers. Although there is a common misimpression that the viral-load tests actually count the number of viruses in the blood, these tests cannot detect free, infectious viruses at all; they can only detect proteins that are believed, in some cases wrongly, to be unique to HIV. The tests can detect genetic sequences of viruses, but not viruses themselves .If to this picture we add human endogenous retroviruses (or HERVs)  as potenA retrovirus is nothing more than RNA with an outer protein shell. The shell enables it to bind to cells of the type it infects, and once it gains entry, the outer coating disappears and the RNA is transcribed to DNA and incorporated as provirus into the host cell’s own genome. It is for this reason that retroviruses are called enveloped viruses, and it is also the reason that it is very difficult to distinguish between exogenous retroviruses (those that originate outside the body from a foreign invader) and endogenous retroviruses  … Much of the genetic material attributed to HIV is in fact DNA or RNA from [these] decaying cells (…) Human beings are filled with such endogenous retroviruses  tcell cultures. They never show HIV particles coming directly from an AIDS patient  –Montagnier also acknowledges the problems with relying on EM to identify a retrovirus, given the difficulties with purifying viral samples. In an interview given in 1997, he reflects on those first HIV images from cultured samples, produced in his laboratory at the Pasteur Institute:DT (Djamel Tahi): Why do the EM photographs published by you, come from the culture and not from the purification?LM (Luc Montagnier): There was so little production of virus it was impossible to see what might be in a concentrate of virus from a gradient. There was not enough virus to do that …(…)DT: How is it possible without EM pictures from the purification, to know whether these particles are viral and appertain to a retrovirus, moreover a specific retrovirus?LM: Well, there were the pictures of the budding. We published images of budding which are characteristic of retroviruses. Having said that, on the morphology alone one could not say it was truly a retrovirus … .It appears, therefore, there is little consensus regarding what the existing EM images reflect: are the visualized particles HIV or something else? According to Papadopulos-Eleopulos and colleagues, “some of the best known retrovirologists including Peter Duesberg, Robert Gallo, and Howard Temin have been telling us that particles may have the morphological characteristics of retroviruses but are not viruses” . From the epidemic’s onset, researchers worked relentlessly to find a vaccine to keep the virus from spreading and to develop drugs for managing the symptoms from opportunistic infections . The chaAfter the public announcement regarding the probable cause of AIDS, various pharmaceutical companies tried to develop drugs to thwart the action of the virus’ reverse transcriptase enzyme . AZT became the first medication of this kind, approved specifically for treating AIDS patients in 1987 . AzidothApproving AZT, however, did not prevent scientists from trying to develop other drugs, during the following decade; but most attempts would make little headway into the treatment of AIDS. Adding to these difficulties, AZT was proving to be extremely toxic and not as effective as initially anticipated. Researchers did learn, meanwhile, that prescribing AZT in lower dosages and in combination with other, well-known drugs such as heparin, acyclovir, and bactrim, was beginning to curb mortality rates .Thus, in the mid-90s “combination therapy” became available. Also referred to as the “drug cocktail,” combination therapy comprised a joint attack on HIV using three main classes of drugs, simultaneously: (a) those inhibiting reverse transcriptase’s ability to duplicate the virus’ genetic material using host DNA sub-divided into two classes – nucleoside and non-nucleoside inhibitors; (b) protease inhibitors (designed to limit certain proteins needed for HIV assembly); and (c) myristoylation or entry/fusion inhibitors (blocking the virus from entering the host cells). These three classes of drugs – known collectively as HAART (highly active ARV therapy) or antiretrovirals (ARVs) – have been praised for their ability to restore the health of patients with AIDS who become extremely ill .The AIDS Pandemic: The Collision of Epidemiology with Political Correctness:Curiously, however, even among mainstream scholars who believe epidemiological data constitute valuable evidence of a viral cause for AIDS, there are those who have turned a critical eye toward the data the US and the WHO have compiled. James Chin – one such critic Table  writes iEstimation and projection of HIV infections and AIDS cases and deaths (HIV/AIDS) can be considered more of an art than a science because of the marked limitations of both available data and methods for estimation and projection. These limitations make it possible for UNAIDS and other AIDS program advocates and activists to issue misleading and inflated estimates and projections The questions regarding the validity and reliability of epidemiological data emerging from within the mainstream/orthodox views have been echoed and amplified by unorthodox scholars. Both camps’ concerns center on four problems plaguing the estimates of incidence (new cases), prevalence (remaining cases), and projection (future cases) of HIV infections, AIDS diagnoses, and AIDS-related deaths: (a) the varying clinical definitions of AIDS  ; (b) varScience Sold Out: Does HIV Really Cause AIDS  factors, immune dis-balance factors, latent infection overload, and malnutrition as culprits.before HIV was identified .Pneumocystis carinii pneumonia, led the search to a halt  and determining both their toxicity and carcinogenic properties in humans and animals . Howevero a halt , 71. Invs ceased  revieweds ceased , p. 393]Other drugs such as those given to transplant patients to prevent organ rejection, as well as routinely prescribed antibiotics, also have been implicated as potential causes of immune dysfunction. Studies have shown that transplant patients who develop Kaposi’s sarcoma will go into remission, once taken off the drugs required to avoid organ rejection. Immune-suppressing drugs (as well as amyl nitrites) have, for instance, been directly correlated with Kaposi’s sarcoma, the rare skin cancer found frequently among AIDS patients during the epidemics’ early days The Silent Revolution in Cancer and AIDS Medicine, Kremer  hypothesis. Oxidative stress is a cellular-level electro-chemical phenomenon that diminishes a cell’s ability to absorb oxygen. This diminished capacity to process oxygen at optimal levels leads to the cell’s disruption and death. Scientists have either hypothesized or empirically connected oxidative stress to many diseases, including type 2 diabetes and cancer , 45, 76.oxidizing agents … At this point, readers might be wondering: given the problems with the mainstream hypothesis, how did we get here? How did we come so far, tethered to such a problematic perspective? The complexity of the answers to these questions aside, it may help to bear in mind the notion that HIV-causes-AIDS emerged and developed within a very specific scientific-cultural-historic context. Although the scope of this article precludes dealing with this complex context, for our purposes it is important to recall at least one element: Funding for President Nixon’s War on Cancer campaign ended in 1981 with very little achieved in the quest for an infectious cancer agent , 85–87. in favor of seriously considering their critiques, not against it.If viewed from this perspective, then, why scientists so quickly and assuredly “jumped on the HIV bandwagon” may not be very difficult to understand. That the scientific establishment world-wide insistently refuses to re-examine the HIV-AIDS hypothesis, however, is more difficult to accept, especially when one examines the credentials of those proposing such a revision. Their expertise carries as much weight as the teams who defend the orthodox hypothesis Table . Seth KaFurthermore, credibility as an argument works both ways: if to question the trustworthiness of unorthodox scholars is vital, it is equally crucial to question the reliability of those supporting the HIV-AIDS hypothesis. Readers who care to learn about HIV-AIDS’ history will encounter ethically questionable actions carried out by some of the most notable orthodox researchers, as well as ethical misconduct charges made against them .If it is difficult to dismiss the unorthodox views due to the credibility of their sources, then, why are not orthodox scientists and practitioners more willing to rethink the hypothesis or, at the very least, test the unorthodox arguments in a scientific, open debate? Although there have been, in fact, several attempts to engage the orthodox community in dialog, nearly all have been unsuccessful Here I would argue, nonetheless, that the debate between orthodox and unorthodox scientists comprises much more than an intellectual pursuit or a scientific skirmish: it is a matter of life-and-death. It is a matter of justice. Millions of lives, worldwide, have been and will be significantly affected by an HIV or AIDS diagnosis. If we – the public health workforce – lose sight of the social justice implications and the magnitude of the effect, we lose “the very purpose of our mission” .The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibro-inflammatory condition with an unclear pathophysiological mechanism affecting different parts of the body. If untreated, the disease can lead to fibrosis and irreversible organ damage. IgG4-RD mostly has been described in adults, hence it is generally unknown among pediatricians. This systematic search of the literature provides an overview of all reports published on IgG4-RD in children in order to create awareness of IgG4-RD in pediatrics and to emphasize the broad clinical presentation of this disease.A systematic literature search of Embase, Medline, Web-of-Science, PubMed publisher, Cochrane and Google Scholar was performed for case reports on IgG4-RD in children.Of total 740 articles identified by the search, 22 case reports including 25 cases of IgG4-RD in children were found. The median age of the children was 13 years, of which 64 % were girls. IgG4-related orbital disease (44 %) and autoimmune pancreatitis type 1/IgG4-related pancreatitis (12 %) predominantly occurred. Less frequently, other manifestations as pulmonary manifestation, cholangitis and lymphadenopathy were also found. Almost all cases were histologically proven. Prednisone was the first choice of treatment leading to favorable clinical response in 83 % of the cases. Maintenance therapy with steroid sparing agents was required in 43 % of the cases needing therapy. Rituximab was successful in all 4 cases, whereas, the disease modifying rheumatic drugs (DMARDs) mycophenolate mofetil, azathioprine and methotrexate were effective in almost 50 % of the cases.IgG4-RD in children is a generally unknown disease among pediatricians, but several pediatric cases have been described. Prednisone is the first choice of treatment leading to disease remission in the majority of the cases. DMARDs and rituximab are alternative effective steroid sparing agents with more positive evidence for the latter. IgG4-RD is a systemic fibro-inflammatory disease affecting different parts of the body . The disWe performed a systematic literature search in order to make an overview of all the case reports that have been published regarding IgG4-RD in children. The main purpose of this study was to create awareness of IgG4-RD in pediatrics and to emphasize the broad clinical presentation of this disease. Furthermore, with the current knowledge about the disease we wanted to provide an overview on epidemiology, pathogenesis and treatment of this disease for the pediatricians.A systematic literature search was conducted to provide an overview of all case reports and (if available) case series regarding IgG4-RD in pediatrics. The study was performed and reported in accordance with the PRISMA statement for systematic reviews.th 2015. Additional references were obtained from PubMed  and Google Scholar (the most relevant citations). No filters for date or language were used in the search strategy. See the additional Relevant articles on IgG4-RD in children were retrieved from Embase.com, Medline (Ovid), Web-of-Science, and the Cochrane Library from inception to last date of inclusion July 16Of a total of 740 articles identified by the search, 34 articles on IgG4-RD in pediatrics were eligible Fig. . After sWith this systematic literature review we identified 22 case reports of IgG-RD in children. Identified studies were published over a 5-year span (2010–2015). The case reports included patients aged ranging from 22 months to 17 years of age. The median age of the children in this study was 13 years and 64 % of the children were girls.The cases described in this study show a spectrum of different organ manifestations Fig.  of IgG4-In this study, all cases of IgG4-RD were histologically confirmed, except one case of Riedel’s thyroiditis , wherebyPrednisone was the first choice of treatment in 23 of the 25 cases , 24–29. The doses of prednisone that was used were not mentioned in all cases, but when specified was usually between 0.5 and 2 mg/kg/day. Prednisone therapy resulted in a rapid response in 19 of the 23 cases treated , 24–29. Rituximab was initiated in 4 cases , 13, 16 In this systematic search of the literature we describe 25 published cases of IgG4-RD in children. The cases demonstrate different organ manifestations of the disease with different clinical outcomes emphasizing the broad clinical spectrum of this disease.IgG4-RD is a rare and recently recognized fibro-inflammatory condition of which the diagnosis is often delayed or unrecognized because of unawareness. Generally it occurs in middle aged patients, more often in men than women . HoweverThe symptoms of IgG4-RD are variable and depend on the affected organs. It can be localized almost everywhere Table . In adulThe diagnosis of IgG4-RD can only be confirmed histologically, the gold standard, while clinical symptoms, serological and radiological findings could be supportive to establish the diagnosis. The typical histological abnormalities Fig. , accordiSerum IgG4 is elevated in most of the cases of IgG4-RD, but about 30 to 50 % of histologically confirmed cases have normal levels of serum IgG4, which can lead to falsely rejecting the diagnosis . InflammThe pathogenesis of IgG4-RD is unclear. Generally abundant serological T-helper cells 2 and regulatory T-cells are observed. These are most probably induced by an antigen triggering the immune system . SubsequWhen untreated, IgG4-RD can cause irreversible organ damage hence early and aggressive treatment is indicated . GlucocoSerum IgG4, when elevated, can be used in disease activity monitoring after initiating treatment, however, the role of serum IgG4 as disease activity marker has not yet fully been outlined . StudiesIn conclusion, IgG4-RD is a relatively new disease and generally unknown to pediatricians. The results of this study suggest that the average age of patients is lower than suggested in the literature. Early recognition and therapy are important to prevent serious and irreversible organ damage. Treatment with prednisone is the first choice for this disease, but maintenance therapy with DMARDs is often required. Rituximab may be a good alternative in therapy refractory disease. Further  studies should confirm these preliminary conclusions. Moreover, serological and histological studies and studies on treatment of children with IgG4-RD are needed in order to confirm the same results in children compared with previous studies performed in adults.


Immunoglobulin G4–related disease (IgG4-RD) is a new clinical entity. Characteristic features of IgG4-RD are elevated serum IgG4 levels, infiltration of IgG4-positive cells, mass-forming lesions with fibrosis and good response to corticosteroids. The variable imaging features of IgG4-RD and the overlap with other differential diagnoses often pose a diagnostic challenge, as they frequently mimic malignant tumors or other inflammatory diseases in the abdomen.A 54-year-old woman visited our hospital with left flank discomfort and palpebral edema. Computed tomography, magnetic resonance imaging, retrograde pyelography and positron emission tomography/computed tomography indicated renal pelvic cancer. However, after a left-sided nephroureteral cystectomy was performed, the mass was pathologically confirmed as an IgG4-related lesion. Her elevated serum IgG4 level and a past history of sicca complex supported the diagnosis of IgG4-RD.It is critical to recognize the importance of laboratory examinations such as serum IgG4 level if a patient has a past history of rheumatic disease. Immunoglobulin G4–related disease (IgG4-RD) is a new clinical entity. Characteristic features of IgG4-RD are elevated serum IgG4 levels, infiltration of IgG4 positive cells, mass-forming lesions with fibrosis and good response to corticosteroids. Variable imaging features of IgG4-RD and the overlap with other differential diagnoses often pose a diagnostic challenge, as they frequently mimic malignant tumors or other inflammatory diseases in the abdomen.A 54-year-old woman presented at our hospital with left flank discomfort and palpebral edema of 1-week duration. She underwent abdominal postcontrast computed tomography (CT) in a local hospital, which showed a low-density renal pelvic mass and hydronephrosis of the left kidney and indicated renal pelvic cancer Figure . On postA few days later the patient underwent a left-sided nephroureteral cystectomy and retroperitoneal lymph node dissection, in which part of the bladder was removed. The surgery was performed to establish a definitive diagnosis and for treatment if the mass was malignant.Gross examination of the kidney showed a 5 × 2.5–cm, pale, whitish-tan, ill-defined mass located in the renal pelvis near the renal hilum. Histologic examination of the mass showed lymphatic tissue hyperplasia and diffuse infiltration of plasma cells. The plasma cells were IgG- and IgG4-positive. The IgG4/IgG ratio was approximately 40% , and her high-sensitivity C-reactive protein test result was 26.3 mg/L . The patient underwent steroid therapy in a local hospital for 1 year. At the fourth month of her steroid therapy, her high-sensitivity C-reactive protein level had descended to 8.76 mg/L . Her enlarged lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions diminished with the steroid therapy.IgG4-RD is a relatively new clinical entity proposed by authors from Japan. CharactThe variable imaging features of IgG4-RD and the overlap with other differential diagnoses often pose a diagnostic challenge, as they frequently mimic malignant tumors or other inflammatory diseases in the abdomen. Renal let al.[IgG4-related renal lesions can mimic renal cell carcinoma or transitional cell carcinoma in uncommon cases of a single unilateral mass, such as a renal lesion or focal unilateral renal pelvic wall thickening. Yoshino et al. reportedIn our present case, all the imaging findings, including CT, MRI and retrograde pyelography, strongly indicated that the mass was a malignant one. On the basis of our experience in the present case, we do not believe PET/CT is a reliable way to differentiate IgG4-RD from renal malignancy. The renal pelvic mass in our patient was observed to be hypermetabolic on a PET scan. Multiple lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions were enlarged and hypermetabolic, vividly mimicking lymph nodes metastasis. We may draw a conclusion that a tumor biopsy should be done for patients with renal pelvic masses, even in cases with confirmed IgG4-RD, on the basis of the fact that the standardized incidence ratio for cancers in patients with IgG4-RD has been reported to be approximately 3.5 times higher than the incidence of cancer in the general population.et al.[et al.[Uehara et al. reported[et al. also repThe past medical history is another important clue in the differentiation of IgG4-RD from renal pelvic malignancy. The salivary gland is one of the target organs in IgG4-RD, and the clinical phenotype is so-called Mikulicz’s disease. In the In patients such as the one we describe in this report, it is critical to recognize the importance of laboratory examinations such as serum IgG4 level if a patient has a past history of rheumatic disease.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


Importantly, this is not equivalent to the total number of deaths among patients with antibiotic resistant infections and may be much less than this for two main reasons: not all patients who may have resistant infections are treated with clinically indicated antibiotics and, for those that are, the measurable difference in outcome for patients with resistant vs susceptible infections may be relatively small.Multiple metrics are used to quantify the “burden” of infectious diseases, including mortality, morbidity, disability adjusted life years, length of stay in hospital, or cost of care. Here we focus on mortality, although similar considerations apply to other metrics. An essential first step is to provide a clear definition of the burden of antibiotic resistance. We consider the most appropriate definition to be: More formally, this definition of burden can be expressed as a population attributable fraction , ie, the number of deaths that would not occur if antibiotic resistance were eliminated. As set out in the Box, to calculate PAF for mortality due to antibiotic resistance requires data not only on the number of patients with resistant infections and the number that die but also enumeration of the population of interest, which includes patients who survived and/or had susceptible infections. Enumeration of the population of interest in turn requires information on the incidence of the relevant clinical condition, its aetiology, and coverage of the antibiotic therapy of choice. Because such information is rarely available, PAF is rarely used to estimate the global burden of resistance; one recent example considered neonatal sepsis , but hadThe main clinical conditions where antibiotic therapy can reduce mortality . Some oGlobal consumption of antibiotics has recently been estimated at more than 70 billion doses per annum . By voluThese data refer to sales by pharmacies; they do not link antibiotic consumption to the treatment of patients with specific clinical conditions. The WHO last published generic guidelines for the therapeutic use of antibiotics in 2001  but thesCurrent antibiotic usage profiles are, of course, influenced by current patterns of antibiotic resistance. Resistance patterns mean that, for example, aminopenicillins alone may not be used to treat serious gram negative bacterial infections, alternative drugs would be used additionally where available. In this scenario, aminopenicillin resistance does not contribute to the population attributable fraction as defined above, although it is arguably an element of the overall burden of antibiotic resistance.The most comprehensive data on global levels of antibiotic resistance come from a recent WHO survey . Even soMoreover, bacteria–antibiotic combinations were not explicitly linked to clinical condition, so it is unclear when the resistances tested were clinically relevant and when they were not. This, together with the lack of data relating antibiotic usage to clinical condition, makes it difficult to estimate the relevant component of the PAF calculation, the fraction of patients with bacterial infections that are resistant to the antibiotic used to treat them /(ID−DR), where I is the overall incidence (number of patients per unit time); F is the number of patients with resistant infections that die; D is the number of patients that die; R is the number of patients with resistant infections. If all deaths are associated with resistance (F = D) then PAF = 1; if deaths are not disproportionately associated with resistance (corresponding to F = DR/I) then PAF = 0. Importantly, PAF = 0 does not equate F = 0.PAF calculation is routinely expressed in terms of the proportion of population exposed to the risk factor  and the risk ratio for mortality standardised to the unexposed group (patients with antibiotic–susceptible infections) . An equiF with treatment “failures”. However, some care is required because, given PAF<1, it is implicit that some of these patients (estimated as DR/I) would have died anyway, even if they had not had a resistant infection . Similarly, of patients with susceptible infections who survive, some would have survived anyway, even had they had a resistant infection; that is, not all positive outcomes can be attributed to successful antibiotic therapy.Intuitively, it seems natural to equate F, D and/or R, there is often insufficient information to determine I. To do so requires additional data on one or more of the following: i) the total number of patients of interest that survive; ii) the number with susceptible infections; or iii) the number with susceptible infections that survive.As detailed in the main text, although there is sometimes information available on Obtaining a single global estimate of mortality attributable to antibiotic resistance presents the additional challenges of combining and extrapolating estimates of PAF for given combinations of clinical condition, antibiotic, aetiological agent and location, and allowing assessment of future trends.attributable to having an antibiotic resistant infection (see Box).Two key quantities for estimating the burden of antibiotic resistance are the frequency and clinical impact of failures of antibiotic therapy. Treatment failure is a complex phenomenon that may well be attributable to factors other than antibiotic resistance, including misdiagnosis. Treatment failure can also occur in patients with antibiotic–susceptible infections. Central to the calculation of burden is the distinction between the death of a patient who has an antibiotic resistant infection and the death of a patient that is Data on treatment failures are not routinely recorded. One source of data on mortality is the ICD–10  codes used by the WHO .Information currently collected at global or multi–national scales is not sufficient to generate estimates of the disease burden attributable to antibiotic resistance. As a result, current knowledge of the burden of antibiotic resistance is still based largely on the collation of one–off, small–scale, individual studies that vary greatly in setting, scope, sampling frame and methodology, and often requires bold extrapolations to be made from very limited data sets. For estimation of the global burden of antibiotic resistance and, even more, for monitoring changes in burden over time more systematic approaches would be helpful. There are several possibilities.Enterobacteriaceae, might be prioritised for inclusion.ICD–10 is due to be replaced by ICD–11 in 2017 [ICD facilitates passive reporting. An alternative is active reporting by recruiting sentinel sites. For example, 660 hospitals from 67 countries responded to an internet survey on antimicrobial stewardship in 2012 . MonitorAs well as estimating the global burden of antibiotic resistance another useful exercise would be to estimate the global burden due to lack of access to suitable antibiotics. For some clinical conditions, this may be a substantially greater burden at the present time . The twoEstimation of the global burden of antibiotic resistance is extremely challenging and arguably not an attainable objective with currently available health data. We stress that this conclusion does not contradict the generally accepted view that antibiotic resistance is a major public health problem of global significance. There is a large number of studies documenting levels of resistance and its clinical impact, and well–founded concerns that both will rise, perhaps dramatically, in the foreseeable future. However, as reviewed here, the valuable insights provided by such studies do not sum to a comprehensive, coherent picture of the global antibiotic resistance burden and how it is changing. Improving this situation will require changes to the ways in which global health statistics are collected; existing approaches are not up to the task. The primary benefit will be more accurate assessment of the global disease burden due to antibiotic resistance and its forward trajectory, helping make the case for investment in combating the problem.


Background. Following the 1988 World Health Assembly resolution to eradicate polio, the government of Nigeria, with support from partners, has been implementing several rounds of supplementary immunization activities (SIAs) each year. In addition to the technical requirements, the success of the polio eradication initiative depends on timely provision of adequate financial resources. Disbursement of funds for SIAs and payment of allowances to numerous vaccination personnel at the grassroots level are enormous operational challenges in a country the size of Nigeria. Upon donors' request for a transparent and effective payment mechanism, the World Health Organization (WHO), in consultation with national counterparts, created the innovative direct disbursement mechanism (DDM) in 2004. The objective of the DDM was to timely deploy operational funds at the field level and directly pay vaccination personnel allowances at the grassroots level.Methods. A detailed operational guideline for funds disbursement was developed in close consultation with central and field stakeholders. Multiyear financial resource requirements and operational budgets for every campaign were produced by an interagency-coordinated finance subcommittee. The WHO engaged a bank and an accounting firm as DDM partners to support disbursement of and accounting for the SIA funds, respectively. The 37 WHO field offices were equipped with electronic financial systems to support the DDM process, and temporary payment sites were set up to facilitate payment to vaccination personnel at the grassroots level. Coordination meetings among DDM partners were held regularly to reconcile financial records and address operational challenges.Results. Between 2004 and 2014, DDM supported 99 polio and nonpolio vaccination campaigns, disbursing more than $370 million to about 16 million beneficiaries across 280 temporary payment sites. To mitigate security risks and reduce operational costs, the WHO and DDM partners introduced mobile payment to vaccination personnel in May 2015 in compliance with national regulations. A total of 97% of the targeted 1871 beneficiaries in 2 pilot sites were successfully paid through mobile payment, although some challenges remain to be addressed.Discussion. The DDM has met its objectives with a high rate of financial accountability and transparency, despite persistent operational and security challenges. With support from Nigeria, the Pakistan polio vaccination program successfully adopted the DDM. The DDM continues to play an important role in effective implementation of the polio endgame strategy and the national immunization strategic plan. As part of polio legacy planning, we recommend the DDM as a model for other opportunities that involve the engagement of large field-level teams as new vaccines are introduced in Nigeria and elsewhere. Nigeria is a federal republic with 36 states and a federal capital territory. There are 774 local government authorities (LGAs) and 9565 wards across the nation. Based on the last census, held in 2006, the country had a projected population of >170 million in 2014, which makes it the most populous in Africa [After the 1988 World Health Assembly resolution to eradicate polio, the government of Nigeria, with support from the World Health Organization (WHO) and partners, has implemented several rounds of immunization campaigns against polio each year . During In addition to technical and logistic requirements, the success of the polio eradication initiative (PEI) depends on timely provision of adequate financial resources to implement planned activities. The funds required for immunization activities in Nigeria are quite substantial, owing to operational complexity; the nature of the oil-driven economy, which makes the cost of goods and services expensive; and the large size of the population , 6. AccoDisbursement of funds for field activities and payment of vaccination personnel allowances down to the LGA and ward levels (wards are the lowest administrative unit in Nigeria) are enormous operational challenges in a country the size of Nigeria, because SIAs are the most labor intensive of the eradication strategies . In NigePrior to 2004, operational funds to support SIAs in Nigeria were deposited by partners in a central dedicated account managed by the central government agency responsible for disbursement of the funds to the field. This mechanism faced a number of challenges, including underpayment or nonpayment of end beneficiaries, delays in payment and retirement, and inadequacy of documentation. According to a study conducted by the World Bank in 2005, nonpayment of entitlements at the LGA level was an endemic problem in Nigeria .Following an audit's recommendations to address the challenges and inadequacies of the old payment system, major donors requested that a new payment mechanism be set up to continue with their financial contributions. The WHO conducted a risk assessment in 2013 and then established an innovative payment scheme, referred to as a “direct disbursement mechanism” (DDM), in 2014.The objective of the DDM was to resolve the shortcomings of the old disbursement system and meet donors' expectations. Accordingly, the DDM aimed to avail operational funds in time for implementation of field activities, ensure timely payment of eligible vaccination personnel, and ensure transparent and secured payment process to enhance accountability.In this article, we describe the process and activities involved in management of the DDM and how it provided an innovative solution for direct payment of activities and vaccination personnel at the grassroots level for successful implementation of SIAs.We conducted a retrospective review of publications of the global and local PEI partners and working groups, WHO internal documents, and unpublished reports to source data for this article.In line with the spirit of the Paris Declaration on Aid Effectiveness, which called for ownership, harmonization, and mutual accountability, the DDM was designed to function with government and partner involvement . The finTo ensure maximum effectiveness and accountability, the WHO engaged the services of a well-established bank and an accounting firm in Nigeria. The bank was responsible for funds disbursement, while the accounting firm provided monitoring, accounting, and reporting services. Figure Broadly, the SIA payments can be divided into 2 categories: payment for campaign activities and payment of allowances for vaccination personnel.Operational funds were transferred electronically to WHO state offices to implement field-level activities 3 weeks before the beginning of the campaign. The major budget lines under this category included microplanning, training, demand creation supplies, engagement of traditional leaders, monitoring and evaluation, logistics, and social mobilization. The disbursement of these funds was coordinated in consultation with local authorities, as per the state-level operational plans.To effectively manage the funds, the WHO equipped its central and 37 field offices with an electronic financial system and separate bank accounts. From 2012 onward, the WHO connected each field office with the organization's integrated global management system to process, control and execute management transactions . The gloOwing to inadequate banking infrastructure at the grassroots level in Nigeria, DDM partners, in collaboration with local authorities, set up about 280 temporary payment sites throughout the country to bring payment facilities closer to the beneficiaries Figure . The banAllowances for vaccination personnel constituted almost half of the overall operational budget for polio SIAs. In aggregate terms, the cost appears substantial. However, when broken down per beneficiary, as shown in Table Activity cards were distributed to each vaccination campaign worker recruited by local authorities before the commencement of the campaign. A supervisor signed the activity card each day an individual worked on the campaign. The WHO state office compiled the team composition as reported by ward or LGA focal persons. The WHO and the paying bank, with input from state officials and LGA focal persons, jointly developed payment schedules and an operational budget for each site. The WHO's central office reviewed the submissions and issued consolidated payment instructions to the bank. Within 7 days after implementation of the SIAs, the bank commenced payment to each beneficiary upon presentation of the duly signed activity card bearing the picture of the payee. The local authorities physically verified the eligibility of the payees to prevent any irregularity. The WHO administrative focal persons coordinated the whole process and submitted the payment site report to the central office in Abuja.As new developments emerged in the national financial regulatory landscape, the WHO approached the Central Bank of Nigeria for technical support to explore the possibility of introducing mobile payment. The Central Bank of Nigeria demonstrated keen interest because it saw such projects as an opportunity to drive development and modernization of the payment system, in line with Nigeria's vision of being among the top 20 economies in the world by 2020 . Mobile The bank compiled the financial documents from all LGAs and aggregated them at the state level. The accounting firm verified the payment/activity cards and other financial documents collected from the bank and the WHO and produced financial and management reports for each SIA.The WHO regularly convened the meeting of central DDM partners, comprising the bank, the accounting firm, and the company in charge of physical sorting and electronic archiving of the payment cards. This meeting evaluated the DDM's performance during the previous round, assessed the state of partners' preparedness for the next round, addressed any operational challenges, and discussed opportunities for system improvements.Between 2004 and 2014, 15.7 million beneficiaries supporting 99 immunization campaigns were paid more than $370 million  was received for various SIAs from the government and effectively managed through the DDM in line with the memoranda of understanding signed between the government and the WHO.The WHO's physical presence throughout the country plays important role in the DDM's effectiveness. The demands for direct funds disbursement prompted continued upgrading of the internal WHO financial management tools and systems, to ensure that field operational funds are made available in a timely fashion and that cash flow requirements are managed prudently. After setting up e-payment platforms in all field offices, the WHO fully migrated from cash-based payment to direct electronic payment to suppliers of demand creation materials and allowances to state teams, independent monitors, quality surveyors, as well as state technical facilitators involved in every SIAs. This was instrumental in mitigating financial and security risks. Transactions produced at the field-office level are monitored at the national and global levels in real time.The rate of financial accountability in the course of reconciling expenditures between the bank's records and the accounting firm's findings has decreased to a negligible margin since 2007 Figure . This waAs summarized in Table For >11 years, WHO Nigeria's DDM has proved to be an important component of the immunization program in Nigeria by providing an innovative solution toward timely deployment of funds for field activities and direct payment of allowances to thousands of vaccination personnel supporting every round of various SIAs. Detailed financial and management reports are produced in a timely and independent fashion by an accounting firm after thorough reconciliation of payment documents with the disbursing bank. The rate of accountability has improved since 2007, with the variance between bank records and those of the accounting firm decreasing to 0% beginning in 2009.The systematic engagement of implementing partners and government counterparts throughout the funds management process has contributed immensely to the credibility and transparency of the mechanism . There aThe operational challenges the DDM faces mainly arise from the voluminous number and cost of transactions, infrastructural constraints, and security risks. The most cumbersome aspect of the DDM process involves payment of the vaccination personnel. The challenge is compounded by the large number of payees; the poor banking network, especially in the rural part of the country; and the low literacy levels . The WHOOne of the steps taken to improve the payment mechanism was the introduction of mobile payments in the DDM. Overall, the first mobile money pilot went well, with 97% of the 1871 targeted beneficiaries receiving their entitlement through the mobile payment scheme. Some of the major challenges encountered in executing the pilot included errors in beneficiary data collection, the poor mobile network, and the poor literacy level of the beneficiaries, which hampered ability to change passwords. The lessons learned from the pilot will be used in scaling up the project. Owing to the limited financial infrastructure in the rural parts of the country, there will still be a significant number of beneficiaries who may not be covered by the new mode of payment. The project should adopt hybrid payment modes to ensure no payee is left out. We anticipate continued reduction of operational cost and better management of financial and security risks once the mobile payment is rolled out over a significant geographic area of the country. While its benefits are appreciated, DDM-implementing partners should also address the customers’ security concerns, as studies show these to be major barriers to the wide use of the mobile payments , 20.The challenges the program faced prior to 2004 were overcome with timely, direct, and full payment of beneficiaries with the successful maintenance of the DDM. Despite prevailing operational and security challenges, the DDM project continues to play an important role in successful implementation of the 2013–2018 polio endgame strategic action plan and the 2011–2020 global vaccine action plan, which require timely deployment of funds at the grassroots level and direct payment to numerous beneficiaries , 22.The DDM was designed to suit the campaign delivery formats of SIAs in Nigeria. With support from WHO Nigeria, Pakistan has successfully replicated the DDM for polio SIAs in that country . As part


Although targeting MET has yielded promising results in preclinical studies, few clinical trials of MET inhibitors have demonstrated the expected therapeutic benefits. This inconsistency raises the possibilities that there are different subsets of MET/HGF-aberrant breast cancer with different responses to MET/HGF-targeted therapies and that MET inhibitors benefit only a particular subgroup of patients. To fully realize the benefits of MET inhibitors, we must clarify the patient population that will benefit from them. Therefore, it is crucial to identify biomarkers that will optimize the use of MET inhibitors in individual breast cancer patients.MET aberrations. MET overexpression with or without amplification has been reported in many cancers [MET mutation or functional single nucleotide polymorphisms (SNPs). Several MET gene mutations have been reported in various cancers, but oncogenic MET mutations occur spontaneously in only 2-3% [MET sequence changes occur in 9% of patients with breast cancer. However, these appear to represent SNPs rather than somatic mutations. The sequence changes were associated with higher metastatic burden and high-grade histology [MET is functionally altered by an uncommon germline SNP, MET-T1010I, which is present twice as frequently in patients with metastatic breast cancer as in the general population. MET-T1010I transforms mammary epithelial cells and drives tumor formation and invasion in human HGF transgenic mice [MET-T1010I should be considered a potential biomarker when implementing clinical trials of MET-targeted agents. cancers . MET pro cancers . The METnly 2-3% . Mutationic mice , suggestHepatocyte growth factor (HGF)/scatter factor upregulation. Not only the MET receptor but also its ligand HGF drives tumor formation, metastasis, and drug resistance [HGF but not in the negative litters. Comparing mutant MET, wild type MET is more stringently dependent on its natural ligand HGF. These data suggest that not only MET status affects cell behavior but also level of its ligand HGF in the tumor microenvironment plays a key role in determining the functional outcomes of MET aberrations. Indeed, overexpression of HGF has been demonstrated in breast cancer, and HGF levels are increased in the serum of patients with breast cancer. Both primary and metastatic tumor cells (autocrine mechanism) and stromal cells (paracrine mechanism) secrete high levels of HGF and aberrantly induce ligand-dependent MET signaling. High HGF level correlates with poor prognosis in breast cancer [sistance . We recet cancer . Hypoxict cancer . TherefoCrosstalk between MET and other pathways. Accumulating evidence suggests that MET plays a key role in resistance to targeted therapies for cancer through crosstalk between MET and other pathways, such as the EGFR family [MET and PIK3CA greatly increased in breast cancer. Our unpublished data show that concurrent aberration of MET and PI3K significantly increased cell proliferation and invasion in vitro and in mice with similar human HGF levels. Targeting both MET and PI3K yielded greater inhibitory efficacy than targeting either agent alone, suggesting that response to MET-targeted therapy in breast cancer is dependent on an aberrant MET-HGF/PI3K axis.R family . InhibitR family . HoweverTaken together, these findings indicate that, to optimize the use of therapies targeting MET signaling and improve treatment efficacy in individual breast cancer patients, MET status, HGF level, and activation of the MET-HGF/PI3K and EGFR-MET axes should be considered as potential biomarkers when implementing clinical trials of MET-targeted agents.


IgG4-related disease (IgG4-RD) is a recently recognized fibroinflammatory condition associated with disease in nearly every organ, including the meninges. A proportion of idiopathic hypertrophic pachymeningitis cases may involve a component of meningeal IgG4-RD. We present a patient with severe bilateral vision loss found to have thickening of the dura mater on MRI, and subsequently diagnosed with IgG4-RD after dural biopsy. A 44-year-old man presented to the emergency department with progressive vision loss. He reported worsening vision for 8 days to near blindness, new-onset severe, and pressure like, non-pulsatile headache. Past medical history was remarkable for diabetes, hypertension, dyslipidemia, and rheumatoid arthritis. Vital signs were stable and the neurological examination showed no light perception on the OS, and only hand motion perception on the OD.2O, glucose 90 mg/dL, protein content of 44 mg/dL, RBC 1, and WBC 21 . Gram stain, cultures, and cytology were negative. IgG index was 1.09 (reference <0.66), and IgG was 13.3 mg/dL (range 0.8–7.7). A left frontal dural biopsy was performed.Non-contrast CT of the head showed no intracranial abnormality. Ophthalmological evaluation found no apparent explanation for the visual loss. Dexamethasone therapy was initiated. Contrast-enhanced MRI of the brain done 1 day later showed diffuse thickening and enhancement of the dura, greater on the left side  in 2001 when pancreatic specimens from patients with AIP were found to have large numbers of IgG4 positive cells (Since then, IgG4-RD has been associated with disease involving nearly every organ system including pancreas, salivary glands, lacrimal glands, thyroid, pituitary, lungs, aorta, pericardium, liver, biliary tree, kidneys, retroperitoneum, breast, prostate, lymph nodes, skin, periorbital tissues, and the meninges –3. TissuThe meninges may be involved either intracranially or intraspinally with a predilection for involvement of the pachymeninges rather than the leptomeninges . The MRIIgG4-related vision loss is rare. IgG4-RD can present as non-specific constitutional symptoms at the time of diagnosis, or more likely as a sub-acute expanding mass, with disease confined to a single organ for many years , 2. A prWe describe a patient with visual loss due to pachymeningitis from IgG4-RD. We believe that a proportion of IHP actually represents IgG4-RD and that clinicians should consider testing for this condition with biopsy and IgG4 immunostaining. Establishing a diagnosis of IgG4-RD is important in planning immunosuppressive therapy to prevent future complications.Consider IgG4-RD in the differential diagnosis of HP. Definitive diagnosis of IgG4-RD requires biopsy demonstrating characteristic histopathology along with IgG4 immunostaining. Initial outcome is favorable with corticosteroids, though response is often unsustained in the long-term, thus, additional immunosuppressive agents may be required. Patients with single organ involvement of IgG4-RD should be followed and screened for systemic involvement as disease may develop in multiple locations.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.