Turkey has been among the leading countries in antibiotic consumption. As a result of the 4-year National Action Plan for Rational Drug Use, antibiotic prescriptions had declined from 34.9% in 2011 to 24.6% in 2018. However, self-medication with antibiotics without prescription is common, which is not reflected in official statistics. The present study aims at investigating antibiotic use in the community and the factors related to it. A web-based survey was conducted among 945 Turkish-speaking respondents . The questionnaire included questions about antibiotic use for different illnesses, ways to obtain and handle leftover antibiotics, knowledge, beliefs of the antibiotic effectiveness, attitudes, health anxiety, and background factors. According to the results, 34.2% of the sample had self-medicated themselves with antibiotics without a valid prescription. The most common way to self-medicate was to use leftover antibiotics. While 80.4% knew that antibiotics are used to treat bacterial infections, 51.4% thought that antibiotics are effective for viral diseases. The most important predictor of antibiotic use frequency was the belief in their efficiency for various illnesses and symptoms, followed by negative attitudes to antibiotics, health anxiety, knowledge level, positive attitudes, and health status. The results underline the importance of targeting misbeliefs about antibiotics in future campaigns. Since the discovery of penicillin in 1928, antibiotics have played an enormous role in public health [At the same time, with increased antibiotic consumption, antimicrobial resistance has become one of the biggest threats to global health . AntimicSeveral studies have shown that antibiotic consumption rates vary significantly between different European countries, the Southern and Eastern European countries using more antibiotics than Northern and Western European countries ,7,8,9. TAntimicrobial resistance occurs because of inappropriate and excessive use of antibiotics, in addition to poor infection control . While pAttitudes, as enduring general evaluation, can influence the use of antibiotics. Earlier studies have addressed the attitudes to antibiotics among physicians, pharmacists, and the general population and reported that positive attitudes towards antibiotic use and interventions for reducing antimicrobial resistance could influence both prescription practices and how the general public uses antibiotics ,25,26,27Earlier studies about antibiotic use in the community have mainly focused on attitudes, beliefs, and knowledge, while personality or emotions have attracted much less attention. In earlier studies, parents’ neuroticism has been found to be related to their child’s medication adherence . In addiThe present study aimed to investigate the relationships between knowledge about antibiotics and antimicrobial resistance, attitudes to antibiotics and antimicrobial resistance, and health anxiety among Turkish participants.The respondents were asked about lifetime antibiotic use; 59.7% of the respondents reported using antibiotics more than 10 times, and 38.1% reported using antibiotics less than 10 times. In terms of antibiotic use in the previous 12 months, 55.8% of the respondents reported having been using antibiotics during the previous year. As expected, antibiotics are commonly used medicines.When asked about using antibiotics without prescription, 34.2% said that they had had antibiotics without a valid prescription. The most common way of obtaining antibiotics was via physician’s prescription (91.6%), followed by using leftover antibiotics (20.3%), from pharmacy/internet pharmacy without a doctor’s prescription an antibiotic which you used before (15.4%), from a pharmacy without a doctor’s prescription an antibiotic which the pharmacist recommended (9.7%), and from a relative or friend (11.3%). It should be noted that obtaining an antimicrobial medicine without prescription should not be possible after the 2014–2017 action plan in Turkey. When asked whom the respondents would address when ill and wishing to have antibiotics, 93.3% would turn to a physician and 6.6% to a pharmacist in the first place.The respondents were also asked about behaviour if they felt better after 2–3 doses of antibiotics. The majority (65.1%) said they would finish the course as prescribed, while 23.0% said they would stop taking the medication and 9.7% reported that they would have a smaller dose . When asked about the leftover antibiotics, 50.7% said that they would keep them for future use in the case of the same symptoms, 39.6% said that they would destroy the leftover medicines, and 7.5% said that they would keep the leftover medicines to use them for any other illness.Respondents’ knowledge of antibiotic use was measured with nine statements see . Most ofBeliefs in antibiotic effectiveness were measured by asking respondents to evaluate the effectiveness of antibiotics in 16 different symptoms/conditions . AntibioPearson correlation coeffects between study variables can be seen in In addition to correlates to antibiotic use, As expected, anxiety about one’s health correlated negatively with positive attitudes (r = −0.11) and self-evaluated health status (r = −0.18). People who evaluated their general health low were also more anxious about health and had a more positive attitude to antibiotics. It should be noted, however, that these correlations were relatively weak, while statistically significant.Hierarchical multiple regression analyses were applied to model the frequency of antibiotic use in terms of the sum of 15 symptoms. In the first step, background variables  were entered into the model. In the second step, knowledge and beliefs about effectiveness were added to the model. In the third step, two attitude scores (positive and negative attitudes) were added. The final full model also included health anxiety see .Models 1, 2, 3, and 4 all were statistically significant, with F-values of 6.78 (df = 4912), 93.05 (df = 6912), 77.21 (df = 8912), 69.87 (df = 9912), respectively, and the R change was also statistically significant in each step.Self-medication with antibiotics without prescription is an alarming problem, especially in low- and middle-income countries , but alsIn addition to an antimicrobial stewardship programme targeting hospital antibiotic use, the Turkish Ministry of Health launched a second programme  for curbing antimicrobial prescriptions in primary care . Recent The present study showed that the great majority (80.4%) of the respondents knew that antibiotics are used for curing bacterial diseases. However, about half (51.4%) thought that antimicrobials are used against viral diseases, and 48.6% thought that antibiotics cure every type of microbial infection. Similar findings have been reported in other studies, the proportion of people believing in antibiotic effectiveness against viruses varying from 20% to 57% ,18,19,20The regression analysis results of the present study show that the belief in antibiotic effectiveness is the strongest predictor of antibiotic use, followed by negative attitudes, positive attitudes, and health anxiety. The importance of beliefs, attitudes, and knowledge has been demonstrated earlier in several studies conducted, for example, in Australia , EthiopiSimilarly, antimicrobial resistance is an abstract concept and should not be explained at the community level, but as a real risk for an individual . BesidesFinally, health anxiety predicted antibiotic use frequency significantly. This means that individuals with health-related anxiety may use antibiotics as a precaution in the case when the aetiology of the illness, e.g., sore throat or fever, is not clear. In this way, the use of medicines in general and antibiotics, in this case, might be used to control health-related anxiety. As demonstrated with medication for chronic illnesses, personality  and patients’ emotional states can influence the adherence to medication . While aThis study has some limitations which should be taken into account. Firstly, the sampling was based on convenience sampling among students and their relatives, friends, and acquaintances. Thus, the sample does not represent the Turkish population in terms of age and education level. It should be noted, however, that collecting representative samples in Turkey is difficult, because the response rate to postal surveys tends to be very low, which compromises the representativeness of the sample. Household or telephone interviews could be an alternative, but those methods are also vulnerable to sampling bias due to the lack of anonymity. The present study was conducted by sending invitations to students and using anonymous internet sampling, which increases the anonymity of the answers. In addition, the respondents’ socio-economic status or place of residence  was not asked, although these factors might influence self-medication with antibiotics. It should be noted, however, that the results in the present study are in line with studies conducted in other countries. In future studies, age- and region-stratified representative samples should be collected to further study antibiotic use in communities in Turkey.The data were collected by advertising the web link to SurveyMonkey among students at the Middle East Technical University, Ankara, Turkey. The students and their friends and relatives were invited to fill in an online survey. The online questionnaire contained information on the background to the study, objectives, voluntary nature of participation, declarations of anonymity and the confidentiality of all data, and informed consent was obtained from all participants. Norwegian Centre for Research Data (NSD) was consulted to see if ethical permission is needed for the study. Since the study was conducted on the internet and no identification data were collected, the survey does not contain any sensitive data as defined by NSD, so no ethical permission was required.The data included 945 Turkish speaking respondents, of which 61.3% were female. The respondents were fairly young  compared to the median age of the population of Turkey (31.5 years), which is understandable, since the sampling was conducted among university students and people related to them. The sample was also more educated than the population on average: 18.6% of the respondents were high school graduates and 77.8% were university graduates or university students, while only 3.6% of the respondents had less than a high school degree. When asked about self-assessed general health, 0.4% evaluated their health “bad”, 1.6% “rather bad”, 10.3% “neither bad nor good”, 41.3% “rather good”, and 46.3% “good”.The survey questions were constructed by modifying questions used in literature, brainstorming based on clinical experiences, and experiences from our earlier studies.The respondents were asked, with five alternatives, how they usually get their antibiotics. The options were “From pharmacy with a doctor’s prescription”, “From pharmacy/internet pharmacy without a doctor’s prescription an antibiotic which you used before”, “From pharmacy without a doctor’s prescription an antibiotic which the pharmacist recommended”, “Use antibiotic which was leftover from an earlier prescription”, and "From a friend or a family member”. The respondents could choose as many alternatives as they wished.The respondents were also asked to indicate if they turned to a physician (antibiotic with prescription) or to a pharmacist (antibiotic without prescription) in the first place to get antibiotics. In terms of completing the treatment, the respondents were asked what they would do if they felt better after 2–3 doses of antibiotic treatment. The answer alternatives were “stop taking medicine to avoid unnecessary use”, “continue the course but with a smaller dose than prescribed”, and “continue the course to end as prescribed”. The respondents were also asked about handling the leftover antibiotics. The three answer alternatives were “I would destroy the leftover antibiotics”, “I would keep them for future use in the case of the same illness”, and “I would keep them for future use for any illnesses”.The dependent variable in this study was the frequency of antibiotic use for 15 illnesses or symptoms see . The resParticipants’ knowledge about antibiotics was measured with a question “Which of the following are the purposes/uses of antibiotics?” about nine different purposes see . The resBeliefs about the effectiveness were measured with the question, “How effective (cure or shorten the illness or make it easier) are antibiotics for following illnesses or symptoms?” Respondents evaluated the effectiveness of antibiotics with a 4-point answer scale  in terms of 16 illnesses see . The totTo measure attitudes to antibiotics and antibiotic resistance, they were measured with 17 statements, to which the respondents replied with a 5-point scale from “totally disagree” (1) to “totally agree”. The responses were analysed with factor analysis  to see if the 17 attitudes group to subfactors. The results of the factor analysis yielded two clearly interpretable factors which could be named as “positive attitudes to antibiotics”  and “negative attitude to antibiotics” . The reliability coefficients  were 0.70 and 0.77 for “positive attitudes” and “negative attitudes”, respectively. The attitude scales correlated negatively with each other (r = −0.57). The altitude scores could range from 1 to 5.Health anxiety was measured with Health Anxiety Inventory (HAE) . HAE conThe survey included questions about age, sex, education level, and use of antibiotics during the past 12 months  and lifetime .The data were collected with SurveyMonkey and analysed with SPSS v27. The data were analysed with descriptive and frequency analysis, factor analysis, reliability analysis, Pearson correlation coeffects, and hierarchical multiple regression analysis.The present study showed that self-medication with antibiotics without prescription is still a significant problem in Turkey, while the antibiotic prescription rate among community physicians has dropped. The public’s misbeliefs about antibiotics are mostly related to the effectiveness of antibiotics in viral infections, such as influenzas and the common cold. These wrong beliefs should be targeted in future campaigns and educational interventions. In addition, the role of health anxiety should be studied further in relation to self-medication with prescription medicines in general, and antibiotics in particular. The public should be warned about the risks of self-medication “just in case”.


MET gene exon 14 (METex14) skipping alterations. The CHMP statement follows Food and Drug Administration-accelerated approval of tepotinib for the same indication, issued on 3 February 2021.On 16 December 2021, the Committee for Medicinal Products for Human Use (CHMP) issued a positive opinion, recommending a marketing authorisation for tepotinib , an oral, highly selective mesenchymal–epithelial transition (MET) inhibitor.MET gene encodes hepatocyte growth factor receptor (HGF), involved in the regulation of cell proliferation, migration, invasion and angiogenesis. Activation of MET tyrosine kinase activity leads to epithelial to mesenchymal cell transition, a process associated with cancer invasiveness, increased metastatic potential and resistance to therapy. MET gene is deregulated in a proportion of NSCLCs via three distinct mechanisms: exon 14 skipping mutations ; MET amplification ; and MET gene fusions (rarely reported). METex14 aberrations occur typically in older patients, relatively frequently smokers and are associated with sarcomatoid histology.P-450 (CYP) drug-metabolising enzymes as well as their possibility to combat multidrug resistance were explored in vivo and in vitro.in vitro data showed that tepotinib is a substrate of CYP3A4, CYP2C8 and P-glycoprotein (P-gp). However, it is not possible to accurately quantify the fractions metabolised by the individual major CYP isoenzymes.Tepotinib is an oral, highly selective kinase inhibitor that targets MET kinase activity, including the isoform produced by exon 14 skipping mutations. The recommended dose is 450 mg once daily with food (two 225 mg tablets). Tepotinib inhibits both HGF-dependent and -independent MET kinase activity, which results in greater suppression of MET signalling as compared to inhibitors of only ligand-dependent activity.Toxicology studies show that the main target organs in animal studies based on tepotinib-related histopathological changes included liver (significant bile duct hyperplasia), lung and gastrointestinal tract, with occasional evidence of oedema in some organs.It is recommended that patient taking tepotinib should avoid using concomitant medications with strong CYP3A and CYP3A4 inducers and with dual strong inhibitors of CYP 3 or P-gp.Brain penetration and observed efficacy of tepotinib in NSCLC METex14 patients with brain metastases have been confirmed in rat studies. The calculated ratio of unbound brain to plasma was 0.25, indicating a brain penetration which is sufficient for inhibition of the intracranial disease.MET gene abnormalities were identified prospectively by tissue- or plasma-based PCR or next-generation sequencing assays. Patients  enrolled in the Vision trial were relatively older (median age of 73 years), mostly of white ethnicity, with equal distribution of sex, and never-smoking history (less than 100 cigarettes in a lifetime) was noted in 45% of subjects. Independent review committee objective response rate, assessed by RECIST 1.1 in patients with at least 9 months of follow-up, was 46% , with a median duration of response of 11.1 months .Tepotinib recommendation, solely for patients with tumours showing METex14 skipping mutations, is based on the results of Vision (NCT02864992), a single-arm, open-label global study.MET amplification, most common grade 3 or higher adverse events were reported in 28% of patients, with peripheral oedema and pleural effusion being the most common, followed by lipase, amylase or liver transaminase increase. Serious adverse events related to tepotinib were noted in 15% of patients, and included mostly events associated with oedema. Dose reduction was undertaken in 15% and permanent treatment discontinuation in 11% of patients, mostly due to peripheral oedema, pleural effusion or dyspnoea. The most common grade 1 or 2 adverse events include peripheral oedema, nausea/vomiting, diarrhoea, creatinine, lipase, amylase or transaminase increase and asthenia/fatigue.In the safety population of 152 patients with tumours showing METex14 skipping alterations or MET amplification (de novo or as a resistance mechanism to other targeted therapies), or rare MET gene rearrangements, should further be explored, in NSCLC and also in other tumour types; fourthly, mechanisms of resistance to tepotinib and capmatinib should be determined to rationally design subsequent therapies.Positive CHMP recommendation of tepotinib for treatment of NSCLC patients with METex14 skipping alterations adds to the enlarging portfolio of targeted therapies in lung cancer and is in line with the National Comprehensive Cancer Network recommendations for the diagnosis and treatment of advanced NSCLC.


PTPRZ1‐MET (ZM) is a critical genetic alteration driving the progression of lower‐grade glioma. Glioma patients harboring ZM could benefit from MET inhibitors. According to the remarkable role of ZM as a driver of glioma progression and indicator of MET inhibitor sensitivity, it is necessary to detect this alteration even when it presents in glioma with relatively fewer copies.ZM could be detected with a high‐sensitive method of reverse transcriptase PCR with 50 amplification cycles. Via this newly proposed detection method, we depicted the incidence preference of ZM fusion in a cohort of 485 glioma patients. To further explore the oncogenic nature of ZM, we predicated the protein structure alteration of MET kinase brought by its fusion partner.Herein, we proposed that ZM fusions was much higher than previous report. ZM fusions exhibited a striking preference in lower‐grade glioma and secondary glioblastoma. By contrast, none of patients with primary glioblastoma was detected harboring ZM fusion. In each of the four variants of ZM, the fusion partner segment of MET contained a remarkable coiled‐coil motif. In glioma cells expressing ZM, MET kinase could be activated in a ligand‐independent manner, which might be contributed by the special coiled‐coil structure brought by the fusion partner. Corresponding to the 3D structural analysis and cell line experiment, the ZM positive clinical specimens showed hyperactivations of MET signaling.The incidence of ZM fusions are critical drivers of glioma progression and effective target of MET inhibitor. Early detection could be performed with a high‐sensitive method of reverse transcriptase PCR. The hyperactivations of MET signaling driving glioma progression might be contributed by a ligand‐independent activation enabled by the protein structure modification of extracellular domain of MET in ZM fusions. PTPRZ1 and MET segments that are common to all the four ZM fusion variants. The PCR products of different ZM variants were of different sizes. All the PCR product bands on agarose gel were purified and sequenced via Sanger sequencing. The sequencing reads were aligned to the known ZM fusion sequences. The existence and the variant of ZM fusions then was confirmed and clinically reported.Glioma tissue RNA was abstracted after surgery. RT‐PCR of 50 amplification cycles then was performed with the primers designed based on the  Herein, we report a high‐sensitive and low‐cost method to detect ZM fusions in glioma tissues. This method could be used as the “gold standard” of ZM positive (ZM+) glioma diagnosis as the fusion point of PTPRZ1 and MET could be confirmed via Sanger sequencing included in this method. Despite the critical roles of ZM fusions in LGG progression that have been proposed, the intrinsic mechanism of MET activation launched by ZM has not been explored. With 3D protein structure predication, we found that the fusion partner fragment added to MET kinase in ZM fusion protein contains a coiled‐coil structure which might contribute to the ligand‐independent MET activation.As 22.1http://www.cgga.org.cn/).Glioma tissues and the patients’ follow‐up information  were obtained from the Chinese Glioma Genome Atlas (CGGA) dataset. Patients treated at Beijing Tiantan Hospital, Sanbo Hospital in Beijing, Harbin Medical University and China Medical University were included in this study. Written consent was obtained from all patients. The glioma tissues were snap‐frozen in liquid nitrogen immediately after surgical resection and preserved in liquid nitrogen. Only samples with >80% tumor cells were enrolled for analysis. The establishment and management of our CGGA databank has been introduced in our previous publications.ZM+ or ZM negative (ZM−) glioma used in this study was collected from dorsalis pedis artery. Two milliliters of whole blood were collected from each patient.The peripheral blood from patients harboring All the processes of tissues and information collection were approved by the Institutional Review Boards of Beijing Tiantan Hospital (No. KY2014‐002‐02) and were conducted in accordance with the principles expressed in the Declaration of Helsinki.2.2Glioma tissue RNA was abstracted using the RNAprep pure Tissue Kit (Tiangen Biotech) followed by cDNA synthesis .RNA concentration and quality were measured using the NanoDrop ND‐1000 spectrophotometer (NanoDrop Technologies). Only RNA with A260/A280 values >1.8 and <2.0 were adopted in following processes. The integrity of total RNA was evaluated by agarose gel electrophoresis after the RNA samples were ten times diluted. Only if the bands of 28S rRNA and 18S rRNA were both bright and clear, and the bright intensity of 28S rRNA: 18S rRNA was about 2:1, the RNA was identified as qualified. Complementary DNA was synthesized from 1 μg of qualified total RNA using the SuperScript III First‐Strand Synthesis SuperMix kit (Invitrogen).ZM (forward: 5′‐CCGTCTGGAAATGCGAATCCTAAA‐3′ reverse: 5′‐CAGGCCCAGTCTTGTACTCAGCAA‐3′) were used to clone the sequences crossing the fusion points with DNA polymerase . The primers were designed based on the PTPRZ1 and MET segments that are common to all the four ZM fusion variants. All the four ZM fusion variants could be specifically amplified using this pair of primers, and amplification products were of different sizes . In every examination, a negative control test to avoid cross‐contamination or false positive was performed simultaneously with nuclease‐free water, and a positive control test to avoid false negative was performed with an already‐known ZM+ cDNA.RT‐PCR were performed using 1 μl of cDNA. The PCR program included denaturing at 95°C (30 s), annealing at 58°C (30 s), and extension at 72°C (30 s). Primers flanking the fusion points of ZM fusion sequences to determine whether ZM fusions were present in the given glioma specimen and which variant it was.After electrophoresis, the amplification product bands were purified and submitted for Sanger sequencing. The sequencing reads were aligned to the known ZM fusions examination step were as the corresponding steps in ZM detection of glioma tissues mentioned above.RNA of whole blood was abstracted with RNAprep Pure Hi‐Blood Kit (Tiangen Biotech). The following reverse transcription step and Quantification of the bands’ gray intensity was performed with the software of ImageJ following phase inversion.2.32.Glioma cell line U87 MG was obtained from the Institute of Biochemistry and Cell Biology, Chinese Academy of Sciences, and was cultured in Dulbecco's Modified Eagle's Medium (DMEM) with 4.5 g/L glucose. The DMEM culture medium was supplemented with 10% fetal bovine serum , 100 units/ml penicillin, and 100 μg/ml streptomycin (Invitrogen). The cell line was cultured at 37°C in a humidified atmosphere of 5% CO2.4ZM variant 1 and ZM variant 2 coding sequences were separately cloned from ZM+ gliomas tissues and transferred into a His6‐tagged pShuttle‐CMV vector. The sequences were then individually recombined into the pADxsi vector. Insertion of the right sequences was confirmed with restriction enzyme digestion and sequencing. The recombinant plasmid was subsequently linearized by restriction enzyme digestion and transfected into HEK293A cells with Lipofectamine2000 (Thermo Fisher Scientific) for the generation of adenoviral vectors. The collected adenoviral vector was aliquoted and stored at −80°C before use. U87 MG cells were treated in the medium containing an appropriate titer of the adenoviral vector for 6 h before medium change. ZM fusions expression in the cell line was confirmed by RT‐PCR.2.5Glioma tissue or U87 MG cells were lysed with RIPA buffer  supplemented with protease inhibitor (Solarbio biotech). Protein concentration was evaluated using Coomassie Brilliant Blue on a microplate spectrophotometer . Equal amounts of tissue or cell total protein (30 μg) were loaded on a 10% SDS/PAGE gel, transferred to a PVDF membrane (Merck Millipore), and detected using an ECL Western Blotting Detection System (Bio‐Rad). The information of the primary antibodies used in the current study was in accordance with the corresponding antibody information in the Star Methods in our previous publication.β‐Tubulin or glyceraldehyde 3‐phosphate dehydrogenase (GAPDH) was used as the loading control. Goat anti‐rabbit IgG‐HRP or goat anti‐mouse IgG‐HRP was used as secondary antibody. The gray intensity of the bands was quantified by ImageJ software.2.6PTPRZ1 binding to exon2 of MET) was submitted to QUARK online service server (https://zhanglab.ccmb.med.umich.edu/QUARK2/). In the returned 3D structure, the additional segments to MET in the other three variants were highlighted in blue with PyMOL (2.3).The sequence of the first 200  amino acids added to MET in ZM variant 4  for each glioma tissue using primers flanking the fusion points. The numbers of amplification cycle in each RT‐PCR were separately 30 and 50. The PCR product bands in agarose gel were purified and sequenced using Sanger sequencing and the fusion point of ZM fusions when they present with a small number of copies. The number of amplification cycles was much more than that commonly used in PCR. Thus, before we determined the mentioned ZM fusion detection method (PCR‐Sequencing), we firstly demonstrated the specificity and robustness of ZM fusions segments amplification using reverse transcriptase PCR of 50 amplification cycles  could be identified ZM+ at 30 amplification cycles. Along with increase in amplification cycles numbers from 30 to 50, the quantity of PCR product grew. Until amplification cycle number reached 50, all the ten samples produced specific bands. Nevertheless, PCR product quantity kept stable and not increased markedly at 60 amplification cycles.Theoretically, quantity of specific PCR product grows exponentially along with numbers of amplification cycles until reaches the plateau phase. To detect early 0 Figure . Among tZM+, all the PCR product bands on agarose gel were purified and sequenced via Sanger sequencing followed by confirmation of the fusion point of PTPRZ1 and MET fragments . As a contrast, none of the primary GBM was found ZM+, which was in accordance with our previous discovery that ZM was a driver of the progression from LGG to sGBM. ZM fusions were more frequent in grade III astrocytomas  and sGBMs (26.7%), whereas only 3.2% of the grade III oligoastrocytomas (AOA) harbored ZM fusions  within MET were confirmed. Fusions with exon 1 or 2 of PTPRZ1 fused to exon 2 of MET  were the most common variants   Figure . Three oZM conferred a negative survival effect in sGBM patients. Kaplan‐Meier survival analysis demonstrated poor overall survival (OS) for patients with ZM fusion‐positive sGBM compared with sGBM patients without ZM fusion    Figure . A simil) Figure . In UnivZM fusions and the critical histology and molecular features counted in the definition of 2016 WHO classification of gliomaZM fusion incidence with the 2016 WHO classification of glioma  was higher (36.84% vs. 17.50%) than elder (Age ≥ 40) patients , the incidence of ZM fusion was 33.33% . After surgical resection, the occurrence rate of seizures in patients with ZM‐ sGBM was prominently reduced to 12.77%. Meanwhile, none of the patients with ZM+ sGBM had seizures occurred after surgical resection  in PTPRZ1‐MET. Via QUARK, an algorithm determining spatial location of every atom in a protein molecule from the amino acid sequence developed by Dong Xu and Yang Zhang.PTPRZ1 binding to exon2 of MET). As ZM variant 4 is the longest PTPRZ1‐MET fusion, the additional fragments of PTPRZ1 in all the other three ZM variants are included in these 200 amino acids  had been enrolled in a clinical trial of blocking malignant progression with a highly selective and BBB‐permeable MET kinase inhibitors.We had previously reported the presence of ZM fusions are critical drivers of glioma progression and the clonal evolution of ZM fusion copies, detection of these fusions even if they are present in glioma tissues with few copy numbers is meaningful and will benefit the patients.In tumors, the canonical driver genetic alterations could be acquired and seeded very early.ZM fusions as this early seeding genetic alterations might be dispersive in tissue bulk with very fewer copies. Bulk tumor with gene rearrangements might be missed as negative via FISH examination while be identified as positive by qRT‐PCR analysis.However, the feature of fusion genes including two sequences from two totally different genes decides the difficulties of their detection, especially in clinical diagnosis. The antibodies for either of the two fusion partners are not specific enough for the fusion protein, while development of a specialized antibody targeting the fusion point is arduous. Fluorescent in situ hybridization (FISH) has a tedious operating process and the diagnostic results prone to be bias depending on the field of the pathological slices under the microscope. It means that FISH is not an ideal approach to detect https://www.sigmaaldrich.com/content/dam/sigma‐aldrich/docs/Sigma/Bulletin/qr0100bul.pdf, Technical bulletin of quantitative RT‐PCR kit from Sigma‐Aldrich). PCR product of such length is not applicable for gel cutting from agarose gel after electrophoresis and the following PCR product purification. As Sanger sequencing and sequence alignment with the known ZM fusion gene sequences is required for ZM detection, the procedure of PCR product purification is needed.Real‐time PCR is a commonly used method to detect clinically meaningful genetic alterations in cancers. However, real‐time PCR is not applicable to detect ZM fusions. The quantify capacity of real‐time PCR assay is based on the stable amplification efficiency of primers. Whereas, ZM fusions contain four variants of different lengths. The amplification efficiency of the primers is difficult to keep consistent when different ZM fusion variants are detected. For real‐time PCR, the optimal PCR product size is between 100 and 150 base pairs  with 30 or 50 amplification cycles separately to amplify ZM fusion genes. The incidence was found higher than our previous reports, in which ZM fusions were detected by RNA‐seq and confirmed by RT‐PCR.ZM+ glioma had emerged, the early detection of these alterations will benefit the patients in prevention or early management.With the proposed PCR‐Sequencing approach, we described the incidence features of MET signaling activation is dependent on binding of MET kinase with its ligand HGF.In classic model of receptor tyrosine kinase (RTK) activation, ligand binds to the extracellular ligand pocket and causes two monomers’ combination in a process termed as dimerization.The dimerization mechanisms vary in different RTKs. The main mechanisms are the three ones as following: Each RTK monomer binds to a ligand molecule and then dimerizes; two monomers are linked by a single ligand molecule and then dimerizes; or two monomers are originally linked by a disulfide bond in their extracellular region, and after ligand binding, the intracellular domains conformation change and bind each other.in vitro experiments with U87 MG cell line. The results suggested that ZM fusions could cause MET hyperactivation in a ligand‐independent manner. As a primary GBM cell line, the use of U87 MG had potential limitation to study the malignant progression from LGG to sGBM. However, considering the lack of low‐grade or secondary glioma cell lines, U87 MG cell line was still a reasonable and reliable choice. Besides, as a MET‐dependent glioma cell line,For MET, the extracellular SEMA domain is the key structure for ligand binding and dimerization. In ZM fusions, the fusion partner sections are added to the SEMA domain, suggesting that the modification prone to affect the critical step of ligand binding and dimerization of MET kinase. To verify this hypothesis, we performed ZM fusions in different age of patients with sGBM was distinct. The occurrence rate of seizures was also different in patients depending on whether their tumors harboring ZM fusions or not. This finding suggested that the ZM fusion status may serve as a potential indicator of epileptic seizures and surgical seizure and the detection of ZM fusion could provide a more accurate assessment of personalized treatment in clinic. The above clinical relevance suggested that there is still a long way before fully uncovering the influence of the existence of ZM fusions in glioma progression.The incidence of The authors declare that they have no conflict of interests.Informed consent was obtained from all individual participants for CGGA project in this study.Supplementary MaterialClick here for additional data file.


Patients with positive LNs require escalation in treatment and experience increased side effects. Effective treatments of the involved LNs are required to prevent metastatic spread. Particular attention should be paid to the side effect profile as therapy can be intolerable for patients. In this study, Sukhbaatar et al utilized a LN metastatic mouse model to optimize a lymphatic drug delivery system (LDDS). They first determined the optimal osmotic pressure and viscosity ranges of the solvent for LDDS that would appropriately deliver the drug to involved LNs while minimizing systemic side effects. They then delivered a single dose of docetaxel at 10 mg/kg and were able to detect a significant antitumor effect with no treatment‐related side effects. Intranodal therapeutic delivery will eventually significantly improve outcomes and quality of life for patients with locally advanced cancer.https://onlinelibrary.wiley.com/doi/full/10.1111/cas.152832Extracellular vesicles (EVs) secretion is elevated in cancer cells. These EVs have been shown to change the local and distant tumor microenvironment, which suggests that they play a significant role in cancer metastasis. Thus, EVs have been studied for use as potential biomarkers and targets for novel therapeutics. However, the mechanism that regulates whether multivesicular bodies (MVBs) fused with lysosomes for degradation or with the plasma membrane for release as EVs is not well established. In this study, Hikita et al examined the role of mitogen‐activated protein kinase kinase (MEK) and mitogen‐activated protein kinase (ERK) on the regulation of EVs. They found that the MEK/ERK pathway inactivated lysosomal activity, which led to increased EV secretion. This increased EV secretion was regulated by MYC upregulation, which localized MiT/TFE transcription factors to the cytoplasm and suppressed transcription of lysosome‐related genes. The MEK/ERK/MYC pathway is an intriguing target to suppresses cancer cell EV secretion.https://onlinelibrary.wiley.com/doi/full/10.1111/cas.152883Title: N‐glycosylation regulates MET processing and signalingN‐glycosylation played in the regulation of MET. They found that inhibition of N‐glycosylation suppressed the processing and trafficking of endogenous MET. Furthermore, the deletion of N‐glycan of MET showed similar results and suggested that the SEMA domain played an important role in N‐glycan mediated regulation of MET. Targeting N‐glycosylation may produce an efficacious MET targeted therapeutic.Tyrosine kinase inhibitors (TKIs) have been extremely effective treatments for lung cancer patients with targetable mutations. The one caveat is that these patients will eventually develop resistance to the TKIs. MET, a receptor tyrosine kinase (RTK) for hepatocyte growth factor (HGF), has been studied because amplification of MET has been associated with TKI resistance. However, there are very few drugs that have any clinical indications. In this study, Saitou et al examined the role that https://onlinelibrary.wiley.com/doi/full/10.1111/cas.15278


Concrete, the most common material in the building industry, involves the use of mineral aggregates that represent an exhaustible resource, despite their large availability. For a series of applications, these mineral aggregates can be replaced by vegetal ones, which represent an easy renewable natural resource. In this study, two types of vegetal raw materials, namely sunflower stalks and corn cobs, were used in developing 10 compositions of ecological microconcrete, with different percentages involved: 20%, 35%, 50%, 65% and 80%; they were analyzed from the perspectives of density, compressive strength, splitting tensile strength, resistance to repeated freeze-thaw cycles, modulus of elasticity and thermal conductivity. The results revealed that the microconcretes with sunflower stalks registered slightly higher densities and better results regarding the compressive strength, splitting tensile strength, modulus of elasticity, and freeze-thaw resistance than those with corn cobs. Lightweight concrete is obtained when more than 50% replacement rates of the mineral aggregates are used. In 2018, they were responsible for 39% of the total CO2 emissions and for 36% of the global energy consumption [Buildings and construction represent high-demand sectors in terms of energy consumption and CO2 for each ton of cement produced [Concrete represents the most used building material all over the world but it is a nonecological material by definition, if we take into account the amount of exhaustible raw materials used for its production, and the energy consumption involved in obtaining Portland cement. To produce one ton of Portland cement, around 1.5 tons of raw materials are used  . Cement produced .Concrete greening methods studied so far include the substitution of cement, as its production determines an energy consumption of about 92% of the total energy , with vaNumerous studies have been carried out on replacing the mineral aggregates in concrete. They have used various variants of substitute materials for mineral aggregates, natural or industrial: bamboo , sugarcaHelianthus annuus) is a widespread agricultural plant in South America, Southern Europe, European Russia and South Africa [Zea mays) is a widely used agricultural plant in Eastern Europe, the United States, China, South Africa, cultivated in 2019 on more than 189,000 ha globally [Among vegetal aggregates suitable for use in concrete are corn cobs and sunflower stalks, given their wide global distribution, annual regeneration nature and the encouraging results of studies carried out so far on these plants ,29,30,31h Africa , grown oh Africa . Maize  and a peripheral woody part (bark) , very si 2 kg/m3 . These v 2 kg/m3 . The the 2 kg/m3 . In rese 2 kg/m3  on the a 2 kg/m3  developeThe aim of this research is to realize a comparison between concrete with aggregates from corn cobs and concrete with aggregates from sunflower stalks. The method applied for obtaining and treating the aggregates was approached similarly to that presented in detail in a previous study . A microThe present study involved the development of microconcrete recipes with vegetal aggregates from corn cobs and sunflower stalks, respectively. As a starting point, we used a reference concrete (RC) made with a conventional microconcrete recipe of the C25/30 strength class, with a maximum aggregate size of 8 mm, according to NE 012/1-2007 . This cl-aggregates: natural sand with diameter of up to 4 mm, and river gravel with diameter of 4–8 mm;-cement type CEM II/A-LL 42.5R MPa, produced in Romania;-polycarboxylate ether superplasticizer additive;-rhodanide-based accelerator additive, to speed up the early strength development of the vegetal concretes , so wateRC was made using the following materials:The water/cement ratio used was 0.50.In the RC recipe, the mineral aggregates were replaced with vegetal ones in volumetric proportions of 20%, 35%, 50%, 65% and 80%. Thus, we obtained five concrete compositions with corn cob aggregates, and five concrete compositions with sunflower aggregates. The vegetal aggregates were in granular form with variable diameter smaller than 7 mm in the case of corn cobs, and chips and fibers smaller than 25 mm length combined with granules with variable diameter of up to 7 mm in the case of sunflower stalks ; they weThe 10 concrete recipes with vegetal aggregates were noted as SFCXX or CCCXX, XX denoting the volume percentage  of sunflower aggregates or corn cob aggregates, respectively.In The density of the hardened concrete was determined 28 days after pouring, according to the methodology of EN 12390-7:2019 . The denThe concrete specimens were tested in monoaxial compression, with a hydraulic concrete press carrying a load evenly distributed on the surface of the specimen, according to EN 12390-3:2019 . The speThe determination of splitting tensile strength was performed on cylinders with diameter of 100 mm and length of 200 mm. This test consisted in compressing a specimen after two diametrically opposed generators .The tests were performed according to EN 12390-6:2009 . A hydraThe freeze-thaw resistance test  was perfAfter completing 50 cycles of 4 h of freezing and 4 h of thawing, the specimens were compression tested, and the loss of compressive strength was determined.For determination of the modulus of elasticity to compression of the concrete developed in this research, method 2 of EN 13412:2006  was appl2 and one third of the compressive strength of the specimen, determined according to EN 12390-3:2019 [The modulus of elasticity is determined by measuring the change in tension in the concrete test specimen at loading, to produce a pressure (force) between 0.5 N/mm0-3:2019 .The thermal conductivity was determined according to a method provided in SR EN 12667:2009  on the tIn the results analysis, we realized an interpretation of the individual values of the vegetal concretes ; the following variants, SFC35, SFC50, SFC65, and SFC80, recorded approximately similar values of this parameter, with small variations between 0.80–0.99 N/mm2.In the case of concrete with sunflower aggregates, there was also a decrease in splitting tensile strength as the percentage of plant material increased . The incIn a comparative analysis, according to RC registered a modulus of elasticity of 35,809.80. According to In terms of compressive strength, after being subjected to 50 freeze-thaw cycles, RC registered a decrease of 12.74%. Concrete with corn cob aggregates recorded decreases to a greater extent than RC . Thus, gIn comparative analysis , and above those that implied broken corn cobs, not shredded. The compressive strength of CCC80 was above other studies on concrete with similar corn cob content. SFC80 recorded bigger or similar values for compressive strength and better thermal conductivity than similar studied materials.As for advantages of sunflower stalks and corn cobs in concrete composition, they had a significant influence in reducing density and thermal conductivity, in addition to their ecological and sustainable character. A concrete with lower density and a more elastic character could lead to a better behavior of the buildings in case of seismic activity, since it would lower overall weight if it is used in nonstructural applications, such as screeds, plaster, partition walls or in masonry blocks form. As screeds, adding their thermal insulation characteristics, a reduction of the thermal bridges at the slab level can be obtained.SFC and CCC can improve a building’s sustainability by diminishing their total carbon footprint through the use of easy-to-obtain, renewable raw materials instead of exhaustible ones.


A significant decrease was observed in antibiotic exposure in SAP , average prophylactic antibiotic cost , and mean LOS ; and a slight decrease in the number of confirmed SSIs was found between the two periods . Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties , clinical outcomes , antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days,  Joint arthroplasties are frequently performed life-enhancing procedures. The need for these surgical procedures continues to rise. Although arthroplasties belong to clean surgical procedures ,2, surgiThe purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on compliance with SAP among patients undergoing joint arthroplasties, as well as antibiotic exposure and cost in SAP.In the pre-intervention (12 months) and the intervention period (7 months) data of 525 and 210 patients, respectively, were collected. Of them, 130 patients were excluded in the pre-intervention period and 28 patients in the intervention period, due to various reasons see .The characteristics of patients and surgical procedures are described in p > 0.05) were observed between the two periods. However, the use of the guideline adherent combination of cefuroxime and amikacin slightly increased  in the intervention period. Data show no differences in dose and frequency of antibiotics used for SAP (The characteristics of SAP and outcomes are summarized in  for SAP .p ˂ 0.001). At the same time, guideline adherence in terms of SAP duration improved significantly  (p ˂ 0.001).No data on the timing of the first dose of SAP were collected. Considering all arthroplasties together, we found a significant difference in the mean duration of SAP between the two periods  . These rp ˂ 0.001) (p < 0.001). As expected, the decrease of SAP duration led to significantly lower prophylaxis costs after intervention  (p < 0.001).Antibiotic exposure in SAP decreased significantly  . When an< 0.001) . Overallp < 0.001) (p ≥ 0.05) (p = 0.21) in the number of confirmed SSIs was found between the two periods. The number of suspected SSIs was higher , which is consistent with the fact that empirical or targeted administration of antibiotics was deemed necessary in 19.5% of the pre-intervention cases and 2.7% of the cases in the intervention period (p < 0.001)  . Hospita ≥ 0.05) . A sligh< 0.001) .Antibiotic resistance occurs everywhere in the world . The antEven though SAP is of major importance in the prevention of SSIs ,16, it iIn the present study, we found that in the pre-intervention period irrational antibiotic use was quite frequent for SAP in orthopedic surgery. Redundant antibiotic combinations of beta-lactams or quinolones with metronidazole, and prolonged SAP duration contributed to the high total antibiotic consumption and costs of SAP. In the intervention period we implemented daily pharmacist intervention, which resulted in remarkable changes in several parameters of SAP and clinical outcomes . There aSeveral studies assessing compliance with SAP guidelines have been published. In the literature, the most important types of non-adherence to guidelines are (i) starting prophylaxis before the day of surgery ,22, (ii)p = 0.122) in the intervention period. Inappropriate use of metronidazole is not uncommon. A study in Pakistan on different surgical procedures, including orthopedic surgeries, found that after the pharmacist intervention the use of combination antibiotic therapies with metronidazole decreased significantly . However, in the same study the rate of inappropriate antibiotic choice did not change significantly, which is consistent with our findings [p = 0.48) [Overall compliance to SAP guidelines is usually in the range of 20–50% ,29,30. Afindings . Also, a = 0.48) .p ˂ 0.001) in the intervention period, which is in line with above-mentioned international findings.In our study we found an overall guideline adherence  of 2% in the pre-intervention period. The adherence to guidelines was relatively high for agent choice (88.6%) and for dosage (86.3%); nevertheless, only 2% of these patients received SAP for an appropriate duration. Due to the shortening of SAP duration, the rate of overall guideline adherence  improved significantly  was observed. This adherence rate for SAP dosage after pharmacist intervention is similar to rates of appropriateness of dosage reported in the literature. Zhou et al. reported an increase in appropriateness of dosage for cefuroxime  after pharmacist intervention in SAP [p ˂ 0.001) [During the intervention phase of the present study, slight improvement in the dosage of guideline adherent antibiotics  .As for timing, El Hassan et al. found a guideline adherence of 30.4% for the timing of the first dose . Data rep < 0.001), as well as the reduction in the proportion of over five days prophylaxis to one-third of the original rate  were particularly favourable changes  [Several studies have focused on the duration of SAP. In Europe, data obtained in a point prevalence survey conducted by the ECDC (European Centre for Disease Prevention and Control) showed that antibiotic use for SAP accounted for 18% of the total antimicrobial use in acute care hospitals in the EU. In surgery, 36% of the administered antibiotics are used for SAP, and more than half (60%) of all these antibiotics were used for more than one day, which implies prolonged use. In Hungary, these rates are above the European average  . In a re= 0.003) . Moreove= 0.003) .p < 0.001) as well as in prophylactic cost , not only in primary arthroplasties, where the adherence to guidelines improved very much , but also in revision hip arthroplasties .As our results show, pharmacist intervention can have a significant impact on SAP compliance resulting in a significant reduction in the amount of antibiotics used for SAP  after intervention . A studyRegarding clinical outcomes, the most important limitation of our study is that data on hospital readmission due to SSIs may be incomplete due to the fact that only patients with severe SSI were readmitted to the hospital in both study periods  , and we p = 0.21). Beside this, median time to diagnosis of SSI in this study was eight days (ranging from 1 to 23 days). At the same time, we believe that these SSI rates are also confirmed by the fact that the number of cases requiring postoperative antibiotic treatment due to infections related to the surgery also decreased significantly (by 16.8%)  .p = 0.02) [According to a literature review, significant variability in the incidence of orthopedic SSIs  was noted between different studies (from 1.9% to 22.7%) ,44. A 4- = 0.02) . These SThe other clinical outcome we studied was the LOS. As the findings reported earlier reveal, neither prolonged prophylaxis, nor choosing agents with a broader spectrum than recommended, nor combinations provided any benefit in terms of length of stay ,40,47,48p = 0.023) [p < 0.001) in patients undergoing hip arthroplasty [p < 0.001). Our results support these findings by showing similar improvement in the intervention period, when LOS decreased significantly for all types of arthroplasties .Some studies found direct association between pharmacist intervention and decrease of LOS; a study on different surgical procedures including orthopedic surgeries found that pharmacist intervention resulted in favorable outcomes with significantly decreased LOS  . Xi et aroplasty . LikewisIn the intervention period, the activity of the clinical pharmacist was not only welcome, but actively sought for. Studies also show that adherence to guidelines may be facilitated by consultation, and even more by regular audits of the prophylaxis practice ,50.One of the important limitations of our study is that this was a single-center study conducted in a university-affiliated hospital; therefore, findings may not be directly extrapolated to other settings. At the same time, this study provides detailed, first-hand observations of everyday work processes on SAP at an Orthopedic ward.This was a single center study including a retrospective observational part (pre-intervention period) and a prospective intervention part (intervention period). The study was conducted at a 61-bed Orthopedic Department of a tertiary-care center in Hungary. The pre-intervention period was from 1 November 2016 to 31 October 2017 while the intervention phase from 1 November 2017 to 31 May 2018 periods. The pre-intervention period was merely an observational period, when the clinical pharmacist was present in limited hours in the ward compared to the intervention period, and collected data retrospectively from all patients receiving an antibiotic. The intervention period was a prospective phase, when the clinical pharmacist spent six hours a day in the ward.The study population included all the hospitalized patients receiving SAP for primary THA , TKA , and revision arthroplasty (surgery performed to replace the worn-out joint) at the aforementioned Department.All patients admitted from another ward/hospital who were on antibiotic treatment, patients receiving preoperative empirical antibacterial therapy due to various suspected or proven infections, or targeted antibacterial therapy, or SAP for other operations than THA and TKA, as well as patients readmitted due to SSI or PJI  were excluded from the study.The data obtained in the pre-intervention period were analyzed by the pharmacist, who later provided feedback to prescribers. Taking into account the HOA (Hungarian Orthopedic Association) national guideline and the clinical practice guidelines for SAP published by ASHP , problemBased on HOA and ASHP SAP guidelines, the recommended first-line systemic antibiotic for prophylaxis in arthroplasties was cefazolin or cefuroxime; for patients with allergy to beta-lactams clindamycin or vancomycin is recommended as an alternative; whereas in cases when the prevalence of Gram-negative pathogens is high, gentamicin or amikacin as an addition to cefazolin or cefuroxime . Dose anProphylaxis was considered appropriate if it did not last for more than one day for primary, and more than five days for revision arthroplasties.of admission from day of discharge, and refers to the number of days that patients spent in hospital. Both the admission and discharge day were counted as one day.All hospitalized patients receiving antibiotics for SAP were identified and their medical records were retrieved. Demographics , clinical characteristics , symptoms: fever > 37.5 °C, C-reactive protein > 5 mg/L, positive blood culture or micro-organism isolated from wound, bone, or synovial fluid samples), data on antibacterial administration , and cost (cost of antibiotic agents) were recorded on data collection forms. LOS was calculated by subtracting day Patients were anonymized, and thus made unidentifiable in the study.We compared prophylactic antibiotic use regimen, namely the number of prescribed antibiotics (single agent or combination), active agent(s), dosage, and duration of prophylaxis, as well as and rate of guideline adherence, antibiotic exposure: DDD/patient, antibiotic costs, and clinical outcomes  during the two study periods using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate, using R statistical environment. To measure the antibiotic consumption, we applied the World Health Organization’s ATC/DDD index (version 2020). Defined Daily Dose (DDD) is the assumed average maintenance dose per day for a drug used for its main indication in adults. Antibiotic costs were calculated based on actual prices obtained from the central hospital pharmacy. Values of equal or less than 0.001 (multiple comparison method) were considered statistically significant.Continuous presence of the clinical pharmacist in orthopedic surgery led to significant improvement of SAP guideline adherence and increased appropriate antibiotic use, which were accompanied by decrease in direct antibiotic cost, number of surgical site infections, and length of stay. Results suggest that clinical pharmacists acting as active members in antibiotic stewardship teams  may play an important role in promoting rational use of prophylactic antibiotics in surgery, and avoiding unnecessary SAP costs.


Q factor). Bilinear classification models were used to evaluate the individual and a combination of the characteristic parameters. It was demonstrated that the best evaluation performance was obtained by using average peak frequency or the combination of average peak frequency and average Q factor, obtained by eight accelerometers in the multi-channel IE device. The results and discussion in this study would improve the understanding of characteristics of multiple IE testing parameters in concrete slab tracks and provide a fundamental basis to develop an effective prediction model of non-destructive evaluation for debonding defects at the interface between TCL and HSB in concrete slab tracks. Multi-channel Impact-echo (IE) testing was used to evaluate debonding defects at the interface between track concrete layer, TCL, and hydraulically stabilized base course, HSB, in a real scale mockup model of concrete slab tracks for Korea high-speed railway (KHSR) system. The mockup model includes three debonding defects that were fabricated by inserting three 400 mm by 400 mm (length and width) thin plastic foam boards with three different thicknesses of 5 mm, 10 mm, and 15 mm, before casting concrete in TCL. Multi-channel IE signals obtained over solid concrete and debonding defects were reduced to three critical IE testing parameters (the velocity of concrete, peak frequency, and  Concrete slab tracks  are widely used in the high-speed railway systems in Germany, the Netherlands, China, Japan, and Korea ,2. The bThe continuous concrete slab tracks in Korea were developed based on the German Rheda 2000 system ,11,12 s. The traVarious defects  have been observed on the actual concrete slab tracks in the KHSR system . TypicalThe overall condition of concrete slab tracks is estimated through visual inspection in a periodic inspection plan in Korea. Visual inspection is primarily used to investigate any surface evidence associated with damages in concrete slabs . However, the information gathered through visual inspection is only limited to the surface, thus, it is challenging to evaluate sub-surface damages  in concrete. In order to collect additional information on the sub-surface defects, field engineers usually tap the surface of concrete using a small hammer. The test region over sub-surface damages can be identified by hollow (or drummy) sounding . The hamThe impact-echo (IE) test has been demonstrated to be an effective evaluation of defects in concrete plates in buildings and civil infrastructure systems ,25. The Q-factor). Third, bilinear classification models were used to evaluate the individual and a combination of the characteristic parameters. As will be discussed, the use of multi-channel IE parameters results in a more accurate prediction model that evaluates the debonding defects in the concrete slab tracks. The primary objectives of this research are to evaluate the multi-channel IE testing parameters measured on a real sale mockup model of concrete slab tracks for the Korea high-speed railway (KHSR) system and to propose a bilinear classification model for non-destructive evaluation of debonding defects in concrete slab tracks by multi-channel IE testing. For these purposes, three main tasks were performed in this study. First, multi-channel IE testing was performed on a real scale mockup model of concrete slab tracks that includes three debonding defects at the interface between TCL and HSB. Second, multi-channel IE signals obtained over solid concrete and debonding defects were reduced to three critical IE testing parameters  and the thickness (H) of the plate as follows,H with the depth of the debonding defect in concrete, h, as follows,Two sets of resonance modes associated with Lamb waves in slabs are generally used to detect and characterize horizontal defects in concrete: the thickness stretch mode and flexural vibration mode. The frequency analysis of the two resonance modes provides useful information on the presence and dimensions of horizontal defects  in concrete. First, the thickness stretch mode dominates the spectral response of a plate that does not contain any near-surface defects see a. Thickn to 0.25 . For the HSB see b. The thThe size of a debonding defect should be large enough compared to the depth of the defect to set up the thickness stretch mode in concrete. There is a shadow zone over a perimeter of the defect that does not produce clear thickness stretch mode. As a rule of thumb, the size of the delamination defect should be about two times greater than the depth of the delamination defect and both sensor and source should be located over the middle of the delamination defect avoiding the shadow zone. The relatively strict criteria pose difficulties on the use of thickness stretch mode to evaluate the horizontal defects in concrete, especially in the field practice. flexf, is dependent on the plate geometry , shape, and boundary conditions [flexf is effective for evaluating the presence of relatively shallow delamination defects compared to the depth of the defect in concrete. It is also useful to estimate the areal extents of the debonding defects [flexf. It can be expressed by mechanical properties of concrete and dimensional sizes of concrete over the square debonding defects (h and h/c) [h and c is the depth and the width of a debonding defect, respectively, and η1, η2, η3, and η4 are constants, whose values are 1.64, 0.0014, −1.812, −0.22, respectively. In contrast, debonding defects in concrete can be characterized by flexural vibration mode. Flexural vibration modes can be interpreted as non-propagating waves because of multiple reflections of Lamb waves at a debonding defect. The propagating Lamb waves (A0 and S0) over a debonding defect are reflected and transmitted multiple times at the edge of the debonding defects . Unlike nditions . The ana defects ,19,20,23flexf over a debonding defect with normalized width  and thickness of a debonding defect. h = 250 mm in A multi-channel IE testing device, developed by a research team at Dong-A University, was used to evaluate the concrete slab track specimen see a. The prThe multi-channel IE testing device was used to measure the dynamic responses of four test regions on the concrete slab track specimen. One test region represents the solid concrete , and ther =  =  and the impact source at s =  = . The time signals shown in r =  =  and s =  = . The spectral amplitude of the dynamic response of concrete was obtained by the Fourier transform of the time signals see c,d. The Q factor was used as a measure of the damping property of the oscillation signal (or the energy lost in the cycle of oscillation). In this study, the Q factor was determined by normalizing a center frequency of a resonance mode (cf) by its bandwidth (B) excited by an impact force on each testing point as follows,B is the bandwidth determined from the difference between the upper frequency (Hf) and lower frequency (Lf), in a −3 dB lower power limit. In addition, it was noticed that spectral amplitude signals corresponding to the flexural vibration mode are even clearer peaks compared to the spectral response from the thickness stretch mode in the sound concrete. In this study the sharpness, of the spectral amplitude was considered as a critical IE testing parameter to evaluate the debonding defects in the concrete slab track specimen. In general, the differences in the sharpness of the special amplitude are caused by different damping properties of vibration signals. The w represents windowed signals, t is time, A unique benefit of using a multi-channel IE device, compared to a single sensor IE device, is its capability of measuring the velocity of concrete at a single IE testing. The velocity of the propagating waves is a good indicator of the quality of concrete in various structures. The velocity of concrete is evaluated from the dispersion curves representing the variation of velocities with the propagating waves. In this study, propagating Lamb waves  were extracted by applying Hanning windows with a size of 2 times of the period at the minima of first dominant time wave signals. The dispersion image was obtained by applying the phase-shift method  on the eA resulting dispersion curve, A histogram presented by blue bars in In contrast, a distribution of the average phase velocity measured over a debonding defect 1 (DB1) is shown as brown bars in c/h = 1.70, 1.74, and 1.78), and P-wave velocity of 4000 m/s. Therefore, it can be inferred that the dominant peak frequency can be interpreted as the flexural vibration mode of concrete over a debonding defect. In contrast, histograms representing the distribution of peak frequency values over the three debonding defects  are shown in requency . FurtherQ factor values determined from spectral amplitude data measured by an individual accelerometer in the multi-channel IE device. Q factor distributions obtained in the solid and the three de-bonded regions are presented in Q factor values measured over the solid concrete region, presented as blue bars in Q factor values over the solid concrete region are sub-divided into two groups (see peakf ≥ 3000 Hz), which is shown as brown bars, and the second data group associated with the secondary peak frequency (peakf < 3000 Hz), which is shown as yellow bars. Furthermore, Q factor values obtained over the three debonding defects, DB1, DB2, and DB3, presented as purple, yellow, and brown bars respectively, are shown in Q factor values than those associated with the first peak frequency (full-thickness mode). In addition, dynamic responses over debonding defects result in an even greater Q factor compared to those in a full-thickness mode in solid concrete regions. Therefore, it can be inferred that the Q factor is a potential parameter that classifies the condition of the concrete in concrete slab tracks. oups see a: one daQ factors in the solid test region by IE testing using an impact source located at S1. Q factor values measured by a single accelerometer and the averaged Q factor values measured by eight accelerometers, respectively. By inspection of the distribution characteristics, the test regions that have Q factor values less than 15 are depicted as blue color in the Q factor maps, and other test regions are presented as red color. It is observed that most regions in the solid concrete are presented in blue color. Therefore, solid concrete regions can be characterized as dynamic responses with relatively low Q factor values . Q factors over the debonding defect 1 are shown in Q factor values based on a single accelerometer and multiple accelerometers are shown in the first and second rows, and the values based on an impact-source at S0 and S1 are shown in the first and second columns in Q factor alone is not sufficient to classify the solid and de-bonded test regions in concrete specimens. However, it is worthy to note that the test regions classified as unknown areas in the frequency maps are presented as solid regions in the Q factor maps. Therefore, it can be inferred that the Q factor values are a potential parameter that could improve the accuracy of condition assessment when those values are supplementarily used with peak frequency values. On the other hand, the spatial distribution of This section evaluates the effectiveness of individual IE parameters for classifying the debonding defects and solid concrete in the concrete slab track specimen. A bilinear classification model was used to evaluate various characteristic parameters in this study: the five individual IE parameters . Debonding defects with larger areal extensions, with greater c/h value, would result in lower peak frequency. Consequently, the performance of the prediction model based on peak frequency values (c/h). However, it should be noted that the overlapped area between the secondary peak frequencies in the solid region (2300 Hz to 3000 Hz) and peak frequency associated with flexural oscillation mode becomes greater as the areal size of debonding defects decreases. Therefore, it can be inferred that the performance of the prediction model that is only based on peak frequency values could be reduced when it is applied to detecting debonding defects with smaller areal dimensions considered in this study. In this case, it can be observed that the use of a dual parameter model would be helpful to classify the flexural vibration mode and the secondary peak frequency in solid concrete regions (2300 Hz to 3000 Hz). Considering the characteristic frequency of sound concrete slabs is about 3420 Hz  and standard deviation about 207 Hz , it can be reasonably said that the width of debonding defects should be sufficiently small to result in the flexural vibration mode frequency lower than 3000 Hz . From c/h) should be greater than 1.0 to satisfy the criterion. Consequently, the minimum width of debonding defects that can be detected by the proposed method is about 240 mm (= the thickness of TCL). The results in this study are obtained from the debonding defects with a limited range of In this study, a multi-channel IE test was applied to the real size railway concrete slab specimen that was fabricated with the same design and materials of concrete slab tracks in the Korea high-speed railway system. Multi-channel signal data were reduced to several critical parameters  that describe the oscillatory behavior of solid concrete and concrete over debonding defects. The distribution of the multiple IE parameters was obtained from the solid and de-bonded regions. The effectiveness of multiple IE parameters is compared by evaluating the performance of a bilinear prediction model with various IE parameters obtained from the multi-channel IE test in this study. The specific descriptions of the primary results in this study are drawn as follows,(1)It was observed that statistical results associated with the distribution of velocity could differentiate the solid regions and test regions with debonding defects. Therefore, the velocity measurement can be useful to evaluate the overall condition of the test slabs. However, special care is needed to identify the location of the debonding defect at the interface between TCL and HSB based on the single velocity value.(2)Overall, the peak frequency map based on the single-channel IE testing is effective for differentiating solid concrete and de-bonded regions in the concrete slab track specimen. However, the presence of multiple peaks in the solid concrete region could increase difficulties in the interpretation of the IE data in actual concrete slab tracks. The primary peak (around 3300 Hz) is corresponding to the full thickness mode, which is usually interpreted as the characteristic frequency of the solid region in IE testing. The secondary peak frequency group (around 2000 Hz to 3000 Hz) is not expected by the IE theory. Dynamic response of concrete over debonding defects is characterized by flexural vibration mode with a peak frequency range of 2100 Hz to 2200 Hz. It was observed that the distribution of flexural vibration mode frequency is overlapped with the lower portion of secondary peak frequency in solid concrete, which could increase the level of error in the prediction model based on peak frequency values based on the single-channel IE testing.(3)It was demonstrated that the use of average peak frequency measured by multiple IE testing devices is effective to suppress the unknown peak frequency in the solid concrete. As a result of averaging, the peak frequency map was generally represented by blue color, representing one and half standard deviations of the average peak frequency. Three debonding defects are clearly identified as green color in the spatial distribution of the average peak frequency values in the three test regions, including debonding defects.(4)Q factor is a potential parameter that can separate the flexural oscillation mode and the secondary peak frequency in the solid concrete when difficult to accurately classify based on differences in peak frequency values. It is noticed that the dynamic response of concrete associated with the secondary peak frequency in the solid concrete region tends to result in lower Q factor values than those associated with the first peak frequency (full-thickness mode). Furthermore, dynamic responses over debonding defects result in even greater Q factor values compared to those in full-thickness mode at solid concrete regions.(5)Q factor  are resulted from the prediction model based on the average peak frequency (


Head and neck cancer is the sixth most common cancer type worldwide, comprising tumors of the upper aero/digestive tract. Approximately 50% of these cancers originate in the oral cavity. Depending on disease stage, oral cancer patients are treated with single-modality surgery, or in combination with radiotherapy with or without chemotherapy. Despite advances in these modalities, the 5-year survival rate is merely 50%. Therefore, implementation of targeted therapies, directed against signaling molecules, has gained attention. One potential target is the MET protein, which can be present on the surface of cancer cells, orchestrating aggressive behavior. As cancer cells can shed the extracellular part of MET from their surface, it is important to identify for MET positive patients whether they possess the entire and/or only the intracellular part of the receptor to assess whether targeted therapies directed against the extracellular, intracellular, or both parts of MET need to be implemented.-) can confer malignant potential. Use of C- and N-terminal MET monoclonal antibodies (moAbs) has illustrated that MET-EC- occurs in transmembranous C-terminal MET-positive oral squamous cell carcinoma (OSCC). Here, we propose that ectodomain shedding, resulting from G-protein-coupled receptor transactivation of epidermal growth factor receptor signaling, and/or overexpression of ADAM10/17 and/or MET, stabilizes and possibly activates MET-EC- in OSCC. As MET-EC- is associated with poor prognosis in OSCC, it potentially has impact on the use of targeted therapies. Therefore, MET-EC- should be incorporated in the design of CDx to improve patient stratification and ultimately prolong survival. Hence, MET-EC- requires further investigation seen its oncogenic and predictive properties.The receptor tyrosine kinase MET has gained attention as a therapeutic target. Although MET immunoreactivity is associated with progressive disease, use of targeted therapies has not yet led to major survival benefits. A possible explanation is the lack of companion diagnostics (CDx) that account for proteolytic processing. During presenilin-regulated intramembrane proteolysis, MET’s ectodomain is shed into the extracellular space, which is followed by γ-secretase-mediated cleavage of the residual membranous C-terminal fragment. The resulting intracellular fragment is degraded by the proteasome, leading to downregulation of MET signaling. Conversely, a membrane-bound MET fragment lacking the ectodomain (MET-EC Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide and comprises epithelial cancers of the upper aero/digestive tract originating in the oral cavity, oropharynx, hypopharynx, or larynx . ApproxiOne target of interest is the predominantly epithelial receptor tyrosine kinase (RTK) MET ,6, oftenMET undergo clonal expansion during HNSCC disease progression [MET gene amplifications have been reported to occur in 1–13% of HNSCC [MET amplification in HNSCC need to be further investigated [In up to 25% of HNSCC, MET is aberrantly activated by mutations and amplifications . Specifigression . Despiteof HNSCC . Althougstigated .MET is transcriptionally activated by stimuli such as hypoxia, inflammatory cytokines, stromal HGF, and pro-angiogenic factors, often abundantly present in the reactive tumor-associated stroma [In the majority of cancers, including HNSCC, d stroma ,13,18,19Although MET expression is known to be associated with poor prognosis in HNSCC  and numeMET proto-oncogene [MET) that undergoes terminal glycosylation and proteolytic cleavage yielding mature MET (p190MET) [α) and a 145 kDa transmembranous β-chain (p145β) possessing the intracellular tyrosine kinase domain [The structural characterization of MET was initially resolved using COOH-terminal  MET antibodies  directedoncogene ,27,28 enp190MET) . The late domain ,30,31. Similar to other receptors having intrinsic kinase activity, MET is subjective to degradation, avoiding overactivity and possibly tumorigenesis . Besides2-terminal  MET monoclonal antibodies (moAbs) [β, 55β, 75β, 85β, and 100β kDa  ,39, dire (moAbs)  specifie100β kDa . Since tt et al.  already eticulum , is medieticulum  showed teticulum , induced-, +/−p60β) constitutively activated MAPK and PI3K-Akt signaling [- expression confers transforming, invasive, and tumorigenic properties to NIH-3T3 cells. Based on the previous observations, it is assumed that MET ectodomain shedding not only suppresses MET signaling by reducing the number of receptor molecules present on the membrane, but it may also give rise to membranous MET-EC- that conveys invasive and aggressive properties to cancer cells, ultimately resulting in poor prognosis. Concurrent with the view that MET proteolysis likely results from an intrinsic cellular mechanism that attenuates excessive MET signaling , it was ignaling . Moreoveβ under reducing conditions could be considered as evidence for the existence of MET ectodomain shedding  are subjective to ectodomain shedding by detecting CTFs  under reducing conditions and detecting N-terminal MET immunoreactivity by performing an ELISA on the culture media [β, p90β, p70β, p60β, and p55β) under reducing conditions illustrated that ectodomain shedding also occurs in fresh frozen tissues of surgically removed primary OSCC [-) [Knowing that MET ectodomain shedding is associated with poor prognosis and possibly potentiates MET’s oncogenic potential ,44,45, ishedding . First, re media . The detary OSCC . Use of ary OSCC . The exiOSCC [-) ,47. TakiOSCC [-) ,47.- on the membrane. Therefore, we propose a model for the molecular mechanism underlying MET ectodomain shedding below.To our knowledge, none of the genetic aberrations known in HNSCC lead to enhanced ectodomain shedding and stabilization of MET-EC2-specific MET antibodies, Nath et al. demonstrated that lysophosphatidic acid (LPA), a serum phospholipid and GPRC ligand, and EGF, a mitogenic growth factor acting through transmembrane tyrosine kinase receptors, increase MET ectodomain shedding in A549 human lung adenocarcinoma cells. Furthermore, it was shown that both LPA- and EGF-mediated MET ectodomain shedding requires the tyrosine kinase enzymatic activity of EGFR. Additional experiments revealed that LPA mediates transactivation of EGFR through metalloprotease mediated autocrine release of HB-EGF, an EGF family growth factor, from the cell membrane and that MEK inhibitors downregulate both LPA- and EGF-induced MET ectodomain shedding, which is also facilitated by metalloproteases. These experiments suggest that in tumors earmarked by high levels of EGFR activation rates of MET ectodomain shedding increase through activation of the MAPK signaling pathway [MET ectodomain shedding has been described to be regulated at the post-translational level by a crosstalk between G-protein-coupled and epidermal growth factor receptors (GPCRs and EGFRs). In 2001, using NH pathway   to its receptor GRPR, which is a GPCR, facilitates MAPK signaling in the 1483 OSCC cell line through transactivation of EGFR. This is accomplished through metalloprotease-mediated release of TGF-α, the primary autocrine EGFR ligand in HNSCC, from the membrane. Accordingly, inhibition of metalloproteases blocks GRP-mediated EGFR tyrosine phosphorylation . AlthougIncreased mRNA and protein levels of the metalloproteases ADAM10 and ADAM17, responsible for MET ectodomain shedding, increase invasive behavior of OSCC and are accordingly associated with advanced tumor stages, regional lymph node metastasis, and reduced survival ,52.- fragments on the tumor cell membrane thus enhancing their stabilization  and constitutive activation, as also observed by Merlin et al. in NIH-3T3 cells [- exists in OSCC. Nevertheless, we hypothesize on the potential value of shedding in the stratification of patients with OSCC eligible for treatment with MET-targeted therapies.Overall, it appears that GPCR transactivation of EGFR  and overT3 cells  ) [-) and poor survival was also established [- [- may represent useful and complementing bio-markers in the identification of OSCC patients that might benefit from MET-targeted therapies in the first line setting. To this aim, it would be recommended to use MET moAbs or tyrosine kinase inhibitors (TKIs) for cancers positive for the full-length receptor, and TKIs or a combination of both for MET-EC- cancers [Accurate C- and N-terminal MET IHC analysis has allowed us to stratify resection specimens from patients diagnosed with primary and treatment-naive OSCC into three categories: MET negative (no MET immunoreactivity), decoy MET , and transmembranous C-terminal MET  or more positivity for the C-terminal moAb (complete MET and/or MET-EC-)) ,46. As O-)) . Since aablished ,47, a reished [- . Hence,  cancers ,47  mutations or amplification are likely to benefit from MET-targeted therapies [Experiments using immortalized cell lines and patient-derived xenografts have illustrated that tumors harboring in vitro  and compin vitro . Whether cohorts . In contr models . Neverthr models . This leherapies . This alherapies ,58. Moreherapies ,60. Moreherapies . As CRT,herapies ,11.Although MET immunoreactivity has been associated with advanced disease stage, tumor recurrence, and poor prognosis, no clear relationship has been established with response to MET-targeted therapy. Therefore, the use of MET immunoreactivity to facilitate the stratification of cancer patients into treatment categories is still a subject of debate . To begi- is associated with poor survival in C-terminal MET positive OSCC, it can lead to improved prediction of prognosis and a more contemplated choice on the use of type of targeted therapy (moAb and/or TKI). The fact that MET remains a target of interest in the wild-type setting [-, which transforming, invasive, and tumorigenic properties require further investigation in the field of OSCC.As MET-EC setting , likely


Since autoimmune pancreatitis (AIP) was established as a new disease entity, sclerosing change with abundant immunoglobulin-4 (IgG4)-positive plasma cells, storiform fibrosis, and obliterative phlebitis are main pathological features in IgG4-related diseases. Regarding IgG4-related sclerosing cholecystitis (IgG4-CC), which is occasionally associated with AIP cases and is rarely isolated, there are no diagnostic criteria and insufficient perceptions of the image findings. Although there have been some reports on IgG4-CC, differentiation between IgG4-CC and gallbladder cancer is very difficult in some cases with a localized lesion. In this review, we especially focused on image findings of IgG4-CC and summarized its image features for diagnostic assistance. The ultrasonography and CT findings of IgG4-CC could be classified into diffuse and localized types. Based on these findings, the presence of wall thickening with an intact or smooth mucosal layer, followed by a homogenously thickened outer layer, would be a helpful morphological finding to distinguish IgG4-CC from gallbladder cancer. Since autoimmune pancreatitis (AIP) was established as a new entity of immune-related diseases, namely, immunoglobulin-4 (IgG4)-related sclerosing pancreatitis in 2002, there have been many reports and knowledge regarding AIP and systemic IgG4-related disease accumulated in Japan and around the world. Although the fundamental cause and detailed mechanism of IgG4-related disease, except for some candidates of antigens ,2 and thRegarding IgG4-related sclerosing cholecystitis (IgG4-CC), which is associated with 25–32% of AIP  and is rAmong the pathological features of IgG4-related diseases, dense lymphocyte and plasma cell infiltration, a ratio of IgG4-positive plasma cells/IgG-positive cells > 40% and the number of IgG4-positive plasma cells > 10/high powered field, and storiform fibrosis/obliterative phlebitis are common.There have not been the definite and specific criteria of IgG4-CC so far. Therefore, we need to follow the 2020 revised comprehensive diagnostic criteria for IgG4-related disease , as follAccording to the report regarding the pathology of IgG4-CC by Kamisawa et al. , there aAccording to our search with keywords “IgG4” or “immunoglobulin-4” and “cholecystitis”, or “gallbladder” on PubMed (1980 to May 2021), there have been 47 cases of IgG4-related sclerosing cholecystitis (IgG4-CC) with some information, including 9 cases of IgG4-CC with AIP  and 11 cAs past reports have shown that 25–32% of AIPs are associated with IgG4-CC , the ninWith regard to 11 rare cases of IgG4-CC without AIP, the patient characteristics are as follows: M/F of 9/2, average age of 58.9 (range of 18–76), and mean serum IgG4 level of 134 mg/dL . AccordiThe fundamental finding in an image of IgG4-CC is the thickening of the gallbladder wall, which reflects fibrosis with a dense lymphoplasmacytic infiltrate. However, the finding of a thickened gallbladder wall is not specific for IgG4-CC, and must be differentiated from other diseases such as adenomyomatosis, cholecystitis caused by gallbladder stone/debris, xanthogranulomatous cholecystitis (XGC), and gallbladder cancer. In practice, special cases without AIP accompanied gallbladder adenomyomatosis in the IgG4-CC lesion that was confirmed by pathological examination have been reported ,18,21.In diagnostic imaging, we need to have some prior knowledge in order to differentiate between the diseases. First, we need to know whether the distribution of the location of IgG4-CC is specific or not. In the abovementioned 47 cases, the locations of the 41 IgG4-CC lesions were 4 in the neck of the gallbladder (Gn), 6 in the fundus of the gallbladder (Gf), 2 in the fundus to the body of the gallbladder (Gfb), and 29 diffuse. Namely, based on location, the lesions of IgG4-CC can be classified into the two types: the localized (Gn/Gf/Gfb) and diffuse type, which resemble the subtypes of gallbladder adenomyomatosis. About 70% of IgG4-CC diffusely developed in the whole gallbladder, while IgG4-CC at the neck of the gallbladder (Gn) developed in the cases without AIP alone /endoscopic ultrasonography (EUS) :US/EUS is a standard imaging modality for the gallbladder because it is available everywhere, is noninvasive, and has a high-resolution for the depiction of the gallbladder. In reviewing previous reports on IgG4-CC, there have been some common image features . A diffuComputed tomography (CT) :CT is also a widely used imaging modality, although not as widely used as US because of its cost and radiation exposure issues, but it has the advantage of objectivity and high image resolution with vascularity information . DiffereMagnetic resonance imaging (MRI):There have been only 3 reports ,20,23 reUS/EUS :Localized IgG4-CC can be classed into the following types: protruding type A (with smooth surface and innermost hyperechoic layer), which can protrude inwardly or outwardly, as shown in CT :Localized IgG4-CC can be classed into the following types: protruding type A (with smooth and contrast-enhancing surface), which can protrude inwardly or outwardly as shown in seven reports ,25,27,28Some of the IgG4-CC cases accompanied adenomyomatosis, xanthogranulomatous cholecystitis (XGC), or hyalinizing cholecystitis (HC), in addition to cholelithiasis, which can all modify and complicate the image findings of the gallbladder in ultrasonography and CT. Hong et al.  indicateBased on the image findings as described above, we could differentiate IgG4-CC from other gallbladder diseases to some extent. However, there were some diseases with similar image findings that occasionally made it difficult to differentiate IgG4-CC, as the previous reports indicated. We summarize the representative lesions to be differentiated from IgG4-CC as follows:Many cases with localized lesions and invasion to the hepatic parenchyma of IgG4-CC have been misdiagnosed as gallbladder cancer because most of the (98%) malignancy of the gallbladder is derived from the epithelium , and occIgG4-CC and adenomyomatosis can be similarly classified based on morphology  and, more troublingly, IgG4-CC can be associated with adenomyomatosis and presents the same characteristic finding, namely dilatation of the Rokitansky−Aschoff sinus. However, the previous cases of IgG4-CC with adenomyomatosis are limited to the localized type of IgG4-CC ,18,21, nAccording to Hong et al. , XGC canAlthough malignant lymphoma of the gallbladder is extremely rare , image fSome neoplasms, including melanoma and carcinoma, can metastasize to the gallbladder and frequently form a polypoid lesion  covered For the diagnosis of IgG4-CC, US/EUS plays a key role, complemented by CT: the wall thickening with the intact or smooth inner layer followed by a homogenously thickened outer layer would be noteworthy and important findings.In the near future, the diagnostic criteria of IgG4-CC should be established based on the abovementioned image features and pathological facts with the accumulation of IgG4-CC cases.