Background. Inappropriate design of sitting furniture and working equipment causes the serious musculoskeletal injuries and various pains as well as reducing working efficiency. Uncomfortable sitting posture in prolonged driving in Bangladesh is an issue to be solved immediately. Therefore, anthropometric databank of user population is significantly essential for the suitable dimensional design for avoiding these remarkable problems. Methods. This study analyses the anthropometric data of the Bangladeshi male vehicle driver aged between 30 and 60 years. A total of 210 Bangladeshi healthy drivers are considered for 15 anthropometric measurements and compared with the similar anthropometrics of other nationalities. Results. The mean stature and sitting height erect of Bangladeshi driver are 1645 mm and 843 mm, respectively. The mean of body mass index (BMI) of the drivers is 26.09 kg/m2, which indicates that the drivers are overweight. The mean stature of Bangladeshi driver is 17 mm shorter than the driver of Korea and 115 mm shorter than the driver of Iran. Conclusion. There are substantial differences between the body dimensions of Bangladeshi driver and similar dimensions of other countries. In comparison, Bangladeshi driver is found to be the shortest compared with the sample of other nationalities.  The mismatch between the seat measurements and the body dimensions of the driver causes various physical problems like discomfort, pain, and disorders in neck, shoulder, back, arm, hand, and wrist which can lead to musculoskeletal diseases . This vaSome researchers, Chimote and Gupta , Tan et This study includes a measurement of 15 sets of anthropometric data and calculation of 3 anthropometric indices of 210 Bangladeshi vehicle drivers including 130 truck drivers and 80 bus drivers with mean age of 41.00 ± 5.99 years. The participated driver sample was selected arbitrarily from central storage depot in Khulna, Bangladesh. The anthropometric data for this research were measured according to Abeysekera  and PheaIn addition, a statistical software named OriginPro 2016 was used to calculate mean value, standard deviation (St. Dev.), standard error of mean (SEM), coefficient of variation (CV), and percentile value of the body measurements. Among the indices, body surface area (BSA) was calculated by Du Bois formula  as shownrding to , respectThe descriptive and inferential statistics of the anthropometric characteristics and indices are depicted in Standard deviation of the anthropometric dimensions varies from 7.9 to 70.4 mm. The highest St. Dev. of stature indicates that the maximum number of sample deviates from their mean of stature measurement. On the other hand, lowest St. Dev. of foot breadth means most of the samples are close to its mean. The 5th, 50th, and 95th percentile values of stature are 1549.9 mm, 1641 mm, and 1770 mm, respectively, which indicates that 5% of the population have a height below 1549.9 mm and 5% of the population have a height above 1770 mm. On the other hand, 50% of the populations have a height almost the same to the mean of the stature. The normal distribution of stature measurement of the sample is presented in The value of SEM for the anthropometric measurements and indices varies from 0.001 to 0.82 indicating the precision how the mean of the sample closes to the mean of the total population. In this study, weight has the highest SEM and RSH has the lowest SEM. The CV measures the relative variability to the mean and varies from 2.88 to 12.79% in this study.Skewness indicates the measurement of asymmetry of a distribution around its mean value. Foot breadth shows the highest positive value (0.38) indicating the distribution of tail extended more towards its positive value from its mean value . On the  E1 and E2 are calculated for all the anthropometric measurements which indicate the necessity of modifying the design of sitting equipment based on stature. E1 is the ratio of the mean of each anthropometric measurement to the mean of the stature, while E2 is the ratio of the SD of each anthropometric measurement to the SD of the stature.  E1 vary within the ranges of 0.06 to 0.51, whereas the values of E2 are calculated from 0.11 to 0.51. Sitting height shows the highest value of E1 and foot breadth shows the lowest value.The ratios2 is considered as normal. In this study, the mean of BMI is 26.09 ± 2.86 kg/m2 indicating that the drivers are slightly overweight. In addition, it is noticeable that almost 5% of the sample is obese having BMI value over 30 kg/m2 and over 45% of the sample is overweight. On the contrary, the percentage of underweight population is approximately below 5% of the sample. Hence, slightly over 40% of the sample is neither overweight nor underweight. According to Mosteller [2 depending on the gender and age of the population. 2 indicating the normal condition of the sample. As an exception to this, the percentile values depict that approximately 95% of the sample is in the range of normal situation and 5% of the sample exceeds the normal range. The mean of relative sitting height of the sample is 0.51 ± 0.01 and the 5th, 50th, and 95th percentile values are 0.49, 0.51, and 0.53, respectively. According to Pheasant and Haslegrave [Frisancho  suggestsslegrave  all the slegrave  indicateHowever, small sample size is the main constraint of developing a reliable anthropometric databank in any region. The measurements of large sample size approximate the actual data of the total population. Therefore, as much as large sample size is required for developing a comprehensive anthropometric database for future studies and design problem.In this study, anthropometric data of Bangladeshi vehicle driver is compared to the similar data of the different vehicle driver of several countries such as Nigeria, Korea, Iran, and China. The comparative study of stature measurement presented in  E1 for available anthropometric measurements found in literature related to driver's anthropometry are calculated and the variation among the countries is presented in  E1 for the most of the anthropometric measurement are approximately the same for the nationalities. The highest values of E1 for sitting height erect and sitting elbow height are found for the Chinese driver and the lowest values are for the Nigerian driver. Bangladeshi driver has the highest value of E1 for elbow to elbow length and shoulder breadth, while the Chinese driver has the lowest value. Moreover, the highest value of E1 for sitting shoulder height is recorded for both Bangladesh and Korea.The values ofThe anthropometric characteristics considered in this study can be comparable to the body dimensions from the list described in ISO 7250 . AccordiThis study develops the first anthropometric database of Bangladeshi vehicle driver. Fifteen anthropometric characteristics and 3 anthropometric indices of 210 vehicle drivers were measured and various descriptive statistics were calculated. These measurements were also compared with those of the other countries available in the literature, though the sample size and the geographic conditions of the studies were different. However, a significant difference among the characteristics was found. In summary, the Bangladeshi drivers were the shortest compared to the other studies and had the widest shoulders and hips. This study was the preliminary step for developing anthropometric database with small sample size. However, a large sample size could develop accurate and precise anthropometric databank of Bangladeshi vehicle driver for commercial design application for future research.


Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognized syndrome that can appear with multiple organ involvement, typically with tumor-like swelling, lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, and elevated serum IgG4 concentrations. We report the case of a 22-month-old female child with failure to thrive and recurrent respiratory tract infections since 8 months of age. Physical examination was normal except for pulmonary auscultation with bilateral crackles and wheezes. Laboratory tests revealed elevated erythrocyte sedimentation rate, and elevated serum IgG and IgG4 with polyclonal hypergammaglobulinemia. Thoracic CT and MRI showed multiple mediastinal lymphadenopathies and a nodular posterior mediastinal mass in right paratracheal location with bronchial compression. Initial fine needle aspiration biopsy was compatible with reactive lymphadenopathy but after clinical worsening a thoracoscopic partial resection of the mass was performed and tissue biopsy revealed lymphoplasmacytic infiltrate and increased number of IgG4-positive plasma cells and a ratio of IgG4/IgG positive cells above 40%. Glucocorticoids therapy was started with symptomatic improvement, reduction in the size of the mass, and decrease of serum IgG4 levels after 6 weeks. There are very few reports of IgG4-RD in children. Long-term follow-up is necessary to monitor relapses and additional organ involvement. Immunoglobulin G4-related disease (IgG4-RD) is an increasingly recognized syndrome of unknown aetiology comprised of a collection of disorders that share specific pathologic, serologic, and clinical features. It is characterized by tumefactive lesions, a dense lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, storiform fibrosis, and elevated serum IgG4 concentrations –3. The dThe clinical picture is highly heterogeneous and the symptoms are related to involvement of the specific target organ, often in the form of a mass lesion. The epidemiology and prevalence of the disease are poorly described and most epidemiologic studies focus on autoimmune pancreatitis. The majority of patients are men older than 50 years , 3, 5.We report a case of a child with pulmonary manifestations of IgG4-RD.A 22-month-old girl was referred to our pulmonology clinic for recurrent respiratory tract infections. She was born after a 38-week gestation and anthropometric measures at birth were normal. She had history of gross motor development delay having sat at 10 months of age and walked independently at 20 months of age.Recurrent respiratory tract infections started at 7 months of age and were associated with failure to thrive. These respiratory infections were frequently associated with fever and wheezing and treated with inhaled short-acting beta 2 agonists. Despite treatment with montelukast and weekly respiratory physiotherapy, she persisted with chronic morning cough.On physical examination, there were bilateral crackles and wheezes on pulmonary auscultation and her weight and height were at the 10th percentile. There were no palpable lymph nodes and no abdominal masses.9/L), and peripheral eosinophilia (0.72 × 109/L) and there was polyclonal hypergammaglobulinemia. Blood biochemistry with liver and renal function, iron metabolism, lactate dehydrogenase, and thyroid function tests were normal . C-reactive protein was normal (2.9 mg/L) and erythrocyte sedimentation rate was elevated (32 mm/hr). The serum angiotensin converting enzyme was normal (22 U/L).Complete blood count revealed normal haemoglobin (12.2 g/dL), normal platelet count  G (1690 mg/dL), elevated IgG4 (805 mg/dL) and IgE (127 kU/L), normal IgA (61 mg/dL), normal IgM (107 mg/dL), normal complement levels, and normal neutrophil oxidative burst tests.Thoracic CT scan showed multiple right mediastinal and hilar lymphadenopathies, a nodular posterior mediastinal mass (21 × 15 mm) in the right paratracheal region, and bronchovascular consolidation of the right lung base but also of the right upper and medial lobe. Thoracic MRI confirmed the presence of a complex nodular posterior mediastinal mass (34 × 22 mm) infiltrating the right hilum along with consolidation of areas in both of the upper lobes and the right lower lobe suggestive of atelectasis . BronchoOne month later, she continued to have chronic cough and wheezing. A thoracoscopic partial resection was performed of a conglomerate of lymph nodes (30 × 25 × 10 mm). Tissue biopsy histopathological examination revealed follicular hyperplasia with germinal centers. A plasmacytic infiltrate was present in some areas. The number of IgG4-positive plasma cells was high, with 16 IgG4-positive plasma cells/high power field (HPF) and a ratio of IgG4/IgG positive cells over 40% . HistopaImmunodeficiency, infectious diseases, tuberculosis, cystic fibrosis, malignancy, lymphoma, sarcoidosis, and Castleman's disease were excluded.After resection there was worsening of respiratory symptoms and two episodes of pulmonary infection treated with systemic antibiotic therapy. Thoracic MRI, repeated 4 months after resection, showed increase in the size of the right paratracheal mediastinal mass compared to its initial dimensions (30 × 19 mm) and was persistence of subsegmental bilateral atelectasis.Glucocorticoid therapy was started (prednisone 2 mg per kilogram) with clinical improvement and decrease of serum IgG4 levels (226 mg/dL) after 6 weeks. Significant reduction of the mass size was confirmed by MRI which showed a small right tracheal nodular image (7 mm). Glucocorticoids were tapered over a period of six months. The patient has been clinically stable for 12 months after stopping therapy, with height and weight at the 50th percentile at 4 years old.Pulmonary involvement in IgG4-RD has been reported with a broad spectrum of intrathoracic findings. These manifestations appear to be rather heterogeneous resulting from involvement of the lung parenchyma, intrathoracic lymph nodes, mediastinum, and pleura . Lung paLymphadenopathy can develop subsequent to the diagnosis of extranodal IgG4-RD or it can be the initial presentation of the disease –5. When In other patients with IgG4 –RD lymphadenopathy increased serum levels of IgG, IgG4, and IgE, polyclonal hypergammaglobulinemia, elevated sedimentation rate, and positive autoantibodies have also been reported , 7, 10. The majority of patients with IgG4-RD have elevated serum IgG4 concentration >135 mg/dL). However, elevated IgG4 may also be observed in other diseases suggesting that high serum IgG4 is not a specific marker of IgG4-RD 35 mg/dL..The diagnosis of IgG4-RD requires both characteristic histopathological features and increased number of IgG4 positive plasma cells or an elevated IgG4 : IgG ratio in tissue. The major histopathological features observed in several organs are a dense lymphoplasmacytic infiltrate, storiform fibrosis, obliterative phlebitis, and eosinophil infiltrate , 5, 10. The appropriate cut-off point of the number of IgG4 positive plasma cells varies in different organs, but the presence of >10 IgG4 positive plasma cells/HPF on biopsy specimens has been proposed as diagnostic feature. However, IgG4 positive plasma cell count alone may not help to distinguish between IgG4-RD and other disorders , 5, 7, 9The comprehensive clinical diagnostic criteria for IgG4-RD were fulfilled: (1) mediastinal and hilar lymphadenopathy, (2) elevated serum IgG4 concentrations, and (3) histopathologic examination with lymphoplasmacytic infiltration and >10 IgG4 positive plasma cells/HPF and IgG4 positive/IgG positive plasma cell ratio >40% .There are very few reports of IgG4-RD in children and only one in a 15-year-old boy with lung involvement to our knowledge . IgG4-reBenign/reactive lymph nodes are more common in children but are less frequently excised compared to adults. Differential diagnostic is broad and although the findings have some distinctive features, in many circumstances, they may not be sufficiently distinctive as to exclude a diagnosis of IgG4-related lymphadenopathy.Multiorgan disease may be evident at diagnosis but also can evolve metachronously over months to years. Spontaneous improvement is reported in a minority of cases but not in intrathoracic IgG4-RD , 5, 9.No randomized treatment trials have been conducted, particularly in children. Glucocorticoids are the first line of therapy and most IgG4-RD patients respond favourably to this treatment. Most centers start with prednisolone at a dose of 0.6 mg per kilogram of body weight or 40 mg for 2 to 4 weeks and taper the dose over a period of 3 to 6 months, although some authors suggest to continue at a dose between 2.5 and 5 mg per day for up to 3 years , 15.Our patient had a good clinical response to glucocorticoids but durability of treatment response is unclear after prednisolone tapering and relapse is frequent. A major determinant of treatment responsiveness is the degree of fibrosis, which was absent in this case , 5. SeriThe natural history of IgG4-RD has not been well defined, particularly in paediatric patients. Long-term follow-up is necessary to closely monitor relapses and additional organ involvement. Other courses of steroid therapy may be needed and eventually immunosuppressive therapy.


Newborns are a population in which antibiotic usage is extremely high.The aim of this study was an assessment of antibiotic usage in BSI treatment in the Polish Neonatology Surveillance Network (PNSN) and determining the possibility of applying this kind of analysis in infection control.Data were collected between 01.01.2009 and 12.31.2013 in five tertiary academic neonatal intensive care units (NICU) that took part in the PNSN. The PNSN is a prospective national surveillance system for the most relevant infections in the group of very low birth weight  infants in Poland.Case BSI patients (both: early- and late-onset) were defined according to Gastmeier et al.  with modThe total duration of antibiotic therapy for 773 cases of BSI, which are incorporated into the present analysis, amounted to 14 056 DOTs or 381.6 DDDs.The median length of antibiotic therapy for a single case of BSI, regardless of microbiological confirmation or its lack, amounted to 8 days; whereas the median consumption expressed in DDD was 0.13. In the case of LC-BSI, median DOT was 8 days, and consumption – 0.12 DDD. Median length of therapy was shorter for unconfirmed cases: 7 days, while the consumption of antibiotics was higher – 0.14 DDD (p<0.0001). High consumption of glycopeptideds expressed in DOTs was observed in studied population.Application of classical methods of microbiological diagnostics significantly reduces the consumption of antibiotics expressed by DDD, however, the high consumption of glycopeptides indicates the necessity of applying rapid diagnostic assays.Nevertheless, the assessment of antibiotic consumption in neonatal units represents a methodological challenge and requires the use of different measurement tools.Analysis of antibiotic consumption is an essential component of infection control, especially for NICU patients – for effective planning and reliable evaluation of interrelationships between individual elements of control programs.None declared.


Mesenchymal to Epithelial Transition (MET) plasticity is critical to cancer progression, and we recently showed that the OVOL transcription factors (TFs) are critical regulators of MET. Results of that work also posed the hypothesis that the OVOLs impact MET in a range of cancers. We now test this hypothesis by developing a model, OVOL Induced MET (OI-MET), and sub-model (OI-MET-TF), to characterize differential gene expression in MET common to prostate cancer (PC) and breast cancer (BC).In the OI-MET model, we identified 739 genes differentially expressed in both the PC and BC models. For this gene set, we found significant enrichment of annotation for BC, PC, cancer, and MET, as well as regulation of gene expression by AP1, STAT1, STAT3, and NFKB1. Focusing on the target genes for these four TFs plus the OVOLs, we produced the OI-MET-TF sub-model, which shows even greater enrichment for these annotations, plus significant evidence of cooperation among these five TFs. Based on known gene/drug interactions, we prioritized targets in the OI-MET-TF network for follow-on analysis, emphasizing the clinical relevance of this work. Reflecting these results back to the OI-MET model, we found that binding motifs for the TF pair AP1/MYC are more frequent than expected and that the AP1/MYC pair is significantly enriched in binding in cancer models, relative to non-cancer models, in these promoters. This effect is seen in both MET models (solid tumors) and in non-MET models (leukemia). These results are consistent with our hypothesis that the OVOLs impact cancer susceptibility by regulating MET, and extend the hypothesis to include mechanisms not specific to MET.We find significant evidence of the OVOL, AP1, STAT1, STAT3, and NFKB1 TFs having important roles in MET, and more broadly in cancer. We prioritize known gene/drug targets for follow-up in the clinic, and we show that the AP1/MYC TF pair is a strong candidate for intervention. Cancer progression is characterized, in part, by altered or aberrant transcription factor (TF) function, leading to changes in expression of cancer related genes . MesenchIn the present work Figure , we explWe established MET gene expression signatures to characterize changes of gene expression in models of PC and BC , we selected the union of sets of genes responsive to OVOL1, OVOL2, or both, using FDR ≤ 0.05 AND Fold Change ≥ ± 2.0 AND “test OK” thresholds  using an NCBI E-Utilities Perl script to search for each of the 739 genes (using the HGNC gene symbol) AND the phenotype of interest. For example, the query for one of these searches was (“TMEM163”[Text Word] + OR + “tmem163”[Text Word] + OR + “Tmem163”[Text Word]) + AND + (“breast cancer”[Text Word] + OR + “breast neoplasms”[Text Word]). Text word searches for these keywords cast a relatively wide net, capturing essentially any co-occurrence of the gene symbol and the keyword(s) of interest in the manuscript. For instance, a manuscript could mention a given gene and cancer but only in a tangential way, not really associating the gene with cancer. These searches are not very specific because the definition of “text words” is broad, but they provide an upper bound on the number of publications associating each gene with the keyword. We tested the significance of over-representation of each of these annotations in our gene set using a re-sampling approach similar to Li, et al. , by rand2 value and corresponding p-value.We are also interested in testing the selected 739 gene set for association with MET, but the text for “mesenchymal to epithelial transition” and “epithelial to mesenchymal transition” are complex, so they are relatively little used in the literature. To overcome this limitation and to balance the high false positive rate expected with the text word searches, we used MeSH   Gene2Promoter  functionSince the OVOLs’ effects on gene expression in MET are not direct, we sought to understand the direct systems involved in OI-MET using ConceptGen  enrichmeAlso consistent with the observation that the OVOL TFs likely regulate gene expression in OI-MET, ConceptGen found enrichment for “Signal Transduction” FDR 1.75E-10 and “Gene Expression Regulation, Neoplastic” FDR 2.06E-08. This led us to pursue the details of gene expression regulation in this annotation, and we found enrichment for regulation of gene expression by five TFs: AP-1 (AP1) FDR 1.16E-04, c-Jun (JUN) FDR 5.47E-03, NF-kappa B (NFKB1) FDR 4.78E-05, STAT1 FDR 3.40E-02, and STAT3 FDR 1.07E-02  that is not part of the input gene set is included in this network. The GeneGo interactions annotation shows that the five TFs of interest do work together to regulate the combined set of genes. For example, NGFR, CARD6, and NALP3 are disconnected nodes in the NFKB1 network but we now see that NGFR and NALP3 are targets of AP1, while CARD6 is a target of STAT1. The OI-MET-TF network shows that many genes annotated as being targets of one of the five TFs of interest are also targets of one or more of the other TFs. For example, SOCS1 is a target of STAT3, STAT1, and AP1. Based on GeneGo interactions data, we find that one gene is regulated by 4 of the TFs of interest, four genes are regulated by 3 of them, and twenty genes are regulated by 2 of them.We further hypothesized that the OI-MET-TF network model is useful in understanding gene expression changes in MET common to BC and PC. Therefore, we would expect a significant proportion of the genes in the network to be associated with BC, PC, cancer, and MET. As we did with the 739 gene OI-MET gene set, we searched PubMed and PMC using an NCBI E-Utilities Perl script to search for each gene (using the HGNC gene symbol) and phenotype of interest[text words], as well as “epithelial-mesenchymal transition”[MeSH].As shown in Table As we tested the OI-MET signature gene set with both literature searches and ConceptGen, we tested the OI-MET-TF model with both literature searches, above, and GeneGo’s built in enrichment algorithm for disease processes Table . Note thBioinformatics analyses like the one offered here have the power to provide evidence capable of intelligently guiding selection of the most promising drug combinations to test from an otherwise near-infinite possible number of synergies between approved and in-approval drugs . Using GAmong recently approved novel cancer chemotherapeutics are those which inhibit HDAC activity , and thoAs seen in the OI-MET-TF model, the effects of the OVOL TFs are complex and they interact directly with only a small number of genes in the network. Focusing on only the nuclear proteins from that network Figure , both OVKeeping in mind that the OI-MET-TF network is necessarily simplistic, this network is strongly consistent with the hypothesis that the OVOLs regulate MET in concert with the other four TFs. However, since the roles of the other four TFs were suggested by enrichment of annotation in the OI-MET signature gene set, we hypothesized that the effects of these TFs from the OI-MET-TF model are consistent across the larger OI-MET signature set. We also observed that, in addition to the four TFs identified by ConceptGen, MAFF, ATF3, MYC, MYB, and IRF9 could be important in this regulatory cascade. Using GGA’s MatInspector function, we searched the 4,102 promoters from the OI-MET gene set, looking for individual binding sites for these promoters Table . Based o2 p-value < 0.01 level. Finding a much greater proportion of promoters with the motif pair than expected by chance suggests that cooperative regulation by AP1 and MYC could be important in the downstream cascade of gene expression regulating MET.Since TFs generally work in pairs or modules, we searched the 4,102 promoter sequences for all pairs of motifs derived from these individual motifs using GGA’s RegionMiner module Table . RegionMTesting for the presence of TF binding motifs is useful in identifying potential regulatory effects in a set of promoters. Enrichment for motifs and, more significantly, enrichment for modules composed of motif pairs, as we did, is potentially even more useful. However, the presence of a binding motif or motif pair does not necessarily mean that the TFs bind, or that they bind under relevant conditions. ChIP-Seq is a high-throughput process for identifying DNA sequences bound by proteins, including transcription factors . To testThroughout the earlier steps in the analysis we found evidence consistent with the hypothesis that the OVOLs regulate MET, but we also found evidence that the OVOLs might impact cancer in a broader sense. These results led us to make a three-way comparison of promoter occupancy across non-cancer, solid tumor, and leukemia models. The classic mechanism for metastasis of a solid tumor is EMT, migration, and MET . This prWe converted the downloaded the .csv ChIP-Seq files to .bed files and uploaded them to Genomatix GGA. We also converted the 4,102 promoter sequences from the OI-MET gene set to .bed files using the GGA mapping utility. For each TF, we aggregated the .bed files by tissue/cancer category . This process created proxy datasets for testing promoter occupancy, allowing us to look for documented binding of the TFs in sites overlapping the 4,102 promoters, in the relevant cellular models. For NFKB, only non-cancer ChIP-Seq data were available. For ATF3, only Non-MET data were available. For STAT1 and MYC, data were available for MET and Non-Met cancers, but not for the non-cancer model. For AP1, ChIP-Seq binding data were available for all three classes , for both FOS and JUN TFs. For all three tissues, for both FOS and JUN, we had relatively large numbers of peaks in each file to compare with the 4,102 promoters of interest, providing an excellent dataset for testing the hypotheses that these TFs occupy the promoters preferentially in MET versus non-cancer cells and in MET versus Non-MET cancer, but not in Non-MET versus non-cancer cells. Also, given that the AP1/MYC TF pair was the most enriched pair in the motif modules analysis, the AP1 ChIP-Seq data for FOS and JUN is a particularly good choice for this hypothesis testing. In addition, though we had only MET and Non-MET cancer data on MYC, we were able to test for enrichment of cooperative AP1/MYC binding in promoter associated locations in the cancer models.As seen in Table Results in Table Table Based on the motif pair data, we hypothesized enrichment of binding by AP1/MYC pairs in our 4,102 promoters in the cancer models, relative to the non-cancer model. We tested this hypothesis Table  in a wayIn this work, we use a systems biology approach to understand how the OVOL TFs induce MET. Based on our previous work, we hypothesized that the OVOL TFs regulate MET in more than one cancer . To testWe also found significant enrichment of annotation consistent with the roles of the OVOLs and AP1, NFKB1, STAT1, and STAT3 in regulating gene expression in OI-MET. To understand how these TFs might interact with the OVOL TFs and potentially impact OI-MET, we first focused the analysis on the subsets of genes associated with each of the five TFs , then assessed their interactions in the set composed of the union of the gene sets regulated by the individual TFs. This process yielded a model of how the OVOLs interact with the other TFs (OI-MET-TF) to influence OI-MET. We tested this model for association with BC, PC, cancer, and MET in the literature and found it to be even more enriched than the OI-MET model. This result is consistent with the hypothesis that the OI-MET-TF model is also useful in understanding the impact of the OVOLs in MET and more generally in cancer, as well as how the OVOLs interact with the other four TFs in this process. By developing an improved understanding the genes, interactions, and related mechanisms impacting disease, we open up the possibility of intervening in disease progression. We used the OI-MET-TF model to understand how known drug/gene interactions could impact the model and offer prioritized options for intervention.We reflected our inference from the OI-MET-TF model back to the larger set of genes in the OI-MET signature and tested this gene set for potential regulation by these TFs. In the OI-MET gene set, we found significant enrichment for binding motifs for the AP1/MYC pair. To investigate potential binding at these sites, we used publicly available ChIP-Seq data to first test the hypothesis that AP1 binds preferentially in MET and Non-MET cancer models, relative to a non-cancer model. We also compared AP1 binding in the MET versus Non-MET models. Results of these tests are consistent with AP1 acting in both the MET and Non-MET cancer models. We then tested for preferential binding of the AP1/MYC pair, and again saw results consistent with this pair acting in both MET and Non-MET cancer models. While AP1 and MYC have long been associated with cancers, to our knowledge this is the first large scale test of the hypothesis that these TFs bind preferentially in cancer versus non-cancer models for cancer-related genes, and that they cooperate in binding. Taken together with evidence that FOS and JUN show differential expression in response to the OVOLs, these results are consistent with a regulatory cascade posed by the OI-MET-TF model. We also must consider the possibility that the OVOLs function in ways that are not specific to MET. This result has been seen with other transcription factors that were initially thought to act primarily in MET but were also found to impact cancer in ways not specific to MET .In this work, we explore the etiology of OVOL-Induced MET (OI-MET), focusing on commonalities between prostate cancer (PC) and breast cancer (BC) models, to test the hypothesis that the OVOLs regulate MET in multiple cancers. We generate a common OI-MET gene expression signature, consistent with a common underlying genetic etiology for MET in PC and BC, and show that the OI-MET gene set is significantly enriched for cancer, BC, PC, and MET associated genes. Using a systems biology approach, we identify regulation of gene expression as the primary influence of the OVOLs on MET, though this effect is indirect and depends on interaction with AP1, STAT1, STAT3, and NFKB1 TFs. We create an OI-MET-TF sub-model of the genes annotated as being regulated by the OVOLs and these other four TFs. We test this model for consistency with known genetic influences on MET, BC, PC and cancer, and find that there is significant evidence supporting the use of this network as a model of gene expression influences on MET. Based on these results, we believe the networks are useful in modeling the impact of the OVOLs and the four other TFs in MET, and may be appropriate for understanding broader influences in MET across multiple cancer types.We use the OI-MET-TF model in several ways to improve our understanding of the mechanisms driving gene expression in MET. Based on the gene/drug and gene/gene interactions evident in the model, we prioritize known drugs for potential clinical application in cancer therapies. This analysis considers the potential for both on-target and off-target drug/gene interactions, as well as downstream effects and the possibility of repurposing drugs for novel cancer therapies. The OI-MET-TF model is also appropriate for future testing based on interactions with environmental factors, other risk genes, or potential drug therapies.We extend the inference from the OI-MET-TF model back to the larger set of all OI-MET genes and show that the effects of the OVOLs and the other TFs in the OI-MET-TF model are likely to be consistent in the larger set, with experimental data significantly in support of this hypothesis. In particular, we find significant evidence that the AP1/MYC TF pair has an important role in regulating gene expression in cancers. In addition, we find that the impact of the OVOLs may extend beyond MET, influencing mechanisms of cancer progression that require further investigation.The construction of PC and BC cell lines overexpressing OVOL1, OVOL2, or both was done as previously described . Total Rhttp://www.bioinformatics.babraham.ac.uk/projects/fastqc/) to assess a range of quality measures, and found overall very good quality aligned reads in each sample. We then used CuffDiff2.0.2, also part of the tuxedo suite, to assess differential expression between groups, using the UCSC hg19.gtf transcriptome, with -u, −N, −-compatible-hits-norm, and -b (relative to the UCSC hg19.fa) parameter settings. We used a locally derived Perl script to identify genes/transcripts as being differentially expressed if they showed: “OK” test status AND FDR ≤ 0.05, AND fold change (≥ 2.0 or ≤ 0.50).Sequencing was performed by the UM DNA sequencing core, using the Illumina Hi-Seq platform to generate 50 base, paired-end reads. We downloaded and concatenated the individual reads files to correspond with individual samples. These .fastq files are GEO datasets (GSE48230 and GSE51975). We aligned the reads to the reference transcriptome (UCSC hg19) using TopHat2.0.2, which is part of the tuxedo next-generation sequencing data analysis suite ,38. We uWe used Perl script with NCBI Entrez Programming Utility functions (e-utilities) to query NCBI literature databases. For each gene in the list, we queried both PubMed and PubMed Central databases using HGNC gene symbol and each of the terms “cancer”, “breast cancer” and “prostate cancer” as text words and “epithelial mesenchymal transition” as the MeSH term for MET. Each query result was parsed to get a list of PMIDs and PMCIDs, respectively, that document the co-occurrence of the gene symbol and the query term. We counted co-occurrence if one or more publication showed both the gene symbol and the query term.For each network, we used parameter settings to develop the most parsimonious network possible . In each case, we used: shortest paths algorithm; merged network; not including canonical pathways; 1 maximum step in the path; showing disconnected seed nodes; showing shortest path edges only; using low trust, functional, and binding interactions for network building, and not using compound-target interactions. Note that, while we allowed for the potential use of low trust interactions in network building, this did not impact the networks built.MET: Mesenchymal-epithelial transition; OI-MET: Ovol-induced MET; TF: Transcription factor; OI-MET-TF: OI-MET transcription factor model.KJP is a member of the board of Curis, Inc., and Oncofusion Therapeutics, Inc.RCM, HR, KJP, and JDC conceived the project and developed an outline for the work. MP developed the E-Utils scripts and performed multiple rounds of analysis to develop the data for hypothesis testing. JSH assessed the gene/drug interactions and potential clinical implications of the OI-MET-TF model. JH and HR developed the samples for input to the sequencing core for RNA-Seq analysis. HR, KJP, and JDC provided context for the biological implications of the work. RCM and HR performed the RNA-Seq data analysis. RCM generated the networks, performed hypothesis testing, and generated the initial draft of the manuscript. All authors edited the manuscript and approved the final draft.Differentially expressed genes in the OI-MET gene set. Excel spread sheet with set of genes at the intersection of BC and PC models, yielding the OI-MET gene set.Click here for fileConceptGen enrichment testing results for the OI-MET gene set. Excel spread sheet with results from the ConceptGen enrichment testing, sorted by category, with the five TF concepts at the top of the page.Click here for fileMetacore quick reference guide.Click here for fileGeneGo MetaDrug gene/drug interactions. Excel spread sheet with connections between network genes, their descriptions, and the therapeutic drugs that target them.Click here for file


Metastasis is the dissemination of a cancer/tumor from one organ to another, and it is the most dangerous stage during cancer progression, causing more than 90% of cancer deaths. Improving the understanding of the complicated cellular mechanisms underlying metastasis requires investigations of the signaling pathways. To this end, we developed a METastasis (MET) network visualization and curation tool to assist metastasis researchers retrieve network information of interest while browsing through the large volume of studies in PubMed. MET can recognize relations among genes, cancers, tissues and organs of metastasis mentioned in the literature through text-mining techniques, and then produce a visualization of all mined relations in a metastasis network. To facilitate the curation process, MET is developed as a browser extension that allows curators to review and edit concepts and relations related to metastasis directly in PubMed. PubMed users can also view the metastatic networks integrated from the large collection of research papers directly through MET. For the BioCreative 2015 interactive track (IAT), a curation task was proposed to curate metastatic networks among PubMed abstracts. Six curators participated in the proposed task and a post-IAT task, curating 963 unique metastatic relations from 174 PubMed abstracts using MET.Database URL:http://btm.tmu.edu.tw/metastasisway Metastasis refers to the spread of a cancer from its primary site to other parts of the body (secondary sites), while maintaining its malignant growth. It is often the major concern of patients and clinicians, as it results in the death of over 90% of cancer patients . HoweverIncreased understanding of the roles of genes in the metastatic mechanism can lead to improved treatment of cancer patients through the control of metastasis. Nevertheless, the large volume of online studies and the complexity of obscure gene–cancer interactions stand as the major obstacle to improving insight into these relations. In light of this, we developed a METastasis network visualization and curation tool (MET) to assist metastatic researchers in accessing metastatic networks of interest while browsing through the large volume of studies in PubMed. With the use of MET, PubMed users can easily access the network information curated in our database that is related to the accessed abstracts. Users interested in contributing their knowledge and findings about the abstracts can register as volunteer curators on our website. Registered users can add metastasis-related concepts found in the articles, and the metastatic relations these concepts are involved in directly to our database.Following our previous success in developing a text mining-based curation system as a browser extension to promote biomarker curation , MET is The main features of MET include (i) display of the text-mined and user-curated recognition and normalization results of the metastasis-related concept terms described in an abstract, (ii) illustration of the extracted metastasis relation information as a network diagram and (ii) the curation interface for curators to update the recognition/normalization and relation extraction results. When the mouse cursor hovers over a recognized concept, a brief pop-up summary of the concept will be displayed as shown in If the user is registered as a curator, the curation function enables him/her to modify the extracted concepts and relations. Editable properties of a recognized concept include the concept type, and the normalized database ID for the concept.As shown in MET is capable of integrating individual networks derived from several abstracts. To view the integrated network, a user can submit the PMID of interest to the PubMed database, and change the display format from the default ‘Summary’ format to the ‘Abstract’ format as shown in Gene → Gene → Neoplasm Metastasis: The positive or negative regulation between genes (including microRNAs) resulted in the regulation of metastatic cancers .Gene → Gene → Neoplasms ⇒ (Tissues | Organs): The positive/negative regulation or regulation between genes (including microRNAs) caused a cancer to metastasize to a certain organ or tissue. The relation (Neoplasms ⇒ Tissues | Organs) indicates that the relation involved a cancer concept as its subject, a tissue or organ concept as its object and a metastasis concept as its trigger.The curatable events for constructing a MET network are summarized as follows.(Gene | MicroRNA) → (Gene | MicroRNA)(Gene | MicroRNA) →(Neoplasm Metastasis | Cytoskeleton | Cell Movement | Cell Adhesion)(Gene | MicroRNA) → (Neoplasms)(Neoplasms) ⇒ (Tissues | Organ)As not all articles contain all the information required, the following relations, deconstructed from the above events, are provided to curators as suggestions to be used when they perform event curation using MET.The symbol ‘⇒’ indicates a metastasis relation, and the symbol ‘→’ means a positive/negative regulation, or neutral regulation if the mode of the control cannot be determined from the context.The BioCreative Interactive task (IAT) is a track designed to engage text-mining curation systems with potential curators by providing a communication channel between the bio-curation and the text mining communities . As one To collect articles for our curation tasks, the query term ‘EMT [title/abstract] AND TGF-β [title/abstract]’ was used to search PubMed for abstracts related to metastasis biological processes. This query retrieved 949 abstracts, 300 of which were randomly selected as the curation dataset for IAT. The dataset was split into six equal sets, with one set assigned to each curator as shown in Following the IAT process, the curation tasks were divided into two phases over 2 weeks. During each phase, the curators were asked to complete the following two tasks.The curators used the MET-enabled browser to curate articles directly on the PubMed website through the MET text mining services. MET highlights all recognized concepts and visualizes the constructed networks in PubMed as illustrated in The curators used the brat annotation tool  to manuaA direct comparison of efficiency between MET and brat tool may not be completely appropriate. Brat is a mature tool with an easy-to-use annotation interface, and some of our curators already had experience using the tool for annotation. In contrast, MET is under development and many new features were implemented and integrated during the IAT. As shown in First, we found that in the brat-based manual curation task, most curators only annotated the locations of the concepts, but did not normalize the annotated concepts to proper database IDs. Although the guidelines do ask them to annotate the IDs, some curators failed to do so. The brat interface does not support the display of the detailed information associated with the assigned ID could be one of the possible reason that the curators overlook the normalization task. In the scenario, if the curator does not familiar with the information associated with that ID, he has to inquire the related information from Entrez Gene by himself to check the correctness. Second, MET provides a comprehensive information set, including all of the metastasis-related concepts recognized by our text mining services, their normalized IDs and the relations among them. Curators had to go through all of these data and correct them if necessary. In contrast, in the manual curation task, curators could focus on annotating relations and the concepts involved within the same sentence, while ignoring all other concepts that exist in the same abstract.more frequently in the cases with high PRL-3 expression’. In our definition, a trigger word should be a verb or a nominal verb that causes direct relations between the concepts. Therefore, in this case, the curator should not annotate the adverb word ‘more’. One of the most crucial issues is that curators might forget to annotate essential concepts and relations in their manual curation task. For instance, they might forget to create the connection between the relation trigger and entities to construct a relation in brat. An automatic qualification test system, as introduced by  or the project page of MET https://sites.google.com/site/hjdairesearch/Projects/met.The manually curated data set can be downloaded from the BioC web site . The curation rate for the post-IAT task was 12.3 abstracts/hour, which is even higher than the curation rate reported in the IAT brat-based manual curation task (9.5 abstracts/hour). We believe this improvement can be attributed to the use of the new curation model in the post-IAT task.In the original curation model used in the IAT MET-assisted curation task, the curator selects participants from a dropdown list including all recognized concepts mentioned in the abstract, while simultaneously provide the supporting sentence. Using the new model, however, the curator curates the supporting sentence first, and then curates the relation participants. Although the new curation model seems to be more time-consuming, the results demonstrate the positive impact of the additional curation step. One of the main reasons that the new model can boost the curation rate is that, by first identifying the sentence, the curator can then select the participants from a dropdown list that contains many fewer candidates. This is also the reason that some of the relation extraction tasks in text mining, such as protein–protein interaction extraction, first define a subtask to identify the target sentence . As descF-score of 0.97 on the miRNA-Test-Corpus (For the recognition of gene mentions, our text mining services integrated the results from PubTator  and our t-Corpus . For theA MET network consists of different biological relationships between the concepts such as gene-gene regulation, gene-cancer regulation and the organs of the metastasis. Our text mining service uses the principle-pattern-based approach , 15 to eWe have developed MET, a network visualization and curation system that can facilitate the curation of metastatic networks. Critical feedback was received from MET users through the participation of the BioCreative IAT. Overall, users found MET to be a unique and easy-to-use tool for metastatic network curation. Participation survey results indicated most of the curators thought that the annotated concepts and visualized networks provided by MET were extremely helpful in suggesting which concept was involved in the metastasis network. MET can help them efficiently extract the metastasis knowledge from the abstracts. The concept types provided by MET are also considered to be unique, because no other tools provide so many concept types to assist in the curation of studies for network information. We believe that with further enhancement, MET could prove very useful, especially in the construction of a database for metastasis networks. MET also has great potential for application to the curation of other concepts.Future work will focus on correcting the inconsistent annotation boundaries of concepts. Furthermore, based on the responses from the MET curators in IAT, we plan to improve MET to recognize additional biological concepts such as drug names and other diseases apart from cancers, and the relations among these concepts such as disease–cancer and drug–cancer relations, aiming to provide a more comprehensive view of the MET networks. All recognized relations would be clustered based on a control vocabulary such as the GENIA Event Ontology  for gene


Inappropriate overuse of antibiotics contributes to antimicrobial resistance (AMR), yet policy implementation to reduce inappropriate antibiotic use is poor in low and middle-income countries.To determine whether public sector inappropriate antibiotic use is lower in countries reporting implementation of selected essential medicines policies.Results from independently conducted antibiotic use surveys in countries that did, and did not report implementation of policies to reduce inappropriate antibiotic prescribing, were compared. Survey data on four validated indicators of inappropriate antibiotic use and 16 self-reported policy implementation variables from WHO databases were extracted. The average difference for indicators between countries reporting versus not reporting implementation of specific policies was calculated. For 16 selected policies we regressed the four antibiotic use variables on the numbers of policies the countries reported implementing.Data were available for 55 countries. Of 16 policies studied, four  were associated with statistically significant reductions in antibiotic use of ≥20% in upper respiratory infection (URTI). A national strategy to contain antibiotic resistance was associated with a 30% reduction in use of antibiotics in acute diarrheal illness. Policies seemed to be associated with greater effects in antibiotic use for URTI and diarrhea compared with antibiotic use in all patients. There were negative correlations between the numbers of policies reported implemented and the percentage of acute diarrhoea cases treated with antibiotics  and the percentage of URTI cases treated with antibiotics . Major study limitations were the reliance on self-reported policy implementation data and antibiotic use data from linited surveys.Selected essential medicines policies were associated with lower antibiotic use in low and middle income countries. Antibiotic drug resistance is a serious global public health problem with high human and financial costs.–6 InapprPolicy-relevant interventions to combat inappropriate medicines use have generally had small effects. In the cIn Europe, coordinated medicine policy implementation resulted in reduced inappropriate antibiotic use –20, but The aim of this study was to perform further analyses of the WHO databases to determine if inappropriate antibiotic use in the public sector is less in low and middle-income countries that report implementing essential medicines policies than in those that do not.Our overall methods have been described in detail previously. In the pA dataset of antibiotic use (outcome) and reported policy implementation (exposure), with one set of policy implementation data and antibiotic use for each country, was created from two WHO databases. Public sector antibiotic use data for 2002–8, by country, were extracted from the WHO medicines use database., 23, 24 We excluded policies that had previously been shown to have no effect on overall medicines use, and overlapping policies, as described previously. Of the rWe chose four outcome variables , 26:% of primary care cases receiving antibiotics. This gives some indication of overall antibiotic use% of upper respiratory tract infection cases that received antibiotics % acute diarrhea cases that received antibiotics % cases not needing antibiotics that received antibiotics (inappropriate use)22 Gross National Income per capita (GNI per capita) in 2009/2010 for countries was extracted from the World Bank data-base http://data.worldbank.org/indicator/NY.GDP.PCAP.CD and used to stratify some analyses (see below).As national wealth has been shown to correlate with policy implementation and quality use of medicines economic status was considered a potential confounder.Univariate analysis was used to estimate the differences in average scores (as proportions reporting the outcome) for each of the four antibiotic use indicators between countries that did or did not report implementation of the 16 individual policies. Each policy was the unit of analysis and for each of these indicators a lower score equated with better use. The sample sizes were too small to enable direct comparisons of different policy impacts, so the effect sizes reported here cannot be used to makes inferences about relative effectiveness of the policies we evaluated. Consequently, we did not adjust the P values for multiple testing. To look at the impact of multiple policies we regressed the scores for each of the 4 outcome measures on the number (out of 16) of policies countries reported implementing. Because of missing data we had to adjust the estimated numbers of implemented policies using the formula: adjusted policy number = )*16. In theseFrom the WHO database, 55 countries had analysable data on policies and antibiotic use. Out of a possible 880 policy responses (16 policies in each of 55 countries), 718 (82%) were available for analysis.Policies associated with statistically significant 20% or greater reductions in use of antibiotics in one or more of 4 settings described in the outcome indicators were: having a MOH department to promote rational use of medicines, having a national Drug Information Centre, and having drug and therapeutic committees in more than half of all general hospitals and more than half of all provinces. Several of the other policies were associated with lower use of antibiotics across all indicators, though the effects were smaller. Only 2 of 64 comparisons were associated with increased antibiotic use and the effects were small (2 and 4% respectively).There were statistically significant, moderate, negative correlations between the reported number of medicines policies implemented (out of 16) and the percentage of acute diarrhoea cases treated with antibiotics  and the We examined the effects of national wealth measures on these correlations. In the case of diarrheal disease, the negative correlation between numbers of policies and antibiotic use was stronger in countries below the median GNIpc ($1365)  than in countries above the median . However, this pattern was not seen with upper respiratory infection, where the negative correlation between policy numbers and antibiotic use was stronger in countries with GNIpc values above the median  than in countries with wealth levels below the median .A number of policies aimed at improving antibiotic use, as recommended by the WHO Global Strategy to Contain Antibiotic Resistance (AMR) and the Global Action Plan on AMR, were associated with reduced inappropriate use of antibiotics., 28, 29 Effect sizes for the two condition-specific indicators of antibiotic prescribing quality  were greater than the effect size for the “general” indicator of antibiotic usage. These were negative correlations and the weaker association for the general indicator may be because lower use is not always better in all patients, in contrast to the specific situations of upper respiratory infection and diarrheal disease.Countries that reported implementing more of the selected policies had lower antibiotic use, particularly in the case of upper respiratory infection and in diarrheal disease. We found that this negative correlation was stronger in low income countries in the case of diarrheal disease but this trend was not seen for URTI. This may indicate genuine differences in the two different disease settings. Diarrheal disease has been a prominent target of public health campaigns in low income countries, including promotion of oral rehydration solutions, rather than antibiotics. Alternatively, the apparent differences may be due to the play of chance because of relatively small sample sizes. Previously, when we analysed the impact of national wealth on the impacts of multiple policies on composite measures of medicines use in a larger number of countries the effects were consistently greater in low income countries.Higher socio-economic status has been previously reported to be associated with better prescribing quality –9, 22–24The majority of interventions, described in the literature, to improve antibiotic use in primary care are educational in nature, and many have been shown to be effective in producing short-term improvements in antibiotic use., 23, 24 Administrative policies, such as a dedicated MOH department to promote rational use of medicines, having drugs and therapeutic committees in hospitals and a national drug information centre, were also associated with significantly better quality of antibiotic prescribing in our study as was the provision of free essential medicines. Administrative and managerial strategies to support decision-making have been found effective elsewhere in improving antibiotic use.–32 A natOther policies associated with better and lower antibiotic prescribing included no over-the-counter antibiotic availability, no prescriber income from antibiotic sales, no unqualified prescribers, and joint regulation by government and industry of drug promotion. Enforcement of non-availability of antibiotics over-the-counter was associated with decreased antibiotic use in Chile  and reduInterventions that aim to appropriately increase antibiotic use in particular settings have resulted in large improvements of 15–25%, such as training community members to diagnose and treat childhood pneumonia cases with antibiotics in Nepal.  However,In our view the policies we have highlighted in these analyses reported here represent a blueprint for a national strategy to promote rational use of antibiotics–a critical component in the fight to contain anti-microbial resistance.We relied on self-reported information on policy implementation. Causality cannot be ascribed to the associations we have highlighted and we cannot be confident that effects associated with one policy are not due to another policy co-intervention. The small sample sizes prevented multi-variable analyses. But these limitations apply to the whole field. In the absence of carefully collected longitudinal data at national level it is not possible to perform time series analysis, which represents a gold standard in policy evaluation.We acknowledge that a multiple correction adjustment, such as Bonferroni, would render some of our findings statistically insignificant. However, our intention was not to test multiple hypotheses, particularly regarding the relative impact of the different policies. Our emphasis here is in identifying patterns in the data rather than emphasising statistical significance. The data themselves have serious limitations, which we address below. Nevertheless, they are the only comprehensive data available to address these important questions. The largest estimated policy effects were seen with the disease-specific antibiotic use measures , and the strongest correlations with numbers of implemented policies were also seen for these outcomes. Taken together these suggest that our overall findings are quite robust.We have previously documented other limitations of the data-sets used here. Briefly,We also need to consider the potential adverse effects of the policies designed to reduce dependence on antibiotics. It is possible that when policies target and reduce one particular antibiotic prescribing behaviour, another inappropriate behaviour is substituted. For example, increased antibiotic consumption has occurred after campaigns to reduce injection use. Thus, itOur findings should be interpreted with a degree of caution. It may be that countries with more functional and efficient health systems are more likely to implement policies to promote better quality use of antibiotics. Better quality of antibiotic use was found in countries with higher economic status and this may be because of healthier populations, better health systems and/or more policy implementationThis is the first study to evaluate the impact of essential medicines policies recommended in the WHO Global Strategy to contain AMR and the WHO Global Action Plan 2015 on antibiotic use in multiple countries. The study shows in detail how different policies and numbers of policies impact on different indicators of antibiotic usage. The findings confirm that countries implementing these policies have less inappropriate use of antibiotics. This finding is important in the fight to contain anti-microbial resistance. It is critical that much more international attention is focused on implementing essential medicine policies to reduce antibiotic use in low and middle income countries.Kathleen Anne Holloway is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.S1 Table(XLSX)Click here for additional data file.S2 Table(XLS)Click here for additional data file.


Recently, many residents living in apartment buildings in Korea have been bothered by noise coming from the houses above. In order to reduce noise pollution, communities are increasingly imposing bylaws, including the limitation of floor impact sound, minimum thickness of floors, and floor soundproofing solutions. This research effort focused specifically on the deflection of resilient materials in the floor sound insulation systems of apartment houses. The experimental program involved conducting twenty-seven material tests and ten sound insulation floating concrete floor specimens. Two main parameters were considered in the experimental investigation: the seven types of resilient materials and the location of the loading point. The structural behavior of sound insulation floor floating was predicted using the Winkler method. The experimental and analytical results indicated that the cracking strength of the floating concrete floor significantly increased with increasing the tangent modulus of resilient material. The deflection of the floating concrete floor loaded at the side of the specimen was much greater than that of the floating concrete floor loaded at the center of the specimen. The Winkler model considering the effect of modulus of resilient materials was able to accurately predict the cracking strength of the floating concrete floor. Residential high-rise buildings have been gaining increasing popularity in densely populated countries due to their favorable properties. High-rise apartment buildings have the advantage of effectively using a relatively small land area, whereas they are also often disadvantaged by their housing environment. One of the most significant residential environment concerns in living in apartments is noise pollution due to floor impact sounds caused by footsteps, falling objects, moving furniture, and so forth.2 in 2011, the third most densely populated country in the world, the number of environmental grievances due to floor impact sound occurring in apartments is rapidly increasing: 12% in 2008, 18% in 2009, 28% in 2010, and 35% in 2011 of the total number of environmental grievances. The communities have established several standards on floor soundproofing to reduce the impact noise of apartments. The Apartment Housing Performance Grade Indication System currently enforced in Korea classifies the sound performance of apartments into several grades according to floor impact sound. In accordance with the dynamic stiffness measurement method of Korea Standard [In reinforced concrete apartment buildings, the floor impact sound from the floor above can easily transfer to the apartment below. Due to interior dry walls and thin floors, neighboring occupants can often hear each other's conversations. In the case of Korea, which has a population density of 503 person/kmStandard  allows tTwo types of floor soundproofing solutions are available to reduce impact noise: acoustic matting and floating floors. Both solutions can reduce impact noise transferring through wooden or concrete floor structures. In the case of floating concrete floors, resilient materials are normally placed between the concrete or wooden slab and finishing materials. The resilient materials may effectively reduce sound impact through a floor by reducing the vibration caused as an item hits the floor. The level of noise that will be transmitted through the floor depends on the force of the impact, the vibration transmission characteristics of the floor structure, and the floor covering. Elmallawany  investigMany studies on the effects of the types and density of resilient materials, dynamic stiffness, size of windows, wall types and materials, and different numbers of stories have been performed to examine the sound insulation of buildings –12. On tThe placing of resilient materials between the reinforced concrete slab and finishing mortar should not only reduce the floor impact sound vibration from the floor but also support the load on the floor. Thus, even if soft resilient materials satisfy the maximum limitation of light- and heavy-weight impact sound, these materials may not support the load on the floor. The density of material increases the dynamic stiffness of the material that is influenced by mass per area. The test results  indicateSince noise caused by movement in above apartments can adversity effect on the amenity of residents, the floor sound insulation systems are considered in design in residential apartments. Soft resilient materials in floor sound insulation systems may not support the load on the floor and cause to crack on the finishing mortar and sink the floor. To investigate this, experimental and analytical investigation on the deflection of floating floor sound insulation systems was conducted using a total of twenty-seven material specimens and ten floating concrete floor specimens in this study. In addition, as a classical method , 15 to cA total of twenty-seven specimens were tested to measure the stress versus strain curves of resilient materials. Three parameters were considered in this investigation: types of materials, bottom shapes, and thickness. Seven types of materials for reducing floor impact sound were tested: polystyrene (PE), tire chip (TC), glass wool (GW), ethylene vinyl acetate (EVA), ethylene polystyrene (EPS), vinyl sheet and polystyrene (VPS), and soft polystyrene (SPE). Three nominally identical specimens were prepared for each specimen type as shown in Aerated concrete laid between the resilient material and finishing mortar was prepared in accordance with the KS F 4039 standard . The comFloating concrete floors for RC apartment buildings generally consist of three materials: resilient materials, aerated concrete, and finishing mortar, as shown in The structural behavior of ten floating concrete floor specimens was observed from the experimental tests. All of the specimens failed due to the cracking of the finishing mortar and the splitting of the aerated concrete. None of the specimens showed the local failure at the residual material. The stress of the tested specimens showed gradual increments with the increase of deflection, as shown in The maximum load significantly increased with increasing the tangent modulus of the resilient material, as shown in In order to perform the numerical analysis for predicting the deflection of sound insulation systems, the Winkler model  was usedP, or uniform load, w, can be calculated by ϕSubstitution of the curvatures, given by , into 1, leads tεcr, of concrete proposed by Belarbi and Hsu [To estimate the cracking strength of the floor, the cracking strain,  and Hsu  was adopA total of twenty-seven resilient material tests indicated that the strength of resilient materials was strongly influenced by the types of materials and the bottom shapes of materials. At the beginning of loading, the compressive stress of EPS and EVA specimens increased with little change in slip, while the stresses of the other specimens increased in a slow grade. The stain of the plat-shaped specimens was smaller than that of the embossed-shaped specimens at the same stress stage.Among nine types of tested resilient materials, the tangent modulus of EPS specimen was the greatest, while that of SPE specimen was the lowest. The tangent modulus of all specimens except EPS specimen was approximately constant up to the strain of 0.3.Ten floating concrete floor tests showed that the maximum load significantly increased with increasing the tangent modulus of the resilient material. The deflection of the floor loaded at the side was greater than that of the floor loaded at the center, and this could be attributed to the decreasing of the supporting area against the external load.The analytical results using the Winkler model indicated that the deflection of the floating concrete floor rapidly increased as the tangent modulus of resilient material decreased, especially for the floor having a modulus lower than 0.5 MPa. Therefore, the resilient material of which the tangent modulus is greater than 0.5 MPa is recommended to be used to support the load on the floor.The proposed equation based on the Winkler model predicted the cracking strength of the sound insulation floor with 1.67 on average and 25.1% in COV.In this study, experimental and analytical investigations were conducted to determine the effects of the types of resilient materials and the location of loading on the structural behavior of floating concrete floors. Based on the experimental and analytical results, the following conclusions can be drawn.


Antimicrobials are the most commonly prescribed drugs. Many studies have evaluated antibiotic prescriptions in the paediatric outpatient but few studies describing the real antibiotic consumption in Italian children’s hospitals have been published. Point-prevalence survey (PPS) has been shown to be a simple, feasible and reliable standardized method for antimicrobials surveillance in children and neonates admitted to the hospital. In this paper, we presented data from a PPS on antimicrobial prescriptions carried out in 7 large Italian paediatric institutions.A 1-day PPS on antibiotic use in hospitalized neonates and children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven institutions in seven Italian cities were involved. The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey, who had at least one on-going antibiotic prescription. For all patients data about age, weight, underlying disease, antimicrobial agent, dose and indication for treatment were collected.The PPS was performed in 61 wards within 7 Italian institutions. A total of 899 patients were eligible and 349 (38.9%) had an on-going prescription for one or more antibiotics, with variable rates among the hospitals (25.7% - 53.8%). We describe antibiotic prescriptions separately in neonates (<30 days old) and children (> = 30 days to <18 years old). In the neonatal cohort, 62.8% received antibiotics for prophylaxis and only 37.2% on those on antibiotics were treated for infection. Penicillins and aminoglycosides were the most prescribed antibiotic classes. In the paediatric cohort, 64.4% of patients were receiving antibiotics for treatment of infections and 35.5% for prophylaxis. Third generation cephalosporins and penicillin plus inhibitors were the top two antibiotic classes. The main reason for prescribing antibiotic therapy in children was lower respiratory tract infections (LRTI), followed by febrile neutropenia/fever in oncologic patients, while, in neonates, sepsis was the most common indication for treatment. Focusing on prescriptions for LRTI, 43.3% of patients were treated with 3rd generation cephalosporins, followed by macrolides (26.9%), quinolones (16.4%) and carbapenems (14.9%) and 50.1% of LRTI cases were receiving more than one antibiotic. For neutropenic fever/fever in oncologic patients, the preferred antibiotics were penicillins with inhibitors (47.8%), followed by carbapenems (34.8%), aminoglycosides (26.1%) and glycopeptides (26.1%). Overall, the 60.9% of patients were treated with a combination therapy.Our study provides insight on the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children. An over-use of third generation cephalosporins both for prophylaxis and treatment was the most worrisome finding. A misuse and abuse of carbapenems and quinolones was also noted. Antibiotic stewardship programs should immediately identify feasible targets to monitor and modify the prescription patterns in children’s hospital, also considering the continuous and alarming emergence of MDR bacteria. Antimicrobials are the most commonly prescribed drugs in the community and hospital setting, especially among paediatric patients . HoweverThe emergence of multi-drug resistant (MDR) pathogens and their rapid global spread, strictly associated with an inappropriate use of antimicrobials, are important global public health threats with a substantial impact on patient outcomes such as hospital length of stay and mortality, as well as on healthcare costs –8. The EMany studies have evaluated antibiotic prescriptions in the paediatric outpatient population highlighting the problem that Italian prescribing habits that differ from those of other European countries. An Italian child is more likely to be exposed to antibiotics than children are in North Europe  and, in Although a positive correlation between outpatient and inpatient antibiotic use has been noted , few stuIn this paper, we present the results of a point-prevalence survey (PPS) on antibiotic prescriptions carried out in seven large Italian paediatric institutions in 2012. The aims of our study were: i) to describe prevalence rates of antibiotic prescriptions for prophylaxis and treatment of infections for neonatal (<30 days) and paediatric (age ≥30 days) patients in seven Italian centers; ii) to evaluate antibiotic prescriptions, indications, number and type of antibiotic agents and administration route in the same age sub-groups both for prophylaxis and treatment of infections; iii) to describe over-all consumption and off-label use of particular classes of antibiotics, such as carbapenems and quinolones, in our cohort; and iiii) to identify targets for improving the quality of antimicrobial prescribing in these centers.This research has been conducted according to the principles expressed in the Declaration of Helsinki. Ethical approval has been obtained for the coordinating centre. No consent was given, because data were collected by reviewing medical charts and were analyzed anonymously. Every patient record was given a unique non-identifiable survey number, which was automatically generated by a computer program specifically designed for anonymous data entry.A 1-day PPS on antibiotic use in hospitalized children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven paediatric or mixed adult-paediatric hospitals in seven Italian cities were involved . The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey who had at least one on-going antibiotic prescription. The wards of admission were: medical , special medical , neonatal and paediatric intensive care (NICUs and PICUs), surgical . For feasibility reasons, one hospital provided data from randomly selected wards, maintaining the patient distribution among medical, special medical, surgical and intensive care units, in agreement with the coordinating centre. Full details of the ARPEC methodology are described elsewhere [The PPS was performed in 61 wards within seven Italian institutions. Characteristics of the centres involved are shown in A wide variability also existed in the proportions of patients treated with at least one antibiotic stratified by ward type. In particular, special medical wards and intensive care units accounted for higher proportions of patients receiving antibiotics compared to surgical and medical wards “”.Characteristics of all patients enrolled are summarized in We analyzed antibiotic prescriptions separately in neonates and children .At the time of the survey, 248 neonates were admitted in participating hospitals and 43 were receiving antibiotics (17.3%). As shown in The main indication to prescribe antibiotic prophylaxis was medical risk factors , accounting for 55.8% of all indications for antibiotic therapy in the neonatal subset. The other neonatal patients were receiving prophylaxis for surgical reasons. Monotherapy was prescribed in 10 of the 27 patients on prophylaxis (37%), and penicillin was the most prescribed antibiotic (7/10). Combination therapies in the other 17/27 patients (63%) were variable: penicillins were combined with aminoglycosides in 7/17 cases, while glycopeptides were used with third generation cephalosporins in 3 cases and with aminoglycosides in 3 cases. The last 4 patients received 3 drug combination therapy, including glycopeptides plus aminoglycosides combined with metronidazole (2/4) or penicillin (2/4).Among all the indications for antibiotic treatment of infection in neonates, the most common was sepsis . Monotherapy was used just in two cases (one case treated with ampicillin and the other treated with meropenem). Penicillins plus aminoglycosides was by far the preferred combination therapy (8/11), while in the other patients (3/11) glycopeptides were used widely in combination with other classes of antibiotics.The paediatric group was composed of 651 patients, 47% (306/651) of whom had an active antibiotic prescription at the time of the PPS. In the group of patients with active antibiotic prescriptions, 64.4% (197/306) were being treated for infections and 35.5% (109/306) for prophylaxis . Third gApproximately half of the children on antibiotics for prophylaxis received antibiotics for surgical reasons , the others for medical problems . The most prescribed antibiotics were third generation cephalosporins for surgery , used as monotherapy in 14/20 cases and combined most often with metronidazole in the other cases (3/20). Cotrimoxazole was the most commonly prescribed agent for the medical problems , mainly used as monotherapy (30/35).The main reason for prescribing antibiotics for infection among children was lower respiratory tract infections (LRTI) , followed by febrile neutropenia/fever in oncologic patients . Focusing on prescriptions for LRTI, 43.3% (29/67) of patients were treated with third generation cephalosporins, followed by macrolides , quinolones  and carbapenems . Cephalosporins were used as monotherapy in 13/29 cases and combined in the other 16 cases, mostly with macrolides (6/16). For 73.1% (49/67) of children with LRTI, the route of antibiotic administration was parenteral.For oncology patients affected by neutropenic fever/fever, the preferred antibiotics were penicillins with enzyme inhibitors , followed by carbapenems , aminoglycosides  and glycopeptides . Penicillins with enzyme inhibitors were used in monotherapy in 5/11 cases and combined mostly with aminoglycosides in the other 6 cases. Carbapenem monotherapy was prescribed in 4/8 cases, while combination therapy with anti-Gram positive agents (glycopeptides or oxazolidinones) was preferred in the other cases. The route of antibiotic administration was parenteral in the 95.7% of cases (22/23).Among the 899 patients admitted to the hospital at the time of the survey, 32 (3.6%) were being treated with carbapenems. Focusing on the group of 349 patients with active antibiotic prescriptions at the time of the PPS, 8.9% (32/349) were receiving carbapenems . Considering the overall rates of therapy by department, those with the highest rates of carbapenem prescription were the special medical wards  and the intensive care units , compared to 2.6% (2/76) in medical wards and 1.7% (1/59) in surgical wards. Indications for prescription of carbapenems were community-acquired infections in 53.1% of cases, hospital-acquired infections in 37.5% and prophylaxis in 9.3%. Febrile neutropenia was the most common reason for carbapenem prescription . Therapy was empirically prescribed in 62.5% (20/32) of patients. Carbapenems were mostly prescribed in combination with one or more other antibiotics , most commonly with glycopeptides (10/21), followed by quinolones (4/21), cotrimoxazole (4/21) and aminoglycosides (3/21). Meropenem was the most prescribed carbapenem, with great heterogeneity in doses and number of administrations recorded. Daily doses of meropenem ranged from 19 mg/kg/day to 129 mg/kg/day, while the mean dose was 70 mg/kg/day. Off-label prescription of carbapenems (i.e. below 3 months of age) was recorded in 18.7% (6/32) of patients and the indications were LRTI, sepsis and surgical prophylaxis.In the entire cohort of patients admitted to the hospital, 3% (27/899) were prescribed quinolones. Among the patients with active antibiotic prescriptions, this rate was 7.7% (27/349). None of them were neonates, but 37% (10/27) were below 2 years of age. Considering the overall rates of prescriptions into the departments, the special medical wards  and intensive care units  reported the highest rates of quinolone prescription, compared to 6.6% (5/76) in medical wards and 3.4% (2/59) in surgical wards. Indications for prescription of quinolones were community-acquired infections in 44.4% of cases, hospital-acquired infections in 40.7%and prophylaxis in 14.8%. Considering the rates of antibiotic prescription by indication, the most common indication was LRTI . Among the group affected by LRTI, 41.6% (5/12) had an underlying chronic lung disease including cystic fibrosis and 25% (3/12) congenital immunodeficiency. In general, quinolone therapy was empirically prescribed in 63% of patients. Quinolones were prescribed as monotherapy just in 29.6% (8/27) of patients. In the other cases, they were widely combined with other antibiotics , especially with third generation cephalosporins (5/19). The mostly prescribed quinolone was ciprofloxacin. Focusing on ciprofloxacin, the prescribed daily dose ranged from 6 mg/kg/day to 30 mg/kg/day, while the mean dose was 18 mg/kg/day.The 1-day ARPEC PPS provided very useful data on hospital antibiotic prescriptions for paediatric and neonatal patients in Italy. According to data collected in seven large Italian institutions, 38.9% of inpatients received at least one antibiotic prescription during hospitalization. This rate is similar to the mean rate reported from the worldwide ARPEC PPS (36.7%) .To better analyze antibiotic prescription patterns and their appropriateness, we assessed antibiotic prescriptions for prophylaxis and treatment of infection separately.Our results show that overall 39% of patients were prescribed antibiotics for prophylaxis with the highest rate observed in the neonatal population . The main indication for neonatal prophylaxis was the presence of perinatal conditions . Prophylactic monotherapy was prescribed just in 37% of neonates and penicillin was the preferred agent, while combination prophylactic therapies including penicillin plus aminoglycosides or glycopeptides plus cephalosporins/aminoglycosides were widely used in neonatal patients. This approach is not in-line with the international literature. Although neonates represent a high risk population due to their immature immune system and the invasive procedure they are likely to undergo in NICU , recent reviews reject the routine use of antibiotic prophylaxis due to lack of efficacy in many conditions –22. MoreIn the paediatric group, the rate of antibiotic prescriptions for prophylaxis was 35.5% of all the prescriptions. Approximately, half of these patients were receiving antibiotics for surgical prophylaxis in accordance with previous European reports in which the proportion of children receiving surgical prophylaxis ranged from 13 to 42% , 26. ThiPneumocystis jirovecii pneumonia in immunocompromised patients [Cotrimoxazole was the most prescribed antibiotic for medical prophylaxis, used alone in most cases. As explanation, most of the treated children were affected by onco-hematological diseases and cotrimoxazole is the best treatment to prevent patients .Regarding the prescription patterns for treatment of infection, the 37.2% of our neonatal cohort was prescribed at least one antibiotic for treating an infection, the main reason was sepsis and the most common antibiotic class was penicillins, combined with aminoglycosides in a large number of patients, in line with international literature , 30. It Focusing instead on the paediatric group, we noticed an excessive use of third generation cephalosporins for treatment of infection similar to that seen for surgical prophylactic use, as underlined before. In children with LRTIs, ceftriaxone was the most prescribed antibiotic, used as monotherapy or often combined with macrolides, with a wide total daily dose variability ranging from 12.1 mg/kg/day to 153.8 mg/kg/day. The frequent choice of ceftriaxone as first line therapy for treatment of uncomplicated LRTIs and, in some cases, the high dosage prescribed, are reasons of concern because they are not supported by current guidelines . In factAn abuse of parenteral cephalosporins in Italian hospitalized children was already denounced in a study conducted by Esposito in 2001  and is aKlebsiella pneumoniae reported by the European Antimicrobial Resistance Surveillance Network (EARS-Net)’s report from 2010 to 2013 [Noteworthy was also the widespread use of carbapenems and quinolones. Indeed, in our study population, among the 349 patients receiving antibiotics, 8.9% were being treated with carbapenems, whereas proportion of carbapenems for therapeutic use reported in the literature in European paediatric units is 4,2% . Though  to 2013 .Clostridium difficile infection [Similar problems were noticed also for quinolone prescription. Quinolones were widely used in our cohort, even if the license for the use of this antibiotic class below 18 years of age is restricted to few rare indications such as cystic fibrosis with pulmonary exacerbations, complicated urinary tract infections, post exposure prophylaxis against inhalational anthrax and severe infections with allergies to other antibiotics ,40. Amonnfection ,44. The Our study highlights many feasible targets that need a prompt intervention with appropriate antimicrobial stewardship programs. International guidelines for stewardship identify a wide set of interventions including: disease-specific clinical pathways, audit with feedback and formulary restriction with preauthorization of select agents. The best type of interventions must be tailored according to local practices, resistance trends, and available resources . While tOur study has some limitations. First, data about microbiological isolates and antibiotic susceptibility tests, length of therapies and prophylaxis and previous antibiotic courses could have been useful to better define the appropriateness of antimicrobial prescriptions. Moreover, the characteristics of involved institutions may have affected at least in part the reliability of some results. Most institutions are in fact tertiary care hospitals that usually manage more complicated and severe cases, which might significantly impact antibiotic prescriptions. In addition, the heterogeneity among institutions, in terms of presence/absence of onco-hematology departments or intensive care units, may strongly affect antimicrobial prescription patterns. Finally, the survey was conducted in 2012 and since then a greater awareness of antibiotic stewardship programs has spread among Italian hospitals –49.Our study took a picture of the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children and identified many feasible targets that require a prompt intervention to reduce the abuse and misuse of antibiotics. Antibiotic stewardship programs should immediately introduce measures to control prescription patterns in particular for prophylaxis, both in neonatal and paediatric populations, and to limit the over-use of third generation cephalosporins, that seems to persist over-time. Surveillance and educational programs are also needed to restrict the use of carbapenems to more severe conditions. The implementation of disease-specific clinical pathways associated with annual PPSs could be a good way to monitor and ameliorate antibiotic prescription patterns in neonatal and paediatric inpatients over time, in order to reduce as much as possible the worrisome emergence of MDR bacteria in this vulnerable population.S1 File(XLSX)Click here for additional data file.


It is not known whether serum IgG4 is autoreactive in IgG4-RD.Immunoglobulin (Ig) G4-related disease (IgG4-RD) is characterized by elevated serum IgG4 and infiltration of IgG4We measured anti-nuclear antibody (ANA) in 19 IgG4-RD cases, determined IgG subclasses of the ANA, and compared them with those of other systemic autoimmune diseases , using subclass-based ANA test (indirect immunofluorescence).58 % of IgG4-RD cases were ANA-positive (cut-off: 1:40). Whereas their subclass of ANA was predominantly IgG2, we observed no IgG4-type ANA. In systemic autoimmune diseases, subclasses of ANA were mostly IgG1, 2, or 3, but IgG4-type ANA was very rarely detected. We also found several patients in whose serum ANA patterns differed among IgG subclasses, probably due to the difference of corresponding autoantigens.Although IgG4 is highly elevated in sera of IgG4-RD patients, their ANA do not include IgG4 subclass. These results offer new insight into the role of IgG4 and the pathogenesis of IgG4-RD, implying that each IgG subclass tends to cover its own spectrum of antigens, and IgG4 is not preferentially used to make ANA. Many clerosis  and carbclerosis  antibodiAt this point, there is no consensus that IgG4-related disease is an autoimmune disorder. To examine whether IgG4 in IgG4-RD is autoreactive, we determined IgG subclasses of serum anti-nuclear antibody (ANA) in IgG4-RD patients and compared them with those in patients with systemic autoimmune diseases such as systemic lupus erythematosus (SLE), Sjögren’s syndrome (SS), systemic sclerosis (SSc), and polymyositis (PM). Using a subclass-based ANA test that was derived from indirect immunofluorescence (IIF), we investigated how frequently IgG4 was included in ANA in IgG4-RD. We also examined how frequently each IgG subclass was included in ANA in systemic autoimmune diseases.+/IgG+ plasma cell ratio > 0.4, and > 10 IgG4+ plasma cells in a high-power field. No IgG4-RD patients were considered having SS, Castleman’s disease, sarcoidosis, granulomatosis with polyangiitis, or malignant lymphoma. As ANA-positive disease controls, we enrolled 8 SLE patients diagnosed by the 1997 American College of Rheumatology revised criteria [Patients were recruited from Department of Rheumatology and Clinical Immunology, Kyoto University Hospital, Kyoto, Japan. The patients were definitely diagnosed by the 2011 Comprehensive Diagnostic Criteria proposed by the IgG4-RD research team of Ministry of Health, Labour and Welfare (MHLW), Japan [We performed subclass-based ANA tests based on the Fluoro-HepANA™ test . Briefly, HEp-2 cell-coated slides were incubated with sera, washed with PBS, incubated with FITC-labeled second antibodies, and observed with a fluorescence microscope. Instead of using anti-total human IgG antibody as the second antibody, we used anti-IgG1 , anti-IgG2 , anti-IgG3 , or anti-IgG4 antibodies . To detect total-IgG ANA, patients’ sera are usually diluted by the ratios starting from 1:40. To detect each IgG-subclass ANA, the sera were not diluted because of relatively low affinities of the second antibodies against subclasses.Of 19 cases that definitely satisfied the 2011 Comprehensive Diagnostic Criteria for IgG4-RD by MHLW, Japan  of an IgG4-RD patient  in IgG4-RD. This implies that IgG4 itself is not used to make ANA.IgG4es Table . HoweverSeveral studies have investigated ANA subclasses in systemic autoimmune diseases. Zouali et al. reported that in SLE and mixed connective tissue disease, anti-double-stranded DNA (dsDNA) antibody was IgG1/3-dominant, and anti-RNP was IgG2-dominant . Anti-SmAutoimmune pancreatitis (AIP) is an organ-specific disorder seen in IgG4-RD. Various autoantibodies, such as anti-lactoferrin  and anti2 receptor (PLA2R) antibody in idiopathic membranous nephropathy mainly consisted of IgG4 [However, some autoimmune diseases reportedly show IgG4-type autoantibodies. Rock et al. reported that IgG4 was the most common (100 %) of anti-desmoglein (Dsg)-1 antibodies detected in sera of patients with pemphigus foliaceus, and showed the pathogenicity of IgG4-type anti-Dsg-1 antibody using Balb/c mice . Anti-Ds of IgG4 . IgG4 is of IgG4 , and MPO of IgG4  were IgG of IgG4 , 24. Eng of IgG4 . However of IgG4 , whereas of IgG4 . In RA p of IgG4 . As IgG4 of IgG4 –32, IgG42R antibody has high affinity and is considered pathogenic in idiopathic membranous nephropathy [2R antibody can exert pathogenicity without ability of complement activation may be because the pathogenicity is brought by the destruction of electrical barriers of glomerular basement membrane.Interestingly, there seem to be pathogenic and non-functional IgG4-type autoantibodies. IgG4-type ANCA is considered less pathogenic, compared to other subclass ANCA in ANCA-associated vasculitis , 27. Thehropathy . Why IgG2R, anti-CCP antibodies, and ANCA, but not with anti-PTSI antibody in AIP or ANA in IgG4-RD and systemic autoimmune diseases (Table Taken together, IgG4 usage rates differ among autoantibodies and among diseases. IgG4 is associated with anti-Dsg-1/3, anti-PLANeisseria meningitidis and Streptococcus pneumoniae [2R, PR3, and citrullinated proteins, it would explain why IgG4-type antibody against those proteins was dominantly generated.In the present study, we observed ANA patterns differed among IgG subclasses in some cases Fig. , 4. Wheneumoniae , 34, so Our results imply that IgG4-RD is not an autoimmune disease, and that high levels of serum IgG4 in IgG4-RD are only nonspecific. Subclass-based ANA tests in this study covered both nuclear and cytoplasmic antigens in HEp-2 cells, and can screen a wide range of unmodified ubiquitous antigens. However, this analysis has limitations: modified antigens like citrullinated proteins and organ-specific antigens are not screened. The number of cases is limited in this study. There remains a possibility that unknown IgG4-type autoantibodies might be found in IgG4-RD. A further analysis is needed.We found ANA in IgG4-RD patients are not IgG4-based despite high serum IgG4 levels. IgG4 was also hardly found in ANA in systemic autoimmune diseases. We also observed several patients in whom ANA patterns differed among IgG subclasses, probably due to difference in corresponding autoantigens. These findings imply that each IgG subclass tends to cover its own spectrum of antigens, and IgG4 is not apparently used to make ANA.


Sepsis remains a leading cause of death in intensive care units. Administration of appropriate antibiotics within the first hour of diagnosis has been found to be the most effective intervention associated with a reduction in mortality . CurrenThis survey aimed to determine how many intensive care units in England currently use extended and continuous infusions of time dependent antibiotics in the treatment of sepsis.One ICU in each acute trust in England was contacted via telephone in June 2014. A doctor working on the unit grade CT1 or above was then interviewed about antibiotic prescribing in sepsis.Of the 148 acute trusts with critical care facilities in mainland England 123 replied to the survey, 23 were unable to be contacted and 2 declined to respond; a response rate of 83.1% was achieved. Of the trusts that responded antibiotic infusions were never used as a clinical strategy in the management of septic patients in 66 (54%). Of the 57 (46%) trusts that did consider using antibiotic infusions for the management of septic patients only 11 (7%) used both continuous and extended infusions of antibiotics, 27 (18%) used continuous infusions only and 19 (15%) used extended infusions but not continuous infusions . Of the 57 trusts that used infusions of antibiotics; Vancomycin was administered by infusion in 48 (84%) trusts and beta-lactams in 16 (28%).There remains disagreement regarding the clinical benefit of continuous and extended infusions of time dependent antibiotics in the management of septic patients in ICU. This is despite a large body of theoretical evidence based on pharmacokinetic studies. We suggest further, larger trials powered towards mortality are indicated for consensus to be achieved.