Over the vast Northwest China, arid desert contains high concentrations of sulfate, chloride, and other chemicals in the ground water, which poses serious challenges to infrastructure construction that routinely utilizes portland cement concrete. Rapid industrialization in the region has been generating huge amounts of mineral admixtures, such as fly ash and slags from energy and metallurgical industries. These industrial by-products would turn into waste materials if not utilized in time. The present study evaluated the suitability of utilizing local mineral admixtures in significant quantities for producing quality concrete mixtures that can withstand the harsh chemical environment without compromising the essential mechanical properties. Comprehensive chemical, mechanical, and durability tests were conducted in the laboratory to characterize the properties of the local cementitious mineral admixtures, cement mortar and portland cement concrete mixtures containing these admixtures. The results from this study indicated that the sulfate resistance of concrete was effectively improved by adding local class F fly ash and slag, or by applying sulfate resistance cement to the mixtures. It is noteworthy that concrete containing local mineral admixtures exhibited much lower permeability (in terms of chloride ion penetration) than ordinary portland cement concrete while retaining the same mechanical properties; whereas concrete mixtures made with sulfate resistance cement had significantly reduced strength and much increased chloride penetration comparing to the other mixtures. Hence, the use of local mineral admixtures in Northwest China in concrete mixtures would be beneficial to the performance of concrete, as well as to the protection of environment. According to the American Concrete Institute (ACI), it can be classified as Class II to III (severe to very severe) sulfate exposure conditions. Therefore, portland cement concrete used in this sulfate environment should be specially designed for improved durability.The Northwest China, including Xinjiang, Gansu, Qinhai, partial Tibet, and partial Inner Mongolia, spans over 3.5 million square kilometers. A significant portion of this area is covered by arid desert, which has similar geographic terrain to that of central Asia where the ancient “Silk Road” passed through. Due to low natural precipitation, saline soils are typical in this arid region. Salts in the soil are mainly from the weathering of minerals or the upward movement of shallow groundwater. Field measurement indicates that the water-soluble sulfate (SOPortland cement concrete (PCC) may be vulnerable when exposed to environment rich in sulfate ions . SulfateWith the rapid industrialization of the Northwest China, huge amounts of by-products are being generated from various industries in the region. Notably, the coal combustion power plants and metallurgical industries in the Northwest China are the key pillars to support the local industrialization. Taking Xinjiang Urgur Automatous Region (a key province in Northwest China) as an example, in 2012, the automatous region produced 9 million kilowatt-hour of electricity from coal power plants and 2.4 million tons of steel, generating a huge amount of by-products including fly ash, silica fume and blast furnace slag. These mineral admixtures, if not utilized in time, would turn into waste materials and poses serious threat to the environment.It has been well documented that mineral admixtures or supplementary cementing materials (SCMs) such as fly ash and blast furnace slag may be used in portland cement concrete and improve the durability of concrete, such as sulfate resistance –8. In ad1.2.3A) content in portland cement and the expansion of cement mortar and concrete [3A content [Previous studies found a positive relationship between the tri-calcium aluminate  in concrete ,21, and et al.  optimizeHowever, mineral admixtures, due to their variable sources and procedures, vary significantly in chemical compositions as well as interactions with cement ,26. Prev2.3A concentrations of the cementitious materials. To evaluate the mechanical and durability of the cement mortar and concrete, compressive strength, sulfate resistance and chloride penetration tests were conducted.The objective of the present study was to determine whether typical local mineral admixtures from Northwest China could be used in significant quantities to produce concrete mixtures that can resist the harsh sulfate environment without compromising the necessary mechanical properties. To achieve this objective, comprehensive laboratory testing was considered to characterize the chemical, mechanical, and durability properties of cementitious materials and concrete. Chemical and thermal analyses were considered to characterize chemical components and C3.Local coarse aggregates, natural sand and cementitious materials were utilized in this study. Cementitious materials included two types of local portland cements: ordinary portland cement (OPC) and sulfate resisting cement (SRC) with a strength level of 32.5 PMa, two types of local Class F fly ash and two types of local slags, named as S75 and S95. Except for the concretes in the rapid chloride ion permeability test (RCIP), standard graded sand  utilized4.2 but less Al2O3 than cements. The hydraulic and pozzolanic reactions of SCMs produce calcium silicate hydrate (C-S-H). Also the pozzolanic reaction consumes the porous calcium hydroxide (Ca(OH)2), which is prone to sulfate attack. With proper selection and proportions of SCMs, the two reactions mentioned above make the microstructure in the concrete denser than ordinary portland concrete [2O3 content would also reduce the reactive aluminates in concrete and potentially improve the sulfate resistance. In addition, the use of SCMs decreases the content of C3A in cementitious materials, and thus the amount of AFm (C3A·CaSO4·12H2O) in concrete, leading to a reduced risk of sulfate attack.concrete , which m5.3A than OPC, indicating SRC concrete may be more durable than OPC concrete in sulfate environment. 2 and produce C-S-H, making concrete less permeability and more durable to sulfate and chloride attack.According to ASTM 1365 , the qua6.3A reacts with water immediately when exposed to water and releases large amount of heat in a very short time. Thus, the content of C3A can be estimated by comparing the heat releasing rate of cementitious materials, which intimately relates to the potential sulfate resistance of the cementitious mixture. In accordance with ASTM C 1679 [w/cm) ratio was 0.4. Two duplicated samples were prepared and tested. −3w/g), indicating a higher C3A content. As SCMs were added into ordinary portland cement, the heat rate was reduced significantly , indicating lower C3A content. Therefore the sulfate resistance of cementitious materials is expected to be improved. Hydration heat of cementitious material is determined by its chemical components. Among the main compounds in cement, CM C 1679 , the hyd7.In addition to satisfy specific strength requirement, concrete used in severe sulfate environment should be designed to have sufficient durability. Compressive strength tests of cement mortar were conducted to evaluate the mechanical property of designed concrete. As mentioned above, to increase the sulfate resistance, the concrete should have lower permeability and less active chemical components prone to sulfate corrosion. Sulfate resistance and rapid chloride penetration tests were conducted to evaluate the permeability of concrete.7.1.w/cm ratio referred from the test of length change of cement mortars exposed to a sulfate solution . The laded sand  was utilded sand  was util7.2.Sulfate corrosion in concrete usually appears in the form of expansion, cracking and spalling. Sulfate resistance of cement mortars was evaluated by measuring the length change of cement mortars immersed in a sulfate solution. According to ASTM C1012 , for the7.3.In accordance of ASTM C1202 , the rap8.8.1.w/cm ratio. The 28-day compressive strength of ordinary cement mortar with 0.485 w/cm ratio was relatively low (15 MPa) and is not presented. The ordinary cement mortar had highest strength increase within the first 7 days of curing. SRC mortar had lowest compressive strength, maybe due to some cementitious admixtures added in it. The 28-day and 60-day results showed that cement mortars with fly ash or slag maintained same strength level as ordinary cement mortar, which could be attributed to the fact that replacing cement with fly ash can extend the process of hydration and thus allow higher strength development in the long term. It is worth to mention that the compressive strength test standards in United States and in China are different in many aspects, such as raw materials, sample size, sample preparation, curing conditions. Therefore, the compressive strength results here should not be used to grade the strength class of cements with/without SCMs.8.2.w/cm ratio on sulfate resistance of cement mortar bars. It can be seen that SRC mortar with 0.485 w/cm ratio continuously expand in 6 months and still had high potential to expand. The SRC mortar with a 0.4 w/cm ratio had much less expansion and became stable after 4 months. It indicates that even with SRC, high w/cm ratio made concrete vulnerable under sulfate attack, which was in good agreement with the findings of other researchers [earchers .w/cm ratio. It can be seen that using SCMs or SRC significantly reduced the expansion of cement mortar in the sulfate solution. It is noted that the long term stability of cement mortars with SCMs were even better than that of the SRC mortar. Only the OPC mortar did not meet the criterion of American Concrete Institute (ACI) specification for sulfate resistance (C201-2R): the length change should be less than 0.05% at 6months. All other formulas satisfied the requirement and can be used in the severe sulfate environment.8.3.Generally, concrete made with fly ash or slag not only maintained similar strength to that of ordinary cement concrete, but also had a higher sulfate resistance and a much lower permeability. Although SRC concrete had a sufficient sulfate resistance, its strength and permeability were compromised. In summary, concrete made with up to 25% fly ash or 30% slag as replacement of ordinary portland cement showed better sulfate resistance than SRC concrete and could be applied in the typical sulfate environment in Northwest China.9.3A concentration of the cementitious materials. To evaluate the mechanical properties and durability of the cement mortar and concrete, compressive strength, sulfate resistance, and chloride permeability tests were performed. Based on the results from the laboratory tests, the conclusions can be drawn and summarized as follows:The present study investigated the chemical, mechanical, and durability properties of concrete made with local mineral admixtures and subjected to typical severe sulfate environment in Northwest China. The chemical and thermal analyses were conducted to characterize chemical components and C2 and lower Al2O3 contents than ordinary portland cement or the selected SRC, which would potentially improve the sulfate resistance of concrete by reducing permeability and reactive aluminates. The thermal analysis indicated low C3A content in the cement mortar with these local mineral admixtures, which was beneficial to the sulfate resistance of concrete.The chemical analysis showed that local mineral admixtures from Northwest China had higher SiOThe X-ray diffraction analyses indicate that pozzolanic reactions will happen when fly ash is added into concrete, which will make concrete less permeable and more durable in sulfate and chloride environment.The compressive strength results showed that the cement mortars made with up to 25% fly ash or 30% slag exhibited similar compressive strength to that of ordinary cement mortar, whereas the cement mortar made with SRC had a much lower compressive strength than the former two.The sulfate resistance test results showed that the cement mortar made with up to 25% fly ash or 30% slag exhibited a higher sulfate resistance than the mortar made with SRC.The permeability test results showed that fly ash and slag significantly reduced the permeability of concrete, whereas SRC increased the permeability of concrete, putting concrete at higher risk of sulfate corrosion.In summary, the sulfate resistance of concrete could be effectively improved by adding local mineral admixtures (class F fly ash or slag), or using the selected SRC. However, SRC significantly reduced the strength and increased the permeability of concrete; whereas use of fly ash or slag could maintain similar strength and reduce permeability concrete, which would be beneficial for the long-term durability of concrete.


Nitazoxanide is a member of a new class of drug, thiazolides, and it was discovered in 1984 with antimicrobial activity effect against anaerobic bacteria, Hepatitis virus, protozoa, and helminths.A bibliometric study on four databases (1984-2016) – Medline, Scopus, LILACS, and SciELO – characterizing the global scientific production of nitazoxanide. We determined the quantity, quality (number of citations), and types of studies developed by each country, characterizing them by years, international cooperation, development, place of publication, authors (with its H-index), and groups with higher impact.There were 512 articles in Medline – the higher scientific production is from the USA (19.71%), Switzerland (7.51%), and Mexico (7.27%). There were 1,440 articles in Scopus – from the USA (8.98%), Mexico (2.13%), and India (1.65%). There were 405 articles in LILACS – from Mexico (4.69%), the USA (4.2%), and Peru (2.47%). There were 47 articles in SciELO – from Brazil (34.04%), Venezuela (21.28%), and Colombia (14.89%). The H-index of nitazoxanide is 75 – the USA (26), Egypt (12), and Canada (10) were the countries contributing more with that.Nitazoxanide research has been highly important. Nevertheless, it is relatively limited when compared with other drugs. Its research has been led by the USA, as revealed in this bibliometric assessment. Although some developing countries, where it is used especially for protozoa and helminths, probably have its influence, and this explains the fact that Mexico and India, among others, are the top countries in the scientific production of this anti-infective agent. This bibliometric study evidenced a relatively low number of publications, however, it has been increased in recent years. Nitazoxanide is a broad-spectrum antimicrobial drug. This antimicrobial inhibits the pyruvate ferredoxin oxidoreductase enzyme on the metabolism of some pathogenic microorganisms. Its spectrum includes mainly bacterial and parasitic (protozoa and helminths) species, as some viruses (Hepatitis B and C), which are etiologic agents of a wide range of diseases in territories of the developing world as Latin American and Asian countries, where it is frequently used .Taenia saginata and Hymenolepis nana. After that, a higher spectrum was discussed, given the discovery of its antimicrobial activity against Enterobacteriaceae, Trichomonas vaginalis, Entamoeba histolytica, and Clostridium difficile. Nitazoxanide was considered an important therapeutic drug in metronidazole-resistant cases. In addition to that, the spectrum of nitazoxanide also includes activity against viral diseases such as hepatitis C. Currently, nitazoxanide is an important option to treat Cryptosporidium and Giardia infections, which are important etiologies of diarrhea in the pediatric population in developing countries, as well as in immunocompromised patients. Nitazoxanide is also an alternative therapy for Clostridium difficile diarrhea in inpatients [This antimicrobial was initially classified as an antiparasitic agent due to its activity against patients -6. In adpatients -8.Nitazoxanide is a drug that preserves its spectrum and this has become as an important therapeutic tool, so it requires more investigation on potential future therapeutic effects . Then, twww.pubmed.com) (English), analyzed through the GoPubMed® (http://gopubmed.com/web/gopubmed/) (January 1809-April 2017), Scopus (https://www.scopus.com/) from Elsevier (January 1959-April 2017) (English), SciELO (integrated) (http://scielo.org/php/index.php) (2004-2016) (Spanish) and LILACS   (1980-2016) (Spanish). All the regions of the world, as well as registered countries in the databases, were searched. As these databases have different literature coverage, results are presented per database, due to the fact that it is not technically possible to integrate them, as they are not of the same quality too, among other limitations.A bibliometric study about the global scientific production on nitazoxanide was done. This assessment was performed in four important regional and international bibliographical databases, two of them in English and two in Spanish: Index Medicus/Medline/PubMed : "Nitazoxanide (nitazoxanide)" AND "Argentina", "Nitazoxanide (nitazoxanide)" AND "Zimbabwe" and in the same way as the rest of countries. We determined the quantity, quality , and types of studies performed by each country, characterizing them for years, international cooperation (IC), country of publication (COP), citations and H-index, authors and groups with the highest contribution.Data was tabulated and analyzed in Excel 365® for Windows 8®, summarizing quantitative variables with means and standard deviations (±DE) and qualitative with proportions.In Medline, we found 512 articles published and indexed in the study period, with a clear trend to increase their research in the last decade , followed by immunology and microbiology (22.8%), and pharmacology, toxicology and pharmaceuticals (22.3%)  (47.5%), followed by review articles 38.9%), among other contributions , followed by Egypt (H = 12) and Canada (H = 10), which are the countries with the highest number of citations, 2305, 677 and 630, respectively.In the regional Scielo database, only 47 articles were found, of which 34.04% are from Brazil, 21.28% from Venezuela, and 14.89% from Colombia, among others Figure .Finally, in LILACS, we found 405 items, of which 4.69% are from Mexico, 4.2% from the USA, and 2.47% from Peru, among others Figure .Nitazoxanide has been an important antimicrobial drug. This has generated significant research in the world. In this study, it was demonstrated the leadership of the USA about nitazoxanide global research , which doubled Switzerland, the second in research production of it. Nevertheless, it is clear that there is still a limited scientific production on this drug. However, after the 1980s, there was an exponential rising in the production, especially in the last 10 years, which counts for the largest scientific production of the topic Figures . Most ofThe above-mentioned information could be explained by the new findings of the mechanisms of action and uses, like its use against plenty of viruses such as rotavirus, hepatitis B (HBV) and C (HCV), yellow fever, dengue, influenza , 10-12. One of the possible explanations for the significant increase in research about this drug in recent years is due to an augmented resistance to antibiotics, thereby serving as an alternative medication for a high impact public health issue as has been considered recently by World Health Organization (WHO) , 13-14.As occurred in multiple other topics, related to tropical diseases -19, affeBesides that, leading research groups on this drug are located in developed countries, where our analysis showed that Dr. Jean-François Rossignol, from the USA, is a leading author, but interestingly this researcher is a piece integrating over a dozen of institutions in different parts of the world Figure  in a larPotential limitations of the study are related to the database used to retrieve articles. Further studies should include Science Citation Index, which was not included because of the costs of subscription for the institution (not affordable). Included databases do not represent all scientific and biomedical journals published; in fact, many articles of importance may appear in journals other than those indexed in used databases or may not be indexed as the case of contributions made to scientific conferences and meetings. However, the recognized quality of the publications included in these databases and their coverage means that the documents selected constitute a more than representative sample of the international research on nitazoxanide -19. In tBibliometric studies are currently important to define the status of research on any topic, particularly of health, of diseases as well as, in this case, of drugs that have been developed and with clinically significant implications, as is the case of nitazoxanide.Despite its methodological limitations, this study represents the first effort, based on the literature review, to explore the development and research productivity on nitazoxanide over time and has pointed out interesting characteristics of nitazoxanide literature. First, the concentration of papers over journals is disseminating the research results, and second, the research in this field is growing and possibly will continue in the years to come. From these findings, it is clear that countries such as the USA lead the research on this drug, but it is evident that there is a need to increase this drug in developing countries, where its use is highly important due to its anti-infective coverage, especially in tropical parasitic diseases.Bibliometric studies in different areas of medicine are of great importance, not only to map research needs in a particular subject but also, as shown here, to throw an accurate view of scientific production over time and their impact in future years, for example, in research on drugs and in particular on anti-infective agents. These results would also be important for the analyses of funding research agencies as well as to academic institutions with interest in the topic. We recommend finally to perform periodically this type of assessment to keep track trends of research in this and other anti-infective drugs.


Biochemical and computational analyses were performed. Everolimus-resistant cells were xenografted into mice (10/group) and studied for their response to everolimus and Met inhibitors. The statistical significance of the in vitro results was evaluated by Student's t test.Inhibition of the mechanistic target of rapamycin (mTOR) is a promising treatment strategy for several cancer types. Rapamycin derivatives such as everolimus are allosteric mTOR inhibitors acting through interaction with the intracellular immunophilin FKBP12, a prolyl isomerase with different cellular functions. Although mTOR inhibitors have significantly improved survival of different cancer patients, resistance and lack of predictive factors of response remain unsolved issues. To elucidate the mechanisms of resistance to everolimus, we evaluated Met activation in everolimus-sensitive/resistant human cancer cells, P<0.01). In mice xenografted with everolimus-resistant cells, the combination of everolimus with the Met inhibitor PHA665752 reduced tumor growth and induced a statistically significant survival advantage (combination vs control P=0.0005).Everolimus reduced Met phosphorylation in everolimus-sensitive cells. This event was mediated by the formation of a Met-FKBP12 complex, which in turn is disrupted by everolimus. Aberrant Met activation in everolimus-resistant cells and overexpression of wild-type/mutant Met caused everolimus resistance. Pharmacological inhibition and RNA silencing of Met are effective in condition of everolimus resistance (FKBP12 binding is required for full Met activation and everolimus can inhibit Met. Persistent Met activation might sustain everolimus resistance. These results identify a novel everolimus mechanism of action and suggest the development of clinical strategies based on Met inhibitors in everolimus-resistant cancers. It exerosphate) , binds Rosphate) –9.Everolimus have gained FDA approval for the treatment of metastatic renal cell carcinoma, for hormone receptor-positive, epidermal growth factor receptor 2 (HER2)-negative breast cancer and for pancreatic neuroendocrine tumors , 4, 11. Met is a transmembrane RTK for the hepatocyte growth factor (HGF), whose ligand-induced activation promotes such biological activities as cell proliferation, cell invasion and protection from apoptosis. The HGF/Met axis drives resistance to targeted therapies in several ways, and preclinical data suggest that combinatorial therapies with Met inhibitors is a promising anticancer approach .In this study, we asked whether Met activation could affect everolimus sensitivity, and if so, whether pharmacological inhibition of Met could be a strategy in patients with everolimus resistance.in vitro sensitivity of these cell lines to everolimus in cell survival assays, and found that all cell lines were highly sensitive to everolimus. The concentration of everolimus causing 50% reduction of cell density was ≤ 0.5 μM (P < 0.0001) , breast (MDA-MB-231 and MDA-MB-361), and lung (PC-9 and NCI-H1975) cancer cells. We first verified the ) Figure .Since rapalogs have been reported to induce a negative feedback on some RTKs , we invein vitro kinase assay comparing the effect of everolimus with that of the Met inhibitor PHA665752 on a number of Met TK variants, both wild-type (wt) and mutants. As shown in Table 50 > 10 μM). Conversely, PHA665752 inhibited Met TK variants albeit to different degrees, the effect being greatest against Met wt (IC50 < 100 nM). This suggested that the phospho-Met reduction could depend on mTOR inhibition. To test this hypothesis, we evaluated the activation/phosphorylation of Met in 786-O and MDA-MB-231 cell lines treated with mTOR inhibitors that have different mechanisms of action: everolimus, an allosteric mTORC1 inhibitor that acts through FKBP12 binding; PKI-587, a dual PI3K-mTOR kinase inhibitor; and OSI-027, a potent and selective inhibitor of mTOR complexes (mTORC) 1 and 2 [To evaluate if the phospho-Met reduction occurring upon everolimus treatment could depend from direct inhibition of the Met TK, we performed an  1 and 2 . PhosphoTo verify that Met phosphorylation is not directly related to mTOR inhibition, we used small interference RNA (siRNA) to silence different components of the mTOR complexes, namely, mTOR, Raptor and Rictor, in 786-O cells. mTOR partecipates in both mTORC1 and mTORC2 complexes, while Raptor and Rictor are part of only mTORC1 and mTORC2, respectively . As expeAs everolimus exerts its mechanism of action by binding to FKBP12, we asked whether everolimus reduces phospho-Met via FKBP12. We first studied the intracellular relationship between FKBP12 and Met in 786-O cells by immunofluorescence analysis. As expected, Met was prevalently localized on the cell membrane, whereas FKBP12 was widely distributed in various intracellular compartments and in juxtamembrane regions. Notably, as shown in the merge staining, Met and FKBP12 partially co-localized Figure .To investigate in greater detail the potential functional/structural relationship between FKBP12 and Met, we immunoprecipitated total cell lysates from everolimus-treated and -untreated 786-O cells with the anti-Met antibody and blotted with the anti-FKBP12 antibody. As shown in Figure vs 786-O, P <0.01; HCT116 vs 786-O, P <0.05). Neither Met inhibition nor p70S6K phosphorylation occurred in the two cell lines after everolimus treatment  cells with acquired resistance to everolimus from the 786-O parental cell line . Moreovet Figure . Importat Figure . Unlike t Figure .P <0.01  with vectors harboring wt Met or constitutively active Met mutants (Y1235D and M1268T). Transfection efficiency was confirmed by Western blot analysis . CompareP <0.01 .in vivo models of everolimus resistance, we first performed subcutaneous transplantation of resistant HCT116 cells in nude mice. The subcutaneous injection was used to evaluate tumor growth and mice survival.To investigate the simultaneous blockade of Met and mTOR in per os, five times a week for 2 weeks; PHA665752 20 mg/kg intravenous (i.v.), five times a week for 2 weeks or the combination of these agents. Untreated mice reached the maximum tumor size allowed on day 42, 6 weeks after cell injection. At this time point, everolimus and PHA665752 alone inhibited tumor growth by 35% and 85%, respectively, while the combination inhibited tumor growth by 90% , and combination vs PHA665752 (P < 0.05) at median survival of control group  to receive one of the following treatments: everolimus 5 mg/kg % Figure . PHA6657p Figure . Consistp Figure . Both evin vivo models of everolimus resistance, we also performed orthotopic transplantation of resistant HCT116 cells in nude mice. The orthotopic model was used to evaluate growth and invasion of tumor cells in their natural location. When orthotopic tumors, assessed with micro-ultrasonography, reached a mean volume of 0.6-0.7 cm3, mice were randomly divided into four groups (10 mice/group) to receive everolimus 5 mg/kg per os, five times a week for 2 weeks, PHA665752 20 mg/kg intravenous (i.v.), five times a week for 2 weeks or their combination. Untreated mice reached the maximum tumor size allowed, about 2 cm3, four weeks after tumor implantation. At this time point, mice were sacrificed, primary tumors excised and tumor volume/weight measured  and for combination vs everolimus , but not for combination vs PHA665752 . Western blot analysis of tumors removed at the end of the experiment showed that the combination reduced the phosphorylation of both p70S6K and Met  that are phylogenetically closed to Met ,19. ThisWe suggest that increased Met activation could induce everolimus resistance. Little is known about factors predictive of response to everolimus, or about the mechanisms underlying everolimus resistance. Mutations in tuberous sclerosis complex 1 (TSC1) and 2 (TSC2), which encode negative regulators of the mTOR pathway, confer sensitivity to everolimus ,43, whilIn conclusion, our experimental data have potentially relevant clinical implications. First, we assign a new role to FKBP12, as a regulator of Met activation. Second, we suggest that everolimus should be considered not only an allosteric mTOR inhibitor, but also a Met inhibitor. Therefore, Met expression/activation could serve as a predictive biomarker of sensitivity to everolimus. Even if our results did not show synergism of action between everolimus and PHA665752, we found that Met inhibitor is effective in condition of everolimus resistance. Therefore, we suggest Met inhibition as an effective strategy to be used, secondarily to everolimus,in cancer patients affected by tumors with intrinsic or acquired resistance to everolimus.Everolimus (RAD001), PHA665752, PKI-587 and OSI-027 were purchased from Selleck Chemicals (Germany). Human recombinant HGF was purchased from R&D Systems .in vivo/in vitro selection after chronic exposure to the drug, as described [Human renal cell carcinoma , breast , and colorectal (HCT116) cancer cell lines were obtained between 2010 and 2013 from the American Type Culture Collection (ATCC). All cells were maintained according to the manufacturer's protocol. Human non small cell lung cancer cell lines (PC-9 and NCI-H1975) were provided by Dr F. Morgillo (Second University of Naples) in 2012. 786-O EveR (everolimus-resistant) cells were generated according to a validated protocol of escribed .Short tandem repeat (STR) profiles of cell lines were obtained using nine highly polymorphic STR loci plus amelogenin . The amplified fragments were analyzed with the ABI PRISM 3100 Genetic Analyzer. Data analysis was performed by GeneMapper® software, version 4.0. Cell lines authentications was performed by IRCCS Azienda Ospedaliera Universitaria San Martino – Istituto Nazionale per la Ricerca sul Cancro . The cells were last tested between april and august 2015.4 cells/well) were grown in 24-well plates and exposed to increasing doses of everolimus and PHA665752, alone or in combination. The percentage of cell density was determined using the 3--2,5-diphenyltetrazolium bromide (MTT) assay according to the manufacturer's instructions . The dose-response curves for each agent alone and in combination were determined at a fixed ratio based on the drug concentration causing 50% inhibition of cell proliferation.Cells (10Transfection of siRNAs (200 pmol) targeting mTOR, Rictor, Raptor, FKBP12 and Met was carried out according to the manufacturer's instructions . We used a scrambled siRNA as negative control. To evaluate target silencing, total protein was extracted 24 and 48 hours after transfection, and examined by western blot.Total protein extracts obtained from cell cultures or tumor specimens were resolved by 4-15% SDS-PAGE and probed with anti-human, polyclonal pMet Y1349, polyclonal Met, monoclonal pp70S6K T412 and p70S6K , monoclonal actin , monoclonal FKBP12, polyclonal mTOR, Raptor, and Rictor. Co-immunoprecipitation analyses were performed with anti-Met; membranes were blotted with anti-FKBP12. The total lysate from 786-O, 786-O EveR and HCT116 cells served as positive control. Immunoreactive proteins were visualized by enhanced chemiluminescence . Densitometry was performed with Image J software .4, seeded on sterile coverslips placed in 24-multiwell plates) were fixed with 4% paraformaldehyde solution and permeabilized with 0.2% triton x-100. They were then incubated for 1 hour at RT with monoclonal antibodies against FKBP12  and polyclonal antibodies against Met . Lastly, they were fluorescently labeled with the following secondary antibodies: Cy2-AffiniPure Donkey Anti-Rabbit IgG and Cy3-AffiniPure Donkey Anti-Mouse IgG . Slides were mounted with glycerol 50% in PBS and imaged using a Zeiss LSM 510 meta confocal microscope equipped with an oil immersion plan apochromat 63x objective 1.4 NA.786-O cells  mice . Forty animals were used to carry out the subcutaneous colorectal cancer model experiment; when tumors reached a mean volume of 1 cmt test was used to evaluate the statistical significance of the in vitro results. The statistical significance of differences in tumor growth was determined by one-way ANOVA and Dunnett's multiple comparison post-test, and that of differences in survival by a log-rank test [in vitro results of everolimus-resistant cells versus sensitive cells (Graph-Pad version 5). All reported P values were two-sided. Analyses were performed with the BMDP New System statistical package version 1.0 for Microsoft Windows .The Student's ank test . The lin


Cesarean surgical site infections (SSIs) can be prevented by proper preoperative antibiotic prophylaxis. Differences in antibiotic selection in clinical practice exist according to obstetricians’ preferences despite clear guidelines on preoperative antibiotic prophylaxis. This study aimed to compare the efficacy of ampicillin and ceftriaxone in preventing cesarean SSIs.The observational prospective cohort study was conducted at a tertiary hospital in Thailand from 1 January 2007 to 31 December 2012. Propensity scores for ceftriaxone prophylaxis were calculated from potential influencing confounders. The cesarean SSI rates of the ceftriaxone group vs. those of the ampicillin prophylactic group were estimated by multilevel mixed-effects Poisson regression nested by propensity score.p = 0.001) and organ space SSIs was  in the ceftriaxone group compared with the ampicillin group. After adjusting for confounders, the rate ratios of incisional and organ/space SSIs in the ceftriaxone compared with the ampicillin group did not differ , and , respectively.Data of 4149 cesarean patients were collected. Among these, 911 patients received ceftriaxone whereas 3238 patients received ampicillin as preoperative antibiotic prophylaxis. The incidence of incisional SSIs was  contains supplementary material, which is available to authorized users. Cesarean section is an operation that has been increasingly performed in the USA  and alsoIntraoperative redosing is required whenever the elapsed time from the first dose of antibiotic prophylaxis and operative time is longer than two half-lives of the antibiotic  because Only one randomized controlled trial has been conducted to directly compare the efficacy of ampicillin vs. ceftriaxone concerning cesarean SSIs prevention and it lacked statistical power . We therThis observational prospective cohort study was conducted from January 2007 to December 2012 in a tertiary center located on the northwest Thai-Myanmar border, where an average of 800 cesarean cases are performed annually.Data of women undergoing cesarean operations during the study period were collected from our local infection control database. All patients undergoing cesarean operations included in the study received either ampicillin or ceftriaxone as the preoperative antibiotic prophylaxis accordingly to surgeon’s preference. In our setting, both ampicillin and ceftriaxone were 2-g dosages. Both preoperative antibiotic prophylaxis regimens were administered at the time of cord-clamp or within 60 min before incision and were discontinued for no longer than 24-h postoperatively. In total, all patients received either 3 doses of ampicillin or 2 doses of ceftriaxone according to standing order protocol in this setting. Patients with chorioamnionitis, prolonged ruptured membranes > 18 h, cases that switched to other regimens during the perioperative period or received other regimens and cases with improper administration time (> 60 min before incision) were excluded from the study. All six obstetricians in our setting followed the Centers for Disease Control and Prevention (CDC) guidelines of SSI prevention  and alsoStreptococcus. Clinical outcomes and data from postdischarge surveillance system were provided 30-day follow-up and recorded. Wounds of all patients were checked on the third postoperative day, whenever necessary and on the day of discharge. One week and 30-day follow-up was appointed for every patient. Any patient with wound complications or gynecologic problems was referred for consultation at our center. Loss of attending any follow-up appointments in our network was classified as lost to follow-up. This observational study was approved by the Research Ethics Committee 4, Faculty of Medicine, Chiang Mai University (reference no. 186/2013).Demographic data, background medical problems, antenatal care history and referral data were collected. Perinatal and perioperative data, e.g., chief complaints, clinical findings on physical examination, progression of labor, transvaginal procedures before undergoing operation, surgeons, place of antenatal care, PROM, being referred from local settings, failure to induce labor, being preterm, having an emergency operation, being affected by acquired human immunodeficiency syndrome, multiple gestations, wound class and operative details, were also gathered. Patients in our center had not been screened for group B The outcome of this study was cesarean SSIs incidence of both antibiotic cohorts and was defined according to the National Healthcare Safety Network surveillance of CDC criteria . Case suContinuous data were described and properly compared using student t-test or Wilcoxon rank-sum test depending on their distributions. Fisher’s exact test was used to compare discrete data.Propensity scores for ceftriaxone prophylaxis were calculated from potential factors influencing or placing patients more likely in one preoperative antibiotic group than another. These included individual surgeons, private antenatal care, premature rupture of the membranes (ROM), being referred from local settings, failure to induce labor, being preterm, having an emergency operation, affected by acquired human immunodeficiency syndrome, multiple gestations and wound class ≥3.P-values were obtained from Cox’s survival regression analysis. We considered P-values of less than 0.05 as statistically significant. All data were analyzed using STATA®, version 11.2 (StataCorp).The cesarean SSI rates of ceftriaxone vs. those of the ampicillin prophylactic group were estimated by multilevel mixed-effects Poisson regression and were expressed as rate ratio (RR). The potential confounding factors revealed from a related study  includinIn total, 5122 patients underwent cesarean sections. Of these, 134 patients were lost to follow-up. Of the remaining patients, 24 received antibiotics other than ampicillin and ceftriaxone as preoperative prophylaxis, 345 patients received improper antibiotic-administration time and 470 patients presented ROM > 18 h accompanied by fever before the cohort zero-th time, and all were excluded from the study  vs. 2.9% (94/3238); P = 0.003 in the ceftriaxone group compared with the ampicillin group  vs. 1.2% 39/3238); 9/3238; Pp-values between the ceftriaxone and ampicillin groups are demonstrated in Figs. After adjusting for propensity scores and other confounding factors included age, being referred, education level, body weight, being an ethnic minority, anemia, pelvic examination more than 4 before cesarean section, being preterm, wound class 3 or more, presence of foul-smelling amniotic fluid, longer than 55-min operative time, emergency operation, ASA-score of 3 or more, being primigravida, estimated blood loss, skin incision line and addition procedures; rate ratios with 95% confidence interval of total cesarean SSIs, incisional SSIs and organ/space SSIs in the ceftriaxone group compared with the ampicillin group were 1.10; 95% CI 0.58–2.08, 0.23; 95% CI 0.03–1.78 and 1.62; 95% CI 0.83–3.18, respectively (Table Our study revealed a comparable efficacy of ampicillin and ceftriaxone, newer generation and broader antibacterial spectra-antibiotics, in preventing cesarean SSIs. In the antibiotic-resistant microorganism era, this is useful for promoting rational antibiotic use programs to prescribe more specific and narrower antibacterial spectra. As a result, it can prevent emerging multidrug resistant organisms after selective pressure from broad spectrum antibiotics overuse –24, a crThe ideal study to compare the efficacy among antibiotic prophylaxis regimens is a randomized control design where all confounders are equally distributed on all comparison groups . HoweverPropensity score or balancing score in other words, represented a scalar quantity that is calculated from a set of confounders by indication and contra-indication. It represents the conditional probability of receiving a particular treatment in the context and is used to control the effect of such confounders by adjusting it in the model of multivariable regression , 32.The estimators for comparing of antibiotic prophylaxis groups concerning cesarean SSIs prevention in this study became non-different after confounders and propensity score was adjusted in the regression model Table  and met The half-life of antibiotics used for SSIs prophylaxis is another important issue of concern. Redosing of antibiotic prophylaxis is needed when operative time is longer than two half-lives of the antibiotic used to ensure that the tissue level of the antibiotic is above the minimum inhibitory concentration of common pathogens of SSIs for that operation . The halThe strength of this study was the large study size that was sufficient to detect differences among groups. Post-hoc power analyses have shown that the power of this study for overall cesarean SSIs, cesarean incisional and organ/space SSIs was estimated to be 99.78, 96.18, and 89.01%, respectively. In addition, our observational design comprised a mixed-population that could represent real-world circumstances, so the results could be more generalized or applied. The propensity score technique with multilevel analysis and advanced statistical methods was used in data analysis to estimate the efficacy of both regimens. The results from our study were comparable to one related meta-analysis of randomized controlled trials . This maThe efficacy of ampicillin and ceftriaxone to prevent cesarean SSIs did not differ indicating that ampicillin may be used as an antibiotic prophylaxis in cesarean sections. Propensity scores can be used in data analysis of an observational study to compare the efficacy of antibiotic prophylaxis regimens and repeat performance as a monitoring measure.


Aim: The consequences of antibiotic overuse are substantial. We combined and analyzed the infection diagnoses and antibiotic prescribing practices of physicians in outpatient settings. Recommendations for targeting policy efforts to focused areas are given. Methods: Antibiotic prescriptions and infections diagnosed were provided by a German statutory health insurance provider over a 12-month period. Antibiotic use was expressed as prescriptions per 100 patients.Results: 2,594,000 patient-physician contacts within twelve months were analyzed. A median of 6.5 antibiotics was prescribed to 100 patients. Antibiotic use in private practice showed large variations between and within medical specialties , by season (antibiotic prescription was 50% higher in winter than in summer) and a considerable proportion of the antibiotics prescribed did not conform with the recommendations of national guidelines. Fluoroquinolones, predominantly ciprofloxacin, were among the top three antibiotics prescribed by all physicians (except pediatricians), although national guidelines do not recommend these agents for uncomplicated respiratory or urinary tract infections. Respiratory tract infections headed the list for the prescription of antibiotics.Conclusions: Antibiotics were still not prescribed appropriately in respect to indication and selection (often unnecessary and/or too broad). We recommend focusing on I) high/over-prescribers, because improved and appropriate antibiotic prescription by this group would result in an over-proportionally lower antibiotic prescription rate, II) respiratory tract infections, because they represent the vast majority of infections treated in primary care and III) intelligent implementation strategies of guidelines. The consequences of antibiotic overuse are dramatic, resulting in a severe threat to public health in Europe and worldwide. Antibiotics are pivotal in the selection of bacterial resistance and the spread of resistance genes in humans, animals, and the environment. Repeated and improper use of antibiotics is the primary cause of increases in drug-resistant bacteria , 2], , , , . Increasp to 16% .Taking into account the findings of our study, we would recommend interventions focusing on three points: high/over-prescribers because this would result in over-proportionally lower antibiotic prescription rates RTIs because they represent the vast majority of infections treated with antibioticsthe implementation as opposed to mere dissemination of specific guidelines Key elements of this approach would include the establishment of concrete plans, numbers, and outcome parameters for reduction and prudent use. The Netherlands and their impressive success can be taken as the best-practice example given its more than 50% reduction of (unnecessary) antibiotic use in animals: antibiotic use in food-production animals is reported and feedback is given to veterinarians. According to the benchmarking data, consumption is depicted in red (top 25%), orange, and green zones . Immediaalternatives were presented, e.g., electronic order sets suggesting non-antibiotic treatmentsaccountable justification, which prompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health recordspeer comparison, in which e-mails were sent to clinicians that compared their antibiotic prescribing rates with those of “top performers”Our study has some limitations. First, it was not obligatory in primary care to encode a diagnosis if antibiotics were prescribed. Therefore, we cannot rule out that some infections were not encoded, although patients suffered from an infection. Second, our data might not be representative because only patients from one statutory health insurance provider from one of 16 federal states in Germany were included.Taking these limitations into account, we conclude that a considerable amount of antibiotics in primary care still are prescribed unnecessarily and/or used too broadly, This is lent urgency by the fact that the data from the federal state Brandenburg with the lowest antibiotic prescription density have been analyzed , 14]. F. F14]. FAOK: statutory health insurance by “sickness funds”ATC: anatomical therapeutic chemical (classification system)DDD: defined daily dosesESAC: European Surveillance of Antimicrobial ConsumptionENT: ear, nose, and throatICD-10: International Statistical Classification of Diseases and Related Health ProblemsRTI: respiratory tract infectionsThe authors declare that they have no competing interests.The study obtained research authorization and was approved by the institutional ethics committee of the Charité – University Medicine (EA4/118/11).The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.The study was supported by the German Ministry for Education and Research (BMBF) (IIA5-2509NIK007).JZ, EM and PG were responsible for the study design. JZ supervised the study. JZ, EM, PG and FS were responsible for data collection and data cleaning. FS conducted the analysis. All authors interpreted the data, gave important intellectual content, and revised the manuscript critically. All authors read and approved the final manuscript.Nordost. We would like to thank Sabine Ebert for excellent support in providing the data from the AOK


The scholarly publication landscape is changing rapidly. We investigated whether the introduction of an institutional publications officer might help facilitate better knowledge of publication topics and related resources, and effectively support researchers to publish.In September 2015, a purpose-built survey about researchers’ knowledge and perceptions of publication practices was administered at five Ottawa area research institutions. Subsequently, we publicly announced a newly hired publications officer (KDC) who then began conducting outreach at two of the institutions. Specifically, the publications officer gave presentations, held one-to-one consultations, developed electronic newsletter content, and generated and maintained a webpage of resources. In March 2016, we re-surveyed our participants regarding their knowledge and perceptions of publishing. Mean scores to the perception questions, and the percent of correct responses to the knowledge questions, pre and post survey, were computed for each item. The difference between these means or calculated percentages was then examined across the survey measures.82 participants completed both surveys. Of this group, 29 indicated that they had exposure to the publications officer, while the remaining 53 indicated they did not. Interaction with the publications officer led to improvements in half of the knowledge items (7/14 variables). While improvements in knowledge of publishing were also found among those who reported not to have interacted with the publications officer (9/14), these effects were often smaller in magnitude. Scores for some publication knowledge variables actually decreased between the pre and post survey (3/14). Effects for researchers’ perceptions of publishing increased for 5/6 variables in the group that interacted with the publications officer.This pilot provides initial indication that, in a short timeframe, introducing an institutional publications officer may improve knowledge and perceptions surrounding publishing. This study is limited by its modest sample size and temporal relationship between the introduction of the publications officer and changes in knowledge and perceptions. A randomized trial examining the publications officer as an effective intervention is needed. In 1994, Doug Altman, a world leader in biomedical research methodology, statistics, and reporting, stated that “we need less research, better research, and research done for the right reasons” . More thResearch: increasing value, reducing waste, which addressed this issue, and potential solutions  and research community best practices, including the development of data management plans’ .https://osf.io/). Outreach on how target a journal for submission and how to write a cover letter may be of further benefit. In addition, advice on how to navigate the peer review process, which has undergone a recent paradigm shift with the introduction of post-publication peer review, as well as changes to the openness of peer review, could be facilitated. Publications officers could work to ensure internal institutional policies related to publishing are updated to keep pace with broader international changes. Finally, they could ensure that the institutional policies and procedures acknowledge developments of novel tools such as research identifiers  for tracking publications, and metrics and alternative metrics  for monitoring research impact.Who is monitoring the steps institutions are taking to provide this support? As Begley and colleagues  recentlyWe recently introduced a publications officer at our institution, The Ottawa Hospital Research Institute (OHRI) . Here, whttp://www.ottawahospital.on.ca/annualreport/fast-facts_en.html), and Bruyere Research Institute reporting fewer than 45 active investigators (http://www.bruyere.org/documents/154/AR_2016_En.pdf). All research investigators, and research staff, at each site were invited to participate. Study approval was given  or waived (CHEO RI) by each location’s research ethics board. Participants were initially recruited via e-mail, using an approved recruitment script which was sent to their institutional e-mail addresses from their respective administration. E-mails contained a link to our online survey. Participants provided online consent before accessing the survey.In September, 2015 we administered an online survey (via SurveyMonkey) to assess researchers’ knowledge and perceptions of publishing. Researchers of all levels of seniority were invited to take part. The sample for this survey was a convenience sample administered at five Ottawa-based hospital research institutions. Specifically, surveys were sent to research staff based at OHRI and CHEO RI , and to researchers at three other local institutions, namely Bruyere Research Institute, The Royal Ottawa Hospital, and The University of Ottawa Heart Institute (control sites). The size of these research institutions varies considerably, with OHRI reporting more than 500 active research investigators  at OHRI and CHEO RI. The publications officer, our intervention, then provided approximately six months of active outreach at these two sites. A ‘post survey’, assessing publication attitudes and perceptions, was then circulated by the research team via e-mail. This e-mail was sent in March and was sent to all respondents to the ‘pre survey’. Participants were told who the primary investigator was (DM) and that the purpose of the study was to examine researchers’ knowledge and perceptions of publishing. Participants took part in the study voluntarily, but were informed that they would be entered into a draw to win an iPad mini after each of the two surveys (if they completed these).http://www.ohri.ca/journalology/). The publications officer was also available for one-on-one consulting, and met with 66 individuals during the study intervention period who contacted her on 94 individual occasions. N = 79) addressed is higher than 66 as some individuals consulted the publications officer multiple times, or about multiple distinct topics.The newly hired “Publications Officer” served as the study intervention. Our rationale for this intervention was that a localized role to support researchers in navigating the publications landscape would lead to improvements in knowledge and perception of publishing topics. As part of our rollout of this position, within the first six months the publications officer gave 24 outreach presentations across the OHRI and CHEO RI. These presentations were given face-to-face, as well as via video-conferencing software. Presentations were open to researchers of all levels of seniority at the experimental sites, and targeted both clinical and pre-clinical researchers. A typical presentation provided an overview of the newly introduced publications officer role, and highlighted internal publication related resources. A webpage of freely available resources to which researchers were sent the details of via email was also generated and updated frequently  topics. As an example, one item asked participants ‘What is Creative Commons?’ and another ‘What are reporting guidelines?’ For a full description of knowledge questions asked and possible responses, please see All data was stored securely and de-identified prior to analysis. We provide descriptive summary data for those who did and did not interact with the publications officer. The journalology knowledge questions, which were recoded to be dichotomous variables , were summarized as proportions and percentages. The publications perceptions items, which were continuous variables, were summarized by means and standard errors. We compared changes across the pre and post survey between each group.N = 41 male, N = 40 female, N = 1 missing data) based at OHRI, CHEO RI, Bruyere Research Institute, The Royal Ottawa Hospital, and the University of Ottawa Heart Institute.A total of 119 participants completed the first survey; however, six provided emails that were no longer in service at the time of the post-survey, and 31 failed to complete the follow-up survey. Therefore, participants analyzed were 82 individuals (N = 29). Those that indicated they had not used any services were classified as not having interacted with the publications officer (N = 53).While we had initially hoped to compare responses at sites receiving our publications officer intervention (OHRI and CHEO RI) with those that did not, the modest response rate made this unfeasible. We therefore compared participants who explicitly indicated that they had interacted with the publications officer to those who indicated they had not interacted with the publications officer for each of our variables of interest. Specifically, on the second survey we asked participants to indicate if they had: (1) visited the Centre for Journalology website maintained by the publications officer; (2) received an email or newsletter from the publications officer; (3) attended a seminar held by the publications officer; (4) had a one-to-one meeting with the publications officer; or (5) had any other interaction with the publications officer. If participants indicated yes to any of these five options, they were considered to have interacted with the publications officer . For example, with the item ‘How Is a journal’s impact factor calculated?’ participants who interacted with the publications officer responded 71.43% correct to the pre-survey, but only responded 42.86% correct to the post survey. On this same item, participants who did not interact with the publications officer improved their knowledge score by 8.70% from the pre to the post survey; however, in spite of this, knowledge on the post-survey (36.96%) nonetheless remained below the levels found among participants who interacted with the publications officer (42.86%).In a few notable cases, exposure to the publications officer resulted in decreases in correct response percentages during the post survey  were able to access resources previously unavailable (or unknown) to them and, in the process, increased their knowledge. This could indicate the value of a publications officer for researchers who are already knowledgeable in journalology-related topics, not only for those who are novices in this domain.For three of the journalology knowledge items, participants who interacted with the publications officer actually decreased their scores from the pre to the post survey. It is not immediately clear why their knowledge scores decreased. However, it is worthwhile noting that in spite of these decreases, the absolute post scores were still higher in the group that interacted with the publications officer. These decreases may reflect random variation due to our small sample size. Concerning participants’ perceptions of publishing, among those that interacted with the publications officer, scores tended to improve. Findings for those who did not interact with the publications officer were more inconsistent, with scores on some variables improving quite considerably, and others reducing. It is worthwhile to note that many of the mean values for responses to these items in both groups, even at the post survey measures, were below 5.5. Given the inherent importance of many of these concepts in order to publish according to best practice, the relatively low confidence rates in perceptions related to publishing is troubling. Shifting perceptions, in contrast to shifting knowledge of particular facts, may require longer periods of time to achieve robust impact.This study is not without limitations. Firstly, our sample size was modest and underpowered to consider use of inferential testing of many hypotheses. A limitation of this work is that we failed to employ a randomized design. As a consequence, and as suggested by the baseline differences in knowledge scores we obtained, it may be that there was a selection bias such that participants who knew more about journalology subsequently were more likely to seek out and interact with the publications officer. Failure to randomly assign participants to interact with the publications officer limits our ability to draw causal inferences. Future work using a larger pool of participants’ with random assignment is therefore warranted. In addition, it is difficult to know whether any effects of the publications officer intervention carried over into the control group. Given the close proximity of researchers , this is certainly possible and may explain the increases in knowledge observed in the control group. There are known collaborations between the various sites. It is possible, for example, that those in the control group actually did have exposure to outreach services by the publications officer, especially the webpage and electronic newsletters which were widely distributed at OHRI and CHEO RI, but that they did not recognize that these explicitly related to the publications officer when surveyed. Alternatively, some may also have indirectly gained knowledge from having interactions with colleagues who had exposure to the publications officer. A further potential confounder of our study is that participants may have adjusted their behaviour or knowledge based on the fact that they knew they were being measured/observed. As noted above, a randomized and blinded trial could address this in the future.Finally, outreach material and presentations given by the publications officer were not all specifically developed to address each of the knowledge based questions used herein. Nor will our purpose-built knowledge based questions completely capture all knowledge areas or domains of publications science. Future studies may wish to build on the items we included, and include items that address situational knowledge. It will be important to determine how effective the various types of outreach provided by the publications officer are at increasing knowledge and strengthening perceptions in future evaluations. This will allow the services of the publications officer to be specified over time to become most effective. An in-depth evaluation of the degree and quality of interaction participants had with the publications officer was also not conducted as part of this pilot study but could prove valuable. This could help to ensure that differences observed between the control and treatment groups herein, are robust, and that improvements in publication science knowledge and perceptions are indeed a consequence of the publications officer as opposed to other factors, such as increased media coverage of these issues.Writing a high-quality transparent manuscript, navigating through the journal submission and peer review process, and eventually publishing are important components of the research continuum. Ensuring that researchers have internal resources available to them to make sure that they are adhering to best practices and compliant with any relevant publishing policies is essential to upholding scientific integrity. Since starting in the role, our Publications Officer has engaged with senior administration locally. This engagement has led to a refresh of three institutional policies  and discussions about how the role can provide novel insights or services for the institution. For example, in response to the development of an automated TrialsTracker tool , the pub10.7717/peerj.3294/supp-1Supplemental Information 1Click here for additional data file.


A classification of  In. In\docu901  on E. Let We work in Hausdorff metric, which is given byK at The space of convex bodies, p-homogeneous if sublinear if it is 1-homogeneous and For surface area measure. For a Borel set K at which there exists a unit outer normal vector of n-dimensional convex body K if and only if K is unique up to translation.A second important way to describe a convex body is through its n-dimensional convex bodies K and L in Blaschke sum is defined as the convex body with surface area measure Blaschke valuation if x, For every sequence (ii)x such that There exists a sequence In this case we write We equip We require some results connecting epi-convergence and Hausdorff convergence of sublevel sets. We say that  is the span of z. The moment body K is defined byK is defined byThe difference body We require the following result where the support function of certain moment bodies and moment vectors is calculated for specific vectors. Let For It is easy to see that A first classification of ished in , where a, the sou are convex bodies and b is 1-homogeneous, the co-area formula  For For fixed example, ), that tote that  holds anNext, fix an even continuous function contravariant of degreep if for p-homogeneous function decreasing on increasing and we say that monotone if it is decreasing or increasing.For eralizes  from conFor As btain by  and the )).Hence  defines n-dimensional convex body. Since Blaschke sums are defined on n-dimensional convex bodies, we do not obtain a characterization of the LYZ operator as a Blaschke valuation on n-dimensional convex bodies. However, Wang’s extended operators We remark that Tuo Wang  extendedation of . The co-ent from . The extons , t, t10), tvex body . In 5],,\documenFor Let mentclasspt{minima(Rn). By , we get fined in  is transform and  imply thform and  is a confined in  is decreThe aim of this section is to prove Theorem If For cone growth function of indicator growth function. By Lemma For a continuous, Every continuous, Next, we establish an important connection between cone and indicator growth functions.Let E is of dimension We fix the Next, we establish important properties of the cone growth function.If  s we can consider In order to prove that P and Q as in Lemma Define the polytopes t in the construction above go to In order to show , let t iimits in  therefortrivial if By Lemma Every continuous, increasing, Lemma Every continuous, If Conversely, let a continuous, monotone, For btain by  that\docThe aim of this section is to prove Theorem If For cone growth function of indicator growth function.For a weakly continuous valuation If Recall that the cosine transform Every weakly continuous, increasing valuation Since Every weakly continuous valuation By Lemma By Lemma fined in  is a weaConversely, let Now, for The operator that appears in Theorem We require the following results.For Fix (and Definition) For Let v. By Lemma Now, let Finally, sinceE(z) for the linear span of Let function , we haveody from .For For every translation The aim of this section is to prove Theorem If For Similarly, if e. Moreover, if If e.By Lemma Similarly, for every I. IfI, then In the proof of the next lemma, we use the following classical result due to H.A. Schwarz .Let I in the span of For a closed interval example, , p. 39).For son with  now giveNow, let If the operator Let By Lemma Every continuous, increasing, cone growth function of For a given continuous, If the operator Let indicator growth function of The function Every continuous, By Lemma Conversely, let now a continuous, monotone, For


Her first name is Cristina.In the article “Genotypic distribution of HHV-8 in AIDS individuals without and with Kaposi sarcoma: Is genotype B associated with better prognosis of AIDS-KS?”,


Aconiti Lateralis Radix Praeparata (Fuzi) and Fritillariae Thunbergii bulbus (Beimu) have been widely used clinically to treat cardiopulmonary related diseases in China. However, according to the classic rules of traditional Chinese medicine, Fuzi and Beimu should be prohibited to use as a combination for their incompatibility. Therefore, it is critical to elucidate the paradox on the use of Fuzi and Beimu combination therapy. Monocrotaline-induced pulmonary hypertension rats were treated with either Fuzi, Beimu, or their combination at different stages of PH. We demonstrated that at the early stage of PH, Fuzi and Beimu combination significantly improved lung function and reduced pulmonary histopathology. However, as the disease progressed, when Fuzi and Beimu combination were used at the late stage of PH, right ventricular chamber dilation was histologically apparent and myocardial apoptosis was significantly increased compared with each drug alone. Western-blotting results indicated that the main chemical ingredient of Beimu could down-regulate the protein phosphorylation levels of Akt and PDE4D, whereas the combination of Fuzi and Beimu could up-regulate PKA and CaMKII signaling pathways. Therefore, we concluded that Fuzi and Beimu combination potentially aggravated the heart injury due to the inhibition of PDK1/Akt/PDE4D axis and subsequent synergistic activation of βAR-Gs-PKA/CaMKII signaling pathway. Pulmonary hypertension (PH) is a progressive and fatal hemodynamic problem, characterized by sustained raises in pulmonary arterial pressure and pulmonary vascular resistance, as well as thickening of small pulmonary arteries24Aconiti Lateralis Radix Praeparata (Fuzi) and Fritillariae Thunbergii bulbus (Beimu), are widely used in clinic to treat various heart and pulmonary diseases in China78911Drug combination shows a unique advantage in the treatment of chronic and complex disease (e.g. COPD), however, the safety of combination therapy should not be ignored. Thousands-years clinical practice in traditional Chinese medicines (TCMs) has led to a series of theories and principles to guide the appropriate use of TCMs. Among them, “Eighteen antagonisms” is one of the fundamental principles on TCM incompatibilitySympathetic adrenergic activity is highly elevated in PH2-AR1819The present study is to explore whether and why Fuzi and Beimu combination caused any adverse effects, which would be an exemplification of the research on the safety of drugs compatibility. Our previous studies have demonstrated that the alcohol amine alkaloids of Fuzi could active βTo evaluate the effectiveness of the combination of Fuzi and Beimu on PH, we first assessed the changes of lung function, including lung index, respiratory parameters  and pulmonary artery systolic pressure (PASP) in MCT-induced PH rats after treatment . Two weeRepresentative micrographs of pulmonary pathological morphology were shown in Fuzi and Beimu combination had no significant changes on heart at early phase of PH .To evaluate whether the combination of Fuzi and Beimu could lead to more cardiotoxicity, treatment in PH rats was initiated 4 weeks after MCT injected, and the alterations of viscera index was measured after two weeks of oral administration . MCT-treTo further investigate the effects of Fuzi and Beimu combination on cardiac function in MCT-induced PH, echocardiographic and hemodynamic analysis were performed. Right ventricular and left ventricular indexes included . Right ventricular function  was deteHistopathological findings confirmed cardiomyocyte specific suffering in Fuzi and Beimu combination-treated rats at the late stage of PH . No hist2-AR stimulating effect by increasing cAMP levels in HEK 293T cells2AR transfected HER293 cells  of Beimu were selected. We performed a western blot assay to investigate PDK1/Akt/PDE4D axis protein expression, which signals regulated intracellular cAMP accumulationIt has been reported that persistent βAR stimulation through Gs/PKA/CaMKII signaling induces a multitude cardiac toxicity, such as myocardial hypertrophy and apoptosis22232AR by PKA induces the switching of the coupling receptor from Gs to Gi252AR-Gi signaling in cardiac tissue is a primary negative regulator of βAR pro-contractile signaling, which contributes to the pathogenesis and progression of heart failure27282AR, and Ser346 was PKA consensus site302AR and P355-β2AR protein expression. As shown in 2AR and P355-β2AR were largely increased after Fuzi and Beimu combination treatment. The results indicated that deterioration of heart failure during Fuzi and Beimu combination treatment was associated with the activation of βAR-Gs-PKA/CaMKII signaling pathway.Previous studies have suggested that phosphorylation of βThe present study for the first time identified an additive heart adverse effect resulting from a typical TCM incompatibility (Fuzi and Beimu) in treating PH. Our results showed that when administrated at the early stage of PH, the combination of Fuzi and Beimu showed a prominent therapeutic efficacy, characterized by decreasing lung weight, improving lung function , as well as abrogating the development of pulmonary arterial hypertension and pulmonary vascular remodeling, and the combination treatment had no serious effect on heart and liver  in this 2AR agonist, which resulted in muscular relaxation. Our previous study reported that hypaconine, aconine, chasmanine and karakolidine in Fuzi or Chuanwu were β2-AR agonists172AR has been shown to lead to cardiac dysfunction and eventually development of dilated cardiomyopathy25A recent study demonstrated that higenamine in Fuzi or Chuanwu was a βRV hypertrophy and failure in MCT-treated rats were manifested with a significant elevation in heart/body weight and RV/LVS ratios, hemodynamically by an increase in values of RVEDP, RVSP, and RV dP/dtmax and RV dP/dtmin, and histopathologically by the evidence of cardiotoxicity. The congested liver and spleen in the late stage of PH further confirmed the existence of the RVF34361AR was selectively down-regulated in human HF, and thus shifted the stoichiometry of β1AR:β2AR from ~75:~20 in the normal and healthy heart towards 50:50 in the heart failure, resulting in a relative increase in the proportion of cardiac β2AR262AR, in particular the Gs/Gi signaling pathway. Consistently, we observed β1AR was markedly down-regulated in heart failure, whereas the expression of β2AR showed no obvious changes  signaling pathway, which elicited inotropic and chronotropic effects2232Previous studies have suggested that β changes . Recent P levels . BesidesP levels . Therefo2AR-Gi signaling was a causal factor in maladaptive cardiac remodeling and the progression of HF. Several animal studies have shown that expression of a peptide inhibitor of GRK2 (βARKct) can ameliorate the systolic function, including promoting reverse remodeling of the LV. Moreover, β2AR phosphorylation mediated by PKA was a prerequisite for β2AR-Gi coupling2728292AR and P355-β2AR were markedly increased after Fuzi and Beimu combination. Therefore, the PKA/GRK2-β2AR-Gi signaling transduction pathway appeared to participate in the process of cardiac function deterioration.Compelling evidence has shown that upregulation of GRK2 by exaggerated βIn summary, our present study for the first time discovered Fuzi and Beimu combination therapy could improve lung function and reduce pulmonary histopathological changes in the early stage of PH, whereas it potentially aggravated the heart injury in the late stage of PH due to the inhibition of PDK1/Akt/PDE4D axis and subsequent synergistic activation of βAR-Gs-PKA/CaMKII signaling pathway. To some extent, the present study was helpful to understand the taboo conditions of drug combination in clinical practice based on the conventional wisdom from ancient TCM knowledge, at least it could provide some research ideas, in which different symptom conditions would be the key terms leading to toxicity or efficacy of the co-use of the drugs.Aconiti Lateralis Radix Praeparata (Fuzi) and Fritillariae Thunbergii bulbus (Beimu) were purchased from Chinese herbs Corporation. Fuzi (Hei Shuenpian) and Beimu (Zhe Beimu) as well as the combination (1:1) of the two herbs were crushed into coarse powder, soaked with distilled water 10 times for 0.5 h, and microboiled twice for 1 h. The merged filtrate was dried under vacuum at 60 °C, and the final powder was either stored at −20 °C or diluted with distilled water to the appropriate concentration for further application.Male Wistar rats (7 weeks of age and weighing 180 to 200 g. Certificate No SCXX 2009-0004) were obtained from Vital River Laboratory Animal Technology Co., Ltd . Rats were housed in an environmentally controlled breeding room . Water and food were given ad libitum. The animal care was performed strictly according to the Care and Use of Laboratory Animals of Institutional Animal Care and all experiments were approved by the Animal Ethics Committee of Tianjin University of Traditional Chinese Medicine (No.TCM-2013-LACE201312-05).PH rat model was induced by a single intraperitoneal injection of monocrotaline  previously dissolved in 1 N HCl and pH adjusted to 7.4 using 1 N NaOH, eventually causing heart failure4344The rats undergoing non-invasive pulmonary function were monitored by whole-body barometric plethysmography ®2100 Rats were anesthetized with urethane (0.6 ml/100 g), and the thoraxes of the rats were shaved. Transthoracic two-dimensionally guided M-mode echocardiography was performed every week after the rats were administered, using an Ultra-high resolution small animal ultrasound scanner VevoHemodynamic assessments were performed using a polygraph system  at a sampling rate of 100 Hz48At the end of the study, the viscera  tissues were rapidly removed and weighed. The viscerosomatic index was calculated using the viscera weight relative to the body weight, viscerosomatic index (VSI) = 100 × /. The hearts were excised with the right ventricle (RV) and left ventricle plus intraventricular septum (LVS) were weighted to calculate the RV/LVS weight ratio as a marker for right ventricular hypertrophy index (RVHI)The myocardial and pulmonary tissues were fixed in 10% neutral buffered formalin and paraffin-embedded, sectioned into 5-micrometer thick, and stained with hematoxylin and eosin (H&E).In Situ Cell Death Detection kit  according to the manufacturer’s instructions. Images were obtained with using OLYMPUS U-CMAD3 optical microscope  pictures were taken with OLYMPUS C5060-ADU camera . The apoptotic ratio was shown as the percentage of positive stainingApoptosis in cardiomyocytes was evaluated with enzymatic labeling of DNA strand breaks detected using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) stain. TUNEL staining was performed with Blood was collected, and centrifuged at 3000 rpm at 4 °C for 15 minutes to separate serum. CK-MB was tested by the semi-automatic biochemical analyzer. The levels of TPI, BNP, ET-1 and NO in serum were determined by ELISA kit  in accordance with the manufacture’s protocols.2 incubator. Cell medium was changed every 2 days. H9C2 cells were plated on the appropriate culture plates and treated with peimine , peiminine  or peimisine  for 24 h, and then the protein of cells was extracted for western blot analysis. HEK293 cell line over-expressing β2-adrenergic receptor was cultured in DMEM supplemented with 10% fetal bovine serum , 100 U/ml penicillin and streptomycin, 100 ug/ml 0.25% Zeocin  at 37 °C in a 95% air and 5% CO2 humidified atmosphere. Cells were cultured in 75 cm2 culture flakes, and plated on the 96 well cell culture cluster. Once they reached 30–40% confluence, cells were co-transfected with solution A: luciferase plasmid pGL4.29  and pRL-TK vector, and solution B: transfection reagents PEI , After overnight incubation, the cells were washed with PBS and incubated with fresh medium for 24 h, prior to the addition of Fuzi, Beimu, Fuzi and Beimu combination, as well as positive control Isoproterenol for 5 h. The luciferase activity was measured by Dual-GloTM reporter assay system  according to the manufacture’s protocol. The firefly/Renilla luciferase activity ratio was used to compare the differences in transfection efficiency. Results are presented as mean ± S.D. of three independent experiments performed in duplicate.The rat embryonic cardiomyoblastic cell line H9C2 was cultured in Dulbecco’s modified Eagle’s medium  supplemented with 10% FBS and 1% penicillin-streptomycin  in a 37 °C, 5% COWestern blot assay was performed as follows. Briefly, the protein of the H9C2 cells or cardiac tissues was extracted using a Total Protein and Neuclear-Cytosol Extraction Kit  following the manufacturer’s protocols. BCA assay was used to measure the protein concentration. Separated by sodium-dodecyl-sulfate polyacrylamide gel electrophoresis, and then transferred onto polyvinylidene fluoride membranes. Membranes were blocked with 5% skimmed milk, and then were incubated with primary antibodies Rabbit anti-tubulin beta antibody  or β-actin (Bioss); PDE4D ; PDK1, p-PDK1(Ser241) Akt, p-Akt (Ser473) ; anti-beta 1 adrenergic receptor antibody, anti-beta 2 adrenergic receptor antibody, anti-GRK2 antibody (Abcam); anti-PKA antibody (millipore); anti-CaMK2antibody(CST); β2-AR phosphorylated serine pSer346 and pSer (sigma), overnight at 4 °C. Secondary antibody goat anti-rabbit antibody  were diluted to identify the corresponding primary antibodies. Further analysis was carried out by using an imaging densitometer (Cuene Genins) to quantify the immunoreactive bands.The SPSS software (IBM SPSS Statistics 20.0) was used for statistical analysis. Quantitative data were presented as mean ± SD., the differences among various groups were performed by one-way analysis of variance (ANOVA), non-parametric equivalents were performed as appropriate. Enumeration data were compared with Chi-square Test. P < 0.05 was considered statistically significant.How to cite this article: Zhuang, P. et al. cAMP-PKA-CaMKII signaling pathway is involved in aggravated cardiotoxicity during Fuzi and Beimu Combination Treatment of Experimental Pulmonary Hypertension. Sci. Rep.6, 34903; doi: 10.1038/srep34903 (2016).


The catastrophic misinterpretation model of panic disorder (PD) predicts that the catastrophic misinterpretation of bodily sensations is a distinctive characteristic of PD. Existing research on this prediction has produced mixed findings. This paper presents a systematic review and meta-analysis of studies comparing the strength of catastrophic misinterpretation of bodily sensations and external events in patients with PD, patients with other anxiety disorders, and healthy controls. Following a systematic screening, seven studies were included in the meta-analysis. For the catastrophic misinterpretation of bodily sensations, analyses showed medium to large effects between patients with PD and healthy controls and between patients with PD and patients with other anxiety disorders. For the catastrophic misinterpretation of external events, analyses showed medium to large effects between patients with PD and healthy controls and a small negative effect between patients with PD and patients with other anxiety disorders. The findings support the assumption that the catastrophic misinterpretation of bodily sensations is a distinctive characteristic of panic disorder and thus lend support to the catastrophic misinterpretation model of PD. Catastrophic misinterpretation plays a central role in the cognitive model of panic disorder . It is aThese assumptions distinguish the cognitive theory from another prominent theory of panic disorder, the alarm theory ,3. The aBoth catastrophic misinterpretation and catastrophic cognition have been found to occur in a wide range of mental disorders . The prCatastrophic cognition describes acute thoughts  about anCatastrophic misinterpretation describes the act of interpreting a stimulus as a sign of an impending catastrophe, for example, “My pounding heart means that I will have a heart attack” . In thisThe cognitive model of panic predicts that the catastrophic misinterpretation of bodily sensations is more pronounced in patients with PD than in healthy controls and patients with other anxiety disorders. However, findings so far have been mixed. Only Clark et al.  have fouThe cognitive model of PD makes no specific predictions concerning the catastrophic misinterpretation of external events. For the comparison between patients with PD and healthy controls, findings so far have been mixed. While some studies have found patients with PD to make more catastrophic misinterpretations of external events than healthy controls ,11, otheThe question of whether the catastrophic misinterpretation of bodily sensations is a distinctive characteristic of patients with PD is important due to its consequences for the focus of treatment. Following the cognitive model, treatment would focus on re-structuring the cognitions underlying the catastrophic misinterpretation . FollowiA systematic search for articles on the strength of catastrophic misinterpretation in patients with PD compared to healthy controls and/or patients with other anxiety disorders was conducted by the first author in three major databases  on February 18, 2016 using the following search term: (“catastrophic interpretation” OR “catastrophic belief” OR “catastrophizing” OR “misinterpretation”) AND (“panic” OR “panic disorder” OR “panic attack” OR “anxiety attack”). The search was updated on February 8, 2017. As elaborated earlier, the present meta-analysis focuses on the cognitive process of catastrophic misinterpretation rather than catastrophic cognitions. Therefore, the term “catastrophic cognition” was not included in the search term. Papers were selected for inclusion if they were (1) empirical studies (2) investigating catastrophic misinterpretation (3) in patients with panic disorder (4) compared to healthy controls and/or patients with other anxiety disorders.The initial search yielded 370 results . An addiIn all seven included studies, a version of the BSIQ was used as the measure of catastrophic misinterpretation. Each version of the BSIQ can be described in the following general terms. The items measure so-called internal events  and external events. External events include general events  and social events . Each item consists of two parts. In the first part, participants are presented with a situation  and are asked to provide an explanation (“Why?”). The open-ended responses are coded as either harm-related , anxiety-related  or benign . Since the meaning of anxiety-related responses is disputed ,18, the In the second part of each item, participants are presented with three potential explanations for the given situation  and are asked to rank them in the order in which they would be most likely to come into their mind in the given situation. In the IQ and the BSIQ by Clark et al. , one of Scores for open-ended and ranked harm-related responses were extracted. The score for harm- and anxiety-related open-ended responses was omitted, since its meaning is still under dispute. Since only two studies using the BSIQ-M reported the newly introduced outcome response, this score was omitted as well. All scores are reported separately for bodily sensations and external events. The data was extracted by the first author.g was calculated from reported means and standard deviations. This was done for the effects between patients with PD and healthy controls and between patients with PD and patients with other anxiety disorders. Hedges' g was chosen over Cohen’s d to correct for small sample sizes. Effect sizes are classified as small (d ≥ 0.2), medium (d ≥ 0.5), or large (d ≥ 0.8), in accordance with Cohen (1980). The heterogeneity of effect sizes across studies was estimated with the I2 index. A high I2 value  reflect2 < 50%; ) reflectAs recommended in the PRISMA statement , the risN = 6), no statistical test of asymmetry was conducted.Concerning the risk of bias across studies, funnel plots  were creConcerning the catastrophic misinterpretation of bodily sensations, medium effects were found for open-ended responses when comparing patients with PD with healthy controls and with patients with other anxiety disorders . For ranConcerning the catastrophic misinterpretation of external events, a medium effect was found for open-ended responses and a large effect for ranked responses comparing patients with PD and healthy controls. Between patients with PD and patients with other anxiety disorders, no effect was found for open-ended responses and a small negative effect for ranked responses.The present paper aimed to explore the question of whether the catastrophic misinterpretation of bodily sensations is a distinctive characteristic of patients with PD. The overall effects reported in this meta-analysis corroborate this assumption. The finding that the catastrophic misinterpretation of bodily sensations was found to be more pronounced in patients with PD than in patients with other anxiety disorders lends particularly strong support to this assumption. Therefore, the catastrophic misinterpretation of bodily sensations seems not to be a facet of catastrophizing that is common to all patients with anxiety disorders . Rather,As mentioned earlier, it is striking that for the catastrophic misinterpretation of bodily sensations, the effects for ranked responses  were considerably larger than for open-ended responses (.76 and .60). An explanation for this discrepancy was discussed by Harvey et al. . They prConcerning the catastrophic misinterpretation of external events, the cognitive model of PD makes no specific predictions. The pattern of effects found in this meta-analysis supports the assumption that patients with an anxiety disorder can be expected to be more inclined to interpret ambiguous situations in a catastrophic fashion than healthy subjects . Both thHowever, concerning the pattern of effects found for external events between patients with PD and patients with other anxiety disorders, it is noteworthy that the level of anxiety for both groups was not assessed in all included studies, even though it can be expected to have an influence on this outcome. Three studies assessed state anxiety Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 Fig(TIF)Click here for additional data file.S5 Fig(TIF)Click here for additional data file.S6 Fig(TIF)Click here for additional data file.S7 Fig(TIF)Click here for additional data file.S8 Fig(TIF)Click here for additional data file.S9 Fig(TIF)Click here for additional data file.S10 Fig(TIF)Click here for additional data file.S11 Fig(TIF)Click here for additional data file.S12 Fig(TIF)Click here for additional data file.S13 Fig(TIF)Click here for additional data file.S14 Fig(TIF)Click here for additional data file.S15 Fig(TIF)Click here for additional data file.S16 Fig(TIF)Click here for additional data file.


Immunoglobulin G4 (IgG4)-related disease is characterized by the typical histopathological features of a dense lymphoplasmacytic infiltrate rich in IgG4-positive plasma cells, a high ratio of IgG4- to IgG-positive cells, storiform fibrosis (cellular fibrosis organized in an irregular whorled pattern), obliterative phlebitis, and variable presence of eosinophils. The disease exhibits systemic involvement but very rarely involves the esophagus.A 33-year-old man was admitted to our hospital for evaluation of a 1-year history of progressive dysphagia. Neck imaging revealed a 3.9-cm mass in the cervical esophagus and multifocal calcified lymph nodes in the lower neck and mediastinum. Two previous tertiary hospitals failed to diagnose the patient's condition despite the use of ultrasound-guided needle biopsy of the neck tumor. We performed neck imaging studies, a flexible endoscopic swallowing study, high-resolution manometry, upper endoscopy, and a review of the previous pathologic slides. The patient was finally diagnosed with IgG4-related esophagitis and showed a good response to corticosteroid therapy.We herein report a rare case of dysphagia associated with IgG4-related disease and present a review of the literature. It was first described in the context of type 1 autoimmune pancreatitis.5IgG4-RD has been described in a variety of organs and often involves the pancreas. Extrapancreatic organs are also frequently affected, including the biliary tree, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, aorta, breast, prostate, thyroid, pericardium, and skin. However, IgG4-RD is extremely rare in the esophagus.3 We herein report a rare case of IgG4-RD presenting as a tumor-like esophageal mass that showed a good response to corticosteroid therapy.The clinical presentation depends on the involved tissues. However, the histopathologic findings seem to be similar regardless of location, and diagnosis is therefore based on histopathology and immunohistochemistry. Additionally, patients often respond well to corticosteroid and immunosuppressive therapy.A previously healthy 33-year-old man presented with a 1-year history of progressive dysphagia involving both solids and liquids and a 5-kg body weight loss. He had no smoking or drinking history. The patient had previously visited 2 different tertiary hospitals, where he underwent neck computed tomography (CT) and magnetic resonance imaging. The neck imaging studies revealed an approximately 3.9-cm mass in the cervical esophagus and multifocal calcified lymph nodes in the lower neck and mediastinum. Ultrasound-guided biopsy of the neck mass showed suspicion of tuberculosis. However, there was no evidence of tuberculosis in the pathologic or microbiologic examinations. During the previous hospital visits, the patient was informed of the findings and the need for empirical treatment of tuberculosis; however, he refused to undergo antituberculosis treatment.Upon presentation to our department, no masses were palpable in the neck, and the physical examination was unremarkable. All laboratory data, including the white blood cell count, platelet count, biochemical parameters, and blood glucose level, were within normal limits. We reviewed the previously performed computed tomography (CT) scan Figure A and obsWe also reviewed the pathological sections obtained from the previous ultrasound-guided needle biopsy. Re-examination of the tissue specimens from the esophageal mass revealed proliferation of spindle cells and small vessels and infiltration of inflammatory cells Figure  on a sclConsidering all of the above findings, the patient was finally diagnosed with IgG4-RD-associated dysphagia and treated with 40 mg/day prednisolone for 4 weeks with a subsequent 10-mg dose decrease every 2 weeks. He was maintained on steroid therapy at 5 mg/day for 11 months, after which he underwent follow-up neck CT (Figure 7 (Table 7Little is known about IgG4-RD-associated dysphagia. To date, only 3 case reports have described IgG4-RD involving the esophagus.7 Table . The 1stFinally, careful interpretation of ultrasound-guided samples can lead to an accurate diagnosis of IgG4-RD. In the present case, the 2 previous hospitals failed to diagnose the IgG4-RD despite the performance of ultrasound-guided needle biopsy. This is because the cytologic findings of IgG4-RD are unfamiliar to many pathologists and gastroenterologists.In conclusion, clinicians should have a high index of suspicion for IgG4-RD in dysphagic patients presenting with an esophageal stricture, ulcer, or tumor.