At birth, calves were randomly allocated considering dam treatment and colostrum as follows: 1) calves from CON cows and colostrum from CON cows (n = 21); 2) calves from CON cows and colostrum from MET cows (n = 18); 3) calves from MET cows and colostrum from MET cows (n = 22); and 4) calves from MET cows and colostrum from CON cows (n = 20). All calves were housed, managed, and fed individually during the first 9 wk of life.Pregnancy and early life are critical periods of plasticity during which the fetus and neonate may be influenced by environmental factors such as nutrition. Maternal methionine (Met) supply in non-ruminants during pregnancy can affect offspring development and growth. Thus, the objective of this study was to investigate if increasing Met supply during late-pregnancy affects developmental parameters of the calf at birth and if either maternal Met or colostrum from Met-fed cows alters calf growth. Calves born to Holstein cows individually-fed a basal control  diet with no added Met or CON plus ethylcellulose rumen-protected Met  during the last 28 ± 2 d of pregnancy were used. A total of 39 calves were in CON (P < 0.05), colostrum quality and quantity were not affected by maternal diet. At birth, MET calves had greater (P ≤ 0.05) body weight , hip height  and wither height . In contrast, concentrations of His, Lys, and Asn in plasma were lower (P ≤ 0.05) in MET calves. Regardless of colostrum source, the greater BW, HH, and WH in MET calves at birth persisted through 9 wk of age resulting in average responses of + 3.1 kg BW, + 1.9 cm HH, and + 1.8 cm WH compared with CON. Average daily gain during the 9 wk was (P < 0.05) 0.72 ± 0.02 kg/d in MET compared with 0.67 ± 0.02 kg/d in CON calves. Respiratory scores were normal and did not differ (P > 0.05) due to maternal Met supply or colostrum source. However, fecal scores tended to be lower (P ≤ 0.10) in MET calves regardless of colostrum source.Despite greater daily DM intake pre-partum in cows fed MET  contains supplementary material, which is available to authorized users. The maternal diet during pregnancy is an important factor that can affect offspring health and performance . Around Despite abundant evidence in non-ruminants, few studies have addressed the role of nutrient manipulations during late-gestation and their influence in fetal and postnatal development of the bovine offspring , 10. “FeAmino acids play important roles in regulating metabolism, growth, and development . EvidencOur general hypothesis was that enhancing the supply of Met during late-pregnancy, besides benefitting cows , 20, wouAll the procedures for this study were conducted in accordance with a protocol approved by the Institutional Animal Care and Use Committee (IACUC) of the University of Illinois (protocol # 14270).n = 39; 1.47 Mcal/kg dry matter (DM) and 15.3% crude protein (CP)] with no added RPM or CON plus ethyl cellulose RPM  diet composition is available in Additional file DL-Met. Mepron® contains an equimolar mixture of the D- and L-isomers, and the dairy cow transforms a minimum of (75 ± 3)% of the ingested D-Met into L- Met  at 08:00 h. Growth performance including body weight, hip height, wither height and hip width was recorded for each calf once a week. Fecal score  based on appearance was evaluated for each calf as: 1 = firm well formed; 2 = soft, pudding like; 3 = runny, pancake batter; and 4 = liquid, splatters. Respiratory score  was recorded for each calf as: 1 = Normal; 2 = Runny rose; 3 = Heavy breathing; 4 = Cough moist; 5 = Cough dry . Rectal n = 6 bulls, 8 heifers in CON or MET) were used for blood biomarker and AA analyses throughout the study (birth and subsequent times). Final breakout of calves in each of the combinations of maternal diet and colostrum type was n = 7 for the CC, CM, MC, and MM groups. Samples were analyzed for cholesterol (Cat. No. 0018250540), creatinine (Cat. No. 0018255540), urea (Cat. No. 0018255440), and glucose (Cat. No. 0018250840) using the IL Test purchased from Instrumentation Laboratory Spa  in the ILAB 600 clinical auto-analyzer . Free fatty acids (NEFA) and hydroxybutyric acid (BHBA) were measured using kits from Wako Chemicals and Randox Laboratories Ltd., respectively [Blood samples were collected from the jugular vein using 20-gauge BD Vacutainer needles and lithium-heparin anticoagulant  at birth, 2, 7, 21, 42 and 50 d of age. Per IACUC guidelines, the same 14 calves from cows that received the CON and MET diet  amino acid analyzer was used for amino acid profiling.Plasma, de-fatted colostrum ; the fixed effects in the model includes maternal diet , colostrum source , Time (Tl), sex , and interactions. εijklm is the residual error. The covariance structure of the repeated measurements was AR (1). Concentrations of all blood biomarkers and amino acids in postnatal colostrum samples were analyzed using the same model for growth data without including the sex of the calf in the model. This was deemed appropriate because of the limited sample size per combination of treatment and sex. The covariance structure of the repeated measurements was SP (POW).Individual daily DM intake, weekly body condition score (BCS), and weekly BW prior to calving also were analyzed. All data were analyzed using PROC MIXED of SAS . The cow performance data prior to parturition was analyzed using a similar model including maternal diet and time. The Kenward-Roger statement was used for computing the denominator degrees of freedom for all data.. When interactions were significant, least square means separation between and within time points was performed using the PDIFF statement with Tukey adjustment. Amino acid profiles of fat-free colostrum were analyzed using the MIXED procedure without repeated measures. The AA profiles, ammonia, and CP content of starter and milk replacer were not analyzed statistically. Data were assessed for normality of distribution using the Shapiro-Wilk test. When the normality assumption was rejected, data were log-transformed before statistical analysis and log-back transformed after analysis. Statistical differences were declared significant at P ≤ 0.05 and tendencies at P ≤ 0.10.Where P < 0.01) DMI (data not shown), consuming during the last 14 d of pregnancy on average 15.7 ± 0.12 kg/d compared with 14.4 ± 0.12 kg/d in cows fed CON. There were no differences (P ≥ 0.73) between treatments for BW (783 vs. 782 ± 15.9 kg) and BCS (3.72 vs. 3.71 ± 0.08) during the last 28 d of pregnancy.Cows fed MET had greater  (Table P > 0.10).At birth, calves born to dams offered MET had greater BW (H P < 0.0 (Table 1P ≤ 0.05) of maternal diet was detected for BW, HH, WH, and average daily gain (ADG) (Table P ≤ 0.10) to have lower fecal score (1.71 vs. 1.83 ± 0.09 out of 4). The differences between treatments for HH and WH were evident at wk 1 of age and continued over time. Despite a lack of difference in daily starter intake  Table . Calves ke Table , clear dP = 0.09) and NEFA (P = 0.07) concentrations (Table P ≤ 0.05) and Met, Ala, and Tyr tended (P ≤ 0.10) to be lower in calves born to cows offered MET.At birth, MET calves tended to have greater cholesterol (ns Table . CompareP = 0.04) in calves receiving MET colostrum.Among the biomarkers and amino acids analyzed, during the first 50 d of age, there was a main effect of maternal diet for concentrations of Glu, and Gln due to greater concentrations in MET calves Table , Fig. 1.P < 0.01) were detected for glucose, Glu, Arg, and Tau (Table P = 0.01) was detected for Glu in part due to a marked decrease in concentration from 2 to 7 d of age in calves fed CON colostrum  were detected for Met and Phe  by maternal diet and averaged 52.4 ± 38.7 mg/dL for CON cows and 55.4 ± 30.8 mg/dL for MET cows. Similarly, colostrum quantity was not different between CON and MET groups (P > 0.05), averaging 5.7 ± 0.52 kg for CON and 5.9 ± 0.49 kg for MET cows. Concentration of Asp was greater (P ≤ 0.05) in colostrum from cows supplemented with MET, while crude protein and other AA were not effect by cow treatment  for Methyl elaidate, Methyl 10-Transnonadecenoate, and C18:1-10 T due to greater concentrations in colostrum from cows offered MET  likely played a mechanistic role. Clearly, additional research in this area to clarify the underlying mechanisms is warranted.Additional file 1:Table S1. Ingredient and nutrient composition of diets fed to cows. Table S2. Amino acid profiles and crude protein content of colostrum. Table S3. Amino acid profiles of milk replacer and starter grain. Table S4. Fatty acid profiles of colostrum. Table S5. Effects of supplementing Holstein cows during the peripartal period with rumen-protected methionine  on colostrum fatty acid profile. Figure S1. Body weight, hip height, and wither height during the first 9 wk of life, and daily starter intake (1–56 d of age) in calves born to cows offered control diet (CON) or CON supplemented with ethyl-cellulose rumen-protected Met  during the last 28 d of pregnancy. (DOCX 61 kb)


The SL could potentially produce viable clinical strategies for improved targeting efficiency of VIN for the treatment of related cancer. More importantly, this report provides an example of controlled release by means of a novel class of ultrasound triggering system.The aim of drug delivery is to increase therapeutic efficacy. Externally triggered drug delivery systems enable site-specific and time-controlled drug release. To achieve this goal, our strategy was based on ultrasound-triggered release of an anticancer agent from sonosensitive liposomes (SL). To realize the ultrasound-triggered drug release, a lipophilic sonosensitizer, hematoporphyrin monomethyl ether (HMME) was incorporated into the lipid bilayer of liposomes. Once irradiated by the ultrasound in tumor tissues, the sonodynamic effect generated by HMME could lead to an efficient disruption of the lipid bilayer in the SL. After encapsulating vincristine bitartrate (VIN) as the model drug, the ultrasound-triggered lipid bilayer breakdown can trigger the instant release of VIN, enabling ultrasound-controlled chemotherapy with great specificity. In the  Over the past few decades, various types of drug delivery systems for cancer therapy have been fabricated from various materials  could generate payload release at the phase transition temperature (39–41 °C) by using a mild hyperthermia. However, ThermoDox® is less stable at physiological temperature, exhibiting high leakage of ∼50% within 1 h . Upon the exposure to ultrasound, the SL would disrupt rapidly due to the sonodynamic destruction of the lipid bilayers in the liposomes. After loaded with vincristine bitartrate (VIN), a model chemotherapeutic agent for cancer therapy, into the inner aqueous lumen of the SL, the prepared VIN-loaded SL showed an instant VIN release profile upon the exposure to ultrasound. When the target sites are irradiated by ultrasound, VIN will release quickly from the SL, as the membranes of SL are destroyed by the sonodynamic effect. In this work, we described the physicochemical and biological characters of SL based on cancer therapy at the cellular level, and the 2000) and 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-maleimide (polyethylene glycol)  were purchased from Xìan ruixi Biological Technology Co., Ltd . Hematoporphyrin monomethyl ether (HMME) was purchased from Shanghai Dibo Chemical Technology Co. . Sulfate vincristine (VIN) was obtained from Baiyunshan Co. . The other chemicals were all reagent grade and purchased from Millipore Sigma , except for special stated.Hydrogenated soy phosphatidylcholine (HSPC) and cholesterol (Chol) were purchased from Lipoid GmbH . 1,2-distearoyl-sn-glycero-3-phosphoethanolamine-N-methoxy (polyethyleneglycol)  (DSPE-mPEG2 atmosphere.Human breast adenocarcinoma cells (MCF-7 cells) purchased from the Cell Resource Center of IBMS , which were maintained in culture medium consisting of Dulbecco’s modified eagle’s medium (DMEM) supplemented with 10% FBS, 100 IU/mL penicillin and 100 mg/mL streptomycin. The cells were maintained in a 37 °C humidified incubator in a 5% COFemale Sprague Dawley (SD) rats (200 ± 20 g) and female BALB/c nude mice (weighing 20 ± 2 g) were purchased from the laboratory animal center of Jiamusi University . All animals were handled according to the code of ethics in research, training and testing of drugs as stated by the Animal Care and Use Ethics Committee of Jiamusi University.2000 (7%) was used. All lipid mixtures were dissolved in chloroform–methanol  in a pear-shaped flask and were subsequently evaporated to form a dry film using a rotary evaporator under vacuum. The lipid film was then hydrated using a 300 mM citric acid buffer solution at 50 °C for 30 min. To control for the size, the lipid dispersion was extruded 11 times through 100-nm polycarbonate filters using a mini extruder . The sonosensitive liposomes (SL) were prepared following the same procedures, except the HMME was added to these lipid mixtures at the required molar ratio .To prepare the normal liposome (NL), a lipid composition (molar ratio) of HSPC (50%), cholesterol (43%) and DSPE-PEG−1, then adjusted pH of extrinsic phase to 7.5 using 100 mM Na2CO3 solution and incubated at 55 °C for about 30 min. Finally, the VIN-loaded liposomes (VIN-loaded NL or VIN-loaded SL) were filtration sterilized by 100-nm polycarbonate filter and sub-packed to aseptic vials.VIN was loaded into various liposomal formulations (NL or SL) using the pH gradient method at 1:20 drug/lipids mass ratio as described by our previously report  was diluted 20-fold with PBS  and incubated at 37 °C for 10 min and immediately transferred into a HUT-105 ultrasound sonication system . Temperature was measured by inserting a K-type thermocouple probe directly into the solution during ultrasound irradiation. After treating with ultrasound irradiation , the suspensions were allowed to stand for 10 min and then centrifuged, and the VIN concentration was determined by HPLC as described above.Sonosensitizer proportion screening. The released VIN from the VIN-loaded SL, which contained the HMME at different proportions , was determined following the same procedures, except the acoustic parameters were partially substituted by a total of 110 s.The morphology of VIN-loaded SL was observed by transmission electron microscopy (TEM) . The diameter of liposomal nanocarriers was determined in three serial measurements using a photon correlation spectroscopy . The VIN encapsulation efficiency (EE) of each formulation was determined by HPLC as described above.in vitro VIN release profiles of various VIN-loaded liposomal nanocarriers. Briefly, the liposomal VIN sample (1 mL) was transferred to a dialysis bag  and dialyzed against 20 mL of PBS  with continuous gentle stirring at 37 °C and treated with or without ultrasound . At various time points, 400 μL aliquots were withdrawn from the conical flask for drug analysis, and an equal volume of the medium was added. The leakage of VIN was determined via HPLC as described above.Dialysis bags were employed to determine the The long-term storage stability of VIN-loaded SL was evaluated. The liposomal nanocarriers were stored at 4 °C in closed amber vials without any other precautions, and samples were periodically removed for routine analysis. The stability parameters, such as diameter, PDI, EE and ultrasound-triggered release rates, were assessed every month for 3 months.2), the cells were treated with various VIN-loaded liposomal formulations or free VIN at a range of concentrations. In the liposomal formulation groups (VIN-loaded NL and VIN-loaded SL), those samples were pretreated with or without ultrasound, as mentioned above. Then, after 72 h, MTT solutions  were applied to the wells. After incubation for 4 h, the cell viability (%) was calculated based on the collected UV data via a Model 680 plate reader .The cytotoxicities of various VIN-loaded liposomal formulations and free VIN on MCF-7 cells were measured via the MTT assay. Briefly, the cells were seeded on a 96-well plate at a density of approximately 4000 cells/well. After incubation for 24 h . Blood was sampled from the retro-orbital sinus at different time points. To prepare samples for analysis, 0.1 mL internal standard (I.S.) solution  was added to 100 µL plasma sample in a 1.5-mL test tube. The sample mixture was deproteinized with 0.8 mL of methanol and vortex-mixed for approximately 1 min, and the precipitate was removed by centrifugation at 12,000 rpm (revolutions per minute) for 10 min. Then, 800 µL of supernatant was transferred to another clean test tube and evaporated to dryness at 37 °C with a CentriVap Concentrator. The dry residue was reconstituted in 100 µL of the mobile phase, vortex-mixed and centrifuged at 12,000 rpm for another 10 min; 20 μL of the clean supernatant was injected into the HPLC for analysis. The analysis was performed using Venusil MP-C18  HPLC column at 20 °C. The mobile phase was a methanol–acetonitrile–phosphate buffer , at a flow rate of 1.0 mL min−1. VIN detection was performed using UV detector at a wavelength of 220 nm.The pharmacokinetic profiles of VIN-loaded NL and VIN-loaded SL were measured in SD rats with a single dose of 1.0 mg kg7/mL in serum-free RPMI-1640 culture medium. Several nude mice were subcutaneously inoculated with 1 × 107 MCF-7 cells in left axilla. Upon reaching tumor size of about 5 mm in diameter after 10-day growth, we began to prepare for the following experiments.A xenograft tumor model was produced via subcutaneous injection of MCF-7 cells as described in previous report . Then, each tumor site was treated with a HUT-105 ultrasound sonication system  with a sonication area of 0.8 cm2 and ultrasound of 1 MHz, 1.5 W cm−2, a 10-s sonication with 10-s pause for a total of 110 s. Meanwhile, other groups that were not subjected to ultrasound were used as controls. One hour after the i.v. injection, three mice of each group were sacrificed with heart, liver, spleen, lung, kidney and tumor collected and stored at –20 °C until analysis. For VIN concentration detection, the samples were homogenized in threefold volumes of distilled water with the homogenate pretreated via a protein precipitation procedure using vinblastine as the I.S. and the supernatant following centrifugation was subjected to LC/MS/MS analysis as described above.Tissue biodistribution of VIN-loaded SL was performed on nude mice-bearing tumor xenografts, and compared with that of VIN-loaded NL and free VIN. The mice were randomly divided into four groups and were treated as follows via intravenously administration: free VIN; VIN-loaded NL; VIN-loaded SL (with ultrasound) and VIN-loaded SL (without ultrasound) at a dose of 4.0 mg kg−1 of free VIN, VIN-loaded NL and VIN-loaded SL on the 6th, 9th, 12th and 15th day. Thirty minutes after the administration, the group cured with VIN-loaded SL was irradiated with or without ultrasound, as described above. The tumor volumes were measured. The estimated tumor volume was calculated using the formula: volume (mm3) = (length × width2)/2. The survival time was calculated from day 0 (tumor inoculation) to the day of death. Kaplan–Meier survival curves were plotted for each group. Meanwhile, the body weight of each mouse was measured daily.The MCF-7 tumor-xenografted mice were injected in their tail vein with 5% glucose (control), 1.0 mg kgp value less than .05 (p < .05) indicated significance.The data are presented as the means ± standard deviation (SD). The difference between any two groups was determined via ANOVA. The p > .05). Thus, 110 s (10-s sonication with 10-s pause) of ultrasound stimulus was used in further experiments.Recently, many groups have reported that HMME could generate a large amount of ROS when irradiated by light for PDT or by ultrasound for SDT. Ultrasound has many advantages over light, especially the deep tissue penetration ability. Therefore, in this study, ultrasound was used as an external stimulus to irradiate liposomes containing HMME for controlled drug release. As illustrated in −2 power density, a 10-s sonication and with a 10-s pause for a total of 110 s). As shown in To confirm the specific requirement of sono-activated HMME for the sono-triggering and VIN release, VIN-loaded NL (with 0% HMME) and VIN-loaded SL (with 6% HMME) were tested under identical ultrasound conditions , and thus, the release efficiency of SL was not ideal. When the HMME proportion reached 6%, upon ultrasound stimulus, over 85% of the VIN was immediately released from the SL. With further increase of HMME ratio to 8%, there was no remarkable increase of drug release compared with the 6% ratio formulation (p > .05). This result indicated that the acoustic parameters  might be insufficient to trigger all of the HMMEs (8%). These results demonstrated that the 6% HMME proportion in the SL was sufficient to generate a sonodynamic effect under current acoustic conditions to trigger a burst release of VIN loaded in the liposomes. Therefore, a molar proportion of 6% for HMME was chosen for the subsequent studies.Since the content of HMME in liposomes was a key factor that influenced the drug release efficiency of SL, the release of VIN from different liposomal formulations with various HMME proportions  were evaluated to guide the formulation optimizing process. As exhibited in in vivo and in vitro. After EE study, the particle sizes of these liposomal nanocarriers were further analyzed by a laser particle analyzer  showed similar blood concentration-time curves. Both the sonosensitive liposomes and normal liposomes showed initial high blood circulating levels, while free VIN was quickly cleared from the systemic circulation. Furthermore, VIN-loaded liposomal nanocarriers (VIN-loaded NL and VIN-loaded SL) demonstrated a significantly slower clearance rate (CL) and higher AUC when compared with free VIN. As expected, no significant difference between CL and AUC was observed between two liposomal nanocarriers. This suggests that the mixing of HMME in the lipids of liposomes did not impair the long-circulation characteristics of DSPE-PEG2000.The plasma concentration-time profiles and pharmacokinetic parameters of VIN after i.v. administration of free VIN and VIN-loaded liposomal nanocarriers without ultrasound are shown in in vivo. To verify this, concentrations of VIN in solid tumors were evaluated in MCF-7 xenograft-bearing nude mice following i.v. administration of free VIN, VIN-loaded NL and VIN-loaded SL with or without ultrasound, respectively. As shown in The selective distribution of drug-loaded nanocarriers in tumors could potentially benefit the anti-tumor efficiencies of chemotherapy in vivo tumor targeting drug delivery via systemic administration.Taken together, VIN-loaded SL (with ultrasound) possesses desirable pharmacokinetic and tumor-distribution profiles, making it suitable for an in vivo, the effects of free VIN, VIN-loaded NL, VIN-loaded SL (without ultrasound) and VIN-loaded SL (with ultrasound) on tumor growth inhibition in animals were investigated. As shown in p < .05). These results were correlated with the abovementioned data revealing the merit of VIN-loaded SL (with ultrasound) over the other liposomal nanocarriers we tested in cytotoxicity induction in vitro  and tumor-specific distribution in vivo (To determine whether VIN-loaded SL (with ultrasound) possesses antitumor activity  in vivo . And it Figure S4, there were no significant changes in the body weights of mice treated with VIN-loaded liposomal nanocarriers during the experimental period (p > .05). These results suggest that there is negligible acute or severe toxicity related to the present treatments at the tested dose. However, more than 15% weight loss was detected in the free VIN group at the end of the experiment. The weight loss of the free VIN group was likely due to the non-targeted effects of drugs and tumor cachexia.The changes in the body weights of the animals were recorded as a safety evaluation index. As shown in in vitro and in vivo studies, combining with ultrasound treatment, VIN-loaded SL showed excellent antitumor efficacies to the target tumors. These research data indicated that SL is expected to be a promising delivery system of anticancer drugs for oncotherapy. In addition, SL might be seen as an alternative to sonodynamic therapy, in which ultrasound is used to generate reactive oxygen species locally at the tumor site that causes cancer cell death but cannot induce the delivery of drugs. To improve the targeting ability of SL, tumor-specific targeting ligands could be added onto the surfaces of the reported nanocarriers here. In future studies, we will continue to improve on the in vivo study by including survival analysis and by further exploring the application of SL in oncotherapy.A novel sonosensitive liposomal nanocarrier (SL)-contained sonosensitizer HMME was successfully developed in this study. The SL accumulates in the tumor site due to the EPR effects and then is disrupted under certain ultrasound irradiation due to the sonodynamic effect. As a result, most of the drug loaded inside the liposomal nanocarriers would release suddenly when triggered by the ultrasound. In the


IgG4-related disease is a fibro-inflammatory disorder characterized by swelling of tissues and affected organs accompanied by the development of scar tissue (fibrosis) and infiltration by IgG4 positive plasma cells. Almost any organ can be affected, including, but rarely, bone marrowinvolvement. Here we present a case of a 76-year-old male with IgG4-related disease presenting primarily with vertebral bone marrow lesions. Histopathology showed the typical features of storiform fibrosis, and increased IgG4 positive plasma cells. Treatment with corticosteroids significantly improved wellbeing and resolved lesion size on MRI. Immunoglobulin G4-related disease (IgG4-RD) is a relatively new fibro-inflammatory condition characterized by tumefactive lesions, a dense lymphoplasmacytic infiltrate rich in IgG4 positive plasma cells, storiform fibrosis, and often elevated IgG4 serum levels. It was first reported in the pancreas and over the years, this entity was recognized in a variety of other organs, with pancreas, bile ducts, salivary and lacrimal glands and lungs being the most common sites –3. We heA 76 year old male was referred to our clinic for a diagnostic second opinion with complaints of fatigue, increased exhaustion after physical exercise, weight loss, and night sweats. Physical examination, including neurological examinations, revealed no abnormalities. Laboratory testing showed an increased erythrocyte sedimentation rate (ESR) of 78 mm/h  and C-reactive protein (CRP) of 77 mg/L . Further evaluation demonstrated a polyclonal hypergammaglobulinemia with increased serum kappa and lambda light chains and negative M-protein. The chest X-ray was normal but magnetic resonance imaging (MRI) showed multiple hypodense bone lesions in the thoracic and lumbar spine and in the iliac crest. A bone marrow biopsy of the iliac crest, including immunophenotyping, was negative for malignancy. A first biopsy of a thoracic vertebral body was performed showing normal marrow with a focus of fibrosis with a slight increase in polytypic plasma cells, eosinophils and mast cells with a normal morphology. In this fibrotic area there was no pre-existing hematopoiesis. Elaborate immunohistochemical analysis excluded a hematologic malignancy, metastatic carcinoma and systemic mastocytosis. At that time IgG4 staining was not performed.During the following months, the constitutional symptoms, and the elevated inflammation markers persisted, and a mild normocytic anemia and leucocytosis developed . A subseIgG4-RD is fibro-inflammatory condition more prevalent in middle-aged and elderly males. The major symptoms of IgG4-RD are related to the mass effect and thus commonly present with site specific symptoms, often raising suspicion of malignancy. Site specific symptoms include, but are not limited to: sicca features, respiratory symptoms, pruritus, eczema, abdominal pain, and diarrhea. 10–20% of patients have a history of atopy , 5, 6.Involvement of the central nervous system in IgG4-RD is rare, and often manifests as hypertrophic pachymeningitis, in which there is a focally or diffusely thickened dura mater. In this disease, the cranial part of the dura is predominantly involved, but over the past years several case reports have been published describing involvement of the spinal dura , 5–10. MBone marrow involvement has previously been described in patients with IgG4-RD as FDG-PET/CT bone marrow FDG-avidity but without lytic or sclerotic bone regions on plain CT  and/or aOur case-report describes a patient with sclerotic, PET-positive IgG4-RD lesions in the vertebrae as primary manifestation of the disease. The clinical differential diagnosis of lesions in the vertebral body is broad, ranging from benign diagnoses , to malignancies , and infectious causes . In our case, elaborate diagnostic work-up, including laboratory, and radiological results and histopathological findings, did not reveal a malignancy. Based on the findings of the second biopsy, IgG4-RD was diagnosed. Histologically, mastocytosis was excluded based on the absence of aggregates or spindled mast cells. Beside, mast cells in the fibrotic focus had no aberrant immunohistochemical profile (CD2 and CD25 were negative) and no KIT mutation was detected using Next Generation Sequencing. Plasma cell dyscrasia was ruled out based on the polytypic immunohistochemical expression of kappa and lambda light chain and the absence of a B-cell clone on clonality analysis.In general, the diagnosis of IgG4-RD is made based on specific histopathological features, with the presence of at least 2 of the following 3 major criteria: (1) dense lymphoplasmacytic infiltrate, (2) fibrosis with a focal or diffuse storiform pattern, and (3) obliterative phlebitis. In addition, an increased IgG4 positive plasma cell / IgG4 positive plasma cell ratio of at least 0.4 in the affected tissue should be present , 16. An Glucocorticosteroids are the first line of therapy for IgG4-RD, inducing a rapid response in the majority of patients. Unfortunately, sustained remission is infrequent, with a relapse rate reported between 40 and 77% of patients , 6. In chttps://clinicaltrials.gov/ct2/show/NCT01584388).A randomized controlled trial recently finished enrolling patients (In conclusion, this case illustrates the occurrence of IgG4-RD presenting with sclerotic, FDG-avid bone marrow lesions and evolvement of an epidural mass in the thoracic spine without any other organ involvement, but with systemic symptoms. Laboratory findings and histopathological findings were consistent with IgG4-RD as described previously in other organs. The non-typical presentation with lesions in the spine and bone marrow resulted in diagnostic and therapeutic delay, yet disease symptoms resolved on initiation of treatment.All datasets analyzed for this study are included in the manuscript and/or the supplementary files.This article presents a case report. Patient gave written informed consent to publish the data. No medical ethic committee was involved in this publication.MdB and RL suggested the diagnosis on histopathology. The diagnosis was confirmed clinically by DvdE and HL who managed the patient. DvdE and CS carried out a literature search, collected data about the case, and drafted the manuscript. TL generated The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Low-income and middle-income countries (LMICs) are crucial in the global response to antimicrobial resistance (AMR), but diverse health systems, healthcare practices and cultural conceptions of medicine can complicate global education and awareness-raising campaigns. Social research can help understand LMIC contexts but remains under-represented in AMR research.To (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers.Observational study: cross-sectional rural health behaviour survey, representative of the population level.General rural population in Chiang Rai (Thailand) and Salavan (Lao PDR), surveyed between November 2017 and May 2018.2141 adult members (≥18 years) of the general rural population, representing 712 000 villagers.Antibiotic-related knowledge, attitudes and practices across sites and healthcare access channels.‘ampi’ in Salavan . Multivariate linear regression suggested that attitudes against over-the-counter antibiotics were linked to 0.12 additional antibiotic use episodes from public healthcare providers in Chiang Rai (95% CI 0.01 to 0.23) and 0.53 in Salavan (95% CI 0.16 to 0.90).Villagers were aware of antibiotics  and drug resistance , but the usage of technical concepts for antibiotics was dwarfed by local expressions like ‘anti-inflammatory medicine’ in Chiang Rai  and Locally specific conceptions and counterintuitive practices around antimicrobials can complicate AMR communication efforts and entail unforeseen consequences. Overcoming ‘knowledge deficits’ alone will therefore be insufficient for global AMR behaviour change. We call for an expansion of behavioural AMR strategies towards ‘AMR-sensitive interventions’ that address context-specific upstream drivers of antimicrobial use  and complement education and awareness campaigns.NCT03241316.Clinicaltrials.gov identifier  Provincial-level representative survey using a three-stage stratified cluster random sampling design.Survey based on preceding qualitative research on antibiotic use in South-East Asia.Inclusion of the general population enables insights into formal and informal healthcare utilisation.Cross-sectional analysis of rural health behaviours excludes seasonal change and urban settings.Two-month recall period enabled greater inclusion but may bias responses towards better educated population groups.Antimicrobial resistance (AMR) threatens modern medicine by rendering antimicrobial drugs ineffective. Multifaceted global strategies target human, animal and plant health alongside the environment, food production and safety to respond to this ‘superbug crisis’.Low-income and middle-income countries (LMICs) play an important role in the global response to AMR. However, diverse health systems, healthcare practices and conceptions related to the use of antimicrobials require social research to understand local contexts and the complexity of human behaviour in LMIC settings. For example, with a focus on the health behaviour of the general public, the anthropological literature suggests that social factors like precarity and discrimination can influence medicine use independently of awareness;10.1136/bmjopen-2018-028224.supp1Supplementary dataWe currently have an insufficient social science knowledge base for behavioural interventions in AMR—a global health priority that has attracted more than £600 million of expenditure and future commitments for research and surveillance.The recent withdrawal of large pharmaceutical companies from antimicrobial research and developmentMore extensive social sciences work can yield novel social innovations as a benefit of disciplinary diversification.‘What are the manifestations and determinants of problematic antibiotic use in patients’ healthcare-seeking pathways?’.Neisseria gonorrhoeae to the UK showed.Using social research methods, the objectives of this paper were to (1) Describe antibiotic-related knowledge, attitudes and practices of the general population in two LMICs. (2) Assess the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers. We report findings from a provincial-level representative survey of rural health behaviours across 69 villages in northern Thailand and 65 villages in southern Lao PDR as part of the interdisciplinary ‘Antibiotics and Activity Spaces’ project.Our study design was a three-stage stratified cluster random survey : FollowiOur study population was the general adult population of rural Chiang Rai and Salavan , from whom we drew a representative sample of 1158 villagers in Chiang Rai and 983 in Salavan. We did not specifically sample patients, but we recorded any acute illness episode or accident-related injury if one occurred within the last 2 months of the interview, both for the respondents and any children under their supervision.This study did not sample patients but only adult members of the general public. The survey instrument was based on preceding qualitative research in South-East Asia,Our survey instrument was a 45 min face-to-face questionnaire see . It was 10.1136/bmjopen-2018-028224.supp2Supplementary data10.1136/bmjopen-2018-028224.supp3Supplementary data‘yah kae ak seb’) in Thai and ‘germ resisters’ (‘ຢາຕ້ານເຊື້ອ’ or ‘yah dtan suea’) in Lao as common local notions of ‘antibiotics’. We next asked about the purposes for which the respondent would use these antibiotics, which served as information alongside inputs from local pharmacists to triangulate in later parts of the questionnaire whether the respondent received antibiotics during an illness. However, 752/2986 (25.2%) medicine use episodes could not be confirmed as either antibiotic or non-antibiotic . We included these uncertain cases as ‘potential’ antibiotic use episodes to capture behaviour more comprehensively.The questionnaire covered basic demographic and socioeconomic information, antibiotic-related knowledge and attitudes, and treatment-seeking behaviour during acute illnesses and accident-related injuries. When measuring people’s awareness of antibiotics, we could not simply ask villagers whether they knew what ‘antibiotics’ are, considering that (1) A variety of local terms related to antibiotics existed. (2) People may be familiar with specific antibiotic brands but not aware of their antibiotic attributes. (3) The understanding of technical language was uncommon (see Results section for evidence on this point). We therefore asked respondents first if they recognised images of common antibiotics in the field site .Lower general antibiotic use and a higher share of supervised antibiotic use from formal healthcare providers among people whose attitudes correspond to awareness-raising messages for AMR . We separately analysed the full sample and the subset of respondents who reported a recent illness, whereby we tested differences in knowledge, attitudes and behaviours across provinces and across antibiotic access channels with Χ2 tests for binary and Wilcoxon rank-sum tests (two-sided) for non-normally distributed variables. We further carried out multivariate analysis of the determinants of antibiotic use from public , private  and informal sources . The multivariate analysis used linear regression models adjusted by the complex survey design (sampling clusters and survey weights), which we compared across the two country samples, using the Chow test to ascertain systematic differences in the determinants of antibiotic use across the two field sites.We stratified and compared the samples by field site  to account for the systemic influence of the health system configuration on people’s health knowledge and behaviour. We estimated provincially representative patterns using poststratification weights based on census data (considering village size and district-specific age and gender composition) and adjusting the descriptive and regression analysis results for the multistage sampling design with the help of the Although the dependent variables were not normally distributed, the otherwise preferable functional form of Poisson regression did not converge in most cases owing to the relatively small sample sizes. However, where they did converge, the linear regressions yielded more conservative estimates. Likewise, the linear regressions adjusted by the complex survey design yielded more conservative results than linear multilevel models that take the hierarchical structure of the data into account. We therefore present the linear regression results in this article. For improved model fitness and to reduce the influence of outliers, we further substituted the duration of the illness with its log. To test for multicollinearity in the cross-sectional survey data, we analysed the pairwise correlations between all independent variables stratified by field site, whereby the largest correlation coefficients in Chiang Rai were +0.59 (ethnicity/religion) and –0.50 (education/age), and in Salavan +0.76 (ethnicity/religion) and +0.62  see . The larRepresentative statistical data of Chiang Rai and Salavan are presented in 10.1136/bmjopen-2018-028224.supp4Supplementary dataRespondents’ recognition of antibiotics in Chiang Rai was significantly higher than in Salavan, but overall high in both sites . Recognition of the phrase ‘drug resistance’ was high as well, whereby 74.8% recognised the term in Chiang Rai and 62.5% (p<0.001) recognised either of the two common variations in Salavan. yah kae ak seb’; a vernacular notion specific to antibiotics).  Only 7.2% used the official term for 'antibiotic’ (‘ยาปฏิชีวนะ’ or 'yah pa ti chee wa na’) alongside ‘germ killer’ and specific antibiotic types like ‘corlam’ . In rural Salavan, a larger portion of 38.6% used the official term for antibiotics  medicine’), while its vernacular equivalent ‘lueng yah’ was often interpreted in the opposite way as a psychological dependence or addiction to medicine (24.9%).According to our survey data, 99.9% of the rural population in Chiang Rai and 91.6% of the rural Salavan population had a public primary healthcare centre within a 10 km radius. Private sources were more varied, as 93.0% and 34% of the rural Chiang Rai population had a private clinic and a pharmacy within a 10 km radius, respectively , whereas informal healthcare through shops and informal healers was nearly universally available within the survey villages .Among our 2141 respondents, we captured 608 illness episodes in Chiang Rai and 356 in Salavan see . HealthcComparing the bivariate differences between individuals who accessed antibiotics from public, private and informal sources see  indicateThe results of the multivariate analysis are presented in Among other covariates, wealthier patients had lower consumption of antibiotics from public  and higher consumption from private  and informal healthcare providers —presumably enabled by their higher purchasing power. Speakers of the majority language were also more likely to consume more antibiotics from public sources, which resonates with anecdotes encountered during the field research according to which speakers of minority languages tended to be less assertive in the patient-doctor encounter (the link to education was less clear). Not surprisingly, longer illness episodes were also associated with more antibiotic use episodes from public and private sources.The Chow test indicated that the determinants of confirmed antibiotic use from private sources were significantly different in Chiang Rai and Salavan , as were all sources of potential and confirmed antibiotic use .Our paper aimed at understanding AMR-related general population behaviour in LMICs through a description of antibiotic-related knowledge, attitudes and practices in rural Thailand and Lao PDR, and an assessment of the role of antibiotic-related knowledge and attitudes on antibiotic access from different types of healthcare providers. We demonstrated that rural populations exhibited:Mixed but surprisingly high levels of awareness and attitudes corresponding to AMR awareness-raising material, although only a minority of villagers were familiar with technical notions of antibiotics and drug resistance.Relatively low levels of antibiotic access from informal sources.Surprisingly counterintuitive links between informal antibiotic use, socioeconomic status, and their attitudes—especially among villagers in Salavan, who had disproportionately high antibiotic use if their attitude showed a disinclination against over-the-counter antibiotics.Our survey data also revealed profound differences between the two field sites despite their cultural and geographical proximity. For example, villagers referred to antibiotics with wide-ranging and locally specific vernacular expressions , and ‘drug resistance’ was typically understood as a general tolerance of the body to medicine but local interpretations ranged from patients refusing medicine to patients being addicted to medicine. Some of these differences could be explained by the local health system configuration. The better endowed and more regulated health system as well as the more extensive public health campaigns in Chiang Rai arguably contributed to the higher rates of public awareness and the comparatively lower rates of antibiotic use, whereas the Salavan health system faced more pressing trade-offs between ensuring access to and preventing the overuse of antibiotics. Alas, as the analysis has shown, antibiotic-related awareness and attitudes appeared to have little bearing on people’s antibiotic consumption when controlling for other determinants of medicine use.The surveys were implemented after the monsoon season to reduce accessibility barriers like landslides, floods and farm work. This temporal focus meant that our survey was not able to capture internal migration or seasonal change affecting the epidemiological environment. The rural survey is also unable to speak for urban health behaviour or behavioural patterns outside rural Thailand and Lao PDR, or for awareness and behaviour among healthcare staff and policy makers . Lastly, our focus on health behaviour and our 60-day recall period could introduce recall and social desirability biases. Most LMIC health behaviour research uses recall periods of 14–30 days; longer recall periods can lead to under-representation of lower educated groups.increased antibiotic use or the use of stronger medicine if people understand drug resistance as stubbornness of patients or as a problem applying to all types of medicines.By virtue of being a representative rural survey in northern Thailand and southern Lao PDR, the specific notions and behavioural patterns around antibiotic use are not generalisable beyond the study context, although similar interpretations of antibiotics as ‘anti-inflammatory medicine’ exist elsewhere ,On the other hand, our study also demonstrated that the link between knowledge, attitudes and antibiotic-related behaviour may be weak in LMIC contexts. This disjunction is not new,Considering potential misunderstandings in AMR communication on the one hand and contextual determinants of behaviour beyond knowledge deficits on the other, we call for an expansion of behavioural AMR strategies to address structural factors of behavioural change. For example, vulnerability and adversity may drive people into seemingly irrational antimicrobial use.


Low atmospheric pressure (LAP) can enormously affect properties of cement concrete in plateau areas. There are fewer studies and attendances on this issue than those of cement concrete in normal atmospheric pressure (AP), because of the limitations of both environmental conditions and instruments. In order to improve properties of cement concrete under LAP, influences of LAP on properties of cement concrete were reviewed in this work. The influence rules and mechanism on properties of cement concrete were summarized. The corresponding mechanism and techniques were put forward for enhancing the properties of cement concrete. The results of researchers show that LAP can significantly reduce the air entraining ability of the air entraining agent (AEA). Air content in concrete linearly decreases with the decrease of AP when other conditions are constant. If the initial air content is high, the decrease rate of air content increases with the decrease of AP. When the initial air content in cement concretes is similar, the greater the slump of cement concrete, the stronger its resistance to the decrease of air content caused by the decrease of AP. In addition, the condition of the bubble characteristics of hardened cement concrete under LAP is worse than that under normal AP. Therefore, the change of concrete properties under LAP is mainly attributed to these bubble characteristics, such as air content, bubble spacing coefficient, bubble radius and bubble specific surface area. In this work, nano-silica (negative charges) with cationic oligomeric surfactants is recommended as a new type of AEA to optimize the bubble characteristics under LAP in plateau areas. Within an altitude of 3000 m, the atmospheric pressure (AP) decreases by 1 mm Hg (about 133 Pa) for each 12 m increase. It is not a linear relationship in which the altitude of the plateau area is higher than 3000 m. But the AP decreases with the increase of the altitude. Therefore, the AP decreases unevenly with the altitude; and the higher the altitude is, the slower the AP decreases. The relationship between AP and altitude is shown in Equation (1).Bubbles have great influences on microstructures and macroscopic properties of cement concrete ,2. The pIn this work, the influence rules and the mechanism of LAP on AEA and bubbles in cement concrete were summarized at first, and then the microcosmic and macroscopic changes of workability, mechanical property and durability of cement concrete were deeply analyzed according to the changes of the bubble characteristics. In view of these influences, corresponding improvement techniques and some opinions on the mechanism for developing new AEA were put forward, which were beneficial to the development of any new AEA. This work can put forward theoretical and technical supports for improving the properties of cement concrete under LAP for its wide applications in construction and building materials in plateau areas.Bubbles introduced by physical means are mostly unstable, which is more evident under LAP. Therefore, it is necessary to add AEA in concrete. The foaming capacity of AEA depends mainly upon its effect of reducing the surface tension of the solution, its diffusion properties and the elastic characteristics. The foam stability of AEA is equally important. The Gibbs-Marangoni theory can explain the role of AEA in foam film formation and persistence .Zhu, et al.  determinLAP can weaken interfacial activity and foam stability of AEA . In the Yan, et al.  studied Li, et al. ,5,33 stuFor example, in Some studies showed that bubbles were no longer spherical ,35,36, ba is average bubble area; the S (μm2) is accumulated bubble area; the N is the number of bubbles.sA is air content, and the n is the number of bubbles per unit area.d is average bubble diameter, and the iS (μm2) is bubble area.α is specific surface area.L is the bubble spacing coefficient, and P (%) is paste content (volume fraction).The bubble characteristics mainly include air content, the bubble spacing coefficient, bubble radius and bubble specific surface area. Equations are as follows:Li, et al.  studied When the air content of concrete reaches a constant, the spacing coefficient of a concrete bubble can reach 200 μm–300 μm under LAP. Li, et al.  studied The properties of the liquid interface have changed under LAP. The bubble film becomes thin, and the strength is insufficient, which makes the bubbles remaining in concrete decrease significantly. At the same time, the whole system is in the unstable state of thermodynamics. In order to achieve a stable state, the interfacial area of each phase is automatically contracted. The bubble amalgamates to reduce its specific surface area, which increases the average radius and spacing coefficient of the bubble. Ma  conducteThe moisture evaporation in fresh concrete can increase during the setting and hardening process of concrete under LAP. The outward migration of moisture is accelerated due to the evaporation of moisture and the humidity field formed by the difference in humidity between the inside and the outside. This causes bubbles to migrate and crack with moisture movement. As a result, the air content decreases; the average radius and spacing coefficient of the bubble increases; the capillary pores increase; the porosity increases, and the average pore size increases.In addition, the evaporation of moisture on the surface of hardened concrete is accelerated during curing. Therefore, it accelerates the internal moisture migration, which results in incomplete hydration, and the increases of macropore porosity and average pore size . To sum Ke, et al.  showed tKe, et al.  showed tGenerally, the AP reduces about 10% for every 1000 m increase in altitude, as shown in Equation (1). The property of pumping concrete can inevitably change at high altitude areas . In mostKe, et al.  showed tLiu  studied To sum up, air content is the key factor that affects the workability of concrete. Under an LAP condition, the surface tension of a liquid increases, which results in a difficulty in bubble introduction and bubble stability. The air content of concrete is seriously affected. As a result, the workability of the concrete can decrease. The main manifestations are that the slump and the slump flow of cement concrete are affected, the pumpability of cement concrete decreases, and the workability of the cement concrete mixture decreases.The air content in concrete is not the only parameter affecting compressive strength ,51,52,53Ma  showed tLiu  showed tAccording to the results of the above two researchers, the compressive strength and air content of concrete are related to pore structures. The fresh concrete is unstable in thermodynamics under LAP. The air content decreased significantly. The pore structure characteristics of hardened concrete change , which affects the compressive strength ,5,6,7,32Ma  showed tLiu  showed tAccording to the results of the above researchers, this work is summarized in nK is durability coefficient; the N is the frequency of freeze-thaw cycle; the P is relative dynamic elastic modulus after N freeze-thaw cycles.Some researchers ,57,58,59Li, et al.  showed tAs shown in Wang, et al.  showed t− invade concrete easily [Giergiczny, et al. , Han, ete easily ,73 and dLiu  showed tAccording to the studies of the above researchers, this work is summarized in According to the results ,79, bubbIn such systems, in-situ hydrophobicity occurs, that is, surfactant molecules with opposite charges are adsorbed to the surface of particles by electrostatic attraction, forming a monolayer, making the surface of particles hydrophobic, so that particles can be adsorbed to the water-air interface to stabilize bubbles. Oligomeric surfactants can be regarded as oligomers of traditional monomeric surfactant fragments, which are linked by spacer groups near their ionic groups ,90,91,92Method, time and temperature for concrete preparation should be mentioned. According to the results in references ,31, if tThe cement concrete prepared under LAP is in an unstable state of thermodynamics. The bubble film thickness is thin, and the bubble stability is poor. Excessive vibration stirring or excessive vibration time can result in more loss of bubbles. Therefore, under the precondition of satisfying compactness, the shortest time of vibration stirring is used to ensure that the cement concrete has enough air content to improve the properties of concrete. The temperature difference under LAP in plateau areas is high. The high temperature increases the surface tension of the liquid film of bubbles, and decreases the thickness and strength of the liquid film, which makes bubbles crack easily. Therefore, the temperature and bubble characteristics should be controlled, in order to ensure the uniform distribution and stability of bubbles.Under LAP conditions, bubbles in fresh cement concrete have been in an unstable state. The bubble characteristics in hardened cement concrete are changed. In addition, LAP accelerates the evaporation of internal and surface moisture in cement concrete. During the process of moisture migration, the bubble spacing coefficient increases; the bubbles’ number per unit volume decreases; the bubble distribution is uneven; and the pore structure deteriorates. Therefore, attention should be paid to the maintenance of cement concrete. Moisture should be supplied to concrete in time to prevent pores changing due to the evaporation of moisture. The internal and external maintenance methods can be used. They play a dual role of internal water retention and external water resistance of cement concrete, which effectively ensures the full hydration of cement materials. It promotes property improvements of cement concrete.To sum up, when cement concrete is prepared under LAP, the changes of bubble characteristics should always be paid attention to. The adoption and the development of AEA, the mixing methods, time and temperature and maintenance methods should also be paid great attention. These methods can be adopted to improve the bubble characteristics to ensure the properties of cement concrete.In summary, the LAP environment in plateau areas is a kind of environmental condition which is easy to be neglected. Its influence on the properties of cement concrete is mainly reflected by the bubble characteristics. Therefore, this work mainly analyzes and summarizes the property changes of cement concrete through the influence of LAP upon bubble characteristics. In view of these influences, corresponding improvement techniques are put forward. Some opinions on the mechanism for developing new AEA were put forward, which were beneficial to the development of AEA. The following conclusions can be drawn:(1) The air content in cement concrete is mainly introduced by AEA. In plateau areas, LAP increases the surface tension of the liquid, while AEA introduce bubbles by reducing the surface tension of the liquid. It leads to the fact that the AEA under LAP is not only difficult to foam, but also poor in foam stability. Therefore, LAP significantly weakens the effects of AEA, which reduces air content in cement concrete.(2) The bubble is the key factor affecting the workability of the cement concrete mixture. Under LAP, the decrease of air bubbles may increase the friction or decrease the adhesion between aggregates, which makes it difficult to mix well, and results in the decrease of the workability of cement concrete.(3) The mechanical properties of cement concrete are closely related to the bubbles therein. The bubble characteristics are deteriorated under LAP. Bubbles are not enough to buffer pressure, which affects the internal structure of cement concrete. In addition, LAP accelerates the moisture movement in cement concrete. On the one hand, it causes incomplete hydration and increases harmful pores. On the other hand, the process of moisture migration leads to the increase of pores in cement concrete, which affects the mechanical properties of cement concrete.(4) Bubbles affect the durability of cement concrete. The changes of bubble characteristics should be mainly considered. Under LAP, the bubble film becomes thin; the strength of the bubble decreases; the proportion of large diameter bubbles increases. As a result, the spacing coefficient and the specific surface area of the bubble increases, which can decrease the durability of concrete. It is suggested that the spacing coefficient of the bubble be used instead of air content to improve frost resistance of concrete.(5) The development of new AEA should be concerned. This work recommends the addition of particles with opposite charges to the ionic oligomeric surfactants as a new AEA, such as nano-silica (with negative charges), coexisting with cationic oligomeric surfactants.(6) Finally, it is hoped that further research on the correlation between the bubble characteristics and cement concrete properties can be carried out in order to accurately reflect the changes of cement concrete properties under LAP. At the same time, it is urgently hoped that new types of AEA for LAP can be developed as soon as possible.


Overuse and misuse of antibiotics are the primary risk factors for antibiotics resistance. Inadequate professional competence of primary care physicians might exacerbate these problems in China. This retrospective study aims to document the clinical pattern of antibiotics use and its overuse and misuse rates in rural primary care institutions and to evaluate the association between antibiotics use and characteristics of physicians and their patients.Medical records from 16 primary care hospitals in rural areas of Guizhou province, China were obtained from the Health Information System in 2018. Classification of unnecessary use, incorrect spectrum of antibiotic, escalated use of extended spectrum and combined antibiotics use was based on the Guiding Principle of Clinical Use of Antibiotics  and guidelines from the US Centers for Disease Control and Prevention. Generalized Estimating Equations were employed to determine predictive factors for inappropriate antibiotics use.A total of 74,648 antibiotics prescriptions were retrieved. Uncomplicated respiratory infection was the most common disease accounting for 58.6% of all prescriptions. The main antibiotic group used was penicillins (51.5%) followed by cephalosporins and macrolides (14% each). Of 57,009 patient visits, only 8.7% of the antibiotic prescriptions were appropriate. Combined use, escalated use of extended spectrum antibiotics, incorrect spectrum and unnecessary antibiotics use was found in 7.8%, 1.9%, 4.3% and 77.3% of patient visits, respectively, of which 28.7% were given intravenously. Antibiotics misuse was significantly more likely among newly employed physicians with lower levels of professional education. Adult patients and those who had public insurance had a higher risk of being prescribed unnecessary antibiotics.Overuse of antibiotics for uncomplicated respiratory infection and use of cephalosporins, macrolides and injection antibiotics in primary care are the major problems of clinical practice in rural areas of Guizhou. Antibiotics resistance is a growing global public health issue . BetweenThe majority of people in southwest China live in rural areas where primary care physicians usually provide the health services . Most phThe aim of this study was to document the clinical patterns of antibiotics prescriptions in a rural primary care setting where physicians are mostly non-degree trained. The secondary objective was to determine the association between antibiotics use and various characteristics of patients and physicians.Ethical approval: This research was approved by the Institutional Review Board of Prince of Songkhla University, Thailand (REC: 60-285-18-5). Ethics committees approved the consent procedure. All participants provided their written informed consent to participate in this study.Out of 1,399 township public hospitals in Guizhou rural areas, 132 use the same health information system (HIS) developed by the Department of Public Health. Those that had more than three outpatient physicians were eligible for the study. Out of the 84 eligible hospitals, we randomly selected 31 to participate in the study.Only data from outpatient units were retrieved. Demographic characteristics of the patients, and education and work experiences of the physicians, were obtained from the Personnel Management Department. All patients prescribed antibiotics during February to August, 2018 were included in the analysis. The primary diagnoses of all diseases except for tuberculosis (since the treatment options are fixed and standardized), were grouped into 10 diagnostic categories according to the international classification for diseases version 10 (ICD-10) code . AntibioWe used the National Health Commission of China for Guiding Principle of Clinical Use of Antibiotics introduced in 2015  were used to determine independent predictors of antibiotic misuse controlling for possible confounding effects by other variables. All p-values were two-sided. R version 3.3.1 was used for all data management and analysis for the database .A total of 96,509 antibiotic prescriptions among 57,009 patient visits were retrieved from the electronic database during the study period. The ten most common diagnoses among these patients accounted for over 77% of all prescriptions; therefore, we focused on only these ten diagnostic categories in the analysis.The crude odds ratios indicate the strengths of the association between inappropriate use and physicians’ and patients’ characteristics. Male physicians were more likely to prescribe antibiotics inappropriately as were those aged 32–38 years (compared to those aged less than 32 years), those who had not completed a college degree, worked for 11–30 years (compared to those who had worked for less than 5 years), and were associate chief physicians (compared to resident physicians). Patients who were female, aged 18 years or more (compared to those aged ≤5 years), received antibiotics intravenously and received financial assistance from an insurance scheme were more likely to be prescribed antibiotics inappropriately.This study showed five patterns of antibiotic use, namely: 1) appropriate use, 2) unnecessary use, 3) escalated use of extended spectrum antibiotics, 4) incorrect spectrum of antibiotics, and 5) combined antibiotic use. More than 90% of antibiotic prescriptions were inappropriately prescribed. Respiratory infection was the most common disease linked with antibiotic prescriptions. While penicillins were the most commonly prescribed antibiotic, cephalosporins and macrolides were more inappropriately prescribed, particularly due to escalation and incorrect spectrum of antibiotic. These antibiotics could have been de-escalated to penicillins. The background education of these primary care physicians was generally below college level. A physician's low level of education and senior position were significantly associated with inappropriate antibiotic prescription. Antibiotic misuse was also associated with injection route as well as adult patients and those who had insurance.In general, uncomplicated respiratory infections are mostly caused by viruses, which cannot be treated with antibiotics . UnnecesAs much as 29% of antibiotics used in this study was administered by injection. Overuse of injections was also seen other countries such as Vietnam, India, and Korea –24. ThisMost of the antibiotic prescriptions in this study were made by resident physicians with a below college level of education, and this was associated with antibiotic overuse and misuse. Based on this evidence, refresher courses on antibiotic prescribing for primary care physicians are necessary , 9. The Furthermore, there are no measures to teach patients how to use antibiotics and manage symptoms of non-bacterial infections. Patient’s attitude, education level and expectations play a key role in inappropriate antibiotic prescribing by physicians in outpatient settings. Patients who are misled by the efficacy of antibiotics were prescribed antibiotics more frequently than those who were not expecting them . PatientOur study has several limitations. Firstly, the results of our study cannot be generalized to hospitals with fewer outpatient physicians and to hospitals outside of our study setting. Secondly, the whole analysis of this study was based on data keyed in by the primary physicians. While the antibiotic information is very accurate, that on disease classification might be less so. Accurate diagnosis is a prerequisite of appropriate selection of antibiotic. Data on appropriateness of antibiotic choice in this study must therefore be interpreted with caution. Thirdly, the time frame of the survey is limited, diseases and medications in different seasons will vary, which is not covered in this study.Overuse of antibiotics for uncomplicated respiratory infections, use of cephalosporins, macrolides and injection antibiotics in primary care are the major problems of clinical practice in the study areas.S1 File(DOCX)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.


L16(45), which consisted of five factors, each with four levels. Base on the fluidity and compressive strength of the tested matrix, three groups of suitable matrixes mix proportions were selected to serve as the matrix type for pervious concrete mix proportion design. Then, an orthogonal array L9(34), which consisted of four controllable three-level factors, was adopted in the pervious concrete. The parameters investigated included the coarse aggregate size, fine aggregate content, matrix type, and aggregate-to-binder ratio. The test results demonstrate that the key factors affecting the compressive strength of the matrix and the pervious concrete were closely related to the cementitious material. In the matrix, the proportion of the cementitious material was the most important factor, while in the pervious concrete, the type of matrix was the most important factor.The mechanical properties of traditional pervious concrete are insufficient, which limits its application. In view of the imperfections of traditional permeable concrete in mechanics, this paper aimed to find a suitable material composition that can be used as a feasible mix design of high-performance pervious concrete, to essentially improve its mechanical properties. Based on the view that concrete is a two-phase material, in order to understand the rheological properties of the matrix, it was subjected to a rheological test, and then the filler aggregate was uniformly incorporated into the aforementioned matrix to further explore the composition and properties of the resulting pervious concrete. For the matrix, the orthogonal array employed was  Most urban areas of the world are covered by reinforced concrete buildings and impervious roads, mainly due to the continuous development of contemporary urbanization . ComparePervious concrete is a porous, lightweight concrete made from aggregates, hydraulic cement, and water, containing a large number of connected pores ,5. In pe3, which is already close to the upper limit of lightweight concrete [The proportion of pervious concrete varies from region to region. The standard pervious concrete used in the United States is a mixture of single-sized coarse aggregates and cement combined at a low water-to-cement ratio . Howeverconcrete . In ordeconcrete . In geneconcrete . Accordiconcrete ,22,25,37concrete ,38,39,40concrete ,43,44,45Pervious concrete has been proven to have the potential to protect the environment and improve road safety. It has gradually become an important material for constructing parking lots and roads ,12,13,252/g was used. The silica fume was locally manufactured with a specific gravity of 2.75. Ultra-fine silica powder was purchased from abroad, and its specific gravity was 2.73. The fine aggregate was natural river sand with a specific gravity of 2.57, a water absorption of 1.45%, and a fineness modulus of 2.7. The coarse aggregate was gravel with a specific gravity of 2.59 and a water absorption of 1.30%. Superplasticizers and the viscous agent were local products . The fibers were polypropylene fibers with a water absorption of 0% and a density of 0.9 g/cm3.The materials used in the test included cement, silica fume, ultra-fine silica powder, coarse aggregates, fine aggregates, superplasticizers, a viscous agent, and polypropylene fiber. A locally produced Type I Portland cement with a specific gravity of 3.15 and a fineness of 3400 cmaL(cb), which represents a total of c factors that can accommodate a maximum of b levels in a groups of experiments; that is, an experimental array has a rows and c columns. As shown in L16(45) was adopted for the matrix, which consisted of five controllable four-level factors. Moreover, an orthogonal array L9(34) was adopted for pervious concrete, which consisted of four controllable three-level factors :Silica fume (SF):Ultra-fine silica powder (SFP)), the superplasticizer content, the viscous agent content, and the fiber content. As for pervious concrete, the test parameters included the coarse aggregate size, the fine aggregate content , the matrix type, and the aggregate-to-binder ratio (A/B).  factors . Based oL16(45) and L9(34), the mix proportions of the matrix and the pervious concrete are listed in According to the aforementioned orthogonal arrays, namely The rheology of the matrix was tested using a viscometer  with a viscosity measurement accuracy of ±1% of the measurement range and a type spindle (#HB04) was selected. The fluidity test of the matrix was in accordance with ASTM C230 , and theS/N) ratio (η) [MSD is the mean squared deviation around the target value; n is the number of repetitions or observations; iy is the observed data; and y0 is the desired nominal value.In the Taguchi experimental design method, the deviation between the experimental value and the expected value is usually calculated by a so-called loss function. Traditionally, the value of the loss function is usually converted to the signal-to-noise ratio (atio (η) . In geneatio (η) :(1)The-sS/N ratios into the contributions of each of the process parameters and the errors [In this study, the observed flow values of the matrixes were set to a nominal level, while the observed values of the mechanical properties of the matrixes and pervious concretes were set to maximum levels. In addition, optimization of the observations was further detected by variance analysis. This was mainly achieved by separating the total variability of the e errors .Fresh matrix can be regarded as a thick suspension that is obtained by uniformly adding cement to water. Basically, the rheological behavior of this suspension structure is closely related to the water–binder ratio, the size and distribution of the binder particles, the interactions between the binder particles, and the ability of the binder particle surfaces to adsorb water molecules. The initial stage of matrix formation , usually the cement particles, will show an agglutination phenomenon called flocculation, and then the flocculation tends to link into a continuous aggregate, this time called the flocculent state. When stirring the fresh matrix, the shear force generated by the stirring will break or destroy the original flocculation structure so that the previously aggregated particles can be uniformly dispersed in water, and this behavior is the cause of thixotropy. If the shear rate of the spindle is kept at a certain value, the matrix maintains an equilibrium structure and exhibits a distinct and invariable viscosity. When the shearing force ceases, the exact opposite of the above process occurs, i.e., the flocculation structure is formed again. Therefore, depending on the shear conditions applied, both opposing conditions may occur. In other words, when the shear force acts, the cement slurry exhibits a fluid behavior, and on standing, the flocculation structure makes the matrix comparable to a weak solid and has significant yield stress. In view of this, the deformation behavior of the matrix under stress should be essentially interpreted by the viscosity test results.As is clear from In addition to the above, the hysteresis loop phenomenon also showed an effect on the rheological test results of the matrix, which was caused by the difference in the rotational speed of the spindle from high to low or from low to high. According to the test results, there were hysteresis loops in different matrixes, as shown in The results of the rheological tests on the matrixes are shown in In addition, The rheological analysis results confirmed that the water–binder ratio is an important factor affecting the rheological properties of the cement paste. For example, in the case of a cement paste having a relatively high water–binder ratio, the water molecules can disperse the attraction between the cementitious particles and thus exhibit a low viscosity. With low water–binder ratios, where the number of bonds between the cementitious particles, the bonding strength, and the friction between the particles are relatively increased, an additional dispersant such as superplasticizers must be considered to obtain plasticity and flow. Therefore, this study used silica fume and ultra-fine silica powders to replace part of the cement. Each matrix was subjected to a rheological test under conditions in which the amounts of superplasticizer, viscous agent, and polypropylene fiber were changed. S/N ratios using Equation (2). As shown in S/N ratio of the first level was calculated by averaging the S/N ratios of experiments M1–M4. The influence of each selected factor on the performance characteristic investigated is described in detail below.Due to the characteristics of the selected orthogonal array, the effects of each test parameter at different levels can be evaluated separately. Taking the water–binder ratio as an example, the mean S/N ratio at each parameter level for flow value, while S/N response graph for flow value. The delta column in S/N ratio from Level 1 to Level 4. In theory, the importance can be evaluated by the delta value of each factor—the larger the delta value is, the greater the influence of the level of change of the factor on the performance parameter and the more important the factor is. As shown in Equation (3), the larger the S/N ratio is, the smaller the variance in flow value around the desired value is . From F values were obtained with a 95% level of confidence, and the percentage contribution of each parameter was also calculated. The superplasticizer content was the most significant factor that contributed to the target value of the flow of the matrix. The percentage contributions of these factors were as follows: superplasticizer content (53.37%), proportion of cementitious materials (18.78%), water–binder ratio (18.19%), and viscous agent content (9.65%). Thus, based on the results of the S/N ratio and variance analysis, the optimal combination of the experimental control factors for achieving nominal flow value is A3B3C1D1E3, i.e., water–binder ratio at level 3, proportion of cementitious materials at level 3, superplasticizer content at level 1, viscous agent content at level 1, and fiber content at level 3.S/N ratio and variance analysis, the optimal combination of the experimental control factors for achieving maximum compressive strength is A1B1C4D2E1.From S/N ratios are shown in 3, the void content of the pervious concrete was between 20.6% and 25.7%, and the hydraulic conductivity was between 21.6 and 24.2 mm/s. It can be seen from the composition of the pervious concrete that as the amount of fine aggregate increased, the void content tended to decrease. In addition, the unit weight was inversely proportional to the void content, while the hydraulic conductivity increased as the void content increased. Overall, the mechanical properties of the C3 mix are superior. The 28-day test results of the pervious concretes and the corresponding It can be seen from S/N ratio at each level for the compressive strength parameters, whereas S/N response graph for compressive strength. From the analysis results of 2B3C3D3.Moreover, In terms of the elastic modulus, the test results showed values between 9479.2 and 29001.5 MPa. The C1 mix had the lowest elastic modulus (9479.2 MPa), and the C3 mix had the highest elastic modulus (29001.5 MPa). The maximum value was three times the minimum value, indicating a very significant difference between the elastic moduli of the various mixtures. In the case where the coarse aggregate had the same particle size, the elastic modulus generally decreased as the void content increased. In other words, the elastic modulus of the pervious concrete is closely related to its material composition. Taking the C1–C3 mixtures as an example, the elastic modulus was inversely proportional to the void content, as shown in S/N ratio of the elastic modulus parameters of S/N response diagram of 2B3C3D3.According to the average As for the bending strength of the pervious concrete, the test results showed values between 1.88 and 2.99 MPa. The C4 mix had the lowest value (1.88 MPa), and the C3 mix had the highest value (2.99 MPa). There was a significant difference between the flexural strength of the various mixtures. In the case where the coarse aggregate had the same particle size, the flexural strength generally decreased as the void content increased. This shows that the flexural strength of the pervious concrete is closely related to its material composition. Taking the C1–C3 mixtures as an example, the flexural strength was inversely proportional to the void content, as shown in 1B3C3D3.On the other hand, as can be seen from Regarding the splitting strength of pervious concrete, the test results showed values between 1.43 and 2.69 MPa. The C4 mix had the lowest value (1.43 MPa), and the C3 had the highest value (2.69 MPa). The maximum value was 1.88 times the minimum value, indicating a very significant difference between the splitting strength of the various mixtures. In the case where the coarse aggregate had the same particle size, the splitting strength generally as the void content increased. In other words, the splitting strength of the pervious concrete is closely related to its material composition. Taking the C1–C3 mixtures as an example, the splitting strength was inversely proportional to the void content, as shown in 3B3C3D2.On the other hand, the analysis results of To verify the optimal combination of the experimental control factors obtained using the Taguchi method, confirmation tests were carried out. The results show that the key factors affecting the compressive strength of the matrix and the pervious concrete are closely related to the cementitious material. For the matrix, the superplasticizer content was shown to be the most important factor affecting the target value of flow, while the proportion of cementitious material was the most important factor affecting the compressive strength. Based on the fluidity and compressive strength of the tested matrix, three matrixes with suitable mix proportions were selected to serve as the matrix types for the mix proportion design of pervious concrete. The test results confirmed that the matrix type was the most significant factor affecting the compressive strength of the pervious concrete. The percentage contributions of each factor were as follows: matrix type (43.54%), aggregate-to-binder ratio (39.99%), and fine aggregate content (16.47%). Further, the matrix type was also the most significant factor affecting the flexural strength of the pervious concrete. On the other hand, the fine aggregate content was the most significant factor that contributed to the elastic modulus of the pervious concrete. Moreover, the fine aggregate content was also the most significant factor affecting the splitting strength of the pervious concrete. The percentage contributions of each factor were as follows: Fine aggregate content (55.24%) and matrix type (42.71%).


Immunoglobulin G4-related disease (IgG4-RD) encompasses a group of immune-mediated disorders that are gaining increasing recognition. Pulmonary presentations are common, with four types of patterns been described on radiography, including solid nodular, bronchovascular, ground glass opacities, and alveolar interstitial. Pleural thickening and pleural effusion have also been reported. However, there have been no reports of IgG4-RD that presents as spontaneous hemothorax.A 61-year-old Chinese woman experienced recurrent right-sided chest pain and transient syncope. A significant decrease in her hemoglobin level and thick bloody pleural fluid demonstrated spontaneous hemothorax. The elevated serum IgG4 and histopathological analysis of the right pleura and intercostal lymph node specimens all supported the diagnosis of IgG4-RD in this patient. Further diagnostic evaluation did not reveal other causes for spontaneous hemothorax. She received steroids and no recurrent bleeding event occurred during a follow-up period of more than 1 year.Recurrent spontaneous hemothorax can be a rare manifestation of IgG4-RD, with pleural involvement as the most probable mechanism. Immunoglobulin G4-related disease (IgG4-RD) encompasses a group of immune-mediated disorders that are gaining increasing recognition. It can involve one or multiple organs, including the salivary glands, orbital soft tissues, mediastinum, lungs, pleura, lymph nodes, large arteries, pancreas, eyes, thyroid etc.  ElevatedA 61-year-old Chinese woman was admitted to the Department of Respiratory Medicine, Peking Union Medical College (PUMC) Hospital with recurrent chest pain and transient syncope. Nine months before her admission, she had developed sudden burning chest and back pain on the right side, along with transient syncope, sweating, fatigue, and dizziness. She was admitted to a local hospital, where hypotension (85/50 mmHg) was detected. Laboratory studies showed a significant decrease in her hemoglobin level (93 g/L to 50 g/L). Thoracic ultrasound revealed right-sided pleural effusion with septa while chest computed tomography (CT) also showed right-sided encapsulated pleural effusion. Her symptoms improved after supportive treatment, and the effusion was seen to be gradually absorbed on serial follow-up CT scans. However, the cause of the chest pain, syncope, and anemia remained unclear.Furthermore, in the 12 years previous to that visit, the patient had developed recurrent periorbital nodules and a submaxillary mass, and had undergone multiple surgeries in other hospitals. Biopsies of these lesions revealed inflammatory pseudotumor, dacryoadenitis , and reactive lymph node (submaxillary) hyperplasia. She exhibited an improvement with steroid treatment, but we were unable to obtain detailed records of her treatment regime. The patient had no history of hypertension, diabetes, hepatitis, or tuberculosis. She took no medication on a regular basis and had never smoked or used illicit drugs.12/L), white blood cell count (5.74 × 109/L), total protein (TP) level (154 g/L), and lactate dehydrogenase (LDH) level . Other laboratory tests showed a significant increase in the C-reactive protein (CRP) level (31.99 mg/L), erythrocyte sedimentation rate , and bleeding time . Chest CT showed encapsulated pleural effusion with atelectasis on the right side, and multiple enlarged lymph nodes in the right intercostal, right hilar, and mediastinal area . The histopathological analysis, conducted by a specialized pathologist, of the right parietal pleura found dense fibrosis of the pleura, lymphoplasmacytic infiltrates, and proliferated small blood vessels with lumen dilation and congestion Fig. . ImmunohThis patient was diagnosed with IgG4-RD after discussions with multidisciplinary experts. She was treated with prednisone 60 mg per day for 4 weeks, which was then tapered by 5 mg every week to 30 mg per day, and tapered more slowly thereafter. The patient adhered well to the therapy and no severe side effects occurred. At follow-up visits, regression of the periorbital nodules, and mediastinal and intercostal lymph nodes was confirmed. CRP level, ESR, BT, and the IgG4 level returned to normal. More than 1 year later, there had been no recurrent bleeding event, and chest CT performed at the last examination revealed no obvious abnormalities such as pleural effusion, nodules, solid infiltration or lymphadenopathy.Multiple organs can be involved in IgG4-RD, presenting with various clinical symptoms. Among various types of pulmonary presentation, pleural involvement has been less common. In the present case, the two episodes of chest pain and transient syncope were considered to be associated with spontaneous hemothorax, which can explain the encapsulated pleural effusion, dramatic decrease of hemoglobin level, and hypotension. This was confirmed by thoracentesis. Because no provoking factors such as trauma are recorded, the bleeding events were considered to be spontaneous. Spontaneous hemothorax is an uncommon condition with different etiologies, including vascular ruptures, arteriovenous malformation, malignancies, anticoagulation medications, pulmonary infarctions, and hematological abnormalities such as hemophilia [Additionally, the skin and soft tissue presentation, elevated IgG4 level, the pathological evaluation of pleura and intercostal lymph node, and the treatment outcome all support the diagnosis of IgG4-RD in this patient. Whether IgG4-RD caused recurrent thoracic bleeding is questionable at first glance. However, we postulated that IgG4-RD was the cause of spontaneous hemothorax in this patient because of the following reasons. First, reassessing the patient’s medical history in light of the current diagnosis reveals that she had developed symptoms and signs of IgG4-RD years before the onset of hemothorax. Second, careful diagnostic evaluations revealed no other causes for spontaneous hemothorax, such as hemophilia, arteriovenous malformations, or malignancies. Third, after a careful review of the literature and discussion with multidisciplinary experts, we were unable to postulate an alternative condition that causes hemothorax and IgG4-RD at the same time. Fourth, the structures adjacent to the hematoma (pleura) were explicitly affected by IgG4-RD, and evidence of small vessel involvement was found in the parietal pleura specimen. Finally, our speculation was confirmed by the normal BT and lack of recurrent bleeding event for more than 1 year after steroid treatment.The exact mechanism underlying the development of spontaneous hemothorax in association with IgG4-RD remains unclear. Li et al.  reportedThere are multiple case reports , 8 of Ig