Two case reports of continued progression of chronic ocular graft-versus-host disease without concurrent systemic comorbidities treated by amniotic membrane transplantation.

BACKGROUND: Chronic ocular graft-versus-host disease (oGVHD) is an ocular comorbidity of graft-versus-host disease (GVHD) that usually occurs concurrently with systemic manifestations. Failure to detect and treat oGVHD in its early stages may lead to progression of ocular signs and symptoms leading to oGVHD that is refractory to conventional treatment. CASE PRESENTATION: We report the clinical course of a 19-year-old male and a 59-year-old female with severe and progressive chronic oGVHD without concurrent systemic signs of chronic graft-versus-host disease (cGVHD). Although their systemic conditions had been stable, both suffered from severe oGVHD and were referred to our clinic. Both cases exhibited marked improvement in conjunctival inflammation and fibrotic changes after amniotic membrane transplantation (AMT). Both cases underwent keratoplasty eventually to stabilize ocular surface conditions and to improve visual function. CONCLUSIONS: We reported the clinical outcomes of 2 cases of chronic oGVHD without concurrent systemic comorbidities that were treated with AMT. The clinician should be aware that cGVHD may persist in target organs even in the absence of concurrent systemic comorbidities following seemingly successful systemic treatment. A multidisciplinary team approach is essential in the early detection and therapeutic intervention for chronic oGVHD.

Quality of life and life-space mobility after total knee arthroplasty in patients with rheumatoid arthritis: a pilot case-controlled study.

[Purpose] The purpose of this study was to identify factors inhibiting improvement in the quality of life after total knee arthroplasty in patients with rheumatoid arthritis. [Participants and Methods] This was a pilot case-control study. The sample comprised of five participants with rheumatoid arthritis and 11 participants with osteoarthritis, who underwent total knee arthroplasty. We compared the groups in terms of physical function, walking ability, Japanese Knee Osteoarthritis Measure, and Life-Space Assessment. Measurements were taken before surgery and at four weeks and five months post-surgery. All patients underwent rehabilitation for five months postoperatively, first as inpatients, and then as outpatients after discharge. [Results] In the period from 4 weeks to 5 months post-surgery, physical function improved similarly in both groups in terms of muscle strength and walking ability. Despite the patients with rheumatoid arthritis being younger, their self-health assessment score by the Japanese Knee Osteoarthritis Measure and measures of life-space mobility by Life-Space Assessment were lower. [Conclusion] It is important to consider exercise therapy, and gait instruction to alleviate anxiety about health status and improve the quality of life and life-space mobility in patients with rheumatoid arthritis who undergo total knee arthroplasty.

The Relation of Ocular Surface Irregularity and Visual Disturbance in Early Stage Acanthamoeba Keratitis.

PURPOSE: To evaluate the relation between ocular surface irregularity and visual disturbance in early stage Acanthamoeba keratitis (AK). METHODS: Fifteen patients with culture-proven AK underwent routine ophthalmic examinations, including best-corrected visual acuity (BCVA) measurement, slitlamp biomicroscope examination, and corneal fluorescein dye staining test, in both the eyes. We also evaluated the corneal sensitivity with Cochet-Bonnet esthesiometer, tear functions by Schirmer's test, and ocular surface irregularity by corneal topography and compared the results with the contralateral healthy eyes in this study. RESULTS: The mean logarithm of the minimum angle of resolution BCVA (0.71±0.77) was significantly lower in the eyes with AK (P=0.002). Epithelial disorders were present in all eyes, and radial keratoneuritis in 14 eyes (93.3%). The mean corneal sensitivity (39.3±24.1 mm) was significantly lower in eyes with AK compared with the healthy eyes (P=0.005). The mean Schirmer's test value (22.5±12.0 mm) in eyes with AK was significantly higher compared with the healthy eyes (P=0.01). The ocular surface irregularity indices (the surface regularity index, 2.47±0.42; the surface asymmetry index, 3.24±1.31) were significantly higher in eyes with AK compared with contralateral healthy eyes (P<0.0001 and P<0.0001, respectively). CONCLUSIONS: The ocular surface disease in AK is associated with decrease in corneal sensitivity and increase in Schirmer's test value and ocular surface irregularity indices. The visual disturbance in AK may owe not only to corneal haze but also to ocular surface irregularity.

Successful treatment of Beauveria bassiana fungal keratitis with topical voriconazole.

We describe a 66-year-old woman who suffered from fungal keratitis after corneal transplantation. The causative organism was identified as Beauveria bassiana on the basis of morphological characteristics and the sequence of the internal transcribed spacer region of the ribosomal RNA gene. The patient was successfully treated with topical voriconazole (VRCZ) use only. We, hereby, present the first report of a case with B. bassiana fungal keratitis that responded to topical antifungal VRCZ treatment.

[A Clinical Case Report Including In Vivo Laser Confocal Microscopic Findings of Keratitis Complicated with Takayasu's Arteritis].

BACKGROUND: We present a clinical case report including in vivo laser confocal microscopic findings of keratitis complicated with Takayasu's arteritis (aortitis syndrome). CASE: A 47-year-old woman was referred to the outpatient clinic of ophthalmology with blurred vision in her both eyes at the onset of Takayasu's arteritis. Since multifocal infiltrates in the stromal corneas with injection were observed with slit-lamp biomicroscope in the both eyes, the diagnosis was keratitis. A large amount of cells infiltrating the stromal cornea and activated keratocytes were also observed with in vivo laser confocal microscope in the both eyes. Systemic and local steroidal agents were initiated, which resolved the keratitis, and the active lesions turned into mild corneal scars. In vivo laser confocal microscopy showed no infiltrating cells in the stromal cornea of both eyes. No recurrence has been observed since. CONCLUSION: A rare case of keratitis complicated with Takayasu's arteritis is reported. An immune response to the stromal cornea as the etiology of the keratitis may be indicated by in vivo laser confocal microscopy.

Wickerhamomyces anomalus fungal keratitis responds to topical treatment with antifungal micafungin.

We describe a 91-year-old woman who suffered from fungal keratitis after corneal transplantation. The causative organism was identified as Wickerhamomyces anomalus (formerly Pichia anomala or Hansenula anomala) on the basis of morphological characteristics and the sequence of the internal transcribed spacer region of the ribosomal RNA gene. The patient was successfully treated with topical micafungin (MCFG) only. We present the first report of a case of W. anomalus fungal keratitis that responded to topical treatment with the antifungal MCFG.

Implantation of Hydrophobic Acrylic Toric Intraocular Lens with High-Water Contents Using Swept-Source Optical Coherence Tomography Biometer Integrated with a Surgical Guiding System.

Purpose: To evaluate postoperative outcomes after implantation of toric intraocular lenses (IOLs) made of high-water-content hydrophobic acrylic material in Japanese patients using a swept-source optical coherence tomography (SS-OCT) biometer integrated with a surgical guiding system. Patients and Methods: In this prospective observational study, toric IOL models CNW0T3 to CNW0T9 (Alcon) were implanted in 33 eyes of 33 patients and followed-up for one month. Powers and toric models were determined using an SS-OCT biometer ARGOS® Ver 1.5 (Alcon), and the IOLs were aligned using surgical guidance. Differences between planned and actual axis positions at the end of the surgery (misalignment) and rotations from the end of surgery to one month postoperatively were measured. Additionally, postoperative uncorrected visual acuity, refraction, and residual astigmatism were evaluated. Results: Mean and median misalignments were 2.3° (standard deviation [SD]: 1.6, 95% confidence interval [CI]: 1.7-2.9) and 2°, and those of postoperative rotation were 2.4° (SD: 2.6, 95% CI: 1.5-3.4) and 2°, respectively. Mean postoperative refraction was 0.06 D (SD: 0.62). Prediction errors within ±0.5 and ±1.0 D were 69.7% and 93.9%, respectively. Mean residual astigmatisms were 0.19 D (SD: 0.41), and mean uncorrected visual acuity was 0.00 logMAR (SD: 0.11), and 64% of the eyes scored 20/20 or better. Conclusion: Implantation of high-water-content hydrophobic acrylic toric IOLs using SS-OCT biometry integrated with a surgical guiding system effectively corrected corneal astigmatism with accurate IOL alignment in Japanese patients.

Accurate measurement of the bond stress between rebar and concrete in reinforced concrete using FBG sensing technology.

Recent earthquakes in several developing countries have shown that reinforced concrete (RC) buildings with improper structural detailing experience severe damage under seismic motions. Using low-quality construction materials such as brick aggregates, resulting in low-strength concrete, significantly impacts the bond between rebar and concrete. Accurate evaluation of the bond performance of such low-strength concrete is one of the key issues for seismic safety assessment of RC buildings, especially in Bangladesh; thus, the bond performance is usually evaluated through laboratory tests. However, conventional measurements of bond stress based on rebar strains measured by electrical resistance strain gauges are likely to negatively impact the bond behavior/performance because of the reduced total contact area between rebar and concrete as well as the changing rebar surface boundary conditions. Under the above social and academic backgrounds, in this study, a new measurement technique that applies fiber Bragg grating (FBG) sensors embedded in optical fiber to rebar strain measurements is developed, and its effectiveness is investigated to realize more accurate measurements of the bond stress between rebar and concrete. Two 70% scaled RC beam-column joint specimens in which the beam rebar was anchored in a straight manner were constructed with identical detailing, except for the beam rebar strain measuring methods. The specimens were then subjected to cyclic lateral loading until failure. By comparing the experimental data acquired by the above two different devices (the FBG sensors and conventional strain gauges), it was found that the experimental bond strength on the beam rebar based on the strain data measured by the FBG sensors was much higher than that from the data measured using conventional strain gauges. Which negatively impacted the test data on the beam-column joint's capacity in the specimen applied the conventional measuring method, indicating the necessity of the presented method not only for accurate evaluation of the bond stress between rebar and concrete but also for seismic safety assessments of RC buildings.

The impact of tear functions on visual outcome following keratoplasty in eyes with keratoconus.

BACKGROUND: To investigate the impact of preoperative and postoperative tear functions on visual outcome and the recovery of visual function following keratoplasty in eyes with keratoconus. METHODS: Twenty-five eyes of 25 consecutive patients (5 females, 20 males, mean age: 34.3 ± 15.8 years (range: 19-70 years) with keratoconus who underwent either penetrating keratoplasty (PKP) or deep anterior lamellar keratoplasty (DALK) were included in this prospective study. One patient who had a rejection episode during the follow-up period was excluded. All subjects underwent best corrected visual acuity (BCVA), corneal topography (refractive cylinder, surface regularity index: SRI and surface asymmetry index: SAI), Schirmer I test, tear film break-up time (BUT), corneal sensitivity, and fluorescein staining score measurements before as well as 1, 3, 6 and 12 months after keratoplasty. The relation between the tear functions and the duration until the achievement of maximum BCVA was also evaluated. Linear regression analysis was performed to study the statistical significance of the correlations and the time wise change of each examined parameter. RESULTS: SRI, SAI, and BCVA significantly improved after keratoplasty. The postoperative corneal sensitivity was still significantly low even at 12 months postoperatively. Postoperative BCVA at 3, 6 months and maximum BCVA showed a significant linear negative correlation with the preoperative BUT (3 months; r = -0.461, p = 0.036, 6 months; r = -0.494, p = 0.023, maximum BCVA; r = -0.473, p = 0.030). The duration until the achievement of maximum BCVA showed a significant negative correlation with the preoperative Schirmer test (r = -0.429, p = 0.036). BCVA at 1 and 3 months postoperatively showed significant linear negative correlations with BUT value at the respective periods (1 month; r = -0.665, p = 0.0036, 3 months; r = -0.580, p = 0.0059). CONCLUSION: Preoperative tear functions appeared to have an influence on postoperative BCVA and the duration of visual recovery in keratoconus patients undergoing keratoplasty. Postoperative tear film stability appears to play an important role for obtaining a better BCVA in the early postoperative period after keratoplasty.

Improvement of lateral property of unidirectional-strengthened CFRP laminates using recycled carbon fiber.

The unidirectional carbon fiber reinforced polymer (UD-CFRP) lacks the modulus of elasticity and strength in the lateral direction. This study investigates whether matrix resin with CFRP waste, recycled carbon fiber (rCF), can improve the lateral properties of CFRP. In total, twelve CFRP strips specimen were prefabricated of unidirectional carbon fiber (CF) sheet by hand lay-up (HLU) method and were tested by tensile test and X-ray computed tomography (X-ray CT). Factors such as fiber direction and void distribution significantly affecting its mechanical properties are assessed by X-ray CT inspection. It can be seen that rCF is mixed in a random direction at the position filled with matrix resin without rCF. However, a similar frequency of unimpregnation and voids can be observed in both specimens. Test results showed that experimental values of CFRP laminates with rCF-mixed matrix resin increased compared to the CFRP laminates without rCF. The percentage increase in the lateral tensile strength and modulus of elasticity of the rCFRP compared to the control specimen without rCF is 27.36% and 10.62%, respectively. This study proved that rCF can increase the lateral properties of unidirectional CFRP and shows the effective use of rCF for strengthening material in construction applications.

Efficacy and safety of diquafosol ophthalmic solution in patients with dry eye syndrome: a Japanese phase 2 clinical trial.

OBJECTIVE: To investigate the dose-dependent efficacy and safety of diquafosol ophthalmic solution for the treatment of dry eye syndrome. DESIGN: Randomized, double-masked, multicenter, parallel-group, placebo-controlled trial. PARTICIPANTS: A total of 286 Japanese patients with dry eye who were prescribed topical diquafosol (1%, n = 96; 3%, n = 96) or placebo ophthalmic solution (n = 94). METHODS: After a washout period of 2 weeks, qualified subjects were randomized to receive a single drop of 1% or 3% diquafosol or placebo ophthalmic solutions 6 times per day for 6 weeks. MAIN OUTCOME MEASURES: The primary outcome measure was fluorescein corneal staining score assessment. The secondary outcome measures were Rose Bengal corneal and conjunctival staining scores, tear break-up time (BUT), and subjective symptom assessment. Safety measures were clinical blood and urine examination and recording of adverse events. RESULTS: Fluorescein corneal staining scores significantly improved with both 1% and 3% topical diquafosol compared with placebo at 4 weeks, respectively (P = 0.037, P = 0.002). There was a dose-dependent effect among the groups. Rose Bengal corneal and conjunctival staining scores also improved significantly with both 1% and 3% diquafosol compared with placebo (P = 0.007 and P = 0.004, respectively). Subjective dry eye symptom scores significantly improved with both diquafosol ophthalmic solutions (P ≤ 0.033), although there were no significant differences in BUT compared with placebo. No significant differences between the treatment groups were observed in relation to the occurrence of adverse events. CONCLUSIONS: Both 1% and 3% diquafosol ophthalmic solutions are considered effective and safe for the treatment of dry eye syndrome.

In vivo confocal microscopy evaluation of meibomian gland dysfunction in atopic-keratoconjunctivitis patients.

PURPOSE: To clarify meibomian gland (MG) alterations in atopic keratoconjunctivitis (AKC) patients and compare the findings with obstructive MG dysfunction (MGD) patients and control subjects using in vivo confocal microscopy (CM). DESIGN: Prospective, controlled, single-center study. PARTICIPANTS: Twelve AKC patients (10 males, 2 females; mean age, 31.0±16.5 years), 12 obstructive MGD patients (7 males, 5 females; mean age, 37.6±5.6 years), and 26 control subjects (13 males, 13 females; mean age, 32.9±5.7 years) were recruited. No significant age or gender differences were observed between the 3 groups. METHODS: All subjects underwent assessment of tear evaporation rate from the ocular surface (TEROS), slit-lamp examinations, tear break-up time (BUT) measurements, vital staining, Schirmer test I, meibography, MG expressibility, and CM examination of the MG (HRTII-RCM). Statistical analysis was performed using the Mann-Whitney test. MAIN OUTCOME MEASURES: The MG acinar unit density, inflammatory cell density, MG acinar unit longest diameter, MG acinar unit shortest diameter, and MG acinar unit area as observed by in vivo CM, MG drop-out, MG expressibility grading, tear stability, tear evaporation, and vital staining scores. RESULTS: The TEROS values, mean BUT, vital staining scores, MG expressibility, and MG dropout grades were significantly worse in AKC patients compared with those in obstructive MGD patients and controls (P<0.05). The mean values of the CM parameters in AKC patients were significantly worse than those observed in the obstructive MGD patients and controls (P<0.001). CONCLUSIONS: Changes in MG in AKC patients seem to be more severe than in patients with obstructive MGD and controls. In vivo CM is a noninvasive, efficient tool in the assessment of MG status and ocular surface disease in AKC.

OCT assessment of tear meniscus after punctal occlusion in dry eye disease.

PURPOSE: To evaluate the tear meniscus changes after punctal occlusion in dry eye patients using Visante optical coherence tomography (OCT) in a prospective controlled study. METHODS: Thirty eyes of 15 symptomatic dry eye patients not responding to non-preserved artificial tears received additional upper and lower punctal occlusion with silicone plugs, and 30 eyes of 15 age- and sex-matched dry eye control patients received only non-preserved artificial tears treatment for 1 month. All subjects underwent tear meniscus height (TMH) measurements with Visante OCT. All study participants also underwent slitmicroscopy graticule scale TMH measurement, strip meniscometry testing, tear film break-up time measurement, ocular surface vital staining with fluorescein and Rose Bengal dyes, and the Schirmer-1 test. Both groups, dry eye and control group patients, were examined before and after 1-month treatment. Wilcoxon-matched pair test was performed. The study was conducted in compliance with the Tenets of the Declaration of Helsinki. RESULTS: TMH measurements by OCT and slitlamp graticule scale significantly improved after punctal occlusion (p < 0.001) and remain unchanged in the dry eye control patients. Similarly, strip meniscometry scores, mean tear stability values, Rose Bengal, and fluorescein staining scores showed significant improvement after punctal occlusion (p < 0.05). Schirmer-1 test values tended to be higher after 1 month of treatment in both groups without any statistical significance (p > 0.05). CONCLUSIONS: OCT TMH measurement appears to be effective in monitoring tear meniscus changes after punctal occlusion. OCT can be a valuable non-invasive and quick clinical tool for evaluation of treatment responses in dry eye patients.

Multi-Bolted Connection for Pultruded Glass Fiber Reinforced Polymer's Structure: A Study on Strengthening by Multiaxial Glass Fiber Sheets.

Pultruded Glass Fiber Reinforced Polymers (PGFRPs) are becoming a new mainstream in civil construction because of their advantageous properties. One of two main elements, glass fibers, have been constructed by unidirectional glass roving in applicate progress. PGFRPs do not have high shear strength, which is determined by another element is the matrix. In the future, the demand for enhanced serviceability of existing PGFRP structures could be seen as unavoidable. Therefore, multi-bolted connection being the most typical type of connecting member, strengthening the connection performance of PGFRPs through connection is necessary. Previous researchers have studied several methods for improving connection capacity, including pasting glass fiber sheets (GFS). However, experimental research is lacking for multi-bolted connection. This study investigated several strategies of specimens, including the quantity of bolts (two bolts, four bolts, and five bolts); the end distance/diameter ratio (e = 2d; e = 3d) under tensile load; and three types of glass fiber sheets (GFS) (0°/90°, ±45° and chopped strand mat (CSM)). The experiment's results showed the strengthening effects and the failure mode on the specimens. These findings could address the gap in knowledge that needs to be resolved with respect to PGFRPs' composite design, through evaluation and discussion of their behavior.

Four cases of corneal perforation in patients with chronic graft-versus-host disease.

PURPOSE: To report the clinical features and investigate the underlying pathological processes of spontaneous corneal perforation in patients with ocular chronic graft-versus-host disease (cGVHD). METHODS: A full ophthalmological evaluation of corneal perforation in four patients with cGVHD was performed. Three of them underwent deep anterior lamellar keratoplasty and samples from two of three patients were used for histopathological analyses. RESULTS: Three patients were successfully treated by corneal transplantation. One patient was treated with a therapeutic soft contact lens, and the wound healed within 2 days. The common clinical features of these patients were (1) the presence of definite dry eye related to cGVHD in 3 of 4 patients and probable dry eye in one patient, (2) a central or paracentral site of corneal ulceration and perforation, with no sign of infection, and (3) prior use of a topical or systemic corticosteroid, and/or topical non-steroidal anti-inflammatory drugs. Immunohistochemical findings revealed an increased number of cluster of differentiation 68(+) (CD68(+)) macrophages and matrix metalloproteinase 9 (MMP-9) expression in the tissue surrounding the perforation. CONCLUSIONS: Our report extends current information on the clinical features and pathological processes of corneal perforation in cGVHD by showing increased MMP-9 expression and the accumulation of CD68(+) positive macrophages in the affected areas.

Evaluation of tear stability after surgery for conjunctivochalasis.

PURPOSE: To evaluate the efficacy of surgical treatment for conjunctivochalasis using the Tear Film Stability Analysis System. METHODS: Fifteen eyes of 15 patients (74.5 ± 4.8 years; 14 females and 1 male) who had surgical reconstruction of the tear meniscus for conjunctivochalasis underwent evaluation with a symptom questionnaire, Schirmer I test, fluorescein tear film break-up time (FBUT), and break-up time index (BUI) measurement by Tear Film Stability Analysis System examinations that were performed preoperatively and 3 months after the surgery. Changes of these tear parameters were statistically analyzed using the paired t test. RESULTS: After the surgery, the mean FBUT and BUI values significantly improved from 5.7 ± 3.2 s and 42.8 ± 18.7, respectively, to 8.4 ± 2.5 s and 60.7 ± 16.5, respectively (FBUT, p = 0.0438; BUI, p = 0.0036). The mean Schirmer test value showed no significant changes before and after surgery (p = 0.9064). Fourteen eyes (93.3%) had improvement of ocular symptoms after surgery. One eye (6.7%) with no improvement of ocular symptoms, FBUT, and BUI after surgery appeared to have aqueous tear deficiency. CONCLUSIONS: Surgical treatment for conjunctivochalasis was associated with improvement of tear stability and clinical dry eye symptoms.

[Risk factors of severe peripheral corneal ulcers].

PURPOSE: To evaluate the risk factors of severe peripheral corneal ulcers. PATIENTS AND METHODS: Twenty three eyes of 15 patients (9 eyes of 7 men and 14 eyes of 8 women) with severe peripheral corneal ulcers, who were treated during the past 10 years at Keio University Hospital, were reviewed about the original disease, status of ulcer, treatment, and visual prognosis. RESULTS: Fifteen eyes of 10 patients with Mooren's ulcer, 4 eyes of 3 patients with rheumatoid arthritis, and 4 eyes of 2 patients with Terrien corneal degeneration were included. Mooren's ulcer tends to advance widely. Systemic administration of immunosuppressive and corticosteroidal agents was required in addition to surgical treatment. Visual prognosis was poor in the Mooren's ulcer and perforated cases. CONCLUSION: Mooren's ulcer and perforated cases are risk factors in peripheral corneal ulcer.

Experimental Investigation on the Buckling Capacity of Angle Steel Strengthened at Both Legs Using VaRTM-Processed Unbonded CFRP Laminates.

Strengthening steel structures by using carbon fiber reinforced polymer (CFRP) laminates showed a growth trend in the last several years. A similar strengthening technique, known as adhesive bonding, has also been adopted. This paper presented a promising alternative for strengthening steel members against buckling by using vacuum-assisted resin transfer molding (VaRTM)-processed unbonded CFRP laminates. A total of thirteen slender angle steel members (L65x6), including two control specimens, were prepared and experimentally tested. The specimens were strengthened only at both legs and were allowed to buckle on their weak axes. The test showed that the unbonded CFRP strengthening successfully increased the buckling capacity of the angle steel. The strengthening effect ranged from 7.12% to 69.13%, depending on various parameters (i.e., number of CFRP layers, CFRP length, and angle steel's slenderness ratio). Flexural stiffness of the CFRP governed the failure modes in terms of location of plastic hinge and direction of buckling curvature.

Pilot Demonstration of a Strengthening Method for Steel-Bolted Connections Using Pre-Formable Carbon Fiber Cloth with VaRTM.

In recent years, many seismic retrofitting methods have been performed to improve the structural performance and prevent the brittle failure of structural members. In the case of steel structures, slender seismic braces have been widely used for buildings, towers, and bridges. The brace connections should resist the full plastic axial tension load to ensure adequate plastic deformation performance for vibration energy absorption. However, certain connections do not satisfy these requirements. Recently, carbon fiber reinforced plastic (CFRP) has been used extensively to strengthen existing structures because of its high-strength, high elastic modulus, and light-weight characteristics. In this paper, we investigate the applicability of CFRP strengthening for brace connections and gusset plates with stepped surfaces using the vacuum-assisted resin transfer molding technique as a pilot demonstration. Stepped surfaces can be eliminated by using alternative CFRP layers to straighten the structural CFRP layers in order to effectively transfer the axial stress. Eventually, it is shown that CFRP strengthening can improve the connection strength and plastic deformation with 3% elongation, even if the CFRP is molded on the stepped surface.