IgG4 autoimmune diseases (IgG4-AID) are an emerging group of autoimmune diseases that are caused by pathogenic autoantibodies of the IgG4 subclass. It has only recently been appreciated, that members of this group share relevant immunobiological and therapeutic aspects even though different antigens, tissues and organs are affected: glomerulonephritis (kidney), pemphigus vulgaris (skin), thrombotic thrombocytopenic purpura (hematologic system) muscle-specific kinase (MuSK) in myasthenia gravis  and autoimmune encephalitis  to give some examples. In all these diseases, patients’ IgG4 subclass autoantibodies block protein-protein interactions instead of causing complement mediated tissue injury, patients respond favorably to rituximab and share a genetic predisposition: at least five HLA class II genes have been reported in individual studies to be associated with several different IgG4-AID. This suggests a role for the HLA class II region and specifically the DRβ1 chain for aberrant priming of autoreactive T-cells toward a chronic immune response skewed toward the production of IgG4 subclass autoantibodies. The aim of this review is to provide an update on findings arguing for a common pathogenic mechanism in IgG4-AID in general and to provide hypotheses about the role of distinct HLA haplotypes, T-cells and cytokines in IgG4-AID. IgG4 autoimmune diseases (IgG4-AID) are a group of autoimmune diseases that are mediated by antigen-specific autoantibodies of the IgG4 subclass , 2. The There are many distinct forms of IgG4-AID with a wide variety of symptoms, caused by IgG4 autoantibodies that may target one of four main organs: 1) the skin and mucosa, 2) the peripheral and central nervous system, 3) the kidneys and 4) the hematological system Figure 1Probably the most commonly known IgG4-AID targets skin and mucous membranes: pemphigus vulgaris. This disease is hallmarked by acantholysis and blister formation caused by the loss of keratinocyte adherence. The targets of IgG4 autoantibodies are the desmogleins (Dsg1 or 3) located at the desmosomes. Desmogleins interact closely with each other to maintain the adherence of the cells, and thereby the tissue architecture of skin and mucosa. The binding of IgG4 to desmoglein 1 or 3 leads to a loss of interaction between desmogleins, which causes the disruption of the cell adhesion and in consequence to the formation of blisters –59.Some IgG4-AID cause central and/or peripheral nervous system dysfunction, depending on the target antigen localization. Antibodies targeting the CNS synaptic scaffolding protein LGI1 disrupt synaptic signaling by blocking the trans-synaptic clustering of receptors and channels mediated by this antigen. This leads to amnesia, epileptic seizures and psychiatric symptoms –62.In the peripheral nervous system, IgG4 autoantibodies may, for example, recognize the protein neurofascin 155 (NF155). NF155 is important for attaching the myelin sheath lamellae to the axon at the paranodes adjacent to the nodes of Ranvier. This leads to disruption of action potentials (conduction slowing and block) and consecutively to chronic neuropathies . In The signal for muscle contraction is transmitted by the release of the neurotransmitter acetylcholine from the motoneuron to the muscle, where it is bound by acetylcholine receptors (AChR). Muscle-specific kinase (MuSK) is a key regulator of the neuromuscular junction that is part of a signal transduction pathway required for dense clustering of acetylcholine receptors (AChR) at the neuromuscular junction. IgG4 autoantibodies against MuSK block its interaction with another protein in the signal transduction pathway, leading to reduced densities of AChR , 72. As via mannose-binding lectins may occur  inside of renal corpuscles. The glomerulus filters the blood, so the adhesion between the cells is important for the function of the glomerulus, but we know very little about the role of PLA2R and THSD7A and what the autoantibodies exactly do. THSD7A-IgG4 was hypothesized to block protein-protein interactions of THSD7 and cell-cell interactions, therefore affecting the glomerular filtration and causing proteinuria –75. Poteay occur –80.Thrombotic thrombocytopenic purpura (TTP) is another well-known disease that is mediated by IgG4. Patients with TTP have IgG4 autoantibodies against a protease located in the blood, ADAMTS13. The normal function of ADAMTS13 is to cleave and inactivate the multimeric forms of the von Willebrand factor (vWF), which is a protein that is (in its multimeric form) required for blood clotting, e.g. following injury. Blocking of ADAMTS13 function by IgG4 leads to accumulation of multimeric vWF, which then binds to platelets. This leads to the formation of microthrombi that may block capillaries and therefore cause vascular occlusion. This is especially severe if the thrombi occur in brain, kidneys or lungs , 81, 82.In the search for common immunopathogenesis, we wanted to investigate mutations or variants of genes that may contribute to a genetic predisposition for the development of IgG4-AID. We therefore investigated whether there are candidate genes that have been identified in genome wide association studies (GWAS) of individual IgG4-AID. Data on pemphigus vulgaris, pemphigus foliaceus, membranous glomerulonephritis and eosinophilic granulomatosis with polyangiitis were identified in the NHGRI-EBI catalog of human genome-wide association studies . The mosMost autoimmune diseases are known to have a genetic association with the HLA class II region, and it is thought that the presence of specific HLA alleles may cause a genetic predisposition to develop specific autoimmune diseases or groups of autoimmune diseases –88. TherFor example, the HLA-DRB1*14 supertype was found associated with MuSK MG, pemphigus and thrombotic thrombocytopenic purpura, HLA-DQB1*05 in Iglon5 parasomnia, thrombotic thrombocytopenic purpura and MuSK MG , 19, 89,If specific HLA class II alleles would contribute to a genetic predisposition for IgG4-AID, it may be possible that geographical differences in HLA class II genotype may correlate with an increased disease prevalence. Interestingly, both in MuSK-MG  and in pBox 1 β1 domain forming a groove that presents the peptide. The α chain is encoded by a single gene (DRA1), but the β -chain can be coded by four different genes . HLA molecules are highly variable, and HLA-DRB1 is one of the most polymorphic genes with at least 1883 different alleles reported in 2015 antibodies. There are three main HLA II molecules, HLA-DR, HLA-DQ and HLA-DP. HLA-DR consists of an α- and a β -chain. The chains consist of two domains, the α1 and α2 as well as the β1 and β2 domain, with the α1 and molecule Figure 4molecule . This mavia specific sequences in the peptide binding groove and/or specific sequences in the presented peptide or in the T-cell receptor (TCR). There is some evidence for this hypothesis.Next we wanted to investigate whether there is any evidence that may support a functional role of HLA class II molecules for disease susceptibility. One possibility is that distinct HLA class II alleles may play a role in inducing a distinct IgG4 specific T-cell response by the presentation of specific immunogenic peptides (that perhaps are best presented by peptide-binding grooves that have a distinct sequence). This would mean that the HLA haplotype may play a role in the susceptibility to develop IgG4-AIDs 13) in HLA-DRB1*15:01 and alanine at position 71  in DRB1*03:01 for interactions with T cell epitopes of PLA2R. The role of arginine13 in HLA-DRB1*15:01 is also mentioned as relevant in another IgG4-AID. IgG4 autoantibodies against the α3(IV)NC1 in Goodpasture disease also have a strong association with HLA-DRB1*15:01, and that arginine13 and proline11 of the DRB1*15:01 encoded DRβ1 chain were associated with disease susceptibility. Furthermore isoleucine137, tryptophan140, glycine142, phenylalanine143 and phenylalanine145 were presented in peptide-binding pockets 1, 4, 6, 7, and 9, and specifically arginine13 in pocket 4 interacts with tryptophan140 of the peptide and forms a hydrogen bond  interaction with the binding pockets of the HLA class II, other studies provide at least a list of predicted peptides Table 4. . T-cell [PBMCs, , which aDSG1-intron 6 and introducing a stop codon in the nucleotide sequence, thus coding for a truncated isoform of Dsg1 containing a peptide that was presented by DRβ1*01:02 and activated autoreactive T-cells (In studies on thrombotic thrombocytopenic purpura (TTP), several T-cell peptides were identified in ADAMTS13 Table 4, T-cells .Peptides presented in the HLA class II molecules are recognized by the T-cell receptor (TCR). Therefore we also wanted to study whether the structure of the TCR may play a role for the recognition of IgG4 antigens, and therefore investigated the literature for evidence of specific TCR VDJ usage (which directly would influence structure of the TCR) in MuSK MG and pemphigus foliaceus. There was no evidence for a preference for a specific Vβ gene in pemphigus foliaceus , but in β1 variants contribute to the generation of IgG4 autoantibodies later on by aberrantly priming T-cells, by the type of peptide that is presented, by the conformation of the peptide in the peptide-binding groove or by altered interaction with the T-cell receptor or CD4. In line with this theory is the observation of one study that risk alleles HLA-DRB1*15:01 and HLA-DRB3*02:02 for PLA2R-IgG4 associated MN  or regulatory T cells (Tregs). A recent study with humanized mice investigated the T-cell response to self-antigen presented by HLA-DR molecules with different β chain alleles, HLA-DR1 or HLA-DR15 in mice . The twod TGF- β . Similard TGF- β . This liia IL-10 –121. Moria IL-10 , suggestia IL-10 . In non-ia IL-10 Figure 5IgG4 subclass autoantibodies are the main cause of IgG4-AID and directly pathogenic, Therefore we were interested whether there is evidence for a mechanism linking specific HLA class II alleles to Tregs to IL-10 and finally to IgG4 autoantibodies. There are contradictory observations. Supporting evidence: 1) MuSK MG patients with the HLA-DRB1*14 type had elevated antibody titers and higher levels of IL-17A and IL-10 than MuSK MG patients with different haplotype . The hig2) In addition, active immunization of mice with MuSK antigen leads to production of MuSK antibodies predominantly of the IgG1 subclass , IL-4 (which induces IgG1- production in mice) and IL-10 . 3) Also−/− mice were more susceptible to disease and IL-10 protected mice from blister formation  Alsoormation , as wellormation , but incormation . 5) Inteormation , which mormation , 144.Taken together, there may not be a simple correlation between Tregs, Bregs, IL-10 and IgG4 autoantibodies, since IL-10 does have multiple function in immune regulation, and may have both anti- and pro-inflammatory effects , also inIn recent years, we could observe a growing number of rare, severe autoimmune diseases mediated by pathogenic autoantibodies of the IgG4 subclass. While these diseases were previously considered to be unrelated, as they may target different organs, there is  evidence that ties them together and suggests that similar immune mechanisms may be at work. These potential mechanisms need to be addressed in large comparative studies, and, once identified, may form the basis for new treatment approaches. These may provide a rationale for repurposing already existing drugs and treatment strategies used in well-known diseases such as MuSK MG or pemphigus for treatment of the very rare and the less-well studied forms of IgG4 autoimmune diseases. Newly identified shared immune mechanisms may also provide new druggable targets and ideas for novel treatments.IK conceived the idea, wrote the first draft of the manuscript, and provided the figures. VY, JT, KL, ST, ET, and TL contributed text. IK, FL, TL, and ET revised the final manuscript. All authors contributed to the article and approved the submitted version.IK was funded by a Hertha Firnberg Fellowship by the Austrian Science Fund, Austria, project number: T996-B30. TL was supported by the German Research Foundation . FL is supported by German Ministry of Education and Research (01GM1908A) and E-Rare Joint Transnational research support .JT and ST have shares in the research and diagnostic laboratory Tzartos NeuroDiagnostics, Athens. FL discloses having received speaker honoraria from Grifols, Teva, Biogen, Bayer, Roche, Novartis, Fresenius, travel funding from Merck, Grifols, and Bayer and serving on advisory boards for Roche, Biogen, and Alexion.The remaining 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.


To explore and describe how healthcare policymakers and healthcare practitioners from different levels of Swedish healthcare perceived the everyday practice of putting national policies to contain antibiotic resistance into effect.A strategic sample of four healthcare policymakers, three healthcare practitioners working in hospital care, and six working in primary care were recruited and interviewed in person. A manifest and latent content analysis was carried out on the transcribed interview data.Analysis revealed how the everyday practice of containing antibiotic resistance in different healthcare levels could be perceived as successful, difficult, or a dilemma. The informants’ perceptions are presented in three categories which describe first; informants’ perceptions of antibiotic use and antibiotic resistance in Sweden; secondly, informants’ perceptions of definable efforts in containing antibiotic resistance in Sweden, most notably responsible use of antibiotics, prevention of infection, improving public knowledge of antibiotic resistance, and international collaboration; and thirdly, informants’ perceptions of problem areas in containing antibiotic resistance in Sweden, such as behavior, attitudes and knowledge among healthcare practitioners and the public, work environment, and resources. Reflection on the underlying meaning of these perceptions led to identification of the latent theme, labelled “A sense of relative success, and many challenges yet to overcome”.This study has given in-depth insight into how a group of healthcare policymakers and practitioners perceived the everyday practice of containing antibiotic resistance, and revealed their perceptions of successful efforts to combat antibiotic resistance so far. It has identified problem areas in different healthcare levels, bringing to light challenges yet to overcome, and areas to focus on in future policies, most notably more emphasis on attitude and behavior change, and increasing awareness of antibiotic resistance among both healthcare practitioners and patients. Antibiotic resistance (AR) is recognized as a significant threat to global health in modern times . AlthougEfforts to combat antibiotic resistance are being driven by global organizations, such as the World Health Organization (WHO), World Organization for Animal Health (OIE), United Nations Food and Agriculture Organization (FAO), as well as health communities in Europe, North America, and Australia . In receIn Sweden, systematic initiatives to contain antibiotic resistance beginning in the mid-1990’s have contributed to the present favorable situation of having limited antibiotic resistance and low antibiotic consumption . One notStrategies to combat antibiotic resistance adopted by the Swedish government in 2016 included “continuous collection of data on the occurrence of resistant bacteria and use of antibiotics”, “continuous strong preventive measure to minimize the spread of multi-resistant bacteria”, “responsible use of antibiotics, ‘”improved awareness and understanding in society about antibiotic resistance”, “clear systems and structures for collaboration”  has become lot better if you compare to how it was in the 80’s and 90’s. We’ve seen that the use of antibiotics has been halved, at least for children, compared to the 90’s. And we haven’t seen any increase in complications…that patients suffer in any way. So antibiotic use in Sweden is pretty good, in any case compared to other countries” (PC Physician H2).All informants shared the opinion that the use of antibiotics in Sweden was much better now than 20, 30 years ago, and that Sweden is one of the furthest in restrictive antibiotic use compared to other countries. “We are generally careful with antibiotics ….we don’t prescribe them if they are not necessary… we start with simple measures for fever, colds, and so on, so not using antibiotics unnecessarily is always in the back of our minds.” (PC physician H10) This quotation is an example of how one informant understood the need for healthcare practitioners to be restrictive in prescribing antibiotics and the need for people to refrain from using antibiotics, if possible. “Every antibiotic cure upsets the bacterial balance in the stomach even more…and can result in resistant bacteria attaching themselves …so every antibiotic cure can disturb intestinal flora for almost a year…you can say…and then it is easier during that year to be infected by resistant bacteria…so that’s why you really have to evaluate every individual antibiotic cure…is it really necessary?” .Still, you can wonder if it really is correct that one of three patients are given a dose of antibiotics, at least once during their hospital stay. So…antibiotics are being overused, even in hospitals.” .Even so, there was an opinion that antibiotics were still being used unnecessarily in Sweden.”“I’ve worked in Ethiopia for example, where amoxicillin was doled out …to children. But there I thought the same way, play it safe, there you have all the more reason to do so …children are undernourished and sick…but yes, generally speaking I believe many received antibiotics without needing it” .Among healthcare practitioner informants there was a general perception that antibiotics were being misused in other countries. Their opinions in this matter were based on personal experience and observations when working abroad, or from scientific and specialized press, and media coverage. Informants’ awareness of the use of antibiotics in animal food production was limited, and also based on media coverage. Very few informants were aware of, or had much knowledge of environmental effects of antibiotics and other drugs.“I think a lot about all the plastic surgery operations being carried out abroad….where they are so much cheaper…so people travel abroad, have a lot of operations, and then come back with MRSA bacteria. And maybe they don’t say anything when they visit a hospital, which spreads infection even more” (PC nurse H8).Policymaking informants had the perception that people felt ‘relatively safe’ in Sweden regarding antibiotic resistance. There was a belief that food in Sweden was produced under good conditions, and therefore was there no need to worry about resistant bacteria or antibiotics in food. Instead, there was a belief that antibiotic resistance was imported into Sweden, via travel, picking up bacteria during hospital stays for cheaper medical care in other countries, eating contaminated food, abroad or at home. “An ordinary doctor comes upon it [antibiotic resistance] two, three, four times a year, or something like that…a urinary tract infection that doesn’t get better, and results in pyelonephritis.” (PC physician H2) Antibiotic resistance was also not a real issue in dental care. “It’s not as if….resistant bacteria cause oral infections, that’s not the way it is….no.” (Policymaker H12) However, according to policymaking informants, resistant bacteria have been involved in outbreaks of infection in hospitals. “Resistant bacteria, we have had outbreaks…we have had big ones involving many hospitals…Vancomycin resistant enterococci for example. And then infection spread in neonatal wards with serious consequences. So the topic is highly relevant in Sweden as well” (Policymaker H4).There was an impression among the informants that antibiotic resistance was still a small problem in primary care. If and when it was suspected, patients were treated according to specific routines, or referred to hospitals. “Imagine a mountain side with water running into a lake containing all the antibiotic resistance. We [Sweden] are a tiny stream, and then you have a giant rapid, a glacial rapid, coming from the rest of the world, Of course it doesn’t matter what we do.. it won’t be noticeable…our efforts almost make no difference in the overall context” (Policymaker H.7).All the informants were aware of the serious consequences of antibiotic resistance, that, in the end, it might not be possible to treat infections with antibiotics at all, and people could die. Policymaking informants had the most extensive knowledge of antibiotic resistance. They felt that people did not really understand the paralyzing breadth of antibiotic resistance, and the death and suffering it could lead to. One policymaker noted that mankind did not react to slow scenarios, where it was possible to adapt slowly, and compared the threat of antibiotic resistance to climate change, something not yet experienced as a direct threat. Antibiotic resistance was a ticking bomb, a threat today, and a potentially greater threat in the future. And the future, according to the following policymaker, was very uncertain. This category presents informants’ spontaneous examples of efforts where they felt they had been successful in their work to contain antibiotic resistance.“These [Strama] doctors have been very good at coming out and informing and putting pressure on our doctors….like…to reduce… and make the right diagnosis ….most importantly the right diagnosis….certain diagnoses do not need antibiotics” (PC nurse H11).One policymaking informant described how work to decrease the use of antibiotics had first focused on primary care, since antibiotics appeared to be overused in many PC clinics. And it was perceived that these efforts had been successful. All the informants were very aware of Strama’s role in facilitating responsible antibiotic use and increasing awareness of antibiotic resistance in primary care. Examples included how PC clinics were regularly visited by healthcare professionals working with Strama, who informed about antibiotics and infection treatment. “In spite of all the alarm reports, I believe, and if you ask my colleagues, that the use of antibiotics in Sweden is going in the right direction That is what I believe and how I feel, and my colleagues feel the same way. On the other hand I don’t know how that is affecting antibiotic resistance, but we are much more rational now than 15 years ago” (PC physician H1).Recommendations for correct antibiotic use in dentistry had been revised in 2014, in collaboration with Strama; telenurses used telephone advice guidelines to advise callers, which also followed Strama guidelines on antibiotic use; Strama regularly followed up antibiotic use in primary care and public health dental clinics; hospitals received data on their total antibiotic use from Strama every 3 months, but how they used this information varied. Patients seek acute dental treatment, for swelling, but most of all for pain…toothache. And antibiotics are not a way to treat toothache…so many times it is enough with local treatment combined with pain relief” (Policymaker H12).There was a general opinion about primary care, that it was easier to be more restrictive when prescribing antibiotics, since infections in primary care require a completely different spectrum of antibiotics compared to infections treated in hospitals. It was a question of choosing where to draw the line, prescribe less antibiotics, only when necessary, and less broad spectrum antibiotics. A policymaking informant had similar thoughts about dentists. ““The chances of being infected with resistant bacteria in the subway is almost zero….there is little risk of being infected in outpatient clinics, but it can be a reality in a hospital.” (PC physician H2) According to one hospital specialist informant, strategic efforts on part of hospital management had led to better hygiene routines in hospitals, which were followed a lot better now compared to 15 years ago.Then we have a hygiene nurse in charge of educating personnel…different personnel categories, from assistant nurses, ward aids, paramedics, nurses, to department heads are expected to register…. and who also is responsible for hygiene rounds, to check up on how we work with basicl hygiene routines (PC nurse H5).Primary care had strict routines regarding clothes and hand hygiene, to prevent the spread of infection, not just resistant bacteria. Hygiene routines in dental clinics followed national guidelines. In nursing care of the elderly a special hygiene nurse had hygiene rounds to control how staff followed basal hygiene routines. Newly hired and temporary staff was required to learn basal hygiene routines, and even sign a document where they agreed to work according to these rules.”All PC clinics had somebody responsible for infection control. One PC physician informant was part of a Strama network comprised of other doctors, disease control specialists, and nurses from other PC clinics in the region. Their network disease control meetings covered many areas, for example chlamydia, HIV, hygiene, as well as antibiotic resistance. One PC nurse informant working in municipal elderly care described her role in being responsible for keeping statistics on infections in elderly care, and how she was always informed if new patients coming from hospitals were carrying resistant bacteria.”You try to explain about resistance…I say [to the patient] ‘ imagine if you really get sick in the future…and need antibiotics…and they don’t help…how would you feel?’… and then I talk a lot about intestinal flora….I usually say you may win a few days….but think about how you are destroying your stomach and intestines…..it takes many months to build up your normal intestinal flora again” (PC nurse H11).One PC physician informant felt it was important to make patients understand why antibiotics were not always necessary. A PC nurse informant, on the other hand, thought that doctors were often stressed, and had little time to inform patients properly. According to this informant, patients received better information from nurses than doctors, who were often stressed, with little time to inform patients properly.“I think the media has played a very important role….describing the problem [antibiotic resistance] … reporting successes and statistics and such…it has been very engaged and ….has understood the importance. There are many medical journalists who have understood the importance through the years and this has resulted in general reporters joining in. That’s how it sunk in.…these newspapers are read by decision makers, doctors, veterinarians, and the general public.” (Policymaker H3) People were beginning to understand the negative effects for self and society, many even were trying to avoid taking antibiotics, if possible. People who insisted on antibiotic treatment still existed, but were fewer in number, and often badly informed.All the informants commented on the media’s role in changing the publics’ expectations regarding antibiotics. “They [EU countries] are very interested…it’s not as if they just sit there because they have to…but they are very engaged in what needs to be done and come with suggestions …so it is very promising.” (Policymaker H4) And, there was a perception that success of Swedish efforts in antibiotic resistance work so far had resulted in an interest in Sweden as a role model.Policymaking informants described their collaboration with animal and environment health sectors in Sweden, and their involvement in global efforts to contain antibiotic resistance. Examples included representing Sweden in projects together with other EU countries, such as monitoring antibiotic resistance and healthcare associated infections, and regular meetings to create national action plans for antibiotic resistance work. People want to keep their eyes closed to the problem of antibiotic resistance, there are too many economical consequences” (Policymaker H7).The policymaking informants also had a good understanding of the realities of global collaboration, how antibiotic resistance work was affected if countries had to deal with lack of water, climate change, natural disasters, and limited resources. For example, Bric countries  wanted the same healthcare outcomes as industrialized countries, but did not have economical or hygienic conditions, and compensated by using a lot of AB in healthcare and food production. It was very hard to stop the actions of these countries. “This category gives insight into informants’ perceptions of problems they faced in their work to contain antibiotic resistance.“Higher antibiotic prescribing in some primary care clinics does not always mean sicker patients, but maybe a different culture” (PC physician H10).In primary care, as noted by PC informants, there were differences in how physicians trained abroad looked upon antibiotics compared to physicians trained in Sweden. There was an impression that some foreign physicians in Sweden still seemed to work according to the antibiotic culture in their homeland, that of treating common infections with antibiotics. As a result, antibiotics appeared to be used a lot in areas with high concentration of immigrants, and in PC clinics with many foreign physicians. So the difficulty, I believe, is when you stand there at night…from my perspective….in the darkness of night and do not really know how sick a child is….so you choose maybe a broader antibiotic …or antibiotics when you don’t really need them.”  As noted by hospital specialist physician informants, antibiotics could be overused to some extent in orthopedic hospital care, as it could be hard to diagnose if or when an infection did not require antibiotics. Furthermore, they noted that regular follow-ups on antibiotic use were not always carried out in orthopedic, or pediatric hospital clinics.Decreasing the use of antibiotics in hospitals was not always straightforward. For example, some specialist physicians felt uncomfortable about treating seriously ill hospital patients with narrow spectrum antibiotics. In pediatrics, the practice was to start with broad spectrum antibiotics, before resistance testing, since pediatric specialists could fear the serious consequences of infection in small children.”Sometimes you can be forced to prescribe something only because your superior thinks you should and because there are many doctors involved in the process.” (Policymaker H7) The policymaking informants were also aware that some doctors were not interested in changing their ways.”Thinking Sweden is good when it comes to antibiotic resistance work can lead to arrogance among healthcare professionals, that we are done, and do not need to bother anymore” (Policymaker H3).Policymaking informants had the opinion that the mindset of ‘it never hurts to prescribe antibiotics’ needed to be changed, and questioning if antibiotics were necessary in treatment planning should be put into practice in hospitals. They realized how difficult this could be for some younger doctors.”Most of the informants had limited knowledge of antibiotic work internationally, in animal food production, and in the environment. Very few were aware of the One Health concept. One PC physician informant thought that One Health was not important to physicians in local PC clinics, and that One Health should work from a higher level, coordinating animal and human sectors, and exerting pressure internationally. This informant would also have liked to see real evidence that antibiotics in animal food-production contribute to antibiotic resistance in humans.“Many parents are very convinced and well read, but base their opinions on wrong sources” .One policymaking informant observed that vaccinations to prevent viral infections that have bacterial consequences could result in less antibiotic use, and, although rare, it was unfortunate that some children were not being vaccinated today, since these children could end up in emergency pediatric clinics. They say … doctors don’t have the time to listen to us, or they didn’t listen, or even inspect my throat, we just got a prescription” (PC nurse H8).PC physician informants were aware that some patients travelled abroad, stocked up on antibiotics to sell to friends when home in Sweden, or took only half their antibiotic cure, to save for the next times. They understood that many of these patients did not believe they would get better without antibiotics. Patients could also demand antibiotic prescriptions from their dentists before going abroad. One PC nurse informant working in telephone advice services described feelings of anger when patients called in and admitted they had bought antibiotics abroad. It was difficult to convince some people to begin with over-the-counter medicines, and try to endure, especially if they were parents of small children with fever. This informant had observed people’s concerns about antibiotics, which may be why they called Sweden’s national telephone advice services. “If you are going to have the opportunity to admit a patient, to wait and see what happens before setting in antibiotics, you need an understanding environment, colleagues, a bed,…and you need more time” .Informants in both hospital and primary care remarked on their stressful work environment, there was just not enough time to convince and inform patients about antibiotic use and antibiotic resistance. Physician informants in both primary care and hospitals said they ended up prescribing antibiotics when stressed and felt the need to act. Furthermore, stress, short hospital stays, lack of beds could result in choosing broad spectrum antibiotics instead of narrow spectrum antibiotics, and which also increased the risk of infection spread in hospitals. And, a very high turnover of hospital staff made antibiotic resistance work, and education of staff difficult. There was a shared opinion that hospital management should be more open and sensitive to the problem of antibiotic resistance, and should take larger responsibility for antibiotic use and antibiotic resistance issues. “It is quite fascinating that everybody says this [antibiotic resistance] is one of the biggest problems we have, a future problem from a global perspective. Still there is no money. The Swedish Research Council abstained from targeting money for antibiotic resistance research….it was targeted for infections, yes, and now we have stronger focus on virus research and such and I don’t think there is much left over for antibiotic resistance research.” (Policymaker H7) International cooperation, according to another policymaking informant, was one way that Sweden, as a role model, could spread knowledge about AR work, and limited resources made it hard to respond to international demands for this knowledge.Resources seemed to be an area of concern for most informants, including even some policymaking informants. It was hard to know if there were enough resources for antibiotic resistance work, funding of campaigns, research, etc.”In summary, insight into perspectives, and from different healthcare levels, has revealed how the daily practice of containing antibiotic resistance could be perceived as successful, difficult, and/or a dilemma. We follow with a discussion of our findings against this background.The informants’ perceptions of successful efforts in responsible use of antibiotics, prevention of infection, improving public knowledge of antibiotic resistance, and international collaboration are in accordance with Swedish official strategies presented in our introduction, suggesting that policy rules and guidelines were being adhered to in these areas. Relevant healthcare providers also appeared to have “knowledge about antibiotic resistance, the spread of infectious diseases, compliance with basic hygiene routines and other preventive measures, knowledge about the seriousness and complexity of the issue from a global perspective,” as expected by the Swedish government .The Swedish context of this study may have contributed to informants’ perceptions of success in these areas. The use of antibiotics differs across Europe, with the lowest level of antibiotic use in Northern countries, and highest in Mediterranean countries . Many faImplementation of health strategies and policies is also influenced by context . NationaDifferences in human behavior and attitudes is one example of how adhering to policy guidelines was not always straightforward. At the end of 2018, 19.1% of the Swedish population were foreign-born . PC clinAdhering to policy guidelines regarding the use of antibiotics was also not so straightforward, and could even be a dilemma for physicians in both primary and hospital specialist healthcare levels. This is in accordance with a Swedish study on general practitioners’ perceptions of infectious disease management in primary care, which revealed the conflict that could be experienced between wanting to preserve the effectiveness of antibiotics for the future, and helping suffering patients . PC physPolicymaking informants’ observations of how younger doctors dared not question older doctors’ attitudes to antibiotic use point to another challenge yet to overcome, the issue of power in the medical hierarchy in hospitals. Students, during their medical training, learn to accept this hierarchical structure, and their place in it . New in In view of the above, and, as stated by policymaking informants, there was a need for continual behavior change regarding antibiotic prescribing in hospitals. For decades, antimicrobial stewardship programs in hospitals have focused on ensuring proper use of antimicrobials to improve patient care, reduce hospital costs, lessen the risk of adverse effects, and reduce or stabilize resistance levels . More emStress was perceived to be a hinder to antibiotic resistance work in both hospitals and primary care. How physicians perceive the stressful work environment, high patient volumes, inadequate staffing, bed shortages, or fatigue in Swedish hospitals has been documented in recent studies , 29. As Most informants, including policymaking informants, appeared to be concerned about resources, the funding of work to contain antibiotic resistance. In our study, policymaking informants seemed to be well informed about problem areas in both primary and hospital care. Their extensive knowledge of antibiotic resistance, and of international collaborative efforts was based on actual experience. In this context, they were experts in their fields. Their concerns about not enough resources and financing of antibiotic resistance efforts was interesting, and may reflect their dedication to antibiotic resistance work. On the other hand, it is possible they indicate the limitation of their position, that of being looked upon solely as experts, and implementers of policies. If this is the case, one can wonder to what extent they are able to influence changes, for example, point to areas in need of improvement.Many of the informants were not aware of the ‘One Health’ concept. This appears to be one area where governmental expectations described in the introduction have not been met. However, this has been observed among healthcare workers in other countries as well, who did not find ‘One Health’ to be relevant in their daily practice of medicine . This isBased on the discussion above, we suggest that the sense of relative success of policies to contain antibiotic resistance in Sweden so far fits well into McConnell’s description of ‘resilient success’ , in thatTo the best of our knowledge, this is the first qualitative study that describes how healthcare providers in different levels of Swedish healthcare perceive their efforts to contain antibiotic resistance. As with all qualitative studies, informants’ realities can be interpreted in various ways, and can depend on the researcher’s subjective interpretation. An important issue in qualitative content analysis therefore is achievement of trustworthiness . Four wiFor practical and financial reasons, our informants were recruited from, and interviews were conducted in four cities in middle and southern Sweden. In striving for credibility, informants from different levels of healthcare were strategically chosen, so as to increase knowledge of efforts to contain antibiotic resistance from these perspectives. In striving for dependability, the research process was described in detail to make it possible, first, for the reader to understand the logic of the findings, and secondly, to enable a future researcher to repeat the process. To assure confirmability, citations were used to show that the results were grounded in the informants’ experiences and perceptions. Our findings are based on the perceptions of a small sample size of informants from each healthcare level, and cannot be generalized. While there is a possibility the findings can be transferred to other healthcare settings in Sweden, the Swedish context can be a hinder regarding the extent to which they can be transferred to settings or groups outside the country. The overall goal was to gain knowledge of and describe the everyday practice of policy implementation. Data saturation was not our primary focus. Interviews with our strategic sample of informants, although few in number, resulted in an abundance of data, which gave valuable real-life glimpses of how national policies can be translated into daily practice. And, as we note in our discussion, the findings are very much in keeping with previous research. The research team was comprised of researchers with different healthcare backgrounds, pharmacy, medicine, and dentistry. Discussions during the process of the study and drafting of the manuscript revealed these different perspectives and assumptions, which contributed to a deeper understanding of the data, and improving the rigor and quality of the study.This study has given in-depth insight into how a group of healthcare policymakers and practitioners perceived the everyday practice of containing antibiotic resistance in Sweden. It has revealed their perceptions of successful efforts to combat antibiotic resistance so far, and their perceptions of problem areas in different healthcare levels. Areas to focus on in future policies have been brought to light, most notably more emphasis on attitude and behavior change, and increasing awareness of antibiotic resistance among both healthcare practitioners and patients. Thus far, these areas have not undermined the core achievements of Swedish national policies. Even so, efforts must continue. Antibiotic resistance will most probably remain a challenge for a long time to come, in Sweden, and the rest of the world.S1 Checklist(PDF)Click here for additional data file.S1 Data(DOCX)Click here for additional data file.


As the COVID-19 pandemic continues to gain momentum around the world, several measures are being put in place to control its spread. One such effort includes the installation of walkthrough sanitization gates to disinfect passersby and prevent cross infection. However, there is lack of clinical evidence on the effectiveness of these walkthrough gates to contain COVID-19. Moreover, there are potential public health concerns associated with these walkthrough gates. Spraying individuals with disinfectant chemicals is strongly discouraged by various health authorities around the globe because of their propensity for eye and skin irritation, bronchospasm following inhalation, and gastrointestinal effects such as nausea and vomiting. This article underscores that the risks associated with the use of these walkthrough gates overweigh any potential benefits. Health authorities must discourage their use and should focus efforts on other preventive measures such as social distancing, wearing masks, and hand hygiene to prevent the spread of COVID-19 among the general public. The containment of the disease is of utmost priority across the world. Because an effective vaccine or specific treatments are currently unavailable, disinfection, sanitization, and distancing are considered the most appropriate measures to mitigate virus transmission. Health organizations around the globe have proposed various precautionary maneuvers to combat the disease, including physical distancing, forced or self-quarantine, and personal hygiene. As the COVID-19 pandemic continues to gain momentum around the world, several measures are being put in place to control its spread. One such effort includes the installation of walkthrough sanitization gates to disinfect passersby and prevent cross infection within the premises. These gates, also termed as sanitizing or disinfectant chambers, tunnels, boxes, booths, or partitions, provide an overhead shower of disinfectant solution for 20–30 seconds as individuals pass through them. Currently, various vendors are actively promoting them, with the claim of killing 99.9% of coronavirus. They have recently been installed in various countries at public places, shopping malls, supermarkets, mosques, railway stations, hospitals, offices, and factories.13 Spraying or fogging of certain chemicals, such as formaldehyde, chlorine-based agents, or quaternary ammonium compounds, is not recommended because of adverse health effects. Moreover, the WHO has endorsed that spraying individuals with disinfectants is not recommended under any circumstances. This could be physically and psychologically harmful, and will not reduce an infected person’s ability to spread the virus through droplets or contact. Moreover, spraying individuals with chlorine and other toxic chemicals could result in eye and skin irritation, bronchospasm due to inhalation, and gastrointestinal effects such as nausea and vomiting.4 During Ebola outbreaks, disinfectant intoxication has been observed among healthcare providers and Ebola survivors; deliberate exposure of humans to chlorine spray was associated with pulmonary, dermatological, and ophthalmic complications even with the use of personal protective equipment, and even after the first exposure to chlorine spray.5 Disinfectants in the forms of fumes and aerosols have high propensity to ingress mucus membrane, posing immediate respiratory symptoms and dermal irritation. In addition, mixing of bleach with other disinfectants may have disastrous effects. The combination of bleach and alcohol can lead to the formation of chloroform, which is a probable carcinogen.3 Fumigation is meant for inanimate objects and surfaces, and it should never be used on people.In an extensive search , we did not come across any scientific evidence regarding the effectiveness of walkthrough gates for the prevention of COVID-19. These walkthrough gates use diluted disinfectant solutions of chlorine, bleach (sodium hypochlorite), alcohol, or chloroxylenol.6 however, their popularity is increasing in various countries.8 The use of these unstandardized gates violates WHO recommendations. In addition, these gates and tunnels may provide a false sense of protection, and attention to this approach could undermine evidence-based coronavirus preventive measures such as adequate hand hygiene, high-touch surface disinfection, and physical distancing. We believe that these walkthrough gates have substantial safety concerns and pose serious public health hazards. We urge health authorities around the globe to discourage the use of walkthrough gates amid the lack of clinical evidences and rather to emphasize the importance of social distancing, wearing masks, and hand hygiene to prevent the spread of COVID-19 among the general public.Although several health authorities around the globe have issued advisories against the use of walkthrough gates,


Immune checkpoint inhibitors (ICIs) are the standard treatment for non-small cell lung cancer. The unique adverse events that can arise after treatment with ICIs are known as immune-related adverse events (irAE). As the number of cases under treatment with ICIs increases, new types of characteristics of irAE have emerged. This case report suggests that IgG4-related pleural disease could occur as an irAE.A 64-year-old man was diagnosed with pulmonary adenocarcinoma stage IIIB. Following concurrent chemoradiotherapy, durvalumab was administered every two weeks. The patient complained of dyspnea on effort 4 months after the initiation of durvalumab therapy. Chest CT scans showed mild bilateral pleural effusion 4 months after the initiation of durvalumab therapy, and the amount of pleural effusion increased further at 7 months. Durvalumab was thought to be a potential cause of pleural effusion and was withdrawn after 13 courses of administration over 7 months. The level of serum IgG4 was 2750 mg/dL. The levels of IgG4 of the pleural fluids were 2790 mg/dL on the right side and 2890 mg/dL on the left side at 7 months. Microscopic examination of the pleural biopsy revealed lymphoplasmacytic infiltration with storiform fibrosis. Immunohistochemical examinations showed that the number of IgG4-positive cells was > 20/high power field and the percentage of IgG4-positive to IgG-positive plasma cells was > 50%. Oral prednisolone at a dose of 30 mg/day was initiated, and remarkable clinical improvements were achieved. After 4 months of prednisolone therapy, the level of serum IgG4 decreased to 370 mg/dL and chest CT revealed the disappearance of bilateral pleural effusion.This was a case of IgG4-related pleural disease in a patient with pulmonary adenocarcinoma under durvalumab treatment. To our knowledge, this is the first case report of IgG4-related pleural disease as an irAE. It is important to consider the possibility of IgG4-related pleural disease in cases of pleural effusion during the treatment with ICIs. Immune checkpoint inhibitors (ICIs) are currently the standard treatment for non-small cell lung cancer (NSCLC). Recently, the administration of a programmed death-ligand 1 (PD-L1) inhibitor following concurrent chemoradiotherapy (CRT) for stage III NSCLC has demonstrated a longer 24-month overall survival of 66.3% than that of 55.6% for controls [Herein, we report a case of IgG4-related pleural disease in a patient with pulmonary adenocarcinoma under durvalumab treatment. To our knowledge, this is the first case report of IgG4-related pleural disease as irAE.A 64-year-old man was diagnosed with pulmonary adenocarcinoma stage IIIB. The patient had a smoking history of 50 packs a year. Immunohistochemical analysis revealed a PD-L1 tumor proportion score of > 50%. Concurrent CRT using weekly courses of carboplatin plus paclitaxel and 60.0 Gy irradiation over 6 weeks was performed and partial response was achieved. Consolidation immunotherapy was initiated 4 weeks after the CRT treatment concluded. Durvalumab (10 mg/kg), an ICI, was administered every 2 weeks. The patient complained of dyspnea on effort 4 months after the initiation of durvalumab therapy.Chest X-ray and computed tomography (CT) scans showed radiation pneumonitis in the irradiated area accompanied with mild bilateral pleural effusion Fig. b. There The patient was treated with a long-acting muscarinic antagonist, a long-acting beta-agonist, a moderate dose of inhaled corticosteroid, a leukotriene receptor antagonist, and a diuretic. The patient was also administered systemic oral corticosteroid (prednisolone 20 mg/day) for five days and antibiotics (levofloxacin) for seven days 4 months after the initiation of durvalumab therapy. Despite these treatments, the dyspnea was progressive. The chest X-ray and CT scans showed increases in the amounts of bilateral pleural effusion Fig. c. No proMycobacterium tuberculosis-specific antigens, was negative. There was an increase in the level of serum immunoglobulin of 6.4 g/dL. The level of serum IgG was 4.329 g/dL , and among the IgG subclass, IgG4 was 2.750 g/dL . Serologic studies indicated that an anti-nuclear antibody was positive. Serum myeloperoxidase- anti-neutrophil cytoplasmic antigen was negative (< 1.0 U/mL). The levels of thyroid stimulating hormone, free triiodothyronine, and free thyroxine were 2.92 μIU/mL , 2.12 pg/mL , 0.87 ng/dL , respectively.Physical examination did not show any findings suggesting the presence of collagen vascular diseases. The levels of C-reactive protein and angiotensin-converting enzyme were 0.13 mg/dL  and 8.6 IU/mL , respectively. The T-SPOT test for TB, which measures the number of interferon-gamma-secreting spot-forming T cells obtained from a patient stimulated by Mycobacterium tuberculosis, avium, or intacellulare DNA were all negative. Adenosine deaminase concentrations were 47.2 U/L and 49.3 U/L in the right- and left-sided pleural fluids, respectively. The levels of IgG and IgG4 of the pleural fluids were 4183 mg/dL and 2790 mg/dL on the right side, and 4366 mg/dl and 2890 mg/dL on the left side.Pleurocentesis was performed on each side separately and revealed unilateral exudative pleural effusion with a predominance of mononuclear cells with no malignant cells. Bacterial culture and polymerase chain reaction analysis of the pleural fluids for On the 12th day of hospitalization, a pleural biopsy was performed using video-associated thoracoscopy and the specimen was collected from the pleura on the right side. Microscopic examination revealed lymphoplasmacytic infiltration with storiform fibrosis (Fig. Oral prednisolone at a dose of 30 mg/day was initiated and remarkable clinical improvements were achieved. After 4 months of prednisolone therapy, chest CT scans revealed the complete disappearance of bilateral pleural effusion Fig. d, the leThis is a rare case of IgG4-related respiratory and pleural diseases in a patient with pulmonary adenocarcinoma under treatment with an ICI, durvalumab. Known irAEs that can arise after treatment with ICI include: pneumonitis, colitis, and thyroiditis . HoweverThe criteria of IgG4-related respiratory disease include an abnormal shadow on chest CT, serum level of IgG4 higher than 135 mg/dL and characteristic findings in tissue specimens . In the Among the eight extant cases describing IgG4-related pleural disease, three cases reported the levels of IgG4 in the pleural effusion to be 124 to 653 mg/dL, and in all eight cases, the levels of serum IgG4 were 136 to 740 mg/dL. Clinical responses to corticosteroid therapy were observed in these cases .IgG4 itself is considered a non-inflammatory immunoglobulin and the actual role of IgG4 itself in the process of IgG4-related disease remains unclear. T helper 2 cells, CD4+ cytotoxic T cells, and T follicular helper cells are among the T helper subsets that are thought to be the drivers of the pathogenesis of IgG4-related diseases. Inflammatory cytokines produced by activation of these T helper cells contribute to the expansion of IgG4-producing plasma cells and activation of fibroblasts. CD4+ cytotoxic T cells and T follicular helper cells play key roles in the production of IgG4 by plasmablasts and plasma cells . DurvaluWhen our patient who had a history of heavy smoking complained of dyspnea during ICI treatment after CRT for lung cancer, the differential diagnoses were exacerbation of COPD, cardiac failure, pulmonary thromboembolism, progression of the lung cancer, and radiation pneumonitis. ICI-related adverse events, such as interstitial pneumonitis were also excluded. Differential diagnoses for pleural effusion included pleuritis carcinomatosa, radiation-induced pleuritis, tuberculosis, cardiac failure, renal failure, and hypothyroidism . This caIgG4-related disease is frequently accompanied by bronchial asthma , 15. In To the best of our knowledge, this is the first report of IgG4-related respiratory and pleural disease in a patient with adenocarcinoma during treatment of ICI. It is important to take into consideration the IgG4-related pleural disease in a case of pleural effusion during the treatment with ICIs.


Chemotherapy remains the mainstay of treatment in the majority of solid and haematological malignancies. Resistance to cytotoxic chemotherapy is a major clinical problem and substantial research is ongoing into potential methods of overcoming this resistance. One major target, the receptor tyrosine kinase MET, has generated increasing interest with multiple clinical trials in progress. Overexpression of MET is frequently observed in a range of different cancers and is associated with poor prognosis. Studies have shown that MET promotes resistance to targeted therapies, including those targeting EGFR, BRAF and MEK. More recently, several reports suggest that MET also contributes to cytotoxic chemotherapy resistance. Here we review the preclinical evidence of MET’s role in chemotherapy resistance, the mechanisms by which this resistance is mediated and the translational relevance of MET inhibitor therapy for patients with chemotherapy resistant disease. MET found on chromosome 7q31, is a cell surface receptor tyrosine kinase (RTK) predominantly expressed by epithelial cells [The protein MET , encoded by the proto-oncogene al cells . Upon bial cells , as oppoal cells .Fig. 1METhe effects of MET activation are crucial to physiological processes such as embryonic development, organ development and wound healing . HGF is MET exon 14 mutation following the GEOMETRY mono-1 trial [MET amplification/overexpression has been shown to lead to dependence on MET for cell survival . An incr-1 trial . Table 1-1 trial .Table 1AAs our understanding of the molecular biology of cancer has progressed, drug development has shifted towards a more targeted and personalised approach to treatment. However, despite a growing number of targeted cancer therapies, cytotoxic chemotherapy remains the mainstay of treatment for malignant disease. Different classes of chemotherapy and their clinical uses are outlined in Table It is known that MET confers resistance to targeted agents including BRAF inhibitors in malignant melanoma and the EGFR inhibitor gefitinib in NSCLC, through activating oncogenic signalling pathways such as PI3K/AKT –27. ThisRecent preclinical studies have shown that MET is involved in the above-cited key mechanisms of chemoresistance, and point towards a synergy between chemotherapy and MET inhibition. The studies use distinct cell lines with differing degrees of chemosensitivity or isogenic pairs of parental and chemoresistant cells. Several studies demonstrate that HGF reduces cell sensitivity to chemotherapy. Others report enhanced MET signalling in the chemoresistant cells compared to the chemosensitive or less resistant cells. This enhanced MET signalling results from: (i) overexpression of MET –36, (ii)Multiple studies report that the observed enhanced MET signalling occurring in chemoresistant cells increases their viability. This occurs through a decrease in apoptosis, as shown in most studies, but also through stimulation of proliferation. Proliferative activity is a vital component of cancer development and progression, with the MET/HGF axis being a known molecular regulator. Apoptosis, the principal route of cell death triggered in response to chemotherapy, is regulated by a multitude of different factors. One important group is the Bcl family of proteins, including Bcl-2, Bcl-XL and Bad. MET has been shown to influence the regulation of pro-apoptotic and anti-apoptotic factors to promote cell survival or proliferation through activating many signalling pathways including the Mitogen-Activated Protein Kinase (MAPK) cascade such as ERK1/2, Jun amino-terminal kinases (JNKs), p38, PI3K-AKT and STAT3 , 42. On Several studies have reported the protective effect of HGF against chemotherapy-induced cell death or the effect of MET inhibition/loss of expression in reducing chemoresistance.Exogenous HGF , 44–48 oL; [The mechanisms reported were: (i) prevention of the downregulation of Bcl-XL; , 47 (ii)L; , 39, 48 L;  and (v) L; . AIF is L; . AnotherL; . BiP hasL; , 38, andL; , 51.Interestingly, the expression of HGF (through HGF cDNA transfection) in Chinese hamster ovary cells reduced their sensitivity to chemotherapy . MoreoveSeveral studies have shown that MET expression and/or activation is increased in cells with acquired chemoresistance compared to their isogenic parental cell lines. This in turn leads to an increase in MET signalling with enhanced sensitivity to MET inhibition and reversal of chemoresistance.MET siRNA knockdown cisplatin-induced apoptosis was enhanced [For example, cisplatin-resistant ovarian cancer cell lines were found to express high levels of MET compared to parental chemosensitive cells. On treatment with cisplatin, MET phosphorylation was increased, but upon MET inhibition with PHA-665752 or enhanced . In a sienhanced .MET siRNA [MET shRNA [MET gene was found to be amplified in chemoresistant SCLC cells [MET with shRNA, was reduced compared to tumours formed by control shRNA transfected cells [Small cell lung cancer (SCLC) cells with acquired chemoresistance to paclitaxel, cisplatin or SN38 , MDR mulET siRNA  or MET sET shRNA  knockdowET shRNA  or enhanET shRNA , 29, 33 ET shRNA , 33 or iLC cells , which cLC cells , 33. ThiThese studies demonstrate that MET signalling is enhanced in various chemoresistant cell lines and that MET inhibition can reverse chemotherapy resistance.A number of preclinical studies have demonstrated that MET inhibition is able to reverse chemotherapy resistance in various different tumour types.A synergy between MET inhibition  and orthotopic transplantation of KPC derived cells, MET inhibition with capmatinib sensitised PDAC tumours to gemcitabine, resulting in a reduction in primary tumour volume and metastatic burden via increased apoptosis [In the genetic PDAC mouse model KPC  reversed resistance to cisplatin in gastric cancer cells in vivo and in vitro . In vitrThese studies highlight the importance of pursuing combination therapy with MET inhibition and chemotherapy in clinical trials.DNA damage can be caused by exogenous and endogenous sources. Endogenous examples include the production of reactive oxygen species (ROS), produced as a natural by-product of normal metabolism, whilst exogenous sources include ionising radiation and chemotherapy. The pathways employed in DNA repair include base excision repair (BER), nucleotide excision repair (NER), mismatch repair (MMR), homologous recombination (HR) and non-homologous end-joining (NHEJ). These are commonly dysregulated in cancer in order to facilitate tumorigenesis . The DNAStudies have shown that repair of chemotherapy-induced DNA damage can be inhibited by MET activation or inhibition. HGF stimulation of breast and prostate cancer cells was shown to enhance the rate of repair of DNA double strand breaks (DSBs) in response to doxorubicin . InteresConversely, in ovarian  and gastThese studies indicate that MET is able to protect cancer cells against the chemotherapy-induced DNA damage response and hence MET inhibition can suppress DNA repair.ATP-binding cassette (ABC) transporters are crucial transport proteins which regulate the removal of substances from the cell through the plasma membrane in an ATP-dependent process . AlteredMET by shRNA repressed BRCP/ABCG2 [MET can upregulate the expression of efflux transporters in the cell membrane, thus reducing the intracellular concentration of the chemotherapeutic agent. MET overexpression was shown to trigger an increase of BRCP/ABCG2 and ABCB1/MDR1 expression in doxorubicin-resistant (DR) ovarian carcinoma cells  and in cCP/ABCG2  and ABCBCP/ABCG2 . SU11274CP/ABCG2 .Thus MET overexpression can promote an increase in drug efflux through regulating the expression of efflux transporters, leading to chemoresistance and increased cell survival.Cancer stem cells (CSCs) are thought to generate differentiated tumour cells, which have limited proliferative potential, and are responsible for seeding tumour populations . CSCs haIn a number of human tumours, overexpression of MET leads to the acquisition of a stem cell-like phenotype , 71. It MET shRNA knockdown significantly reduced their tumourigenicity in vitro and in vivo and reduced the population of CSCs. This demonstrates the role of MET in CSCs’ tumourigenicity. Moreover, combination treatment with cabozantinib and gemcitabine inhibited tumour growth and metastatic spread more than either drug alone [Hage et al. demonstrated that the MET inhibitor cabozantinib increased gemcitabine efficacy through triggering apoptosis and reducing the expression of several CSC markers, including SOX2 and CD133 in pancreatic ductal adenocarcinoma (PDAC) cells . Li et aug alone . Consistug alone . It was ug alone .These studies indicate that MET is a key driver of cancer cell stemness that leads to chemoresistance.The process of epithelial-mesenchymal transition (EMT) enables cells to invade surrounding tissues and metastasise, with enhanced migratory capacity, invasiveness, production of extracellular matrix components and resistance to apoptosis , 75. EMTCulturing a SCLC cell line in the presence of HGF for 10–14 days induced EMT features, with increased Snail expression and invasiveness. The mesenchymal subpopulation of this cell line was found to secrete HGF, thus leading to an autocrine loop of MET activation. These mesenchymal cells displayed an HGF/MET-dependent EMT phenotype and acquired etoposide resistance both in vitro and in vivo xenograft experiments in nude mice. This chemotherapy resistance was reversed upon MET inhibition using crizotinib. Interestingly, an upregulation of phosphorylated MET and mesenchymal markers were observed in SCLC patient samples at relapse .Two cisplatin-resistant NSCLC cell lines display MET overexpression and increased expression of N-cadherin, vimentin, ZEB1 and Snail and reduced expression of E-cadherin compared to their isogenic parental cells . MET, thThese studies suggest that MET-dependent EMT confers chemoresistance although a direct link remains to be clearly demonstrated.During tumorigenesis cancers outgrow their blood supply and develop a necrotic, hypoxic core. Hypoxia facilitates cell survival under stress, by causing cell cycle arrest and downregulation of apoptosis, senescence and mitochondrial activity . HypoxiaIn response to intra-tumoural hypoxia, cancer cells express hypoxia-inducible factor-1α (HIF-1α), which induces the expression of the pro-angiogenic vascular endothelial growth factor (VEGF), MET and HGF. The MET/HGF signalling axis itself promotes cancer cells’ upregulation of VEGF and downregulates the expression of anti-angiogenic proteins, such as thrombospondin 1. In turn, VEGF or HGF can bind on VEGFR or MET, both expressed on the surface of endothelial cells, stimulating their proliferation, migration and angiogenesis .Two different relationships between chemoresistance and MET activated on endothelial cells through cancer cell-derived HGF have been shown.Proliferation, survival, migration, tubulogenesis and in vivo neovascularisation of HUVEC  was increased significantly more with the HGF-containing conditioned medium of MDR HCC cells, compared to the conditioned medium of the isogenic parental chemosensitive cells, which contained no HGF . FurtherMET (through the generation of Tie-Cre Metfl/fl mice) led to normalised vasculature, reduced intra-tumoural hypoxia, slowed glioblastoma growth and importantly, sensitised glioblastoma tumours to temozolomide treatment, prolonging mouse survival [Huang et al. reported that the HGF-containing conditioned medium of patient-derived glioblastoma cancer cells drives endothelial cells to acquire a fibroblastic phenotype, in a process called endothelial-mesenchymal transition (Endo-MT) , resultisurvival .These two studies indicate that MET activation on endothelial cells by HGF secreted by cancer cells can facilitate chemoresistance in two different ways. Drug resistance can trigger an increased production of HGF by cancer cells, leading to tumour angiogenesis. Alternatively, HGF secretion by cancer cells can trigger chemoresistance through altering angiogenesis and triggering hypoxia.MET exon 14 mutation [As discussed above, a number of clinical trials have evaluated MET inhibitors as a monotherapy against other targeted therapies or standard of care chemotherapy regimens  that comprises cancer cells, tumour stroma, blood vessels and immune infiltrate, promotes cancer progression and alters tumour sensitivity to therapy. Until now the interplay between MET signalling and the immune system has been largely uncharacterised. One key study has demonstrated that MET/HGF signalling is involved in mediating the recruitment of neutrophils into the TME, and as such is thought to play a role in regulating tumour immunity to some therapies . FinigueAccurate patient selection for MET-targeted therapy is vital. A number of studies have determined that increased expression of MET is linked with poor clinical outcomes. For example, MET overexpression has been associated with more invasive advanced tumours in glioblastoma  and oesoThe modest effect of MET-targeted treatments seen in clinical trials to date may be due to inadequate patient stratification. Patient stratification has unfortunately been hindered by the lack of a reliable biomarker of MET activity. As seen in Table The use of total MET as a surrogate marker for pathway activation is questionable for the following reasons:(i) Levels of expression do not necessarily correlate with levels of activity. For example, MET may still be highly activated in tumours with low expression if the level of HGF in the TME is high. Also, oncogenic mutations that trigger MET activation do not necessarily trigger MET overexpression .(ii) As discussed above, total MET IHC is usually scored on staining within the plasma membrane. MET has been shown to remain active post-endocytosis and furthermore to require endocytosis to sustain its activation and/or downstream signalling –5. There(iii) Importantly, in all preclinical and clinical studies to date, different antibodies, molecular tests and evaluation criteria have been used, limiting the validity of the outcomes. Unlike other molecular markers, such as the oestrogen receptor and HER2, robust comparable testing and evaluation criteria for MET have not yet been developed.MET gene copy number (amplification) and soluble MET concentrations  and eletions , but METs so far . Unfortus so far , 37. In s so far , whereass so far . As a coTherefore, until a reliable biomarker of MET activity is elucidated, the method of patient stratification in trials will continue to be a matter for debate. It is possible that once biomarkers used for selection of patients for targeted therapies against MET have been adequately established, they might also be used for as an adjunct for identification of resistance to chemotherapy.In conclusion, chemotherapy resistance remains one of the fundamental barriers to effectively treating cancer. MET provides a promising target to reverse chemoresistance, but to date there has been poor translation of preclinical data to positive clinical trials outcomes. By further exploiting the mechanisms of MET-mediated chemoresistance and optimising patient stratification, there is hope for improved outcomes in targeting MET in patients with chemotherapy resistant cancers.


This article highlights publications in Enviromental Microbiology and Microbial Biotechnology papers about antibiotic resistance. It concludes that the One health approach is basic to addressing this problem. Since then, antibiotic treatments have saved millions of lives, revolutionizing the treatment of infectious diseases worldwide and increasing our life expectancy  strains were first reported in hospital settings, where antimicrobial use was most prevalent. Nevertheless, nowadays antibiotic compounds are essential not only for human therapy but also for prophylaxis and growth promotion in the animal food industry  Salmonella isolates  and consequently of E. coli mobile‐mediated ARGs that provided resistance to other drugs not administered to the calves. Antibiotic treated calves also showed an increase in body weight compared to the non‐treated group, although both groups followed the same diet. Authors propose that antibiotic treatment of healthy animals led to unbalanced, disease‐ and obese‐related microbiota, that promotes the growth of microorganisms carrying clinically relevant mobile ARGs, and potentially increasing the risk of transmission of antibiotic‐resistant bacteria to humans  that contain clusters of genes for resistance to multiple drug classes and that are shared among isolates from multiple sources  ‐NQR) system, which in turn decreased the membrane potential and a concomitant decrease in the intracellular concentration of gentamicin (Zhang et al., V. alginolyticus strains identified glucose as the most down‐regulated metabolite, and the authors proposed that glucose in this microbe can function as an antibiotic resistance‐reverting molecule.Given that the effectiveness of an antimicrobial compound is determined by the possible tolerance or resistance of the targeted bacteria, understanding the drivers of antibiotic resistance and the mechanisms of selection for resistant bacteria is of vital importance. Mechanisms of antibiotic resistance have been well documented for several drug classes. In a nutshell, these mechanisms block drug function by reducing its intracellular concentration via efflux pumps, reducing the membrane permeability, or modifying the antimicrobial compound or its target in the cell (Munita and Arias, et al., et al., The use of alternative therapies to broad‐spectrum antibiotics such as bacteriocins, CRISPR‐Cas antimicrobials, bacteriophage therapy, the local release of toxins, and the use of predatory bacteria have been reported in recent years (Kadouri None declared.


Concrete shrinkage is a phenomenon that results in a decrease of volume in the composite material during the curing period. The method for determining the effects of restrained shrinkage is described in Standard ASTM C 1581/C 1581M–09a. This article shows the calibration of measuring rings with respect to the theory of elasticity and the analysis of the relationship of steel ring deformation to high-performance concrete tensile stress as a function of time. Steel rings equipped with strain gauges are used for measurement of the strain during the compression of the samples. The strain is caused by the shrinkage of the concrete ring specimen that tightens around steel rings. The method allows registering the changes to the shrinkage process in time and evaluating the susceptibility of concrete to cracking. However, the standard does not focus on the details of the mechanical design of the test bench. To acquire accurate measurements, the test bench needs to be calibrated. Measurement errors may be caused by an improper, uneven installation of strain gauges, imprecise geometry of the steel measuring rings, or incorrect equipment settings. The calibration method makes it possible to determine the stress in a concrete sample leading to its cracking at specific deformation of the steel ring.  The shrinkage of composite materials is a phenomenon where the material reduces its volume as a result of drying, carbonation, and autogenous processes ,2,3,4,5.One of the basic research methods for the controlled reduction of concrete shrinkage deformations is the use of ring methods. Presumably, the first tests of this type were carried out by Carlson and Reading  in the 1Established in the standard ASTM C 1581/C 1581M–09a “Determining Age at Cracking and Induced Tensile Stress Characteristics of Mortar and Concrete under Restrained Shrinkage” dimensions of the steel and concrete rings mean that the tensile stresses due to the constraints are similar to the tensile stresses due to the drying of the outer surface of concrete samples. This configuration of boundary stress causes uniform straining of the concrete section. A similar value of the edge tensile stress determines the fracture of the concrete sample as a result of exceeding its tensile strength . The rinIn modern concretes with low water/cement ratios, the overall shrinkage is significantly affected by the autogenous shrinkage, which occurs in the first stage of hardening. High-performance concretes undergo autogenous shrinkage even up to 200 µm/m after the first day of maturing. In the case of traditional concretes with a water/cement ratio of 0.5, the value of autogenic shrinkage after 28 days reaches 100 µm/m and in practical conditions is negligible ,18 and tTests performed in accordance with the ASTM C 1581/C 1581M–09a standard allow determining concrete sample cracking time as a result of restrained shrinkage exceeding concrete tensile strength. However, it is not possible to determine the exact value of the shrinkage; instead, the strain of the steel ring needs to be measured. Before test measurements can be used in further analysis, the steel measuring rings must be calibrated. The calibration process eliminates measurement errors caused by strain gauge installation, which could give different results than those calculated with theoretical equations. Those errors can significantly affect or even disrupt the mesurements entirely. Tests performed on calibrated steel rings using the restrained ring method allow accurately measuring strains in steel rings and make it possible to determine tensile stresses in concrete ring samples.The article presents the calibration process of three steel measuring rings. Using calibrated restrained rings, the testing procedure was carried out for two self-compacting high-performance concretes with light and natural aggregate. Obtained steel ring deformation values and developed tensile stresses in annular concrete samples were analyzed for two maturation conditions: deformation due to autogenous and drying shrinkage—the side formwork removed after 24 hours of concreting—and deformation due to autogenous shrinkage only without side surface drying effects. The use of various test modes has made it possible to check the measurement precision and stability of strain development during short- and long-term tests.The aim of the study was to calibrate three steel measuring rings for deformation registration in accordance with values resulting from the theory of elasticity. A novelty of this test is the calibration stand and procedure dedicated to measuring steel rings strain according to ASTM C 158/C 1581M–09a, which obtained a patent for an invention.The basic scheme of the calibration test bench is shown in The rubber collar should be connected through a digital manometer to the air compressor for simultaneous recording of its pressure and the deformation of the measuring ring. The steel measuring ring is connected with cables to strain gauge bridge and measurement equipment. The calibration system shown in The system used in the lab ulitizes a strain gauge bridge without the internal temperature compensation, which requires connecting strain gauges with Wheatstone half- or full-bridge circuits. Each measuring point consisted of a pair of strain gauges, which were vertically and annularly glued to the inner surface of the steel ring. The temperature compensation was provided by the strain gauges placed in the vertical axis, which are a part of a circuit of another measuring ring. The setup is shown in First, the passive stage of the calibration begins with placing the measuring ring on the test bench, connecting it tightly to the plates, and connecting the measuring equipment and the compressor. The active calibration process starts in the second stage, as shown in Additionally, to minimize friction between the expanding collar and the measuring ring, the outer surfaces of the measuring ring, collar, and inner surface of the outer ring were covered with synthetic oil before the test. The friction of expanding torus on the outer surface of the measuring ring can cause discrepancies and uneven strain. This results from Poisson’s ratio for steel and can induce cumulative measurement error for each calibration of measuring rings.The measurements allow acquiring a time function of pressure and strain. The result is visible as a linear dependency between circumferential strain and radial stress. A comparison of functions, which were both acquired from the measurements and calculated from theoretical equations, allows determining the calibration coefficient for the tested ring. The calibration allows comparing the results of measured strains for three independent rings. −3), Calibration analysis was made individually for three steel rings, using a theoretical function :(1)σR=−εBased on the calibrated relationship of circumferential deformation of measuring rings e sample :(2)σθmaxThe steel ring deformations were recorded individually for each of the four circumferential strain gauges as a function of time and depending on the acting pressure. To eliminate potential measurement errors and to increase the precision of the calibration, the measurement of the pressure acting on each ring and the measurement of strain at each strain gauge was taken 6 times. This allowed incorporating three measuring cycles, turning the steel ring around the rubber collar each time, with two measurements per cycle. Then, the mean value of the steel ring strain could be calculated. The influence of air pressure that ranged from 0 to 5.5 bars on the strain function in time was consistent and repeatable for each tested ring, as shown in The measured values of steel ring strains per each gague and for each trial test are shown in Based on the deviations shown in When strain gauges record differenciated strain values at a constant pressure level, this indicates their incorrect or non-parallel installation on the inner surface of the ring. However, if all recorded deformation values are similar and lower or higher than the theoretical value, then most likely, the measuring ring geometry differs. −6), −6), and The result of calibration process is an individually determined ring calibration coefficient (3) that adjusts the slope coefficient of the measured value plot to the theoretical plot. This coefficient accounts for ring geometrical imperfections and faulty strain gauge installation. The calibration coefficients for the three measuring rings considered are shown in −6), and The recorded strains of rings A and B are within the lower bound tolerance of 5%, so they do not need to be calibrated, and they can be directly used in further analyses. The measured strains for ring C must be computed, including the calibration coefficient, accordingly to the equation:The calibration coefficient can also be used to rectify the concrete cracking time, as shown in Equation (5). In the case of a uniform deviation of recorded strains from all the strain gauges of a given ring, this clearly indicates stiffness that deviates from the stiffness of the theoretical ring. In such a situation, when the deformation deviation is in the range of 5% to 15%, it is reasonable to modify the recorded concrete cracking time with a calibration factor. Based on the results in The use of such calibration is necessary for each measuring ring, which was prepared for susceptibility to cracking tests in accordance with the Standard ASTM C 1581/C 1581M–09a.The use of calibration coefficients for each measuring ring allows for a common interpretation of results, averaging the deformation values, determining of the average cracking time as a mean of the cracking times for individual samples, and determining the function of circumferential deformation of the measuring ring An analysis of the impact of the steel measuring ring calibration was carried out for two self-compacting concretes: concrete C-1 with fine and coarse natural aggregate, and concrete C-2 with pre-soaked fine and coarse lightweight aggregate. Two types of concrete shrinkage tests were performed for both concretes analyzed; the first was based on concrete deformation after 24 hours from concreting, while the second did not involve sample deformation. The composition of concrete mixes under consideration is shown in Deformation tests were carried out simultaneously on three calibrated measuring rings, as shown in The performed deformation tests allowed to conduct two separate analyses. The first analysis concerned the deformations of the measuring ring C before and after calibration, taking into account the determined calibration factor. On its basis, it can be concluded that calibration validates the C ring relative to rings A and B. Therefore, the deformation values are characterized by a low standard deviation and allow for determination of the average deformation development affecting the correct interpretation of the results.The second analysis referred to the interpretation of the material properties of concrete based on the relationship of the steel ring deformation to tensile stress on the inner surface of the annular concrete samples as a function of time. The natural aggregate used in C-1 concrete resulted in higher strength parameters as well as a more airtight and homogeneous structure compared to C-2 concrete with lightweight aggregate. Yet, C-1 concrete cracked in the third day after concreting at the average deformation value of the steel ring of −76.8 µm/m and a mean tensile stress of 6.2 MPa at the inner surface of concrete samples. The dynamic development of autogenous shrinkage in the first day and the additional impact of drying shrinkage after one day resulted in a rapid loss of strength due to the cracking of C-1 concrete samples. In the case of C-2 concrete, no autogenous shrinkage was observed in the first day and there was moderate development of the shrinkage from drying out after sample deforming. Light soaked aggregate led to internal care, which caused a slower development of shrinkage and stress. The use of lightweight aggregate extended the cracking time to about 5 days and reduced the strength of the concrete. C-2 concrete cracking occurred at the average deformation value of the steel ring of −16.3 µm/m, causing an average inner surface tensile stress of 1.3 MPa. In the following type 2 restrained concrete tests, the impact of steel rings calibration on the correctness of measurements over a longer period of time was analyzed. Ring samples of C-1 and C-2 concretes were not deformed after 1 day but remained insulated for 28 days. At that time, only autogenous shrinkage developed, and its impact on steel ring deformations was analyzed. The test results are shown in The measurement of deformation of steel rings under the influence of autogenous shrinkage, especially for concrete C-1, showed the correctness of the calibration procedure in the range of 28 days. For the C-ring, the results before and after calibration are presented. The application of the calibration factor for the C-ring deformation course allowed for correct analysis of the results and the determination of concrete susceptibility to cracking in both short and long measurement periods.Based on the analysis of the development of parameters of C-1 concrete with natural aggregate, a monotonic increase in the deformation of the measuring rings can be noticed as a result of the continuous development of autogenous shrinkage of concrete. Within 28 days, concrete does not show susceptibility to cracking at a given limitation level. On the other hand, the nature of the increase and the value of the average tensile stress at the inner surface of the concrete samples at the level of 5.5 MPa may indicate the development of micro-cracks in the structure and fracture of the samples at a later time. A lack of sample cracking within 28 days is caused by the increase in concrete strength during the test and by the absence of drying shrinkage.Analysis of the deformation progress of measuring rings for C-2 concrete with lightweight aggregate showed no impact of autogenous shrinkage. In the whole measuring range, the soaked lightweight aggregate showed curing properties, as a result of which autogenous shrinkage did not develop in concrete ring samples. The registration of steel ring deformations throughout the entire measuring range was between 0 and −10 µm/m, generating minimal tensile stress in concrete samples.In the calibration test, the pressure applied to the measuring ring by the rubber collar imitates the load caused by the shrinkage of concrete. Measurement of the air pressure with the digital manometer determines the graph of the circumferential strain–radial stress function. The calibration test additionally eliminates the error caused by the geometry and elastic modulus of the material. Pneumatic calibration allows compensating for errors due to improper strain gauge installation by the application of a test-determined calibration coefficient, which translates registered strains into calibrated circumferential strains closely aligned to theoretical values.The calibration procedure allowed for simuntanous strain measurements under given stress for all rings of the test bench. Acquired calibration functions are used to calculate the mean values of the results, which can be used in further studies. Calibrated strains help determine the stresses occurring at the moment of cracking of concrete ring samples using a standard rigid measuring ring. This enables the classification of concrete’s susceptibility to cracking.Short-term and long-term tests confirm the effectiveness of calibration to correctly interpret the test results on concrete susceptibility to cracking using restrictive rings. The applied calibration method extends the scope of tests with the correct analysis of the average deformability of steel rings and determination of the value of tensile stress in concrete at a given level of steel ring deformation.In the future, it is planned to carry out research on the impact of the percentage of mineral additives on the time of cracking of concrete ring samples caused by the effect of autogenous shrinkage.No. PL225785: Method for the calibration of measuring rings used for measuring their deformability in result of the shrinking strain of poured-in materials and the system for the calibration of measuring rings used for measuring their deformability as a result of the shrinking strain of poured-in materials.