IgG4 related disease is a poorly understood immune mediated condition. Lung involvement is rare and difficult to diagnose and can mimic primary lung malignancy on imaging. A patient who was found to have an incidental lung lesion with risk factors for primary pulmonary malignancy is reported. A 70-year-old woman was found to have an incidental left lower lobe lung mass on chest radiograph in setting of lower respiratory tract infection symptoms. She is an ex-smoker but with long history of smoking since the age of 18 years. Past medical history includes breast cancer that was treated with wide local excision and nodal dissection 7 years earlier. Apart from very short duration of lower respiratory tract symptoms patient denied history of chronic cough or hemoptysis. However, patient revealed 14 kilograms of weight loss over a period of 4 years.Further investigation with computed tomography (CT) demonstrated a 3.9 cm spiculated mass in the left lower lobe with an 8 mm satellite nodule. Patient subsequently underwent a positron emission tomography (PET) scan that demonstrated an intensely avid left lower lobe mass with standardized uptake value (SUV) max of 18.82. Satellite nodule, ipsilateral hilar, and mediastinal lymph nodes showed low-grade FDG uptake Figures , and 2. Patient's serum IgG count was normal 10 g/L with normal reference range of 7.5−15.6 g/L. Serum IgG4 test was not performed. Patient underwent a CT guided biopsy of the left lower lobe mass that demonstrated inflammatory fibroblastic lesion. However due to high clinical suspicion of primary lung malignancy, left lower lobectomy was performed. Histological examination revealed lymphoplasmacytic infiltration with mainly IgG4 positive plasma cells. Hence IgG4 related pulmonary inflammatory pseudotumour was diagnosed.IgG4 related disease is a poorly understood immune mediated condition consisting of group of disorders that share specific pathologic, serologic, and clinical features . Common Type 1 autoimmune pancreatitis is the most common manifestation of IgG4 related disease. Other common IgG4 related diseases include sclerosing cholangitis, dacryoadenitis/sialadenitis, idiopathic retroperitoneal fibrosis, interstitial pneumonitis, and pulmonary inflammatory pseudotumours to name a few .IgG4 related lung disease has been reported in as many as 13% of patients with autoimmune pancreatitis .Parenchymal mass-like lesions or nodules often have spiculated margins and are confined to one lobe, thus mimicking a primary pulmonary malignancy. Enlargement of hilar or mediastinal lymph nodes is also common in patients with IgG4 related lung disease. PET imaging can demonstrate intense FDG uptake in mass-like lesions as well as the nodal disease. Pulmonary disease can be isolated with no involvement of other organs; however, extrapulmonary involvement, most commonly type 1 autoimmune pancreatitis, often precedes pulmonary disease .Pathogenesis of IgG4 related disease is not well understood. Diagnosis of IgG4 related disease requires characteristic findings upon biopsy of affected tissue. Pathological diagnosis criteria include dense lymphoplasmacytic infiltrate, “storiform” fibrosis, and obliterative phlebitis . “StorifCompared to other organ systems of pathology, lung IgG4 related disease has fewer plasma cells per high power field, infrequent findings of “storiform” fibrosis and obliterative phlebitis, and a more common finding of obliterative arteritis.There is a recent international consensus for management and treatment of IgG4 related disease which states that all symptomatic patients and a subset of asymptomatic patients require treatment. Glucocorticoids are the first line agent for active disease, unless there are contraindications for such treatment. Some patients may require additional steroid-sparing immunosuppressive agent, including B-cell depletion agent such as Rituximab, from the start of treatment. Patients with organ threatening IgG4 related disease and with an increased risk of relapse  are likely to benefit from maintenance therapy after a successful induction therapy. For patients who relapse after cessation of successful initial therapy with clinical remission, retreatment with glucocorticoids is indicated. Steroid-sparing agent for continuation in the remission maintenance period should also be considered .Natural history of IgG4 related disease is not clear. Most patients respond to treatment. However, relapses are common. Further organs and tissues may become involved, sometimes despite apparently effective treatment. Although no definite causal relationship has been established, several types of lymphomas have been reported in patients with IgG4 related disease .Our case demonstrates IgG4 related lung disease mimicking high-grade primary lung malignancy on structural and functional imaging. It is a rare condition that can be mistaken for lung malignancy on imaging particularly when there is isolated pulmonary involvement. IgG4 related disease could involve multiple organ systems. Pulmonary involvement is usually preceded by another organ involvement most commonly autoimmune pancreatitis.Recognize that although IgG4 related lung disease is rare, it can mimic primary lung malignancy on structural and functional imaging.Appreciate IgG4 related disease can often involve multiple organs. What is the pathophysiology of IgG4 related disease? Which extrapulmonary organs may be involved in IgG4 related disease?Pretest includes the following questions:Posttest includes the following questions: What Is the Pathophysiology of IgG4 Related Disease? IgG4 related disease is a poorly understood immune mediated condition consisting of group of disorders that share specific pathologic, serologic, and clinical features. Common features include tumour-like swelling of involved organs, lymphoplasmacytic infiltrate with IgG4 positive plasma cells, variable amount of fibrosis, and elevated serum level of IgG4 in up to 60% of patients. Pathological diagnosis criteria include dense lymphoplasmacytic infiltrate, “storiform” fibrosis, and obliterative phlebitis. Which Extrapulmonary Organs Are Frequently Involved in IgG4 Related Disease? Pancreas is the most common organ involved in IgG4 related disease with autoimmune pancreatitis. Other IgG4 related diseases include biliary disease with sclerosing cholangitis, retroperitoneal involvement including retroperitoneal fibrosis, and lacrimal/salivary gland inflammation.


Objectives. To systematically review and analyze the current status and characteristics of usability studies in China in the field of information technology in general and in the field of healthcare in particular. Methods. We performed a quantitative literature analysis in three major Chinese academic databases and one English language database using Chinese search terms equivalent to the concept of usability. Results. Six hundred forty-seven publications were selected for analysis. We found that in China the literature on usability in the field of information technology began in 1994 and increased thereafter. The usability definitions from ISO 9241-11:1998 and Nielsen (1993) have been widely recognized and cited. Authors who have published several publications are rare. Fourteen journals have a publishing rate over 1%. Only nine publications about HIT were identified. Discussions. China's usability research started relatively late. There is a lack of organized research teams and dedicated usability journals. High-impact theoretical studies are scarce. On the application side, no original and systematic research frameworks have been developed. The understanding and definition of usability is not well synchronized with international norms. Besides, usability research in HIT is rare. Conclusions. More human and material resources need to be invested in China's usability research, particularly in HIT. Usability is essential for the effective, efficient, and safe design, use, and learning of information technology. Research and application of usability have received significant attention by scientists, designers, and industry professionals in Western countries where there are active study populations, comprehensive theories, methods, practices, practical results, and mature industrial and professional organizations. In the field of health information technology (HIT), usability research has been identified as an important cognitive challenge for the adoption and meaningful use of HIT by the Office of National Coordinator for Health Information Technology (ONC), which is part of the U.S. Department of Health and Human Services (DHHS), and has become an active area for research, design, and practice in HIT –8. Methocnki.net), China Science and Technology Periodical Database (cqvip.com), and Wanfang Electronic Journal Database (wanfangdata.com.cn). We only searched the “title” and “keyword” fields in the literature published from the time period between 1980 and 2012.Usability is a broad and interdisciplinary field with inconsistent terminologies. This problem is compounded when translating these terms into Chinese because the words often have multiple meanings. After carefully reviewing the literature in August 2012, we decided to conduct a literature review using the Chinese equivalents of the following search terms: “usefulness,” “usability,” “user experience,” “user satisfaction,” and “user-centered design.” We used the advance search functions of following three mainstream databases in China: China National Knowledge Infrastructure  screening the published literature on usability in the field of HIT in China.Exclusion criteria include (1) excluding research literature about usability in other fields; (2) for duplicate entries, excluding those without complete information; and (3) excluding those without full text.The information summary sheet was designed to extract data from the selected literature. Information extracted included author, article title, year, journals, subcategory types for theoretical research, subcategory type for empirical studies, definition of usability, evaluation objects in empirical study, subcategory type of evaluation research in network application, and evaluation method used in empirical study. See Repeated retrievals: it is common that the same article may be retrieved in all three databases.Study fields involved in the retrievals are unrelated. For example, topics on architecture, transportation, and so on rather than “information technology” were excluded.Limitation of search function by certain database: for instance, the Wanfang database returned 6411 items, far more than 1347 and 1698 items from VIP and CNKI databases. The reason is that Wanfang is unique in the way that it does not support whole word search; rather, it will return all results containing each composite word of a complete word. In Chinese usability is composed of three “words.”Excluded nontechnical items: for example, some items retrieved were advertisements released by companies for new products or news published on nontechnical magazines. The inclusion and exclusion process and the results are listed in Through searching of the literature for thirty-two years in the three databases and EBSCO, we obtained a total of 9814 publications. After applying our inclusion and exclusion criteria, 617 Chinese and 30 English publications were included in our analysis and accounted for 6.6% of the total retrieved literature. Reasons for the high exclusion rate are as follows.Publication dates of the 647 publications span from 1994 to 2012. The distribution across the years is shown in In the 647 items incorporated into our study, 564 are periodical publications and account for 87.2% of the total items, 52 are conference proceedings and account for 8.0%, 30 are theses/dissertations and account for 4.6%, and one was a book chapter accounting for 0.2%.Among the 1190 authors (including the second and the third coauthors) that contributed to the selected research publications, the following 10 authors listed in Journals or conference proceedings in the 647 publications (top 14 with the highest quantity) are listed in There are a total of 2229 keywords in the 647 publications. The keywords with the top 8 occurrence frequencies are listed in Usability research in China may be roughly divided into two categories. The first category is the study about usability theories; there are a total of 395 publications accounting for 61% of the total retrieved publications. The other category includes empirical studies of usability, of which qualitative research methods were primarily utilized. The theoretical study mainly includes the following three aspects in contents: (a) usability history of development, influencing factors and problems encountered in usability (in different branch fields); (b) usability evaluation methods (in different branch fields); and (c) usability design principles and design concepts (in different branch fields).Empirical studies related to usability accounted for 39%  of the retrieved publications. Those publications related to the integration of usability during software or technology development account for 17%  of the total retrieved publications. Most studies  focused on usability evaluations in specific target areas through the selected evaluation methods. The evaluation methods mostly applied are the combination of qualitative and quantitative studies.The categorization of theoretical studies is shown in Based on the retrieved publications, the usability concepts in In the China national standard GB/T16260-2006 “Software engineering products quality,” usability is defined as “the ability of a software product to be understood, studied, used and as well as [sic] the ability to attract users in a particular use environment.”In the usability definition given by Nielsen in 1993 , usabiliIn the ISO 9241-11:1998  “ErgonomIn the ISO/IEC 9126-1:2001  “SoftwarIn recent years, with the advancement of usability research, new terminology emerges constantly. In the 647 publications, the “user experience, user satisfaction, and user-centered design” are also mentioned; among them, “user experience” is mentioned 118 times, “user satisfaction” 25 times, and “user-centered design” 12 times.Specific definitions are as follows.Through analyzing the retrieved publications, we found that the Chinese empirical studies on usability focused mainly on website application , statistical analyses through system logs, cognitive walkthrough, behavior analyses, observation and interviews, eye movement analyses, distance of information-state transition (DIT), and other methods. The specific applications of these methods in the empirical studies are listed in In usability evaluation research, some studies may use two or more evaluation methods to obtain a greater understanding of the system's usability. Of special note is that among the 647 publications only nine are about usability as it relates to HIT  of the total publications printed. The fields of the main publications in which the publications are produced are relatively simple and centralized. The top 11 journals that publish the most literature are mostly library information journals. The publication quantity distribution shows that the top 14 journals published 150 publications about usability research, accounting for 23.3% of the total publications. This shows that, in the information technology usability research field, articles are published across a diverse spectrum of journals and there is no journal with a major focus on usability. Of course, these journals are respectively included in the “China Journal Citation Report” by the China Science and Technology Information Institute and the “Chinese core journals” of the Peking University, which are believed to have a good reputation. In the United States, there are many pioneers and authorities in the field of usability, such as Jakob Nielsen, who have produced many publications, but China has yet to have such established and prolific experts on these topics. What is more, besides specific peer reviewed journals for usability, such as “Journal of Usability Studies”, there are more than 50 types of journals/magazines which are directly associated with usability.The data on study types show that theoretical studies on usability account for 61% of the total publications, including 27% about usability evaluation methods. Through analyzing the retrieved literature, we found that theoretical studies typically combine usability with specific branch fields (such as study of usability in web application) in terms of usability influencing factors, usability problems, usability design principles, and usability evaluation methods. However, the theoretical studies typically do not have significant original proposals or innovative methods and frameworks. At present, major advancements in theoretical and methodological studies are lacking in China.From the data on the understanding on usability concepts, we found that the Nielsen  and ISO From the data on study targets, we can see that most Chinese usability studies are combined with evaluation studies and the evaluation objects are mainly focused on Internet applications. In evaluation studies, 66% are usability studies in Internet applications; this is partially because usability studies on Internet started relatively early in western countries. Many usability experts in web applications have proposed various website usability evaluation methods and practice guidelines. For example, in the US, Story argues that a website developer should follow 10 usability principles when the site is designed . The NorMeanwhile, with the development of digital multimedia technology and wireless network technology, evaluation objects in usability evaluation studies are also changing gradually.From the data on usability methods we can see that evaluation methods are divided into two categories: usability testing and questionnaires. They account for 58.2% of all evaluation methods. In most cases, a single method is applied in usability evaluation and this accounts for 63.8% of the evaluation methods. The data on combination of different evaluation methods are listed in Further analysis of the data on distribution of study targets shows that Chinese usability studies are mostly concentrated on web information technology and usability studies in the healthcare information technology field are quite limited. Among the 647 publications, only nine are about this field  Usability research is an interdisciplinary field and researchers in different disciplines often use different terminologies. To minimize any effects of overrepresentation, we used many different keywords such as “usability,” “user satisfaction,” “user experience,” and “user-centered design” to query the related literature. (2) Three major databases are used in our study and we searched via the field of keywords. However, keywords in Chinese publications do not have corresponding vocabulary similar to Mesh, and all keywords in Chinese publications are manually added by the author. We had to assume that if the authors had considered the subject of the article to be mainly about usability, they would have used one of the above related usability terms in the keywords, especially given the frequent references to Nielsen  and ISO


Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory disorder that may involve single or multiple organs. Biopsy-proven lung involvement of this disease is occasionally reported, but not well understood.Patients with the diagnosis of biopsy-proven IgG4-related lung disease (IgG4-RLD) from Peking Union Medical College Hospital between January 2011 and July 2015 were retrospectively analyzed. Age, sex, clinical symptoms, laboratory findings, pulmonary function test results, chest CT tests, positron emission tomography (PET) examinations, treatments and prognoses were retrieved from medical records and analyzed.Seventeen patients were included in this study (mean age: 44.8 ± 15.0 years). Ten patients were diagnosed via surgery, and 7 patients were diagnosed via percutaneous transthoracic core-needle lung biopsy. Extrapulmonary involvement was observed in only one patient. The clinical symptoms included cough, fever, dyspnea, chest pain and hemoptysis. The serum IgG4 concentration was elevated in 7/13 patients (mean: 1955 ± 1968 mg/L). The chest CT findings included mainly nodules and masses with spiculated borders, alveolar consolidations with air bronchograms, and ground glass opacities with or without reticular opacities. PET scans indicated increased standardized uptake values, and 7/8 patients were correctly diagnosed with benign inflammation. Corticosteroids and immunosuppressants were administered to 14/17 patients and effectively alleviated the disease.In biopsy-proven IgG4-RLD, a normal serum IgG4 concentration is commonly seen, while extrapulmonary involvement is infrequent. Alveolar consolidation with air bronchograms is an important imaging finding of IgG4-RLD, which has not been emphasized before. Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a recently recognized fibroinflammatory condition that is characterized by tumefactive involvement of single or multiple organs, marked lymphoplasmacytic infiltrates and fibrosis with abundant IgG4-positive plasma cells. IgG4-RD is often associated with elevated serum IgG4 concentrations . Since HIgG4-RD lung involvement was first reported in 2004 by Taniguchi and colleagues in a patient with interstitial pneumonia, autoimmune pancreatitis and IgG4-positive plasma cells in the interstitium . AlthougPatients suspected of IgG4-RLD at Peking Union Medical College Hospital from January 2011 to July 2015 were investigated in October 2015. Only patients who fulfilled the following inclusion criteria were included in this study: (i) pulmonary parenchymal abnormality via chest computed tomography (CT) scanning; (ii) histopathological examination of a lung specimen obtained by thoracotomy, VATS or a percutaneous transthoracic CT-guided core-needle lung biopsy that demonstrated the features of IgG4-RD, including (a) marked lymphocyte and plasmacyte infiltration and fibrosis; and (b) a ratio of IgG4+/IgG+ cells > 40 % and/or > 10 IgG4+ plasma cells/HPF ; and (ii18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) examinations, treatments and prognoses.Patients were defined as definite, probable or possible IgG4-RLD according to the 2011 comprehensive diagnostic criteria for IgG4-RD . In ordeThe study was approved by the Ethical Committee of Peking Union Medical College Hospital (Reference number: S-K038). Informed consent for participation and publication was obtained from all patients at the time of diagnosis or follow-up. If the patient was dead or uncontactable, the informed consent was obtained from their families.Data were analyzed using the Statistical Package for the Social Sciences  . Mean values were expressed as values + standard deviations.A total of 19 Chinese patients fulfilled the inclusion criteria (i) and (ii) and IgG4-RLD was suspected. However, 2 patients were excluded due to other malignant diseases that were pathologically discovered at the time of diagnosis. Therefore, 17 IgG4-RLD patients were included in this study. The inclusion procedure is illustrated in Fig. Among the 17 included patients, 4 patients were initially diagnosed with nonspecific interstitial pneumonia (NSIP) in the 2000s. However, a pathological review performed in 2012 confirmed a diagnosis of IgG4-RLD , and patients with high serum IgG4 concentrations were more prone to have fever, compared with those with normal serum IgG4 concentrations (5/7 vs 1/6).Main laboratory findings are listed in Table Chest CT findings and pulmonary function test results are listed in Table 18F-FDG PET examinations. The maximum standard uptake values (SUVs) ranged from 4.0 to 11.8 (7.4 ± 3.0). Benign inflammation was diagnosed in 7/8 (87.5 %) patients, and malignancy was suspected in only 1/8 (12.5 %) patient. During evaluation, PET showed a high SUV in sublingual gland in one patient, however, biopsy excluded IgG4-RD involvement.Eight patients received A wedge resection or lobectomy was performed in 8 patients using VATS and 2 patients using posterolateral thoracotomies. Seven other patients were diagnosed using a CT-guided core-needle lung biopsy. Three patients first received a transthoracic core-needle lung biopsy and eventually underwent VATS or posterolateral thoracotomy due to nonspecific results.Histopathologically, all specimens showed diffuse lymphoplasmacytic infiltration and irregular fibrosis within the peribronchial and perivascular connective tissues Fig. . The alvPrednisone (20–50 mg per day) or an equivalent dose of another glucocorticoid was administered to 14 patients. Immunosuppressive agents were administered in 6 of theses patients, including cyclophosphamide (4 patients), azathioprine (1 patient) and mycophenolate mofetil (1 patient). During the follow-up , clinical remission was achieved in all patients. However, relapse was observed in 4 patients during glucocorticoid tapering  during the mean follow-up time of 3 years.Death was observed in one patient, who died of respiratory failure caused by relapse of IgG4-related interstitial lung disease after glucocorticoid tapering.As a newly recognized disease, IgG4-RLD is still not well understood. In this retrospective study, we analyzed 17 cases of biopsy-proven IgG4-RLD in Chinese to identify the characteristics of this rare disease.It is still unclear how often lung involvement occurs in patients with IgG4-RD. A retrospective study of 90 patients with autoimmune pancreatitis revealed that 54 % of patients had lung lesions , but anoCompared with typical IgG4-RD involving two or more organs, this study showed uncommon extrapulmonary involvement in biopsy-proven IgG4-RLD, even with the help of PET. Although selection bias exists because patients with only lung involvement are more prone to receive a lung bi,opsy, this association indicates that lung involvement is probably over-estimated in IgG4-RD patients. Thus, pathological confirmation seems crucial for the diagnosis of IgG4-RLD.Helicobacter pylori has been identified in more than 90 % of patients with autoimmune pancreatitis [The etiology of IgG4-RLD is still unknown. Autoimmunity is currently considered as the main pathogenic mechanism . Two patreatitis , proposiThe clinical symptoms of IgG4-RLD depend on the lesion locations and are usually nonspecific . In our One study of IgG4-RD patients demonstrated that serum IgG4 concentrations > 1350 mg/L and serum IgG4/IgG ratios > 8 % had a sensitivity of 97.0 and 95.5 %, respectively . HoweverInoue and colleagues summarized four patterns of CT findings: solid nodular, round-shaped ground glass opacity, alveolar interstitial, and bronchoalveolar . However18F-FDG PET uncovers more organ involvement than conventional evaluations in IgG4-RD patients [The use of patients . Howeverpatients , as demoAlthough lung tissue obtained via a less-invasive, CT-guided, transthoracic core-needle biopsy is convenient, it failed to yield a definitive diagnosis in about one third of patients in this study. Thoracotomy or VATS can obtain more lung tissue, and are usually required to make a pathological diagnosis of IgG4-RLD. Transbronchial cryobiopsy is a new technique that allow to obtain larger and more qualified specimen than forceps biopsy. The use of cryobiopsy in diagnosing interstitial lung disease has been proved to be proper and promising , 21. HowTo treat IgG4-RLD, corticosteroids are still the cornerstone therapy. The exact regimen for corticosteroids is still not detailed, but a regimen similar to extrapulmonary IgG4-RD therapy, such as during autoimmune pancreatitis, is recommended . In thisThe value of this study is limited by the small number of included patients. Our study show that although IgG4-RLD and typical IgG4-RD share common features, IgG4-RLD has its own distinct characteristics.Biopsy-proven IgG4-RLD is different in many ways from typical IgG4-RD. In biopsy-proven IgG4-RLD, a normal serum IgG4 concentration is commonly seen, while extrapulmonary involvement is infrequent. Alveolar consolidation with air bronchograms is an important imaging finding of IgG4-RLD, which has not been emphasized before.Data are available from the corresponding author upon request.


Idiopathic membranous nephropathy (iMN) is a single-organ autoimmune disease characterized by subepithelial deposition of immune complexes containing IgG4 resulting in proteinuria, nephrotic syndrome, and, in some, end-stage renal disease. The pathogenesis involves a chronic IgG4 response against specific podocyte antigens which have now been at least partially defined in the neonatal, early childhood, and adult varieties. More has recently been learned about the genetic predisposition as well. This review discusses the pathophysiology of iMN in light of these discoveries and what is known about the genesis and potential clinical ramifications of an antigen-specific IgG4 response.  Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults and is the second commonest glomerulopathy to progress to end-stage renal disease (ESRD). Most cases are idiopathic (iMN), but ~ 20% are secondary to various causes, including cancers, infections, autoimmune diseases, and medications . The chaIt is well established that an IgG4 response is intimately involved in the pathogenesis of iMN. It has been shown repeatedly that IgG4 predominates in the glomerular ICs in iMN, less so in secondary cases. Bannister et al.  found stIn the setting of secondary MN, other subclasses are usually found to predominate. In lupus MN, some have reported IgG4 , 9, but The exact pathophysiology of iMN has remained an enigma. Experimentally, a similar disease can be produced in rats (Heymann nephritis) via antibodies directed primarily against megalin, a protein expressed on the epithelial surface in clathrin-coated pits on the soles of podocyte foot processes , 16. ThiIn human neonatal MN, pathogenic IgG4 and IgG1 antibodies against neutral endopeptidase can be detected in maternal serum from mothers deficient in this enzyme who were presumably immunized during prior pregnancies , 18. TheIn early childhood iMN, unusually cationic bovine serum albumin (BSA), along with BSA-specific IgG4 and IgG1, were detected in serum, and co-localized in subepithelial IC deposits in 4 of 5 consecutive patients who were less than 5 years of age . In the In adults with iMN, IgG4 antibodies against a variety of proteins can now be detected in the serum of a significant proportion of patients. They can also be eluted from glomeruli and co-localized along with IgG4 within the ICs on the subepithelial side of the GBM. The first to be described were antibodies against the M-type phospholipase A2 receptor (PLA2R), which is normally expressed on the cell membrane of podocytes. In their seminal paper, Beck et al.  detectedUtilizing the same methodology in 60 Chinese patients with iMN, anti-PLA2R antibody was found in 49 (81.7%) . By enhaThese findings have been replicated by other groups. Debiec and Ronco  studied In the transplant setting, Debiec et al.  studied Beck et al.  evaluateOthers have detected IgG4 antibodies against different antigens in the serum and in renal tissue of patients with iMN. Prunotto et al. demonstrated a de novo expression of aldose reductase (AR) and superoxide dismutase-2 (SOD) in glomeruli of patients with iMN as compared to normal glomeruli and other glomerulopathies . Both anA genetic predisposition has been known to underlie iMN for many years. In 1979, Klouda et al.  found a More recently, Stanescu et al. [34] performed a genomewide association study of single nucleotide polymorphisms (SNPs) in 556 Caucasian patients with iMN. The SNP rs2187668 for HLA-DQA1 strongly associated with the disease, with an odds ratio (OR) of 20, as did the intronic SNP rs4664308 for the PLA2R (OR of 4); homozygosity for both at-risk SNPs markedly increased the risk (OR of 78.5). Two other groups studied SNPs resulting in amino acid substitutions in the PLA2R protein in Asian patients with iMN. Both groups found significant associations at rs35771982, a locus different from the one detected in Caucasians. Liu et al. [35] studied 129 Chinese and found a significant association with the G allele . On the other hand, Kim et al. [36] found a significant association with the C allele at this same locus with an adjusted OR of 2.934 for homozygosity (vs. CG or GG genotypes) in 199 Korean patients. Polymorphisms at other loci have also been associated with risk for iMN. These include the genes for nephrin , the infA T-helper (Th)-2 polarization is said to underlie iMN , 42, 43.Once differentiated, Th1 cells produce interferon-γ (Inf-γ) and interleukin (IL)-2 while Th2 cytokines include IL-4, Il-5, IL-9, and IL-13. Th17 cells produce IL-17, IL-21, and IL-22, while Tregs are notable for their production of IL-10 and transforming growth factor (TGF)-β. Evidence of Th polarization has been studied in patients with iMN by several groups. Hirayama et al. [41] used flow cytometry to study cytokine expression in the CD4+ cells of 8 patients. IL-2+ cells (Th1) were lower than normal, Inf-γ (Th1) and IL-4 (Th2) were the same, but IL-10 (Treg) cells were higher. Using the same methodology, Masutani et al. [42] also showed no difference in Inf-γ+ cells but did find increased IL-4+ cells in 24 iMN patients. This resulted in a lower Th1/Th2 ratio (~ 5) compared to normals (~ 8) and other nephrotic illnesses (~ 10), suggesting a Th2 predominance. Kuroki et al. [43] showed increased mRNA from peripheral blood mononuclear cells for the Treg cytokine IL-10 compared to normal, although no difference for Il-4 or the Th1 cytokine Inf-γ. However, a greater than normal IgG4 response was produced from B-cell cultures when exposed to IL-4, a Th2 cytokine, but not Il-10, IL-13, or Inf-γ. Total circulating IgG4 levels were in the normal range. Together these studies support a modified Th2 response underlying iMN; that is, a Th2 polarization modified by activation of a Treg response producing antigen specific IgG4 antibodies. IgG4 is a unique subclass of IgG , 46. It It is also possible that IgG4-containing ICs activate complement via the mannose-binding lectin (MBL) pathway. This pathway is reportedly involved in various immune complex glomerulopathies , most noThe regulation of IgG4 production is somewhat similar to IgE. It requires typical Th2 cytokines (IL-4 or IL-13) for appropriate class switch . Hence, Such a modified Th2 response is not uncommon and may occur in normal individuals. It can be found in situations with chronic antigenic exposure, e.g., in bee keepers and those occupationally exposed to animal proteins . It may The clinical manifestations of an antigen specific IgG4 reaction are thus quite variable . There mIn both pemphigus vulgaris and foliaceus, IgG4 antibodies directly produce acantholysis, independent of complement activation or FcR binding . In bullDuring chronic administration of therapeutic proteins, an IgG4 response may unfortunately abrogate their therapeutic benefits. Examples include an IgG4 response inhibiting the effect of Factor VIII infusions in hemophilia  and antiIgG4-related systemic disease is a recently named multisystem disease, originally described as autoimmune pancreatitis (AIP) , 57. UsuRenal involvement is common in IgG4-RSD, detectable radiologically in 30% of cases of AIP in the form of diffuse patchy cortical involvement or hypo-attenuating round or wedge shaped lesions . PerhapsAlthough the presence of > 10 IgG4+ PCs/hpf and/or an elevated ratio is required to diagnose IgG4-TIN, it is clearly not specific. Nearly one third of cases of pauci-immune GN had this level of IgG4+PCs in one series . In anotOther GNs in addition to iMN involve an IgG4 response. These include anti-neutrophil cytoplasmic antibody (ANCA) positive necrotizing and crescentic GN, circulating anti-glomerular basement membrane mediated GN, and fibrillary GN. In granulomatous polyangiitis  anti-proteinase-3 ANCA may be predominantly IgG4 in some, but not all, patients . This isWhile much has been learned recently regarding the pathogenesis of iMN, many questions still remain. It clearly represents a single organ autoimmune disease. A genetic basis for risk exists but it remains to be determined what the most relevant factors are and how to apply these data in the clinic. Target antigen(s) on podocytes have now been defined, and antibodies against one or more of these antigens can be detected in the circulation of the majority of patients. That the vast majority of these antibodies are of the IgG4 subclass has been clearly established. It remains unknown, however, what causes the chronic antigenic presentation required to initiate a modified Th2 response with IgG4 predominance. Is PLA2R the initiating antigen? What initiates the disease in those patients with no detectable anti-PLA2R antibodies? What is the role of neo-expressed antigens such as AR and SOD? Are there other, as yet undefined, antigens of equal or greater importance? Why do some patients with high levels of anti-PLA2R antibodies at the time of transplantation not have recurrence? Can the presence and/or serial titers of podocyte specific antibodies  be used to guide immunosuppression? Hopefully, as more knowledge accumulates, we may be better able to tailor therapy for the individual patient.


MET is a proto-oncogene that encodes a receptor tyrosine kinase, and aberrant activation of MET signaling occurs in a subset of advanced cancers as result of various genetic alterations including gene amplification, polysomy, and gene mutation. Our preclinical studies have shown that inhibition of MET signaling either with the small-molecule MET inhibitor crizotinib or by RNA interference targeted to MET mRNA resulted in marked antitumor effects in cancer cell lines with MET amplification both in vitro and in vivo. Furthermore, patients with non-small cell lung cancer or gastric cancer positive for MET amplification have shown a pronounced clinical response to crizotinib. Accumulating preclinical and clinical evidence thus suggests that MET amplification is an “oncogenic driver” and therefore a valid target for treatment. However, the prevalence of MET amplification has not been fully determined, possibly in part because of the difficulty in evaluating gene amplification. In this review, we provide a rationale for targeting this genetic alteration in cancer therapy.Certain genetically defined cancers are dependent on a single overactive oncogene for their proliferation and survival, a phenomenon known as “oncogene addiction”. A new generation of drugs that selectively target such “driver oncogenes” manifests a clinical efficacy greater than that of conventional chemotherapy in appropriate genetically defined patients.  BCR-ABL fusion gene in chronic myeloid leukemia as well as by mutant forms of the epidermal growth factor receptor (EGFR) gene and by the EML4-ALK fusion gene in non-small cell lung cancer (NSCLC). A new generation of drugs that selectively target such “driver oncogenes” and which include tyrosine kinase inhibitors (TKIs) has shown a therapeutic efficacy greater than that of conventional chemotherapy in individuals with these specific molecular alterations [Certain genetically defined cancers are dependent on a single overactive oncogene for their proliferation and survival, a phenomenon known as “oncogene addiction” that is exemplified by the erations ,2. The iMET encodes the receptor tyrosine kinase c-MET (or MET). The binding of its ligand—the hepatocyte growth factor (HGF)—to MET results in tyrosine phosphorylation of the receptor and activation of downstream signaling pathways mediated by phosphoinositide 3-kinase (PI3K) and AKT, by signal transducer and activator of transcription 3 (STAT3), or by RAS and mitogen-activated protein kinase (MAPK). Whereas normal activation of MET is essential for wound healing and embryonic development [MET [MET alterations including polysomy, gene amplification, and gene mutation has not been well established.The proto-oncogene elopment , excessielopment ,6,7,8,9 elopment . Althougent [MET , the tarMET amplification or mutation, we have examined the effects of a MET-TKI and of a small interfering RNA (siRNA) specific for MET mRNA on cell survival and signal transduction in NSCLC cells with or without such genetic alterations of MET [MET mutation, including those that affect the kinase domain or other domains of the encoded protein, have been identified in tumors. The small-molecule drug crizotinib (PF-02341066) inhibits the tyrosine kinase activity of MET as well as that of oncogenic fusion variants of anaplastic lymphoma kinase (ALK) [MET amplification but not in those positive for a non-kinase domain mutation (N375S or deletion of exon 14) of MET [MET amplification but not for that of those without this genetic alteration, including those with a non-kinase domain mutation of MET, although MET-TKIs have been shown to be active against MET with mutations in the kinase domain [MET amplification, whereas it had little effect on those negative for MET amplification, including those with a MET mutation, consistent with our results obtained in vitro. Together, these findings suggest that gene amplification, but not gene mutation, renders MET active as a driver oncogene.To investigate the biological impact of s of MET . Severalse (ALK) ,14. We f) of MET . These re domain . CrizotiMET are exceedingly rare [MET has been attributed to gene amplification [MET amplification [MET amplification [MET amplification but not in those without it, suggesting that MET signaling is essential for the survival of MET amplification-positive cells. Crizotinib also manifested a marked antitumor effect on gastric cancer xenografts positive for MET amplification, whereas it had little effect on those negative for this genetic change. Crizotinib thus showed a pronounced antitumor action both in vitro and in vivo specifically in gastric cancer cells positive for MET amplification.In gastric cancer, in which gain-of-function mutations of gly rare ,17,18, afication ,20,21. Afication . We therfication . Consistfication , we founMET. Tumor cells positive for MET amplification are thus dependent on (“addicted to”) sustained MET activity for their growth and survival, with the result that inhibition of MET signaling either with a small-molecule MET inhibitor or by RNA interference targeted to MET mRNA has marked antitumor effects both in vitro and in vivo. These findings provide a rationale for targeting MET amplification with MET-TKIs in the clinical setting.In summary, our preclinical studies have shown that gene amplification, but not gene mutation, confers “oncogenic driver” potential on MET amplification, it is important to determine the prevalence of this gene alteration in patients with advanced cancer. Unfortunately, however, different studies have used different methods and criteria to detect MET amplification (in situ hybridization (FISH) analysis have identified MET amplification in up to ~5% of patients with NSCLC [MET copy number was found in up to ~20% of NSCLC [MET is located) was indeed observed ~30% of NSCLC [MET copy number. Furthermore, such tumors might not be MET driven, given that breast tumors with an increased copy number for the human epidermal growth factor receptor 2 (HER2) gene as a result of polysomy 17 behave as HER2-negative tumors [MET amplification in cancer. Given the potential of MET-targeted therapy for cancer with fication . Studiesth NSCLC ,25,26,27th NSCLC ,28,29, wof NSCLC ,33,34,35of NSCLC ,38,39,40of NSCLC . On the e tumors . SoutherOn the other hand, FISH analysis is a semiquantitative method that can be performed with two probes for determination of the number of signals both for a target gene and for the centromeric portion of the corresponding chromosome. Given that the number of centromeric signals directly indicates the copy number of the chromosome, FISH analysis reveals the copy number increase for the target gene from the ratio of the copy number of the gene to that of the chromosome . ComparaHER2 testing, gene amplification is defined as positive with a target gene/centromere ratio of >2.2, negative with a ratio of <1.8, and equivocal with a ratio between 1.8 and 2.2 [FISH is thus currently the gold standard for detection of gene amplification. According to the recent ASCO/CAP guidelines for  and 2.2 . Importa and 2.2 .MET amplification as a MET/CEP7 (centromeric region of chromosome 7) ratio of >2.2 as determined by FISH analysis, we identified nine out of 229 patients with advanced NSCLC (3.9%) as being positive for MET amplification [MET amplification as determined with a combination of PCR-based screening and FISH confirmation [MET amplification identifies a small but clinically important subgroup of cancer patients who are likely to respond to MET-TKIs.With the strict definition of fication . We alsoirmation . These rMET amplification. In NSCLC, MET amplification is one of the mechanisms responsible for the development of resistance to EGFR-TKIs, with dual inhibition of EGFR and MET having been shown to induce apoptosis in such resistant cells [MET amplification.To date, at least 17 MET-TKIs with kinase selectivity profiles ranging from highly selective to multitargeted have been or are currently being subjected to clinical evaluation . Althougnt cells . Combinant cells , has beeMET amplification-positive cancer to crizotinib have come from an enriched molecular cohort of individuals with advanced cancer in a phase I trial of this drug . This cohort includes patients with various tumor types harboring specific genetic alterations of MET or ALK, including MET amplification defined as a MET/CEP7 ratio of >2.2  as well as ALK chromosomal translocation or gene amplification. A patient with stage IV lung adenocarcinoma that was negative for ALK rearrangement but positive for high-level MET amplification (MET/CEP7 ratio of >5.0) started treatment with crizotinib at a dose of 250 mg twice a day [MET amplification-positive glioblastoma was also treated with crizotinib at 250 mg twice a day [Preliminary reports of the clinical response of patients with ce a day . The patMET amplification (MET/CEP7 ratio of >2.2) [Another study revealed a pronounced clinical response to crizotinib in two of four patients with gastric cancer positive for of >2.2) . After 1ALK rearrangement-positive NSCLC in 2011, and a recent report has addressed the clinical efficacy of this agent in a clinical practice setting [MET amplification (MET/CEP7 ratio of >2.2) and negative for ALK rearrangement by FISH analysis. He was treated with crizotinib monotherapy at the normal dose of 250 mg twice daily. An almost complete response of tumors in the left lung and a major response of the primary tumor to therapy were demonstrated by chest CT and positron emission tomography (PET)-CT after 8 weeks of therapy.Crizotinib was approved by the U.S. Food and Drug Administration for the treatment of  setting . A male MET amplification-positive NSCLC were reported at the 2014 Annual Meeting of the American Society of Clinical Oncology (ASCO) [MET amplification status as determined by FISH analysis: low (MET/CEP7 ratio of ≥1.8 to ≤2.2), intermediate (MET/CEP7 ratio of >2.2 to <5.0), and high (MET/CEP7 ratio of ≥5.0). Thirteen patients with a low (n = 1), intermediate (n = 6), or high (n = 6) MET/CEP7 ratio received crizotinib. Of the 12 evaluable patients, four (33%) showed a partial response and were found to have an intermediate (n = 1) or high (n = 3) MET/CEP7 ratio. These findings are thus suggestive of an association between the MET/CEP7 ratio and the clinical benefit of crizotinib in patients with MET amplification-positive cancer.Preliminary results of the NCT00585195 phase I study for patients with y (ASCO) . PatientMET amplification as strictly defined by a MET/CEP7 ratio of >2.2 has the potential to act as an oncogenic driver and thereby to render at least a subset of affected tumors responsive to MET-TKIs such as crizotinib. Not all MET amplification-positive cancer patients respond to MET-TKI treatment, however, and most such patients who do respond, even those who show an initial marked response, eventually develop resistance to MET-TKIs. Preexisting and acquired resistance to MET-TKIs is thus an important clinical problem that is shared with other targeted therapies. Several mechanisms of resistance to MET-TKIs have been identified in preclinical models, including additional mutations in the activation loop of MET [SND1-BRAF fusion [KRAS [The accumulating clinical evidence thus suggests that p of MET , ligand-p of MET ,62, SND1F fusion , and ampon [KRAS . FurtherMET amplification has been identified as a potential oncogenic driver for several neoplasms, and targeted therapy with MET-TKIs for such tumors is thus a reasonable and effective treatment. Clinical trials of such drugs are strongly warranted for patients with advanced malignancies positive for MET amplification as strictly defined by a MET/CEP7 ratio of >2.2 determined by FISH.


Urinary tract infections (UTIs) are common drivers of antibiotic use. The minimal effective duration of antibiotic therapy for UTIs is unknown, but any reduction is important to diminish selection pressure for antibiotic resistance, costs, and drug-related side-effects. The aim of this study was to investigate whether an algorithm based on procalcitonin (PCT) and quantitative pyuria reduces antibiotic exposure.From April 2012 to March 2014, we conducted a factorial design randomized controlled open-label trial. Immunocompetent adults with community-acquired non-catheter-related UTI were enrolled in the emergency department of a tertiary-care 600-bed hospital in northwestern Switzerland. Clinical presentation was used to guide initiation and duration of antibiotic therapy according to current guidelines (control group) or with a PCT-pyuria-based algorithm (PCT-pyuria group).The primary endpoint was overall antibiotic exposure within 90 days. Secondary endpoints included duration of the initial antibiotic therapy, persistent infection 7 days after end of therapy and 30 days after enrollment, recurrence and rehospitalizations within 90 days.P = 0.011) in the ITT analysis. Mortality, rates of persistent infections, recurrences, and rehospitalizations were not different.Overall, 394 patients were screened, 228 met predefined exclusion criteria, 30 declined to participate, and 11 were not eligible. Of these, 125 (76% women) were enrolled in the intention-to-treat (ITT) analysis and 96 patients with microbiologically confirmed UTI constituted the per protocol group; 84 of 125 (67%) patients had a febrile UTI, 28 (22%) had bacteremia, 5 (4%) died, and 3 (2%) were lost to follow-up. Overall antibiotic exposure within 90 days was shorter in the PCT-pyuria group than in the control group  contains supplementary material, which is available to authorized users. Urinary tract infections (UTIs) are common drivers of antibiotic use and hospitalizations. In the United States, almost 10 million outpatients are diagnosed with UTIs each year . DespiteAny reduction of antibiotic exposure is important to diminish selection pressure for antibiotic resistance, costs, and drug-related side-effects . CurrentThe biomarker procalcitonin (PCT) was established for antibiotic stewardship in respiratory tract infections ,22 and sWe conducted an investigator-initiated, single-center, factorial design, randomized controlled (1:1) and open-label trial. Herein, we focus on the efficacy of an algorithm based on clinical symptoms, PCT, and pyuria to safely reduce the duration of antibiotic therapy compared to current guidelines ,15,28. DThe trial was conducted in accordance with the ethical principles of the Helsinki Declaration. The local ethical review committee of the Canton Aargau, Switzerland, approved the study protocol. All patients or their next-of-kin provided written informed consent.From April 2012 to March 2014, we screened all consecutive immunocompetent adults with community-acquired non-catheter-related UTIs as the main diagnosis presenting to the emergency department of the cantonal hospital of Aarau, a tertiary-care 600-bed hospital in northwestern Switzerland.A UTI was defined by at least one clinical symptom  and one urinary criterion  ,30, and/Patients were excluded if they presented with other infections that required antibiotic therapy or had been treated with antibiotics within 48 hours before presentation; pregnancy; prostatitis defined as painful digital rectal examination, a prostate-specific antigen value of >4 ng/mL or ≥2× baseline before infection; foreign bodies within the urinary tract; endovascular prostheses; non-endovascular prostheses within 6 months after implantation; insufficient language skills with no possibility for translation; foreseeable non-compliance for follow-up, e.g., current drug abuse; severe immunodeficiency: neutrophils <500/μL, CD4 cells <350/μL in patients with HIV-infection, leukemia, lymphoma, myeloma, cytotoxic medications, hemodialysis, transplant patients; or life-threatening medical comorbidities leading to possible imminent death.The allocation of patients to either the PCT-pyuria group or the control group was based on a pre-specified computer generated randomization list and was concealed on the study website.Clinical presentation without (control group) or with PCT and pyuria (PCT-pyuria group) was used to guide initiation and duration of antibiotic therapy. The choice of antibiotics and the minimal duration of therapy were based on recent guidelines ,15. The 2 or ciprofloxacin (250 mg twice daily) for eGFR <30 mL/min/1.73 m2. In the PCT-pyuria group, patients with uncomplicated simple UTIs were planned to receive only non-steroidal anti-inflammatory drugs (NSAIDs) for 3 days regardless of PCT-values [For simple UTIs, we used fosfomycin (3 g single dose) , trimethT-values ,33.2), if intravenous therapy was necessary ceftriaxone (2 g once daily) was chosen. When known, antibiotic resistance profiles of prior or current pathogens were taken into account and antibiotic therapy was adjusted.For febrile UTIs/pyelonephritis, ciprofloxacin was chosen as standard oral treatment for better comparability with recent studies  than in the control group . Accordingly, 99 patients per arm would provide an 80% power at the 5% alpha level .The primary analysis was performed including all randomized patients following an intention-to-treat (ITT) principle. The per-protocol (PP) analysis was performed in a defined population with microbiologically confirmed UTI and without patients who violated inclusion or exclusion criteria or were lost to follow-up. If the initial urine culture was missing, sterile, or contaminated but a uropathogen was isolated in concomitantly withdrawn blood cultures, the patients were still included in the PP analysis. We used predefined urine culture cut-offs for significance .As the study was conceived in a two-by-two factorial design, we checked for interaction between the two randomization arms. As there was no evidence for interaction, the second randomization (proadrenomedullin-assisted site of care decision ) was no Discrete variables were expressed as counts (percentage); continuous variables as medians and interquartile range, unless stated otherwise. For the analysis of the primary endpoint of antibiotic exposure, we used the Mann–Whitney U test for similarly shaped not normally distributed continuous data. In sensitivity analysis, we also used median regression to model the primary endpoint and adjusted the analysis for bacteremia. Logistic regression analyses of persistent infection, recurrence, and rehospitalization rates were performed to assess safety endpoints. Since this was a feasibility study we did not plan to have enough power for non-inferiority testing.We screened 394 patients, of whom 269 were not eligible due to the exclusion criteria, patient refusal, or other reasons. Thus, 125 patients were enrolled in the ITT analysis and 3 (2%) patients were lost to follow-up. As predefined, 96 (77%) patients with microbiologically confirmed UTIs and no protocol violations constituted the PP analysis  in the control group and 9 (15%) in the PCT-pyuria group  and in the PP analysis  groups. In subgroup analyses, PCT-pyuria led to shorter antibiotic therapies in women  and in patients with complicated febrile UTI/pyelonephritis ; for male patients, the difference did not reach statistical significance  and of new infections 7 days after end of therapy were similar in both groups . The microbiological isolates obtained from the urine cultures on day 7 after end of therapy are presented in Table P = 0.95 in ITT analysis). There were no symptomatic infections with new organisms 30 days after enrollment . Among bacteremic patients, the initial antibiotic therapy was shorter in the PCT-pyuria group ; overall antibiotic exposure within 90 days was not different. The recurrence rate was higher in the PCT-pyuria group  but rehospitalization rates were not significantly different.As the distribution of patients with bacteremia was not well balanced between the two study arms we performed a stratified analysis of the primary and secondary outcomes for bacteremic and non-bacteremic patients .The rates of persistent infection 7 days after end of therapy were similar in both groups , the PCT-pyuria algorithm led to shorter initial duration of antibiotic therapy. The tested algorithm can help to determine the optimal length of antibiotic therapy and avoid antibiotic overuse.There was an imbalance in randomization of eight patients with uncomplicated simple UTI with only two being randomized to the PCT-pyuria group. Since all six patients in the standard guidelines group were treated according to our algorithm with single-dose fosfomycin, the median duration of the initial antibiotic therapy in this subgroup was similar between both groups.Only one patient in the PCT-pyuria group, who relapsed with urosepsis and had to be hospitalized for 3 days and treated with intravenous antibiotics, was initially treated with NSAIDs according to the study protocol. Given the small number of outpatients, the safety of NSAIDs for simple uncomplicated UTIs cannot be determined based on our study. Despite recent data with promising results for this approach ,33, a rePatients with complicated febrile UTI were older and had multiple comorbidities. Especially in this population with the highest disease burden, in whom the longest antibiotic therapy is recommended by current guidelines, our algorithm proved to be effective.The safety subgroups were small, but no trend for difference in rates of persistent infection was shown at 7 days after end of therapy or at 30 days after enrollment. The slightly higher, but non-significant, rate of bacteriuria and asymptomatic infection in the PCT-pyuria group should not be viewed as an unsuccessful treatment. There is vast evidence that asymptomatic bacteriuria should not be treated . In factEnterococcus faecalis (Table Furthermore, the follow-up mid-stream urine cultures in the PCT-pyuria group yielded in the majority of cases is Table , which hEscherichia coli were resistant to fluoroquinolones in 2013, compared to 22.3% in the European Union in 2012 [The antibiotics chosen in our algorithm, derived from international guidelines, should not deter from the necessity to adapt antibiotic choices to local epidemiology and resistance data . In Swit in 2012 ,40.A major strength was the innovative study design with antibiotic guidance based on the combination of the systemic and local response against a control group receiving antibiotic therapy according to the low end of currently recommended guidelines.Our study has the following limitations. First, the small sample size due to slow recruitment and the heterogeneity of patients within the predefined subgroups limit the power of the analysis, especially regarding safety outcomes. Second, the follow-up mode by telephone interview and by urine samples which were returned by mail harbors potential recall bias and underreporting, which we tried to counteract by contacting the primary care physician and by obtaining discharge letters of subsequent hospitalizations. Third, the analysis of the recurrence rate in the subgroup of patients with bacteremia was limited due to the small numbers. Further studies will have to clarify whether this algorithm needs to be adapted for patients with bacteremia.An algorithm based on PCT and pyuria significantly reduces antibiotic exposure when compared to current guidelines without apparent negative effects on clinical outcomes, especially in patients with complicated febrile UTI. Further randomized controlled multi-center studies with larger patient numbers are needed to confirm our findings for all subgroups and to proof the feasibility in other settings.


Antibiotic resistance is present globally. Contributing factors in Cambodia include self-medication by the community, uncontrolled sale of antibiotics and unregulated antibiotic use in food animals.Our objective was to explore the prescribing practices of physicians in Cambodia and perceptions of antibiotic use and resistance in the country.A sample of 482 physicians from 6 national hospitals was surveyed for knowledge and prescribing practices using common disease scenarios. Focus group discussions (FGD) with physicians explored barriers to evidence-informed prescribing. Approval was given by health research ethics committee of Cambodia, UNSW Australia and ITM.Our preliminary findings from combining the survey and FDG results identified that while physicians were aware of antibiotic resistance and perceived prescribing antibiotics appropriately as difficult, they were unlikely to utilize their diagnostic microbiology service to assist their daily prescribing practice. The most common barrier to evidence-based prescribing was their habitual and routine prescribing practices and that of their peers instead of utilizing the microbiology service. Habitual prescribing practices remain unchanged despite the introduction of microbiology services. Surveyed physicians commonly reported that their patients at the time of admission had self-medicated. During discussions physicians reported that antibiotic choice was based on severity of clinical presentation: milder presentations were prescribed ampicillin and gentamicin while severe presentations or patients who had self-medicated were immediately prescribed ceftriaxone. Support from microbiology services was only accessed when patients did not respond to this prescribing regime.Antibiotic self-medication and resistance are among challenges for Cambodian physicians to prescribe antibiotics appropriately. Yet, their prescription is likely to be driven by their habit rooted from the era when there was no microbiology laboratory rather than seeking evidence from microbiology laboratory they can now access to. Training programs focusing on rational antibiotic prescribing are urgently needed.None declared.


A checklist is an effective implementation tool, but addressing barriers that might impact on the effectiveness of its use is crucial. In this paper, we explore barriers to the uptake of an antibiotic checklist that aims to improve antibiotic use in daily hospital care. We performed an online questionnaire survey among medical specialists and residents with various professional backgrounds from nine Dutch hospitals. The questionnaire consisted of 23 statements on anticipated barriers hindering the uptake of the checklist. Furthermore, it gave the possibility to add comments. We included 219 completed questionnaires  in our descriptive analysis. The top six anticipated barriers included: (1) lack of expectation of improvement of antibiotic use, (2) lack of expected patients’ satisfaction by checklist use, (3) lack of feasibility of the checklist, (4) negative previous experiences with other checklists, (5) the complexity of the antibiotic checklist and (6) lack of nurses’ expectation of checklist use. Remarkably, 553 comments were made, mostly (436) about the content of the checklist. These insights can be used to improve the specific content of the checklist and to develop an implementation strategy that addresses the identified barriers. A better use of current antibiotic agents is necessary to help control antimicrobial resistance (AMR) . AntibioBox 1: The antibiotic checklist based on generic quality indicatorsaAdequate means:1: When the antibiotic is available orally;2: When oral intake and gastrointestinal absorption are adequate;3: Adequate in terms of diagnosis .Barrier studies performed during or after checklist implementation –24 descrThe present study aims to identify barriers to the uptake of an antibiotic checklist in Dutch hospitals prior to checklist implementation and to select implementation activities to target the predominant barriers that obstruct checklist uptake.We performed an online questionnaire survey among medical specialists and residents to explore anticipated barriers hindering the uptake of an antibiotic checklist.We based our questionnaire on the Dutch validated measurement instrument for determinants of innovations (MIDI), combined with barriers found in the literature. The MIDI is developed by the Netherlands Organisation for Applied Scientific Research (TNO) and is meant as a tool for researchers to survey determinants that influence the uptake of an innovation . AdditioBox 2: Terms for literature searchThe final online questionnaire started with a description of the antibiotic checklist Box 1) and was followed by 23 statements on anticipated barriers related to the checklist (seven items), the individual professional (six items), professional interactions (seven items), the patient (two items) and to resources (one item)  or as a facilitator helping uptake , all answers (1 through 6) were re-coded into dichotomous scores: anticipated barrier ‘yes’ or ‘no’. The answers ‘I don’t know’ were excluded from the analyses. We computed frequencies and percentages and created a top five of the statements that were most often mentioned as barriers.We categorised the comments on the checklist added by the participants. If comparable comments were mentioned three times or more, the comment was considered to be relevant. We also created a top five of comments.The online questionnaire was filled out by participants in eight of the nine hospitals that initially agreed to participate in the cluster-randomised trial on the implementation of the antibiotic checklist. One non-university hospital no longer wanted to participate and was replaced by a similar hospital. In another hospital, the link to the questionnaire was only emailed to physicians of the department of infectious diseases. In total, 250 physicians participated in the survey, of which 219 participants completed 50 % or more of the questionnaire statements. These 219 questionnaires were included in the analyses. The participants’ characteristics are summarised in Table Table To exclude the possibility that the single hospital in which 90 physicians completed the questionnaire influenced the results disproportionally, we compared the appraisals of the 219 participants  with the appraisals of 129 participants . The top five anticipated barriers from these eight hospitals differed on one statement: instead of ‘complexity of the checklist’, the statement ‘nurses will expect me to use the checklist’ was in the top five. For this reason, this barrier was added to the list of frequently mentioned barriers (6). This top six contains barriers from four different domains, namely the individual professional (1 and 4), the patient (2), the checklist (3 and 5) and professional interactions (6).In total 553, comments were given, of which 436 were comments and suggestions regarding the content of the checklist, 59 were general comments and 58 were organisational comments. These organisational comments described contextual factors that should be taken into account in these specific hospitals, i.e. implementation of a new electronic medical record (EMR) system (14.6 %) and merger of the hospital with another hospital (7.3 %). Comments on the content of the checklist or general comments that were relevant for all hospitals and were mentioned at least three times are presented in Table We developed an implementation strategy that could be applied in all hospitals to address the top six anticipated barriers.The barrier (1) “lack of expected quality improvement of the physician’s antibiotic prescribing” can be addressed in the following two ways: first by showing the room for improvement, i.e. giving feedback on their current antibiotic use based on a baseline measurement, and second by providing evidence for a reduction in the length of hospital stay for the patient with adequate antibiotic use . This inThe barrier (2) “lack of expected patients’ satisfaction with checklist use” can be addressed by giving information about the study at the nursery department, i.e. by supplying flyers about antimicrobial resistance and the expected effects of appropriate antibiotic use .Two anticipated barriers, namely (3) “the feasibility of the checklist” and (5) “the complexity of the checklist”, can be addressed by adapting the checklist. Table To address the barrier (4) “negative previous experiences with other checklists”, the differences between these previous checklists  and this antibiotic checklist should be emphasised, for example in group discussions. Differences are, e.g. that this checklist is short and does not involve other physicians to complete it. In addition, it should be stressed that the antibiotic checklist was adapted based on their comments and the comments of other colleagues participating in the trial.Finally, to address the barrier (6) “lack of nurses’ expectation of checklist use”, nurses working at participating departments should be informed about the checklist use and its aims, for example through email, e-learnings and/or the department lecture showing the room for improvement and the evidence for reduction in the length of hospital stay for the patient with adequate antibiotic use.We adapted the checklist design based on the top five comments. First (1c), to reduce duplication of documentation, we left out the name, dose, interval and route of administration of the antibiotic, and the item was reduced to ‘documentation of indication’. This is appropriate since all Dutch hospitals are, nowadays, obliged to work with an electronic medical record that already requires this information. Second (2c), since 10.5 % of the participants felt that taking blood cultures was not necessary for all diagnoses, we added the option “In my opinion, not necessary with this diagnosis” in the checklist. Third (3c), we left out the clarification of “adequate in terms of diagnosis” for the item IV to oral switch, and included options in the checklist so that the physicians could tick their reasons for not switching: “Insufficient clinical improvement”; “No oral antibiotic available”; “No adequate oral intake/gastrointestinal absorption” and “No oral therapy possible with this diagnosis”. In addition, we ensured that the information on switch criteria could be easily found: we developed informative posters and laminated pocket versions of the checklist, which included a reference to the website with all necessary information concerning this topic. The information about dosage adaptation when the patient has an impaired renal function (4c) can also be found on this website. Last (5c), we added in the checklist that, for taking two different blood cultures, one should use two different sites.In this study, we identified the barriers that need to be addressed when implementing an antibiotic checklist. We created a top six of anticipated barriers to the uptake of the checklist, and a top five of comments on its components. The top six barriers encompassed four different domains, namely barriers related to the individual professional, to the patient, to professional interactions and to the checklist itself. The top five comments mostly encompassed suggestions to more clearly specify the content of the checklist, i.e. the quality indicators included. We adapted the checklist to the survey results; two barriers and all top five comments could be addressed by adapting the design of the checklist, and by re-phrasing various checklist items Table .Our most frequently mentioned barrier, the lack of expected improvement of care, has been described by several other barrier studies of checklist implementation , 18, 20.Feasibility is also a known barrier in the implementation of checklists; items in the surgical safety checklist were perceived to be inappropriate for certain surgical procedures  or for cThe current study has some strengths. To our knowledge, our study is the first to assess and quantify barriers prior to checklist implementation. We based our questionnaire on a validated instrument to measure determinants of innovations, combined with a literature search. The barriers to the uptake of the antibiotic checklist were reported by a large sample of physicians from nine different hospitals. Furthermore, we included residents and specialists of surgical departments and medical departments, while previous barrier studies only focussed on people in the surgical , 23, 24 The most important limitation of our study is that the physicians of one university hospital completed 90 of the 219 questionnaires. We compared, however, the appraisals of the 219 participants  with the appraisals of 129 participants . This comparison resulted in the addition of a sixth anticipated barrier on nurses’ expectations regarding checklist use. During the implementation process, this barrier should also be addressed. A second limitation has to do with the chosen recruitment method. We emailed the contact physician a link to the questionnaire, and asked him/her to forward this email to the target group. Through this approach, we aimed to invite as many professionals as possible to participate in the questionnaire study. The downside of this approach is that the exact number of physicians that received the link to the questionnaire was unclear and, consequently, that it was impossible to determine the response rate. Based on an analysis in one hospital where we could retrieve information on the number of invitations sent, we estimated the response rate to be about 30 %, which is also found in other studies , 35. AltPerforming a barrier analysis prior to checklist implementation creates the opportunity to address barriers in an early stage, and to adapt its design structure and content. This iterative survey resulted in a checklist adapted to the perceptions of frontline clinicians, which should facilitate implementation. The results of our barrier analysis may be specific for our setting and our checklist. Since our developed questionnaire is based, however, on a validated instrument and a literature search, we assume that the checklist questionnaire itself can be used for barrier identification for the implementation of other checklists.This survey provides insight into the anticipated barriers that have to be addressed when implementing an antibiotic checklist in Dutch hospitals. Taking into account these factors that hinder the uptake of the antibiotic checklist, implementation in daily practice will be challenging. Education, feedback, involvement of the whole healthcare team in the implementation process and adaption of the checklist itself Table  will be


Candida albicans causes superficial and life-threatening systemic infections.These are difficult to treat often due to drug resistance, particularly becauseC. albicans biofilms are inherently resistant to most antifungals.Sophorolipid (SL), a glycolipid biosurfactant, has been shown to have antimicrobialand anticancer properties. In this study, we investigated the effect of SL on C.albicans biofilm formation and preformed biofilms. SL was found to inhibitC. albicans biofilm formation as well as reduce the viability ofpreformed biofilms. Moreover, SL, when used along with amphotericin B (AmB) orfluconazole (FLZ), was found to act synergistically against biofilm formation andpreformed biofilms. Effect of SL on C. albicans biofilm formation was furthervisualized by scanning electron microscopy (SEM) and confocal laser scanningmicroscopy (CLSM), which revealed absence of hyphae, typical biofilm architectureand alteration in the morphology of biofilm cells. We also found that SLdownregulates the expression of hypha specific genes HWP1, ALS1,ALS3, ECE1 and SAP4, which possibly explains the inhibitoryeffect of SL on hyphae and biofilm formation. Candida species is one of the most common form of hospitalacquired opportunistic infection1C. albicans remainsthe major causative agent, infection caused by other Candida species like C.tropicalis, C. glabrata, C. lusitaniae, C. parapsilosis and C.krusei are becoming more prevalent134Candida infections6729Candida biofilms which are inherently resistant to most antifungaltreatments. Biofilm is an organized community of cells, embedded in a matrix ofexopolymeric substances71112138151718CandidaCandidiasis caused by Starmerellaspecies23242325Candida species has also been reported. However,the activity of SL against Candida biofilms is not known. Recent reports showedthat combinatorial therapy of various drugs is highly effective to eradicateCandida biofilmCandida biofilm formation andpreformed biofilms of Candida, alone and in combination with AmB or FLZ. We havealso investigated the mechanistic basis for SL mediated biofilm inhibition, which ispossibly through inhibitory effect of SL on hyphae formation. Hyphae are the one of themajor constituents of biofilms.Biosurfactants show antiadhesive and antimicrobial activities2021C.albicans and NAC in RPMI-1640 medium employing standard CLSI methodC. albicans were incubated withserially double-diluted concentrations of purified SL(0–1920 μg/ml) in 96-well microtiter plates andincubated at 37 °C for 2 days. At the end of incubation, growthof cells was determined by OD600 nm reading. TheMIC80 is defined as the lowest concentration of SL which inhibits80% cell growth as compared to control (without SL). MIC80 of C.albicans was found to be 60 μg/ml species, we extended our study to C. lusitaniae, C. tropicalis and C.glabrata. The MIC80 for C. tropicalis and C.glabrata was 60 μg/ml and 120 μg/ml,respectively. C. lusitaniae was found to be the most susceptible (MIC8030 μg/ml) among NAC strains tested (The MIC (minimum inhibitory concentration) for SL was determined against 60 μg/ml . Higher s tested .C. albicans and NACstrains. Biofilm formation was initiated in 96-well microtiter plates in thepresence of serially double diluted concentrations of SL(0–1920 μg/ml) and incubated at 37 °Cfor 2 days. Quantification of biofilms was performed by colorimetric XTTreduction assay and viability was expressed in terms of percentage metabolicactivity. The BIC80 (biofilm inhibiting concentration) was defined asthe lowest concentration of SL that inhibits 80% metabolic activity of biofilmformation as compared to control (without SL). We found that C. glabratahas highest BIC80 (480 μg/ml)  , whereas20 μg/ml .C. albicans and NAC strainmature biofilms, we performed SL susceptibility testing against preformedbiofilms. Biofilms were formed in 96-well microtiter plates for 2 days at37 °C and thereafter, serially double-diluted concentrations ofSL (0–1920 μg/ml) were added to preformed biofilms andfurther incubated at 37 °C for 2 days. Subsequently, metabolicactivity was determined by colorimetric XTT reduction assay. TheBEC80 (biofilm-eradicating concentration) was defined as thelowest concentration of SL that eradicates 80% of biofilm compared to conrol (SLuntreated biofilms). The BEC80 for C. albicans was 4-foldhigher (480 μg/ml) compared to biofilm forming planktonic cells(BIC80 120 μg/ml)  . Viabili0 μg/ml) . For C.th cases.C. albicans biofilm and theircellular morphology. Biofilms were formed in presence of serially double-dilutedconcentrations of SL (0–1920 μg/ml) on poly-L-lysinecoated glass cover slips in 6-well microtiter plates for 2 days at37 °C, and visualised by SEM and CLSM. SEM images of controlsample (0 μg/ml SL) demonstrated the presence of complexstructure of biofilm having hyphae and yeast cells (80 concentration of SL (120 μg/ml)  , biofilm0 μg/ml) .Aggrega0 μg/ml) . CLSM im0 μg/ml)  showed dC. albicans hyphalgrowth assay was performed in presence of different concentration of SL inRPMI-1640 medium and RPMI-1640 medium containing hypha inducer (10% FBS) at37 °C. After 5 hrs of incubation aliquots of the cellswere microscopically visualized. In control samples (0 μg/ml SL)massive C. albicans hyphae were observed  wasfound to have massive hyphae  for both SL treated as well as untreated cells and presentedin the form of relative expression fold change. Expression of HWP1,ALS1, ALS3, ECE1 and SAP4 in SL treated cellswas reduced significantly by 10-fold, 2.5-fold, 8.7-fold, 37.7-fold and 3.6-foldrespectively as compared to control  used in this study. Fractionalinhibitory concentration (FIC) of each compound in each combination (SL and AmBor SL and FLZ) was calculated for biofilm formation and preformed biofilms. SLat 0.125× BIC80 and 0.250× BIC80concentrations reduced the BIC80 of AmB by 4-fold and of FLZ by32-fold, respectively  indicated significant role of SL in hyphal growthinhibition.Since hyphal growth is a virulence factor The effect of subinhibitory concentration of SL on mature hyphae of C. albicans cellswere also tested. Hyphae in presence of 15 μg/ml were shortened andcompletely absent at 30 μg/ml concentration of SL used. There was no tracesof broken hypha found in both concentrations . AnotherC. albicans mutantsof HWP1 and ALS3 are defective in biofilm formation39HWP1 and ALS3 in cells treated with higher concentration ofSL was also quantified and found to be further reduced (data not shown). SL mediateddown-regulation of the expression of these genes and inhibition of hyphal growthcould be a reason for abrogation of C. albicans biofilm formation.To gain insight into the molecular mechanism of SL mediated hyphal growth inhibition,expression profile of hyphal growth associated genes were analyzed. Transcriptsresult reveal that SL downregulates the expression of hyphal genes resulting ininhibition of hyphal growth. It was earlier reported that C. albicans biofilms are intrinsically resistant to most of the currentantifungal drugs1718434446Candida biofilm and thereby candidiasis infectionC.albicans biofilmCandida biofilm as wellas can be used in combination with AmB and FLZ. To the best of our knowledge, thisis the first study demonstrating the role of SL in inhibition of C. albicansbiofilm formation and hyphal growth. Further evaluation is required to determine theantibiofilm activity of SL in vivo. SL also enhances the efficacy of AmB andFLZ against C. albicans biofilm, implying a promising synergistic combinationfor the treatment of candidiasis.C. albicans SC5314C.glabrata CG462C. tropicalis MYA340450 and C. lusitaniae CL6Wild type strains of Starmerella bombicola MTCC1910, was used for SL production. It was grownas described in the supplement. SL was separated from the fermentation broth byethyl acetate extraction and concentrated by vacuum evaporation of the solventat 40 °C. Residual hydrophobic components were washed withn-hexanes to obtain a crude mixture of SL. Different components of the crudemixture were monitored by thin layer chromatography (TLC) (254 10 cm × 5 cm TLCplates using chloroform /methanol (65:15:2) as mobile phase. Crude mixture of SLwas also characterized by HPLC (Shimadzu) with UV detector (207 nm) anda RP-C18 column  using gradient elution. Initially,acetonitrile:water (30:70) was used for 5 min, increased toacetonitrile: water (80:20) in 25 min and maintained there for next25 min. The flow rate was 0.5 ml/min and injection volume was10 μl. Column chromatography was carried out to isolate thelactonic form of SL. 50 gm of silica mesh size (60–120) inhexane was packed in (50 × 5 cm) glass column.200 ml of eluent (chloroform/ methanol) is run through the column beforeloading the crude SL. 300–400 mg of crude SL dissolved in asmall volume of ethanol was mixed with silica (3.5 gm) and evaporatedunder reduced pressure at 40 °C. Once the silica is fully driedit was loaded into the column. Diacetylaed form of lactonic SL was eluted fromthe column by using chloroform and methanol at a ratio of 98:2 and dried undervacuum at 40 °C and stored for further use. HPLC analysis showeda single peak of SL with more than 99% purity (hy (TLC)  on Merck% purity . Differe% purity   guidelines3 cells/ml.100 μl of cell suspension was added into the SL containing andcontrol wells to provide 2 × 103 cells/mlin 200 μl working volume. Thereafter, microtiter plates wereincubated at 37 °C for 2 days. After incubation, growth of cellswas measured by microtiter plate reader (BioTek) at 600 nm.SL activity against planktonic cells of 6 cells/ml and dispensed intothe wells of microtiter plates (100 μl per well). Seriallydouble-diluted concentrations of SL in RPMI-1640 medium were added(100 μl per well) to the wells such that final cell densityremains 1 × 106 cells/ml for biofilmformationThe biofilm formation assay was performed in 96-well microtiter plates asdescribed previously526 cells/ml52For preformed biofilms, the cell suspension was prepared in RPMI-1640 medium at acell density of 1 × 10Subsequent to the appropriate incubation of the microtiter plates, medium wasaspirated from the wells and nonadherent cells were removed by washing thebiofilms as described above. Colorimetric XTT reduction assay of biofilm wasperformed as previously reported52et al.The effect of SL on biofilms was qualitatively analyzed by SEM and CLSM. Biofilmswere formed on poly-L-lysine (Sigma) coated glass cover slips (Blue Star) in6-well cell culture plates (Nunc). Glass cover slips were coated withpoly-L-lysine (2% wt/vol) as described by Dong etal.For SEM, biofilms were dried and processed as described by Ramage For CLSM, biofilms were stained as described previously7cells/ml in medium and incubated with different concentrations of SLat 37 °C with agitation (200 rpm) for 5 hrs.Aliquots of samples were visualized under bright field using 100X objective lensby Zeiss fluorescence microscope and photographed. Samples incubated indifferent concentrations of SL for zero hour were also examined under similarcondition.Hyphal growth assay was performed in 10 ml of RPMI-1640 medium andRPMI-1640 medium supplemented with 10% foetal bovine serum .Cell suspension was diluted at 1 × 10C. albicans hyphae was studied by growing the cells inRPMI-1640 medium supplemented with 10% FBS (Invitrogen). Differentconcentrations of SL  was added to mature hyphae and incubated for5 hrs at 37 °C. Subsequently, aliquots of samples werevisualized under bright field using 60X objective lens by Zeiss fluorescencemicroscope and photographed. Samples at time point zero were also examined undersimilar condition.Effect of SL on HWP1, ALS1, ALS3, ECE1 and SAP4 wasevaluated by two-step quantitative real time polymerase chain reaction(qRT-PCR). Total RNA of the cells was extracted from SL treated(15 μg/ml) and untreated (0 μg/ml) hyphal growthsamples of RPMI-1640 medium using hot phenol/chloroform extraction methodHWP1, ALS1, ALS3,ECE1 and SAP4) and housekeeping internal control (ACT1)genes were designed using Gene Runner software (® Green Supermix (BIO-RAD) were used in reactionmixture in accordance with manufacturer’s instructions and qRT-PCR wasperformed in Mastercycler® ep realplex Real-time PCR system. Tocheck the DNA contamination in templates, DNase I treated total RNA wereincluded in each run. The following parameters were used for qRT-PCR: an initialdenaturation at 95 °C (3 min), followed by 40 cycles ofdenaturation (95 °C/1 min), annealing(58 °C/30 sec), and extension(72 °C/20 sec), melting-curve analysis starting frominitial temperature 50 °C to 95 °C, with gradualincrease in 0.5 °C/15 second. Specificity of the primerswas confirmed by melting curve analysis. The generated CT values oftarget genes were normalized to the CT value of housekeepingACT1 gene. Relative expression fold changes were evaluated byΔΔCT method using2−ΔΔCT formulaEffect of sub inhibitory concentration of SL on the expression of hypha specificgenes software and syntcompound A with compound B/BIC or BEC compoundA + BIC or BEC compound B with compound A/BICor BEC compound B). The interaction is considered synergistic whenthe FICI is ≤0.5, indifferent when the value is0.5 < FICI ≤4 and antagonistic when the value is>4Nature of the interaction of SL with AmB and FLZ was evaluated by chequerboardassay. Serially double-diluted concentrations of SL(0–1920 μg/ml), AmB (0–32 μg/ml)and FLZ (0–1024 μg/ml) were prepared in RPMI-1640medium. 50 μl of each dilution of two compounds (SL and AmB orSL and FLZ) were dispensed in 96-well microtiter plates. Biofilm formation wasinitiated in the presence of combination of compounds and incubated at37 °C for 2 days as described above. For preformed biofilms,combination of compounds were added into the wells of PBS washed biofilms andfurther incubated at 37 °C for 2 days. Following incubation,medium was aspirated from the wells and biofilms were washed 3-times with PBS.Thereafter, metabolic activity of biofilms was determined by colorimetric XTTreduction assay. To evaluate the interaction between compounds, FractionalInhibitory Concentration Index (FICI) was calculated from the data obtained withbiological triplicates. FICI is the sum of the FICs of either compound . A p-value of<0.05 was considered statistically significant.All experiments were performed in triplicate and on three different days. Alldata were expressed as mean values with the corresponding standard deviations(SD). Statistical significance between treated and control groups was analyzedby Student’s How to cite this article: Haque, F. et al. Inhibitory Effect ofSophorolipid on Candida albicans Biofilm Formation and Hyphal Growth. Sci.Rep. 6, 23575; doi: 10.1038/srep23575 (2016).


IgG4-related kidney disease is a comprehensive term for renal lesions associated with IgG4-related disease, which mainly manifests as plasma cell-rich tubulointerstitial nephritis with increased IgG4+ plasma cells and fibrosis. IgG4-related kidney disease in the renal pelvis is rare.We describe a 53-year-old Asian woman who was referred to our hospital with a space-occupying renal lesion discovered by medical examination. A physical examination and laboratory evaluation revealed no significant abnormalities. Computed tomography scans showed a soft-tissue mass with an irregular border and mild homogeneous enhancement in the right renal pelvis and calyces. A positron emission tomography/computed tomography scan revealed soft-tissue density shadows with increased radionuclide uptake. To investigate a suspected pelvic carcinoma, a right ureteronephrectomy was performed. A pathologic examination of the renal sections showed a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, with fibrosis beneath the urothelial epithelium of the renal pelvis. Postoperatively, the serum IgG4 level was significantly elevated. The patient was diagnosed with IgG4-related kidney disease.We present a case of IgG4-related kidney disease mimicking urothelial carcinoma in the renal pelvis. When a buried and solitary hypovascular tumor is detected in the kidney, we must consider IgG4-related kidney disease as a differential diagnosis. Accordingly, elevated serum IgG4, radiologic findings, and pathologic examination may improve the diagnosis. IgG4-related disease (IgG4-RD) has recently been proposed and is considered to involve conditions of systemic inflammatory fibrosis, including autoimmune pancreatitis, retroperitoneal fibrosis, chronic sclerosing cholangitis, and inflammatory pseudotumor. IgG4-RD has now been reported in nearly every organ, though it was first identified in the pancreas and salivary glands –6. This IgG4-related kidney disease (IgG4-RKD) is a comprehensive term for renal lesions associated with IgG4-RD, which mainly manifests as plasma cell-rich tubulointerstitial nephritis (TIN) with increased IgG4+ plasma cells and fibrosis  , 7. Few A 53-year-old woman was referred to our hospital with a space-occupying renal lesion that was discovered incidentally by an ultrasound scan. The patient’s past medical history was positive for a gastric ulcer.A physical examination revealed no significant abnormalities. Laboratory evaluations, including urinalysis, were within normal limits, and urinary cytology was negative. Computed tomography (CT) scans showed a soft-tissue density mass with an irregular border and mild homogeneous enhancement in the right renal pelvis and calyces Fig. . A positBecause pelvic carcinoma was suspected, a right ureteronephrectomy was performed. Gross examination revealed only thickened mucosa of the renal pelvis but no obvious abnormalities in the renal cortex or medulla Fig. . A pathoIgG4-RKD is a comprehensive term for renal lesions, including renal parenchymal lesions and renal pelvic lesions, related to IgG4-RD, which is a recently recognized and proposed clinical entity characterized by a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells with fibrosis that affects several organs , 9. TIN A comprehensive English and non-English search for all articles pertinent to IgG4-RD of the renal pelvis was conducted using PubMed. Since Naoto Kuroda  first rePatients with IgG4-RD often have lesions in several organs, either synchronously or metachronously, although others may show the involvement of only a single organ. Renal lesions are recognized as extra-pancreatic manifestations of IgG4-RD; the condition can develop as IgG4-RKD singly or associated with the lesions of other organs. In previous cases, renal and extra-renal  involvements in IgG4-RD have presented simultaneously in two patients , 12. In On the basis of the results of a diagnostic algorithm procedure and with references to several diagnostic criteria for AIP, Mitsuhiro Kawano  proposedA rapid response to corticosteroid therapy is a characteristic feature of IgG4-RD, and corticosteroids are typically the first line of therapy, although no controlled trial has been performed. Moreover, the protocol used for corticosteroid therapy varies among countries and institutions . BecauseRecent studies have revealed several characteristic clinical features of IgG4-RKD, including predominance in middle-aged to older men, frequent association with IgG4-RD in other organs, high levels of serum IgG and IgG4, and a good initial response to corticosteroids. However, longer follow-up data for IgG4-RKD, including relapse information, are still sparse. Takako Saeki and his colleagues  retrospeWe present a case of IgG4-RKD that mimicked urothelial carcinoma in the renal pelvis. When a deep and solitary hypovascular tumor is detected in the kidney, we must consider IgG4-RKD as a differential diagnosis. Accordingly, elevated serum IgG4, radiologic findings, and pathologic examination may be helpful for the diagnosis.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.