Cystic renal cell carcinoma (CRCC) is relatively rare; CRCC is frequently misdiagnosed as a benign renal cyst. CRCC carries an excellent prognosis following surgical treatment. The aim of our study was to summarize the management of CRCC and to characterize the prognosis of affected patients.A retrospective study of 67 patients with CRCC was conducted at our center between January 2005 and April 2013. Patient prognosis as well as the clinical manifestations, imaging characteristics, treatment, and pathologic features of CRCC were summarized based on available medical record data.We identified 67 cases of CRCC, representing 2.5% of all renal cell carcinoma cases. The tumor was discovered incidentally in 70% of the cases. Ultrasonography was found to be a useful screening tool, but computed tomography remains the imaging study of choice for identifying malignant features. Magnetic resonance imaging can be used in equivocal cases. Regarding treatment, radical nephrectomy was performed in 52% of the cases, and partial nephrectomy was selected in the remaining 48% of cases. None of the 46 patients (68% of the study group) available for follow-up showed any evidence of recurrence.CRCC is an uncommon subtype of renal cell carcinoma, occurring in 2.5% of cases. CRCC carries an excellent prognosis after surgical treatment. Partial nephrectomy should be regarded as the preferred surgical technique for CRCC. Cystic renal cell carcinoma (CRCC) is relatively rare; it represents a special subtype of renal cell carcinoma (RCC) associated with a low nuclear grade and stage and an excellent prognosis regardless of tumor size. However, CRCC is frequently misdiagnosed as a benign renal cyst because it shares similar clinical manifestations and imaging characteristics. In the present study, we retrospectively analyzed 67 CRCC cases treated at our center; we summarize patient prognosis and the clinical manifestations, imaging characteristics, treatment, and pathologic features of CRCC based on medical record data. To our knowledge, this represents the largest series of CRCC cases, and it includes four cases with other concurrent RCCs.We reviewed our center’s pathology files and identified all RCC cases with a cystic component occurring between January 2005 and April 2013; 67 cases of CRCC were identified. Clinical data, including clinical and radiographic characteristics, surgical management, pathologic features, and outcomes, were retrospectively reviewed.Prior to surgery, patients underwent renal ultrasonography, abdominal computed tomography (CT), and magnetic resonance imaging (MRI) for evaluation of each patient’s overall and renal status. All cystic masses were graded according to the Bosniak classification system , and theThe Medical Ethics Committee of the First Affiliated Hospital of Medical College, Zhejiang University approved this retrospective study; the study was exempted from the requirement to obtain informed consent from the other 63 patients (not including 4 cases of concurrent RCCs) in consideration of the nature of the study. Written informed consent was obtained from the 4 patients (4 cases of concurrent RCCs) for publication of this manuscript and accompanying images.We identified 67 cases of CRCC, which represented 2.5% of the 2679 cases of RCC resected at our institution between January 2005 and April 2013; 217 out of all 2679 RCC patients had concurrent cystic renal lesions, and 4 out of the 67 CRCC patients had other concurrent RCCs , open partial nephrectomy n =12), laparoscopic radical nephrectomy (n =9), laparoscopic partial nephrectomy (n =20), and a second anesthesia for radical nephrectomy . Prior to 2010, 3 of 14 patients underwent partial nephrectomy. After 2010, 29 of 53 cases underwent partial nephrectomy. Fifty-three cases (79%) were nuclear grade I, 12 cases (18%) were nuclear grade I-II, and 2 (3%) were nuclear grade II ; among these, 7 patients  were followed for 56 months (range: 35–77 months). Their overall outcomes were excellent: there was no evidence of neoplastic recurrence or metastasis. Four cases died of non-neoplastic diseases.Cystic degeneration of the kidney is very common among renal lesions. However, CRCC is rare, accounting for only 1% to 4% of all RCCs in previous studies ; in our Accurate diagnosis is sometimes difficult because CRCC, conventional RCC with cystic change, and benign renal cystic disease have similar imaging characteristics. Ultrasonography has been found to be a useful screening tool. On sonography, CRCC appears as a cystic or cystic-solid structure with thick capsule walls, hyperechoic internal septa, and heterogeneous echogenicity , 8; duplThe differential diagnoses for CRCC include RCC with cystic change, hereditary leiomyomatosis manifesting as a cystic renal lesion, cystic nephroma, clear cell papillary RCC, and other cystic lesions of the kidney. These cystic tumors are extremely difficult to distinguish based on clinical, radiological, and gross features, and they can cause a diagnostic dilemma. Cystic renal cell carcinoma is a predominantly cystic lesion with a small solid component (25% or less). Renal cell carcinoma usually presents as a solid mass; however, in 10–22% of cases, it appears as a unilocular or multilocular cystic mass on imaging studies. Four mechanisms have been described to account for RCC with cystic features: intrinsic unilocular cystic growth (papillary cystic adenocarcinoma), intrinsic multilocular cystic growth, tumor necrosis resulting in cyst formation (pseudocyst), and tumor origination in a preexisting simple renal cyst. Typically, hereditary leiomyomatosis-associated renal tumors display type 2 papillary architecture, but they can show a variety of patterns, including cystic, tubular-papillary, tubular, and solid. Cystic nephroma consists of a circumscribed mass of cysts with intervening fibrous septa, occasionally areas of calcification, and regions of cellular bland ovarian-like stroma. The cysts are lined by a single layer of flattened low cuboidal or hobnail benign epithelium. Clear cell papillary RCC is usually cystic, with cyst walls lined by clear cells; however, much of the tumor typically exhibits papillary architecture, a feature not found in CRCC. It is important to avoid misdiagnosing CRCC as conventional clear cell RCC, which is one of the reasons that we chose to present this series of CRCC cases.Because of potential tumor rupture or spillage, the traditional treatment for CRCC has been radical nephrectomy. However, CRCCs tend to be smaller tumors at initial diagnosis and to have a lower T stage and nuclear grade; therefore, these lesions may be more amenable to partial nephrectomy. Because of the benign nature of CRCC, along with accumulating experience with partial nephrectomies and improved surgical techniques, increasing numbers of surgeons are choosing partial nephrectomy as the first-choice therapy for CRCC. Gong et al. suggested that a partial nephrectomy should be considered when a complex multicystic renal mass with enhanced density is observed, particularly as CRCC — like conventional RCC — is often located in the renal polar regions, which makes a partial nephrectomy approach feasible . Based oIntraoperative pathological examination may facilitate accurate diagnosis and help clinicians to modify their surgical approach. However, a minority of CRCC cases may not show any malignant signs on intraoperative pathology. In our study, three CRCC cases were intraoperatively diagnosed as simple renal cysts; these patients required a second anesthesia for radical nephrectomy. Indeed, even with frozen section evaluation at the time of surgery, confusion may remain in the determination of benign versus malignant disease. The cause of inexplicit pathology on frozen biopsy and aspiration is probably due to compression or ischemia of the cyst wall. If there is any intra-operative doubt regarding the absence of neoplasm, the renal cystic mass should be removed with clear margins. If suitable, a renal sparing approach should be considered. Currently, we are attempting to implement this philosophy to all patients.In our series, 217 of the 2679 RCC patients had concurrent cystic renal lesions, and 4 of the 67 CRCC patients had other concurrent RCCs. The kidneys are prone to a variety of cystic disorders that include developmental, acquired, and neoplastic lesions. However, the synchronous occurrence of two different tumors within the same kidney is a rare event. With the widespread use of ultrasonography, CT, and MRI, such coexisting tumors are now more readily diagnosed. Two or three concurrent renal cell tumors have been reported in cases involving hybrid tumors  and BirtMurad et al. suggested Fuhrman nuclear grade 1 as a defining criterion for CRCC . HoweverCystic renal cell carcinoma carries a better prognosis than other RCCs because of its low nuclear grade and TNM stage regardless of tumor size . The 10-Our results indicate that CRCC is uncommon. CRCC carries an excellent prognosis following surgical treatment. Partial nephrectomy should be regarded as the preferred surgical technique in the management of CRCC.Written informed consent was obtained from the 4 patients (4 cases of concurrent RCCs) for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


The control of antibiotic resistance and nosocomial infections are among the major challenges for specialized burn centers. Early detection of those epidemic outbreaks is crucial to limit the human and financial burden.We hypothesize that data collected in the frame of antibiotic consumption medico-economic surveys could be used as warning signal to detect early nosocomial outbreaks.Retrospective analysis including all burn patients staying more than 48 h and receiving systemic therapeutic antibiotics admitted to the Lausanne BICU between January 2001 and October 2012. Infection episodes were characterized according to predefined criteria. Antibiotic consumption data, obtained from the quarterly surveillance of drug consumption surveys, were translated in defined daily doses (DDDs).Pseudomonas aeruginosa (26.2%), Staphylococcus aureus (11.5%), Candida albicans (7.0%) were the main pathogens. We observed three distinct outbreaks of P. aeruginosa infections . These outbreaks were correlated with an increase in the DDD of anti-Pseudomonas antibiotics.297 out of 414 burn patients stayed more than 48 h for a total number of 7458 burn-days. We identified 610 infection episodes , due to 774 microorganisms. a paradigm shift in the epidemiological surveillance of nosocomial P. aeruginosa epidemics in Burn Centers, by using the rise in antibiotic consumption as an early trigger to initiate molecular typing of P. aeruginosa strains and reinforcement of standard infection control procedures.Our data support None declared.


MET oncogene promotes tumor growth, invasion and metastasis in several tumor types. Additionally, MET is activated as a compensatory pathway in the presence of EGFR blockade, thus resulting in a mechanism of resistance to EGFR inhibitors.Activation of the MET gene status, and MET-activating mutations on cetuximab sensitivity in recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC) patients.We have investigated the impact of HGF and MET expression, MET activation (phosphorylation), MET amplification in 39 % and MET activation (p-MET) in 30 %. Amplification was associated with MET overexpression. Log-rank testing showed significantly worse outcomes in recurrent/metastatic, MET overexpressing patients for progression-free survival and overall survival. Activation of MET was correlated with worse PFS and OS. In multivariate logistic regression analysis, p-MET was an independent prognostic factor for PFS. HGF overexpression was observed in 58 % patients and was associated with MET phosphorylation, suggesting a paracrine activation of the receptor.A single-institution retrospective analysis was performed in 57 patients. MET overexpression was detected in 58 % patients, HGF/MET pathway activation correlated with worse outcome in recurrent/metastatic HNSCC patients. When treated with a cetuximab-based regimen, these patients correlated with worse outcome. This supports a dual blocking strategy of HGF/MET and EGFR pathways for the treatment of patients with recurrent/metastatic HNSCC.The online version of this article (doi:10.1186/s12967-015-0633-7) contains supplementary material, which is available to authorized users. The incidence of head and neck cancer is increasing worldwide, and has recently become the sixth most common malignancy . MalignaTraditionally, the concurrent use of surgery, radiation, and/or multiagent chemotherapy for the management of patients with late-stage, locoregionally advanced unresectable disease has been the standard for treatment of HNSCC . Alternahttp://clinicaltrials.gov) were conducted with HGF antagonists  and MET inhibitors  in order to determine whether the inhibition of the HGF/MET pathway may be of therapeutic benefit in HNSCC patients AATACATTACCACATCTGACTTG; sequencing primer, 5′-GCTGATTTTGGTCTTGCC. Fifty ng of DNA were PCR amplified, modified, and finally pyrosequenced on a PyroMark ID system (Qiagen) following the manufacturer’s instructions. Cut-off value vas set to 8 % nucleotide mutation.Pyrosequencing was used to evaluate the status of selected Y1248C and Y1253D 2 test (Fisher’s exact test) or Mann–Whitney test. Overall survival (OS) was defined as the time elapsed from the date of initial diagnosis to the date of death from any cause or the date of last follow-up. Progression-free survival (PFS) was defined as the time from treatment to either progressive disease or death from any cause, censored at last contact [Statistical analysis was carried out with IBM SPSS Statistics version 21.0. Overexpression criteria were defined by receiver operating characteristic (ROC) curve for each protein. ROC analysis was used to determine the optimal cut-off value based on the progression endpoint for each protein, in agreement with the methodology used in prognostic studies . Amplifi contact . Surviva contact .Clinical-pathological features for both test and control groups of patients are summarized in Table EGFR elevated expression was confirmed in all the cases, both at the gene . In our series, all the cases displaying gene amplification except one also showed high levels of receptor expression, confirming the straightforward link between genomic dose and protein synthesis. All the test cases that showed MET amplification were also overexpressing the protein (100 %). In the case of the control samples, 6 out of the 7 (86 %) patients with amplification showed high levels of MET expression. Additionally, other significant associations were found between receptor activation with gene amplification (P = 0.047) and receptor expression (P = 0.013).ses Fig. b. Twentyes Table . Althougon Table   that had shown p-MET overexpression did in fact hold elevated mRNA levels of its ligand. Importantly, HGF overexpression was associated with MET phosphorylation (P = 0.001), suggesting a paracrine activation of the receptor (Table Elevated levels of ligand HGF are coupled with activation of the MET receptor. The expression levels of the or Table .MET mutations in HNSCC. One case (2 %) was deemed positive with 12 % mutation TGT in position Y1248. In addition to the pyrosequencing analysis, de novo sequencing was performed in the amplified 34-nucleotide length region spanning the Y1248 and Y1253 area in the MET locus, in order to check for the presence of hotspots surrounding the 2 targeted codons 1248 and 1253.Sequencing screening was performed for the two most frequent Y1248 and Y1253 P = 0.002) and OS (P = 0.045). p-MET expression was also significantly associated with a poor clinical outcome for OS (P < 0.001). Patients with p-MET overexpression had worse prognosis  compared with p-MET negative/low expression cases . Moreover, p-MET overexpression also correlated with worse PFS (P = 0.014). Multivariate Cox analysis in the test group . It was found that the amplified MET was constitutively activated, suggesting an oncogene addiction phenomenon that was required for cell survival . Our preMET amplification. In fact, HGF overexpression did not correlate with MET amplification (P = 0.786), although it was associated with MET phosphorylation (P = 0.001), suggesting a paracrine activation of the receptor , probably due to the small probability of finding low-prevalence mutations in our small series. Although these mutations are barely detectable in primary tumors from patients, it has been shown that cells carrying the mutations are selected during the metastatic spread [MET gene tend to accumulate mutations in the tumoral cells, and it might be related to the mechanisms and consequences of the previously described Y1248 and Y1253 mutations in HNSCC.Regarding the third possible mechanism of MET activation, two somatic constitutively active MET mutations have been identified in lymph node metastases of HNSCC (Y1248C and Y1253D) . Only onc spread . This isFrom a clinical perspective, the most relevant finding of this study was the prognostic role of MET and p-MET expression in HNSCC. In the literature debate surrounds the possible prognostic role of total MET in human cancer, with many studies suggesting a negative prognostic role , 47, whiSince the first reports of EGFR-targeted therapy in HNSCC, it has been known that EGFR expression is needed for cetuximab response, although EGFR expression does not predict response. Our data suggest that combined treatments of a MET inhibitor and cetuximab may be cumulative, and therefore dual blocking of EGFR and HGF/MET pathways could be a reasonable therapeutic option for clinical practice. Among the various options for inhibiting MET, most efforts concern to the use of small molecule inhibitors of MET, or antibody inhibitors of MET or its ligand, HGF .MET gene amplification, while HGF overexpression is required for MET activation in non-amplified cases. In recurrent/metastatic HNSCC patients, MET and p-MET overexpression are associated with poor outcome, and phosphorylation of MET is considered an independent prognostic factor in these patients. Finally, and in accordance with previous suggestions in different cancer types, we propose that the HGF/MET pathway might act as a primary resistance mechanism for EGFR inhibitors. The absence of a correlation between HGF/MET pathway activity and outcome in the control group is a significant finding that reinforces this hypothesis. Consequently, we would contemplate a dual blocking of both routes, in a combination therapy of EGFR and HGF/MET tyrosine-kinase inhibitors, for those patients with recurrent or metastatic HNSCC.Due to the limited number of patients in our study and the fact that our analysis did not include a validation cohort, we must assume the conclusions as a preliminary indication of the role of the HGF/MET pathway regarding cetuximab resistance in HNSCC. We have confirmed that the pathway is overexpressed and overactivated in HNSCC patients. This activation of MET is constitutive in those patients with


We will show that the HGF/c-Met pathway is associated with breast cancer progression and suggest that there is a firm basis for continued development of anti-c-Met treatment, particularly for patients with basal-like and triple-negative breast cancer.c-Met is a receptor tyrosine kinase that upon binding of its ligand, hepatocyte growth factor (HGF), activates downstream pathways with diverse cellular functions that are important in organ development and cancer progression. Anomalous c-Met signalling has been described in a variety of cancer types, and the receptor is regarded as a novel therapeutic target. In breast cancer there is a need to develop new treatments, particularly for the aggressive subtypes such as triple-negative and basal-like cancer, which currently lack targeted therapy. Over the last two decades, much has been learnt about the functional role of c-Met signalling in different models of breast development and cancer. This work has been complemented by clinical studies, establishing the prognostic significance of c-Met in tissue samples of breast cancer. While the clinical trials of anti-c-Met therapy in advanced breast cancer progress, there is a need to review the existing evidence so that the potential of these treatments can be better appreciated. The aim of this article is to examine the role of HGF/c-Met signalling in  MET gene were subsequently described in hereditary and sporadic papillary renal cell carcinomas [The receptor tyrosine kinase (RTK) c-Met was originally identified as the product of a transforming gene generated from a chemically transformed osteosarcoma cell line . In 1991rcinomas . Since trcinomas -10. Accorcinomas .New therapeutic targets are needed in breast cancer, particularly in patients with triple-negative (TN) breast cancer and the related basal-like (BL) subgroup of breast cancer. Although distinct, BL tumours can be considered an aggressive subgroup of TN cancers, and both are characterised by a lack of oestrogen receptor and c-erbB2 (Her2) expression, limiting systemic treatment options ,13. Sincin vitro and in vivo models of breast cancer, and the various mechanisms of aberrant c-Met signalling identified in breast cancer tissue. We will also outline the anti-c-Met compounds currently being investigated as possible breast cancer treatments.The aim of this review is to explore the roles of HGF/c-Met signalling in breast development, different c-Met is first produced as a 170 kDa precursor that then undergoes proteolytic cleavage, generating a 50 kDa α-subunit and a 145 kDa β-subunit ,14. The The only known mammalian agonistic ligand for c-Met is HGF  . As is tWhen HGF binds to c-Met, the receptor undergoes autophosphorylation of the Y1234 and Y1235 residues in the kinase domain . SubsequThe only other ligand known to bind c-Met in mammals is decorin, a leucine-rich proteoglycan . DecorinIn common with other RTKs, c-Met is regulated by the ubiquitin ligase, Cbl ,20. FollThe relationship between HGF and c-Met during development is complex and dynamic. In a study of mouse embryos, Andermarcher and colleagues described a shift in expression of HGF and c-Met from gastrulation to early organogenesis . It was The HGF/c-Met pathway may also have distinct roles in the different compartments of the mammary epithelium. Exposure of luminal epithelial and myoepithelial cells to HGF evokes contrasting effects in the two cell types . The groin vivo models have further emphasised the importance of the HGF/c-Met pathway in mammary development [Other studies utilising primary murine mammary epithelial cells in elopment ,27. Overelopment ,27. ImpoA broad range of mechanisms may result in aberrant c-Met signalling, including activating gene mutations, gene amplification, protein overexpression, increased ligand-dependent paracrine stimulation and the acquisition of autocrine signalling  Table 11. In breMET in hereditary and sporadic papillary renal cell carcinomas [MET mutations have also been found in up to 30% of cancers of unknown primary origin [MET mutations in primary breast cancer. In a small study comprised of 11 patients with breast cancer (including six patients that showed loss of heterozygosity in the region of the MET gene), no mutations in the tyrosine kinase domain of the MET were identified [Following the discovery of mutations in the tyrosine kinase domain of rcinomas , MET muty origin . These my origin . Howeverentified . A truncentified .MET gene (located on chromosome 7), like mutation, is unusual in invasive breast cancer: in a study of 155 patients, Carracedo and colleagues did not identify MET amplification at all  [MET in a minority of cases (82 out of 971 tumours studied) [MET was not an independent predictor of recurrence-free survival, these workers did note lower recurrence-free survival rates in the MET-amplified group on univariate analysis [MET copy number and TN status [Amplification of the olysomy) . Elsewhestudied) . Althouganalysis . MoreoveN status .MET may also be important in other molecular subtypes of breast cancer: in a study of 130 Her2-positive breast cancers, both MET and HGF amplification were associated with trastuzumab failure and patients with MET amplified tumours had a shorter time to progression [Amplification of gression .Several lines of evidence suggest that HGF-dependent c-Met signalling (both paracrine and autocrine) is an important mediator of breast cancer progression -38. HGF While analysis of HGF/c-Met coexpression provides useful insight into the role of ligand-dependent c-Met activation, measuring c-Met phosphorylation would also take into account ligand-independent c-Met activation, theoretically giving a more global readout of c-Met signalling. Unfortunately, the detection of c-Met phosphorylation in human formalin-fixed, paraffin-embedded samples is complicated by the poor stability of phospho-epitopes in general ,40 and bc-Met protein overexpression, as assessed by immunohistochemistry (IHC)/immunofluorescence, is now generally accepted to be a poor prognostic factor in invasive breast cancer ,38,45-51In an analysis of six different commercial c-Met antibodies (five of which recognised the protein at western blot), Pozner-Moulis and colleagues found a low correlation between c-Met expression on different sections of the same tissue microarrays stained with the same antibody . MoreoveMost studies have found no association between c-Met expression and established prognostic factors, such as age at presentation, tumour size and lymph node status ,46,49,53In our own analysis we identified significantly different levels of c-Met expression in two special histological subtypes of breast cancer: levels were lower in the E-Cadherin-negative invasive lobular carcinomas and higher in tubular carcinomas  Figure , a well-MET overexpression at the RNA level and c-Met protein overexpression are more often seen in the BL BCLs [A variety of breast cancer cell lines (BCLs) have been used to study the role of HGF and c-Met in a range of cellular processes implicated in the progression of breast cancer. Although these BCLs include those representative of the luminal, Her2-overexpressing and BL subtypes,  BL BCLs ,56.The extent of tubule formation is a key component of the grading system in invasive breast cancer . A lack The promigratory and proinvasive effects of HGF have been shown in several BCLs, including MCF7, MCF10.DCIS and MDA-MB-231 -62. AdmiNumerous studies have sought to uncover the mechanisms through which HGF/c-Met signalling contributes to the migratory and invasive phenotype in breast cancer, particularly focusing on pathways associated with epithelial adhesion -67. E-CaIn addition to favouring epithelial dissociation via E-Cadherin downregulation/internalisation, there is some evidence that HGF/c-Met signalling contributes to breast cancer progression by promoting cancer cell adhesion to components of the extracellular matrix . HGF trein vitro setting [in situ cell lines (MCF10.DCIS cells and SUM102 cells). Increased collagen IV degradation was also demonstrated, along with increased numbers of invasive outgrowths in three-dimensional cultures of ductal carcinoma in situ cells when in the presence of HGF [in situ to invasive cancer [Proteolytic pathway regulation is another mechanism influenced by HGF/c-Met signalling in the  setting . Conditie of HGF . Togethee cancer .HGF/c-Met signalling has been associated with both pro-apoptotic and anti-apoptotic effects . Using tL [A similar mechanism may also exist in breast cancer cells, where treatment of preneoplastic MCF-10AT breast epithelial cells with anti-FAS  induced c-Met/FAS complex dissociation and apoptosis . It has L ,74.It is widely appreciated that c-Met can cross-talk with a variety of other cell surface receptors (reviewed in ). In breMET resulted in increased Her2 phosphorylation and, conversely, knockdown of Her2 was associated with an increase in c-Met activity [Similarly, another member of the c-erbB family – Her2 – has been noted to cross-talk with c-Met in HCC1954 breast cancer cells, which overexpress c-Met and Her2 . In HCC1activity .The relationship between c-Met and other RTKs has important implications for the development of resistance to anti-RTK therapies already in clinical use – now a significant problem in breast cancer treatment . Indeed,in vivo effects of aberrant HGF/c-Met signalling have been explored in different mouse models [WAP-HGF transgenic construct show elevated HGF expression in mammary epithelium, compared with wild-type mice, and go on to develop mammary tumours characterised by a high Ki67 proliferation index, a reduced progesterone receptor immunoreactivity and areas of squamous differentiation (a feature of BL breast cancers) [The e models -83. Micecancers) ,84.MET [MET in the mammary epithelium, under the control of the murine mammary tumour virus promoter [TP53, in addition to oncogenic MET expression, was associated with the formation of tumours with a claudin-low profile, a recently described subgroup of TN tumours that is distinct from the BL subtype [Squamous metaplasia was also detected in a high proportion (65%) of mammary tumours that developed in mice with mutationally activated MET . The majMET . Elsewhepromoter . About opromoter  such as promoter . These tpromoter . Interes subtype ,86.There are various strategies for antagonising HGF/c-Met signalling: antibodies can be directed against c-Met; HGF itself can be targeted with antibodies; and the catalytic function of c-Met can be opposed with tyrosine kinase inhibitors, which account for the majority of anti-c-Met compounds under investigation . Four thAs well as breast cancer, the anti-c-Met monoclonal antibody MetMab is also being trialled in lung cancer and colon cancer . Unlike Tivantinib belongs to the c-Met tyrosine kinase inhibitor class of c-Met antagonists, and is a non-ATP competitive inhibitor of the receptor ,90. A phin vivo, but also promotes tumour hypoxia and cell death and inhibits the growth of MDA-MB-231 tumours in a dose-dependent manner [Cabozantinib is another small molecule inhibitor of c-Met, which targets a range of tyrosine kinases, including RET, KIT and AXL, but particularly c-Met and VEGFR2 . Cabozant manner . It has t manner .in vivo model of lung cancer [Foretinib is a small molecule kinase inhibitor that principally targets c-Met and vascular endothelial growth factor receptor . Foreting cancer . A phaseg cancer .in vitro and in vivo evidence that this is an important pathway in mammary development and cancer progression. Clinical studies have confirmed the prognostic significance of c-Met expression in breast cancer and highlight the potential of c-Met inhibitors as a novel form of targeted therapy. The possible role of c-Met signalling in promoting BL breast cancer is noteworthy, and merits further investigation in the experimental and clinical trial settings. The outcomes of ongoing and future clinical trials of anti-c-Met therapy will be eagerly anticipated, but issues such as receptor cross-talk and resistance may need to be addressed if treatment efficacy is to be maximised. It is also important to stratify patients appropriately, and the development of standardised prognostic/predictive assays will be crucial in identifying those subgroups of patients most likely to benefit from anti-c-Met therapy.Much progress has been made in our understanding of c-Met/HGF signalling in recent years, and there is now convincing


Dosing antibiotics in critically ill patients to achieve therapeutic concentrations is a significant challenge. The presence of septic shock and prescription of continuous renal replacement therapy introduces further complexities for the clinician. Unfortunately, this is a dilemma encountered daily by intensivists. Although small pharmacokinetic studies are emerging to provide data to help address this problem, the variability in results from these studies is profound. As such, effective antibiotic dosing guidelines for critically ill patients who have septic shock and who receive continuous renal replacement therapy are not available. Dosing flowcharts and therapeutic drug monitoring represent the best available options for clinicians to optimize antibiotic dosing. Critical Care seeks to describe the challenges of beta-lactam antibiotic dosing in critically ill patients who have septic shock and who are receiving continuous renal replacement therapy (CRRT). Along with patients on extracorporeal membrane oxygenation [The review article from Ulldemolins and colleagues  in this genation  or thosegenation  or rapidgenation , the patgenation ,6.The dosing of antibiotics is more complex than that of other therapeutic classes, such as sedatives, vasoactive agents, and other drugs commonly used in the intensive care unit, because an ‘end-of-needle’ effect is not apparent. This complicates attempts to titrate antibiotic dosing on the basis of clinical evolution. Given that critically ill patients who have sepsis and who are receiving renal replacement therapy (RRT) have a 50% higher mortality than their non-septic equivalents and that the mortality rate is unacceptably high (more than 60%) , optimizThe review by Ulldemolins and colleagues  describeThe authors highlight some interesting concepts based on pharmacokinetic differences between three selected antibiotics: ceftriaxone, piperacillin, and meropenem. Ceftriaxone has high, but variable, protein binding , and avaP = 0.12), piperacillin , and vancomycin . Although antibiotic clearance in these patients has not been well correlated with achievement of therapeutic concentrations, one would assume that a strong relationship does exist. Furthermore, knowledge of recovering renal function is important given that this is a pathway for additional drug excretion for many beta-lactams in these patients.CRRT enhances the elimination of antibiotics, and so this effect must be anticipated and the dosing regimen adjusted. Important components that should be considered include the CRRT technical settings  and duration of use (on- and off-time). The authors highlight that the delivered dose of RRT is an informative predictor of antibiotic clearance. Subsequent to the literature review by Ulldemolins and colleagues, a published meta-review by Jamal and colleagues  demonstrGiven the sources of beta-lactam pharmacokinetic variability highlighted, Ulldemolins and colleagues suggest a general approach to dosing of patients. Although the concepts are useful, a paucity of data means that robust guidance and conclusions are limited. For example, data on the size of loading doses, the influence of patient morphology , sites of infections , susceptibility of the bacteria, and the risks from antibiotic overdosing  are not included. It is anticipated that these factors are important considerations for optimizing beta-lactam dosing, although their significance on the basis of existing data and the other complex changes noted in critical illness requires further research. Other research of interest, prompted by this research, includes the utility of biomarkers of organ function and disease severity for guiding antibiotic dosing and the clinical impact of dose optimization on patient outcomes. The poor overall outcomes of critically ill patients with sepsis mandate the importance of such research.To develop a dosing guideline that accounts for variation in each of these parameters as well as in RRT modalities and settings, a large multicenter RRT pharmacokinetic study is required. The newly commencing SMARRT  Study may, in time, provide such answers .Until such a robust guideline becomes available, clinicians will be reliant on applying dosing flowcharts such as that proposed by Choi and colleagues  or by acCRRT: Continuous renal replacement therapy; RRT: Renal replacement therapy; TDM: Therapeutic drug monitoring.The authors declare that they have no competing interests.


A 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. Colonoscopic findings were intermittent nodular lesions with redness which were atypical to primary rectal cancer. Endoscopic retrograde cholangiopancreatography showed narrowing of the bilateral intrahepatic bile duct. However, the findings were improved 1 month later. Blood biochemistry showed high level of serum IgG4 up to 1140 mg/dl. The patient matched to comprehensive diagnostic criteria for IgG4-related disease as a possible diagnostic case. Laparoscopic low anterior resection with creation of ileostomy was performed for rectal cancer. Histological findings revealed cancer cells spread horizontally at submucosal layer and subserosal layer. There was marked infiltration of the plasma cells and lymphocytes at tumor stroma, and more than half of the plasma cells were positive for IgG4. After surgery, the level of serum IgG4 was decreased to 597 mg/dl. Although the association with IgG4-related disease and colorectal disease is unclear, the tumor progression was atypical for rectal cancer. Some report that the disease may rise up the risk of a malignant disease. It is necessary to perform systemic examination keeping in mind for concurrence of malignancy. IgG4-related disease is the notion which involves enlargement, tumor, nodule, and thickening lesion in various kinds of systemic organs. It is characterized by marked infiltration of lymphocytes and IgG4-positive plasma cells and fibrosis . AutoimmA 67-year-old man was referred to our hospital with suspicion of rectal tumor, hilar tumor, and urinary tumor. He had hyper urine acid and diabetes mellitus. There were no abnormal physical findings. Blood biochemistry showed slight increase of the CEA, CA19-9, and SPAN-1 levels to 6.7 ng/ml, 45.7 U/ml, and 33 U/ml, respectively. Computed tomography (CT) showed thickening of the hilar bile duct, dilatation of the bilateral intrahepatic bile duct, swelling of the para aortic lymph node, dilatation of the left renal pelvis, and thickening of the rectal wall. The pancreas was not enlarged Fig. . They weIgG4-related disease is a relatively new disease entity transmitted to the world from Japan. Comprehensive diagnostic criterion for IgG4-related disease was advocated in 2012 [In this case, thickening of the bile duct and elevated serum IgG4 concentration strongly suggested IgG4-related cholangitis. Infiltration of plasma cells and fibrosis in the retroperitoneal tissue also supported the existence of IgG4-related retroperitoneal fibrosis. Pathological findings of the rectal specimen showed that IgG4-positive plasma cells infiltrated to the connective tissue around rectal cancer. Some reported abundant infiltration of IgG4-positive plasma cells was revealed around malignant tumor in six of eight cases of malignant tumor with autoimmune pancreatitis . On the Histological findings revealed that cancer cells mainly resided in submucosal layer and they partly spread to mucosal layer. The cluster of cancer cells was seen diffusely through the rectal wall. We speculated that the cancer progressed by mural metastasis, and this unique pattern of progression might be affected by infiltration of IgG4-positive plasma cells.To assess the stage of cancer progression, PET was performed. Because the positive accumulation to the lesion of IgG4-related disease was also observed, it was difficult to distinguish cancer from the disease. In this case, systemic lymph node swelling and accumulation to them were shown by PET. We considered that it was due to IgG4-related disease because distribution of the swelling lymph nodes was not usual for rectal cancer. The patient received adjuvant chemotherapy (modified FOLFOX6) because the cancer was staged as stage IIIC.Intraoperative findings showed sclerosis around the artery and stenosis of the ureter which indicated periarteritis and retroperitoneal fibrosis. These findings also supported to make diagnosis of IgG4-related disease.Although sclerosing esophagitis, gastric ulcer, and polyps were reported as gastrointestinal tract lesion of IgG4-related disease –6, the aRecently, coexistence of IgG4-related disease and malignant tumor was reported –12. The We experienced a case of IgG4-related disease with rectal cancer which had atypical progression. It is difficult to distinguish IgG4-related disease from malignancy. As the disease sometimes coexists with malignant disease of other organs, it is necessary to perform systemic examination keeping in mind for concurrence of malignancy.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


The rheological or flow properties of concrete in general and of high performance concrete (HPC) in particular, are important because many factors such as ease of placement, consolidation, durability, and strength depend on the flow properties. Concrete that is not properly consolidated may have defects, such as honeycombs, air voids, and aggregate segregation. Such an important performance attribute has triggered the design of numerous test methods. Generally, the flow behavior of concrete approximates that of a Bingham fluid. Therefore, at least two parameters, yield stress and viscosity, are necessary to characterize the flow. Nevertheless, most methods measure only one parameter. Predictions of the flow properties of concrete from its composition or from the properties of its components are not easy. No general model exists, although some attempts have been made. This paper gives an overview of the flow properties of a fluid or a suspension, followed by a critical review of the most commonly used concrete rheology tests. Particular attention is given to tests that could be used for HPC. Tentative definitions of terms such as workability, consistency, and rheological parameters are provided. An overview of the most promising tests and models for cement paste is given. The rheological (flow) properties of concrete are important for the construction industry because concrete is usually put into place in its plastic form. This importance can be attested to by the large body of literature existing on concrete rheology ,2,3,4. UThe purpose of this paper is to assess the state of the art in measurements of flow properties of concrete. A critical review of the tests available is given with special emphasis given to tests for high performance concrete (HPC). Definitions of terms commonly used in the field and their link to material properties are provided.Concrete and mortar are composite materials, with aggregates, cement, and water as the main components. Concrete is really a concentrated suspension of solid particles (aggregates) in a viscous liquid (cement paste). Cement paste is not a homogeneous fluid and is itself composed of particles (cement grains) in a liquid (water).η = viscosityv/dy  use at least two parameters to describe the flow. In the case of a concentrated suspension such as concrete, it has been shown ,5 that aen shown  that in en shown  in most “Workability is a measure of how easy or difficult it is to place, consolidate, and finish concrete”“Consistency is the ability of freshly mixed concrete to flow”“Plasticity determines concrete’s ease of molding”.In the construction field, terms like workability, flowability, and cohesion are used, sometimes interchangeably, to describe the behavior of concrete under flow. The definitions of these terms are very subjective. Class I: qualitativeWorkability, flowability, compactibility, stability, finishability, pumpability, consistency, etc. To be used only in a general descriptive way without any attempt to quantify.Class II: quantitative empiricalSlump, compacting factor, Ve-be, etc. To be used as a simple quantitative statement of behavior in a particular set of circumstances.Class III: quantitative fundamentalViscosity, yield stress, etc. To be used in conformity with the British Standard Glossary .It is clear that the definitions are descriptive and no agreement can be found. In the field, the situation is often worse because these terms are used differently by the various persons involved. From the previous list, all the terms used are defined according to the feelings of the person and are not based from the physical behavior of the material. Richtie  attempteAs stated in Sec. 2.2, the properties that could be used to describe the concrete flow are the yield stress and the viscosity. Any test that describes the flow behavior of concrete should at least measure these two properties. Unfortunately, most existing tests measure only one factor, either related to the yield stress or to the viscosity. Descriptions of these tests are given in Sec. 3.1. Tests measuring both parameters exist but are neither cheap nor easy to carry out, so they are not widely used. Section 3.2 describes these tests.Aside from measuring the flow of concrete, rheology is concerned with the prediction of the flow from the properties of the components  or from the mix design . No attempt to develop a prediction model has yet been successful. One difficulty comes from the fact that the size range of the particles is very wide (micrometers to tens of millimeters). Also, the factors influencing the flow properties of concrete are more than the factors influencing the rheology of the parts (cement paste and aggregates). There is no linear relationship between the rheological parameters of cement paste and those of concrete. The main reason being the gap between the aggregates which varies with the concrete cement paste volume content. Ferraris et al.  showed tIt should be kept in mind that all the models or methodologies given here assume that the concrete is formed of particles but no interparticle forces are directly considered. The only reference to particle interaction is the acknowledgment that all properties are time-dependent, implying that phenomena, such as flocculation of the cement particles and hydration, are continually taking place.In summary, concrete is a suspension, including particles that may range from less than 1 mm to over 10 mm. The flow properties of such a suspension can often be described approximately using a Bingham model, defined by two factors, plastic viscosity and yield stress. Most of the widely used tests are unsatisfactory in that they measure only one parameter, which does not fully characterize the concrete rheology. High performance concrete (HPC) is defined by ACI  as folloTo achieve this property special precautions need to be taken. According to Malier , a more “How to evaluate simply rheological performance of portland cement and its compatibility with given superplasticizers?How to evaluate simply in the laboratory and in the field, the workability of a concrete having a very low water/cement ratio by means other than the slump test?How is diminished the rheological performance of a given portland cement in the domain of low water/cement ratio?How to optimize the use of supplementary cementitious materials when making low water/cement ratio concrete?”Aitcin  has raisToday, the workability of HPC is evaluated using the same tests as used for normal concrete. However, the specific characteristics of HPC hinder the correct interpretation of current tests. This situation is demonstrated when the yield stress, as measured by a slump cone, is in the range desired but the viscosity (not measured in a slump cone test) may be so high that the mix is labeled “sticky” and is difficult to place in the molds even with vibration.Therefore, new tests are being designed specifically for HPC, as will be described in Sec. 3.2.3.Test methods for flow properties of concrete can be divided into two groups in regard to whether the output of the experiment gives one or two parameters. As was discussed in Sec. 2.2, to correctly define the rheology of concrete both the yield stress and the viscosity need to be measured.SlumpPenetrating rod: Kelly ball, Vicat, Wigmore testK-slump testVe-Be time or remolding test (Powers apparatus)LCL apparatusVibration testing apparatus or settling curveFlow coneTurning tube viscometerFilling abilityOrimet apparatus.Most currently used tests measure only one rheological value or factor. The relationship between the factor measured and either of the two fundamental rheological parameters is not obvious. In most cases, the fundamental parameter cannot be calculated from the factor measured, but can only be assumed to be related. The tests that are discussed here are :Tests 1 through 3 are related to the yield stress because they measure the ability of concrete to start flowing. Tests 4 to 10 are related to the viscosity because they measure the ability of concrete to flow after the stress exceeds the yield stress. The stress applied is either by vibration (tests 4–6) or by gravity (tests 7–10).A truncated metal cone, open at both ends and sitting on a horizontal surface, is filled with concrete, and lifted quickly. The slump of the concrete is measured as shown in The variability in the slump measurements is attributed mainly to the operator and to variations in mixture proportions. This test is a useful quality control tool because it can help detect changes in the composition of concrete delivered, e.g., changes in the amount of mixing water. This test is a standard in the United States (ASTM C143)  and is uA modification of the slump test, used for concretes with very high slump (as high as 305 mm (12 in) minus the coarser aggregate diameter), is to measure the spread instead of the height drop. This measurement is rarely reported and is not a standard. A second modification of the slump cone see  is the tRecently, the slump cone test procedure was modified to allow the estimation of both the yield stress and the viscosity ,30. As tThe principle of these tests is that the depth of penetration of an object will depend on the yield stress of the concrete. The mass or the force applied on the penetrating object will measure the yield stress of the concrete. Usually, the mass or the force is pre-established, i.e., it does not vary depending on the sample. Therefore, these tests really measure whether the applied stress is higher or lower than the yield stress of the concrete. Similar to the slump test, these tests are useful mainly on work sites as quality control tools to determine if the composition (mainly the water content) has been changed. These tests are also frequently used to determine the setting time of concrete. It should be noted that the Kelly Ball described in ASTM C360  was up fThe turning tube viscometer consists of a tube (60 mm in diameter and 800 mm long) that can be filled with the material to be measured . A ball This test was widely used  before iThe schematic design of the probe is shown in Nasser et al.  showed tThese tests measure the capability of the concrete to change shape under vibration . In bothThe LCL  apparatuhf, is represented by the asymptote of the settling curve.The Fritsch test measures the ability of concrete to be remolded or consolidated. The flow cone  is widelTwo slightly different tests exist to measure the filling capacity of concrete, i.e., the capability of concrete to flow into a form  and 16. This instrument consists of a 600 mm long tube, closed at the bottom by an openable trap. The time for the concrete to flow through the long tube is recorded. The test method of the Orimet is similar to the flow cone. This test has been used for underwater concrete. The instrument is more flexible than the flow cone because the orifice or diameter of the tube can be selected to accommodate different aggregate sizes.We now examine the tests whose output gives two parameters. The values measured by these tests do not necessarily allow a direct calculation of the viscosity and yield stress. The factors measured are often indirectly related to the two fundamental parameters in a nontrivial way. The difficulty in designing correct rheological tests, tests that allow direct measurement of the fundamental parameters, is largely due to the size of the coarse aggregates, the tendency of segregation, and to the time effects. The most common fluid rheometer geometry is coaxial cylinders. In this geometry, having aggregates with a size of 10 mm or greater would force the dimensions of the instrument to be huge because these dimensions are dictated by the desirability of having a linear flow gradient between the shearing surfaces. A good approximation of this linear flow gradient can be achieved if the difference between the inner and outer radii is at least five times the diameter of the maximum size aggregate and if the ratio between the radii is held between 1 and 1.10. Therefore, the minimal dimensions, with a maximum aggregate size of 10 mm, will be 0.5 m for the radius of the inner cylinder and 0.55 m for the outer cylinder radius. These are relatively large dimensions for a relatively small maximum size aggregate.This is the first and most widely known instrument for measuring the flow properties of concrete. The apparatus  consistsh, and the intercept at zero speed, g, are related to the plastic viscosity and the yield stress, respectively. Assuming that the effective average shear rate is proportional to the speed of the impeller, Tattersall [T = torqueG = constant obtained by calibration with Newtonian fluidsK = constant obtained by calibration with non-Newtonian fluidsN = speed of the impellerτ0 = yield stressη = viscosityTherefore, τ0 = g/(G/K) and η = h/G, where g and h are the two values measured. Unfortunately, the entities G and K are almost impossible to obtain for three main reasons:G and K.The flow pattern in the instrument is too complicated and not linear (or turbulent flow) to allow a calculation of The specimen container is too large to be able to use a standard oil to calibrate the rheometer . We belNo standard granular material exists with which to calibrate the instrument.Tattersall  designedttersall  gave theg and h . Two issues that remain are:The maximum aggregate size should be limited to 13 mm (0.5 in), calculated as being 1/5 of the gap between the cylinders.The ratio between the radii of the two cylinders radii is 1.45. This is considered too high to have a linear flow gradient, raising the question as to whether the calculation of the rheological parameters is correct.This instrument is not commercially available.This test apparatus was developed at the Technical Research Centre of Finland. Concrete is placed between two concentric cylinders of 480 mm and 330 mm diameters. The outer cylinder rotates in a oscillatory mode. The operator selects the frequency and amplitude. The torque induced by the movement is measured in the inner cylinder. This configuration allows the operator to calculate the viscosity and the yield stress of the concrete as a function of frequency. The advantage of this instrument is that is allows the operator to calculate the intrinsic rheological parameters of the materials and not only two related values, such as τ0 = shear yield stressη = viscosityR1 and R2 = inside and outside radii of the apparatush = height of the sheared part of the sampleΓ = torque applied to the sampleΩ = angular velocity of the rotating partΓ0 and ∂Γ/∂Ω = ordinate at origin and slope of the experimental straight line Γ(Ω).The rheometer, BTRHEOM, was developed at the Laboratoire Central des Ponts et Chaussées (LCPC), France by de Larrard et al. . It cons−1 and 8 s−1. De Larrard et al. [The instrument was used to collect data on shear stress versus shear rate. The results confirmed that the assumption of concrete being a Bingham fluid is correct if it had certain characteristics—These being a relatively fluid or soft concrete  with shear rates ranging between 0.5 sd et al.  found thThe limitations of this instrument are the range of plastic viscosity and yield stress that can be attained, i.e., high yield stress or high plastic viscosity concretes cannot be sheared. There is always a possibility of segregation during the test especially under vibration.The original method consists of measuring the time for a plate resting on the top of the concrete to slide down with the concrete  a distanResearchers at Sherbrooke University  eliminatRecently, a modification of the slump cone was developed to allow the measurement of viscosity. As mentioned in Sec. 3.1.1, the standard slump test can only be correlated with the yield stress. The modification consists in measuring not only the final slump height but also the speed at which the concrete slumped. There are two methods to measure the speed at which the concrete slumped :The oriThe second method has the advantage that there is no risk of the plate getting stuck, but has the disadvantage that it may be difficult to see the appearance of the rod.τ0, can be calculated from the final slump, using the following empirical equation:ρ is the density expressed in kg/m3, and S is the final slump in mm. The viscosity can be determined from the 100 mm slump time using an empirical equation that was determined by de Larrard et al. [μ is the viscosity in Pa·s and T is the slumping time in seconds. To facilitate the interpretation of the results, these equations can be represented in a graphic form as shown in The yield stress, d et al. ,30. The Concrete flow properties need to be characterized by more than one parameter because concrete is a non-Newtonian fluid. The most commonly-used model is the Bingham equation that requires two parameters, i.e., yield stress and the plastic viscosity. The yield stress determines the stress above which the material becomes a fluid. The plastic viscosity is a measure of how easily the material will flow, once the yield stress is overcome. Other models for special concretes, such as self-leveling or self-compacting, require a more complex model, such as the Herschley-Bulkley equation.Most of the common tests for measuring the flow properties of concrete yield only one parameter that is related either to plastic viscosity or to yield stress, or to some ill-defined combination of both. Most of these tests try to simulate field conditions and the results cannot easily be related to fundamental rheological properties. Their usage should be limited to quality control, or to check that mixture proportions have not been changed between batches. Of course, combining two tests, one related to yield stress and one related to viscosity, should give a better description of the concrete flow.Recently, tentative steps have been made to develop tests that can measure both parameters, possibly in fundamental units. These tests are the rheometers  that allow shearing at various rates, or the modified slump cone test.It is hard, if not impossible, to relate results obtained with different testsThe factors measured are not linked to independently measurable factors, that can be defined in fundamental physical units.This paper review has pointed out that most of the available tests are empirical. This is not a satisfactory situation for two reasons:The author would like to emphasize that more research, novel tests, and models should be developed to better characterize the rheology of concrete in general and HPC in particular.


WM) impairments hinder addicts' engagement in and benefit from treatment. The predictive value of WM integrity in heroin addicts during methadone maintenance treatment (MMT) for future relapse is unclear.Cognitive deficits caused by heroin‐induced white matter  and abstainers  according to the results of 6‐month follow‐up. Intergroup comparisons were performed for fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD). The correlation between diffusion tensor imaging indices and the degree of heroin relapse was analyzed.Forty‐eight HA group, HR group had reduced FA in the right retrolenticular part, left anterior and posterior limb of internal capsule, bilateral anterior corona radiata, and right external capsule. Three out of the six regions showed increased RD, with no changes in AD. The FA and AD values in the left posterior limb of internal capsule correlated negatively with the heroin‐positive urinalysis rate within follow‐up.Compared with WM integrity in MMT patients may add to neurobiological factors associated with relapse to heroin use. Strategies for improving WM integrity provide a new perspective to prevent future relapse to heroin abuse.Lower  Heroin addiction is an illness characterized by its chronic and relapsing nature. Despite a variety of effective therapies for heroin addiction  meeting the diagnostic criteria of DSM‐IV  for heroin addiction; (2) volunteering to receive long‐term and stable treatment at the MMT center; (3) taking MMT for at least 3 months and receiving a stable dose for at least 1 month before baseline; and (4) being strongly right handed as judged by the Edinburgh Handedness Inventory Oldfield . The excThis study was approved by the Institutional Board of the Fourth Military Medical University, Xi'an, China. As required by the Institutional Review Board of the Tangdu Hospital, all subjects were informed of the experimental details and aims of the study, and written consent for their involvement was collected from each subject.Methadone maintenance treatment was performed on each subject for at least 3 months before baseline and throughout the whole period of follow‐up after MRI scanning. The baseline for investigation was defined as the time point of MRI scanning. A 6‐month follow‐up was started at baseline by performing a structured interview along with urine test monthly to gather information on heroin intake and MMT status, similar as the design used previously . Routine Thttp://www.fmrib.ox.ac.uk/fsl/) were used for preprocessing and WM microstructure analysis  and AD (AD = λ1) were calculated using DTIFIT from FSL (Lim and Helpern Diffusion Toolbox (FDT) and Tract‐Based Spatial Statistics (TBSS) from FMRIB's Software Library  space. Then, the dimension of the image was resampled at a resolution of 1 × 1 × 1 mmhttp://www.fmrib.ox.ac.uk/fsl/randomise/index.html). The number of permutation tests was set to 5000 ‐ICBM‐DTI‐81 WM labels atlas and JHU WM tractography atlas in MNI space . Intergroup differences in RD and AD values in these ROIs were calculated with a two‐sample t‐test using a statistical significance level of P < 0.05.The FA values were compared between two groups and the skeletonized FA data were fed into voxel‐wise statistical analysis, based on a nonparametric approach utilizing permutation test theory by a randomized tool in FSL  and the positive urinalysis rate of HR within the 6‐month follow‐up period after baseline. The positive urinalysis rate was calculated by the proportion of positive urinalyses in all urinalyses of every patient in HR group. The general linear model was used to regress out the covariates of nuisance including age, years of education, duration and dosage of smoking, and heroin/methadone use. Due to the intergroup difference of the age, duration of smoking and history of methadone used prebaseline, we checked the potential correlations between these variates and the states of heroin relapse  or the DTI indices, using the binary logistic regression and pearson correlation analysis, respectively. Two‐sample t‐test and correlation analysis were performed using the Statistical Package for Social Sciences version 13.0 . A Of the 69 participants who underwent baseline DTI scans, 21 were excluded from the analysis because of incomplete brain coverage, head movement, gross cerebral abnormality, and incomplete follow‐up. According to the defined criteria for relapse, the rest 48 subjects were divided into two groups: 25 for HR and 23 for HA. All the heroin addicts in this study used heroin by snorting and 19 of them involved syringe injection.No significant difference was obtained in education level, number of cigarettes smoked per day, previous heroin consumption history, or daily methadone maintenance dosage between HR and HA groups Table . The meaP < 0.05, corrected by TFCE and FWE)  Fig. , Table 2P < 0.05), including the right retrolenticular part of internal capsule, left posterior limb of internal capsule, and right external capsule. No significant changes in AD were observed between groups (P > 0.05).The mean RD and AD values extracted from the six regions with significantly reduced FA were further analyzed Table . Resultsr = −0.89, P < 0.001; r = −0.88, P < 0.001, survived after Bonferroni correction)  and in internal capsule . Duration of cigarette smoking were negatively correlated with the AD values in right retrolenticular part of internal capsule and left anterior limb of internal capsule .ROI‐based correlation analysis demonstrated that in HR group, the FA and AD values in the left posterior limb of internal capsule significantly negatively correlated with the heroin‐positive urinalysis rate within 6‐month follow‐up (n) Fig. . No signThis study compared baseline WM integrity during MMT between heroin addicts who relapsed (HR) and those who did not (HA) within 6‐month follow‐up. Significantly lower baseline FA was detected in HR group than in HA group in six WM regions. This result supports the hypothesis that lower baseline WM integrity during MMT could predict the heroin relapse. Our observation of significantly increased RD in three regions with reduced FA also supports the above hypothesis. In HR group, FA and AD values in the left posterior limb of internal capsule correlated negatively with the heroin‐positive urinalysis rate. This finding may highlight the predictive value of this WM region for the severity of heroin relapse.Decreased WM integrity in the relapsers was found mainly in the internal/external capsule and the anterior corona radiata. These regions are regarded as important components of the neural circuit involved in substance addiction. As part of the limbic–thalamo–cortical circuitry, anterior corona radiata involves thalamic projections from the internal capsule to the prefrontal cortex areas, which are critical in reward seeking and inhibitory control in substance dependence and relapse  and lower risk of relapse among those who were stable in MMT program; however, the magnitude of the effect of methadone dose was considered to be only moderate, and those using methadone in high dosage were still at a considerable risk of relapse (Termorshuizen et al. In summary, this study demonstrated that future relapsers have lower WM integrity than abstainers under MMT. Since lower WM integrity is associated with higher frequency of relapse, it may add to neurobiological factors associated with relapse to heroin use. Furthermore, our findings provide insight into the strategies for reducing relapse risk to heroin addiction by improving WM integrity, which requires further test.The authors have no conflicts of interest to declare.


Five antibiotics including ciprofloxacin, amikacin, ceftazidime, piperacillin, and imipenem were tested against 10 clinical isolates of Pseudomonas aeruginosa. Each isolate was tested against ten double and nine triple combinations of the antibiotics. A 96-well plate was used to test three antibiotics, each one alone and in double and triple combinations against each isolate. The minimum bacteriostatic and bactericidal concentrations in combination were determined with respect to the most potent antibiotic. An Interaction Code (IC) was generated for each combination, where a numerical value was designated based on the 2-fold increase or decrease in the MICs with respect to the most potent antibiotic. The results of the combinations were verified by time-kill assay at constant concentrations of the antibiotics and in a chemostat. Only 13% of the double combinations were synergistic, whereas 5% showed antagonism. Forty-three percent of the triple combinations were synergistic with no antagonism observed, and 100% synergism was observed in combination of ciprofloxacin, amikacin, and ceftazidime. The presented protocol is simple and fast and can help the clinicians in the early selection of the effective antibiotic therapy for treatment of severe infections.An Empirical antibiotic combination therapy is employed to treat severe infections in neutropenic and severely ill patients when the antibiotic susceptibility profile of the causative pathogen is unknown. Combined antibiotic therapy is preferred over monotherapy because it has a broader antibacterial spectrum, synergistic effect, and reduced risk of emerging resistance during therapy . It is rIn patients with severe sepsis, the decision of selection of the combination therapy must be taken in the first hours of diagnosis . It has  Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae have a substantial impact on hospital costs and mortality rates  as described before [μM menadione. The samples were incubated in the dark for 1 h at 37°C, after which a colorimetric change in the XTT was measured using a microtiter plate reader at 490 nm. Drug-free experiments were used as control.To verify the results obtained by the microdilution method, the bactericidal activity of CIP, AMK, and CAZ alone and in double and triple combinations was determined by time-kill assay. Briefly, 24-hour-old culture of isolate PA14 was suspended in normal saline and used to inoculate 100 mL of cations-adjusted MHB in 250 mL Erlenmeyer flasks to give initial inoculum size of 1 to 5 × 10d before . In brie in vivo situation in which bacteria are exposed to supra-MIC and sub-MIC of the antibiotics  to the bottles after 10 hours of inoculation. The bottles were connected to two IV infusion pumps via IV infusion sets. The first pump delivers fresh medium to the bottles at 10 mL/h to provide nutrients and continuously dilute the antibiotics. A second pump was connected to the bottle through disposable syringe bacterial filter (0.45 μm pore size) to withdraw the medium without the bacteria at 10 mL/h. The bottles were placed over magnetic stirrer at 37°C. Second and third doses of the antibiotics were added at 30 and 60 h and the flow rate was kept at 10 mL/h throughout all experiments. To avoid clogging of the filter, 2 mL portions of the fresh medium were injected into the filter in opposite direction to remove any bacterial cells back to the bottles, and the filters were replaced when needed. At different time intervals, 1 mL samples were taken for determination of the viable cell by viable count. Drug-free experiments were used as control.The experiment was configured to simulate theibiotics . The tesp < 0.05) to determine significant difference between means.Each experiment was performed in triplicate and the mean and the Standard Deviation (SD) were calculated. One-way analysis of variance (ANOVA) was used to determine the differences between various treatments. Tukey's pair comparison test was used at the chosen level of probability  in 15 isolates (data not shown) compared to 13 isolates with the presented model, where the IC value was 2 or more in double combination of the antibiotics. Antagonism was demonstrated in addition of IMP to either CAZ or PIP in 5% of the combinations similar to the results obtained by the presented microdilution model. in vitro antibiotic synergism using time-kill assay. The double combinations of the antibiotics  were found to be additive (IC = 1). Triple combination of the antibiotics, on the other hand, was synergistic (IC = 3). The time-kill assay showed that the double and triple combinations of the antibiotics at their 1/4 MICs had no significant effect (p > 0.5) on the bactericidal activity compared to each antibiotic alone (data not shown). When the drugs were tested at their 1/2 MICs, triple combination of the antibiotics significantly inhibited the growth of the bacteria (p < 0.05) compared to each drug alone and to all sets of double combination . The β-lactam antibiotics represent the penicillin, cephalosporin, and carbapenem antibiotic classes, respectively. therapy . Five anTwo of the tested isolates were resistant to four antibiotics, and one isolate was resistant to two antibiotics . Because P. aeruginosa using different assessment methods [Synergism was more common with triple combinations than with double combinations with no antagonism observed in all isolates compared to double combinations Tables  and 4. T methods , 24. P. aeruginosa and consequently increase uptake of other antibiotics in the combined therapy [ in vitro studies and are different from others [In triple combination, the best outcome was obtained when AMK was included in the therapy. Synergism was found in all isolates when AMK was combined with CIP and CAZ, whereas 80 and 70% of the interaction were synergistic when the antibiotic was combined with PIP and CAZ and with CIP and PIP, respectively. Aminoglycosides induce outer membrane changes in therapy . The resm others –29. Thism others . The resβ-lactam antibiotics may be beneficial in providing a synergistic activity or a broad spectrum of antibiotic coverage against specific pathogen in certain clinical cases [β-lactam antibiotic therapy was found to be effective in treatment of febrile granulocytopenic patients [β-lactam antibiotics against pathogenic bacteria including Pseudomonas [β-lactams targets different penicillin-binding proteins [β-lactam combinations which involve imipenem, a potent inducer of ampCβ-lactamase genes, when tested against Pseudomonas [Synergism was demonstrated in 40% of the combination of CAZ with PIP, while antagonism was obtained in 30 and 20% of the combination of IMP with CAZ or PIP, respectively. Combinations of two patients , 31. Synudomonas . Synergiudomonas , 34. in vivo condition in which bacterial growth precedes the antibiotic therapy and microorganism is exposed to supra-MIC and sub-MIC of the antibiotics. Synergism was demonstrated in the triple combination of the antibiotics when they were tested at 1/2 of their MICs (Two sets of time-kill assay were used to verify the results obtained by the presented model using isolate PA14. In one set, CIP, AMK, and CAZ were added at 1/4 or 1/2 of their MICs. In the second set of experiment, the antibiotics, alone or in combination, were tested in a chemostat at double of their MICs. Three doses of the drugs were added after 10, 30, and 60 hours of incubation, where their concentrations decreased over the time course of the experiment. This configuration simulates theeir MICs . Synergieir MICs . It is p in vitro model provides an easy and simple technique for the evaluation of antibiotic interaction especially when more than two antibiotics are used. Unlike the checkerboard and the time-kill assay methods, the presented model needs fewer materials, and one microtiter plate is enough to test three antibiotics when tested alone or in double or triple combinations. The results obtained by the presented method were reproducible and comparable to the data obtained by checkerboard method. The method can be a useful tool to help the clinicians in the selection of the appropriate antibiotic therapy and consequently avoid the delay in starting effective treatment of severe infections. Further work needs to be performed on larger numbers of Pseudomonas and other problematic Gram-negative and Gram-positive bacteria with wider selection of the antibiotics to verify the results obtained by the presented model.The presented


Hepatocellular carcinoma (HCC) patients with activated HGF/c-Met signaling have a significantly worse prognosis. Targeted therapies using c-Met tyrosine kinase inhibitors are currently in clinical trials for HCC, although receptor tyrosine kinase inhibition in other cancers has demonstrated early success. Unfortunately, therapeutic effect is frequently not durable due to acquired resistance.+) HCC cell line to explore the compensatory survival mechanisms that are acquired after c-Met inhibition. MHCC97-H cells with stable c-Met knockdown (MHCC97-H c-Met KD cells) were generated using a c-Met shRNA vector with puromycin selection and stably transfected scrambled shRNA as a control. Gene expression profiling was conducted, and protein expression was analyzed to characterize MHCC97-H cells after blockade of the c-Met oncogene. A high-throughput siRNA screen was performed to find putative compensatory survival proteins, which could drive HCC growth in the absence of c-Met. Findings from this screen were validated through subsequent analyses.We utilized the human MHCC97-H c-Met positive  significantly reduced cell viability and increased apoptosis compared with either PHA665752 or Gefitinib treatment alone.We have previously demonstrated that treatment of MHCC97-H cells with a c-Met inhibitor, PHA665752, results in stasis of tumor growth + HCC tumor growth. Inhibition of both c-Met and EGFR oncogenic pathways provides superior suppression of HCC tumor growth. Thus, combination of c-Met and EGFR inhibition may represent a superior therapeutic regimen for c-Met+ HCC.c-Met inhibition monotherapy is not sufficient to eliminate c-Met Hepatocellular carcinoma (HCC) represents the third leading cause of cancer-related death worldwide, and HCC is the only carcinoma with increasing mortality in the United States during the last decade . AlthougHepatocyte Growth Factor (HGF) is produced by stromal cells. HGF acts on c-Met, a high affinity receptor tyrosine kinase . Followi+ tumors; however c-Met inhibition is unable to completely eradicate HCC  kit  according to the manufacturer’s protocol as previously described .Cell lysates were collected, and blotted as previously described . c-Met (Cells were collected and washed with cold 1XPBS followed by Annexin V and PI staining using the Alexa Flour 488 Annexin V/Dead Cell Apoptosis kit (Invitrogen) per the manufacturer’s recommendation. Flow cytometry analysis was performed using a FACS Calibur (BD Biosciences). Post-FACS analysis was performed using the Flow-Jo program .Trizol  was used to isolate total RNA from cells according to the manufacturer’s protocol. The extracted RNA was quantified using an ND-1000 spectrophotometer  and complementary single strand DNA (cDNA) was synthesized using an Omniscript RT kit . qRT-PCR experiments were performed as previously described .Student’s t-test was used to compare data from two groups, and one-way ANOVA with Tukey’s posthoc testing was used to evaluate the differences amongst multiple groups with p<0.05 considered as statistically significant.http://www.ncbi.nlm.nih.gov/geo (accession number GSE38343). Genes that had a statistically significant (p <0.05) 1.4-fold or greater change in expression between c-Met shRNA and scrambled shRNA cell lines were considered differentially expressed.Using the stably transfected MHCC97-H c-Met shRNA and MHCC97-H scrambled shRNA cell lines, mRNA was extracted and hybridized to an Illumina human gene chip in biological triplicates according to the manufacturer’s protocol and as described . QIAGEN’+ MHCC97-H cell line (referred to as MHCC97-H c-Met KD cells). Compared with scrambled shRNA transfected MHCC97-H (referred to as MHCC97-H shRNA control) cells, MHCC97-H c-Met KD cells have decreased c-Met expression with significantly suppressed phospho-c-Met (p-c-Met) and the downstream targets of the c-Met pathway, phospho-Akt (p-Akt) and phospho-Erk (p-Erk)  cell line in the c-Met (p-Erk) .To further investigate the potential tumor survival mechanisms after c-Met knockdown in MHCC97-H cells, we conducted an siRNA library screen using 873 kinases and phosphatases in MHCC97-H c-Met KD cells. In 96-well plate format siRNA for each of the 873 targets was seeded into individual wells. Three scrambled siRNAs served as negative controls to obtain baseline cell viability. Potential survival pathways were determined by cell viability assay with a Z-score of -2 or less . From thErbB3 and EGFR (ErbB1)  . Based o- Huh7 and Hep3B cells and in c-Met+ MHCC97-L and MHCC97-H cells. The basal p-EGFR level is barely detectable in MHCC97-H cells compared with Huh7 cells, although there is baseline expression of EGFR protein itself. Additionally, EGF treatment at 50 and 100 ng/ml leads to increased p-EGFR, p-Akt, and p-Erk levels in Huh7 cells, whereas they do not lead to increased levels in c-Met+ MHCC97-H and MHCC97-L cells , an activated form of EGFR and its downstream targets phosphorylated Erk (p-Erk) and phosphorylated Akt (p-Akt), at baseline or upon EGF ligand stimulation in c-Met-L cells . Additio-L cells . Gefitiniability . The HCCility , c-Met inhibition in combination with gefitinib led to statistically significant decreases in cell viability in MHCC97-H cells  and SNU-+ HCC survival after c-Met knockdown, we sought to determine which EGFR family members and/or ligands might be upregulated by c-Met inhibition. Our microarray data suggested that EGFR (ErbB1) and ErbB3 are upregulated by c-Met inhibition in MHCC97-H cells , a Mek inhibitor , or a c-Met inhibitor . We determined that LY290042 and PHA665752 led to statistically significant increases in ErbB3 mRNA  family is a group of four structurally related receptor tyrosine kinases. This includes Her1 , Her2 , Her3 (ErbB3), and Her4 (ErbB4). Evidence supports the four members of the ErbB protein family as capable of forming homodimers and heterodimers in order to activate downstream signaling cascades . AdditioMET gene, leading to higher c-Met expression in the cell membrane [Signaling interactions between c-Met and EGFR pathways have been reported in various tumor types but are incompletely understood. In non-small cell lung carcinoma (NSCLC), 70% of patients with Epidermal Growth Factor Receptor (EGFR) activating mutations will have a favorable initial response to EGFR inhibitors gefitinib or erlotinib . Howevermembrane , 43. Mormembrane , 45. Indmembrane , 47. The+ HCC models, c-Met pathway inhibition leads to EGFR pathway upregulation. We found that c-Met is constitutively activated but that EGFR is not at baseline. In addition, monotherapy using an EGFR inhibitor has no significant effect on in vitro cell survival .c-Met(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Modulating the methylation process induces broad biochemical changes, some of which may be involved in schizophrenia. Methylation is in particular central to epigenesis, which is also recognized as a factor in the etiology of schizophrenia. Because methionine administration to patients with schizophrenia has been reported to exacerbate their psychotic symptoms and because mice treated with methionine exhibited social deficits and prepulse inhibition impairment, we investigated whether methionine administration could lead to behavioral changes that reflect schizophrenic symptoms in mice.l-Methionine was administered to mice twice a day for 7 days.We found that this treatment induces behavioral responses that reflect the 3 types of schizophrenia-like symptoms  as monitored in a battery of behavioral assays . Moreover, these responses were differentially reversed by typical haloperidol and atypical clozapine antipsychotics in ways that parallel their effects in schizophrenics.l-methionine treatment as an animal model recapitulating several symptoms of schizophrenia. We have established the face and predictive validity for this model. Our model relies on an essential natural amino acid and on an intervention that is relatively simple and time effective and may offer an additional tool for assessing novel antipsychotics.We thus propose the  Methylation impacts a wide range of substrates, including proteins, phospholipids, polysaccharides, RNA, and DNA  . An epigam) with food and water available ad libitum. All experimental procedures were approved by the Institutional Animal Care and Use Committee of University of California, Irvine and were performed in compliance with national and institutional guidelines for the care and use of laboratory animals.Male Swiss Webster mice, 8 to 11 weeks old, were obtained from Charles River Laboratories . Mice were group-housed and maintained on a 12-hour-light/-dark cycle (light on at 7:00 am/3:00 pm) for 7 consecutive days. In the locomotion test, HAL  and CLZ  were administered 40 minutes before the test. In the forced swim test and PPI test, HAL  and CLZ  were administered 60 minutes before the test. In the novel objects recognition test, HAL  and CLZ  were administered 30 minutes before the training test.MET (Sigma-Aldrich) was dissolved in saline. Haloperidol  and clozapine  were dissolved in saline with 0.3% tartaric acid, after which the pH was adjusted to pH 5–6 with sodium hydroxide. MET  was administered twice a day / (Tnovel + Tfamiliar)×100%. Tests were video recorded and analyzed by ANY-MAZE software (Stoelting Co.).The novel object recognition assay was carried out 18 hours after the last MET injection as described previously . This taMice were tested for inhibitory avoidance 18 hours after the last MET injection as described previously . The appThe open field assay was carried out 18 hours after the last MET injection as described before with slight modifications . BrieflyThe rotarod assay was carried out 18 hours after the last MET injection as described before with slight modifications . Mice weThe tail flick assay was carried out 18 hours after the last MET injection as described before . In brieStudent t test or ANOVA followed by the appropriate post hoc comparisons, and P<.05 was considered statistically significant.Graphpad Prism  was used for statistical analysis. Data are presented as means ± SEM. Results were analyzed by MET (750mg/kg) or saline was administered to mice twice a day for 7 days. Mice were then observed and subjected to different behavioral assays to evaluate their phenotypes as they relate to psychotic syndromes.P>.05; P>.05; P>.05; P>.05; The MET treatment did not have any evident pathological effects nor did it affect the body weights P>.05; . When coThe MET treatment, however, did affect several behavioral responses that mimic schizophrenia symptoms.P<.01; P<.05; MET-treated mice exhibited a 2-fold increase in their locomotor activity, indicated by the increase in total distance that they travelled P<.01; . They alP>.05; P<.001; P<.001; In the social interaction assay, the MET-treated mice displayed less interaction with the unfamiliar mice P>.05;  than didP>.05; P<.05; P>.05; P<.001; P<.01; P<.05; We studied the effect of MET treatment on sensorimotor gating behavior. MET-treated mice did not display a significant change in their startle reactivity compared with control mice P>.05; , yet thesupplementary Figures S1–S4).Because MET-treated mice displayed behaviors reflecting schizophrenic-like symptoms, we investigated the effects of 2 antipsychotic drugs on these behaviors. We chose HAL and CLZ as representative of the typical and atypical antipsychotics, respectively. Dose response experiments were first carried out on control mice for both drugs in each assay to determine the appropriate dose to administer  and were therefore selected. At these doses, a single injection of HAL or CLZ reversed the MET-induced locomotor hyperactivity and stereotypic behavior . However, HAL at 0.25  nor CLZ  affected the immobility of naïve mice in the forced swim assay . HAL (0.25 and 0.5mg/kg) was able to reverse the PPI deficit induced by the MET treatment . At these doses, only CLZ reversed the object recognition deficit found in MET-treated mice in terms of discrimination index P<.01;  nor CLZ  affected the PPI ratio of naïve mice .We therefore tested whether the repeated methionine administration model possesses predictive validity by assessing the reversal of the behavioral abnormalities by 2 well-established prototypical antipsychotic drugs that are known to show efficacy in humans. HAL is a D2 antagonist and is known to possess good efficacy against positive symptoms but poor efficacy against negative symptoms. CLZ, an atypical antipsychotic, has a broader pharmacological profile and better efficacy against negative symptoms and cognitive deficits of schizophrenia.supplementary Figure S1). On the other hand, CLZ but not HAL reversed the negative symptoms (increased immobility) induced by MET . We also have shown that CLZ but not HAL can reverse the memory deficit in the novel object recognition assay (The positive symptoms (hyperactivity and increased stereotypic behavior), induced by MET, were reversed by HAL and CLZ at doses that did not induce any behavioral changes in naïve mice  . However67 of the GABAergic interneurons in various cortical and hippocampal areas. In the MET-treated mice, the number of methylated CpG dinucleotides in the reelin promoter was shown to be inversely correlated with the reelin expression in the brain (While the construct validity is beyond the scope of this paper, DNA hypermethylation of certain genes might be the mechanism responsible for our behavioral findings. Previous studies by the Guidotti group  showed the brain . TuetingIn conclusion, we were able to show that the behavioral impairments induced by the repeated MET treatment are consistent with those observed in schizophrenia patients. We therefore propose MET treatment as an animal model recapitulating several symptoms of schizophrenia. Our model relies on the use of an essential amino acid that we consume daily and on an intervention that is relatively simple and time effective. We have established the face and predictive validity for this model, and it may offer an additional tool for assessing novel antipsychotics.None.