The receptor tyrosine kinase mesenchymal–epithelial transition factor (MET) is frequently altered in cancers and is a common therapeutic target for cancers with MET variants. However, abnormal MET alterations and their associations with patient outcome across different cancer types have not been studied simultaneously. In this study, we try to fill the vacancy in a comprehensive manner and capture the full MET alteration spectrum.A total of 10,967 tumor samples comprising 32 cancer types from The Cancer Genome Atlas (TCGA) datasets were analyzed for MET abnormal expression, mutations, and copy number variants (CNVs).MET abnormal expression, alteration frequency, mutation site distribution, and functional impact varied across different cancer types. Lung adenocarcinoma (LUAD) has most targetable mutations located in the juxtamembrane domain, and both high expression and amplification of MET are significantly associated with poor prognosis. Kidney renal papillary cell carcinoma (KIRP) harbored the third highest alteration frequency of MET, which was dominated by mutations. While most mutations were in the Pkinase_Tyr domain, a few were targetable. Pancreatic adenocarcinoma (PAAD) harbors very few alterations, but increased MET expression is associated with poor outcomes. Esophageal carcinoma (ESCA), stomach adenocarcinoma (STAD), and ovarian serous cystadenocarcinoma (OV) had similar characteristics: a high frequency of MET CNVs but relatively few MET mutations, and high MET expression associated with poor prognosis.This study provided significant and comprehensive information regarding MET abnormal expression, alterations (mutations and CNVs), and their clinical associations among 32 cancer types and offered insights into the full MET alteration spectrum and its implications for prognosis and treatment. The human MET gene is located on chromosome 7q21–31 and encodes c-mesenchymal-epithelial transition factor (MET), which belongs to the family of receptor tyrosine kinases , 5, thusBecause of its important roles in tumors, MET is considered to be a critical target for anticancer therapy. Multiple MET inhibitors have already been elaborated and tested in preclinical and clinical studies , 12. EspAs previous research about MET aberrations in cancer is limited to the limited sample size and/or to the individual cancer type, a comprehensive profiling across different cancer types to explore their significance has not been studied. In this study, we first profiled the expression, mutations, and copy number variants (CNVs) of MET across 32 cancer types from The Cancer Genome Atlas (TCGA) datasets. Then, survival analysis was conducted to further examine the aberration patterns and potential clinical significance of MET in distinct tumors. Taken together, these findings highlight the important roles of MET in tumorigenesis and present promising targetable pathways and clinical opportunities for cancer research.1), which collects transcriptome data in a wide variety of tissue types from healthy individuals , a web server for cancer and normal gene expression profiling and interactive analyses (4)  .The cBioportal is a portal that enables users to interactively investigate genetic alterations across samples, genes, and, when available in the underlying data, to link these to clinical outcomes . In this5, an open source platform that can be used to assess the effect of genes on patient survival. Moreover, Kaplan–Meier plotter is established by a PostgreSQL server, which can simultaneously integrate the clinical data and gene expression from several databases, such as GEO, EGA, and TCGA  and progression-free survival (PFS) –22. The and TCGA . The hazt-test, Cox regression analysis, and linear regression analysis were performed when appropriate. P < 0.05 was defined as statistically significant. In addition, the statistic calculations on the Mutual Exclusivity tab are conducted using all cancer samples in cBioPortal. A sample is defined as altered or unaltered (controls) for each gene based on the Onco Query Language (OQL) utilized in the query. Especially, in single- and cross-cancer queries, OQL algorithm can be utilized to accurately identify copy number alterations, mutations, mRNA, and protein expression profiles . Student’s profiles .MET overexpression has been reported in many human cancers –26. Prevr = 0.5459, p = 0.0015), indicating a critical role for gene expression regulation in driving the protein expression of MET and its functional status in the tumor  for all patients and 2.8%  for all cancer samples. MET mutations were observed most commonly in UCEC (12.3%), SKCM (10.5%), KIRP (8.8%), bladder urothelial carcinoma , COADREAD (4.4%), and LUAD (4.2%). In contrast, however, adrenocortical carcinoma (ACC), CHOL, ESCA, KICH, LAML, mesothelioma (MESO), pheochromocytoma and paraganglioma (PCPG), TGCT, THYM, and uveal melanoma (UVM) virtually barely had MET mutations . The numBased on the Pfam database, MET harbors six functional domains, including the Sema (59–498 aa), PSI (520–561 aa), TIG (563–654 aa), TIG 657–728 aa), TIG (742–815 aa), and PKinase-Tyr domains . The Sema domain, a seven-bladed β-propeller semaphorin domain, could lead to receptor oligomerization when binding to ligand ; the PSI aa, TIG ∗ (one UCEC)]. However, the oncogenic function of mutations at this position was considered unknown, and there were no FDA-approved treatments specifically for patients with these mutations. The most mutated positions in KIRP (17 of 25 mutations) were located at the Pkinase Tyr domain, especially at the 1,250-aa position (four samples with M1250T) and the 1,092- to 1,094-aa position . The mutation at these positions was known to be oncogenic , followed by truncating mutation (46 mutations), other mutation (14 mutations), and in-frame mutation (one mutation) . The mosncogenic . UCEC hancogenic .From oncogenic effect and predictive significance, these 311 somatic mutations were classified into four categories: oncogenic (30 mutations), likely oncogenic (16 mutations), predicted oncogenic (one mutation), and unknown (264 mutations). Most of these mutations belonged to the unknown class, suggesting that more efforts are needed to determine the meanings of these mutations . HoweverNext, we analyzed the clinical targeted therapy implications of MET mutation using cBioPortal, which could provide the annotation of variants from different databases, including COSMIC, Cancer Hotspots method, CIViC, My Cancer Genome, and OncoKB. However, the exact levels of clinical actionability displayed in cBioPortal can be fully defined using OncoKB . Thus, fr = 0.1511, p < 0.0001) . Most of them were gained , followed by amplification (129 samples), shallow deletion (899 samples), and deep deletion (17 samples). The most common tumors with MET CNVs were GBM (80.1%), TGCT (71.8%), ESCA (66.5%), KIRP (62.5%), and ACC (62.0%). In contrast, PCPG (15.7%), LAML (11.5%), UVM (8.8%), and THCA (4.2%) showed very low MET CNV frequencies . To dete 0.0001) , indicat 0.0001) . As showOverall, the combined MET mutation and CNV frequency in all cancer types were observed in 3.6% of cases . However, MET alterations are quite variable across different cancers. MET alterations were observed most commonly in UCEC (10.21%), SKCM (10.14%), and KIRP (9.89%), in which mutations were more common. Other cancer types with dominant MET mutations but at much lower mutation rates included LUAD (3.53%), BLCA (3.89%), COADREAD (3.2%), UCS (3.51%), and PAAD (0.54%). Furthermore, tumors such as ESCA, STAD, GBM, and OV mainly had MET CNVs but relatively few mutations . Tumors including ACC, TGCT, THYM, UVM, MESO, CHOL, and PCPG had neither MET CNVs nor MET mutations .Interestingly, CNVs and mutation location were found to be associated. Approximately half of the mutations (29 of 67 mutations) in the Pkinase-Tyr domain also had MET copy gain, while nearly half of the mutations (44 of 90 mutations) in the other function-unknown domain were accompanied by amplification, gain, and shallow deletion. Mutations in the PSI domain and the TIG domain had very few CNVs .To explore the clinical significance of MET expression, we analyzed the association between MET mRNA expression and patient OS and PFS in individual cancer types. The results showed that high MET expression was associated with poor patient OS in HNSC, LUAD, OV, PAAD, sarcoma (SARC), and THYM. However, among patients with BRCA, READ, and THCA, high MET expression was associated with better patient OS . MeanwhiWe further explored the clinical significance of the MET alteration, and survival association analysis regarding alteration status in each cancer type showed that MET alteration was associated with short survival in PRAD. However, MET alteration was found to be associated with a better prognosis in UCEC . This opOur study profiled the characteristics of MET in 32 cancer types and showed that MET expression, mutation, and CNVs varied across different cancer types, which are of great clinical significance. UCEC, SKCM, and KIRP had the highest MET alteration, and mutations accounted for the major proportion. While mutations in UCEC and SKCM were most commonly located in the Sema domain and the other function-unknown domain, mutations in KIRP were primarily located in the Pkinase-Tyr domain, which is more important for treatment selection. Furthermore, although studies have shown a high MET expression in UCEC, SKCM, and KIRP, no association was observed between MET expression and patient prognosis. Other cancer types, including LUAD, BLCA, COADREAD, and UCS harbored similar characteristics; all their alteration frequency was between 4 and 6%, and mutation was the primary alteration. Mutations in LUAD are mainly X1010_splices, which are in exon 14, and mutations in this region are known for targeted therapy in clinical practice in NSCLC . On the In recent years, splice site mutations have been discovered in MET, leading to exon 14 skipping. NSCLC patients who were carrying this splice variant typically overexpressed MET and showed a response to MET small molecule inhibitors such as crizotinib and cabozantinib . In thisThe MET pathway was reported to play an important role in KIRP . In thisThe patients with UCEC had the highest frequency of MET alterations, which was mostly driven by a high proportion of mutations. However, the detailed functional roles of these mutations were unknown. It is well known that genomic instability and high mutation rates cause cancer to acquire numerous mutations during evolution. Most are termed passenger mutations, which represent approximately 97% of all cancerous mutations and do not confer cancer phenotypes. Driver mutations are usually defined as mutations that give cancer cells a fundamental growth advantage for its neoplastic transformation . HoweverIn addition, several reports have showed that some gene mutations, like BRAF mutation and ERBB2 mutation, were associated with MSI status in several cancer types –54. WhatThe prognostic roles of MET in PAAD were quite clear in this dataset. High MET expression was significantly associated with both short OS and PFS of patients with PAAD. However, PAAD harbored very few alterations in which mutations accounted for the most, and the meaning of these mutations is rarely known. Thus, more efforts to interpret these unknown mutations are needed.Esophageal carcinoma, STAD, and OV harbored similar characteristics in this dataset: high expression of MET, high frequency of MET CNV, but relatively few MET mutations. Multiple therapeutic agents that target the hepatocyte growth factor (HGF)–MET pathway in these cancers are under development . TargeteNevertheless, there were some limitations that need to be noted in this study. First, although we profiled 32 cancer types, some cancer types did not have sufficient sample size, leading to the full expression and alteration spectrum of MET being hard to achieve. More studies with sufficient samples in these cancers should be investigated further. Additionally, the alteration frequency of MET across all cancer types was approximately 0 to 10%. This low alteration frequency also made our analysis more difficult and challenging. Moreover, we mainly focus on the pancancer analysis of MET expression and alterations across multiple cancer types, without in-depth analysis for individual cancer types. In addition, though several papers have reported the alteration profiles of MET in human cancers , 63, 64,In conclusion, we first reported the comprehensive pancancer views of MET aberrations and their association with patient outcomes across 32 TCGA cancer types. Some alterations are more involved in the development of tumors, while others participate more in targeted therapy. Moreover, some cancer types with low MET alteration frequency were associated with outcomes, but unexpectedly, others with high alteration frequency were not. Taken together, these results provide a significant novel understanding of MET deregulation in cancer biology. The data presented here are also relevant for targeting MET in cancer therapy, both by revealing vulnerable cancer types and by identifying potential therapeutic biomarkers.All datasets presented in this study are included in the article/YY and ZX contributed to the conception and design of this study. JL, KH, YY, and ZX contributed to writing, review, and/or revision of the manuscript. LZ, JH, and SZ provided administrative, technical, and/or material support. All authors approved the final version of manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Insight into antibiotic prescribing quality is key to general practitioners (GPs) to improve their prescribing behavior and to national antibiotic surveillance and stewardship programs. Additionally to numbers of prescribed antibiotics, quality indicators (QIs) linked to the clinical indication for prescribing are urgently needed. The aim of this proof of concept study was to define indication-linked QIs which can be easily implemented in Dutch primary care by collaborating with data-extraction/processing companies that routinely process patient data for GP practices. An expert group of academic and practicing GPs defined indication-linked QIs for which outcomes can be derived from routine care data. QI outcomes were calculated and fed back to GPs from 44 practices, associations between QI outcomes were determined, and GPs’ opinions and suggestions with respect to the new set were captured using an online questionnaire. The new set comprises: (1) total number of prescribed antibiotics per 1000 registered patients and percentages of generally non-1st choice antibiotics; (2) prescribing percentages for episodes of upper and lower respiratory tract infection; (3) 1st choice prescribing for episodes of tonsillitis, pneumonia and cystitis in women. Large inter-practice variation in QI outcomes was found. The validity of the QI outcomes was confirmed by associations that were expected. The new set was highly appreciated by GPs and additional QIs were suggested. We conclude that it proved feasible to provide GPs with informative, indication-linked feedback of their antibiotic prescribing quality by collaborating with established data extraction/processing companies. Based on GPs’ suggestions the set will be refined and extended and used in the near future as yearly feedback with benchmarking for GPs and for national surveillance and stewardship purposes. General practitioners (GPs) are responsible for prescribing 80% of antibiotics in the outpatient setting and therefore have a major responsibility to continuously focus on appropriate antibiotic prescribing . InapproTo address AMR, antibiotic stewardship programs have been implemented globally. The Center for Disease Control and Prevention defined outpatient antibiotic stewardship as the efforts: (1) to measure antibiotic prescribing; (2) to improve antibiotic prescribing by clinicians and use by patients so that antibiotics are only prescribed and used when needed; (3) to minimize mis- or delayed diagnoses leading to underuse of antibiotics; (4) to ensure that the right drug, dose, and duration are selected when an antibiotic is needed .To support these efforts and for national surveillance purposes, there is an urgent need for a valid instrument to assess antibiotic prescribing quality at a GP practice level. Reporting numbers of prescribed antibiotics does not tell the full story ,10,11. T(1)Linking to clinical indications, as this was also strongly requested by practicing GPs and the Dutch College of GPs;(2)Outcomes derivable from practices’ electronic patient information systems, based on a uniform data extraction/processing procedure, and done by specialized companies;(3)Appreciated by GPs, as the yearly feedback should serve as a trigger and motivation for targeted quality improvement ,18; and(4)Useful for national antibiotic surveillance and stewardship programs.Commissioned by the Dutch Ministry of Health, we aimed to define such a set of antibiotic prescribing QIs, with the following features and prerequisites:The main aim of this study was to define an initial concise set of antibiotic prescribing QIs by an expert group of academic and practicing GPs, and investigators in the field of antibiotic research, based on Dutch guidelines and studies using routine care and registration data ,19,20. AThe QIs were defined by an expert group of two academic GPs, one practicing GP, a researcher in the field, and a representative of the National Institute for Public Health and the Environment. The group-based in depth discussion was on: (1) experiences of the Dutch ARTI4 prospective registration ,14; (2) https://www.medworq.nl/) and INSZO-STIZON (https://www.stizon.nl/inszo/). Extraction and processing of patient data is the core business of these companies as they provide GP practices with patient, management, prescribing and chronic care data. These companies were responsible for data-extraction/processing and calculating QI outcomes based on all data from 2017.Routinely registered data from patients’ medical files were extracted from 44 GP practices by two Dutch data-extraction/processing companies, Medworq ((1)All antibiotic prescriptions for systemic use (ATC code: J01);(2)The mid-period population of registered patients; and(3)All episodes of respiratory tract infections (RTIs) and urinary tract infections (UTIs) in women, whether or not an antibiotic was prescribed, and which one.For each practice, three data sets were generated:To this aim, the data processing step searched for potential infectious ICPC-R chapter codes: R02, R03, R05, R07-R09, R21, R22, R25, R29, R70-R72, R74-R78, R80-R83, and separately for potential infectious ICPC-U chapter codes: U01-U14, U29, U70-U72 in women ,21. WhenAdditional to the QI outcomes, the percentage of total J01 prescriptions that were captured in the R and U episodes was calculated for each practice.Total number of J01 prescriptions/1000 registered patients/year;Number of J01CR prescriptions/total J01 × 100%;Number of J01FA prescriptions/total J01 × 100%;Number of J01MA prescriptions/total J01 × 100%; andNumber of J01CR + J01FA + J01MA prescriptions/total J01 × 100%General QIs:6.Upper RTI: episodes of upper RTI with any J01/total upper RTI episodes × 100%; and7.Lower RTI: episodes of lower RTI with any J01/total lower RTI episodes × 100%Prescribing percentages for:8.Tonsillitis: J01CE in R76 episode/R76 episodes with any J01 × 100%;9.Pneumonia: J01AA or J01CA04 in R81 episode/R81 episodes with any J01 × 100%; and10.1Cystitis women: J01XE or J01XX in U71 episode/U71 episodes with any J01 × 100%1st choice prescribing for:Part of the obligatory continuing education for GPs is organized by collaborating groups of GP practices with their pharmacist(s) who provide prescribing feedback for the subject of the session. Six of those groups, with a total of 44 practices and 104 GPs, volunteered in participating and organizing a session on ‘prudent antibiotic prescribing’. They used the QI feedback developed in this study. Feedback was provided per practice with reference to the other practices in the group, and to outcomes of all practices. AvdV presented this feedback during the educational sessions. Participating practices, from both rural and urban areas, were from the central and southern parts of the Netherlands.The day after the educational session an invitation and link for an anonymous online survey was e-mailed to participating GPs to evaluate various aspects of the QI set. A reminder was e-mailed 2 weeks later. Answers were allowed on a 7-point Likert scale with answer options ranging from ‘not at all …’ to ‘very …’ and with answer option 4 as ‘moderate’. The specific wording of the questions and answer options are shown in Table 3. Suggestions and remarks concerning the QIs were allowed in free text.QI outcomes are presented as means, with minimum and maximum values, median and quartiles. Pearson’s correlation coefficients were calculated to determine correlations between the QI outcomes.Questionnaire results are presented by showing percentages of respondents providing the answer options 5–7 (above moderate), or ‘yes’. Free text answers are summarized.-As a first quantitative indicator, the number of prescribed antibiotics per 1000 registered patients per year was chosen, as GPs are familiar with this measure. The focus was on how to define the number of registered patients to obtain a valid and comparable outcome. Consensus was for patients registered at the practice, irrespective of a consultation (for infectious diseases), omitting passers-by, and measured at the first day of month 7. Taking the mid-period population was considered to correct for births, deaths and moving in and out of the practice, and is also used by the WHO . Countin-In the Netherlands, amoxicillin/clavulanate, macrolides and quinolones are generally non-1st choice antibiotics for those indications where the most antibiotic are prescribed for: upper and lower RTIs, otitis media, uncomplicated UTIs and most skin infections ,20. It w-Prescribing percentages are often calculated as percentages of contacts for a specific ICPC code in which antibiotics were prescribed . A major-International and Dutch studies emphasize that most antibiotics are prescribed for RTIs and that most overprescribing is for RTIs ,20. It w-The expert team assumed that this approach would also tackle diagnostic labeling (misclassification), the phenomenon that GPs tend to justify their prescription by registering a more severe infection, for example ‘pneumonia’ . Whether-Streptococcus pneumoniae to doxycycline (15%) was the reason to change the 1st choice antibiotic for pneumonia to amoxicillin. In 2017, Strep. pneumoniae resistance to amoxicillin was 2% [E. coli to nitrofurantoin and fosfomycin was respectively 2% and 1% in the Netherlands [Another aspect of inappropriate prescribing is non-1st choice prescribing. The expert group reached consensus to measure non-1st choice prescribing for three specific clinical indications: tonsillitis, pneumonia and cystitis in women. These indications were chosen as they belong to different types of infection, an upper, a lower RTI and a UTI, and because the Dutch guidelines recommend different antibiotic classes for these indications, a small-spectrum penicillin, amoxicillin or doxycycline, and nitrofurantoin or fosfomycin, respectively . The Dutn was 2% . For theherlands .In total, 44 practices participated in the project. Mid-term practice sizes varied between 1406 and 12,660 registered patients, with a mean of 3866. As a control for (correct) ICPC coding and data-processing into episodes, the percentage of all prescriptions (from QI1) that were captured in the upper- and lower RTI and cystitis in women episodes was determined for each practice. This measure varied between 30% and 62%, with a mean of 43%.Inter-QI outcome correlations were determined as a proxy for their validity, and also between the QI outcomes and the percentage of prescriptions captured in the episodes . Strong For validity and reliability reasons, it is relevant if QI outcomes correlate with the control for ICPC coding and data-processing. None of the QI outcomes correlated with the percentage of prescriptions captured in the episodes.In order to have an impact, the set of QIs needs to be appreciated by GPs, and GPs need to trust the data extraction/processing of their electronic patient files. The online questionnaire results are shown in Nearly 70% of GPs expected this QI feedback to change their antibiotic prescribing behavior, mentioning the following reasons: increased reticence towards 2nd choice antibiotics and prescribing for RTIs, more insight in overprescribing, increased awareness, and necessity to re-evaluate old habits. Reasons mentioned by those who did not expect a changing prescribing behavior were: the feedback indicates prudent prescribing already, and these practice outcomes do not apply to me working in a group practice.The following relevant suggestions and questions were fed back: the request for individual prescriber feedback, whether outcomes can/need to be corrected for complexity/age of the practice patient population, and that prescriptions for long-term, or preventive antibiotic use disproportionally add to the outcome of QI1.In this study we have shown the feasibility of using routine primary health care data to determine antibiotic prescribing QI outcomes, with additional novelties of linking to clinical indications and analyzing disease episodes. The pilot set of 10 QIs was highly appreciated by GPs and seen as a stimulus to appropriate prescribing habits. Regular analysis and feedback of these QI outcomes thereby significantly adds to national antibiotic surveillance and stewardship programs and can be implemented by other countries as well .Numerous sets of antibiotic prescribing QIs for the outpatient setting have been described and evaluated in the literature ,26. To oStudies with QIs often present acceptable ranges, or target values . We haveThe inter-practice variation in QI outcomes reflects the highly variable antibiotic prescribing quantity and quality shown in many other studies ,31,32,33The overall strength of this study is a new procedure resulting in a set of antibiotic prescribing QIs providing information in which indications antibiotics may be inappropriately prescribed. This can be of much added value to national antibiotic surveillance and stewardship programs, as outcomes can be obtained for nearly all GP practices. We have shown that outcomes can be derived without involvement or time investment of GPs, using their routine electronic patient health records, by professional data-extraction/processing companies. Our procedure could be adapted by other countries, implementing their indications and antibiotic groups of interest, thereby enabling European, or even worldwide surveillance of antibiotic prescribing quality. The involvement of professional companies seems a prerequisite for national implementation as it enables uniformity of procedures, comparability, and adaptability. When guidelines implement another 1st choice antibiotic, due to for example increasing resistance, the professional companies can easily adapt this in their data processing procedure.Indicative for the reliability of the procedure and QIs were the as to be expected inter-QI correlations: highly significant correlations were found between high overall prescribing and high prescription percentages for upper and lower RTIs, and between overall high 2nd choice prescribing and low 1st choice prescribing for tonsillitis and pneumonia. Moreover, interesting correlations were seen for QIs that are not necessarily linked, like high overall 2nd choice prescribing with prescribing percentages for RTIs, and with high overall prescribing. This implies that practices have an overall  good, or less favorable performance. The detailed feedback highlights specific targets for improvement for the latter group. GPs’ appreciation of the procedure and QI set will aid in motivating them to appropriate prescribing practice .Some limitations should be acknowledged, most of which were also mentioned by the GPs in the evaluation. First, GPs from group practices expressed a need for outcomes at the individual GP level. Unfortunately, data capture per individual GP is complicated from most electronic patient systems, and even more difficult in the procedure using episodes. Moreover, determining the patient population belonging to an individual GP in a group practice is complicated. Second, in some electronic patient systems, chronic or preventive use of antibiotics is registered as a weekly prescription. Those 52 prescriptions per year disproportionally add in QI1. In refining the set, focus will be on omitting these prescriptions from QI1. Third, for reliability of the procedure, patient contacts need to be ICPC-coded and correctly coded. Correct ICPC coding is stimulated in the Netherlands, but can still be improved. The variation in (correct) ICPC coding is reflected by the variation in the percentage of prescriptions captured in the episodes. We estimated that around 50–60% of all prescriptions would be for an RTI or cystitis in women , and a mThis proof of concept study has shown that electronic patient systems routinely used in Dutch primary care can reliably deliver outcomes of clinical indication-linked antibiotic prescribing QIs. Thereby, a useful tool has been established to regularly monitor antibiotic prescribing quality per GP practice, for internal use by the GPs, and for external use by the government, the Dutch college of GPs, and educational organizations. Herewith, the way is paved for the implementation of this procedure to support national antibiotic surveillance and stewardship programs.


Real-time ex vivo drug testing tailors individual therapeutics based on predicted drug responses. Most technologies to date rely on conventional drug screening that provides low confidence data. Here, we present high-content analysis-based drug testing of glioblastoma patients to identify the right glioblastoma patients for a given drug. This generates multi-parameter biomarker and phenotype readouts providing a better reliability of the assay. Additionally, we showed a high-content drug repurposing screen and defined a new c-Met-inhibiting function of the CDK4/6 inhibitor Abemaciclib. Large-scale high throughput screening results demonstrate that Abemaciclib sensitivity in glioblastoma patients is highly correlated with the c-Met inhibitors sensitivity, further supporting the accuracy of the platform and important new clinical implications regarding multiple functions of Abemaciclib.(1) Background: Recent advances in precision oncology research rely on indicating specific genetic alterations associated with treatment sensitivity. Developing ex vivo systems to identify cancer patients who will respond to a specific drug remains important. (2) Methods: cells from 12 patients with glioblastoma were isolated, cultured, and subjected to high-content screening. Multi-parameter analyses assessed the c-Met level, cell viability, apoptosis, cell motility, and migration. A drug repurposing screen and large-scale drug sensitivity screening data across 59 cancer cell lines and patient-derived cells were obtained from 125 glioblastoma samples. (3) Results: High-content analysis of patient-derived cells provided robust and accurate drug responses to c-Met-targeted agents. Only the cells of one glioblastoma patient (PDC6) showed elevated c-Met level and high susceptibility to the c-Met inhibitors. Multi-parameter image analysis also reflected a decreased c-Met expression and reduced cell growth and motility by a c-Met-targeting antibody. In addition, a drug repurposing screen identified Abemaciclib as a distinct CDK4/6 inhibitor with a potent c-Met-inhibitory function. Consistent with this, we present large-scale drug sensitivity screening data showing that the Abemaciclib response correlates with the response to c-Met inhibitors. (4) Conclusions: Our study provides a new insight into high-content screening platforms supporting drug sensitivity prediction and novel therapeutics screening. Glioblastoma is the most common primary intracranial tumor, with a median survival of only 14 months ,3. Due tc-Met is a receptor tyrosine kinase (RTK) that regulates diverse cellular processes such as proliferation, survival, cell migration, and invasion . c-Met aEx vivo drug testing of patient-derived tumor cells has emerged as an important platform to guide clinical decision-making. A recent high throughput screening using a pan-cancer tumor spheroid reported the first large-scale pharmacogenetic study , and canIn this study, we used a high-content analysis platform to examine c-Met-overexpressed patient-derived cells and test their response to c-Met-targeted agents. We measured c-Met immunofluorescence and multi-parameter cellular phenotypes, and identified 1 out of 12 glioblastoma patients who would be likely to respond to c-Met-targeted drugs. Genomic analysis and immunoblotting confirmed that the patient had c-Met overexpression, suggesting the reliability of the platform. Additionally, we identified CDK4/6 inhibitor Abemaciclib as an inhibitor of c-Met phosphorylation by screening the patient-derived cells with 60 different drugs. Our data provide a new insight into the possibility of high-content analysis strategies in ex vivo drug testing and precision oncology.This study was approved by the Institutional Review Board (IRB file #201512092) of Samsung Medical Center, and informed consent was obtained from all 12 patients. Tumor specimens were resected from 12 patients who were diagnosed with glioblastoma. Patient-derived tumor tissues were dissociated using an enzyme and incubated in neurobasal-A media  supplied with N2, B27, L-Glutamin (Gibco), penicillin streptomycin (Gibco), human recombinant basic fibroblast growth factor (bFGF), and epidermal growth factor (EGF), as previously reported . Cells oEBC-1 and MKN45 cells were purchased from the American Type Culture Collection (ATCC). Cells were grown in RPMI  with 10% fetal bovine serum and 1% antibiotics.c-Met inhibitors  and CDK4/6 inhibitors  were purchased from Selleckchem . The c-Met-targeting antibody, SAIT301 was produced according to the previous literature . AntibodLaminin was coated onto a CellCarrier 384 well plate  as previously reported . A totalImmunoblot assay was conducted as previously described . BrieflyCells were seeded in a laminin-coated 384-well plate (2000 cells in 40 uL culture media/well); after 24 h, drugs were treated for 7 days. Cell viability was measured using either image-based live cell analysis or adenosine triphosphate (ATP)-based cell viability assay as previously described . For theTargeted exome sequencing that covers only glioma-related genes was conducted for GBM (Glioblastoma Multiform) patient-derived cells. The resulting sequence data were mapped to the human genome (hg19) with the Burrows−Wheeler Aligner (BWA) as previously described .The in vitro kinase assay was performed using the ADP-Glo + MET Kinase Enzyme System  according to the manufacturer’s instructions. Small molecules  were mixed with ATP, substrate, and MET enzyme at room temperature for 60 min. ADP-Glo™ reagent was added and incubated at room temperature for 40 min. Then, kinase detection reagent was added at room temperature for 30 min. The luminescence was measured with an Envision plate reader (PerkinElmer). Resulting data were normalized to the control and analyzed regarding the dose-response curve. The equation was Y = 100/(1 + 10[(LogIC50-X) * HillSlope]).We previously suggested that patient-derived live cells can be subjected to ex vivo drug testing to identify potentially effective drugs ,21. To cNext, we explored the feasibility of additional assays that can generate more readouts by high-content analysis. SAIT301 is a humanized c-Met antibody that causes degradation of the c-Met protein . In respp < 0.0001), while PDC3 cells were largely unaffected (p = 0.28). We also acquired the single cell level images and analyzed the closest distance between individual cells. As shown in n = 11,780, mean distance: 6.514 μm) compared to human IgG control . However, we identified no difference in cell-to-cell distances in PDC3 between IgG control  and SAIT301 . The mean average of cell aggregation induced by SAIT301 was statistically significant in PDC6 (p < 0.0001) but not in PDC3 (p = 0.5006) (One of the key features of PDC6 cells upon SAIT301 treatment was cell aggregation and reduced cell motility E. We mea 0.5006) H. Furthe 0.5006) I. CollecPDC6 cells were validated as c-Met-addicted glioblastoma cells as we characterized their genetic, molecular, and drug sensitivity information by high-content analysis and traditional methods. Next, we tested the feasibility of a drug repositioning screen using PDC6 cells and high-content analysis to explore new therapeutics that potentially inhibit c-Met. PDC6 cells were grown on laminin, treated with increasing concentrations of 58 different targeted agents, and p-c-Met intensity was analyzed A. Dose-rTo support our findings, we performed immunoblot on PDC6 cell extracts treated with the drugs. Abemaciclib led to a dramatic decrease in the p-c-Met level in PDC6 cells, while palbociclib and ribociclib had no effect A,B. Totap < 0.0001 and p = 0.002, respectively). In 125 glioblastoma patient-derived cells evaluated, we found that the sensitivity of these cells to abemaciclib was highly correlated with crizotinib and cabozantinib   C,D. TakePrecision oncology refers to the tailoring individual therapeutics based on predicted drug responses, seeking the most effective treatment for a given patient . Large-sIn this study, we present a high-content analysis-based ex vivo drug testing platform that can identify glioblastoma patients who may respond to c-Met-targeted agents. Among 12 glioblastoma patient-derived cells, only one sample (PDC6) exhibited a markedly high level of c-Met intensity with increased sensitivity to c-Met-targeted drugs. Genomic analyses validated the c-Met overexpression in PDC6 through identifying the c-Met gene amplification and mutation. Moreover, immunoblot assay detected the c-Met protein only in PDC6 cells. Since it appears that the c-Met is not detected in most glioblastoma cells, only a small subset was highly selective to c-Met-targeted agents. Therefore, the significance of selecting potential responders is high particularly in the case of c-Met-addicted glioblastoma.Conventional in vitro drug sensitivity results alone are insufficient to understand the complex context of tumor cells owing to the absence of genetic or molecular information. High-content analysis described here offers a number of advantages over traditional high throughput screening. First, it addresses whether specific biomarkers important for drug response are significantly high or low. These provide high reliability of drug effects by explaining the target-drug association. Secondly, high-content analysis simultaneously acquires multi-parameter phenotypes. In the present study, we assessed target expression, cell viability, apoptosis, cell-to-cell distances, and real-time cell movement speed in a single experiment. This technology allows for more reliable experimental assays through concurrent collection of multi-layered data. Thirdly, high-content analysis supports the drug repositioning screen to find novel therapeutics for specific functions, which can be further exploited to reveal the underlying mode of action of the alternative mechanism of the drug. We devised a screening method using PDC6 cells to identify potential c-Met inhibiting compounds; this is not achieved with traditional high throughput screening. To inhibit the c-Met in different ways, devising a method to screen anti-WNT (Wingless-related integration site) pathway drugs in PDC6 will also be important, as the WNT pathway is a potential downstream of c-Met .Abemaciclib is the most potent and the latest FDA-approved CDK4/6 inhibitor to date. Abemaciclib has a unique function with a wider range of kinase inhibition activity, suggesting it has additional mechanisms besides CDK4/6 inhibition . Our finCollectively, our findings provide unprecedented insights into high-content analysis of patient specimens, which will contribute to empowering precision oncology and new drug discoveries. These results raise an important new possibility for high-content analysis application in a diverse area of biomarker research, drug discovery, and clinical study. Our work will facilitate expanded development of specific experimental assays and improved clinical decision-making platforms.


Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% . The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines. Staphylococcus Aureus (MRSA) varied from 2–50%, while Extended Spectrum Beta-lactamase (ESBL) prevalence ranged from 10–75% [Antibiotic resistance (ABR) has recently been rising steadily worldwide and has reduced the ability of antibiotics to effectively control infectious diseases . ABR caum 10–75% . In addim 10–75% . In lineThe main driver of ABR is misuse of antibiotics, aggravated by other factors such as unrestricted access to antibiotics . Common Studies in Uganda show that most of the medicine use problems are caused by irrational prescribing practices . HoweverIn the review period, a total of 10,402 (23%) prescriptions of the 45,160 prescriptions contained an antibiotic. The 500 sampled prescriptions of the 10,402 prescriptions with at least an antibiotic prescribed contained 669 antibiotics.The common diagnoses for which antibiotics were prescribed were respiratory tract infections , urinary tract infections , and malaria  .The most commonly prescribed antibiotics were penicillins , nitroimidazoles , quinolones , cephalosporins , and aminoglycosides  .Percentage of encounters with one or more antibiotics prescribed was 23%  with 55% (369/669) of the antibiotics prescribed by generic name. On average, 1.3 (669/500) antibiotics were prescribed per patient and 29% (144/500) of the patients received two or more antibiotics. Of the total number of patients, 125 (25%) received antibiotic injections. All the medicines prescribed were from the Essential Medicines and Health Supplies List (EMHSL) of Uganda. The average cost of antibiotics prescribed per patient was USD 0.5. Antibiotics were prescribed for an average duration of 4.8 days (3–10), with majority of patients 440 (88%) receiving antibiotics for a duration of five days. Majority of the prescriptions, 485 (97%), had diagnosis of the patient recorded. However, 133 (27%) of the diagnoses did not comply with the Uganda Clinical Guidelines (UCG) and were, therefore, considered inappropriate. Of the 367 (73%) of the diagnoses that were compliant with the guidelines, 155 (42%) of the antibiotics prescribed for the diagnosis were not compliant with UCG. .The main reasons for noncompliance of the prescriptions with the guidelines included prescribing antibiotics for malaria ; helminthiasis (worm infestation) ; dental conditions  such as pulpitis and gingivitis, for which antibiotics are not indicated; and noninfectious conditions such as dysmenorrhea and lumbago  . The diaAll the facilities had UCG and no EMHSL. Only two (40%) facilities had diagnostic laboratory facilities for complete blood count, and these were the health center grade IVs (HCIVs). On average, 68% (50/75) of the antibiotics were available on the day of the visit. No health facility had all the selected antibiotics available on the day of the visit and two injectable antibiotics, penicillin benzyl and penicillin procaine fortified (PPF), were available throughout the review period. The average number of days the antibiotics were out of stock was eight days. Cloxacillin was most frequently out of stock with only one facility that did not register a stock out in the review period. The percentage cost contribution of antibiotics was 38%  of total expenditure on essential medicines . The percentage contribution for higher-level facilities (35% and 27%) was less than that of lower-level facilities . .In order to design effective interventions to improve appropriate use of antibiotics, it is important to understand prescribing practices of antibiotics. This study provides an understanding of these prescribing practices.The findings of this survey revealed high percentage of patients receiving antibiotics and low percentage of prescribing by generic name. Studies done on antibiotic prescription patterns in a Ghanaian primary health care facility and Khartoum state found a higher percentage encounter of one or more antibiotics prescribed, of 29% and 54%, respectively ,23. ThisThe average cost of antibiotics prescribed per patient ($0.5) was higher than per capita allocation for medicines ($0.3). The expenditure on antibiotic medicines as a percentage of total facility medicine costs was also high (38%). These show the health facilities operated with small budgets for medicines and spent more on antibiotics. The lower health facilities that receive kits (push system) had higher expenditure on antibiotics compared with higher levels that determine their own needs (pull system). Adding to this expenditure was the high percentage of patients receiving parenteral antibiotics more than the WHO standard for percentage of encounters, with an injection prescribed 13–24% and national standard of less than or equal to 15% ,26. MoreAdherence to UCG was found to be suboptimal. Recording of diagnosis before prescriptions was above the national target of 85%, though lower than WHO standard of 100% ,25,26. RAs a limitation, these indicators highlight major problem areas of antibiotic use patterns and quantify the magnitude of the problem at glance, but they do not exhaustively answer why the problem existed. The study was also limited only to outpatients and, therefore, could not give overall antibiotic prescribing patterns in the facilities.This study was conducted in Yumbe district located in the northwestern part of Uganda, located approximately 590 km from Kampala, Uganda’s capital city. The district total population is 485,582, of which 48% are males and 52% are females. The district hosts refugees mainly from South Sudan and the Democratic Republic of Congo. There are 27 health facilities in the district. These include a general hospital , which is the district referral hospital, two HC IVs, seven (7) health center grade IIIs (HC IIIs), and 17 health center grade IIs (HC IIs). These health facilities provide both curative and preventive services including Outpatient, in patient, Maternal and child health services, and community outreaches, plus other specialized services depending on the level of the facility. The study was conducted in five Health facilities: Yumbe Hospital/Yumbe HC IV, Midigo HC IV, Ariwa, Barakala, and Kulikulinga HC IIIs. These Health facilities were purposely selected. They attend to refugees and have admission facilities and laboratories. Yumbe Hospital was under major renovation and its services were transferred to Yumbe HC IV during the data collection period.This was a cross-sectional study. Outpatient records for a period of three months from March–May 2019 were reviewed. WHO core medicine use indicators for assessing outpatient medicine use were used.The study population included outpatients who were prescribed antibiotics from the five health facilities and tracer antibiotics.Prescriptions containing systemic antibiotics for both adults and children were considered for inclusion, while prescriptions containing topical antibiotics such as lotions, ointments, vaginal pessaries, and eye preparations like eye drops were excluded. Also, prescriptions from outreach and special doctors’ clinics were excluded. Only the selected 15 tracer antibiotics were used to assess for availability. Antibiotics in this study refer to medicines for treatment of bacterial infections only.Based on WHO/DAP/93 recommendation for sample size determination and sampling technique for prescribing indicators, 100 prescriptions were taken from each corresponding Health facility , meaningPrescribing indicators;Percentage of encounters with one or more antibiotics prescribed;Percentage of antibiotics prescribed by generic name;Average number of antibiotics prescribed per patient;Percentage of patients prescribed antibiotic medicines with diagnosis recorded;Percentage of patients receiving antibiotic injections;Percentage of antibiotics prescribed, consistent with the EMHSL;Average cost of antibiotics prescribed per patient;Average duration of prescribed antibiotic treatment;Percentage of prescriptions in accordance with the Standard Treatment Guidelines (STGs);Facility indicators/factors;Existence of STGs for infectious diseases;Existence of an approved hospital formulary list or essential medicines’ list (EML);Availability of a set of key antibiotics in the facility stores on the day of the study;Average number of days that a set of key antibiotics is out of stock;Expenditure on antibiotics as a percentage of total facility medicine costs; andAvailability of diagnostic laboratory facility (complete blood count).The study indicators included:Data were collected using a structured check list for prescribing and health facility indicators. Data regarding prescribing indicators were taken from sampled prescription records retrospectively and were filled or recorded in the structured check list accordingly. Additionally, the availability of tracer antibiotics, which were assessed from the store, and the presence of EML and STG in the Outpatient Department (OPD) were also assessed in the facility indicator form accordingly. Data were collected from OPD registers, Dispensing logs, and stock cards or stock book. Additional information  was obtained from recent invoices. Data collection was supervised by the researchers.Microsoft Excel 2010 version was used for the analysis. The scores of the indicators were compared with national and WHO standards/targets.Makerere University School of Health Sciences Research Ethics committee (MU-SHS-REC) granted ethical approval for the study.Irrational prescribing practices observed in this study included a high number of encounters with an antibiotic prescribed, low percentage of prescribing by generic name, higher percentage of patients receiving injectable antibiotics, and low compliance with standard treatment guidelines even though the treatment guidelines where available in all the facilities. Most of the diagnoses did not comply with the treatment guidelines and antibiotics were prescribed for indications such as uncomplicated malaria, helminthiasis, and allergy that do not require antibiotic interventions in their standard management guides. The facility factors that could have affected the prescribing practices included low availability, out-of-stock medicines, and lack of diagnostic laboratory facilities. These can lead to suboptimal therapeutic outcomes and perpetuate development of drug resistance.There is need to strengthen antibiotic use in health facilities and hospitals through setting up stewardship programs and interventions to enforce the national standard treatment guidelines and provision of diagnostic facilities. More emphasis needs to be placed on teaching the art of writing a prescription to prescribers and compliance with standard treatment guidelines. There is also need to improve availability of the antibiotics. We recommend future studies on the outcomes of antibiotic treatment, underlying causes of irrational antibiotic use, and antibiotic resistance patterns in these facilities.


Overuse of antibiotics and inappropriate prescribing has resulted in a rapid increase in the rate of antibiotic resistance, with poorer patient outcomes and increased health costs. In the out-of-hours setting, a high proportion of antibiotics are prescribed and practices need to improve to reduce antibiotic resistance.To identify antibiotic prescribing practices in European out-of-hours primary care services that are contributing to antibiotic resistance.The review was conducted in alignment with the PRISMA statement .A literature search was performed using MySearch to identify European literature. The search was focused on antibiotic/antimicrobial prescribing in an out-of-hours environment, and any reports that described factors correlating with the nature of prescribing practices were examined.The literature search located 91 articles, out of which seven met the inclusion criteria. Two articles described clinicians’ experiences in antibiotic prescribing in out-of-hours, two compared in-office and after-hours prescribing, two described prescribing patterns in out-of-hours and one examined prescribing in children. Four main themes were identified: antibiotics prescribed and conditions associated with prescribing; consultation time; the day of consultation; and parental opinion.Overprescribing to self-limiting conditions, prescribing of broad-spectrum antibiotics, time constraints, safeguarding issues and poor communication are all contributing to inappropriate antibiotic prescribing. Further research is needed relating to whether clinicians are adhering to antibiotic guidelines and to explore patients’ experiences and expectations from the out-of-hours practitioners with respect to antibiotic prescribing. Antimicrobial resistance is considered a serious threat to global public health , with anA literature review was conducted in accordance with the PRISMA  statement  tools , dependiSeven articles met the inclusion criteria and were deemed suitable for further review. Two papers were qualitative, three were cohort studies, one was a case-control study and one a secondary analysis of a randomised control trial . All sevThe location of the studies varied throughout Europe: two studies were based in the United Kingdom, two in the Netherlands, two in Norway and one in Denmark. Three of the papers included healthcare professionals as their participants while four studies used patients as their target groups. Four of the papers had both child and adult patient participation groups of both sexes. Female patients between the ages of 18 and 60 were most likely to receive a prescription. Overall, the sample sizes of the included studies seemed adequate; even the qualitative papers had appropriate numbers of participants for their methodology. For example, The qualitative articles by Antibiotic consumption is contributing to the spread of antimicrobial resistance, and prudent antibiotic prescribing has been identified as an essential strategy to curb this problem . PrudentMultiple studies and current clinical management guidance suggest that tonsillitis, sinusitis and cystitis will resolve without treatment in healthy patients . UncomplIt is apparent from the evidence that the frequent prescribing for self-limiting conditions such as cystitis, sinusitis and tonsillitis suggests room for improvement of rational antibiotic use. Stricter guidance to further reduce the number of broad-spectrum antibiotics prescribed needs to be put in place to tackle antimicrobial resistance effectively. Further research into whether clinicians are adhering to guidelines would be beneficial. This evidence is already apparent in the in-hours setting; however, there are currently no studies that have investigated why physicians are prescribing for self-limiting conditions in OOH.Two studies highlighted that time restrictions in the consultation lead to a higher antibiotic prescription rate. The reasons behind the increase in prescriptions could be down to GPs and nurse practitioners (NPs) feeling the pressure of the time constraints, not being able to discuss alternative approaches or the nature of the illness with the patient and ultimately prescribing antibiotics as a time-saving strategy. In the OOH this is intensified, with patients being more impatient and demanding antibiotics as they consider themselves more unwell . One solOOH in Europe was described in most articles as services provided outside of regular working hours, typically evenings and weekends, although evening time varied by location. The evidence revealed associated implications with the day of consultation. Respiratory tract infection, which is predominantly self-limiting, is the most common reason why children consult a GP . De BontOverall, parents’ assessments of sickness and seriousness were significantly associated with the treatment outcomes. This may reflect that they know their child well or may suggest that clinicians often prescribe to satisfy parents. The results from There are certain limitations to this review. ‘Grey’ literature was not accessed as it is difficult to find and beyond the scope of the literature review; therefore, it is possible that unpublished articles and non-academic articles were missed. Another limitation is that it comprised an electronic search, and despite the advancement in electronic searching, digital searching tools are not 100% comprehensive and will not identify all the literature. A further limitation is that the review was limited to literature written in the English language. Only European literature was included, hence location bias is also present in the review, as is the potential for clinical practice to vary depending on location, such as European practices varying from British practices.Overprescribing for self-limiting conditions – especially of broad-spectrum antibiotics – time constraints, safeguarding issues and poor communication are all contributing to inappropriate antibiotic prescribing. Further research is needed relating to whether clinicians are adhering to antibiotic guidelines and to explore patients’ experiences and expectations from the OOH practitioners with respect to antibiotic prescribing.None declared.None.


Due to the heterogeneity of soft tissue sarcomas (STS), the choice of the proper perioperative treatment regimen is challenging. Neoadjuvant therapy has attracted increasing attention due to several advantages, particularly in patients with locally advanced disease. The number of available neoadjuvant modalities is growing continuously. We may consider radiotherapy, chemotherapy, targeted therapy, radiosensitizers, hyperthermia, and their combinations. This review discusses possible neoadjuvant treatment options in STS with an emphasis on available evidence, indications for each treatment type, and related risks. Finally, we summarize current recommendations of the STS neoadjuvant therapy response assessment. Due to the growing number of available treatment options and the rarity and heterogeneity of soft tissue sarcomas (STS), the decision-making process is very complex. In comparison to surgery alone, the addition of adjuvant radiotherapy (RT) allows obtaining a high local control rate in patients with STS of extremities or trunk wall. Nevertheless, this combination does not improve patients’ overall survival (OS) . AdditioThe introduction of neoadjuvant treatments in clinical practice was initially limited to challenging cases, such as unresectable STS, albeit currently it should be considered as an equal alternative to adjuvant therapy, bringing more advantages than risks. It is highly improbable to create a universal neoadjuvant treatment regimen for STS due to the variety of molecular subtypes and related clinical factors . Thus, aDespite several advantages of neoadjuvant RT in STS and no differences in long-term outcomes as compared to adjuvant RT, neoadjuvant treatment is not widely used in clinical practice  10]. Th. Th10]. In neoadjuvant RT, it is recommended to contour gross tumor volume (GTV) using magnetic resonance imaging (MRI) T1 post-gadolinium . ClinicaRT techniques in STS slowly evolved from 3D-conformal RT to IMRT. IMRT allows better coverage of target volumes with the prescribed dose along with higher conformity but at the cost of an increase in volume irradiated with low doses . TheoretNeoadjuvant RT in STS may be prescribed in conventional and altered fractions . The conUnfortunately, even the best perioperative treatment cannot replace high-quality R0 surgery . It has Novel neoadjuvant RT approaches in STS include a return to abandoned spatially fractionated RT that used sieve-like collimators to produce fluctuating dose distribution with extremely high doses in selected subvolumes of a tumor. Mohiuddin et al. used spatially fractionated RT with ifosfamide-based CHT to treat bulky STS, obtaining excellent pathological responses and acceptable toxicity . DynamicAccording to the NCCN guidelines, neoadjuvant RT is recommended as one of the possible options in stage II, III resectable extremity, superficial trunk, or head/neck STS with acceptable functional outcomes (category 1) . In the The most significant disadvantage of neoadjuvant RT is the increased risk of wound complications. In the Canadian trial, authors randomized patients to neoadjuvant or adjuvant RT . Due to The role of perioperative CHT in patients with localized STS remains controversial . NeoadjuAn updated large meta-analysis of 18 randomized controlled trials of adjuvant CHT for localized resectable STS showed that anthracycline-based CHT marginally improved local recurrence, distant recurrence, overall recurrence, and OS . Even leHistologically driven CHT showed good preliminary efficacy of selected drugs in chosen pathological STS subtypes. Four sarcoma groups  performed a phase III randomized clinical trial (NCT01710176) with neoadjuvant histologically driven CHT ,50. Two 2 with ifosfamide 9 g/m2  fusion in inflammatory myofibroblastic tumors), gene amplifications , oncogenic mutations , and complex genomic rearrangements (vast majority of STS) [EZH2) histone methyltransferase, tazemetostat, registered in the USA for metastatic or locally advanced unresectable epithelioid sarcoma [INI1 suppressor gene in epithelioid sarcoma cells causes deregulation of EZH2 that leads to the activation of multiple oncogenic signaling pathways. Tazemetostat competitively inhibits EZH2, stopping epithelioid sarcoma growth. Another effective novel therapy, namely the inhibitor of tropomyosin receptor kinases A, B and C, targets NTRK fusions. An analysis of databases from three ongoing phase I or II clinical trials with entrectinib , which enrolled 54 patients with metastatic or locally advanced NTRK fusion-positive solid tumors, showed a high ratio of objective durable responses  with good treatment tolerance [The only routinely used highly effective neoadjuvant subtype-targeted therapy in STS is imatinib for unresectable localized dermatofibrosarcoma protuberans and gastrointestinal stromal tumors ,126. How of STS) . A clear sarcoma . A mutatolerance . In the olerance ,130,131.Promising results of immune checkpoint inhibitors in various cancers encouraged investigators to assess their potential in STS. This group of molecules targets the most important regulators of the immune system that are responsible for anticancer response. Immune checkpoint inhibitors are especially active in tumors with a high mutational burden. Approved molecules include anti-CTLA4, anti-programmed cell death 1 (PD-1), and anti-PD-1 ligand immunotherapies. Despite a strong theoretical basis and expectations, preliminary results from phase I and II clinical trials showed moderate activity of immunotherapy in STS . The excPatients with high-risk STS may benefit from neoadjuvant therapy. Neoadjuvant RT should be a part of the treatment provided that a risk of wound complications is acceptable. Due to high risk of distant metastases, RT may be combined with neoadjuvant CHT. Anthracycline–ifosfamide CHT regimens are preferred regardless of STS subtype. In fragile patients, less intensive CHT regimens, such as anthracyclines alone, may provide adequate efficacy without the risk of a significant increase in CHT toxicity.Slowly growing locally advanced low-grade tumors bring a low risk of metastatic spread. Thus, administration of CHT is not recommended. This group of STS is relatively more radioresistant. Therefore, based on radiobiological models, hypofractionated RT might provide benefit in local response. Additional radiosensitizing modalities such as HT may enhance efficacy of RT.Neoadjuvant therapy is the gold standard for the treatment of marginally resectable or non-resectable STS. Both CRFT and HFRT may be considered. In bulky, symptomatic tumors, shorter RT regimens are preferred. RT might be combined with anthracycline-based CHT to increase local response and decrease the risk of distant metastases. Due to the usually large volume of those tumors and related symptoms, the application of regional HT or nanoparticles may be problematic or even unfeasible.Epithelioid sarcoma, extraskeletal myxoid chondrosarcoma, clear cell sarcoma, solitary fibrous tumor, alveolar soft part sarcoma and inflammatory myofibroblastic tumor constitute STS subtypes resistant to conventional cytotoxic chemotherapy. In those subtypes, neoadjuvant CHT is not recommended due to lack of efficacy and risk of disease progression. In the case of resectable chemoresistant STS, the preferred neoadjuvant approach is RT followed by surgery. More locally advanced and marginally resectable chemoresistant STS may benefit from additional radiosensitizing modalities, such as HT or nanoparticles. Although no targeted therapies have been investigated as a neoadjuvant treatment specifically in chemoresistant STS, tyrosine kinase inhibitors and antiangiogenic agents may be considered individually in selected cases. The only exception is the inflammatory myofibroblastic tumor presenting the ALK gene mutation, which is susceptible to ALK inhibitors .The management of radiation-induced or in-field recurrent STS is challenging. The only curative modality in localized tumors is radical resection with wide negative margins. The role of secondary RT is unclear, mostly due to the concerns about possible severe side effects after re-irradiation. However, RT may be carefully considered in selected cases, especially after a long period from the first RT, and absence of significant late toxicity from previous irradiation. HT may allow RT dose reduction without a decrease in treatment efficacy. CHT and targeted therapy may be used in metastatic disease, but their role in neoadjuvant therapy is not established.There are multiple options for neoadjuvant treatment in STS that are focused on improving local and distant control. Any neoadjuvant approach should be considered individually at the MTB, taking into consideration tumor site, stage, pathology, comorbidities, age, resectability, institutional protocols, and availability of methods. The authors’ consensus on available combinations that could be considered in various clinical situations is presented in


There has been substantial growth in eHealth over the past decade, driven by expectations of improved healthcare system performance. Despite substantial eHealth investment, little is known about the monitoring and evaluation strategies for gauging progress in eHealth availability and use. This scoping review aims to map the existing literature and depict the predominant approaches and methodological recommendations to national and regional monitoring and evaluation of eHealth availability and use, to advance national strategies for monitoring and evaluating eHealth.Peer-reviewed and grey literature on monitoring and evaluation of eHealth availability and use published between January 1, 2009, and March 11, 2019, were eligible for inclusion. A total of 2354 publications were identified and 36 publications were included after full-text review. Data on publication type , country, level , publication year, method , and domain  were charted.The majority of publications monitored availability alone or applied a combination of availability and use measures. Surveys were the most common data collection method (used in 86% of the publications). Organization for Economic Co-operation and Development (OECD), European Commission, Canada Health Infoway, and World Health Organization (WHO) have developed comprehensive eHealth monitoring and evaluation methodology recommendations.Establishing continuous national eHealth monitoring and evaluation, based on international approaches and recommendations, could improve the ability for cross-country benchmarking and learning. This scoping review provides an overview of the predominant approaches to and recommendations for national and regional monitoring and evaluation of eHealth. It thereby provides a starting point for developing national eHealth monitoring strategies. With this scoping review, we aim to provide an overview of the current literature produced by researchers, organizations, or government bodies, and to assess the foci, methodology, and scope of monitoring and evaluating eHealth. The focus of this scoping study lies not in addressing the quality of the studies and obtaining ‘best evidence’,This scoping review is based on the approach suggested by the Joanna Briggs Institute, adapted and developed from the five stages by Arksey and O’MalleyeHealth is “the application of information and communication technologies across the whole range of functions that affect the health sector and including products, systems, and services that go beyond simply Internet-based applications.”The search strategy aimed to ensure the identification of both peer-reviewed publications providing quantitative and/or qualitative evidence on monitoring or evaluating eHealth at a national or regional level; and other publications, peer-reviewed or not, opinions or reports. The search targeted a number of potential sources including journal citation databases, bibliographic databases, and output from known centers of excellence and governments. The protocol for this scoping review contains further information on the preliminary search strategies.To identify original peer-reviewed publications, we used the databases PubMed, SCOPUS, and Web of Science. Further, a structured search for grey literature, such as national or organizational reports, was performed using the Canadian Agency for Drugs and Technologies in Health (CADTH) checklist for grey literature “Grey Matters”.availability of eHealthMonitoring or evaluating use of eHealthMonitoring or evaluating Monitoring and Evaluation, eHealth, and Availability. Each key term had several synonymous sub-terms. When applicable, major terms were used . To ensure the detection of literature not yet indexed with major terms, free text search was used. We did not seek to identify the specific metrics used for monitoring  as these metrics would be specific to the organizational setup of national health systems and context.In the availability section, key search terms were A full search strategy for a PubMed search can be found in An iterative approach to selecting literature was applied, entailing continuous assessment of eligibility criteria and the screening process. A literature directory was created in Mendeley All materials were categorized into one of three broad categories based on an approach described by Wong et al.Category 1: Peer-reviewed study with empirical measures of availability/use. Clear articulation of the methodological approach to monitoring or evaluating availability or use of eHealth at a national or regional level, covering design, data collection, analyses, and relevance.Category 2: Non-peer-reviewed report with empirical measures of availability/use. Reports by government or non-government, health associations, professional bodies, and centers of excellence. We included these because national monitoring data is intended for public/broad consumption and therefore often not submitted for peer-review.Category 3: Methodology recommendations. Material presenting comprehensive recommendations of methodology of national monitoring or evaluating availability and/or use of eHealth. Often non-peer-reviewed.Based on the approach by Arksey and O’MalleyA general issue when comparing systems and services across countries is the subtle differences in terminology and understanding of what constitutes, for example, an electronic health record. Collecting and comparing data on functionalities rather than systems is a method of overcoming these cultural differences.Provider-centric electronic records cover the range of Electronic Medical Records (EMRs), Electronic Health Records (EHRs), and Electronic Patient Records (EPRs) and “include systems that are used by healthcare professionals to store and manage patient health information and data, and include functionalities that directly support the care delivery process.”The results of the search strategy provided a list of 1135 indexed publications for monitoring and evaluating eHealth availability and 1219 indexed publications for monitoring and evaluating eHealth use, see A total of 117 full-text publications were reviewed with 80 excluded due to not fulfilling eligibility criteria after all  or not having a clear description of the methodology. After removing one additional duplicate, a total of 36 publications were included in this scoping review. Of the 36 publications, 64% were empirical research studies, 28% were reports by governments or organizations, and 8% were published recommendations of methodology. ,The geographical origin of monitoring and evaluating activities  is distrMapping the publications showed that the majority of monitoring and evaluation activities were set in the Northern European countries and the United States. In 89% of the publications, the primary purpose was to monitor the availability and use of eHealth. Surveys were most commonly used (86% of the publications) and 42% of the publications referred to continuous or repeated data gathering activities.Publications: n = 28Category: 20 empirical studies,,,,,,,,,,,,Focus: The main aims were on monitoring the availability and use of provider-centric electronic records or functionalities, for example, entering and viewing clinical data, medication list, picture archiving, and clinical decision support.,,,,,,,,,,,Methods: Most publications had a national scope (n = 24). Surveys were the data collection method most used to gauge the availability and use of provider-centric electronic records. Few publications also used business data  to measure availability and use of provider-centric electronic record functionality.,,n = 18) and continuous or repeated activities (n = 10).Publications: n = 13,,,,,,,Category: Five empirical studies,,,,,,,,,,,Focus: The main aims in all publications were on monitoring the availability and use of patient-centric electronic records or functionalities, for example, online appointment scheduling, medication renewal, viewing of clinical data, and electronic communication with General Practitioners. Four publications addressed the citizens’ perceptions of eHealth.,,,Methods: All publications had a national scope and used surveys to gauge the availability and use of patient-centric electronic records. One publication also used business data  to assess the amount of use of patient-centric electronic record functionality.n = 7) and continuous or repeated activities (n = 6). Only two publications surveyed patients directly,,Publications: n = 16,,,,,,,,Category: 10 empirical studies,,,,,,,,,,,,,,Focus: The main aim was on monitoring the availability and use of HIE (n = 15), such as ePrecriptions, eReferrals, and exchange of clinical history, laboratory results, or radiology reports with external organizations. Only one publication regarded evaluating the systems’ effect on the organization.Methods: Most publications had a national scope (n = 13). Surveys were the data collection method most used to gauge the availability and use of HIE functionalities. A few publications also used business data .,,n = 6) and continuous or repeated activities (n = 10).Publications: n = 3,,Origin: Canada Health Infoway,Focus: The publications present thorough methodological recommendations and approaches to monitoring and evaluating eHealth. Methodological recommendations and a wide selection of indicators are provided within different domains and functionalities. All OECD domains presented in ,Methods: Data collection through survey methods is the main methodology described. Canada Health Infoway also emphasizes the use of business data  and describes which indicators could be monitored by methods other than surveys.,This scoping review synthesizes the current literature on national approaches to monitoring and evaluation of availability and use of eHealth.,,,ability to use a given functionality or system , whereas patient-centric electronic records were only addressed in 44% . This co,,Surveys are by far the most common data gathering method for monitoring and evaluating national availability and use of eHealth (used in 86% of the publications). Surveys are cost-efficient and can be used to obtain information on phenomena that are not easily measured otherwise. However, surveys are prone to issues of low external validity and bias. Recall and social desirability biases are also common limitations of surveys.Our results also reveal the potential challenge of lack of repeated national monitoring and evaluation efforts. Repeated or continuous data collection is needed to measure secular progress or to evaluate the impact of policy changes (or other interventions). Ongoing measures of eHealth progress, therefore, supports evidence-based approaches to eHealth policy.,,Finally, our results reveal that, while there are national or international methodological approaches to eHealth monitoring, there are multiple approaches that are not harmonized.The search strategy required iteration as the terminology within the research field of eHealth changed over the years, and it required adding new terms and definitions . In addition, many publications on eHealth monitoring and evaluation might only be disseminated through conferences or posters, which are not indexed in bibliographic databases in general. Thus, the choice of search terms and the focus on bibliographic databases may induce selection bias.Most publications evaluated eHealth at the single institution or single-system level - and were therefore excluded. To capture a broader set of eHealth monitoring efforts, we included grey literature and it is possible that our results would be different if we had limited studies to the peer-reviewed literature. However, we do not feel that the peer-review process would fundamentally alter the content or methods of the monitoring that was the focus of our review.Monitoring eHealth adoption is essential for providing an evidence base on which to formulate future national eHealth policies and for evaluating the effectiveness of the efforts.The authors contributed to the manuscript as follows:Substantial contributions to the conception and design of the work (Villumsen and Nøhr); and the acquisition, analysis, or interpretation of data for the work .Drafting the work (Villumsen and Nøhr) and revising it critically for important intellectual content (Adler-Milstein).Final approval of the version to be published .Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved .ooz071_Supplementary_DataClick here for additional data file.


IgG4-related disease is a systemic fibroinflammatory disorder that occasionally affects the prostate. It is usually considered that patients with IgG4-related disease are at high risk of developing malignancies. A 71-year-old man presented to our hospital with a chief complaint of urinary retention. Prostate biopsy revealed concomitant IgG4-related prostatitis and prostate cancer. IgG4-related prostatitis was a possible cause of urinary retention, and the aggressive nature of prostate cancer was the cause of the patient's death 2 years after diagnosis. This is the fourth case report of prostate cancer accompanied by IgG4-related prostatitis; however, there have been no reports of the two diseases coexisting with high clinical significance. Our case report indicates that patients diagnosed with IgG4-related prostatitis should be carefully followed up considering the risk of prostate cancer. IgG4-related disease is a rare systemic fibroinflammatory disorder characterized by the enlargement of affected organs, a significant increase in serum IgG4 levels, tissue infiltration with IgG4-positive plasma cells, and fibrosis –3. IgG4-Although a complete consensus has not yet been established, patients with IgG4-related disease are typically considered at high risk of developing malignant disease –12. Here3 was defined using transabdominal ultrasonography. Urinary catheterization was performed, and alpha-blocker treatment was initiated. A follow-up examination conducted 1 month later showed serum prostate-specific antigen (PSA) levels of 74 ng/mL, although the last PSA test performed a year ago had revealed normal PSA levels. Blood and urine test results were nearly within normal limits, except that mild anemia and mild hypoalbuminemia were noted. Prostate tissue samples were obtained via transrectal needle biopsy. Digital rectal examination revealed a firm prostate; however, a prostate tissue sample stained with hematoxylin and eosin showed inflammation but no malignant cells. One month after the first biopsy, urinary retention recurred, but 2 weeks of clean intermittent self-catheterization improved the obstructive symptoms. One month later, the patient had elevated PSA levels of 180 ng/mL, and a second prostate biopsy was performed th month of hormonal therapy and returned to normal when prednisolone at a dose of 10 mg/day was coadministered with abiraterone in the following month. Notably, he never complained of urinary retention until death.A 71-year-old Japanese man presented to our hospital with a chief complaint of urinary retention. He had chronic obstructive pulmonary disease, hypertension, and a history of left femoral head replacement due to osteoarthritis of the hip. Additionally, he had a history of alcohol consumption and cigarette smoking. Prostate volume of 42 cmIgG4-related prostatitis was first reported by Yoshimura et al. –8. In paIn the present case, acute urinary retention resulted in a hospital visit. Buijs et al. reported that >50% of patients with IgG4-related prostatitis presented with obstructive urinary tract symptoms , and we To the best of our knowledge, only three cases of prostate cancer with IgG4-related prostatitis have been reported to date , 14. TheIn our case report, the histopathological characteristics of IgG4-related prostatitis were retrospectively detected in the specimens of the first biopsy. As the patient had no history of IgG4-related disease, the immediate diagnosis of IgG4-related prostatitis was difficult. Nevertheless, an additional careful examination could have led to the diagnosis of IgG4-related prostatitis after the first biopsy. However, if steroid therapy administered for IgG4-related prostatitis had reduced the serum PSA levels, the detection of prostate cancer would have been delayed. Our case report indicates that patients diagnosed with IgG4-related prostatitis based on the symptoms of inflammation should be carefully followed up considering the risk of prostate cancer.In the present case report, the association between IgG4-related prostatitis and the development of prostate cancer remains unclear. However, a possibility exists that IgG4-related prostatitis and prostate cancer, which manifested concomitantly and were diagnosed almost simultaneously, were associated and that their concomitant existence was not a coincidence. However, further investigation is necessary to ascertain the association between these two diseases.


While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches  and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response. Clostridioides difficile infection.Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel viral pathogen and its associated clinical syndrome COVID-19) is the cause of an ongoing global pandemic involving hundreds of thousands of deaths. While current research efforts focus primarily on identifying therapeutic interventions, it is important to consider the collateral effects of COVID-19 on other public health crises. Specifically, early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens.9 is the As the hospital entry point for most patients with potential COVID-19, the emergency department (ED) is a critical setting for stewardship efforts.Most available reports on COVID-19 have focused on characterization of the disease and associated outcomes; so there is limited information available on antibiotic use patterns. Two recent systematic reviews identified that 72% of patients with COVID-19 receive antibiotic therapy despite only 7% having a bacterial co-infection.Due to unique, system-level factors, optimizing antibiotic prescribing in the ED is challenging. Emergency care providers have specifically reported that time pressures, clinical inertia, perceived patient expectations, and diagnostic uncertainty can lead to overuse of antibiotics.12These challenges in optimizing antibiotic prescribing in the ED are further exacerbated by diagnostic limitations inherent to the first pandemic wave. Patients with COVID-19 infection can present with a wide spectrum of illness severity and non-specific clinical features  that overlap substantially with other common acute respiratory conditions such as asthma, congestive heart failure, and bronchitis.16The increased prevalence of early hypoxia and progression to respiratory failure reported for COVID-19 compared to other infectious respiratory conditions is another potential factor underlying high rates of antibiotic utilization.20Although not directly related to COVID-19 infections, the pandemic public health response effort appears to have significantly altered patterns of ED utilization. Several reports confirm dramatic decreases in ED volumes for emergent conditions, potentially related to “stay at home” orders or fear of COVID-19 exposure in the hospital.There are several relevant stewardship interventions with established effectiveness in curbing inappropriate antibiotic usage for acute respiratory conditions in the ED. Academic detailing, care pathways/guidelines, and pharmacist review can improve empiric antibiotic selection for community-acquired pneumonia.Although the availability, diagnostic performance, and turnaround time of diagnostic tests for SARS-CoV-2 is likely to continue improving over time, we are over five months into this pandemic and rapid testing is still not widely available in the ED. There is an immediate need for research elucidating the role of host response biomarkers in helping clinicians identify bacterial infections in patients with acute respiratory illnesses. Procalcitonin (PCT) is a Food and Drug Administration-approved biomarker that differentiates viral from bacterial infections and can safely guide antibiotic decision-making for stable patients with acute respiratory infections.36Early reports indicate PCT remains negative in COVID-19 infection and may be useful in easing concerns of bacterial co-infection, although further research is needed to confirm these findings.40The ongoing COVID-19 pandemic is exacerbating known challenges to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health via antibiotic overprescribing and promotion of bacterial resistance. There is an immediate need for research characterizing ED antibiotic prescribing patterns and the performance of host response biomarkers among patients with confirmed or suspected COVID-19. Antibiotic stewardship approaches shown to effectively mitigate the impact of COVID-19 in the ED should be widely disseminated and inform future pandemic responses.