Tumor cells can result from gene mutations and over-expression. Synthetic lethality (SL) offers a desirable setting where cancer cells bearing one mutated gene of an SL gene pair can be specifically targeted by disrupting the function of the other genes, while leaving wide-type normal cells unharmed. Paralogs, a set of homologous genes that have diverged from each other as a consequence of gene duplication, make the concept of SL feasible as the loss of one gene does not affect the cell’s survival. Furthermore, homozygous loss of paralogs in tumor cells is more frequent than singletons, making them ideal SL targets. Although high-throughput CRISPR-Cas9 screenings have uncovered numerous paralog-based SL pairs, the unclear mechanisms of targeting these gene pairs and the difficulty in finding specific inhibitors that exclusively target a single but not both paralogs hinder further clinical development. Here, we review the potential mechanisms of paralog-based SL given their function and genetic combination, and discuss the challenge and application prospects of paralog-based SL in cancer therapeutic discovery. ParalogHomozygous paralog loss occurs more frequently than singletons in cancer , suggesthttps://depmap.org/portal/), new targets related to the most common genetic drivers have not yet been discovered  repair genes , a polyprotein complex that plays a vital role in reversing membrane remodeling, have been confirmed as an SL gene pair both  in vivo , 38, 42. in vivo .2.4This category includes functions with fewer reported SL interactions. For instance, the simultaneous inactivation of phosphatase DUSP4 and DUSP6 selectively impairs the growth of cells with mutations in NRAS or BRAF by hyperactivating MAPK signaling . BCL2L1 3It was first shown in 2005 that SL genes can be a selective and effective target for precision cancer treatment. Ashworth and Helleday demonstrated that inhibition of PARP inhibitors selectively kills BRCA1/2-deficient tumor cells, revealing an SL interaction between PARP and BRAC1/2 , 13. MorAlthough a pair of paralog genes provide a highly straightforward SL interaction by virtue of their similar functions, it is worth noting that drug development from paralog-based SL is still scarce in clinical trials  and cancer therapies . The sloSex paralogs provide a new opportunity for male tumors. Some paralogous genes are located between sex chromosomes. The prevalent loss of chromosome Y in male cancer patients makes depletion of the chrX-encoded paralog attractive as a therapeutic strategy. For example, chrX- and chrY-encoded paralogs including DDX3X-DDX3Y, ZFX-ZFY, and EIF1AX-EIF1AY have been proven to buffer for each other’s loss and dependent on chrX-encoded paralog in cancers with loss of chrY . Accumul4Paralog-based SL can generally be divided into four types: 1) SL interactions within the paralog family ..26). An 4.2The functional redundancy of paralogs hides some key SL targets, which highlights the existence of SL interactions between multiple paralog members and other genes , 102. Th4.3Despite the redundancy of most paralog members, paralogs can acquire some non-overlapping functions through sub-functionalization and neo-functionalization. This can also lead to SL interactions with other genes , but PRMGenes can also form an SL interaction with upstream regulatory genes of their paralogs . Additio5Notably, not all paralogs are capable of functionally compensating. Functional divergence is a major limiting factor for their ability to compensate for their function . In addiThe buffering effect of paralog can be subdivided into different mechanisms, passive paralogous compensation  and active compensation . Change From an alternate point of view, the paralog interaction relationship can be used as an argument for compensation ability. For example, the protective redundancy of paralogs partly depends on their independent functions. A large fraction of paralogous proteins may establish functional interdependence by heteromerization , which reduces the ability of paralogous genes to compensate for each other’s loss . This in6Some SL pairs could be uncovered using genome-wide single gene perturbation (RNAi or CRISPR) combined with background abnormality in cancer cell lines , 45, 52.6.1Caenorhabditis elegans or Drosophila melanogaster  offers abundant single gene perturbation resources. Bioinformatic approaches leveraged these resources to systematically discover cancer-relevant paralog-based SL interactions by correlating genetic biomarkers  with gene dependency , opening up a new avenue for finding compensatory genes beyond paralog genes (The evolutionary characteristics of tumor initiation and development are closely tied to the robustness provided by buffer systems. Paralog variations in tumor cells provide rich resources for developing SL-based cancer therapies. Thorough characterization of the paralog buffer system can be useful for future tumor research and therapeutic development. This includes understanding the importance of paralog members, predicting functional divergence and buffering effects, and identifying regulatory differences among paralog members. The same paralog SL gene pair can elicit different responses in different cell lines  dependinog genes , 124. Thog genes –128.In conclusion, paralog-based SL provides a powerful genetic engine for cancer research and clinical development. Understanding the mechanisms of SL pairs and the characterization of buffer systems in tumors will shed light on future research and development of precision cancer therapy.YX and YZ initiated the project. XY wrote the manuscript. YZ provided feedback on the manuscript. All authors contributed to the article and approved the submitted version.


The usefulness of intraoperative cultures in complicated appendicitis is controversial. The current evidence presents important methodological limitations and studies are needed to evaluate outcomes in patients with intraoperative cultures. We analyzed the impact of intraoperative aerobic culture on the modification of antibiotic therapy and the clinical evolution of patients with complicated appendicitis.Appendectomy is one of the most performed surgeries and is the leading cause of acute abdomen.Retrospective cohort study of 144 adults with complicated appendicitis  in a high complexity hospital in Colombia from 2014 to 2022. The intraoperative sample was taken according to the attending surgeon’s decision. The procedure of how the cultures were taken and analyzed can be found in the supplementary material. The primary outcomes included the modification of antibiotic therapy, surgical site infection (SSI) during the first 30 postoperative days, reintervention, length of hospital stay, and mortality. All patients were evaluated in a postsurgical outpatient visit. A Cox proportional hazards model was used with the subsequent reporting of the hazard ratio. The project was approved by the Health Ethics Committee .n=61) patients, 56.2% had a laparoscopic approach. In most cases, the chosen empiric antibiotic as well as the therapy duration was guided according to the hospital protocol  of the cultures. Four of them were positive for extended-spectrum beta-lactamase (ESBL), and 13 presented inhibitor-resistant TEM. Three of the 13 isolates of P. aeruginosa were found to be resistant to beta-lactams, one of them was resistant to carbapenems . The risk of presenting SSI was reduced by 73% in patients with intraoperative culture   with initially empirical piperacillin/tazobactam treatment Table . There wE. coli infections (14–54%), which is one of the most common isolated microorganisms. Colombian Association of Infectious Diseases suggests taking intraoperative cultures in patients with fibrinopurulent fluid or generalized peritonitis, to document the local epidemiology of community-acquired intra-abdominal infections and to provide target antibiotic treatment.High rates of bacterial resistance in intra-abdominal infections had been reported among  86.9% of our samples had a positive result with an overall resistance to beta-lactams of 40.6%, comparable to international reports. A change in antibiotic therapy was observed in 57.4% of patients, leading to targeted antibiotic therapy in 72.1% of the cases and to a reduction in antibiotic spectrum. A protective effect of intraoperative cultures on the development of surgical site infections was detected; as findings in previous studies. Although the low percentage of laparoscopy appendectomy mainly due to limitations in our healthcare system, there were no statistically significant differences in SSI rates between open and laparoscopic approaches.Although there is evidence of positivity and resistance rates of 24% and 2% respectively for intraoperative cultures,This is a single-center study with selection biases due to non-protocolized intraoperative culture sampling. seeking to provide targeted antibiotic management and to reduce surgical site infection, readmissions and the costs derived from hospital care.We recommend routinely intraoperative cultures in patients with complicated acute appendicitis according to IDSA statement,ESM 1


C-S-H is responsible for developing concrete because it fills pores and cracks, forms a platy structure, and makes the concrete much denser, thereby improving its macroscopic performance and microstructure.Diatomite is a siliceous sedimentary rock containing amorphous silica, which can be used as a green mineral admixture to improve the properties of concrete. This study investigates the affecting mechanism of diatomite on concrete performance by macro and micro tests. The results indicate that diatomite can reduce the fluidity of concrete mixture and change its water absorption, compressive strength, resistance to chloride penetration (RCP), porosity, and microstructure. The low fluidity of concrete mixture containing diatomite can reduce workability. With increasing diatomite as partial replacement for cement in concrete, water absorption of concrete decreases before increasing, while compressive strength and RCP rise first and then drop. When diatomite is added to the cement at a content of 5% by weight, the concrete has the lowest water absorption and the highest compressive strength and RCP. Through the mercury intrusion porosimetry (MIP) test, we determined that the addition of 5% diatomite reduces the porosity of concrete from 12.68% to 10.82% and changes the proportion of pores with different sizes in concrete, the proportion of harmless and less harmful pores increases, and the proportion of harmful pores reduces. Based on the microstructure analysis, the SiO Diatotability ,11,12,13Diatomite was first discovered in Germany in 1833. In the last 200 years, diatomite development, purification, processing, and application have considerably evolved, as has a new understanding of it. Diatomite resources are abundant and widely distributed, with the United States and China ranking first and second, respectively, in terms of reserves of diatomite. China has the second largest supply of diatomite in the world, but more than 80% of it is low quality. Utilization and expansion of low-quality diatomite resources are crucial. If diatomite can be widely used as a green building material, it will be of great significance. Concrete is the most widely used construction material in the world, and it is utilized in the construction of buildings, highways, bridges, tunnels, hydraulic engineering, and special structures. Large-large use of concrete has consumed many natural resources and negatively impacted the ecological environment. Particularly, the cement in concrete mixes poses the greatest threat to the natural environment and human health. Due to its high amorphous silica content, diatomite is considered a possible substitute for cement in cementitious composites. This type of silica can react with calcium hydroxide to form calcium silicate hydrates, which are responsible for developing concrete strength . TherefoAlthough numerous studies on the use of diatomite as a mineral admixture have been conducted, the following gaps in knowledge require further investigation. First, most analyses have focused primarily on the effect of diatomite on the physical and mechanical properties of cement paste and mortar, while the effect of concrete properties has received less attention. In addition, the results of studies on the effects of diatomite on concrete properties are diverse. Second, diatomite is employed to replace cement in concrete as a mineral additive, and there are various studies on its replacement of cement mass below 2% or above 10%, but almost none between 3% and 9%. Furthermore, the results of comprehensive studies on the effects of diatomite on the workability, physical and mechanical properties and durability of concrete are limited, especially due to the absence of multi-scale research methods combining macroscopic and microscopic. This research addresses the above deficiencies and provides theoretical support for applying diatomite in concrete. Based on the eco-balance evaluation method of European standards EN ISO 14040 and EN ISO 14044 ,33, the 2/kg. 3, 1.0% mut content) and crushed stone  were utilized based on the Chinese standard [Ordinary Portland cement (P.O 42.5), conforming to the Chinese standard GB175-2007 , was usestandard . Polycar2 and small amounts of Al2O3, Fe2O3, K2O, CaO, TiO2, MgO, and others. 3 for compressive strength and water absorption tests (20 groups). The size of concrete samples was ϕ100 × 50 mm3 for the coulomb electric flux test (4 groups). The size of mortar samples was ϕ8 × 10 mm3 for the mercury intrusion porosimetry test (4 groups). The size of cement paste samples with water/binder ratio of 0.4 was 40 × 40 × 160 mm3 for the thermogravimetry and Fourier transform infrared spectroscopy tests (4 groups).The size of concrete samples was 100 × 100 × 100 mmVarious types of concrete samples were cast in different molds. The produced samples were demolded after 24 h and cured in the standard curing room until testing. The room temperature was 20 ± 2 °C, and the relative humidity was greater than 95%.The slump value was measured after uniformly stirring the concrete mixture of each mix proportion. Based on the Chinese standard GB/T 50080-2016 , the consM is the mass of the samples saturated with water, and dM is the dry mass of the samples.Referring to ASTM C 642 standard  and acco3 cubes were investigated according to the Chinese standard GB/T 50081-2019 [Compressive strength was evaluated on the concrete samples at 3, 7, 14, and 28 days. The concrete specimens of 100 × 100 × 100 mm081-2019 . Three s3 cylindrical specimens in accordance with the Chinese standard GB/T 50082-2009 [Testing the Coulomb electric flux adopted ϕ100 × 50 mm082-2009  with the3 were extracted from the mortar samples using an electric drill as the samples for the MIP test  and derivative thermogravimetric (DTG) curves were obtained. The TG analysis was conducted using a German-made TGA 209F3 analyzer with a uniform heating rate of 10 °C/min from room temperature to 1010 °C in a gas flow atmosphere.Cuboid cement paste samples measuring 40 × 40 × 160 mm−1 at a resolution of 4 cm−1. The sample could absorb infrared of specific frequencies, causing the intensity of the interference light to change and be received by the detector, thereby obtaining the interference patterns of various samples.Cement paste powders specimen was utilized for the FTIR test. The sample was placed in the detector and scanned from 4000 to 400 cmSmall fragments of concrete specimens crushed in the compressive strength test were utilized for the SEM test. The samples were dried at ambient temperature, then placed in a gold spraying equipment to spray gold on a paste–aggregate interface, and finally placed in an SEM instrument to scan and observe the microstructure .a values of 75.9% and 77.6%, respectively, which are higher than OPC with 70.6%. At 28 days of age, the compressive strengths of DC3 and DC5 are only 0.4 and 0.5 MPa greater than that of OPC. This demonstrates that adding 3% and 5% diatomite to concrete can accelerate the hydration reaction and raise its early compressive strength more effectively while having little effect on its late compressive strength.The compressive strength of concrete samples OPC, DC3, DC5, and DC7 at 3, 7, 14, and 28 days were tested, and the results are shown in The main factors of the Influence of diatomite on the compressive strength of concrete samples are the following: (1) The filler effect: The diatomite’s particles are relatively small, and they are uniformly mixed in the concrete mixture, which can fill the pores larger than the diameter’s particles, reducing the porosity of the concrete and improving the compactness. (2) The dilution effect: As an additive, diatomite replaces part of the cement in the concrete mixture, reducing cement’s content and the total hydration reaction of cement. (3) The pozzolanic effect: The main content of diatomite is amorphous silica, which can react with the hydration products in concrete to produce calcium silicate hydrate with cementation ability, and further improve the concrete’s performance.The factors mentioned above have beneficial and detrimental effects on concrete. Filling pores and generating C-S-H gel are advantageous features. As diatomite content rises, diatomite will agglomerate and drop the hydration reaction, which is undesirable. The detrimental effects are insignificant when the diatomite content is less than 5%. The detrimental impacts are great when the diatomite content exceeds 5%. The coupling of favorable and unfavorable factors improves the compressive strength of concrete when the diatomite content is 5%. Hence, the compressive strength of concrete varies dynamically with the content of diatomite.The resistance to chloride penetration (RCP) of concrete was tested by Coulomb electric flux test. Based on the above experiments, when the content of diatomite is 5%, the concrete’s physical mechanics and RCP ability were optimal. Therefore, the MIP test analyzed the difference in pore characteristics between DC5 and OPC. 3), respectively [ectively ,43,44,453. There are more CaCO3 and CH in OPC than in DC5. This means that diatomite consumes the CH generated by the hydration reaction after being added to the concrete. DC5 contains more C-S-H than OPC, showing that diatomite can induce more C-S-H gel in concrete. C-S-H gel fills the pores and improves compactness. In short, diatomite can increase the performance of concrete by participating in the cement hydration reaction.The results indicate that both OPC and DC5 contain the compound products C-S-H, CH, and CaCO−1 corresponds to the absorption band generated by SiO2. The absorption band of DC5 is stronger than that of OPC, suggesting more SiO2 in DC5 than in OPC. This is reasonable because DC5 contains 5% diatomite, but OPC contains none, and the main component of diatomite is SiO2. The strong absorption band at 923 cm−1 is caused by the vibration of SiO42− groups. This absorption is more prominent for DC5 than OPC, indicating that the former contains more SiO42− groups. The characteristic wavenumbers 875, 1642, and 3642 cm−1 are induced by the vibration of ettringite (AFt), which possess approximately the same absorption bands, indicating the presence of nearly equal amounts of ettringite in OPC and DC5. The vibration of C-S-H causes the absorption bonds at 1423 and 3441 cm−1 wavenumbers. The absorption band of DC5 is stronger than that of OPC, demonstrating that DC5 contains more C-S-H. Accordingly, the addition of diatomite to concrete produces more C-S-H, which can reduce concrete porosity and improve its properties.In order to investigate the effect of diatomite on the microstructure of concrete, SEM testing was conducted on concrete samples crushed by the compressive strength test. 2, which can be added to the concrete as a green mineral mixture. The physical and mechanical properties, RCP ability, porosity, and microstructure of concrete containing diatomite are investigated, and the following conclusions are drawn:Diatomite is a mineral silica source material rich in active SiO(1) Diatomite can reduce the fluidity of concrete, leading to poor workability. It can also change the water absorption and compressive strength of concrete. With the addition of 5% diatomite, the concrete has the smallest water absorption and the greatest compressive strength.(2) The charge passed of concrete decreases and then increases with the addition of diatomite. The smaller the charge passed, the stronger the RCP ability. The RCP ability is at its peak when diatomite content is 5%, resulting in the greatest durability. The compressive strength of concrete and RCP ability are positively correlated.(3) The 5% diatomite is highly effective at reducing concrete’s porosity and enhancing its pore characteristic. The porosity of concrete can be decreased from 12.68% to 10.82%. The most probable apertures can be dropped from 40.8 to 30.4 nm. The proportion of harmless and less harmful pores increases, and the proportion of harmful pores falls.(4) Compared to OPC, the studied DC5 with the pozzolanic effective has better concrete properties. More CH is contained in OPC than in DC5, which is harmful to concrete. More C-S-H gels are produced in DC5 than in OPC, which is beneficial to concrete. C-S-H gels effectively fill the concrete pores and cracks, optimize the internal structure, and improve the physical and mechanical properties and durability.


The aim of our study was to develop a methodology that uses the metronome to constrain the swimmers' stroke rate with the aim to monitor changes in stroke length (SL) during two different periods of the season. Thirteen young trained swimmers (15.7 ± 1.7 y) performed three 50 m front crawl time trials during pre-season (PRE) and after 2 months, during the in-season period (IN). They were asked: (I) to swim at their maximum intensity (NO-MET condition); (II) to synchronize their stroke with a metronome beat set to their preferred intra-stroke-interval (ISI) ; (III) to synchronize their stroke with a metronome beat set at 5% higher than their preferred ISI . The outcome parameters used to evaluate the performance were ISI, SL and total time of 50 m (TT). In NO-MET condition, results showed that TT in IN improved with respect to PRE, but no changes in ISI and SL. In 100% condition, no differences were obtained between the imposed and the performed ISI, whilst in 95% condition, the performed ISI was lower than the metronome ISI, and lower than that in 100% condition. At last, when using the metronome, SL was higher during IN compared to PRE and SL was lower in the 95% condition compared to the 100% condition. Results indicate that the use of the metronome successfully allowed monitoring changes in SL during different periods of the season. This methodology provides valuable information to coaches and athletes to enhance their performance throughout the season. In this context, scientific research has investigated different methodologies to monitor workload to evaluate physical effort and to collect data on the athlete's response to a specific training program . In swimThe search for the best performance and training has led to a rapid development of technology as support during athletic preparation. Thanks to specific devices, coaches are able to measure, evaluate and control the physiological and technical parameters essential to achieve the sport targets –16. InerIn the last few years, although some criticisms related to the higher physiological stress and distraction have been evidenced in using the metronome during swimming , 26, an The aim of the study was to test the possibility to use the metronome to constrain the inter-stroke-interval to measure changes in stroke length during two different periods of the training season. We hypothesize that, only when using the metronome, changes in SL will be evident, whilst when swimming without metronome this will be not possible.2.2.1.a-priori power analysis was conducted using G*Power (version 3.1.9.7) (n = 2) and CONDITION (n = 2) was applied with a significance criterion of α = 0.05 and power = 0.8. The minimum sample size needed was N = 11 for detecting differences in discrimination sensitivity among measurements. Thirteen swimmers from the same team  volunteered to participate in this study. According to McKay et al. (An 3.1.9.7)  to deter3.1.9.7) . A F-tesy et al.  these aty et al. . The stu2.2.The experimental protocol was conducted during pre-season (PRE) and 2 months later, i.e., the in-season period (IN), in a 50 m indoor swimming pool with water temperature at 27 °C. During the 2 months between PRE and IN, swimmers followed their regular training. In both periods, swimmers performed three 50 m front crawl trials with a push-off start and 6 min of rest between trials to attempt total recovery . Before In the first trial, participants were asked to swim at their maximum intensity, namely as fast as possible, without the use of metronome (NO-MET condition). The intra-stroke-interval (ISI) was considered as the time between the head emerged from the water (thus excluding the underwater phase) until the end of the lap, divided by the number of strokes. Since ISI quantifies the duration of a single stroke, it also indirectly gives a measure for stroke rate. ISI values of each subject were used as individual reference value to set the interval between two consecutive metronome beats in two conditions: in 100% condition the metronome was set at the mean ISI value corresponding to MET100, whilst in 95% condition the metronome was set at 95% of ISI (MET95), thus imposing a faster stroke rate. In the second trial, participants were asked to swim in synchronous with the audio feedback provided by a waterproof metronome  positioned under their swimming cap and set at MET100. In the text we will use the acronyms PRE100 when referring to swimmers' data acquired in pre-season, and IN100 when referring to those acquired in in-season. In the third trial, the metronome was set at MET95. In the text we will use the acronyms PRE95 when referring to data acquired in pre-season, and IN95 when referring to IN. In IN, MET100 and MET95 were the same as those imposed in in-season .2.3.Outcome measures used to evaluate swimming performance were: the mean ISI value (s), and the 50 m total time  . Further2.4.post hoc tests were applied in case of significant interaction. Hedges' g and partial η2 values were used to measure the effect size when applying t-test and ANOVA, respectively. Concerning Hedges' g, 0.2, 0.5 and 0.8 represent small, medium and large effect, respectively. Concerning partial η2, 0.01, 0.06, and 0.14 indicated small, medium, or large effects, respectively . In NO-MET condition, TT, SL and ISI acquired in PRE and IN periods were compared by means of paired t-test. With the aim to test if participants swam synchronously with the metronome in the two periods of the season and at the two conditions, we applied on ISI values recorded in 100% condition an ANOVA comparing MET100  with PRE100 and IN100 , and a second ANOVA on ISI values acquired at 95% condition comparing MET95 with PRE95 and IN95. With the aim to compare ISI and SL when using the metronome in the two periods of the season, an ANOVA with CONDITION  and PERIOD  as within subject factors was applied. Newman–Keuls ectively . Linear 3.3.1.t(12)= 2.40, p = 0.03, g = 0.28]. No changes were observed in ISI  and SL .The statistical analyses showed an improvement in TT during IN (30.57 ± 0.49 s) with respect to PRE (31.04 ± 0.44 s) . Differently, a main effect on ISI in 95% condition was found . Post hoc analysis showed that PRE95  and IN95  were higher with respect MET95 (0.59 ± 0.01 s) (ANOVA on ISI recorded in 100% condition showed no main effect  and indicated a lower ISI value in 95% (0.61 ± 0.01 s) with respect to 100% (0.63 ± 0.01 s). No main effect of PERIOD was observed . ANOVA on SL showed a main effect of CONDITION  that indicated a lower SL value in 95% (0.96 ± 0.07 m) with respect to 100% (0.99 ± 0.06 m). A main effect of PERIOD , with SL larger in IN (0.99 ± 0.06 m) than in PRE (0.96 ± 0.06 m) was observed  and IN  (ANOVA on ISI highlighted a main effect of CONDITION [observed . Positiv= 0.025) .4.Results of this study showed that, in NO-MET condition, TT improved during the IN period with respect to PRE period with no changes in SL and ISI. When the metronome was imposed, participants were able to swim in synchronous with the time set by the device only during the 100% condition (imposed stroke rate 48 ± 0.7 cycles/min). Although during 95% condition (imposed stroke rate 51 ± 0.8 cycles/min) ISI was lower than in 100% condition, swimmers were not able to follow the metronome. SL was higher during IN than PRE period and lower during the 95% with respect to the 100% condition. Finally, a linear relationship between ISI and SL in both PRE and IN periods was found.The beneficial effects of the auditory information on movement control and timing, as well as movement execution, have been shown by several studies . ClinicaIn the present study, we proposed a methodology that used the metronome to constrain swimmers' stroke rate and measure the changes in SL in two different periods of the season (PRE and IN) and with two different values of ISI (100% and 95% conditions). Monitoring changes in stroke length is important when considering the results of the studies by Craig et al.  and LetzIt is worth to note that SL was greater in 100% than in 95% condition. Indeed, when athletes were asked to deviate from their preferred stroke rate, decreasing the ISI value, the stroke efficiency decreased, thus detrimentally influencing the SL. This was also confirmed by the correlations between ISI and SL in both PRE and IN periods, in accordance with a previous study that reported that the improvement in TT was achieved by the combination of increases/decreases in stroke rate and SL .Another point that needs to be discussed is athletes' ability to synchronize their strokes with the acoustic stimulus provided by the metronome. Results showed that they managed to follow the beat of the MET100, namely their preferred stroke rate. Instead, when they were asked to swim at a higher pace, following the beat of the MET95, swimmers tried to speed up the strokes, as demonstrated by the difference between the conditions, but they were unable to follow the metronome. This confirms what has been shown by previous studies where the stroke rate error (error between imposed and preferred stroke rate) was the lowest at the preferred stroke rate , 60. ThuA possible limitation of this study is that the proposed methodology was tested only on athletes competing at trained/developmental level. Thus, we are not aware of its effectiveness when applied on athletes of other levels. Future studies to verify the reliability of this metronome-based methodology in other categories are needed. Another limitation is that we neither evaluated their level of maturation nor collected detailed information on the anthropometrics characteristics, except body mass and height. Indeed, both stroke rate and stroke length might be influenced by these aspects.In conclusion, the use of the metronome allowed us to quantify the changes of one of the key performance parameters, namely the stroke length. Our findings suggest that coaches and young trained swimmers can monitor with this small, waterproof, easy to set up and economic tool, both the stroke length and the stroke rate during different periods of the training season and then customize their best race strategy. At last, since swimmers were not able to swim with a slower ISI (95% condition), it would be useful to introduce during the in-season training period, resistance exercises characterized by a low-volume and high-velocity/force intensity.


Background: Antimicrobial resistance is one of the world’s most serious health issues. Antibiotic resistance, excessive drug expense, and an increased risk of adverse reactions are all common outcomes of incorrect antibiotic prescribing. The goal of this study was to evaluate the prevalence of antibiotic prescriptions for inpatients to find areas for improvement. Methods: A retrospective study at Emergency Clinical County Hospital of Oradea, Romania was performed for five years between 2017 and 2021. Data was collected using medical records of the patients and reports from the pharmacy. Antibiotic consumption was expressed as DDD/100 BD according to the World Health Organization (WHO) by antibiotics, classes, and AWaRe classification. Results: The prevalence of antibiotic prescription was 53.8% during five years evaluated with a significant increase in 2021. A total of 13,677.42 DDD/100 BD antibiotics were prescribed, especially for surgical and medical prophylaxes. The most prescribed antibiotics were ceftriaxone, followed by metronidazole, and cefuroxime but there were some differences between years and wards. The most frequent antibiotic classes prescribed were cephalosporins (43.73%). The use of Watch Group antibiotics was high in all wards (59.69%). Conclusions: The prevalence of antibiotic use was high with cephalosporins being the most prescribed antibiotics. As a result, interventions are required. Clostridioides difficile infection resulting from the misuse of antibiotics. Irrational prescribing can be result of a lack of drug understanding, unethical drug promotion, a high patient load, inefficient laboratory facilities, medication availability, ineffective law enforcement, and failure to assure compliance with recommendations [Antibiotics are the most prescribed drugs in hospitals, and their inappropriate use contributes to the rise in antimicrobial resistance (AMR) which is a global problem. Antibiotic use has increased in the past, putting selective pressure on susceptible bacteria, resulting in the growth of AMR. Antimicrobial resistance is one of the most serious public health issues, it cannot necessarily be completely eradicated but can be managed. As a result, attempts to decrease antimicrobial resistance by using suitable antibiotics are gaining universal attention . Treatmendations ,3. Escherichia coli and methicillin resistance in Staphylococcus aureus, and more than 50% resistance to third generation cephalosporins and carbapenems was reported in Klebsiella pneumoniae in hospital settings. The same report attributed 45% of deaths in both Africa and South-East Asia to multi-drug resistant (MDR) bacteria, especially Klebsiella pneumoniae [The World Health Organization (WHO) published the first global surveillance report on antibiotic resistance in 2014 showing that six WHO regions had more than 50% resistance to third generation cephalosporins and fluoroquinolones in Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) which were responsible for 3.57 million deaths associated with AMR in 2019 [Staphylococcus aureus caused more than 100,000 deaths attributable to AMR in 2019, while six more each caused 50,000–100,000 deaths: MDR excluding extensively drug-resistant tuberculosis, third generation cephalosporin-resistant Escherichia coli, carbapenem-resistant Acinetobacter baumannii, fluoroquinolone-resistant Escherichia coli, carbapenem-resistant Klebsiella pneumoniae, and third generation cephalosporin-resistant Klebsiella pneumoniae [There was an estimated average of 4.95 million deaths associated with bacterial AMR in 2019 [The key issue is that antibiotic use and a high number of prescriptions do not follow the optimum pattern . AntimicPrevious studies have reported that 28 to 68% of antibiotic prescriptions in hospitals and ambulatory care facilities are inappropriate and that broad-spectrum antibiotics are overprescribed ,8. EveryClostridioides difficile infection rates [The Centers for Disease Control and Prevention (CDC) advised all hospitals to use ASP and outlined the basic principles of hospital-based ASP to optimize antibiotic use . Some hoon rates ,12. Poteon rates ,14. Impoon rates .Antibiotic consumption can be expressed in grams, number of units, number of prescriptions or cost but these variables are different between hospitals, regions, and countries over time. This is why it is difficult to compare local and international consumption. To solve this issue, a technical unit of measurement named Defined Daily Dose (DDD) was created by the WHO International Working Group on Drug Statistics Methodology. DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults, but DDD is not necessarily the same as Prescribed Daily Dose (PDD). It is obvious that therapeutic doses for patients often differ from DDD as they will be based on individual characteristics such as age, weight, type of disease, and many other pharmacokinetic considerations.A very useful instrument to monitor the ASP is the AWaRe classification developed by the expert committee of the WHO using the Essential Medicine List (EML) in 2017 ,17,18,19The aim of this study was to undertake an antibiotic prescription review to identify the possible measures and interventions for promoting a rationale use of antibiotics by using the WHO AWaRe classification and to plan future antimicrobial stewardship efforts. A retrospective investigation was conducted at the Emergency Clinical County Hospital of Oradea, Romania for five years. Our teaching hospital has a tertiary one with a capacity of >500 beds and a large-scale of disease. It includes Intensive Care Units (ICUs), surgical and medical wards,  as main departments. Oral administration routes and intravenous, intramuscular injections were included. Antifungals, antiviral, anti-tuberculosis, and anti-parasitic or nebulization drugs were excluded.Data regarding all antibiotic administration and diagnoses were collected from the hospital’s software program InfoWorld that electronically stores patient files, explorations, and treatment information. There are recorded antibiotic names, doses, routes of administration, and departments. Data on antimicrobial use between January 2017 and December 2021 were extracted from the pharmacy information system including consumption of intravenous and oral antibiotics. An evaluation was conducted for antibiotics prescribed according to the WHO Collaborating Centre for Drug Statistics Methodology, Anatomical Therapeutic Chemical (ATC)/DDD Index 2022 [We classified antibiotic agents into beta-lactams, macrolides, glycopeptides, lincosamide, polymyxins, tetracyclines, oxazolidinone fluoroquinolones, aminoglycosides, rifamycin, and azoles. Fosfomycin for oral administration was included in the category of other antibiotics for systemic use. The beta-lactams evaluated were penicillins, combination beta-lactam/beta-lactamase inhibitors, and cephalosporins/beta-lactamase inhibitors, 1st-generation cephalosporins, 2nd-generation cephalosporins, 3rd-generation cephalosporins, 4th-generation cephalosporins, and carbapenems. We performed an analysis of the distribution of antibiotics using the 2021 WHO AWaRe classification . Descriptive statistics were used to summarize findings on Excel software. Continuous variables are expressed as the median and range. Categorical variables are expressed as percentages and proportions. Resistance rates to antibiotics were calculated by using Whonet software.Individual patients’ written informed consent for the data collection was obtained at admission. The hospital’s Institutional Review Board gave its approval for the study (25322/12.10.2018).The number of hospitalized patients decreased during the five years evaluated, but the number of patients treated with antibiotics was relatively stationary. Worth noting is the slight decrease in the percentage of patients who were administered antibiotics in 2020, but a significant increase in the number of patients treated with antibiotics in 2021, under the COVID-19 pandemic conditions . Antibiotics were prescribed in 94,299 of the 175,272 patients (53.8%) which corresponds to a total number of DDDs/100 BD of 13,677.4 and about half of them were prescribed in a single year, 2021. Moreover, at the level of 2021, there was over a double of the consumption of antibiotics compared to 2020 or a tripling of it compared to the years 2017, 2018, and 2019.The detailed pattern of antibiotic prescription is shown in The evaluation of antibiotic consumption by class shows a high consumption of more than half (62.46%) of beta-lactams, followed by azoles, fluoroquinolones, and aminoglycosides in approximately equal percentages (7.96 vs. 7.78%). Rifamycins, lincosamides, glycopeptides, tetracyclines, oxazolidinones, and polymyxins were prescribed in percentages below 3% of the total consumption of antibiotics by class .Third generation cephalosporins were the most common antibiotics (32.46%), followed by second generation cephalosporins (11.05%). Besides cephalosporin prescriptions accounted for about 43.73% of all antibiotic prescriptions. Carbapenem and glycopeptides accounted for 2.48% and 1.42%, respectively, of the prescriptions.Similarly, in the medical wards, the most prescribed were ceftriaxone (23.98%), rifaximin (12.66%), ciprofloxacin (9.52%), metronidazole (7.34%), amoxicillin/clavulanic acid (6.55%), cefoperazone/sulbactam (5.70%), ampicillin (4.24%), meropenem (3.88%), ceftazidime (3.30%), cefuroxime (3.19%), cefoperazone (2.52%), and amikacin (1.98%), while ceftazidime/avibactam (0.10%), imipenem/cilastin (0.09%), ertapenem (0.05%), cefaclor (0.04%), ofloxacin (0.03%), rifampicin (0.02%), and erythromycin (0.02%) were less prescribed.The same ceftriaxone was the most prescribed in the ICU (47.78%), followed by amoxicillin/clavulanic acid (6.83%), metronidazole (5.71%), cefoperazone/sulbactam (5.49%), ciprofloxacin (4.44%), cefuroxime (4.43%), meropenem (3.59%), moxifloxacin (2.71%), levofloxacin (2.01%), vancomycin (1.82%) amikacin (1.76%), colistin (1.47%), and gentamicin (1.46%). The least prescribed antibiotics were clarithromycin (0.17%), fosfomycin (0.16%), amoxicillin (0.08%), norfloxacin (0.08%), azithromycin (0.07%), cefixime (0.06%), cefaclor (0.03%), rifampicin (0.03%), cefazolin (0.01%), and ofloxacin (0.01%).According to AWaRe classification, 59.69% of the antibiotics prescribed were in the Watch Group class while only 37.07 were in the Access Group regardless of the evaluated year. Not Recommended Group class antibiotics were more highly used than reserve one and the evolution during the five evaluated years does not show a trend in decreasing the prescription of antibiotics from these classes. It should be mentioned that only cefoperazone/sulbactam was prescribed from the Not Recommended Group in our hospital .Comparative evaluation of the consumption of antibiotics according to AWaRe classification showed that most Access Group class antibiotics were prescribed in surgical wards, but without reaching the percentage recommended by WHO. A worrying aspect was the approximately equal percentage regarding the prescription of antibiotics from the class Not Recommended in medical wards and the ICU at 5.70% and 5.49%, respectively. Antibiotics from the Reserve Group were especially prescribed in the ICU .We set out to analyze the resistance rates of the prescribed antibiotics. As Since antibiotics were discovered, they have saved lives in patients with infectious diseases, but at the same time the development of antimicrobial resistance has occurred. Efforts to develop new therapeutic solutions against infectious agents, including herbal ones, have led to modest results ,22.Our study demonstrates a high prevalence of antibiotic use in patients from our hospital for five years. More than 50% of our patients received antibiotics, the same was reported by Castro Nunes et al. from a European country , but lesThe evaluation in this study included antibiotic use for prophylaxis and therapeutical purposes. The prevalence of antibiotic use was concentrated especially in the surgical wards where one third of the total amount of antibiotic use was for surgical prophylaxis (60.23%) If wards are compared, the surgical ward’s rate of antibiotic prescriptions was the highest in the entire hospital (65.42%). This result could be explained by prophylactic hospital policies, but it is in concordance to other similar studies where ceftriaxone and metronidazole were the most prescribed for this purpose .The parenteral route was the most used (89.63%) similar to other studies. This is a result of the type of hospital (emergency one), late presentation of critically ill patients, comorbidities, advanced age, and difficulties for oral intake. In addition, the most prescribed antibiotics in our study  are available as parenteral injections. A reduced parenteral route and increase in the oral route of administration could be another strategy to reduce cost of healthcare by shortening of hospitalization and reducing the risk of catheter-associated infections.Ceftriaxone, metronidazole, and cefuroxime were the most prescribed. Prescribing of broad-spectrum antibiotics is the first option for a large number of prescribers reported in many other studies, but this practice is responsible for promoting an emergency of antibiotic resistance . The preWe also reported an increased trend to prescribe beta-lactams during the evaluated period, especially in 2021. This increase could be explained by the difficulty in distinguishing between viral and bacterial etiology in some critically ill patients or uncertainty in treating COVID-19 patients. A study about sales of broad-spectrum antibiotic in 71 countries demonstrated an increase in the middle of the 2020 COVID-19 pandemic year especially for four broad-spectrum antibiotics: cephalosporins, penicillins, macrolides, and tetracyclines .There were differences in the prescriptions between our wards but ceftriaxone was the most prescribed in all of them, accounting for 26.46% of prescriptions. Otherwise, third generation cephalosporins were among the most prescribed antibiotics 32.36%) and the prescribing rate was less than seen in other published studies ,34,35. O% and theThe easier and most useful to support antibiotic stewardship is AWaRe classification provided by the WHO. Antibiotics are grouped into three major classes and a not recommended one. The WHO encourages a priority use for the Access Group and recommends that at least 60% of the overall antibiotic use should belong to this group. Our study identified that Watch Group antibiotics were more frequently prescribed (59.69%) contrary to this recommendation. The Watch Groups consists mostly of broad-spectrum antibiotics, those antibiotics more frequently responsible for infections with multidrug resistant pathogens and microbiota dysbiosis.Access Group antibiotics are generally narrow-spectrum antibiotics, but they were prescribed only in 37.07% of patients, especially at the surgical wards. Even if antibiotics from the Reserve Group were prescribed only in the ICU and in relatively small quantities (0.82%), a problem identified in this study was the prescription of Not Recommended antibiotics in a similar proportion in ICU and medical wards. The consumption of antibiotics evaluated at the same time as the sensitivity and resistance rates confirms an otherwise well-known aspect: that a high consumption of a certain antibiotic leads to an increase in the resistance rate and could indicate which intervention is necessary.There are limitations in this study. First, the evaluation was limited to a single hospital, but with many specialties including acute and chronic diseases and ICU. This also explains the wide range of antibiotics prescribed. Our data may not be representative of the large hospitals in Romania that would be our study population of interest. Second, we explored an annual assessment without observing monthly variations. Third, the evaluation did not consider the duration of the antibiotic prescriptions. More accurate results will be known only after the evaluation of optimal duration antibiotic prescription, as an evaluation criterion. Next, we expressed antibiotic consumption by DDD instead of days of therapy (DOT). According to a recent guideline for antibiotic stewardship programs, DOT is preferred to DDD as a measure of antibiotic consumption . HoweverWe demonstrated the pattern of antibiotics prescribed in our patients despite measures provided by the antimicrobial stewardship program. Considering that our hospital is an emergency one, it is estimated that the antibiotic prescription is higher and intervention is required. A significant proportion of antibiotic prescriptions were cephalosporins (third and second generation) followed by azoles, fluoroquinolones, and aminoglycosides. In our study, antibiotic prescribing patterns differed from those indicated by WHO standard treatment guidelines. Most of these were in the form of parenteral drug formulations and belong to Watch Group antibiotics. Our results provide key areas to future quality improvement measures and capacity in the development of reliable ASPs in our hospital. Targeted AMS interventions are required first to reduce prescriptions. Next is the evaluation of appropriateness of antibiotic prescriptions, medical and patient education, and antimicrobial surveillance. Implementing the WHO AWaRe metrics is also recommended to manage antibiotic prescriptions and develop guidelines.


MET aberrations and new targeted therapies for MET-driven cancers and resistance mechanisms are explored. Aberrations in the MET gene leading to impaired MET-dependent signaling have been identified as primary and secondary drivers of cancer development. To optimally detect and potentially counteract these effects with mono- or combination therapy, it is crucial to understand the underlying cellular mechanisms involved in MET-dependent cancer cell development and growth.This Special Issue features contributions from leading international researchers in the field of MET (hepatocyte growth factor (HGF) receptor) biology and therapeutics. Recent discoveries regarding non-small cell lung cancer (NSCLC) and gastric cancer, as well as advancements in the detection of MET gene amplification, MET kinase mutations, mutations resulting in MET exon 14 skipping, MET rearrangements, and MET fusions [Dysregulated MET signaling, which predisposes cells to cancer development, can occur due to MET overexpression,  fusions ,3,4,5.MET splice variants leading to MET exon 14 skipping in NSCLC. Their study highlights the importance of recognizing noncanonical splice events by integrating next-generation sequencing data with in silico predictions in order to assess the potential impact of mutations. Additionally, they demonstrated the potential of routinely using cytology slides for RNA-based NGS testing.Das et al.  revealedMET gene, including MET amplification. In NSCLC patients who had progressed on osimertinib, early clinical trials have shown promising antitumor activity following a combination therapy with the third-generation EGFR TKI lazertinib and the MET-EGFR bispecific antibody amivantamab.Feldt et al.  report tMET alterations in radon-exposed patients compared with the control group.Gamerith et al.  utilizedIn a systematic review following PRISMA guidelines, Bodén et al.  examinedMET amplification is known as a pivotal biomarker, but establishing the optimal thresholds for recognizing MET amplification in patient samples is challenging [MET copy number can be achieved through ISH and NGS, and according to Kumaki et al. [MET amplification [MET amplification plays a key role in resistance to tyrosine kinase inhibitors (TKI) and discuss strategies to overcome this.llenging ,9. The di et al. , a signification . With refication  elaboratBy employing a proteomics approach, Jie et al.  presenteMET and HGF amplification, excessive production and misfolding of HGF, induction of endoplasmic reticulum stress-response signaling, and an increased uptake and degradation of rilotumumab. Collectively, these mechanisms enable resistant glioblastoma cells to sustain adequate HGF-dependent MET signaling, thereby promoting survival and cell growth.To gain further insights into the mechanisms underlying drug resistance, Cecchi et al.  investigMET exon 14 skipping mutations. Hsu et al. specify that ongoing clinical research aims to improve the treatment efficacy and explore new indications for capmatinib, including addressing MET amplification that has developed following EGFR TKI resistance. Combination therapies with capmatinib and other agents are also under investigation. Based on data from various clinical trials, Hsu et al. compared the efficacy outcomes of the three approved MET TKIs—capmatinib, tepotinib, and savolitinib—in the treatment of patients with metastatic NSCLC with MET exon 14 skipping mutations [In a narrative review by Hsu et al. , the devutations . These cMET exon 14 skipping mutations, and this review outlines preclinical models, phase I studies in Chinese patients, and the TATTON study combining savolitinib with osimertinib. The authors conclude that both preclinical and clinical evidence support the efficacy and tolerability of savolitinib in treating advanced NSCLC patients with MET exon 14 skipping mutations. Furthermore, when using savolitinib in conjunction with EGFR-TKIs, the authors indicate that it demonstrates potential in terms of overcoming treatment resistance stemming from both MET amplification and MET overexpression.Similarly, the review by Zhu et al.  examinedMET amplification received treatment with savolitinib and achieved an ORR of 50%. The authors emphasize that a major challenge remains in establishing clinically significant cut-off values for MET amplification and MET overexpression to guide treatment-related decisions.The review by Van Herpe and Van Cutsem  focuses Cancers, only a few MET inhibitors have obtained regulatory approval, and this is so far limited to the treatment of metastatic NSCLC patients. A key challenge in the development of MET inhibitors appears to be related to identifying the appropriate predictive biomarker to guide drug use. In NSCLC, a small number of MET TKIs have demonstrated efficacy when patients are selected based on MET exon 14 skipping mutations. Another potential predictive biomarker for MET-targeted therapy is MET amplification, identified as a resistance mechanism in patients with EGFR-mutated NSCLC. However, their full potential in both NSCLC and gastric cancer remains to be fully explored, which we hope to witness in the coming years.The development of companion diagnostic assays for targeted cancer therapies requires a profound understanding of the pathophysiology and the drug’s mechanism of action . In the


Compliance regarding the interruption of antibiotic therapy based on PCT was lower on weekends and holidays (p = 0.01). Outcomes did not differ according to compliance. Conclusion: This study assessed real-life compliance with the PCT protocol to monitor antibiotic treatment for VAP. Improving the measurement of PCT at the bedside would increase the rate.Background: Procalcitonin (PCT) protocols to guide antibiotic treatment for ventilator-associated pneumonia (VAP) in the intensive care unit aim at reducing antibiotic exposure. Our study goal was to measure compliance with a PCT protocol for VAP and to determine the associated variables. Methods: From 2017 to 2021, we conducted a retrospective, monocentric study including patients treated for VAP. In our PCT protocol, PCT was measured at the initiation of antibiotic treatment and every 48 h until treatment completion; antibiotics were stopped if PCT decreased by more than 80% from its highest value or fell below 0.5 ng/mL. We assessed the compliance with the PCT protocol and compared the compliant and noncompliant groups. Results: Among the 177 included patients, compliance with the PCT protocol was assessed at 58%. Noncompliance was due to lack of PCT measurements in 76% of cases. Compliance was higher in the medical patients ( Antibiotic treatment of ventilator-associated pneumonia (VAP) is a daily challenge in the intensive care unit (ICU) . There iProcalcitonin (PCT) has been evaluated in the setting of bacterial infection for guiding clinicians to initiate and monitor antibiotic treatment. During sepsis, PCT becomes ubiquitous through the activation of proinflammatory cytokines; serum concentrations are therefore rapidly increased . HoweverIn the literature, only few articles report compliance with ICU protocols ,12. To oThe first objective of our study was to describe the compliance rate with a protocol for monitoring the antibiotic duration using serum PCT in patients with confirmed VAP. The secondary objectives were to determine the variables associated with compliance, and the association between weekends/holidays and compliance. We also assessed the association between protocol compliance and the following variables: ICU and 28-day mortality, duration of ICU stay, duration of mechanical ventilation, and antibiotic exposure.During the study period, 3303 patients were admitted to the ICU, of whom 355 met the eligibility criteria. Among them, 177 patients were included in the final analysis . The meaCompliance was found in 103 (58%) patients. Early interruption of antibiotic treatment according to the PCT protocol was achieved in 36 (35%) patients. The noncompliant group included 74 (42%) patients. A lack of PCT measurement was found in 56 (76%) patients, while antibiotic treatment was continued in disagreement with the PCT protocol in 16 (21%) patients .p = 0.04). Compliance was also higher in the patients with SARS-CoV-2 pneumonia (32 (74%) vs. 71 (53%) in COVID-19-positive vs. COVID-19-negative patients, respectively, p = 0.021). Of note, higher rates of noncompliance in stopping antibiotic therapy based on PCT was observed during weekends and holidays .Gender, age, comorbidities, severity of disease (septic shock and ARDS), type of bacteria, and multidrug-resistant pathogen carriage were not associated with compliance. In contrast, compliance was 68% in the medical patients versus 51% in the nonmedical patients (p = 0.11). However, the complete achievement of the repeated PCT measurements according to the PCT protocol increased significantly during the study period (p = 0.012) (The assessment of compliance over time is shown in = 0.012) b.p = 0.74 and p = 0.87, respectively). The duration of the ICU stay (p = 0.73), the duration of invasive mechanical ventilation (p = 0.85), and the duration of antibiotic treatment did not differ in the two groups   .In our cohort, compliance with the PCT protocol was achieved in 58% of patients. We observed that compliance was higher among medical and SARS-CoV-2 patients. However, compliance in the interruption of antibiotic therapy based on PCT was lower during weekends and holidays. There was a slight trend toward improved protocol compliance over the years. Nevertheless, compliance with the PCT protocol did not have any significant effects on outcomes, particularly the duration of antibiotic treatment.In our patients, compliance with the PCT protocol was assessed at 58%. Previous studies assessing the adherence to a PCT protocol for both initiating and interrupting antibiotic treatment showed rates from 47.7% to 51.6% ,14, whicThe primary reason for noncompliance was the absence of serum PCT measurements in 75% of cases. When blood samples were collected for serum PCT measurement, the antibiotic treatment was in agreement with the PCT protocol in 85% of cases. This underlines the importance of measuring serum PCT concentrations, especially during the on-call periods. Another way for improvement is the automation of biological prescription, as we implemented during the COVID-19 pandemic, which resulted in improved compliance among those patients.Among 24.3% of patients with no compliance with the PCT protocol despite measurements of serum PCT concentrations, the clinical picture probably supported the medical decision. However, we cannot exclude that the PCT results were not seen at the time by the medical team. As the cost of PCT dosages is significant, this issue should be resolved in the future. The decreased compliance during weekends and holidays, regarding the interruption of antibiotic therapy based on PCT, which corresponded to days with a small team on-site, seems in line with this last hypothesis. In the literature, the effects of on-call periods are variable ,16. One Importantly, our PCT protocol did not impact patient outcomes. Measuring serum PCT concentrations has been shown to reduce antibiotic exposure, as demonstrated by large multicenter randomized controlled trials ,9, and tOur study has several limitations. Firstly, we selected only patients with a definitive diagnosis of VAP. Thus, we excluded those with suspected VAP in whom the antibiotics were interrupted early due to a diagnosis refinement. In these patients, the use of PCT could participate to the decision to prematurely interrupt antibiotics. This could explain the lack of difference in terms of antibiotic exposure in our study. Secondly, the retrospective nature itself is a limitation in the interpretation of observational studies. Thirdly, our collection of data did not include the evolution of patients in terms of severity; one can suggest that compliance decreased if serum PCT concentrations were low despite an increase in severity (and vice versa). Lastly, the experience of senior physicians may have been included in our analysis. However, as most of our decisions are collective, this would not reflect our real-life practices.Our study was an observational, monocentric, retrospective study conducted between 20 December 2017 and 30 April 2021 in the polyvalent ICU (15 beds) of the Hospital North within the Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.This retrospective, monocentric, noninterventional study was based on the review of clinical and laboratory medical records. Under French law, patient consent was not required for this type of noninterventional study, provided the patients had received information about the potential use of anonymized medical data for research purposes and retained the right to oppose it  [Patients with VAP were treated according to guidelines ,3,22,23.The list of patients was collected from the diagnosis coding service (ICD-10 nomenclature) and medical procedures (French CCAM nomenclature) of our institution. The codes used for the research were, on the one hand, the codes corresponding to bacterial pneumonia and, on the other hand, the codes for mechanical ventilation procedures. Retained patients were those who had both a bacterial pneumonia code and a mechanical ventilation code. Ventilator-associated pneumonia was defined according to international definition . If a paDuring the study period, eligible patients included all patients admitted to our ICU who were both coded for bacterial pneumonia and mechanical ventilation. The study period started with implementation of PCT protocol in March 2017. Patients under 18 years of age, those with coding errors, those with ICU stays below three days, the second episode of VAP, and pregnant women were excluded from the analysis.at ICU admission: reason for admission, prior medical history, risk factors for multidrug-resistant pathogen carriage, and existence of antibiotic treatment in the previous three months;during the ICU stay: duration of mechanical ventilation, identified germ(s), antibiotic(s) used, date of the onset of antibiotic treatment, duration of antibiotic treatment, and failure of the first line of antibiotic treatment;at the onset of antibiotic treatment: presence of acute respiratory distress syndrome (ARDS), presence of septic shock, plasma creatinine and the use of extrarenal replacement therapy, and first day of antibiotics  versus working hours);during the antibiotic treatment for VAP: serum PCT concentrations.All study data were extracted retrospectively from the institutional computerized patient record. Data collected included selected demographic data, such as age, gender, simplified acute physiology score (SAPSII) at admission, and mortality rates in the ICU and at 28 days. We also collected:Our PCT protocol derived from the SAPS trial: all patients receiving antibiotics for a suspected infection had a serum PCT measurement on the day of initiation of antibiotic treatment and then every 48 h . The firSerum PCT measurements were performed as required by the PCT protocol;Antibiotic treatment was adapted to serum PCT concentrations in agreement with the PCT protocol.Two groups were identified:Compliant group: antibiotic treatment was continued because serum PCT concentrations did not decrease under the protocol threshold, and antibiotic treatment was interrupted because serum PCT concentrations decreased according to PCT protocol;Noncompliant group: serum PCT measurements were not performed, or antibiotic treatment did not respect the PCT protocol. Four cases were identified: (1) PCT not available during the antibiotic treatment; (2) PCT partially available during the antibiotic treatment; (3) continuation of antibiotics despite PCT protocol indicating its interruption, and (4) interruption of antibiotic treatment despite PCT protocol indicating its continuation.Patients were classified into two groups based on the compliance with PCT protocol. Compliance was defined by:The human factor was assessed by determining whether the day on which the protocol was not respected corresponded to the on-call periods defined by weekends and holidays.Due to the exploratory nature of the study, no specific sample size was defined. Data are expressed as numbers and percentages for categorical data and as mean and standard deviations  for quantitative variables. Missing data were omitted from analyses without imputation because of the expected small sample size. Outliers were searched for and removed, without replacement.Comparisons of categorical variables were performed using a Fisher’s exact test when 2 groups were considered and by a multiclass Chi2 test (χ2) in other cases. Comparisons of quantitative variables between groups were performed using a nonparametric Mann–Whitney test (if two groups were considered) or a Kruskal–Wallis test (if more than two groups were considered).p-value < 0.05 was required to reach statistical significance. The statistical tests were bilateral. Analysis was performed using R 4.0.4 software  [A a, 2021) .Our study shows that real-life compliance with the PCT protocol aiming at monitoring the duration of antibiotic treatment was 58%. Noncompliance was mainly explained by a lack of PCT measurements. Compliance with the PCT protocol was increased for medical patients including those admitted for SARS-CoV-2 pneumonia and was reduced on weekends and holidays, regarding the interruption of antibiotic therapy based on PCT. No association was found between compliance with the PCT protocol and outcomes, questioning the relevance of serum PCT measurements.


MET exon 14 skipping mutation since May 2020 by the USFDA [MET fusions, which occur rarely in 0.2–0.3% of patients with lung cancer [Several alterations in the MET gene were identified as targetable oncogenic changes leading to non-small cell lung cancer (NSCLC). These include genomic amplifications, exon 14 skipping mutations and fusion . Capmatihe USFDA . A studyMET tyrosine kinase inhibitors (TKIs) have been developed or are under clinical evaluation. TKIs are categorized into type I TKIs  and type II TKIs . Combination therapy reduces resistance and enhances clinical outcomes [in vitro and led to a significant reduction in tumor outgrowth in vivo compared to either MET inhibitor alone [A major challenge arising after the introduction of tyrosine kinase inhibitors is limited clinical benefit, which is due to primary and potential secondary acquired drug resistance , 5. Seveor alone . Furtheror alone . This hior alone .EGFR and MET. It has shown promising results against NSCLC patients with EGFR 20 insertion and NSCLC patients with MET exon 14 skipping mutations. The drug is given as 1050 mg (pts <80 kg) or 1400 mg (pts ≥80 kg) once weekly in cycle 1 and twice a week until disease progression. This study included 43 pts with MET exon 14 skipping mutations. Overall response rate was 33%. The study is still ongoing and results are promising [Based on ongoing Phase I CHRYSALIS, Amivantamab; fully human bispecific antibody targets both romising .Other Phase I/II study conducted in China, assesses the use of APL-101 a novel, potent, selective c-MET inhibitor, in patients with NSCLC and advanced malignancies with c-Met dysregulation. Study is still ongoing and results are not yet available .These clinical trials along with others will show us if other MET inhibitors or combination therapy may be better than the current standard of care. The future looks bright for patients with MET mutations and NSCLC.


Targeted therapy in non-small cell lung cancer (NSCLC) patients with mesenchymal epithelial transition (MET) exon 14 skipping mutations (METex14) and MET amplifications has improved patients’ outcomes. The development of more potent MET kinase inhibitors could further benefit these patients. The aim of this trial is to determine the safety and recommended phase 2 dose (RP2D) of OMO-1  and to assess preliminary clinical efficacy in METex14-positive NSCLC and other MET-positive solid tumors.This was a first-in-patient, open-label, multicenter study of OMO-1 in patients with locally advanced or metastatic solid malignancies. A standard 3 + 3 dose escalation design was utilized starting at a dose level of 100 mg BID continuously. Preliminary efficacy was investigated in patients with METex14-positive NSCLC, and MET amplified NSCLC and other solid tumors (MET basket).In the dose-escalation part, 24 patients were included in 5 dose levels ranging from 100 mg twice daily (BID) to 400 mg BID. Most common adverse events (≥ 20%) were nausea, fatigue, vomiting, increased blood creatinine, and headache. The RP2D was determined at 250 mg BID. In the expansion cohorts, 15 patients were included (10 in METex14-positive NSCLC cohort and 5 in MET basket cohort) and received either 200 or 250 mg BID. Eight out of the 10 patients with METex14 positive NSCLC had stable disease as the best response.OMO-1 was tolerated at the dose of 250 mg BID and shows initial signs of MET inhibition and anti-tumor activity in METex14 mutated NSCLC patients. Targeted therapy for non-small cell lung cancer (NSCLC) with mesenchymal epithelial transition (MET) exon 14 skipping mutations and MET amplifications have improved outcomes. This study aimed to determine the safety and recommended phase II dose of OMO-1 to assess preliminary clinical efficacy in METex14-positive NSCLC and other MET-positive solid tumors. The oral dual MET kinase/OCT-2 inhibitor OMO-1 has an acceptable safety profile at doses up to 250 mg BID and shows preliminary clinical efficacy in pre-selected patients with MET exon 14 skipping mutated lung cancer. The potential immune-modulatory effect of OCT-2 inhibition could be particularly interesting in this population of patients with MET-mutated lung cancer because of the MET-induced immunosuppressive tumor-microenvironment.MET amplifications or MET mutations are associated with the development of several solid tumors.1 The therapeutic strategy of inhibiting the MET pathway in MET-addicted solid tumors has been mostly best researched in NSCLC. In NSCLC, 4%-10% of the tumors are considered to be MET dependent2; in patients with NSCLCMET exon 14 skipping (METex14) mutations are present in 3%-5%, and high-level MET amplifications are present in 1% and 4.1% depending on the definition (MET/Centromere ratio (MET ratio) ≥5 and MET gene copy number (GCN) ≥5, respectively, by in situ hybridization).3-7MET amplifications are also described as a resistance mechanism to EGFR TKIs in EGFR-positive NSCLC.8 Targeted therapy with MET tyrosine kinase inhibitors (TKIs) has led to improved outcomes in patients with advanced METex14 mutated NSCLC.9 MET inhibitors with higher affinity for MET, eg, capmatinib and tepotinib, seem to perform better than less selective inhibitors.10 Sensitivity of MET amplified NSCLC to MET TKIs is more heterogeneous, both in the de novo and in the acquired resistance setting.10-13Dysfunction of the mesenchymal epithelial transition (MET) tyrosine kinase receptor and the MET pathway through 14 Therefore MET-induced IDO upregulation in the tumor leads to an immunosuppressive tumor microenvironment (TME).15-17 Besides increased IDO expression, patients with MET-positive NSCLC display a higher tumor mutational burden (TMB) and PD-L1 expression than MET wild-type NSCLC resulting in possible benefit from immune checkpoint inhibitors (ICI) in contrast to EGFR mutated NSCLC.18-20 The combination of targeted therapy with an immunomodulating agent could have a synergic anti-tumor effect on MET-driven NSCLC.Besides its role in tumorigenesis, the MET pathway is known to have immune regulatory functions, amongst others through the upregulation of indoleamine-2,3-dioxygenase (IDO), an immunosuppressive enzyme. IDO catalyzes the degradation of tryptophan to kynurenin. Depletion of tryptophan leads to decreased differentiation of immune cells, while the metabolic intermediate kynurenin inhibits immune cell function.21 In addition, in EGFR TKI-resistant models with MET amplification, the combination of erlotinib and OMO-1 induced tumor regression.21 In addition to MET inhibition, OMO-1 was identified as a potent inhibitor of the organic cation transporter 2 (OCT-2), which is involved in the active secretion of creatinine and tryptophan.22 The suppressed OCT-2 mediated secretion of tryptophan might lead to increased plasma levels of tryptophan, thereby stimulating T-cell proliferation and differentiation.OMO-1 is a highly potent, orally bioavailable dual MET kinase/OCT-2 inhibitor. In preclinical studies, OMO-1 leads to complete inhibition of tumor growth in diverse in vivo MET-activated tumor models.Here we describe a phase I study to establish the safety and preliminary efficacy of the dual MET kinase/OCT-2 inhibitor OMO-1 in patients with solid tumors refractory to standard treatment and, subsequently, in patients with MET-positive solid tumors.Trial registration: Clinicaltrials.gov registry number NCT03138083.This study was part of a modular, first-in-patient, openlabel multicenter study of OMO-1, administered orally, mono-therapy, and in combination with EGFR-TKI, in patients with locally advanced, unresectable, or metastatic solid malignancies (study protocol can be). OMO-1 is a small molecule inhibitor of MET. Module 1 (OMO-1 monotherapy) consisted of Part A  and Part B (expansion cohorts). Part A assessed the safety and tolerability of ascending doses of OMO-1 given as monotherapy in unselected patients with locally advanced, unresectable, or metastatic malignancies and determined the recommended phase 2 dose (RP2D). Part B assessed the preliminary efficacy of the RP2D of OMO-1 in patients with METex14-positive NSCLC (cohort 1) and patients with MET amplified NSCLC or patients with other MET positive solid tumors, either METex14 or MET amplification . The MET status of the tumor was assessed locally by site-specific guidelines. For MET exon 14 skipping mutations next generation sequencing (NGS) was used and for MET amplifications either NGS or fluorescence in situ hybridization . Prior tThe primary objective of the study was to determine the safety and tolerability of OMO-1 when given orally to patients with locally advanced, unresectable, or metastatic solid malignancies and to define the dose and schedule for further clinical evaluation. Secondary objectives were to assess the preliminary efficacy of OMO-1 by response evaluation criteria in solid tumors (RECIST) v 1.1 and to characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of OMO-1, following a single dose and/or at steady state after multiple dosing, when given orally as monotherapy or in combination with epidermal growth factor receptor (EGFR)-tyrosine kinases inhibitor (TKI).Eligible patients were aged ≥18 years with Eastern Cooperative Oncology Group (ECOG) performance score 0-1, adequate organ function, histological, or cytological confirmation of locally advanced, unresectable, or metastatic solid malignancy refractory to conventional treatment. Exclusion criteria included a diagnosis of diabetes mellitus or current use of metformin (OMO-1 might increase exposure to metformin because metformin is secreted by OCT-2), prior splenectomy, active illness or viral infection, symptomatic CNS metastases, a history of epilepsy or uveitis, abnormal urinary function or outflow obstruction, and previous bone marrow transplant or recent surgery.23 In addition to urea and creatinine, tests of renal function such as serum Cystatin C and urinary KIM1 were conducted at baseline and on day 1 of subsequent treatment cycles. During the monotherapy dose escalation Module 1 Part A, blood samples were collected for PK analysis throughout the study as per protocol (S1). To explore the effects of the OCT-2 inhibition plasma levels of tryptophan and kynurenine were sampled. The difference in mean tryptophan plasma levels before and after OMO-1 exposure was statistically tested with a paired t-test  or a Wilcoxon signed rank test .OMO-1 was administered orally, twice daily (BID) with a minimal interval of 4-5 h with food in a continuous 21 day/cycle regimen until clinical progression or emergence of significant toxicity. The starting dose was 100 mg BID. The dose was escalated sequentially in cohorts of at least 3 patients using a standard 3 + 3 dose escalation design. Dose-escalation stopped when significant safety or tolerability concerns were observed in 2 or more patients and where the non-optimal long-term exposure dose (OLED) was exceeded. The RP2D was defined as the maximum dose whereby the safety or tolerability findings did not exceed 1 out of 6 patients. Computed tomography (CT) based tumor assessments were conducted according to RECISTv1.1 at screening and every 6 weeks once study treatment had commenced. Safety assessments were continually assessed and based on all adverse events ), clinical laboratory data, and physical examinations. In view of the association between MET inhibition and ocular toxicity, ophthalmological examination was conducted at baseline.The dose-limiting toxicity (DLT) evaluation period was within the first cycle of treatment; although all events beyond this point were also reviewed at the time of dose escalation to ensure an OLED was chosen as RP2D. A DLT was defined as any of the following occurring during the DLT-evaluation period: grade 3 or 4 non-hematological toxicity , grade 4 hematological toxicity, febrile neutropenia, grade 3 thrombocytopenia with bleeding, QTc prolongation , any toxicity related to OMO-1 that was clinically significant or unacceptable or unresolved after a treatment delay of >14 days and any toxicity clinically significant and/or unacceptable, greater than that at baseline and judged to be a DLT by the SRC.Safety analyses were descriptive. With respect to primary objectives and endpoints, no specific hypotheses were tested statistically. The primary focus was on determining the safety profile and RP2D, and the identification of a range of biologically active doses and PK of OMO-1 in patients with cancer. Safety, PK, and PD biomarker data were reviewed on an ongoing basis in line with the cohort progression criteria by the Safety Review Committee (SRC). Preliminary efficacy of OMO-1 by RECIST 1.1. was assessed locally. The best overall percentage change in tumor size is defined as the percentage change from baseline value that represents the largest decrease or smallest increase . The clinical benefit rate is derived as the proportion of patients with a partial response or a duration of stable disease (SD) of at least 8 weeks. Initially, the design in Module 1 Part A included parallel cohorts of patients with MET-positive tumors per dose level. Eventually, these patients were analyzed in Part B in expansion cohorts. Therefore, patients in Part B have received either 200 mg or 250 mg BID.Cmax, trough concentration (Ctrough), AUC∞, AUC0-last, Vd, clearance, elimination half-life (t½), and Tmax of OMO-1.24 In the paired biopsy analysis, expression of total MET and phosphorylated MET was performed by immunohistochemistry.Analysis was performed using PKSolver to define Between August 08, 2017 and December 09, 2019 a total of 40 patients were enrolled in the study. The primary analysis cutoff date was 25 May 2020 and the final cutoff date was 05 August 2020. At the time of data cutoff, no patients remained in study. In the dose-escalation part  24 patients were included in 5 dose levels: 100 mg BID, 200 mg BID, 400 mg BID, 250 mg BID, and 350 mg BID . In the T½ of 2.5-3 h and plasma exposure as measured by AUC(0-8 h) is dose-proportional without accumulation  was 5684 h ng/mL.OMO-1 has a mulation . OMO-1 iIn cohorts 1 (100 mg BID) and 2 (200 mg BID) no DLTs or other safety concerns were seen as concluded by the SRC. In cohort 3 (400 mg BID) also no DLTs were reported, but 2 out of 3 patients required a dose reduction due to treatment-related toxicity and 6 TEAEs led to OMO-1 treatment discontinuation in 2 patients (66.7%). In one of these 2 patients, the TEAEs leading to discontinuation were drug-related nausea, increased bilirubin, increased creatinine, and diarrhea (increased stoma output) (CTCAE grade 2). The other patient was discontinued due to hypersensitivity to OMO-1  after a previous dose reduction due to drug-related flu-like symptoms (CTCAE grade 3). Although these TEAES were not reported as formal DLTs, further treatment at that dose level was precluded as decided by the SRC. In addition, the planned dose level of 600 mg BID was replaced by a lower dose level of 250 mg BID (cohort 4). No DLTs or significant safety concerns were seen in cohort 4. Cohort 5 (350 mg BID) was the final dose-escalation. However, the nature of the AEs reported in the 400 mg BID and 350 mg BID, along with the high rate of TEAEs leading to withdrawal resulted in the SRC deciding that these doses were not in keeping with long term dosing; therefore, 250 mg BID was chosen as the monotherapy RP2D.In 23 out of 24 patients in Module 1 Part A , 129 drug-related TEAE were recorded. The most common drug-related TEAE (≥ 20%) were nausea , fatigue , vomiting , increased blood creatinine , and headache  . A higheIn total, 11 drug-related SAEs were reported in 7 patients. Nausea and vomiting were reported as drug-related SAEs in more than 1 patient (in 3 and 2 patients respectively).No grade 5  TEAEs were recorded.Six patients were on treatment with OMO-1 for more than 100 days of which 2 patients exceeded 200 days . All thePaired biopsy analysis was achieved for one patient with NSCLC with a MET exon 14 skipping mutation, dosed with 200 mg BID. The on-treatment biopsy showed a near-complete inhibition of phosphorylated MET, without affecting total MET levels .Mean creatinine levels were higher than baseline for all patients in all cohorts at all time points measured throughout the study (ranging from 6.6% to 121.5% increase from baseline), in keeping with on-target OCT-2 inhibition; however, throughout the study, overall mean creatinine levels were within the normal ranges and changes in mean creatinine levels over time were lowest in cohort 1 (100 mg BID).P = .014). The median kynurenin level in the pre-dose sample  396-624) slightly decreased in the 8 h post-dose sample (471 ng/mL IQR 396-559), but significance was not reached (P = .57).Plasma tryptophan and kynurenin levels on cycle day 1 at pre-dose and 8 h first post-dose were available for 30 patients in Module 1. A significant increase in mean tryptophan plasma levels on cycle 1 day 1 was seen between pre-dose samples and 8 h post-dose samples . The changes in plasma tryptophan levels and kyn/trp ratio were not dose or Cmax dependent.A decrease in mean kyn/trp ratio was seen between pre-dose samples and 8 h post-dose samples  . No patiOne patient was treated in Module 2 (combination with EGFR TKI); a 55-year-old female, with an EGFR-positive stage 4 NSCLC who had progressed on gefitinib. Tumor biopsy at progression showed an acquired MET amplification for which the patient was included in Module 2. Patient was treated with 200 mg BID of OMO-1 in combination with gefinitib (EGFR TKI). OMO-1 was interrupted due to serum Cystatin C increase of >1.5 fold from baseline, considered related to OMO-1. OMO-1 was restarted at one dose level lower (100 mg BID). Best response by local assessment was stable disease and best response by central assessment was partial response. Treatment was discontinued in week 23 due to disease progression.25In this phase I clinical trial, we found that OMO-1 had an acceptable long-term safety profile at 250 mg BID. PD analysis of a paired biopsy of a patient with METex14 mutated NSCLC showed near-complete inhibition of phosphorylated MET. Moreover, we observed modest clinical efficacy of OMO-1 in patients with METex14 mutated NSCLC. The development of more highly selective MET inhibitors is crucial for optimal treatment of MET exon 14 skipping mutation-positive NSCLC patients.10 Also, more gastrointestinal toxicity was seen in patients on OMO-1 , than with capmatinib , and tepotinib . The mechanism behind the difference in toxicity is unknown. Another important drug-related TEAE was increased blood creatinine which is due to the competitive inhibition of creatinine secretion by OCT2. In the phase I trial of OMO-1 in healthy human volunteers no renal toxicity was observed, suggesting that increased blood creatinine does not translate into kidney injury during OMO-1 treatment.26 In this trial, additional markers for renal function to reliably evaluate possible kidney injury, eg, cystatin C and KIM-1, did also not identify any significant renal function issues in monotherapy OMO-1. This on-target effect on blood creatinine levels was notable, but mostly mild and overall did not cause any issues with OMO-1 administration. In contrast, the predecessor compound of OMO-1, JNJ-38877605, had renal toxic properties, which precluded it from further development.27 No reports were made of peripheral edema related to OMO-1, which is described as a common AE for MET inhibitors.28 The mechanism behind MET inhibition-related peripheral edema is yet to be elucidated, so it is unclear why OMO-1 does not cause edema.In the dose-escalation cohorts, OMO-1 was tolerated in the majority of the patients on the lower dose-levels . As discussed in the dose-escalation results section, 400 mg BID and 350 mg BID were deemed not suitable for long-term dosing. The safety profile of OMO-1 is mostly comparable to other MET TKIs, but more patients on OMO-1 had to discontinue treatment due to toxicity than with capmatinib and tepotinib .As theorized, the mean plasma tryptophan level increased 8 h after OMO-1 administration and the mean kynurenin/tryptophan ratio decreased. This supports the hypothesis that OMO-1 inhibits the active secretion of tryptophan through OCT-2. In some patients, tryptophan levels decreased which could be due to low drug exposure, but we could not confirm this. As tryptophan is an amino acid present in most protein-based foods, food intake could be a confounding factor. Validation of these results in a larger cohort with dietary monitoring would be needed to confirm this hypothesis.10 However, no patients were treated with a MET TKI prior to OMO-1. Additionally, in 40% of the patients a co-occurring mutation was present potentially causing intrinsic resistance.29 Other new MET TKIs, like capmatinib and tepotinib, have shown impressive results in METex14 mutated NSCLC with object response rates of 68%  to capmatinib and 43%  to tepotinib with a median response duration of respectively 12.6 months  and 10.8 months .10 Both drugs have also received accelerated Food and Drug Administration (FDA) approval for the treatment of metastasized NSCLC. In the MET basket cohort, no clinical efficacy was seen. We believe this can be attributed to the level of MET amplification in the tumors, as none of the patients had a tumor with a high-level MET amplification (≥10 GCN). The most recent research shows that only high-level MET amplifications should be recognized as driver events and are therefore susceptible to targeted therapy.10 This is substantiated by the fact that low to medium MET amplified tumors (<10 GCN) are less sensitive to MET TKIs than high MET amplified tumors.10 In addition to the difference in response, high-level MET amplifications seem to be mutually exclusive with other known driver mutations, whereas low-level amplified tumors often contain a co-occurring driver mutation.30 At the time of trial design, the stratification of MET amplification was not yet common practice and therefore this was not part of the inclusion criteria. In further research with MET TKIs it would be recommended to enrich for high-level MET amplified solid tumors. Unfortunately, there is still no gold standard definition of high-level MET amplification and this also differs per technique used.31 There are signals that MET amplified NSCLC might be sensitive to immune checkpoint inhibitors, however only limited and retrospective research has been done.33 Therefore, compounds like OMO-1 combining potential immunomodulatory effects with targeted therapy could be an interesting mode of therapy for this group, although the actual immunomodulatory effects of OMO-1 in vivo remain unclear. Because OMO-1 will not be further developed for this indication, no additional insights can be gained.Following the dose-escalation part, the efficacy of OMO-1 was investigated in selected expansion cohorts; METex14 mutated NSCLC, other MET amplified, or MET mutated solid tumors (basket cohort). In METex14 mutated NSCLC, OMO-1 showed modest efficacy as almost all patients had stable disease as best response and no partial response (RECIST v.1.1) was recorded. One of the reasons for this low response rate could be the prior therapy status of the patients. Most patients had received prior anti-cancer therapy, which could have induced molecular heterogeneity and instability leading to accelerated development of resistance mechanisms. This negative effect of prior therapy has also been seen in trials with other MET TKIs.35The combination of OMO-1 and an EGFR TKI in EGFR mutated and MET-amplified NSCLC (Module 2) was investigated after the dose-escalation part in Module 1. As the trial was closed prematurely due to a strategic decision (including lack of funding), only one patient was included in this combination cohort in Module 2. After failure on an EGFR TKI, OMO-1 was able to bypass the resistance to the EGFR TKI, resulting in a partial response with a treatment benefit of more than 5 months, which is comparable to similar trials.In conclusion, OMO-1 is safe and well tolerated to administer at doses up to 250 mg BID and shows preliminary clinical efficacy in pre-selected patients with METex14 mutated NSCLC.We thank the participating patient and site staff for their participation and contributions to this study. M.W. acknowledges support from National Institute for Health Research (NIHR) Manchester Biomedical Research Centre, NIHR Manchester Clinical Research Facility at The Christie and Manchester Experimental Cancer Medicine Centre . Manchester, Newcastle and UCL clinical sites acknowledge support from CRUK/DOH England as Experimental Cancer Medicine Centres.oyad146_suppl_Supplementary_MaterialClick here for additional data file.