Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field.The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits.When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions. The inoculation occurs when the trauma breaks natural barriers against infections. All attempts to reduce the bacterial charge in the tissues should be made. Cleaning, irrigation, disinfection of wounds, followed by the appropriate early surgical treatment when indicated, are crucial for infection prevention. Antimicrobial prophylaxis is only one element integrating these interventions and should be limited to the period immediately after the trauma.One major drawback of exposure to antibiotics is the emergence of drug-resistant bacteria strains, as the result of selection pressure on resistant colonizing strains or on bacteria with newly acquired mutations. Unfortunately, most studies dealing with antibiotic prophylaxis have not adequately investigated this issue, which is particularly relevant in critical care settings where bacterial resistance to antibiotics has become a major problem. Here, we focused on studies comparing antibiotic prophylaxis and placebo in reducing infections in several trauma-related conditions taking into account the risk of antibiotic-resistant bacteria selection to produce a fair risk/benefit ratio assessment, in contrast with other guidelines addressing similar issues In the present paper, we report the contents of the review, the analysis and discussion of the literature, and the conclusions of the conference.The works was organized in three sequential steps:Step 1: The Coordinating Committee formed by five intensivists selected an initial list of topics. Head, thorax, abdomen, and limbs trauma were considered. Because of time constraints (there were only two days to discuss the issues during the convention) only four clinical conditions were selected based on traumatic event frequency and/or infection severity. The scenarios included antibiotic prophylaxis for 1) early VAP in comatose patients, 2) meningitis in severe skull fractures, 3) wound infection in long-bone open fractures , 4) deep surgical-site infections in abdominal trauma with hollow viscus perforation. We also considered but discarded pneumonia in thoracic contusion, empyema after chest tube insertion, surgical-site infection for long-bone closed fractures, infection after soft tissues open injuries, abdominal trauma without bowel perforation, and inhalation pneumonia in pre-hospital intubation.The Coordinating Committee then generated the queries for the literature search and selected the articles fulfilling the criteria established for each subject. The fundamental criterion, shared by all the investigated issues, was the comparison between adult patients subjected to antibiotic prophylaxis and controls. When such studies were not available comparison between groups receiving different pharmacological protocols were considered.The MEDLINE database was searched using the free PubMed provider. Randomised trials, reviews, meta-analyses, or observational studies were selected. Pediatric and animal studies, and articles not written in English, were excluded. The MEDLINE search covered a period between January 1970 and January 2014. This search was integrated with the consultation of reference lists of retrieved articles.The Coordinating Committee members unanimously selected the articles after reviewing the abstracts, with the help of one of the authors with specific expertise in statistics and research methodology. Full-texts were then retrieved and a further selection was carried out.ad hoc for this revision, and tested and refined using the studies on early VAP prevention with antibiotic prophylaxis.The statistical and methodological expert also performed data extraction according to a predefined plan (the protocol was not pre-registered), using a dedicated electronic form that automatically performed all planed computations and plot generation. The electronic form was developed Data collected included study inclusion criteria, antibiotic class and dose, duration of prophylaxis, antibiotic-resistant bacteria selection when investigated, infection rates, and mortality rates when available, along with information needed for the GRADE evidence quality assessment.Data were presented as event rates in treatment arms and controls, absolute risks, absolute risk reductions, and relative risks. Adjusted odds ratios were reported when dealing with multivariate analysis results in observational studies. Numbers needed to treat were also calculated. Confidence intervals were computed for all the above measures. Relative risks were graphically represented in Forest plots.Design heterogeneity among selected studies advised against their combination in meta-analyses. For the same reason statistical approaches to investigate presence of asymmetry and potential publication bias were not carried out The queries and the results of the summarised results were submitted to the External Scientific Advisory Panel, formed by four intensivists with expertise in the field of infections and trauma in critical care settings, who discussed them together with Coordinating Committee members.Evidence provided by randomised controlled trials (RCTs) and observational studies was ranked on the basis of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The GRADE stratifies quality of evidence on a four-level scale, ranging from high to very low, The reporting of RCTs was evaluated on the basis of currently shared standards. Our evaluation of meta-analyses was restrictive, according to the principle that heterogeneity among studies in terms of inclusion criteria, study design, study treatment, type of outcome, which are not accounted for by statistical methods focused on heterogeneity of outcome rates, Step 2: The results were presented to the physicians invited to the symposium - intensivists, infectious disease specialists, surgeons, emergency physicians, radiologists, and physiatrists – and the issues were collectively discussed. The discussion was audio-recorded and at a later stage revised by members of the Coordinating Committee to identify and highlight the main opinions that emerged from the discussion.Step 3: the scientific advisors and the Coordinating Committee members formed the jury that provided recommendations that were presented as preliminary results on the final day of the conference, but discussed and refined in the following months by e-mail. A final meeting was held one year after the conference, to discuss diverging opinions until unanimity was reached. To develop the recommendations the panel followed the GRADE framework. This is based on four points: quality of evidence, balance between desirable and undesirable effects, values and preferences, uncertainty about whether the intervention represents a wise use of resources other criterion which included other weak features of the study, such as the unbalance in important variables between study arms in RCTs that may occur when the sample size is small.The GRADE initially attributes a high default level of evidence to RCTs and a low level to observational studies. For RCTs the first criterion, i.e. bias, takes into account allocation concealment and blinding, completeness of follow-up and adherence to the intention-to-treat principle, premature study interruptions for benefit, and selective reporting of outcomes. Limits in observational studies can include lack of controls, as in case series, or, when controls are present, lack of adjustment for important covariates, which may be unevenly distributed between study groups Initially, evidence is rated only one point up when the relative risk is between 0.5 and 0.2 or between 2 and 5, and two points up when lower than 0.2 or higher than 5, obviously when dealing with statistically significant results. However, even in the presence of large effects, when imprecision is strong  and negligible effects cannot be ruled out, upgrading is not performed. The rating can also be increased when a dose-response is evident or plausible potential confounders would only increase the confidence in the results The strength of recommendations can be strong or weak, in favour or against interventions. The conference dealt with four different issues of broad clinical interest but focusing especially on relevance for critically ill patients and from the point of view of intensive care unit (ICU) and emergency department physicians.To investigate the main undesirable effects of prophylaxis, we preliminarily performed a systematic research on the effect of short antibiotic administration on bacterial antibiotic-resistance selection, to provide a fair assessment of the balance between benefits and risks. The results of this investigation integrated, when appropriate, the evidence concerning antibiotic prophylaxis in the clinical conditions we explored.A transparent report of the reviewing process and of evidence grading is provided for each query in the supporting information.The review was conducted complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations  increases the risk of colonization with resistant bacterial strains, The contemporaneous combination of the mutant bacteria and antibiotic exposure determines the spread of antibiotic-resistant bacteria. In a study carried out on a cohort of 2,641 patients receiving antibiotic prophylaxis for cardiac surgery, of 1,094 undergoing cultures 426 were shown to harbour bacteria resistant to the antibiotic they were exposed to. Logistic regression, adjusting for many possible confounders, indicated an increased risk of resistance selection in case of antibiotic prophylaxis lasting more than 48 hours. Pseudomonas Aeruginosa (CRPA). Pseudomonas Aeruginosa. Cephalosporins, quinolones, and macrolides were the antibiotics more frequently administered . Absence of control (i.e. patient not exposed to antibiotics) although not irrelevant was not a major issue, in our opinion, because we do not expect factors other than antibiotic pressure to affect the colonization rate within a 48-hour period. A low colonization rate, as in this study, is still clinically relevant if we account for the duration and possibility of horizontal spread of resistant bacterial colonization, especially in environments such as the ICU In a before/after study involving 5 wards, the rate of acquisition within 30 days from initial antibiotic exposure, was 3% for MRSA (22/724), 2% for vancomycin-resistant enterococci (VRE) (10/430), and 1% (11/840) for ciprofloxacin-resistant Another study investigated 29 patients undergoing cardiac surgery and 10 coronary angioplasty, receiving prophylaxis for three days with a first or a second-generation cephalosporin. Finally, in a study investigating the effect of a five-day course with clarithromycin, 5 patients colonised by susceptible enterococcus strains few days after the end of treatment developed resistant types, which in 3 cases persisted for one year or more. The limitation of antibiotics use is widely recognized as an effective strategy for the reduction in bacterial resistance. Conclusions: there is low evidence indicating that antibiotic prophylaxis lasting 48 hours or more is capable of determining the colonization with resistant bacterial strains, that is the undesirable effect reported in the text and tables for each of the interventions under scrutiny.Results: the MEDLINE search provided only three studies, two RCTs and one observational study, The results of a recent observational study, including 129 patients suggested that a single dose of ceftriaxone was an independent predictor of reduced incidence of early-onset pneumonia. Conclusions: The two RCTs had substantial different interventions and outcomes, thus we provided recommendations for two different queries .Level of evidence in favour: No evidence.Level of evidence against: Low evidence.Recommendation: Weak against intervention.Prolonged (ten-day) antibiotic prophylaxis for the prevention of wound infections .Level of evidence in favour: Low evidence.Level of evidence against: High evidence.Recommendation: Strong against intervention.Results: out of 504 articles resulting from the literature search, none compared treatment and no-treatment arms. Our results were consistent with those of two recent Cochrane meta-analyses that did not find any RCTs investigating the effectiveness of antibiotic prophylaxis compared to placebo in reducing infections following penetrating abdominal trauma Since no direct evidence exists with regard to the effectiveness of antibiotic prophylaxis in abdominal trauma compared to placebo, under the assumption that antibiotic prophylaxis is effective in preventing surgical site infections, The first two studies dealt almost exclusively with deep surgical site infections, i.e. intra-abdominal abscess, peritonitis, and necrotizing fasciitis, while the third one reported disaggregated data concerning deep and superficial surgical site infections. Thus, we were able to analyse data concerning deep surgical infections. The studies recruited 317, 515, and 300 patients respectively, and infections rates were 10 vs. 8% in the 5-day and 24-hour treatment arms in the first two studies, and 6% in both arms in the third one . AlthougIn the studies, surgical management was carried out within few hours from the injury, and early surgery appears to be a reasonable condition for short (i.e. ≤24 hours) antibiotic prophylaxis. We adopted the Infective Disease Society of America (IDSA) definition of early surgery (i.e. carried out within 12 hours from trauma). Conclusions: The review was focused on different antibiotic strategies under the assumption that antibiotic prophylaxis is effective in reducing infections compared to placebo , the undesirable effect is the selection of antibiotic-resistant bacteria, an outcome not investigated in most of the studies. The risk of resistant mutant selection due to short antibiotic pressure has not been investigated with RCTs. We had therefore to rely on before-after studies investigating either the colonization of single patients after treatment or the effect of antibiotic policies changes in single centres.We were able to find observational studies suggesting that a 2/3-day antibiotic course could already result in the selection of antibiotic-resistant bacteria. We graded this evidence as low or very low, due to several limitations of the studies. However, in the face of similar strength of evidence in favour and against the intervention, as in the case of the 3-day antibiotic prophylaxis for wound infections in open-fractures or early-VAP prevention in comatose patients, we considered the antibiotic-resistant resistant selection the main concern in terms of clinical impact and social relevance of the outcome., Antibiotic-resistant bacteria spread constitutes an emergency for the global health-care system, given its high burden of mortality and resource consume. Klebsiella Aerogenes, which at its peak caused urinary infections in 1 of 4 patients, respiratory infections in 1 of 8, and 9 cases of meningitis 8 of which were fatal. In conclusion, we would like to mention a striking report from a neurosurgical centre that in the late 1960s had to face an outbreak of resistant Figure S1Absolute proportions differences and relative risks for the studies concerning the first query.(PDF)Click here for additional data file.Figure S2Absolute proportions differences and relative risks for the studies concerning the second query.(PDF)Click here for additional data file.Figure S3Absolute proportions differences and relative risks for the studies concerning the third query.(PDF)Click here for additional data file.Figure S4Absolute proportions differences and relative risks for the studies concerning the fourth query.(PDF)Click here for additional data file.File S1MEDLINE database search, flow diagram illustrating the literature selection process, and Table S1 illustrating evidence assessment for the first query.(DOCX)Click here for additional data file.File S2MEDLINE database search, flow diagram illustrating the literature selection process, and Table S2 illustrating evidence assessment for the second query.(DOCX)Click here for additional data file.File S3MEDLINE database search, flow diagram illustrating the literature selection process, and Table S3 illustrating evidence assessment for the third query.(DOCX)Click here for additional data file.File S4MEDLINE database search, flow diagram illustrating the literature selection process, and Table S4 illustrating evidence assessment for the fourth query.(DOCX)Click here for additional data file.File S5MEDLINE database search, flow diagram illustrating the literature selection process, and Table S5 illustrating evidence assessment for antibiotic-resistant bacteria (undesirable effect).(DOCX)Click here for additional data file.File S6Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations checklist (Table S6).(DOC)Click here for additional data file.


MET proto-oncogene. Aberrant activation of c-Met resulting from MET amplification and c-Met overexpression is associated with poor clinical outcome in multiple malignancies underscoring the importance of c-Met signaling in cancer progression. Several c-Met inhibitors have advanced to the clinic; however, the development of inhibitory c-Met-directed therapeutic antibodies has been hampered by inherent agonistic activity.c-Met is the receptor tyrosine kinase for hepatocyte growth factor (HGF) encoded by the We generated and tested a bivalent anti-c-Met monoclonal antibody ABT-700 in vitro for binding potency and antagonistic activity and in vivo for antitumor efficacy in human tumor xenografts. Human cancer cell lines and gastric cancer tissue microarrays were examined for MET amplification by fluorescence in situ hybridization (FISH).MET amplification undergo apoptosis upon exposure to ABT-700. ABT-700 induces tumor regression and tumor growth delay in preclinical tumor models of gastric and lung cancers harboring amplified MET. ABT-700 in combination with chemotherapeutics also shows additive antitumor effect. Amplification of MET in human cancer tissues can be identified by FISH.ABT-700 exhibits a distinctive ability to block both HGF-independent constitutive c-Met signaling and HGF-dependent activation of c-Met. Cancer cells addicted to the constitutively activated c-Met signaling driven by MET provide rationale for examining its potential clinical utility for the treatment of cancers harboring MET amplification.The preclinical attributes of ABT-700 in blocking c-Met signaling, inducing apoptosis and suppressing tumor growth in cancers with amplified The online version of this article (doi:10.1186/s12885-016-2138-z) contains supplementary material, which is available to authorized users. MET gene, with consequent c-Met receptor tyrosine kinase (RTK) overexpression and constitutive kinase activation, is an oncogenic driver in multiple malignancies [Amplification of the gnancies –4. Unlikgnancies , 5–7. Bignancies , 8. Prevgnancies , 10. Thegnancies  but the gnancies .MET and focused preclinical studies to assess its antitumor activity in models driven by MET amplification. These findings provide scientific rationale for the clinical activity observed in patients with MET amplified tumors following treatment with ABT-700.ABT-700 is a bivalent humanized IgG1 that displays distinctive properties compared to other c-Met-targeting antibodies. ABT-700 binds cellular c-Met and disrupts its productive dimerization and activation induced by HGF or by the high density of c-Met on the cell surface independent of ligand. We hypothesize that ABT-700 might be effective in treating cancers harboring amplified ABT-700, an anti-human c-Met antibody derived from the mAb 224G11  was prod96-well plates (Costar #3369) were coated with 100 μL/well of mouse anti-His antibody (Invitrogen #37-2900) at 1 μg/mL in PBS pH7.4 at 4 °C overnight, and then blocked using Superblock  for one hour at room temperature. Plates were washed 4 times with PBST and then incubated with 100 μL of recombinant human c-Met extracellular domain (rh-c-Met ECD-6His) at 2 μg/mL in 10 % Superblock in PBST for 1 h at room temperature. Plates were washed 4 times with PBST and then incubated with ABT-700 or control human IgG in serial dilutions in 10 % Superblock in triplicate wells at room temperature for 1 h. Plates were washed 4 times with PBST and then incubated with 100 μL of 1:15,000 goat anti-human IgG-HRP  at room temperature for 1 h. Plates were washed 4 times in PBST and 100 μL of TMB  was added to each well and incubated at room temperature until color developed (approximately 10 min). Reactions were stopped by addition of 2N sulfuric acid  and optical density (OD) was read at 450 nm.6 cells/mL in FACS buffer. Cells were added to a round bottom 96-well plate  at 100 μL/well. Ten μL of a 10x concentration of ABT-700 or controls in duplicate wells was added and plates were incubated at 4 °C for four hours. Wells were washed twice with FACS buffer then resuspended in 50 μL of 1:500 anti-human IgG Ab  diluted in FACS buffer. Plates were incubated at 4°C for one hour then washed twice with FACS buffer. Cells were then resuspended in 100 μL of PBS/1 % formaldehyde and analyzed on a Becton Dickinson LSRII flow cytometer. FACS binding studies were performed for each cell line in at least two independent experiments.For cellular c-Met binding studies, cells were harvested from flasks when approximately 80 % confluent using Cell Dissociation Buffer (Invitrogen #13151-014 or #13150-016). Cell viability was checked by trypan blue staining to ensure >90 % live cells. Cells were washed once in PBS/1 % FBS (FACS buffer) then resuspended at 1.5-2.5 × 102. Cells were treated with control hIgG (Sigma I4506) and ABT-700 at 10 μg/ml for 24 h. Cells were transferred from 12-well plate into 1.5 ml microcentrifuge tubes, pelleted, and washed with cold PBS. Cells were resuspended in 0.1 ml 1X Binding Buffer provided in kit (BD Pharmingen kit cat# 556547). 5 μl of FITC Annexin V and 5 μl propidium iodide (PI) were added and cells were incubated in the dark for 15 min. 400 μl of 1X Binding Buffer was added and cells were analyzed on a Becton Dickinson LSRII flow cytometer within one hour.For Annexin V apoptosis detection, tumor cells were plated at 300,000 cells/ well in 12-well dishes in 2 ml serum-free media . Cells were incubated overnight at 37 °C, 5 % COA549 cells were plated at 40,000 per well in 96-well plate in growth media. Twenty four hours later, cells were pretreated with antibodies in duplicate wells for one hour at 37 °C, and then stimulated with HGF for 10 min at 37 °C. 1 nM (~100 ng/mL) HGF was used to stimulate c-Met as described in the literature . For SNUCells were plated at 300,000 per well in 12-well tissue culture plates and were incubated overnight in growth media. Cells were incubated with ABT-700 or control for the time points as indicated at 37 °C. Cells were then lysed with 100 μL/well of 2X LDS NuPAGE sample buffer (Invitrogen NP0007) with reducing reagent (Invitrogen NP0009). Cell lysates were resolved by SDS-PAGE using 4-12 % Bis-Tris NuPAGE gels (Invitrogen NP0322) and transferred to PVDF membranes (Millipore Immobilon-FL # IPFL07810). Blots were blocked with Odyssey Blocking Buffer (LI-COR # 927-40000) for one hour at room temperature, washed three times with PBST, and then incubated overnight with appropriate primary antibodies at 4 °C. Following overnight incubation with primary antibodies, blots were washed three times with PBST for ten minutes, and then incubated with either AlexaFluor680 goat anti-rabbit IgG  or goat anti-mouse IRDye 800CW  for one hour at room temperature. Blots were then washed three times with PBST, and visualized by scanning using an LI-COR Instrument Odyssey (Model # 9120). Primary antibodies included mouse anti-c-Met , rabbit anti-phospho-Y1234 c-Met , phosphor-PLCr  , phosphor-Erk (Invitrogen #44680G), phosphor-Bad , total bad , Bim , Bcl-xL (BD #51-6646GR), cytochrome C (BD Pharmingen Cat 556433), cleaved PARP (Epitomic #1074-1), and mouse anti-actin . At least two independent experiments were carried out for each cell line.6) were treated with control hIgG or ABT-700 for 24 h. Cells were washed in PBS, pelleted and resuspended in 50–100 μL Digitonin Lysis buffer  by pipetting up and down, and incubated for 30 s. Cells were pelleted at high speed in microcentrifuge for 1 min, supernatant (cytosolic fraction) was collected and 2x NuPAGE sample buffer was added for Western analysis. Pellets (organelle-containing membrane fraction) were washed in cold PBS 3 times, and lysed by sonication in 1x NuPAGE sample buffer for Western analysis. The study was performed in two independent experiments.SNU5 cells  in triplicate wells. Untreated control wells (for 0 % control) and wells treated with 10 μM staurosporin (for 100 % kill) were included in each plate. The plates were incubated for 3–5 days at 37 °C with 5 % CO2. To quantify live cells, media was removed and 1x Cell Titer Aqueous One Solution  diluted in Opti-mem media (Invitrogen # 31985–070) was added to plates and the plates were then incubated for one hour at 37 °C. The OD at 490 nm was read on a M5 Spectramax plate reader (Molecular Probes). Percent inhibition was calculated based on 100 % kill and untreated control wells using the following formula: 100x (0 % control - treated)/(0 % control - 100 % kill). For cells grown in suspension such as SNU5, cells were plated in 96-well plate in 180 μL medium at 10,000 cells/well and incubated overnight at 37 °C with 5 % CO2. The same protocol as above was used for treatment and data processing except live cells were detected by adding forty μL of Cell Titer Aqueous One Solution to each well and the plates were then incubated for one hour at 37 °C. The experiments were repeated at least twice for each cell line.Tumor cells were plated in 96-well plate  in 180 μL growth media at 3000–5,000 cells/well. The cells were incubated overnight at 37 °C with 5 % COad libitum and manipulated according to French and European guidelines. Animals were examined before the initiation of experiments to ensure that they were healthy and acclimated to the laboratory environment.Studies with gastric (SNU5 and SNU620), lung  and glioblastoma (U87MG) were carried out at Pierre Fabre. Animal Ethical Committee was registered under the CEA-CIPF-108 number. All experiments conformed to the United Kingdom Co-ordinating Committee on Cancer Research (UKCCCR) Guidelines for the Welfare of Animals in Experimental Neoplasia UKCCR for animal care and use. SCID mice were from Charles River Laboratories . Athymic Nude Mice were acquired from Harlan . All animals were housed on a 12 h light/dark cycle, in sterilized filter-topped cages, in a temperature 22 +/−2 °C and in humidity (30 to 70 %) controlled room. Mice were maintained in sterile conditions with food and water provided 6) were implanted s.c. into the right flank region of mice. Tumor bearing mice were size matched and randomized into study groups (n = 5 or 6 as shown in figure legends). Each experiment consisted of an ABT-700 dose evaluation injected i.p. compared to controls. Evaluation of the anti-tumor activity was determined by measuring tumor volume twice a week using the formula: π/6 × length × width × height.Cells  for treatment with ABT-700 or control administered by i.p. injections every 21 days. From D5 to D21, tumor volume was monitored twice a week with an electronic caliper. On day 21, subcutaneous primary tumors were resected from mice anesthetized with a Ketamine/Xylazine mixture (70/30) injected intra-muscularly. ABT-700 antitumor activity was monitored by following animal mortality.For the ectopic EBC1 lung metastasis and survival model, mice were injected s.c. with 7x10Additional animal groups were introduced for the gastric xenograft model SNU5 in order to evaluate pharmacodynamic markers by immunohistochemistry as described in detail in Additional file Experiments with the gastric Hs746T s.c. xenograft model were conducted at AbbVie in compliance with AbbVie’s Institutional Animal Care and Use Committee and the National Institutes of Health Guide for Care and Use of Laboratory Animals guidelines in a facility accredited by the Association for the Assessment and Accreditation of Laboratory Animal Care. SCID mice were obtained from Charles River . Mice were acclimated to the animal facilities for a period of at least one week prior to commencement of experiments.6) were inoculated in the flanks of male SCID mice and tumor-bearing animals were size matched and randomly assigned to cohorts to a mean tumor volume of approximately 225 mm3 per group (N = 10) 15 days post inoculation of cells. Dosing for all agents was initiated on day 16. ABT-700 (10 mg/kg) was administered twice a week i.p. while docetaxel (7.5 mg/kg) was administered i.v. as a single dose. A human IgG control antibody was used as a negative control agent. Tumor dimensions were determined twice weekly and volume determined with the formula (L x W2)/2.Hs746T cells  using protocols described in detail in Additional file P value <0.05 was considered significant.Results are expressed as the mean ± SEM. All data were analyzed with GraphPad Prism V6.05 . The difference in tumor growth between different groups was analyzed by two-way ANOVA Turkey’s multiple comparison tests. The survival data were analyzed using Log-rank (Mantel-Cox) test. A ABT-700 is a humanized bivalent IgG1/kappa monoclonal antibody derived from the m224G11 mouse hybridoma . ELISA aMET amplification. ABT-700 shows monophasic and saturable binding to cell lines expressing endogenous c-Met including A549, IM95, SNU5 and EBC1 with EC50 values of 0.2 – 1.3 nM  and/or by over-expressed c-Met in the absence of added HGF, we used ELISA-based assays to quantify phospho-c-Met in cell lysates of A549 and SNU5. ABT-700 and parental mAb m224G11 blocked the HGF-induced c-Met phosphorylation of A549 tumor cell line with an IC nM Fig. . 5D5, th nM Fig.  although nM Fig. . ABT-700 nM Fig. . Given t nM Fig.  and d.MET constitutively activated Hs746T cells after treatment  with an average ratio of MET and CEP 7 (a centromere control) copy numbers of 2 or greater . Collectively, these results demonstrate that ABT-700 can inhibit the proliferation and consequently induce apoptotic cell death in cancer cells addicted to c-Met signaling driven by MET amplification.Given that ABT-700 inhibited SNU5 cell growth by more than 90%, we further examined its effect on c-Met signaling pathways and induction of apoptosis in these cells. SNU5 cells possess constitutively activated c-Met as indicated by the high levels of phosphorylated c-Met Fig.  and f. AMET. ABT-700 inhibited the growth of established SNU5 tumors harboring amplified MET at doses ranging from 2.5 to 40 mg/kg, with long-term tumor regressions including complete responses observed at doses of ≥ 10 mg/kg . Among these 3 patients, the duration of response was 19, 23, and 24 weeks, respectively [MET amplification and to better define predictive biomarkers, safety and clinical benefit.MET amplification is associated with poor prognosis in a variety of cancers highlighting the significant unmet medical need of this patient population. We describe preclinical results that justify the clinical investigation of ABT-700 in cancer types with addiction to the d tumors , ABT-700d tumors . By RECIectively . This stMET gene amplification, as defined by FISH analysis, and overexpress c-Met protein, are sensitive to ABT-700. Cancer cells addicted to constitutively activated c-Met undergo apoptosis upon exposure to ABT-700 monotherapy leading to tumor regression in preclinical animal models. Our data emphasizes the need for a patient selection strategy that harbor MET amplification as they most likely would benefit from ABT-700 treatment. Ultimately, ABT-700 may have broader clinical utility as the prevalence of MET amplified tumors increases with disease progression, recurrence and/or treatment regimens [MET amplification. Recently somatic splice site alterations at MET exon 14 (METex14) that result in exon skipping and MET activation were described in human cancers [The tumor cell lines evaluated in our study herein that harbor regimens –4. Thus, cancers . AlthougIn addition to inhibiting tumors with MET gene amplification, ABT-700 also inhibits the subcutaneous xenograft growth of human tumor cell lines that have c-Met protein overexpression or autocrine HGF. Patients with tumors driven by HGF-dependent c-Met activation may benefit from combination of ABT-700 with chemotherapy. In this context, the demonstration of more robust and sustainable anti-tumor activity in animal models following the combination of ABT-700 with different standard of care cytoreductive chemotherapies provides the basis for exploration of effective combination therapy in the clinic.ABT-700 is among the first reported bivalent anti-c-Met antibodies that lack agonistic activity , 15. By MET. Collectively, the attributes of ABT-700 coupled with early signs of activity in a phase 1 clinical trial support investigation of this antibody, as monotherapy and in combination, in malignancies characterized by aberrant activation of c-Met signaling including cancers harboring MET amplification.ABT-700 shows preclinical activities in blocking both HGF-dependent and HGF-independent c-Met signaling, inducing apoptosis and suppressing tumor growth in cancers with amplified


Evidences highlights exposure to fine particulate matter (PM2.5) as a risk factor for development of type 2 diabetes (T2D), especially in high-fat diet (HFD) fed mice. Under stressful conditions, cells respond by synthesizing a suite of intracellular stress response proteins, that plays a fundamental protective role in metabolic disorders, the 70 kDa family of heat shock proteins (iHSP70). However, while iHSP70 presents anti-inflammatory proprieties, their extracellular levels (eHSP72), presents pro-inflammatory roles. We propose to investigate the effects of HFD+PM2.5 association in the HSP70 status, and this relation to the risk of developing T2D.Male mice (n=20) were fed standard chow or HFD for 12 weeks, and then, were randomly exposed to daily nasotropic instillation of low doses of PM2.5 (5 μg/10 μL) or saline solution for additional 12 weeks, performing four groups (n=5): Control, PM2.5, HFD and HFD+PM2.5. At the end of the study, we assessed the eHSP72 plasma concentration by highly sensitive EIA method and the pancreas iHSP70 expression by immunoblot analyses. Assuming the ratio R=[eHSP72]/[[iHSP70]=1 for the Control group, the R was analyzed separately for each group. R values between 0.0 and 1.0 indicate a predominantly anti-inflammatory (cytoprotective) status, conversely R values higher than 1.0 denotes pro-inflammatory response. Statistical analysis was developed using ANOVA and post hoc Tukey's test.There were no alterations on eHSP70 plasma concentration (P=0.2798). Pancreas iHSP70 expression was lower in HFD groups , already indicating low cytoprotection in these groups. Furthermore, the [eHSP72]/[iHSP70] ratio was increased 3.8 fold in HFD+PM2.5, as shown in Figure Our study showed that HFD consumption decreases the pancreatic cells defense, and this condition associated with sub-chronic exposure to PM2.5 promotes imbalance in HSP70 status, described by the [eHSP72]/[iHSP70] ratio, indicating an immunoinflammatory status, which can be determinant to trigger a chronic pro-inflammatory state that leads to insulin resistance. These data provides evidence for an important interplay between environmental and dietary challenges that may potentiate the development of T2D, highlighting HSP70 status as a biomarker of this condition.


The prognostic value of c-Met in breast cancer remains controversial. A meta-analysis of the impact of c-Met in breast cancer was performed by searching published data.Published studies analyzing overall survival (OS) or relapse free survival (RFS) according to c-Met expression were searched. The principal outcome measures were hazard ratios (HRs) for RFS or OS according to c-Met expression. Combined HRs were calculated using fixed- or random- effects models according to the heterogeneity.Twenty-one studies involving 6,010 patients met our selection criteria. The impact of c-Met on RFS and OS was investigated in 12 and 17 studies, respectively. The meta-analysis results showed that c-Met overexpression significantly predicted poor RFS and OS in unselected breast cancer. Subgroup analysis indicated that c-Met overexpression was correlated with poor RFS and OS in Western patients, but was not associated with RFS or OS in Asian patients. C-Met was associated with poor OS in lymph node negative breast cancer and with poor RFS in hormone-receptor positive and triple negative breast cancer, but was not associated with prognosis in human epidermal growth factor receptor (HER)-2 positive breast cancer.C-Met overexpression is an adverse prognostic marker in breast cancer, except among Asian and HER-2 positive patients.http://www.diagnosticpathology.diagnomx.eu/vs/1869780799156041The virtual slide(s) for this article can be found here:  Breast cancer is the most common cancer among women worldwide . The cliThe tyrosine kinase c-Met, a key regulator of invasive growth, is overexpressed in certain aggressive cancer cells . c-Met, In the present study, we enrolled and combined all eligible published studies analyzing the relationship between c-Met expression and relapse free survival (RFS) or overall survival (OS) in breast cancer to clarify the relationship between c-Met expression and prognosis in breast cancer. c-Met plays a critical role in early-stage invasion of cancer cells , and croWe searched the electronic databases PubMed, Embase, and the Chinese Biomedical Literature database (CBM)  by using the keywords “breast cancer”, “hepatocyte growth factor receptor”, “HGFR”, “c-Met”, and “prognosis”. The titles and abstracts of the studies were firstly scanned to exclude all irrelevant papers. Then, the final inclusion of studies was determined by reading the full text of the remaining articles. The citation lists of all retrieved articles were scanned to identify other potentially relevant reports.The search results were screened according to specific inclusion and exclusion criteria as follows. Inclusion criteria: (1) research limited to human primary breast cancer; (2) the study was published in English or Chinese; (3) inclusion of female patients; (4) evaluation of survival information, such as RFS, OS, according to c-Met expression; (5) the study provided the hazard ratios (HRs) and 95 % confidence intervals (CIs), or data that could be used to calculate the HRs and 95 % CIs, or Kaplan–Meier survival curves that provided sufficient data to extract HRs and 95 % CIs; (6) peer-reviewed and published original articles. Exclusion criteria: (1) no data on survival, or inability to calculate the hazard ratios of RFS and OS based on the data provided; (2) letters to editor, reviews and articles published in a book. If patients were enrolled from the same institutions during the same period, the most recently published data were included in the study.Two reviewers (Yan SC and Jiao X) performed the search and assessed the studies independently, and the inclusion of a study was decided by consensus. The following items were recorded from each study: the first author’s name, year of publication, language, cohort size, assessment methods of c-Met expression, type of patients, hazard ratio (HR) of OS and/or RFS. The studies were assessed for quality using REMARK (reporting recommendations for tumor MARKer prognostic studies) , and the2-square test was used to assess heterogeneity. A P-value < 0.05 was considered significant. If the test of heterogeneity was significant, a combined HR was calculated using the random-effects model; otherwise, the fixed-effects model was used. Engauge Digitizer version 2.11 (free software downloaded from http://sourceforge.net) was used to extract data from Kaplan–Meier curves. Data combining was performed using RevMan version 5.2 (free software downloaded from http://www.cochrane.org). Begg’s tests were used to assess publication bias. Probable significant publication bias was considered at P < 0.05. In cases of publication bias, the combined estimate was recalculated after imputation from the asymmetry of the funnel plot of the number of “missing” studies, a method known as “trim and fill”. Begg tests and “trim and fill” were performed using StataSE12.0 .HRs with 95 % CIs were combined to determine the effective value. If data on HRs and 95 % CIs were not provided directly, the published data and Kaplan-Meier survival curves were used to calculate the HR according to the methods described by Parmaret et al.  and TierAs shown in Fig P = 0.02, I2 = 50 %), and a random-effects model was used. The combined HR was 1.60  . Seventeen studies including 4228 cases were evaluated for the effect of c-Met overexpression on OS . The combined HR was 1.52 , which indicated that c-Met overexpression was associated with a 1.52-fold increased risk of mortality in breast cancer patients. The trim and fill method omitted one study with a revised estimate of HR and continued to show a statistically significant poor OS in c-Met overexpressing patients .RFS was analyzed in 12 studies and in a total of 3570 cases. The results showed significant between-study heterogeneity , and the fixed-effects model was used. The results showed that c-Met overexpression was significantly associated with a 1.52-fold increased risk of recurrence  . The impact of c-Met expression on the OS of Western patients was evaluated in 13 studies including 2969 cases. The random-effects model was used because of the observed heterogeneity . The results of the meta-analysis showed a significantly poor OS in the c-Met overexpression group  . Four studies including 1257 cases evaluated the impact of c-Met expression on the RFS of Asian patients, and four studies including 1259 cases evaluated the impact of c-Met expression on the OS of Asian patients. The random-effects model was used because of the observed heterogeneity . Although there was a trend toward increased recurrence   , and the fixed-effects model was used. The results showed that c-Met overexpression was associated with a 2.04-fold increased risk of mortality   was observed among these studies. The fixed-effects model was used, and the results of the meta-analysis showed that c-Met overexpression was associated with a 1.41-fold increased risk of recurrence  . Although there was a trend toward increased recurrence among patients with c-Met overexpression   was observed among these studies. The fixed-effects model was used and the result of the meta-analysis showed that c-Met overexpression was significantly associated with a 2.31-fold increased risk of recurrence     Fig. a, sugges29) Fig. b. The me05) Fig. c. The tr05) Fig. d. The geIn recent years, the development of target-based therapies has improved the prognosis of cancer patients. However, only a subset of patients benefits from the use of specific drugs, and the development of resistance often results in clinical treatment failure. The identification of novel targets is a challenging task for the medical oncologist, and valuable prognostic markers might become potential therapeutic targets in the future. The trasmembrane tyrosine kinase receptor c-Met plays a vital role in cell survival, growth and metastasis . c-Met iOriginally, Iressa, a selective EGFR inhibitor, showed promising results among Asian patients, but not in Western populations, suggesting a possible role of ethnic differences between Asian and Western lung cancer patients . The difP < 0.0001) in lymph node negative breast cancer. These results demonstrate that c-Met might act at the early stages of breast cancer, and its expression should be detected on postoperative pathology to predict prognosis and guide the postoperative treatment.Lymph node status is the best indicator of prognosis in breast cancer. Additional makers are necessary to predict prognosis in patients with lymph node negative breast cancer. C-Met expression is higher and more frequently positive in metastatic lymph nodes than in the primary tumor . In the P = 0.005) in the hormone-receptor positive group. Endocrine therapy is the most important systemic treatment for hormone-receptor positive breast cancer at all stages [Breast cancer is divided into five molecular subtypes based on the status of ER, PR, HER-2 and Ki67 . In the l stages . C-Met al stages , 47. Ovel stages . Zagouril stages . In addil stages . ConsequP = 0.20). Additionally, Minuti et al. found that c-Met is associated with shorter time to progression (TTP) in HER2-positive metastatic breast cancer [Functional crosstalk of c-Met with HER-2 has been reported to enhance cell invasion in Madin-Darby canine kidney (MDCK) epithelial cells in vitro . In breat cancer . Thus, aP < 0.0001), which was the highest risk in this study. The results indicate that c-Met could be a therapeutic target, thereby providing new treatment options for TNBC.According to currently available data, TNBC is the most aggressive subtype of breast cancer, and no targeted therapy is currently available . TNBC coQuality assessment according to REMARK guidelines was performed for all 21 included studies. The studies fulfilled, on average, 14 items  of the guidelines. Sensitivity and sub-group analyses were performed to ensure that the results were reliable and valid. However, our meta-analysis had several limitations. First, the results of sub-analysis were less powerful because the combined HR of some subgroups was calculated on the basis of 2–5 studies with a relative small patient sample size. Second, c-Met was detected by five different methods, although most studies detected c-Met by IHC (excluding the molecular subtype groups). In addition, there were differences in the criteria for c-Met positivity in IHC detection. Third, the funnel plot analysis showed some asymmetry, suggesting the possibility of publication bias in unselected patients and Western patients. The trim and fill sensitivity analysis did not change the general results, suggesting that the results were not influenced by the unpublished negative studies or the small sample size. Additional high-quality data are necessary to draw more reliable conclusions.Our comprehensive meta-analysis of all published studies showed that c-Met overexpression is significantly associated with poor survival in breast cancer patients, especially in the TNBC subgroup. In Asian patients and HER-2 positive breast carcinomas, c-Met might not be associated with prognosis.


The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome.Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years.p < 0.001).There were 511 MET activations: 389 (76 %) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8 %), concern of medical staff in 121 (31.1 %) and decrease in GCS > 2 in 98 (25.2 %) patients; MET calls for cardiac arrest occurred in 68 patients (17.5 %). The median (IQR) time the team stayed at the scene was 35 (20–50) minutes. At the scene, the most frequent actions were related to airway and ventilation, namely oxygen administration in 145 (37.3 %); in circulation, fluid were administered in 158 (40.6 %); overall medication was administered in 185 (47.5 %) patients. End-of-life decisions were part of the MET actions in 94 (24.1 %) patients. At the end of MET intervention, 73 (18.7 %) patients died at the scene, 190 (60.7 %) stayed on the ward and the remaining 123 patients were transferred to an increased level of care. Crude hospital mortality rate was 4.1 % in the 3 years previously to MET implementation and 3.6 % in the following 3 years  end-of-life decisions made, reinforcing the inclusion of a doctor in the MET. A significant decrease in overall hospital mortality rate was observed after the implementation of the MET.The composition of our MET with an ICU doctor and nurse was reinforced by the need of medical actions in more than half of the situations . After MET implementation there was a significant decrease in hospital mortality. This study reinforces the benefit of implementing an ICU-MET team. The implementation of Medical Emergency Teams (MET) seems to be associated with a reduction in hospital mortality and in-hospital cardiac arrest . TherefoIn 1994 the first national cardiac arrest team was organized in this hospital, by the intensive care unit, already composed by an Intensive care Unit (ICU) doctor and nurse, and it remained like that until 2010 when a MET system was implemented Between 1995 and 2010, the cardiac arrest team was activated 1811 times. Activation for non-cardiac arrest situations steadily increased, reaching 61 % of all calls in the last 3 years (2008–2010) which prompt the readjustment of the cardiac arrest team to a MET  provision to all healthcare professionals. Following this evolution an emphasis on early identification of signs and symptoms of clinical deterioration that should prompt MET activation Fig.  was inclMET is activated by a dedicated phone line in ICUand responds to calls from everywhere in the hospital on a 24/7 basis. Specific resuscitation trolleys that include equipment for resuscitation  and drugs are available on all wards and specific locations around the hospital. The nurse team in each location is responsible for the maintenance of the resuscitation trolleys and the MET is responsible for auditing its maintenance.After activation, the MET performance on site includes patient assessment and emergency treatment, referral to the most appropriate place for continuation of care and in some cases discussions about goals of clinical care which might include end-of-life decisions. Issues such as determining the best composition of the team or the ideal interventions performed by the MET at the scene as well as the immediate outcome for patients after MET intervention have not yet been sufficiently explored .For this reason, the aim of this paper is to characterize MET activations and actions at the scene and the immediate patient outcome.Retrospective cohort study, conducted at Hospital Santo António, Centro Hospitalar do Porto, a university-affiliated, tertiary care, 600-bed hospital, in the north of Portugal.Demographic and outcome data were obtained from the hospital administrative system. In 2012, a MET database was implemented to allow periodic audits. Data concerning team activations, with special emphasis on MET local clinical actions, was retrieved from this database.All inpatients activations from January 2012 to December 2013 were included in the study.The study was approved by the hospital’s institutional review board, ethics committee (Ref.143/11 – 098DEFI/124CES) and national commission for data protection.During the study period (2 years), there were a total of 511 MET activations: 389 (76 %) were for inpatients and the remaining 122 (24 %) for outpatients .p < 0.001).MET activation rate was 8.6/1,000 inpatients:11.5/1,000 medical inpatients and 6.1/1,000 surgical inpatients (p = 0.16).Most MET calls happened during the night shift (20:01–8:00) with 175 calls (46 %), followed by the morning shift (8:01–14:00) with 116 calls (30 %) and the afternoon period (14:01–20:00) with 96 calls (24 %). In two patients, time of activation was not registered. During the study period, there were 506 weekdays, during which 285 MET activations occurred, resulting in 56,3 activations/100 weekdays. The same period contained 225 weekend/holidays days on which 104 MET activations occurred, resulting in 46.2 activations/100 weekend/holidays days  age of 72 (±10.8) years, 224 (58 %) were male and 207 (53 %) were medical. Fifty patients (14 %) had been transferred from high dependency units and six (2 %) from intensive care in the previous 24 h.In Table During activation, the median (IQR) time that the team stayed with the patient was 35 (20–50) minutes.At the scene, the most frequent actions were related to airway and ventilation, namely oxygen administration in 145 (37.3 %) and bag and mask ventilation in 78 cases (20.1 %). For circulation, placement of additional peripheral venous access was performed in 116 (29.8 %) and fluid administration in 158 cases (40.6 %). In 185 (47.5 %) patients, medication was administered and in 136 (35 %) more than one type of medication was given  before MET activation. An additional 94 (24.1 %) DNR orders were made during the MET approach. Of these, 42 (11 %) were decisions to withhold therapy.End-of-life decisions were also part of the MET actions, either as a clinical decision maker or supporter. Of all patients, 20 (5.1 %) had already a DNR order and/or a withhold therapy decision  patients died at the scene  patients, there was not a need to increase the level of care, so they remained on the ward. In 36 (18.9 %) patients, this decision was related to end-of-life decisions. Of these, 33 (91.6 %) were implemented by MET.n = 204).In the group of patients alive at the end of MET intervention, 182 were alive at the time of hospital discharge Fig. . In thisOver the 2 years of the study period, 1,441 inpatients died in hospital and MET was activated for 204 (8.6 %) of these.n = 114), 23 were alive at hospital discharge (15 had a withhold therapy decision and eight a DNR order).Among the group of patients with end-of-life decisions (n = 68) had a hospital mortality rate of 88 % (n = 60); of these 28 (41.1 %) had an end-of-life decision (5 previously and 23 during MET intervention).Patients for whom MET activation was due to cardiopulmonary arrest (p < 0.001).Mean hospital mortality rate in the three years previously to MET implementation (2008–2010) was 4.1 % and in the following three years 3.6 % (2011–2013), The main goal of this study was to describe and analyze MET actions during activation and the immediate patient outcome.During the study period, the MET activation rate was 8.6/1,000 inpatients, which is similar to what has been described in other studies , 6. The Fifty patients (14 %) had been transferred from HDU and six (2 %) from ICU during the previous 24 h, indicating some kind of severity of acute disease. The activation of MET in the following 24 h might reflect an abrupt downgrade of clinical care. This data also prompts the respective clinical teams to pay more attention to the presence of firm criteria of discharge.On the other hand, the fact that the vast majority of patients who needed an upgrade in clinical care had to wait in the emergency room due to a lack of available beds indicates an insufficient number of beds for differentiated clinical care. Most of the time, the occupation rates of our HDU and ICU are above 90 %, meaning that the need for a new admission frequently prompts an early discharge. This lack of differentiated clinical care beds may not be absolute and reflect the difficulty to discharge patients to the appropriated wards.Portugal is in the lower range of high dependency and intensive care unit (HDU-ICU) beds /100.000 population among many other countries like the UK, Ireland, Sweden, Netherlands, Greece, Finland among others (between 4.2 and 6.7/100.000) and similar to South Africa, China and New Zealand, which might explain the urge in downgrading patients. Despite that, our activation rate was similar to that reported by hospitals from countries with higher (the USA) and lower (Sweden) number of HDU-ICU beds number suggesting that our reality has external application, specially to these other countries if the structure of acute care is similar .Cardiac arrest was the fifth cause for MET activation (in less than 18 % of cases), which nonetheless represents a significant number of patients. Bellomo , 8, 12 dThe team stayed on site for half an hour, similar to what was described in the Konrad study , but lonEnd-of-life decisions were made in 24 % of the patients, a higher proportion than the one described by Maharaj . MET actMore than a third of the patients who survived, stayed on the same ward. Of these, only 19 % had end-of-life decisions, reinforcing that early recognition and intervention solve an important proportion of cases, thus avoiding an upgrade of care or unplanned ICU admissions and improving patient outcome , 12. AmoA significant decrease in overall hospital mortality rate was observed after the implementation of the MET.This is a single center study with a limited number of patients included in it. It was performed at a tertiary care university-affiliated hospital and therefore the findings and suggestions may not be applicable to other realities. Nevertheless, the share of facts from different clinical realities and countries is what allows the development of worldwide recommendations, and our local suggestions could be applied to similar clinical settings around the world.Time to reach the location of the call might play a role in the outcome, but unfortunately only three random measures were taken. The target is to reach the location of the call in less than 2 min and a systematic audit is planned to determine if the team reaches the place in less than two minutes in all cases and if not what is the impact of time to scene in patient outcome.The composition of our MET with an ICU doctor and nurse was reinforced by the need of medical actions in more than half of the situations . The MET team common with the emergency room team made it easier to deal with the lack of available HDU or ICU beds while still maintaining the same level of care.Given these results, it can be assumed that our hospital’s MET model allows a prompt attendance, assessment and adequate treatment of the deteriorating patient on the ward, thus preventing unplanned ICU admissions and improving patient outcome, with a significant decrease in hospital mortality observed after its implementation.Reinforcement in the hospital’s educational program is needed to improve the objectivity of MET calls.


The aim of the study is to evaluate the effect of Drug Rational Usage Guidelines System DRUGS) were selected and their demographic and clinical data were collected. The selected operations include thyroid resection, breast mass resection, myomectomy, etc. The evaluation criteria were antibiotic administrative categories, the time of initial dose, duration of administration, length of stay, the costs of antibiotics, SSIs and drug adverse reactions(ADR).10 common surgical operations which included 1543 cases (where 778 cases using paper-based guidelines and 765 cases using DRUGS and 256 (32.90%) with paper-based guidelines according to the protocol. For the clean wounds incision, 547 patients (91.62%) were within 24 h of withdrawal antibiotics with using paper-based guidelines versus 91 (14.79%) with using DRUGS. A total of 19 kinds of antibiotics were used in the 1543 cases. The leading three on the list of frequency were piperacillin and sulbactam sodium, cefathiamidine and cefoperazone. While after the intervention, the list of frequency changed to cefazolin, cefathiamidine, cefoperazone. The average hospital stay was (7.00±4.31)d with paper-based guidelines and (2.54±1.57)d with DRUGS, respectively. The average cost of antibiotics was ¥(3481.36±2584.46) with paper-based guidelines and ¥(1693.39±1478.27) with DRUGS, respectively. However, there were no significant differences in the incidence of SSIs and ADR between two groups.The antimicrobial agents were mostly administrated within 0.5 h to 2 h before incision, 656 patients (85.75%) were intervened with DRUGS, was associated with an enhanced surgeon adherence to guidelines.In this study, the increased availability of antibiotic guidelines at the time of drug ordering, combined with  Surgical site infections (SSIs) account for approximately 15% of nosocomial infections and are associated with prolonged hospital stays and increased cost In recent decades, guidelines have been developed to promote a rational use of SAP DRUGS) was designed by the Fourth Military Medical University and Beijing TYT software technology Co, Ltd (http://www.tytsoft.com.cn/). Specialists on the field of medication and healthcare management would be organized to establish databases involving all aspects of rational drug use guidelines according to the national or international newest guideline in antimicrobial prophylaxis use in surgery In Xijing hospital, Drugs Rational Usage Guideline System . First-generation cephalosporins are generally recommended for prophylaxis; Class II/Clean-contaminated wounds, a surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs. Since these technique such as percutaneous endoscopic gastrostomy (PEG), laparoscopic cholecystectomy(LC) and endoscopic retrograde cholangiopancreatography(ERCP) were already employed in the surgery of the abdominal cavity organs, and the wounds incision were mainly infected with the gram-negative Enterobacteriaceae the first or second generation cephalosporins is recommended to inhibit the infection. S aureus was responsible for more SSIs than any other microorganism. The first generation of cephalosporins are effective against S. aureus,have narrower spectrum of antibacterial activity, are safe and not so expensive as well. Therefore, these agents are preferred to most surgical procedures. According to the requisition of special actions of antimicrobial agents launched by the Ministry of Health of China in 2013 cefazolin was recommended as antimicrobial prophylaxis for Class I/Clean wounds incision and cefuroxime for Class II/Clean-contaminated wounds, and lincomycin or aztreonam was the alternatives for patients allergic to cephalosporin.Most of Class I/Clean wounds incision is an uninfected surgical wound in which no inflammation is encountered, which infection pathogen is 1/2) data. Optimal time to give an antibiotic is 0.5–2 hour before incision. and optimal duration remains as an area of discussion. For many surgical procedures, a single dose is adequate to prosthetic device. As part of the development of the computerized order entry system of the hospital, DRUGS was integrated into the antibiotic order entry. At the beginning of surgical antimicrobial prophylaxis, in order to improve surgeon adherence to antibiotic guidelines, an intervention was decided by the Pharmacy and Therapeutics Committee(PTC)and received consensus from all the head of the surgical department before being implemented in our hospital. The study was approved by the institutional Ethics Committee for the use of humans in research of Xijing hospital(NO. LL-2012-026) and obtained their written informed consent where this the consent procedure were approved by ethics committees. The intervention was embedding the guidelines in the computerized physician order entry system of the hospital so that they were available online to the prescriber at the time of antibiotic ordering. Additionally, reinforcement was performed by the pharmacy department every 3-month period through an educational round with newly arrived physicians in the hospital. Although there was,no clinical pharmacist in the wards.For the purpose of prophylaxis, and inoculums is minimal/none, antibiotics are administrated only for the duration of surgical procedure. If no infection exists, prophylaxis is preferred to surgery single dose. If the procedures last more than 3 hours, readministration is recommended when the antibiotic has a relatively short half-life. For example in prolonged procedures, an additional intraoperative dose of cefazolin should be given at 3 hours based on serum half-life  of the possible infection, and data of the related antibiotic order .The information and data of inpatients were collected through DRUGS (computerized guidelines).All the cases of antibiotic prophylaxis of the 10 surgical operations mentioned above were supervised and their data were recorded during the hospital stay. There were totally 1543 cases, including 778 episodes of surgical operations followed the paper-based guidelines, and 765 adhered to Conformity of antibiotic orders to guidelines, reflecting surgeon adherence, was evaluated independently by the members of the antibiotic clinical therapeutics and supervision group according to the guideline for prophylaxis use of antibiotics:the choice of antibiotic categories;the time of initial dose of antibiotic;the duration of administration.For pharmacoeconomics, 10 cases were evaluated independently by two members of the PTC according to the following criteria:the length of stay;the costs of antimicrobial agents;surgical site infections and drug adverse reactions.Those antibiotic regimens with discordant evaluations between the reviewers were discussed to reach an agreement.2) test was used for categorical variables including the time of the initial dose of antimicrobial agent, the disposition and kinds of SSIs. The student's t test was applied to analyze the continuous variables including the duration of administration in each surgical department, average cost and hospitalization days in DRUGS and paper-based guidelines.  Statistical analyses were performed by SPSS17.0 for Windows . Two-tailed P<0.05 was considered statistically different.The chi-square  was 1.10 and 1.24, respectively. More than one episode of surgical operations occurred in 60 patients All information was obtained from five clinical departments, including Department of orthopedics (717cases), general surgery (265 cases), liver and gall (139 cases), stomach intestine surgery (159 cases), gynaecology and obstetrics (263 cases). The disposition and kinds of DRUGS and 256 cases (32.90%) with paper-based guidelines, which showed that the time of the initial dose of antimicrobial agent changed significantly by χ2 test (P<0.05). Furthermore, the dose used in DRUGS group (92.94%) was significantly higher than the paper-based guidelines group (87.40%) in the pre-operation. There was also significantly different in the time of the initial dose of antimicrobial agent among the three stages of operation (P<0.05).To prevent surgical site infection, antimicrobial agents were mostly administrated within 30 min and 2 h before incision. There were 656 patients (85.75%) intervened with P<0.05) by t-test (or t'-test).The time of antibiotic prophylaxis was shown in  t'-test). The numDRUGS, respectively. The changes of average cost and hospitalization days are shown in A total of 19 kinds of antibiotics were involved in this study, the leading three places on the list of frequency were piperacillin and sulbactam sodium, cefathiamidine, and cefoperazone, while after post-intervention, the list of frequency changed to cefazolin, cefathiamidine and cefoperazone. Compared to the paper-based guidelines, the intervention was followed by a significant increase in the proportion of cefazolin, 89.71% DRUGS vs. 15.43% (P<0.05). The average hospital stay was significantly decreased, and the average cost of antimicrobial agents after the intervention decreased significantly (P<0.05). The average cost of antibiotics was ¥(3481.36±2584.46) with paper-based guidelines and ¥(1693.39±1478.27) with DRUGS. The physicians' adherence rate to the surgical antibiotic prophylaxis was significantly increased 11.18%(87/778) with the paper-based guidelines versus 69.93%(535/765) with DRUGS (P<0.01).Totally, 1543 surgical operations were recorded in this study, where 778 followed the paper-based guidelines and 765 followed SSIs are common risks in surgical procedure. Therefore, prophylactic antibiotics was still used in the post-operative to reduce the risk of SSIs DRUGS, respectively.In the proceeding of diagnose and treatment, drugs for patients are not prescribed on the basis of treatment guidelines and the individual situation, but on their randomized self-experiences, even on the amount of rebates from pharmaceutical companies, which were the major reasons that led to overly expensive medical service in China. It was very common that the cost of treatment for the same disease in differed several times or in different hospitals. One patient in Beijing saw the doctors in four hospitals with the same medical complaint DRUGS inserted into the Computerized Physician Order Entry System. When the clinicians prescribe on the computer, the pop-up box will remind and assist them using antibiotics rationally.To promote clinicians' adherence to the guidelines, we distributed them in booklet form in all the wards of our hospital. However, this way of dissemination does not ensure that information will be read and considered by the clinicians. Grimshaw and Russel DRUGS system improved the rate of the surgeons' adherence to the antibiotic guidelines during prevention from SSI. In the period using paper-based guidelines, only 15.43% of patients were prescribed antibiotic categories and 32.9% of patients were administrated according to time course recommended by the guidelines during antibiotic prophylaxis of surgical operations. It was reported that the most predictable impact was achieved when the guidelines are made available through computer-based reminders that are integrated into the clinician's workflow and provide therapeutic information to prescribers ‘just-in-time’ to influence the decision at the time of clinical decision DRUGS also showed exciting results 89.71% and 85.75% of the patients were reasonably administrated antibiotic prophylaxis of surgical operations in the choice of antibiotic categories and the time of administration, which was much higher than those of the group with paper-based guidelines.Inappropriate prophylaxis would slow recovery, prolong hospital stay, increase antibiotic resistance and costs of antimicrobial agents, and so on. In this study, we investigated whether the DRUGS, the guidelines effect on the gynaecology and obstetrics department appeared to be relatively sustained in the later period. It still keeps longer duration of administration than other department in the antibiotic orders. This might be due to the low adherence rate of physicians of gynaecology and obstetrics than other.In addition to the global improvement of surgeons' adherence to guidelines associated with the The increased availability of antibiotic guidelines at the time of prescription, combined with a periodical reinforcement educational round, was associated with an enhanced adherence of surgeons to the guidelines. Therefore, compulsory training courses on the infection declaration process and the computerized antibiotic guidelines have been performing every three month by the pharmacy department and infection control unit to the newly recruited doctors in our hospital, which will assist them to use DRUGS system fully and prescribing reasonably.DRUGS system for improving descriptions of antibiotics reasonably.Another recommended method to improve the quality of clinical pharmacists to antibiotic prescribing DRUGS system only involves several specific diseases/operations.In order to minimize the potential bias of current research,we will investigation and validation with more diseases/operations in further study. Secondly, because of the lack of enough experience and education for the pharmacists, it may have prevented the detection of more interventions. Therefore, a longer training period for the researcher might have produced better results. Thirdly, the patients in this study were mainly came from urban area in Xi'an city .So, there may be a lack of statistical power to represent more significant differences for patients in other areas. Thus, to generalize the results, larger sample sizes and wider areas would be needed. Finally, the limited number of cases in some kinds of operations may also impact the reliability of the conclusion of this study, such as thyroid resection only has 100 participants, 53 for PBG and 47 for DRUGS.There were several limitations in our study. Firstly, the DRUGS, which was applicable to hospitals in China providing with such an information technology. As shown by the results obtained in this study, it remains, however, that additional reinforcing interventions, such as immediate concurrent feedback by hospital pharmacists, appear to be necessary for further enhancing appropriateness of antibiotic prescribing.In conclusion, we developed a system embedding clinical practice guidelines in a computerized surgeon order entry system,


IgG4-related disease is recognized as one form of autoimmune pancreatitis. During the last ten years, it has also been described in several other organs. We present two patients with lesions showing a histological picture of fibrosis and lymphoplasmacytic infiltrations with abundant IgG4 positive plasma cells at hitherto unreported symmetrical nasal locations. The symmetrical complex consisted of one central lesion in the anterior nasal septum and the two others in each of the lateral nasal walls. The lesions extended from the anterior part of the inferior concha into the vestibulum and caused severe nasal obstruction. IgG4-related disease was first associated with autoimmune pancreatitis. In 2003, it was recognized as a systemic condition  and lesiA 34-year-old healthy Caucasian male complained of progressive nasal obstruction for several years. Clinically there was a severe narrowing of the nasal inlet due to three tumors in the soft tissue. One was located in the anterior part of the nasal septum; the other two were symmetrically located in both lateral nasal walls. The bulk of the lesions were in the vestibulum. A CT scan showed a thickening of the soft tissues at the nasal inlet without erosion of bony structures. The sinuses were clear. The tumors were removed surgically. At the first examination (2009) we were not aware of IgG4-related disease. The patient had no other respiratory symptoms or signs. Three years later there was a recurrence of all lesions dorsally involving the inferior conchae. The pseudotumors were resected relieving the obstruction. Serum IgG4 level was 1.630 g/L . The haematological values and the other serum IgG subclasses were within normal limits. The histology was identical to case number 2. During the ensuing nine months there has been no apparent recurrence of the manifestations.A 34-year-old woman originally from Sri Lanka complained of increasing nasal obstruction for two years. There was no history of trauma, infection, or surgery. Clinically, the soft tissues of the caudal end of the nasal septum, the inferior conchae, and the vestibuli were enlarged in size and created a swelling on the external nasal wall . A CT scThe biopsies from both patients showed the same histological features. The greater part of the tissue was fibrous with few cells . The patThe diagnosis of IgG4-related disease is based on histology. The “Consensus Statement on the Pathology of IgG4-Related Disease” . Case 1 IgG4-related pseudotumors have been reported in the nose and the sinuses. One was located in a maxillary sinus causing destruction of the bony sinus wall  and anotIgG4-related autoimmune pancreatitis and Mikulicz disease have been associated with chronic rhinosinusitis (10 out of 31 patients) . There wNasal crusting and nasal obstruction were found in 10 of 23 patients with IgG4-related disease in other organs [IgG4 has been implicated in nasal disease. An increase in the number of IgG4 positive plasma cells without fibrosis or phlebitis has been found in the nasal mucosa in chronic rhinosinusitis both with and without IgG4-related disease in other organs. This increase, however, was not consistently present in the patients with nasal symptoms. Histology did not distinguish between rhinosinusitis with and rhinosinusitis without an increased concentration of IgG4 positive plasma cells. This is in strong contrast to the IgG4-related pseudotumors which exhibit specific histologic findings. Our patients had pseudotumors with characteristic criteria but no signs of allergy or chronic rhinosinusitis. The disease manifested itself with tumors arranged in a symmetrical pattern which resulted in nasal obstruction at a relatively early age.These findings highlight the need for otorhinolaryngologists to be aware of the symmetrical nasal manifestations of IgG4-related pseudotumors. Given that the lesions recurred within three years in the first patient, surgery may not be the only therapeutic solution. One should be prepared to provide corticosteroids, particularly if the lesions recur.


Urinary tract infections (UTI) are among the most frequently acquired infections in the community, but also in hospitals and other health care institutions, causing a huge amount of antibiotic consumption. During the last decade we have seen significant changes in the field of urinary tract infections regarding causative pathogens and antibiotic treatment calling for an update of current trends.The worldwide increase of uropathogens resistant to former first line antibiotics, such as cotrimoxazole, fluoroquinolones and cephalosporins, has had detrimental consequences not only for treatment but also for prophylaxis of infectious complications after urological interventions. A paradigm shift concerning asymptomatic bacteriuria has had a great impact on the definition and management of UTIs today ,2,3,4.For uncomplicated lower UTI, such as acute cystitis in otherwise healthy women, not only a revival of old  antibiotics, such as fosfomycin trometamol, pivmecillinam, nitrofurantoin, can be observed in many guidelines ,6,7, butHowever, for complicated, nosocomial and severe UTI including pyelonephritis, antibiotic therapy will still be a corner stone in combination with treatment of the underlying complicating conditions. Unfortunately, there are few new antimicrobial drugs in the pipelines of pharmaceutical companies with prospects to overcome the problem of multi and extended drug resistant uropathogens .Although the classical distinction between uncomplicated and complicated UTI is still valid in principle, the different criteria to be considered are so heterogeneous, that a better  subclassification might be helpful, as proposed by the European Section of Infection of Urology (ESIU) of the European Association of Urology (EAU) .In consideration of so many new aspects related to optimal management of UTI, it has been our pleasure to edit a joint presentation of the results from different research groups in one special scientific publication challenging established as well as new scientific approaches to improve prophylaxis and treatment of patients suffering from UTI.


The arithmetic mean was 49 γ s−1 for measurements taken without a collimator. The average gamma flux inside the Lab was 0.25 γ cm−2 s−1. The sedimentary rocks surrounding the Lab are characterized by low activity concentrations of uranium and thorium, equal to 1.7 and 1.4 Bq kg−1, respectively.In situ gamma-ray measurements were taken at eight locations in the Gran Sasso National Laboratory . Count rates for gamma radiation within the energy range of 7–2,734 keV varied from 8 to 60 γ s The measurements were done at the Laboratory of Natural Radioactivity .Samples of dolomitic limestone and concrete from measurement locations 7 and 8 were crushed and dried, and several months after collection they were placed in a Marinelli beaker with volume 450 cm−1) at all measurement locations are listed in Table −2 s−1 from locations 3, 5, 7, and 8 are provided in Table The count rates γ s− at all m−1 at location 8 to ~60.1 γ s−1 at location 4 , the highest total gamma flux, 0.384 γ cm214Pb), and then under the peaks at 609.3 keV (214Bi) and 1,460.8 keV (40K)  and 2,614.5 keV (208Tl), are characterized by reduced areas compared with lines 351.9, 609.3, and 1,460.8 keV. The gamma transition of 2,204.2 keV from 214Bi (238U) is characterized by the lowest count rates, ranging from 0.022 γ s−1 at location 1 to 0.042 γ s−1 at location 4 (measurements without a collimator), and from 0.004 γ s−1 at location 8 to 0.012 γ s−1 at location 7 (measurements with a collimator). Despite the low yield (1.28 %) of the 2,204.2 keV transition [The highest integral areas from the main gamma transitions were noted under the peak at 351.9 keV  are on the order of 10−1 and the concentrations in 10−6 g g−1 of 40K and 232Th in concrete are about three times higher than those in dolomitic limestone. The concentration of 238U is about five times higher in concrete than in dolomitic limestone. Activity concentrations of 40K, 232Th, and 238U equal to 70, 8, and 25 Bq kg−1, respectively, have been noted in typical carbonate rocks, and concentrations equal to 89, 8.5, and 31 Bq kg−1, respectively, have been noted in limestone concretes [40K and 232Th that are clearly below the levels observed for typical carbonate rocks and limestone concrete. The 40K concentrations are roughly comparable, but the 40K activity in the dolomite limestone at location 8 is still three times lower than the activity for typical carbonate rocks.The results of the activity measurements for dolomitic limestone and concrete collected from locations 7 and 8 are provided in Table oncretes . Both th−1 in the energy range of 7.4–2,734.2 keV. Gamma fluxes were obtained from four locations for parent rock and concrete. The gamma flux for the parent rock was 0.151 γ cm−2 s−1, and the flux values for the concrete varied between 0.230 and 0.384 γ cm−2 s−1. The average value for both the parent rock and concrete was 0.249 γ cm−2 s−1. Samples of both dolomite limestone and concrete showed low activity concentrations of 40K, 232Th, and 238U, which are below the activity concentrations of these primordial radionuclides as noted in typical carbonate rocks and limestone concrete.The average measured gamma background in LNGS was 49 γ s


Aims. Inhibitors of the MET pathway hold promise in the treatment for metastatic kidney cancer. Assessment of predictive biomarkers may be necessary for appropriate patient selection. Understanding MET expression in metastases and the correlation to the primary site is important, as distant tissue is not always available. Methods and Results. MET immunofluorescence was performed using automated quantitative analysis and a tissue microarray containing matched nephrectomy and distant metastatic sites from 34 patients with clear cell renal cell carcinoma. Correlations between MET expressions in matched primary and metastatic sites and the extent of heterogeneity were calculated. The mean expression of MET was not significantly different between primary tumors when compared to metastases (P = 0.1). MET expression weakly correlated between primary and matched metastatic sites (R = 0.5) and a number of cases exhibited very high levels of discordance between these tumors. Heterogeneity within nephrectomy specimens compared to the paired metastatic tissues was not significantly different (P = 0.39). Conclusions. We found that MET expression is not significantly different in primary tumors than metastatic sites and only weakly correlates between matched sites. Moderate concordance of MET expression and significant expression heterogeneity may be a barrier to the development of predictive biomarkers using MET targeting agents. Small molecule tyrosine kinase inhibitors of the vascular endothelial growth factor receptors have been widely used as a standard of care for metastatic renal cell carcinoma (RCC) since FDA approval of the multiprotein kinase inhibitors, sunitinib, and sorafenib in early 2006 –3. Since In vitro studies have demonstrated that with VHL loss, activation of the MET pathway drives a more invasive phenotype [The MET pathway is constitutively phosphorylated/activated with loss of the VHL protein , a featuhenotype . Moreovehenotype . MET mig In vitro targeted inhibition of MET in ccRCC cell lines, in which its expression is upregulated, decreases proliferation and colony formation [Limited data exists on the relationship of MET expression and prognosis in ccRCC. Clear cell renal tumors can have wide variability in MET expression. However, those with increased protein and mRNA levels have more aggressive pathologic characteristics and worse prognosis –13. In vormation , providiMultiple therapeutic strategies have been developed to block the MET pathway including several small molecule inhibitors and antibodies . MET patIn the era of targeted therapy, response may be dictated on whether the actual therapeutic target is present in the cancer cell. Therefore, the presence of an upregulated, overexpressed, or mutated pathway may serve as a useful predictive biomarker. Adaptive biomarker trials have become more common in recent years as clinicians have tried to match patients with an appropriate therapy. Previous studies have shown that MET expression in clear cell RCC can be variable , somethiWith Institutional Review Board approval (HIC #9505008219/2014), we reviewed charts of patients treated at Yale University between 1972 and 2011. A TMA was created from a cohort of thirty-four patients and all patients had matched nephrectomy and metastasectomy specimens. Patient and tumor characteristics and other clinical information have been described previously , 18. BriTMA slides were deparaffinized and processed for antigen-retrieval. Endogenous peroxidase activity was blocked before overnight incubation with MET4, a mouse anti-c-Met antibody . This antibody was validated and utilized in a previous study . Anti-moHigh-resolution (1024 × 1024 pixels) images were obtained of each histospot as previously described . In brie t and chi-squared testing. For heterogeneity assessment between cases, a composite median absolute deviation (MAD) score was generated for each tumor site by patient and compared using a Wilcoxon paired, two-sided rank test, as previously described [JMP 5.0 software was used for analysis . Associations between continuous AQUA scores and clinical/pathological parameters were assessed by analysis of variance. Correlations between the AQUA scores of matched primary and metastatic histospots were calculated paired sampleescribed .To compare MET expression in primary and metastatic RCC tumors and evaluate expression heterogeneity, MET expression was quantitatively assessed on a custom TMA previously described , 18. BriR = 0.92).As was previously reported, MET staining was predominantly cytoplasmic . To asse t-test, we confirmed this association in this small cohort of predominantly clear cell RCC cases. As shown in  P = 0.019). For the mixed histology cases, no significant differences were seen between MET expression in tissue with sarcomatoid features and tissue without.Using a larger RCC TMA we previously demonstrated an association between MET expression and Fuhrman grade . By usin t-test. The mean expression of MET in primary tumors  was not significantly different when compared to their metastatic counterparts . While some cases had a low level of discordance, a number of cases exhibited very high levels of discordance. One such example is shown in χ2 P = 0.375).Seeing that archival primary RCC tissue is often more readily available to determine patient eligibility for targeted therapy, we studied the correlation of MET expression between primary sites and paired metastatic tissues using the Pearson correlation test. As shown in P = 0.39).To estimate the degree of heterogeneity of MET expression in primary and metastatic sites, we used the scores from the four cores for each tumor and determined the median absolute deviation (MAD). As seen in NCT01865747 and CABOSUN, NCT01835158) evaluate XL184 in patients with clear cell RCC, both of which require tissue submission from either the primary tumor or a site of metastasis for retrospective correlative biomarker analysis. As many patients have had a prior nephrectomy, this tissue is more readily available for study than a distant site, which is generally assessed with a small core biopsy. With increasing recognition of tumor clonality in kidney cancer, it is necessary to understand if the correlative biomarker analyses should be performed on tissue that represents the metastatic disease. Our data indicate that expression of MET in primary sites does not necessarily correlate with expression at distant sites. While studies have investigated MET expression in the primary clear cell RCC [With multiple agents now available in the current era of kidney cancer treatment, selection and sequencing is becoming a challenge for clinicians. In order to investigate predictive biomarkers of clinical response, many trials involving targeted agents have incorporated access to resected tissue into the trial eligibility. Two ongoing trials .While there are multiple commercially available MET antibodies, many have been reported to have insufficient sensitivity and specificity for biomarker analysis . The antP = 0.019). This result supports work from our group and Choi et al. demonstrating tumors with increased MET expression are associated with higher grade and stage disease [Limited data exists to demonstrate a correlation between increased MET expression and aggressive pathologic characteristics or/and worse prognosis in RCC. Similar to previous studies, we found that high grade tumors have a greater degree of MET expression . Based on these findings, caution should be used when interpreting correlation of systemic response to MET therapy if MET expression was generally obtained from tissue from the primary tumor.When treating systemic disease with molecular targeted therapy, one would hope the target is highly expressed outside the primary tumor and that the degree of expression would predict response. Our data is the first to evaluate MET expression in sites of distant RCC. We demonstrated that MET expression was not significantly different in metastases when compared to primary sites. For trials involving MET inhibitors, correlative biomarkers are planned on the available tissue, which has generally been submitted from the nephrectomy specimen. While there has been renewed interest in neoadjuvant approaches in locally advanced tumors , the majTumor heterogeneity is a concern for any biomarker that may affect treatment, particularly, if the biomarker is to be assessed using tissue from core needle biopsies, which are similar in diameter to our TMA histospots. While the primary tumors often had more MET expression heterogeneity, overall there was no significant difference between sites. We found that MET expression heterogeneity was occasionally high in both the primary tumor and metastatic sites. This raises some concern that sampling expression on limited amount of tissue such as a small core biopsy of either the primary or a distant site may not represent the biology of the majority of the tumor.Our findings represent the first effort to characterize MET expression patterns in primary and metastatic clear cell RCC. The strengths of this study involve our unique TMA design of matched sites of disease and a novel method of quantitative immunohistochemistry (AQUA). Limitations include the relatively small number of samples, the use of various sites of metastatic disease, and our inability to study pMET in this cohort.MET is a therapeutic target in clear cell RCC and selective inhibitors are currently in clinical trials. Studies of biomarkers predictive of response are planned in many of these trials with the goal of improving the therapeutic window of these inhibitors. Here we demonstrate a weak positive correlation between MET expressions in matched primary and metastatic sites. Moderate concordance of high and low levels of MET expression and significant expression of heterogeneity may be a barrier to the adoption of tissue biomarkers assessing MET expression. Prospective validation of our findings is warranted, as agents targeting the MET pathway appear promising in this disease.