Gene expression profiling of p53 and c-myc in HTLV-1 positive blood donors in Congo.

OBJECTIVES: The HTLV-1 infection persists for life, remaining as asymptomatic viral reservoirs in most patients, ensuring the chain of transmission, but around 4% develop adult T-cell leukemia/lymphoma (ATLL). HTLV-1 is an oncogenic retrovirus that transforms CD4+ T lymphocytes and deregulates the lymphoproliferative pathways that contribute to the development of ATLL. To achieve cell transformation, most oncogenic retroviruses use proto-oncogene capture transduction, with proviral integration disrupting the expression of tumor suppressors or proto-oncogenes. THE AIM: We conducted this study on the prevalence of HTLV-1 infection in blood donors to expand the HTLV-1 database, assess the risk of transmission via blood products, as well as evaluate the risk of persistent infection or development of neoplastic diseases in HTLV-1 carriers. MATERIALS AND METHODS: This is a cross-sectional study of blood donors of all categories. For this study, 265 blood donors were recruited at the Centre National de Transfusion Sanguine in Brazzaville. After testing for HTLV-1 antibodies by ELISA, proviral DNA was extracted from all ELISA-positive samples for detection by nested PCR, followed by RT qPCR using specific primers p53 and c-myc for gene expression. RESULTS: 20/265 were positive for anti-HTLV-1 antibody, 5 donors were positive for proviral DNA. The prevalence of HTLV-1 was 1.8%. All HTLV-1-positive donors were male (1.8%), with a positive correlation (p = 0.05); the 1.1% of positive donors were regular, with the majority aged between 31 and 45 years (1.5%), and concubine donors were the most frequent (1.1%). All samples showed normal expression of the p53 and c-myc genes. CONCLUSION: The prevalence, though low, remains a serious problem. No abnormal p53 or c-myc gene expression was detected in HTLV-1-positive donors, which could mean that none of the T lymphocytes in these donors had been transformed by HTLV-1.

Moroccan Women's Attitudes Regarding Pap Smear Test and Adherence to Cervical Cancer Screening.

In Morocco, cervical cancer is the second most common cancer affecting women after breast cancer. Encouraging more women to practice cervical cancer screening remains a major public health concern. There is a lack of data on awareness and of data concerning the determinants of the acceptability of Pap smear test in Morocco. To fill this gap, our study aims to assess the level of awareness of cervical cancer and human papillomavirus (HPV) infection among Moroccan women and to understand the determinants of the acceptability of Pap smear test. We conducted a cross-sectional study including 857 women in the following three Moroccan regions: Casablanca-settat, Marrakech-Safi, and Tanger-Tetouan-Al Hoceima, by using a structured interviewer-administered questionnaire between November 2019 and February 2020. Out of the total sample, 83.9% of participants were aware of cervical cancer, 87.2% of participants were unaware of HPV, and 51.8% of participants were aware of Pap smear test. The rate of women who had ever had a Pap smear test in our population was only 19.36%. Moreover, our study revealed that more than 78% of participants were willing to undergo Pap smear test regularly in the future. The study revealed parity, age, educational level, risk perception, and the belief that early screening improves the chances of successful treatment, as determinants of acceptability of Pap smear test. Our results have shown that there is an urgent need to implement a strategy to sensitize women on the prevention of cervical cancer. Furthermore, the results of this study should be taken into account in the development of strategic and action plans for the prevention of cervical cancer.

Impact of the number of retrieved oocytes on IVF outcomes: oocyte maturation, fertilization, embryo quality and implantation rate.

The process of oocyte retrieval represents a key phase during the cycles of in vitro fertilization (IVF). It involves controlled ovarian stimulation to retrieve the highest number of oocytes possible. According to many previous studies, the higher the number of oocytes the higher the chances of obtaining embryos for multiple transfers. In this study, in total, 1987 patients were retrospectively reviewed to investigate the correlations between the number of retrieved oocytes and the subsequent IVF outcomes. Patients were divided into three groups according to the number of retrieved oocytes (Group 1: ≤5 oocytes; Group 2: 6-15 oocytes; Group 3: ≥15 oocytes). The results showed a significant negative correlation between oocyte number and maturation rate as well as fertilization rate. However, a significant positive correlation was found between oocyte number and the blastulation rate. The implantation rate after fresh embryo transfers was higher in group 2 (6-15 oocytes) compared with group 1 (≤5 oocytes). According to our findings, we conclude that oocyte numbers between 6 and 15 oocytes can result in the highest chances of positive IVF outcomes in terms of embryo quality and fresh embryo transfers with lower risks of ovarian hyperstimulation.

Comparative thermo-stability of two Rift Valley fever virus vaccine candidate CL13T with a recombinant arMP-12ΔNSm21/384.

Rift Valley fever (RVF) is a zoonotic, viral disease, transmitted by mosquitoes, characterized by high mortality rates in young animals. RVF is an endemic and enzootic disease in the Arabian Peninsula and Africa, causing public health and economic instability. Therefore, it is important to develop vaccines to minimize outbreaks and combat the disease. We documented the stability of the thermo-stability of live attenuated RVF CL13T and recombinant arMP-12ΔNSm21/384 vaccine candidates at different temperatures, including these vaccine viruses in liquid and lyophilized form. The study revealed that both CL13T and recombinant arMP-12ΔNSm21/384 strains were stable for more than 18 months at 4°C. We show that at room temperatures (37°C and 45°C) the CL13T was less temperature sensitive than MP-12NSm-del in both lyophilized and liquid form. These findings are useful for the preparation of RVF vaccines that will avoid the need for a cold chain and therefore, will improve the application of the vaccines under field conditions.

Immunological responses and potency of the EG95NC- recombinant sheep vaccine against cystic echinococcosis.

Cystic echinococcosis (CE) is a zoonotic disease caused by the cestode parasite Echinococcus granulosus. The disease has an important impact on human health as well as economic costs including the cost of treatment as well as loss of productivity for the livestock industry. In many parts of the world where the disease is endemic, sheep and other livestock play an important role in the parasite's transmission. A vaccine to protect livestock against CE can be effective in reducing transmission and economic costs of the disease. A recombinant antigen vaccine has been developed against infection with E. granulosus (EG95) which could potentially be used to reduce the level of E. granulosus transmission and decrease the incidence of human infections. Further development of the EG95 recombinant vaccine as a combined product with clostridial vaccine antigens is one potential strategy which could improve application of the hydatid vaccine by providing an indirect economic incentive to livestock owners to vaccinate against CE. In this study we investigated the efficacy of the EG95 recombinant vaccine produced in Morocco by vaccination of sheep, including a combined vaccine incorporating EG95 and clostridia antigens. Vaccination with EG95 either as a monovalent vaccine or combined with clostridia antigens, protected sheep against a challenge infection with E. granulosus eggs and induced a strong, long lasting, and specific antibody response against the EG95 antigen.

Vaccination Against Hydatidosis: Molecular Cloning and Optimal Expression of the EG95NC- Recombinant Antigen in Escherichia coli.

Cystic echinococcosis (CE) is a widely distributed zoonosis that is highly endemic in the Mediterranean basin. The disease represents a serious public health threat and causes economic losses. The parasite life-cycle involves dogs and ruminants as definitive and intermediate hosts; humans are accidently infected, causing serious clinical issues. Vaccination of ruminants and dog treatments represent the most efficient measures to prevent parasite transmission. The recombinant protein vaccine, EG95, has been used successfully in sheep vaccine trials against CE in several countries. In this study, we expressed the modified antigen, EG95NC-GST, in Escherichia coli for use as a vaccine against Echinococcus granulosus in ruminants. We tested three different media formulations for E. coli culture and established for each culture conditions for optimal levels of soluble EG95 expression. The results demonstrate that SOC and TB media provided high yields in cell density and EG95 protein expression. Purification of the recombinant protein with affinity chromatography (using FPLC) was also performed to increase the purity of the EG95NC--GST antigen.

Safety and immunogenecity of a live attenuated Rift Valley fever vaccine (CL13T) in camels.

BACKGROUND: Rift Valley fever is an emerging zoonotic viral disease, enzootic and endemic in Africa and the Arabian Peninsula, which poses a significant threat to both human and animal health. The disease is most severe in ruminants causing abortions in pregnant animals, especially sheep animals and high mortality in young populations. High mortality rates and severe clinical manifestation have also been reported among camel populations in Africa, to attend however none of the currently available live vaccines against RVF have been tested for safety and efficacy in this species. In this study, the safety and efficacy (through a neutralizing antibody response) of the thermostable live attenuated RVF CL13T vaccine were evaluated in camels in two different preliminary experiments involving 16 camels, (that 12 camels and 4 pregnant camels). RESULTS: The study revealed that the CL13T vaccine was safe to use in camels and no abortions or teratogenic effects were observed. The single dose of the vaccine stimulated a strong and long-lasting neutralizing antibody response for up to 12 months. CONCLUSION: The presence of neutralization antibodies is likely to correlate with protection; however protection would need to be confirmed by challenge experiments using the virulent RVF virus.

Investigation of a Possible Link Between Vaccination and the 2010 Sheep Pox Epizootic in Morocco.

Sheep pox is endemic in most parts of Northern Africa and has the potential to cause severe economic problems. Live attenuated vaccines are used in Morocco, and in many other countries, to control the disease. Sheep pox virus (SPPV) re-appeared in 2010 causing a nodular clinical form previously not observed in Morocco. The severe clinical signs observed during the course of this outbreak and initial reports citing similarity in nucleotide sequence between the Moroccan vaccine strain and field isolates warranted a more in depth analysis of this epizootic. In this study, sequence analysis showed that isolates obtained from four provinces of eastern Morocco were identical, demonstrating that a single SPPV strain was responsible for the 2010 epizootic. In addition, the genome fragments sequenced and phylogenetic analyses undertaken as part of this study showed significant differences between field isolates and the Moroccan vaccine strain. New PCR methods were developed to differentiate between wild-type isolates and vaccine strains of SPPV. Using these methods, no trace of wild-type SPPV was found in the vaccine and no evidence was found to suggest that the vaccine strain was causing clinical disease.

PCR-based assay to detect sheeppox virus in ocular, nasal, and rectal swabs from infected Moroccan sheep.

Sheeppox is now enzootic in Morocco. The development of a reliable method for rapid diagnosis of the disease is a central part of any control strategy. The aim of this study is to determine the diagnostic value of a variety of clinical samples such as ovine nasal, ocular or rectal swabs for the detection of sheeppox virus (SPPV) by qualitative conventional polymerase chain reaction (PCR), using a single pair of primers targeting the inverted terminal repeats of the SPPV InS-1 strain, a virulent field isolate. Swab and blood samples were collected from forty animals naturally infected with SPPV who had clinical signs of sheeppox. All animals tested PCR-positive for SPPV. Positive results were obtained infrequently with blood samples, whereas swab samples from at least two sites (nasal, ocular, rectal) were positive per evaluated animal. These results indicate that swab samples are suitable for quantitative molecular SPPV diagnosis. PCR product sequences obtained from all types of sheep samples proved to be identical to the corresponding regions of sheeppox virus strain Romania 65.

Interleukin-32 expression is associated with a poorer prognosis in head and neck squamous cell carcinoma.

Head and neck squamous cell carcinoma (HNSCC) represent the sixth most common malignancy diagnosed worldwide. Patient's survival is low due the high frequency of tumor recurrence. Inflammation promotes carcinogenesis as well as the formation of metastasis. Indeed, proinflammatory mediators are known to stimulate the expression of specific transcription factors such as Snai1 and to increase the ability of tumor cells to migrate into distant organs. The atypical interleukin-32 (IL32) was mainly described to exacerbate inflammatory responses in rheumatoid arthritis and inflammatory bowel diseases. IL32 is expressed in various cancers but its role in HNSCC physiology is still unexplored. Here, we analyzed the expression of IL32 and its implication on HNSCC aggressiveness. We showed that patients with tumor expressing high amounts of IL32 exhibit decreased disease-free periods (20.5 mo vs. 41 mo, P = 0.0041) and overall survival (P = 0.0359) in comparison with individuals with weak IL32 tumor expression. This overexpression was negatively correlated with gender (P = 0.0292) and p53 expression (P = 0.0307). In addition, in vitro data linked IL32 expression to metastasis formation since IL32 inhibition decreased Snai1 expression and tumor cell migration in a Boyden chamber assay. Our data provide new insight into the role of IL32 in HNSCC aggressiveness.

Development and validation of three Capripoxvirus real-time PCRs for parallel testing.

Capripoxviruses have the potential to cause outbreaks with a severe socio-economic impact. The latter, combined with an altered virus dissemination pattern, warrants its status as an important emerging disease. Disease control or eradication programmes can only be applied successfully if the necessary diagnostic tools are available allowing clear and unequivocal identification of the pathogen. Real-time PCR combines high sensitivity/specificity with a reduced analysis time and is thus a proven useful tool for identification of many pathogens, including Capripoxviruses. In order for a real-time PCR to be used in a diagnostic capacity, the different analytical and diagnostic parameters need to be evaluated to assure data quality. The implementation of parallel testing using multiple real-time PCRs with similar characteristics can improve further Capripoxvirus diagnosis. It was therefore the purpose of this study to develop a triplet real-time PCR panel with similar high sensitivity/specificity and provide sufficient validation data regarding the performance characteristics that the panel can be used in parallel, depending on the purpose and local situation.

Control of potato soft rot caused by Pectobacterium carotovorum and Pectobacterium atrosepticum by Moroccan actinobacteria isolates.

Pectobacterium carotovorum and Pectobacterium atrosepticum are dreadful causal agents of potato soft rot. Actually, there are no efficient bactericides used to protect potato against Pectobacterium spp. Biological control using actinobacteria could be an interesting approach to manage this disease. Thus, two hundred actinobacteria isolated from Moroccan habitats were tested for their ability to inhibit in vitro 4 environmental Pectobacterium strains and the two reference strains (P. carotovorum CFBP 5890 and P. atrosepticum CFBP 5889). Eight percent of these isolates were active against at least one of the tested pathogens and only 2% exhibited an antimicrobial activity against all tested Pectobacterium strains. Four bioactive isolates having the greatest pathogen inhibitory capabilities and classified as belonging to the genus Streptomyces species through 16S rDNA analysis were subsequently tested for their ability to reduce in vivo soft rot symptoms on potato slices of Bintje, Yukon Gold, Russet and Norland cultivars caused by the two pathogens P. carotovorum and P. atrosepticum. This test was carried out by using biomass inoculums and culture filtrate of the isolates as treatment. Among these, strain Streptomyces sp. OE7, reduced by 65-94% symptom severity caused by the two pathogens on potato slices. Streptomyces OE7 showed a potential for controlling soft rot on potato slices and could be useful in an integrated control program against potato soft rot pathogens in the objective to reduce treatments with chemical compounds.

Calcium- and ROS-mediated defence responses in BY2 tobacco cells by nonpathogenic Streptomyces sp.

AIMS: The early molecular events underlying the elicitation of plant defence reactions by Gram-positive bacteria are relatively unknown. In plants, calcium and reactive oxygen species are commonly involved as cellular messengers of a wide range of biotic stimuli from pathogenic to symbiotic bacteria. In the present work, we checked whether nonpathogenic Streptomyces sp. strains could induce early signalling events leading to defence responses in BY2 tobacco cell suspensions. METHODS AND RESULTS: We have demonstrated that nonpathogenic Streptomyces sp. OE7 strain induced a cytosolic Ca(2+) increase and a biphasic oxidative burst in the upstream signalling events, leading to defence responses in BY2 tobacco cell suspensions. Streptomyces sp. OE7 also elicited delayed intracellular free scopoletin production and programmed cell death. In agreement with scopoletin production, OE7 induced accumulation of PAL transcripts and increased accumulation of transcripts of EREBP1 and AOX genes that are known to be regulated by the jasmonate/ethylene pathway. Transcript levels of PR1b and NIMIN2α, both salicylic acid pathway-linked genes, were not modified. Moreover, Streptomyces sp. OE7 culture filtrates could reduce Pectobacterium carotovorum- and Pectobacterium atrosepticum-induced death of BY2 cells and soft rot on potato slices. CONCLUSIONS: New insights are thus provided into the interaction mechanisms between Streptomyces sp. and plants; Streptomyces sp. could be sensed by plant cells, and through cytosolic Ca(2+) changes and the generation of reactive oxygen species, defence responses were induced. SIGNIFICANCE AND IMPACT OF THE STUDY: These induced defence responses appeared to participate in attenuating Pectobacterium-induced diseases in plants. Thus, Streptomyces sp. OE7 could be a biocontrol agent against Pectobacterium sp.

Rapid screening and diagnosis of tuberculosis: a real challenge for the mycobacteriologist.

Tuberculosis (TB) is an infectious, devastating and contagious disease, which infects third of the global population worldwide with high rates of incidence in the developing countries, where the health care providers face a serious problem and a real challenge during their clinical practice for controlling and preventing the transmission of this illness. Indeed the first step of control is the correct diagnosis and the initiation of the drug treatment regimen at the early stage of infection, which mandate the rapidity of screening and the accuracy of laboratory testing. In this paper we aim to highlight the different actual techniques, regarding the rapid screening and diagnosis of tuberculosis.

[Hepatitis B prevalence and risk factors in Morocco]. / Prévalence de l'infection par le virus de l'hépatite B et l'évaluation des facteurs de risque au Maroc.

AIM: The aim of this study was to determine the prevalence of hepatitis B and the risk factors in Morocco. STUDY DESIGN: A total number of 16,634 individuals were screened for HBsAg using the Murex HBsAg Version 3 assay and were interviewed using a structured standard questionnaire to collect information about risk factor. RESULTS: Two hundred seventy-six subjects were positive for HBsAg, the prevalence of HBV infection was 1.66%. Using a structured standard questionnaire we reported that sexual behaviours (43.84%) are among the main risk factors for HBV transmission. CONCLUSION: This study indicates that the prevalence of HBsAg in Morocco is currently estimated at 1.66% in the active population. The risk factors for HBV infection identified here indicate that prevention is the most cost-effective method for successfully controlling HBV infection, so vaccination remains the best way to control this infection and its related complications.

Occurance and survival of Vibrio alginolyticus in Tamouda Bay (Morocco).

The objectives of this study were to investigate the spatial and seasonal fluctuations of Vibrio alginolyticus in marine environment of the Tamouda Bay on the Mediterranean coast of Morocco and to determine the dominant factors of the environment that govern these fluctuations. The samples (sea water, plankton, shellfish and sediment) were collected fortnightly for two years from three study sites on the coast Tamouda Bay in northern Morocco. The charge of Vibrio alginolyticus is determined by MPN method. The physicochemical parameters including temperature of sea water, pH, salinity, turbidity and chlorophyll a concentration were determined. Analysis of variance of specific variables and several principal component analyses showed that the temperature of seawater is the major determinant of seasonal distribution of Vibrio alginolyticus. The results showed a positive linear correlation between Vibrio alginolyticus and the water temperature, pH, turbidity and chlorophyll a. Similarly, there are seasonal variations and spatial of Vibrio alginolyticus in marine environment of the Tamouda bay and the highest concentrations were recorded in both years of study during the warm season whereas it was minimal during the cold season. Linear positive correlation was recorded between Vibrio alginolyticus populations in all ecological types of samples studied.

Microbiological impact of treatment lagoons on the economics of water for reuse in agriculture a case study in Morocco (Settat and Soualem regions).

This study was undertaken to enumerate pathogens: fecal coliforms, Escherichia coli, fecal enterococci and Salmonella in the areas irrigated with treated wastewater. The samples were isolated from Settat (33°00'N, 7°37'W) and Soualem regions (34°26'N, 5°53'W). A total of (n= 48) raw water, (n=48) treated water, (n=71) of vegetables samples irrigated by treated water taken from Waste Water Treatment Plant Settat; A total of (n=24) raw water, (n=24) treated water, (n=97) of vegetables samples irrigated by treated water taken from Waste Water Treatment Plant Soualem. The results show the total average in the two stations of raw water 7.9, 6.1 log MPN 100 ml⁻¹ for respectively fecal coliforms and E. coli, 5.4 log CFU 100 ml⁻¹ for fecal enterococci and 5.2 log MPN L⁻¹ for Salmonella; for treated water 4.6, 3.1 log MPN 100 ml⁻¹ for respectively fecal coliforms and E.coli and 3.5 log CFU 100 ml⁻¹ for fecal enterococci. Regarding plants, four types of crops were harvested and analyzed (forage, herbs, cereals and vegetables), the germs charges were found with fecal coliforms, E.coli and fecal enterococci respectively 3.2, 2.8 and 4.1 log CFUg⁻¹. Salmonella was never detected in both treated water and crops samples.

Mycobacterial species as case-study of comparative genome analysis.

The genus Mycobacterium represents more than 120 species including important pathogens of human and cause major public health problems and illnesses. Further, with more than 100 genome sequences from this genus, comparative genome analysis can provide new insights for better understanding the evolutionary events of these species and improving drugs, vaccines, and diagnostics tools for controlling Mycobacterial diseases. In this present study we aim to outline a comparative genome analysis of fourteen Mycobacterial genomes: M. avium subsp. paratuberculosis K­10, M. bovis AF2122/97, M. bovis BCG str. Pasteur 1173P2, M. leprae Br4923, M. marinum M, M. sp. KMS, M. sp. MCS, M. tuberculosis CDC1551, M. tuberculosis F11, M. tuberculosis H37Ra, M. tuberculosis H37Rv, M. tuberculosis KZN 1435 , M. ulcerans Agy99,and M. vanbaalenii PYR­1, For this purpose a comparison has been done based on their length of genomes, GC content, number of genes in different data bases (Genbank, Refseq, and Prodigal). The BLAST matrix of these genomes has been figured to give a lot of information about the similarity between species in a simple scheme. As a result of multiple genome analysis, the pan and core genome have been defined for twelve Mycobacterial species. We have also introduced the genome atlas of the reference strain M. tuberculosis H37Rv which can give a good overview of this genome. And for examining the phylogenetic relationships among these bacteria, a phylogenic tree has been constructed from 16S rRNA gene for tuberculosis and non tuberculosis Mycobacteria to understand the evolutionary events of these species.

Occurrence OF Pectobacterium carotovorum strains isolated from potato soft rot in Morocco.

Pectobacterium carotovorum subsp. carotovorum, Pectobacterium astrosepticum and Pectobacterium chrysanthemi are the soft rot tuber of potatoes pathogens (Solanum tuberosum). The aim of this study was to determine the occurrence of these pathogens in Moroccan regions producing potatoes. Fifty three isolates of Pectobacterium were isolated on medium Crystal Violet Pectate. The comparison of their bacteriological characteristics with standard strains allowed us to conclude that all the isolates belonged to the Pectobacterium. With regard to phenotype characteristics, the variability that was found included 32 typical Pectobacetrium carotovorum subsp. carotovorum, 3 typical Pectobacterium atrosepticum, and 18 atypical Pectobacterium carotovorum subsp. carotovorum. Three strains of the atypical group; showed that the biochemical properties overlap among the Pectobacterium carotovorum and Pectobacterium chrysanthemi. These data were needed molecular characterization. However, the PCR amplification of total genomic DNA of 53 isolates with the two primers Y1/Y2 and P143/P145 yielded an amplified fragment of the expected size (434 bp) only with Y1/Y2, indicated that all the isolates collected and tested belonged to the Pectobacterium carotovorum species. On the basis the pathogenicity tests, these strains revealed that they were pectinolytic, and showed differences in aggressiveness against potato and leaves of tobacco.

EGFR, p16INK4a and E-cadherin immuno-histochemistry and EGFR point mutations analyses in invasive cervical cancer specimens from Moroccan women.

The involvement of human papillomavirus in the development of cervical cancer has been firmly established. However, better management of cervical cancer rests on good diagnosis and an effective therapy. In this study we evaluated the frequency of point mutations in epidermal growth factor receptor (EGFR) for future use of tyrosine kinase inhibitors in clinical treatment and to assess the use of EGFR, p16INK4a and E-cadherin as biomarkers in cervical cancer diagnosis with immunohistochemistry. Fifty-three patient specimens of cervical cancer were analysed for HPV infection, for EGFR mutations in exons 18 through 21, and for expression of EGFR, p16INK4a and E-cadherin by immunostaining. Results showed that 79.24% of the cases (42/53) are HPV positive and the HPV types more closely associated with risk are HPV 16 and 18. In all 53 analysed specimens, any mutation affecting the EGFR kinase domain in exons 18 through 21 was observed. Expressions of EGFR, p16INK4a and E-cadherin were detected in 88,67% (47/53), 92,45% (49/53) and 79,24% (42/53) of analysed specimens respectively. Thus, EGFR, p16INK4a and E-cadherin would be excellent tools for IHC analysis during the cervical cancer development. EGFR and p16INK4a can be used for early diagnosis and E-cadherin for cancer progression and cell migration. However, treatment of cervical cancer with TKIs may not be effective and the identification of other EGFR inhibitors is needed.