Depressive rumination is considered a prominent risk factor for the occurrence, severity, and duration of depressive episodes. A variety of treatment options have been developed to treat depressive rumination of which mindfulness based programs are especially promising. In the current study, we investigated the neural underpinnings of a short mindfulness intervention and mindful emotion regulation in high and low trait ruminators in an ecologically valid environment using functional near-infrared spectroscopy (fNIRS). Participants were randomly assigned to a mindfulness instruction (MT) group or an instructed thinking (IT) group. Participants in the MT group were trained to either focus their attention mindfully on their breath or their emotions, while the IT group focused their attention on the past or future. Afterwards, all participants underwent an emotion regulation paradigm in which they either watched negative or neutral movie clips. During both paradigms cortical hemodynamic changes were assessed by means of fNIRS. Participants in the MT group showed lower activity in the cognitive control network (CCN) during the focus on breath condition in comparison to the focus on emotion condition. Additionally, oxygenated hemoglobin in the MT group tended to be lower than in the IT group. Further, self-reports of emotional distress during the instruction paradigm were reduced in the MT group. During the emotion regulation paradigm, we observed reduced emotional reactivity in terms of emotional distress and avoidance in the MT group in comparison to the IT group. Furthermore, on a neural level, we observed higher CCN activity in the MT group in comparison to the IT group. We did not find any effect of rumination, neither on the intervention nor on the emotion regulation task. The results of this pilot study are discussed in light of the present literature on the neural correlates of mindfulness based interventions in rumination and emphasize the use of fNIRS to track neural changes in situ over the course of therapy. Despite the abundance of readily available treatment options, the prevalence and burden of MDD has not decreased, most probably due to moderate recovery rates and reduced stability of treatment effects2. Between one to two thirds of patients successfully treated with cognitive behavioral therapy (CBT) relapse within two years of initial treatment4. Relapse rates after discontinuation of pharmacotherapy are even higher7. One of the factors that increase the risk for relapse is habitual depressive rumination9, which is often defined as a pessimistic self-referential repetitive thinking style about problems with little or no goal- and change-orientation10. On a conceptual level, rumination lines up with and is correlated to other maladaptive perseverative phenomena such as worry and intrusive thought8. In addition to worsening relapse rates, depressive rumination is associated with further clinical outcomes, such as higher symptom severity, longer duration of depressive episodes and higher risk of suicide15. Further, rumination is associated with cognitive malfunctioning17, reduced emotional wellbeing, emotion dysregulation19, and higher physiological stress parameters20. On a neural level, rumination has been shown to be related to increased activity in areas of the cognitive control network (CCN) and default mode network (DMN) during induction paradigms25, decreased activity in cognitive tasks27 as well as aberrant functional connectivity between these networks29. The CCN is typically involved in tasks that require effortful control and top-down regulation and comprises areas such as the dorsolateral prefrontal cortex and posterior parietal cortex31. In contrast, the DMN involves areas such as the medial prefrontal cortex, posterior midline, precuneus and lateral temporal cortex, and is most active during rest33. With respect to emotion regulation, high trait ruminators show a pattern of decreased prefrontal activity during the downregulation of negative affect in prefrontal areas of cognitive control34 and increased activity in subcortical areas35.Major Depressive Disorder (MDD) is considered a leading contributor to the global burden of disease36, interventions for the acute treatment and relapse prevention have been developed that specifically target processes such as negative self-referentiality including depressive rumination42. With respect to acute treatment, interventions such as Emotion Regulation Therapy (ERT) incorporate techniques from CBT and mindfulness-based intervention to tackle pathological processes such as worrying and rumination. First empirical evidence suggests that ERT is indeed highly effective in reducing pathological self-referential thinking such as worry and rumination and symptoms in generalized anxiety disorder (GAD) and MDD45. Furthermore, a recent study by O’Toole et al.46 showed that ERT-related increase in cognitive reframing (CBT skill) and decentering (mindfulness skill) preceded decreased worry in GAD46. In terms of relapse prevention, a recent meta-analysis suggests that Mindfulness-based Cognitive Therapy (MBCT) decreases the risk for relapse by a hazard-ratio of 0.7 in comparison to active treatment37. In this meta-analysis, participants that received MBCT had an 11% reduced relapse risk as compared to subjects that did not receive MBCT (38% vs. 49%) within 60 weeks. Similarly, findings indicate that Rumination Focused Cognitive Behavioral Therapy as compared to usual care lowers the rate of relapses within a 6 months follow-up (9.5% vs. 53%)38.In light of the increasing evidence indicating how depressive rumination complicates the severity and treatment efficacy of conditions such as MDD50. With respect to neural correlates, it is important to distinguish between studies of advanced meditators and novices as the latter usually activate more areas of the CCN during meditation52. Most likely, this difference is attributable to effects of acquiring and learning the skill of mindfulness in novices, e.g. needing more effortful control to achieve and maintain the meditative state. In general, mindfulness has been associated with activity in brain areas that are involved in emotion regulation , attentional control  and self-awareness . Meta-analytic data on different forms of meditation showed further overlapping activation in the limbic system, basal ganglia and medial prefrontal cortex for different forms of meditation53. In a study on the neural correlates of Mindfulness-Based Stress Reduction (MBSR) in GAD, Hölzel et al.54 showed that an 8-week MBSR program reduced amygdala activation and increased ventrolateral prefrontal activation during an affect labeling task. Further, frontolimbic connectivity increased in the treatment group and changes in activation and functional connectivity were associated with changes in clinical assessments54. These findings were replicated recently in a healthy cohort by Doll et al.55 who found that attention-to-breath mindfulness practice was associated with lateral and medial prefrontal activation and with fronto-limbic coupling during an emotion-regulation task in an fMRI investigation55. Aside from the reported long term intervention studies, first evidence from short-term laboratory manipulations suggests that mindfulness reduces induced negative mood57, as well as perceived stress during social evaluative situations58 and increases attentional control and immune reactivity59.As outlined above, mindfulness—the ability to direct one’s attention to the present moment and cultivate a non-judgmental awareness—is often a component of successful treatment of depressive ruminationThe current pilot study aimed to investigate the neural correlates of mindful emotion regulation in high and low trait ruminators. To this end, we employed the optical imaging method of functional near-infrared spectroscopy (fNIRS) during two paradigms in high and low trait ruminators. By using fNIRS we were able to assess cortical blood oxygenation in an ecologically valid environment, as fNIRS is able to be applied in various body positions  and is relatively subtle in terms of measurement related noises or hardware.In the first phase of the study, 34 high trait ruminators and 33 low trait ruminators were randomized to either a mindfulness (MT) or instructive thinking (IT) group after a baseline assessment. In the mindfulness group, subjects were asked to cultivate either a mindfulness focus on the breath or mindfulness focus on experiences and emotions during 14 trials of 40 s duration. In the instructive thinking group, subjects were asked to direct their attention either to a situation in the past or in the future and think about this situation over and over again during 14 trials of 40 s duration. After each block, subjectively rated success, effort, emotional distress and attentional lapses were assessed. In the second study phase, all subjects completed an emotion regulation task during which subjects watched video clips with neutral and negative valence. After each trial, subjectively rated emotional distress and avoidance were assessed. Furthermore, emotion ratings, state rumination and state decentering were measured over the course of the experiment with questionnaires .Based on our prior work on rumination, we hypothesized that high ruminators would show generally elevated levels (main effect rumination) of state rumination, negative affect, emotional distress and avoidance, as well as higher reactivity following the emotion regulation task in comparison to baseline (interaction rumination*time). Further, as even brief mindfulness trainings have been shown to be effective on short-term emotion regulation, we expected that the mindfulness instruction would decrease the emotional reactivity in general (main effect) and within the high ruminators more strongly than in the low ruminators .2Hb) as measured with fNIRS, we expected that the MT group would show higher CCN activity than the control group, especially during mindful non-judgmental focus (interaction: intervention*condition). We investigated the effect of rumination in an exploratory manner during the instruction paradigm.With respect to cortical oxygenation . For a detailed description of the hypotheses per paradigm and used post-hoc tests see Supplementary Table 61. In total, 193 subjects completed the RRS online questionnaire. High ruminators were defined by an RRS mean score higher than 2.25 (percentile > 65), low ruminators by a score lower than 1.8 (percentile < 34). Cut-off criteria were defined as in previous studies in our group62, based on comparisons between depressed patients and non-clinical controls26 . As expected, low ruminators showed reduced levels in depressive symptomatology  = 22.161, p < 0.001, partial η2 = 0.15), habitual rumination  = 303.709, p < 0.001, partial η2 = 0.83), state rumination  = 18.120, p < 0.001, partial η2 = 0.23), negative affect  = 7.777, p < 0.01, partial η2 = 0.11) and increased levels of baseline measured habitual mindful acting  = 8.552, p < 0.01, partial η2 = 0.12), acceptance  = 38.202, p < 0.001, partial η2 = 0.37) and decentering  ) = 5.292, p < 0.05, partial η2 = 0.08)  or Instructed Thinking (IT). Sociodemographic and clinical characteristics are shown in Table 63, Kentucky Inventory of Mindfulness Skills (KIMS)64, Experiences Questionnaire (EQ)66 in the trait form, the state form of the Positive and Negative Affect Schedule (PANAS)67 and a state rumination questionnaire27. Afterwards, subjects were given written information about the first task of the study: either the MT or IT. After reading the instruction  or future event (condition two: future) and to think about this event over and over again. The IT was designed as a control paradigm to the MT group, as thinking about the future is a non-mindful task (at least in non-meditators). Furthermore, we sought to create a control condition for the MT aside from baseline comparisons.Both of the short interventions were similar in their design. First, subjects were asked if they had any questions about the task. Afterwards, subjects were instructed via audio to close their eyes. A 10 s baseline measurement followed before a peep-tone marked the start of the trial. During the first 10 s of the trial, subjects were instructed about their focus during this trial. Afterwards, subjects performed the task for 30 s. A second peep-tone marked the end of the task, followed by a 6 s inter-trial interval before subjects were instructed to open their eyes again. At the end of each trial, subjects gave ratings on perceived success, effort, emotional distress and attentional shifts during the trial. Subjects performed 14 blocks with randomized ordering of conditions. At the end of the completion of the short intervention, the MT group was instructed to stay in the mindful focus during the following emotion regulation task, while the IT group was left without instruction. We chose not to give specific instructions to the IT group to lower the risk for artificial neural activity (e.g. while subjects are actively trying to not regulate). Therefore, the emotion regulation task measures the mindful emotion regulation in the MT group and the emotional reactance in the IT group.After this first phase of the study, subjects completed state measurements of decentering, negative emotion ratings and state-rumination. In the second study phase, all subjects participated in an emotion regulation task. During the paradigm subjects were asked to watch 28 different movie clips of 20 s length each with strongly negative or neutral valence. During the experiment, movie clips were presented in blocks, each consisting of 7 trials of a given valence. Movie clips were presented in an ABAB and BABA version in randomized order of movie blocks within each version. This procedure was used as some movie clips were in relation to each other, e.g. a suicide scene was cut to be used in 4 clips starting from the beginning of the suicide to the finding of the corpse by the parents of the suicide victim. Each trial consisted of a 10 s baseline followed by a 5 s prompt, instructing which trial would follow (anticipation phase). Next, a 2 s fixation cross was presented before the 20 s video clip started (watching phase). At the end of each clip, subjects rated their emotional distress and their avoidance during the movie clip on a 1  to 9 (very much) Likert-scale. Avoidance was defined as the urge or act of fleeing the situation and withdrawing from the emotional experience. Negative clips included holocaust scenes (movie “The pianist”), suicide (“13 Reasons why”), murder (“American History X”), crying girl (“The fault is in our stars”), a dead baby (“Trainspotting”); neutral clips included informational film clips about sunflowers, gardening, chess, paper plane folding and knitting  with a temporal resolution of 10 Hz. The same probeset placement was used as in previous studies of our group on the CCN in rumination70: Temporal Derivative Distribution Repair (TDDR). Briefly, the method uses an adaptive algorithm to identify and correct sharp high amplitude movement artefacts based on the signal’s amplitude distribution70. Afterwards, we performed the correlation based signal improvement method of Cui et al.72 to reduce low amplitude artefacts that would not be captured by the TDDR. Further, interpolation of single artifact-loaded channels was performed, before data were bandpass filtered (0.1–0.01 Hz). As hemodynamic data might be confounded by global physiological artefacts through respiration, we performed a global signal reduction with a spatial Gaussian kernel filter73 with a standard deviation of σ = 40. Finally, the signal was z-standardized before event-related averages were computed.After the assessment, data was further analyzed using MATLAB R2019a . We used the relatively new motion correction method of Fishburn et al.In the MT and IT instruction paradigm, a 10 s baseline correction in a 70 s window was used. Mean activity was extracted between 10 and 40 s, as auditory instructions were given in the first 10 s of each trial. For data in the emotion regulation task, a 10 s baseline correction in a 32 s window was used for linear detrending. Data were averaged for the anticipation of negative and neutral videos (0–7 s) and the watching of negative and neutral videos (7–27 s).69.Data was averaged in 5 regions of interest (ROI) comprising the superior parietal lobule (SPL), bilateral dlPFC and inferior frontal gyrus (IFG). ROIs were selected according to previous studies on the CCN2(V) = 0.19 for comparisons between two groups (main effect instruction group/rumination) with 4 dependent variables and f2(V) = 0.21 for 5 dependent variables, which are both moderate effect sizes. A within-between interaction needed to have an effect of f(V) = 0.34 for two groups (e.g. instruction group *condition) and f(V) = 0.42 for 4 groups (instruction group *rumination), which are moderate to large effect sizes.Statistical analysis has been conducted with IBM SPSS State Statistics 24. Figures have been created with the ggplot2 package in R. Brain maps have been created with self-written MATLAB routines. Multiple comparisons of post-hoc tests were corrected by the Benjamini–Hochberg procedure. As this study was a pilot study to investigate the usefulness of a blocked mindfulness short intervention and the potential effects on emotion regulation, we conducted a sensitivity analysis given an alpha level of α = 0.05 and a power of β = 0.80 with G-power. Given the sample size of N = 67, we were able to detect effect sizes up to fWe separately analyzed the first (instruction group) and second (emotion regulation) paradigm, as well as changes in emotion, decentering and state-rumination. In all analyses we used mixed MANOVAs with the between subject factors rumination (high vs. low) and instruction group (MT vs. IT) and the within-subject factor condition  of the related instruction. Dependent variables (DVs) were the behavioral scores (ratings) during the paradigm and NIRS data of the five ROI. Prior to the analysis, the assumptions of MANOVA were checked. Data for the behavioral ratings were transformed to achieve normal distribution. Post-hoc analysis was conducted on the DVs that further showed significant results in the univariate statistics. Univariate analyses following the MANOVAs were corrected by the Benjamini–Hochberg procedure. According to our hypothesis, we were mainly interested in main effects and interactions of the between subject factors. In each instruction group, we analyzed subjective ratings first as part of the manipulation check and subsequently fNIRS data.Behavioral data in the instruction groups was analyzed using a 2 (rumination: high vs. low) by 2 (instruction: MT vs. IT) by 2 (condition: focus/past vs. equanimity/future) MANOVA with 4 DVs . As post hoc tests, we performed planned comparisons between (1) the groups and (2) the conditions within the groups . Interactions with the factor rumination were explored by comparing the subgroups  and the higher order interactions in the same manner  to assess the general activation pattern during the intervention paradigm  by 2 (instruction group: MT vs. IT) by 2 (condition: focus/past vs. equanimity/future) MANOVA with 5 DVs . Planned comparisons were equivalent to those of the behavioral data. Additionally, for descriptive purposes we performed tests of OIn the emotion regulation task we directly analyzed difference scores of the experimental contrast  for reasons of simplicity. Behavioral data in the emotion regulation task was analyzed using a 2 (rumination: high vs. low) by 2 (instruction group: MT vs. IT) MANOVA with 2 DVs . Post-hoc tests were performed in DVs with significant univariate effects and included comparisons between the instruction groups and subgroups of rumination  in the ratings.fNIRS data were analyzed with a 2 (rumination: high vs. low) by 2 (instruction group: MT vs. IT) by 2 (phase: anticipation vs. watching) MANOVA for the contrast of the conditions  on 5 DVs (ROI: left DLPFC vs. left IFG vs. right DLPFC vs. right IFG vs. SPL). Post-hoc tests included comparisons between the instruction groups and rumination groups separately for the different ROI  were conducted. We used time-related contrasts  to track changes over the course of the experiment. Planned comparisons included interactions of the time factor with instruction and rumination , a main effect of condition  = 5.849, p < 0.001, Wilk’s Λ = 0.719, partial η2 = 0.28) and an interaction of condition by instruction group  = 6.652, p < 0.001, Wilk’s Λ = 0.693, partial η2 = 0.31). No main effect of or interaction with rumination was found .During the instruction, we observed a main effect of instruction group  = 5.618, p < 0.001, partial η2 = 0.23) and attention shifts  = 5.048, p < 0.05, partial η2 = 0.07); however, the latter finding was not significant after correction for multiple comparisons in the univariate ANOVAs. The main effects indicated lower emotional distress and marginally more attention shifts in the MT group in comparison to the IT group  = 18.765, p < 0.001, partial η2 = 0.20) and perceived success  = 9.669, p < 0.01, partial η2 = 0.13). Post-hoc tests were only performed between the conditions of each instruction group, as the main effect already showed significant differences between the groups. Post-hoc tests revealed that the MT group showed reduced emotional distress (t(33) = 3.940, p < 0.001, d = 0.73) and higher perceived success of task completion (t(33) = 3.422, p < 0.01, d = 0.39) during the focus condition in comparison to the equanimity condition, while no differences in these variables were observable between the conditions of the IT group  = 16.001, p < 0.1, Wilk’s Λ = 0.851, partial η2 = 0.15), a significant main effect of condition  = 3.631, p < 0.01, Wilk’s Λ = 0.762, partial η2 = 0.24) and a marginally significant interaction of condition by instruction group  = 2.354, p < 0.1, Wilk’s Λ = 0.831, partial η2 = 0.17). The marginal main effect of instruction group was characterized by a tendency towards reduced CCN activity in the MT group in comparison to the IT group.The analysis of fNIRS data during the instruction paradigm showed a marginally significant effect of instruction group  = 2.025, p < 0.01, partial η2 = 0.12), left DLPFC  = 9.825, p < 0.01, partial η2 = 0.14), right DLPFC  = 8.121, p < 0.01, partial η2 = 0.12), and SPL  = 18.160, p < 0.001, partial η2 = 0.22). As combined comparisons of the instruction groups on the condition factor during the short intervention are somehow misleading, e.g. as the equanimity condition of the MT group is not directly comparable/equivalent to the future condition of the IT group, we reanalyzed the condition effect for both groups separately. Here again, we observed a main effect for condition in the MANOVA in both groups  = 3.667, p < 0.05, Wilk’s Λ = 0.604, partial η2 = 0.40); IT: F = 2.622, p < 0.05, Wilk’s Λ = 0.665, partial η2 = 0.33). Univariate analysis for the MT group indicated significantly higher activity in the equanimity than in the focus condition in left IFG  = 15.027, p < 0.001, partial η2 = 0.32), left DLPFC  = 7.154, p < 0.05, partial η2 = 0.18) and SPL  = 11.522, p < 0.01, partial η2 = 0.27). In contrast, no univariate comparison in the IT group survived the correction for multiple comparisons. Tendencies towards higher activity in the future in comparison to the past condition were observed in the left DLPFC  = 3.204, p < 0.1, partial η2 = 0.10), right DLPFC  = 5.013, p < 0.05, partial η2 = 0.14) and SPL  = 7.064, p < 0.05, partial η2 = 0.19). The different impact of the condition factor in both groups might further explain the marginally significant interaction of condition by instruction group in the main analysis  = 8.295, p < 0.001, Wilk’s Λ = 0.181, partial η2 = 0.82). Univariate analysis indicated higher emotional distress  = 275.084, p < 0.001, partial η2 = 0.82) and higher avoidance  = 89.545, p < 0.001, partial η2 = 0.60) during watching of the negative movies in comparison to neutral movies . Univariate analysis showed significant results for emotional distress  = 5.099, p < 0.05, partial η2 = 0.08) and avoidance  = 4.781, p < 0.05, partial η2 = 0.07), but both effects did marginally not survive the correction for multiple comparisons .After the short intervention, all subjects participated in the emotion regulation task. With respect to behavioral ratings during the emotion regulation task, we found a significant main effect of condition  as indicated by a significant constant of the experimental contrast  = 135.483, p > 0.1).No main effect of or interaction with rumination was found   = 12.855, p < 0.001, Wilk’s Λ = 0.470, partial η2 = 0.53), a main effect of instruction group  = 2.986, p < 0.05, Wilk’s Λ = 0.792, partial η2 = 0.21) and a main effect of phase  = 3.318, p < 0.05, Wilk’s Λ = 0.775, partial η2 = 0.23).With respect to cortical O2Hb levels in the left IFG  = 19.705, p < 0.001, partial η2 = 0.24), left DLPFC  = 16.125, p < 0.001, partial η2 = 0.21), right DLPFC  = 7.599, p < 0.01, partial η2 = 0.11) and SPL  = 43.790, p < 0.001, partial η2 = 0.42), indicating increased cortical blood oxygenation in these brain areas during negative in comparison to neutral movie clips.Univariate analysis of the constant term showed significantly increased O2Hb levels in the MT in comparison to the IT group in the left DLPFC  = 4.589, p < 0.05, partial η2 = 0.07), although the effect did not survive the correction for multiple comparisons for the univariate analysis, and a marginally significant effect in the right IFG  = 3.394, p < 0.1, partial η2 = 0.53)  = 12.793, p < 0.001, partial η2 = 0.17) and SPL  = 4.586, p < 0.05, partial η2 = 0.07).Finally, the univariate analysis of the main effect of phase showed significantly increased Op > 0.1).No main effect of or interaction with rumination was found  and time  = 13.182, p < 0.001, Wilk’s Λ = 0.301, partial η2 = 0.70). The univariate analysis of the main effect of rumination showed significantly increased state rumination  = 19.157, p < 0.001, partial η2 = 0.25), and negative affect  = 4.187, p < 0.05, partial η2 = 0.07) in the high ruminators. However, the latter effect was not significant after correction for multiple comparisons. The main effect of time showed significant effects in all DVs: negative affect  = 25.939, p < 0.001, partial η2 = 0.31), state rumination  = 5.633, p < 0.001, partial η2 = 0.09) and decentering  = 8.911, p < 0.001, partial η2 = 0.13). The change in negative affect was characterized by a quadratic  = 29.686, p < 0.001, partial η2 = 0.34) and cubic  = 42.293, p < 0.001, partial η2 = 0.42) change with a relatively steady level until the beginning of the emotion regulation task, an increase in negative affect after this task and a decrease 10 min later  and cubic  = 6.727, p < 0.05, partial η2 = 0.10) term reached significance. In this case, the effects were driven by a linear increase over the course of the experiment with a first peak after the short intervention, a subsequent decrease after the emotion regulation task and a maximal peak 10 min following the end of the emotion regulation task  and cubic  = 11.071, p < 0.01, partial η2 = 0.16) change. The effect was driven by an increase in state rumination following the short intervention, a decrease after the emotion regulation task and a steady level 10 min later  = 6.454, Although we randomized subjects to the instruction groups, there were significant differences in the average age between the treatment conditions. Further, sex was not equally distributed within the sample and prior experience to any kind of relaxation or meditation showed tendencies to an unequal distribution as well. Therefore, we repeated the analysis with these variables as covariates with MANCOVA. In Supplementary Table The present study aimed to investigate an adapted mindfulness short intervention and corresponding effects on behavioral and neural parameters of emotion regulation in low and high habitual ruminators. To this end, 67 habitual high and low ruminators either underwent a mindfulness or instructed thinking short intervention while functional near-infrared spectroscopy (fNIRS) was assessed. Afterwards, all subjects watched either affectively neutral or negative movie clips during an emotion regulation task.74. In their framework, the authors suggest that—during model-based emotion regulation—plans and internal models are used to guide behavior and that areas of the CCN are involved in this process74. The mindful focus on the emotional state versus the breath might just be more related to follow internal plans, which would be associated with higher model-based control. Interestingly, this interpretation might also be related to findings from meditation stages. For example, Hasenkamp et al.75 postulate that during meditation four stages are involved: mindwandering, awareness of mindwandering, attention shifting and sustained attention. In their study, Hasenkamp and colleagues observed increased activity within areas of the default mode network during mindwandering, increased activity within the salience network during awareness of mindwandering and increased activity in the cognitive control network during attention shifting and sustained attention75. Associations of CCN activation and attentional control/shifting have also been shown in other fNIRS and fMRI studies79. Correspondingly, we propose that our results might reflect a naturally occurring effect that is present during mindfulness meditation when reflecting on emotions in a mindful state. The non-judgmental reflection of these emotional processes may be accompanied by increased activity in areas of the cognitive control network, before attention is reallocated, similar to the observed increased O2Hb levels during the equanimity condition.As expected, we observed reduced emotional distress in the MT in comparison to the IT group on a behavioral level. Further, emotional distress within the MT group was lower in the focus when compared to the equanimity condition. Likewise, perceived success was reduced in the equanimity in comparison to the focus condition. No differences in these variables were observed between the conditions of the IT group. On a neural level, contrary to our hypothesis, we observed a marginally significant effect of the instruction group towards reduced activity in the CCN in the MT group. Further, we found a significant condition effect in the whole sample, reflecting higher activity in the equanimity/future condition than the focus/past condition in the instruction groups. As both groups did perform different tasks, we subsequently performed the post-hoc tests for the condition effect separately for both groups, without comparing the instruction groups directly (within-subject comparison vs. between-subject comparison). Post-hoc analysis showed an expected higher activity during the equanimity than the focus condition in the MT group in the left DLPFC, left IFG and SPL. The supplementary analysis of the activation pattern in the two conditions further indicated that this effect was due to no CCN activation during the focus condition but during the equanimity condition. In the IT group differences between conditions were not significant after correction for multiple comparisons, pointing only to tendencies towards higher activation in the future than in the past condition in the bilateral DLPFC and SPL. However, the supplementary analysis of the activation during the two conditions showed that the past as well as the future focus induced activity in the CCN different from zero. In the design of the study and the formulation of the hypotheses, we did not expect that the IT conditions would induce such high CCN activity. The differences between the MT conditions, however, point towards two different neural processes that are characterized by different levels of emotional distress and perceived success in the task completion. One explanation for this might be that the mindful focus on the emotional state provoked effortful control for emotion regulation to maintain a distanced mindful focus on the emotional state. This interpretation is in line with the model of model-based and model-free emotion regulation of Etkin et al.p > 0.001) and in light of the significant multivariate test might be interpreted in terms of improved overall affective well-being. This effect is well in line with the work of Arch and Craske57 who found that a short mindfulness induction reduces negative affect and increases willingness to be confronted with negative material in comparison to an unfocussed attention and worry intervention57. In line with this, Creswell et al.58 observed reduced perceived stress and increased cortisol responses during the Trier Social Stress Test in subjects after 3 days of a mindfulness training in comparison to a control training. Additionally, the training was most effective in subjects that showed low pre-existing levels in dispositional mindfulness58. From this point of view, we suggest that the training of a mindful state within the utilized block design is comparable to the effects of mindfulness on mood found in the literature59.Following the short intervention, all subjects underwent an emotion regulation task during which emotional video clips were first cued and then watched by all participants. Interestingly, on a behavioral level we again observed a main effect of the instruction group on behavioral ratings of emotional distress and avoidance, although both effects were significant only without correction for multiple comparisons in the univariate analysis. Therefore, this effect needs to be interpreted with caution, but hints towards a marginally significant improvement when looking at both variables separately. However, emotional distress and emotional avoidance were moderately positively correlated in this study , who used a short mindfulness intervention before an emotion regulation task was assessed. They observed increased prefrontal activation during expectation of negative material in the mindfulness group relative to controls84. In another study, Hölzel et al.54 observed increased prefrontal activity in an affect labeling task following an MBSR intervention in GAD54. Nonetheless, our results must be interpreted with caution, as the univariate analysis for the behavioral and neural effects was only significant without correction for multiple comparisons. However, as this study was designed as a pilot study, we might suspect that increases in the dose of intervention might increase the observed tendencies found in this study. Further, we hypothesize that the overall effect of the blocked instruction paradigm, which differs substantially from traditional meditation settings in terms of timing and interruptions, might have the potential to be effective in a higher dosage.On a neural level we observed a main effect of the constant indicating higher CCN activity during negative vs. neutral movie clips and a main effect of phase that was characterized by increased cortical oxygenation already in the anticipation of the negative movie clips. Similar effects have been reported with other emotionally relevant material62. In general, it must be noted that reactivity in negative emotion and state rumination were rather low. As expected, high trait ruminators showed elevated general levels of state rumination and negative emotion. Surprisingly, interactions of instruction group, rumination and time were not significant, indicating that time-related changes in state rumination, negative affect and decentering were not dependent on these factors. The first explanation for this might be that the implemented factors to influence these dependent variables—e.g. the intervention and the instructed thinking task—were not strong enough to have an impact. Interestingly, the significant main effect of time indicates that state rumination increased in all subjects regardless of the instruction group, implying also increases in state rumination in the MT group following the instruction paradigm. It might be the case that the MT instruction had indeed some kind of negative side effects. Other studies have found that mindfulness based interventions may have “side effects” in terms of actualization and realization of emotionally loaded problems during meditation85. This effect may be in accordance with higher emotional distress in the MT group while focusing on one’s emotional state with a mindful focus. Another explanation may be that the instruction was too short for influencing ruminative tendencies.Importantly, the factor of habitual rumination showed no significant effect, neither in the instruction paradigm nor in the emotion regulation task. In previous investigations using clinical analogue samples, we found encouraging effects in high habitual ruminators, despite the non-clinical groupings62. Indeed, in subjectively relevant stress paradigms like those used by our group, the reactive negative emotion and state rumination were much higher than in the current study. It may be the case that group differences were not significant in this study, as the absolute effect of the paradigms utilized on subjective emotion and state rumination was rather small. In future studies on the effects of mindful emotion regulation, it might be of advantage to use paradigms such as the Trier Social Stress Test87.Furthermore, state rumination did not increase during the emotion regulation task in high ruminators, which emphasizes the use of subjectively relevant emotional situations for the induction of state rumination89. However, in terms of ecological validity, fNIRS is the best available option for measuring cortical hemodynamic changes90. Further, it is important to bear in mind that the current study used a non-clinical population and future studies are needed to support the usage of the implemented mindfulness training in clinical samples. However, because one aim of the current study was to investigate the effects of the paradigm, our sample used also had some advantages. For example, high ruminators were medication-free, meaning our study was free from confounding of the observed effects with medication status of the high ruminating group. Also, although the sample was non-clinical, high ruminators showed significantly elevated levels of subclinical depression scores, indicating that this subgroup is potentially at-risk93. Another limitation concerns the instruction during the emotion regulation paradigm. During the emotion regulation paradigm, we did not give direct instructions how to regulate in the IT group, as we wanted to contrast a naturally occurring spontaneous emotion regulation in the IT group versus mindful emotion regulation in the MT group. However, without a direct instruction how to regulate, the IT group might have used a variety of different emotion regulation strategies. On the other hand, control instructions—such as not to regulate—themselves might induce neural activity, which is why we decided to design the paradigm in the current way. In future investigations it might also be interesting to investigate the spontaneous emotion regulation strategies in the non-intervention group in detail. Lastly, although most probably due to the limited sample size of this pilot study, the investigated subgroups of this study showed significant differences with respect to their age. However, controlling for the age of participants did not affect the results of our analysis. This is most probably due to the relatively low differences between groups in age, as all subject groups were on average between 22 and 29 years old. Most age-related changes in brain functioning occur in certain developmental windows. Following adolescence, brain functioning may be comparable across different age groups (e.g. 22 and 29 year old subjects) within adults until age-related decline starts. A last limitation concerns the study design. The development of control conditions for laboratory mindfulness inductions is rather complicated. We did not choose to use a non-intervention group—e.g. just resting for 15 min—as subjects in such a group could be mindful while performing the control condition. Instead, we used a non-mindful instructed thinking instruction that might have contributed to the differences between the groups. In future studies, it may be preferable to investigate a third non-intervention group. However, such study designs are cost and time expensive. In future studies it should be assessed if subjects practice Yoga more explicitly, as such a practice could improve mindfulness skills. Furthermore, in future studies additional physiological measures (e.g. heart rate) might be assessed, and larger sample sizes should be collected to allow the analysis of brain-behavior-correlations.Despite these promising findings, some limitations have to be noted. First, this study was conceptualized as a pilot study to investigate the implementation of a block-designed mindfulness instruction and the estimation of potential effect. Although the results are encouraging, the power of the used sample size is limited, resulting in the conflicting results following the correction for multiple comparisons. In future studies the estimated effect sizes of the short intervention in this study might be used to a priori estimate a sufficient sample size for the correction of multiple comparisons. Further, fNIRS only allows measurement of the upper layers of the cortex, because the penetration depth of the NIR light is limitedIn conclusion, we showed that an fNIRS mindfulness block design showed promising results on brain activation and behavioral indices of emotion regulation. Moreover, different mindfulness states were accompanied by different involvement of areas of the cognitive control network demonstrated in a within-subject comparison. The results of this study show that the intervention paradigm might be useful in future studies to investigate the neural correlates of mindfulness-based interventions in situ using fNIRS. In future studies, the current training paradigm should be further investigated in clinical populations and longitudinal investigations to track changes in CCN activity through longer training periods.Supplementary Information.


Internal hernia (IH) is a serious complication following laparoscopic Roux-en-Y gastric bypass (LRYGB), and closure of mesenteric defect has been recommended to reduce this complication. But what kind of material about suture and how to close the mesenteric defects were still controversial. The main aim of this study was to compare the incidence rate of internal hernia after LRYGB between patients with different surgical techniques.Three hundred and thirty-one patients underwent LRYGB between June 2004 and December 2017 in one single institute were retrospective analysed. The IH rate was evaluated according to different surgical methods and surgical materials before and 12 months after LRYGB.n = 6). In the six IH cases, the duration of IH occurred time ranged from 1 month to 36 months postoperatively, and for the IH sites, one for intestinal defect, three for transverse mesocolon defect and two Peterson defect respectively. There was a significant difference about IH rate between interrupted suture and running suture groups (p = 0.011), and there were no significant differences between the other two groups.All the cases were subdivided into three groups based on the suturing method, Roux limb position, and Suture material. The mean follow up time was 36 ± 12 months, and the total incident rate of IH was 1.8% , glycometabolism condition, and Roux limb position and suture material had no effects on the IH prevalence after LRYGB. The rising prevalence of overweight and obesity has been defined as a global pandemic . BariatrIn spite of the increasing number of LRYGB procedures in China , some ofTherefore, the incidence of IH should be decreased by closing mesenteric defects , which c2 or a BMI ≥27.5 kg/m2 with type 2 diabetes or metabolic syndrome that cannot be controlled by lifestyle alternations and medical treatment. Exclusion criteria were patients who had previously bariatric procedures, abdominal surgery, mental diseases, and severe chronic disease. Three hundred thirty-one patients undergoing the surgical operation of LRYGB were evaluated by nutritionist, psychiatrist, and anesthetist preoperatively for their nutritional status, mental state, and cardio-pulmonary functions respectively. All patients have clear fluids up to 4 h and solids up to 8 h prior to induction of anaesthesia. And the anaesthesia were operated by experienced anesthetist. Bi-level positive airway pressure was used on patients with Obstructive Sleep Apnea preoperatively and all patients postoperatively. Clear liquid meal was initiated at first day after surgery, semiliquid meal was taken after upper gastrointestinal tract radiography. Gastric mucosal protective drug and proton pump inhibitor were administrated immediately after surgery and last for 2 months. They were advised to take calcium tablet and multivitamin supplementations for life. All patients were discharged 5 days after surgery.A retrospective analysis of 331 cases underwent LRYGB between June 2004 and Dec 2017 in the Department of metabolic and obesity surgery of the First Affiliated Hospital of Jinan University  were conducted. All procedures were performed by the same surgical team. Inclusion criteria for the study were Chinese patients aged from 18 to 65 years, and BMI ≥35 kg/m2. And complications have been reported during the follow-up. As a retrospective study, ethnic approval was not necessary due to the local ethics committee .Data recorded included gender, age, height, weight, BMI, diabetes and surgical techniques, such as different suturing method, suture material and the Roux limb position. All patients were followed up at 1,3,6, 12 months and one time for each year after 12 months postoperatively regularly. And only the cases that had been followed up for more than 12 months after LRYGB has been presented in this study. Weight loss outcomes were reported as percentage of excess weight loss(%EWL). %EWL was computed by the formula as followed: [Initial weight(kg) - current weight(kg)]/[initial weight(kg) - ideal weight(kg)]X100%, where ideal weight (kg) = 25 × [height(m)]The LRYGB was performed through a 5-port technique with the patient supine position. The gastric pouch was designed with the volume of approximately 10–20 ml. The length of the Biliopancreatic limb was 25 cm, and the Roux limb was 150 cm in simple obesity and 175 cm in obesity with diabetes mellitus. The Roux limb was positioned through a retro-colic or ante-colic method and fixed to the transverse mesocolon with absorbable or nonabsorbent braided sutures. The anastomotic stoma between the stomach and jejunum was 1.5 cm and 6 cm between jejunum and jejunum. The jejunum mesentery defect, transverse mesocolon defect, and Peterson defect were closed by running suture or interrupted suture, and absorbable suture or non-absorbable suture. No drainage tube was used in all patients. There was no conversion to open operation, and no mortality.p value < 0.05 was considered to be statistically significant.Statistical analysis was carried out using the Statistical Product and Service Solutions version 13.0 (SPSS13.0). Continuous data were presented as mean standard deviation and categorical data were expressed as percentage (%). Subgroups were compared using Chi-square or Fisher’s exact test. A 2, reduced to 27.3 ± 10.7 kg/m2 after 12 months, the %EWL post-operation 12 months were 82.1 ± 9.2%  were female, 145 (43.8%) were male. The mean age was 32.1 ± 11.4 years old, the mean operation time was 125 ± 15.4 min, and the mean blood loss was 8 ± 3.0 ml. The mean BMI before surgery were 43.7 ± 11.1 kg/m2. Three patients were discovered IH 1 month after surgery, 1 patient was found 3 months after surgery, and one IH occurred 17 months after surgery, and another IH occurred 36 months postoperatively. All 6 patients’ initial symptom was abdominal pain, each of them have underwent computed tomography scan and diagnosis with IH. All of the IH cases received reoperations. Four patients who occurred IH in 1 to 3 months were successfully conducted laparoscopic hernia repair, and one case occurred IH 17 months postoperatively cured by open hernia repair. Another case who had IH complicated with bile pancreatic limb perforation 36 months postoperatively received open hernia repair and 5 cm bile pancreatic limb resection. During the hernia repairing surgery, we found that 3 IH occurred at transverse mesocolon defect, 2 occurred at Peterson defect, and 1 occurred at jejunum mesentery defect. As to the herniated segment of intestine, 4 of them were common limb, 1 of them was Biliopancreatic limb and common limb  encountered IH after LRYGB, 4 were females and 2 were males. The age ranged from 26 to 48 years old, BMI ranged from 32.6 to 48.2 kg/mp = 0.011). According to the relative orientation of Roux limb to transverse colon, there was no significant difference between the ante-colic group and retro-colic group. One hundred thirty cases were divided to the antecolic group, which had 3 IH case; and 201 cases were divided to the retro-colic group,, which had 3 cases of IH occurred(p>0. 05). According to the difference of suture materials, there were absorbable group and non-absorbable group. Two hundred fifty-three cases belonged to the absorbable group, which had 5 cases of IH; and 78 cases belonged to the non-absorbable group, which had 1 cases of IH. There did not have a significant difference between absorbable group and non-absorbable group (p>0. 05).Three hundred thirty-one cases were divided into three subgroups depend on the suturing methods, Roux limb position, and suture material. According to the suturing methods, 157 cases belonged to the interrupted suture group, which had 6 cases of IH, and 174 cases belonged to the running suture group, which had no IH case. The prevalence rate of IH was higher for interrupted suture than running suture after LRYGB (p>0. 05). Among the 156 patients who had type 2 diabetes, 3 patients had IH; and there were 3 IH cases in 175 patients without diabetes(p>0. 05).93 patient’s age were over 40 years at LRYGB time point and 2 of them developed IH, 238 patient’s age under 40 years old and 4 of them developed IH(p>0. 05). Seventy-nine patient’s BMI at LRYGB time point were over 50 kg/m2and none of them developed IH, 252 patient’s BMI under 50 kg/m2and 6 of then developed IH(p>0. 05) . Running closure technique seems to have better leakproofness to reduce the incidence of IH compared with interrupted closure fashion.Running suture is usually faster and associated with a lower leakage rate , 18. ButTable In our experience, the retro-colic LRYGB would change the anatomy of gastrointestinal tract, where the alimentary limb is brought up to the gastric pouch, resulting in three potential sites at which the hernia can occur. One potential site is located between the mesentery of two small bowel loops at the jejunojejunostomy mesenteric defect. The second space where an IH could occur is the Petersen space, between the mesentery of the alimentary limb and the transverse colon, mesocolon, or retroperitoneum which the small intestine may become interposed. The third is the transmesocolic space because biliary limb needed to pass through a retro-colic tunnel. Even though some reports reveal that antecolic approach has advantages like reduction of the risk of bleeding and pancreatic damage, reduction of surgical time and less potential defects in the technique . In our But there are still some shortcomings of our study. At first, this is a retrospective study, more evidence-based research is needed to prove it. Second, 6 cases are small sample and the statistical results are not very convincing, high quality evidence from randomized trials are needed.Compared with the interrupted suturing, running suture closure may prevent internal hernia after LRYGB. Patient’s gender, age, body mass index, glycometabolism condition, and surgical technique such as using an ante-colic or retro-colic approach and absorbable or non-absorbable sutures have no effect on the IH ratio after LRYGB, but there still need more solid evidence to support this conclusion.


CMR), however this is a crude measure. New CMR measures of RV function beyond RVEFCMR have emerged, such as RV lateral atrio-ventricular plane displacement (AVPDlat), maximum emptying velocity (S’CMR), RV fractional area change (FACCMR) and feature tracking of the RV free wall (FWSCMR). However, it is not fully elucidated if these CMR measures are in parity with the equivalent echocardiography-derived measurements: tricuspid annular plane systolic excursion (TAPSE), S’-wave velocity (S’echo), RV fractional area change (FACecho) and RV free wall strain (FWSecho). The aim of this study was to compare regional RV function parameters derived from CMR to their echocardiographic equivalents in patients with pulmonary hypertension and to RVEFCMR.Right ventricular (RV) function is a major determinant of outcome in patients with pulmonary hypertension. Cardiac magnetic resonance (CMR) is gold standard to assess RV ejection fraction  evaluated for pulmonary hypertension underwent CMR and echocardiography. AVPDlat 5.5 ± 4.6 mm (33.2 ± 25.2%), FWS 4.4 ± 5.8% (20.2 ± 37.5%) and for FAC 5.1 ± 8.4% (18.5 ± 32.5%). In correlation to RVEFCMR, FACCMR and FWSecho correlated strongly, FACecho, AVPDlat, FWSCMR and TAPSE moderately, whereas S’ had only a weak correlation.A strong correlation was demonstrated for FAC whereas the remaining measurements showed moderate correlation. The absolute bias for S’ was 2.4 ± 3.0 cm/s (relative bias 24.1 ± 28.3%), TAPSE/AVPDCMR was FWSecho. At present, FACecho and FWSecho as well as RVEFCMR are the preferred methods to assess and follow up RV function in patients with pulmonary hypertension. Future investigations of the CMR right ventricular measures, beyond RVEF, are warranted.This study has demonstrated a moderate to strong correlation of regional CMR measurements to corresponding echocardiographic measures. However, biases and to some extent wide limits of agreement, exist between the modalities. Consequently, the equivalent measures are not interchangeable at least in patients with pulmonary hypertension. The echocardiographic parameter that showed best correlation with RVEF Right ventricular (RV) function is a major determinant of outcome in patients with pulmonary hypertension , 2. Compecho), RV fractional area change (FACecho) and myocardial strain derived from the RV lateral free wall (FWSecho) , as appropriate according to normal distribution. Normality was assessed visually from histograms. Categorical data was expressed in absolute numbers and proportion (percentage). Pearson’s correlation coefficient  was used for association between echocardiography and CMR. Degree of correlation between tests was classified as either weak (r = 0.3–0.5), moderate (0.5–0.7), strong (0.7–0.9) or very strong (0.9–1.0) . Bias acBaseline characteristics of the included 55 patients  are shown in Table n = 40) and chronic thromboembolic pulmonary hypertension (n = 9). Median NT-proBNP was 979 ng/L [329–2286 ng/L]. 18% of the patients were treated with pulmonary arterial vasodilators (60% of these with double or triple medication). 87% of the patients were in WHO-functional class II or III and the median 6-min walk test was 325 m [200–412]. Comorbidities were present in 28 patients . No differences were seen between the patients with PAH (n = 40) and those without PAH (n = 15)   Table , Fig. 3.es Table , Fig. 4.CMR and AVPDlat being lower and FWSCMR and FACCMR higher (Table lat 5.5 ± 4.6 mm (33.2 ± 25.2%), FWS 4.4 ± 5.8% (20.2 ± 37.5%) and for FAC 5.1 ± 8.4% (18.5 ± 32.5%).CMR measurements differed significantly in absolute values compared to echocardiographic measures, with S’er Table , Fig. 3.lat. In comparison with RVEFCMR, a strong correlation was demonstrated for FACCMR and FWSecho, whilst a moderate correlation was demonstrated for FACecho, AVPDlat, FWSCMR and TAPSE, respectively. Only a weak correlation was demonstrated for S’ measured by both modalities.To our knowledge, this is the first comprehensive study comparing conventional and new RV function parameters derived from CMR to their echocardiographic equivalents in patients with pulmonary hypertension. Our results indicate strong to moderate correlation of CMR measures of RV function to corresponding echocardiographic parities. However, there are biases that needs to be addressed. As such, lowest relative bias was shown for FAC, then FWS, S’ and highest was for TAPSE/AVPDlat/TAPSE. These are measures of longitudinal contraction, and the longitudinal contribution accounts for approximately 80% of the RV stroke volume in normal hearts [lat is a relatively new and sparsely evaluated method, and not referenced in consensus documents for CMR [lat to be decreased in patients with pulmonary hypertension in alignment with a prior study [lat in pulmonary hypertension remains to be investigated.Our results demonstrated a moderate correlation for AVPDl hearts . TAPSE il hearts , howeverl hearts . As the l hearts . Other r for CMR . We founor study , 17, howlat with lower absolute values by CMR compared to echocardiography. This is an unexpected finding since AVPDlat is considered to be less angle dependent than the measurements of TAPSE. Consequently, the bias is probably methodological since they are measured from differently obtained 4-chamber views. In CMR, acquisition of the 4-chamber view is planned from the short-axis view to perfectly rotated into the RV focused view [In our study, the highest bias was demonstrated for TAPSE/AVPDsed view . These aCMR has only been described twice previously [CMR to the echocardiographic equivalent. The disadvantage of S’echo not being representative for RV global function is substantial since it only measures the velocity in one specific point in the basal segment of the RV lateral wall [echo and TAPSE have in previous studies been presented within normality in pulmonary hypertension even when other RV parameters were impaired [CMR is derived from the AVPD curve and is defined as the highest measured instantaneous velocity measured as the steepest systolic slope of the AVPD curve. The velocity at peak emptying (S’CMR) could hence be considered as in parity to the peak systolic annular velocity from echocardiography S’echo [CMR diminishes some of the limitations for S’echo such as angle-dependency and image quality. On the other hand, S’CMR is acquired with a lower framerate than S’echo and with a subsequent post processed smoothing of the curve. In comparison, S’echo is derived from pulsed-wave tissue-doppler imaging and with a high frame rate. The two methods cannot be considered methodologically fully interchangeable. In our study, S’ showed the best agreement with narrow limits in absolute values between the methods. However, as with the other methods there was a systematic substantial relative bias and broad limits of agreement.S’ showed a moderate correlation between echocardiography and CMR. S’eviously , 23 and impaired , 11. Mety S’echo . S’CMR decho reflects both radial and longitudinal contribution to the overall RV function [The strongest correlation between the modalities were shown by FAC and to our knowledge this is the first study to compare the two modalities. FACfunction  and predfunction  in patieIn this study, FWS showed a moderate correlation between modalities. Prior studies have shown conflicting evidence as some are in concordance with ours , while oCMR and other measurements parameters.While RVEF is invaluable in assessment of pulmonary hypertension, it is not a direct measure of RV contractility, RVEF requires augmentation with other global and regional parameters to assess the function on a myocardial level , 36. Thiecho and FACecho/CMR [CMR with a modest correlation for TAPSE/AVPDlat and a weak correlation for S’echo compared to RVEFCMR [CMR to AVPDlat [CMR [CMR could be explained that RVEF is more related to fractional transverse movements than to longitudinal movements in patients with pulmonary hypertension [CMR.Our results are in concordance with previous studies on FWSecho/CMR , 17 pres RVEFCMR , 17. As lat [CMR , 37. Thertension . This coCMR to S’CMR, and to explore a comprehensive paired comparison of equivalent parameters of echocardiography and CMR.To our knowledge, this is the first study to evaluate the poor relationship of RVEFCMR is a robust and precise method for risk assessment and clinical follow up. However, RVEFCMR is an incomplete method of assessing myocardial contraction as it only evaluates relative volume changes. Several studies have shown regional functional assessment of the RV has incremental value beyond EF [echo, TAPSE, S’echo and FWSecho [lat are used for assessment of systolic function although their prognostic values are not fully explored. FACCMR, FWSCMR and S’CMR are new measures that are not yet implemented in clinical practice. To some extent the echocardiographic parameters have been showed to be associated to clinical outcome in pulmonary hypertension [RV function is an important determinant of outcome in patients with pulmonary hypertension , 2 and Reyond EF , 15, 19.eyond EF , 39, 40.rtension , while trtension , 36.CMR, but the equivalent measures are not interchangeable at least in pulmonary hypertension. Clinical outcome data was not within the scope of this study. However, investigating which of the different RV functional markers in the present study is most predictive of outcome is of interest for future studies.According to clinical practice in our center, the majority of patients evaluated for pulmonary hypertension are investigated within CMR of two main reasons: to exclude presence of congenital heart disease  and also to have accurate measurements for RVEF and RV size since CMR is considered as gold standard for this purpose and these measures carry prognostic information , 43. CMRn = 15) and poor acoustic windows (n = 20). However, strain analysis on atrial fibrillation patients are at present not recommended and RV assessment by echocardiography is highly dependent on image quality. Therefore, one could debate which imaging modality is preferred for assessing RV function in this highly selected patient population. Echocardiography and CMR were performed contemporaneously, but not immediately so. Since RV function parameters are load-dependent, small changes in treatment (e.g. diuretic) may affect RV function parameters. However, median time was only 1 day with no cardiac events, medical changes, or clinical deterioration between examinations. FWSecho was measured using an algorithm developed for the left ventricle. However, this method is standard procedure and has been propagated into guidelines [CMR was assessed in RV dedicated algorithm. Further standardization between different vendors for both CMR and echocardiography are required [There are some limitations in our study. This is a rather small study of 55 selected pulmonary hypertension patients since 35 were excluded due to atrial fibrillation (idelines . On the required  as well CMR was FWSecho. At present, FACecho and FWSecho as well as EFCMR are the preferred methods to assess and follow up RV function in patients with pulmonary hypertension. Future investigations of the CMR right ventricular measures, beyond RVEF, are warranted.This study has demonstrated a moderate to strong correlation of regional CMR measurements to corresponding echocardiographic measures. However, biases and to some extent wide limits of agreement, exist between the modalities. Consequently, the equivalent measures are not interchangeable at least in patients with pulmonary hypertension. The echocardiographic parameter that showed best correlation with RVEFAdditional file 1: Table S1. Differences in characteristics and ventricular function parameters between gender, comorbidities and aetiology of pulmonary hypertension.


Ficus deltoidea Jack (Moraceae) is capable of reducing hyperglycaemia. However, whether F. deltoidea could protect against diabetic osteoporosis remains to be determined. Diabetes mellitus increases the risk of bone diseases including osteoporosis and osteoarthritis. We have previously demonstrated that F. deltoidea on bone histomorphometric parameters, oxidative stress, and turnover markers in diabetic rats. The study examines the effect of n = 6 animals per group) received one of the following treatments via gavage for 8 weeks: saline (diabetic control), metformin (1000 mg/kg bwt), and methanol leaves extract of F. deltoidea (1000 mg/kg bwt). A group of healthy rats served as normal control. The femoral bones were excised and scanned ex vivo using micro-computed tomography (micro-CT) for histomorphometric analysis. The serum levels of insulin, oxidative stress, and bone turnover markers were determined by ELISA assays. Streptozotocin (STZ)-induced diabetic Sprague-Dawley rats  (from 526.98 ± 11.87 to 637.74 ± 3.90). Higher levels of insulin (2.41 ± 0.08 vs. 1.58 ± 0.16), osteocalcin (155.66 ± 4.11 vs. 14.35 ± 0.97), and total bone n-3 PUFA (2.34 ± 0.47 vs. 1.44 ± 0.18) in parallel with the presence of chondrocyte hypertrophy were also observed following F. deltoidea treatment compared to diabetic control. Treatment of diabetic rats with F. deltoidea could prevent diabetic osteoporosis by enhancing osteogenesis and inhibiting bone oxidative stress. These findings support the potential use of F. deltoidea for osteoporosis therapy in diabetes. Diabetes mellitus is a metabolic disorder characterised by hyperglycaemia. It has been demonstrated that diabetes is associated with several lower extremities orthopaedic conditions and complications that affect the quality of life   is an evergreen shrub or a small tree that is easily found in Malaysia and widely distributed in Southeast Asian countries such as Thailand, Sumatra, Java, Kalimantan, Sulawesi, and Moluccas. The decoction of F. deltoidea has traditionally been used in postpartum care specifically to improve uterine strength, regain energy, and prevent postpartum bleeding   was deposited in the Herbarium Unit, Universiti Kebangsaan Malaysia for further reference. The leaves were washed thoroughly, oven-dried at 37 ± 5 °C, ground to a fine powder in an electric grinder, and weighed. The powdered leaves (100 g) were soaked in 1 L absolute methanol for three days at room temperature. Liquid extracts were concentrated using a rotary vacuum evaporator  under reduced pressure. The extracts were kept in tightly closed glass containers and stored at −20 °C until further use.The leaves of The study was conducted with 24 male Sprague-Dawley rats, weighing 100–120 g, purchased from Chennur Suppliers, Malaysia. The animals were maintained in a temperature-controlled room (22 ± 1 °C and a 12 h light/dark cycle) and fed with standard rat chow  and free access to water. The experiment protocols including diabetes induction and sacrifice operation were approved by the Universiti Putra Malaysia, Animal Care and Use Committee (UPM/IACUC/AUP-R090/2014).Diabetes-like hyperglycaemia in rats was induced chemically by a single intraperitoneal injection of 60 mg/kg STZ dissolved in 10 mM citrate buffer (pH 4.5). To prevent the drug-induced hypoglycaemic shock, the rats were given 5% glucose water for 2 days following STZ injection . The assigned groups were as follows: normal control rats received saline (NC), diabetic control rats received saline (DC), Diabetic rats treated with 1000 mg/kg b.w. of metformin (DMET) and diabetic rats treated with 1000 mg/kg b.w. of F. deltoidea (DFD). Treatments were given via oral gavage once daily for a 56-day duration. At the end of the experiment, all animals fasted overnight and blood glucose levels were measured. Animals were then anaesthetised with ketamine (80 mg/kg) and xylazine (8 mg/kg), followed by terminal exsanguination. The femur and tibia were separated by cutting at the stifle joint. Blood samples (10–15 mL) were collected via cardiac puncture from the rats into a plain red-top tube containing no anticoagulants . The blood samples were then centrifuged at 4000  g for 15  min, and serum was stored in aliquots at −80 °C.A total of 24 male rats were divided into four groups  equipped with a 1 mm aluminium filter at a voltage of 41 kV and a current of 232 μA as described by Azmi et al. . The rot3) of each femoral diaphysis, a calibration curve was obtained by phantom experiments. This procedure allows the conversion of Hounsfield units (HU) into BMD values. The phantom was made up of a plastic base material, polyethylene; containing five cylindrical holes with 190 ± 0.5 mm diameter. Four cavities were filled with 50, 150 and 500 mg/cm3 solutions of K2HPO4 in distilled water, as known reference bone substitutes, and the fifth is a fat equivalent that was filled with 60% ethanol.To calculate the BMD  at 4 °C for 2 months  for 10 min to remove nuclei and debris. The obtained supernatant was assayed using commercial kits: TBARS assay kit for monitoring lipid peroxidation, glutathione peroxidase (GPx) assay kit for GPX activity, and superoxide dismutase (SOD) assay kit for SOD activity . Protein concentration was estimated by the method of Lowry et al. (The pieces of femur bone were ground using mortar and pestle. Bone tissues were homogenised in 10% (w/v) homogenising buffer  using a Teflon pestle . The homogenates were centrifuged at 9000 y et al. , using bAll markers of bone formation and bone resorption were measured in serum. The osteocalcin level was determined by using Rat-Mid Osteocalcin ELISA kit  whereas the rat BALP ELISA kit  was used to examine the levels of BALP. To assess bone resorption DPD was measured by using Rat deoxypyridinoline (DPD) ELISA Kit . All samples were run in triplicate and the optical density was read at 450 nm with a microplate reader  as described by Abdul-Majeed et al. .The total fatty acids were extracted from bone, identified and quantified by gas chromatography method as described by Nurdiana et al. . The fatAll data were tested using one-way ANOVA. Duncan’s multiple comparison test was employed to elucidate significant means. Results were presented as the mean ± 1 SD. All analyses were performed at 95% confidence level.F. deltoidea significantly reduced the level of fasting blood glucose and significantly increased the levels of serum insulin in the diabetic rats.The DC rats showed high fasting blood glucose and low insulin levels compared to the NC group . TreatmeF. deltoidea treatment. It was also noticed that TbSp returned to near-normal levels and BMD increased significantly in response to F. deltoidea treatment.As depicted in Micro-CT scanning analyses of the femoral bone showed that the DC rats exhibited cortical thinning  and trabF. deltoidea treatment. However, the DFD rats were associated with thicker calcified cartilage with chondrocyte hypertrophy.The histological section of normal rat femur showed a network of bone trabeculae at the distal femoral metaphysis which separated by bone marrow spaces . It was F. deltoidea on bone lipid peroxidation and the activities of antioxidant enzymes. It was found that the DC rats showed a significant increase in the levels of MDA with no significant difference in GPx and SOD activities as compared to the NC rats. A similar observation is seen in the DFD rats.F. deltoidea treatment.The injection of STZ resulted in a sharp drop in serum osteocalcin and ALP while serum DPD was significantly higher than the NC group . Althougn − 3 PUFA was significantly decreased while the ratio of n − 6 to n − 3 PUFA was significantly increased in the femur of DC rats. Similar observations were noticed in the DMET group. Remarkably, the total bone n − 3 PUFA increased and the n − 6 to n − 3 ratio decreased in the DFD group.The recorded data in F. deltoidea treatment (F. deltoidea treatment for delaying the progression of osteoporosis in diabetes. Consistent with our findings, it has been demonstrated that plants with antiosteoporotic activity significantly increased the thickness of cortical and trabecular bone as well as improved BMD in the rat (Kumar et al. It is well known that bone strength is determined by BMD and the spatial structure of trabecular bone (Wakabayashi et al. reatment . A greatF. deltoidea treatment is effective in delaying the pathogenetic progression of osteoarthritis in diabetic rats.Articular cartilage is known to lubricate the ends of bones, thus, changes in articular cartilage can ultimately result in osteoarthritis. We further observed, via H&E staining, that injection of STZ leads to a decrease in the thickness of the femoral articular cartilage, lower chondrocyte numbers, and increased tidemark roughness. Some reports explained the cartilage becomes hypocellular in the late stages of osteoarthritis (Hwang and Kim F. deltoidea can delay the progression of osteoarthritis.Both clinical and preclinical studies pointed out that the pathogenesis of osteopenia, osteoporosis, and osteoarthritis are influenced by oxidative stress (Guo et al. As oxidative stress can destabilise the balance between osteoblast and osteoclast activities, it provides a strong rationale for the measurement of bone turnover markers (Starup-Linde F. deltoidea treatment (F. deltoidea treatment.Another important finding from the present study is that the levels of serum osteocalcin increased while DPD decreased following reatment . Similarreatment . Althougreatment , the levreatment . Earlierreatment . Indeed,reatment . Of inten − 3 PUFA and an increase in n − 6: n − 3 ratio (F. deltoidea treatment. Recent work by Longo and Ward (n − 3 PUFA was possible to increase BMD and reduce the risk of fragility fracture. Previous works also demonstrate that n − 3 PUFA supplementation may have a protective effect on bone metabolism by decreasing bone resorption markers (Griel et al. F. deltoidea treatment against bone loss in STZ-treated rats.The present studies have also indicated that there is a close relationship between bone health and fatty acids profile. The DC and DMET rats with histological and biochemical evidence of bone loss and osteoarthritis-like disorder showed a significant decrease in total bone  3 ratio . These cand Ward  has showF. deltoidea has the potential to prevent bone loss in STZ-treated rats. Treatment with F. deltoidea significantly reduced the levels of fasting blood glucose, DPD activity, and increased insulin secretion, osteoblast activity, BMD, TbN, and BV/TV.Our data confirm that


KRAS) is one of the most common mutant oncogenes in non‐small cell lung cancer (NSCLC). The survival of patients with KRAS mutations may be much lower than patients without KRAS mutations. However, due to the complex structure and diverse biological properties, it is difficult to achieve specific inhibitors for the direct elimination of KRAS activity, making KRAS a challenging therapeutic target. At present, with the tireless efforts of medical research, including KRAS G12C inhibitors, immunotherapy and other combination strategies, this dilemma is expected to an end. In addition, inhibition of the downstream signaling pathways of KRAS may be a promising combination strategy. Given the rapid development of treatments, understanding the details will be important to determine the individualized treatment options, including combination therapy and potential resistance mechanisms.Kirsten rat sarcoma viral oncogene homolog ( The survival of patients with KRAS mutations may be much lower than patients without KRAS mutations. At present, with the tireless efforts of medical research, including KRAS G12C inhibitors, immunotherapy and other combination strategy, this dilemma of KRAS mutated NSCLC is expected to an end. Lung cancer, known as the most common cancer worldwide, remains a leading cause of cancer related deaths around the world, including China.KRAS and anaplastic lymphoma kinase (ALK), as the most commonly altered oncogenes acting as tumor driver genes.EGFR sensitive mutation , ALK or ROS proto‐oncogene 1 (ROS1) gene fusion have significantly improved survival time, with median OS of three years or more.KRAS mutation do not respond to the EGFR tyrosine kinase inhibitors (TKIs) mentioned above, even those with concurrent sensitive EGFR mutation, which could be attributed to continuous activation of the downstream Raf‐MEK‐ERK pathway.KRAS mutation respond poorly to traditional chemotherapy, leading to worse prognosis compared to the wild‐type group.KRAS‐mutated NSCLC patients has not yet been discovered. There is therefore an urgent clinical need to review the prognostic and predictive role of KRAS in NSCLC patients. In this study, we focus on the molecular biology, clinicopathological features and treatment progress of KRAS gene mutation, in order to improve our understanding of KRAS‐mutant NSCLC.During the previous decades, numerous genetic variations have been described in NSCLC, including epidermal growth factor receptor (EGFR), et al. are intracellular guanine nucleotide binding proteins (G proteins), belonging to the family of GTPases.KRAS, first described in NSCLC in 1984 by Santos KRAS mutation have been identified in the Chinese population. Generally, KRAS mutations which affect exons 2 and 3 are the most common, with G to C transition in codons 12 or 13, resulting in G12C (GGT → TGT) mutations (33.6%), followed by G12D (GGT → GAT) (23.9%), G12V (GGT → GTT) (22.1%), and G12A (GGT → GCT) mutation (7.1%).KRAS in lung adenocarcinoma ranges from 15% to 30%, including 12% of G12C.KRAS mutations are more common in young women diagnosed with adenocarcinoma who have a history of smoking.KRAS mutations have been found to be more common in males.KRAS mutations has been reported to reach between 25%–35% in smokers and 5% in nonsmokers.KRAS‐mutated patients are more likely to present with brain and lung metastases. Pleuro‐pericardial metastases are more common in patients with G12V mutations, while bone metastases occur more often in patients harboring the G12C mutation.Nine subtypes of KRAS mutations are speculated to be mutually exclusive with EGFR mutations and EML4‐ALK translocations. Recently, cases harboring KRAS mutations coexisting with EGFR or ALK have been reported more frequently, suggesting KRAS‐mutant NSCLC may be a molecularly diverse entity.et al. detected EGFR, KRAS and ALK genes in 282 patients simultaneously, and found that coexisting EGFR/KRAS or ALK/KRAS mutations accounted for 1.1% and 2.5%, respectively.KRAS mutations (co‐mutation), as suggested in a clinical study which included 330 patients with advanced KRAS‐mutant lung cancers.Generally, KRAS‐mutated adenocarcinoma , while not in squamous cell carcinoma.KRAS positive) showed a worse OS when KRAS mutations were present .P = 0.12).KRAS mutation also determine its prognostic utility. In a study involving 677 patients, Yu et al. suggested that patients with codon 13 mutation had an increased risk of death , while there was no statistically significant difference between the patients with G12C/G12V mutation and other mutation subtype (P =  0.74).Whether KRAS could be defined as a prognostic factor of NSCLC remains controversial, due to heterogeneity among different studies. Multiple meta‐analyses have been conducted in view of the disparity from individual studies. A meta‐analysis from 28 studies including 3620 patients suggested a lower survival rate of KRAS mutation has been found to co‐occur with TP53, STK11/LKB1 or CDKN2A in a large proportion of patients. When co‐mutated with STK11/LKB1, not TP53, patients have been reported to suffer even worse survival, as previously reported in a clinical study.On the other hand, as mentioned above, KRAS mutation could cause the downstream Raf‐ERK‐MEK pathway to persistently activate, leading to reduced efficacy of EGFR‐TKIs. Two published meta‐analyses have shown lower response rates of EGFR TKIs, but no impact on survival in patients with KRAS‐mutant NSCLC.KRAS mutations predict poor survival and efficacy of EGFR‐TKIs.KRAS mutation subtypes may lead to different prognosis. Zer et al. conducted a pooled analysis of 275 patients with KRAS mutation treated with EGFR‐TKIs, which showed that patients with G12C/G12V mutation had a poor prognosis, while G12D/G12S positive patients could benefit from EGFR‐TKIs.et al. showed that patients harboring G12C KRAS mutation had shorter progression‐free survival (PFS) and OS than those with non‐G12C KRAS mutations who were treated with EGFR‐TKIs, suggesting that non‐G12C KRAS mutations may act as wild‐type KRAS and wild‐type EGFR genotype.Being a downstream gene of EGFR, KRAS mutation. As far back as 1990, KRAS mutation was described as a negative prognostic marker for both OS and disease‐free survival (DFS) in lung cancer.KRAS mutation could be evaluated as a predictive factor to select patients for chemotherapy regimens remains highly controversial. Some researchers tend to believe that there is no relationship between KRAS mutation and therapeutic response. An IFCT‐0002 trial included stage I and II NSCLC patients to compare TC regimen (carboplatin and paclitaxel) and GC regimen (cisplatin and gemcitabine) in pre‐ or perioperative chemotherapy. Univariate analyses showed that KRAS status was associated with ORR. However, this association was not significant in the multivariate analysis. In the TRIBUTE trial, which compared first‐line paclitaxel/carboplatin plus erlotinib or placebo in advanced NSCLC patients, the objective response rate (ORR), time to progression (TTP) and OS did not differ according to KRAS mutation status.KRAS mutation was not predictive for worse response to chemotherapy, neither for PFS nor OS.et al. suggest that KRAS mutation appears to negatively affect sensitivity to first‐line platinum‐based chemotherapy in patients with advanced nonsquamous and EGFR wild‐type NSCLC, including ORR, disease control rate (DCR) and survival. In terms of subtypes, patients with mutations at codon 13 may perform worse than codon 12 even without statistical significance.KRAS‐mutated NSCLC, significantly improved ORR (P < 0.01) was observed for taxanes in patients with G12V, but not PFS or OS.et al. found that KRAS‐mutant NSCLC had a significantly shorter PFS. It has also been reported that patients with KRAS G12V mutation had the poorest PFS compared with non‐G12V mutant cases (P = 0.045).Cytotoxic chemotherapy is still recommended as the standard therapy for NSCLC patients with KRAS mutations in stage IV or earlier stage for specific chemotherapy regimens.Overall, there is still no evidence confirming the predictive value of KRAS‐mutant NSCLC may express a higher level of PD‐L1 protein and TMB compared with wild‐type tumors, which may reflect the efficacy of immune checkpoint inhibitors (ICIs) against PD‐1/PD‐L1. Confirming our conjecture, Scheel et al. found that PD‐L1 expression was highest in the tumor specimens with mutant KRAS, mutant TP53 and wild‐type STK11.KRAS mutations.Studies have reported that smoking‐related lung cancers are significantly associated with greater tumor mutation burden (TMB) and programmed death ligand 1 (PD‐L1) expression. Therefore, because of the correlation with smoking history, we suggest that et al. investigated the functional significance of PD‐1/PD‐L1 blockade in KRAS‐mutant lung adenocarcinoma. They found that PD‐L1 was upregulated by KRAS‐G12D mutation through pERK signaling, inducing the apoptosis of CD3+ T cells. Blockade of PD‐1/PD‐L1 pathway may be a promising therapeutic strategy for KRAS‐mutant lung adenocarcinoma.et al. indicated that KRAS mutations are associated with an inflammatory tumor microenvironment and tumor immunogenicity, together with an increased proportion of PDL1/CD8 tumor infiltrating lymphocytes (TILs), which may reflect a better response to ICIs.Chen KRAS‐mutant NSCLC than in wild‐type NSCLC. However, there was no significant difference reported in ORR, PFS and OS in terms of KRAS mutation status, or in the mutation subtypes.et al. reported that TP53 and KRAS mutations could be potential predictors of anti‐PD‐1/PD‐L1 therapy.et al. also found that KRAS‐mutant patients had a better response to PD‐1 inhibitors than patients with KRAS wild‐type.KRAS‐mutant subgroup .KRAS‐mutant chemorefractory NSCLC patients.KRAS positive patients from the KEYNOTE‐042 trial were presented at the European Society for Medical Oncology (ESMO) Immuno‐Oncology Congress. Clinical data from this exploratory analysis showed that pembrolizumab reduced the risk of death by 58%  in patients with any KRAS mutation and by 72%  in patients with KRAS G12C mutation compared to chemotherapy. In addition, in the pembrolizumab arm, ORR and PFS was significantly elevated in the KRAS‐mutant population than the wild‐type population .To understand the relationship between ICIs and oncogenic driver genes, a retrospective study was conducted from the IMMUNOTARGET registry. In certain subgroups, driver genes were found to be positively associated with PD‐L1 expression  and PFS was longer .KRAS‐mutant lung adenocarcinoma patients exploring the benefits of ICIs are still ongoing . It is anticipated that ICIs will bring new hope for KRAS‐mutant NSCLC patients in the future.Other clinical trials for KRAS mutation in NSCLC, more and more attention is being paid to the therapy. However, the development of new drugs which directly inhibit KRAS has been challenging because of the complexity of KRAS biochemistry, such as SML‐8‐73‐1 (compounds that target the guanine nucleotide binding pocket) or ARS‐853 .KRAS mutation could cause constitutive activation of KRAS, leading to the persistent stimulation of downstream signaling pathways that promote tumorigenesis. Therefore, inhibition of the downstream pathways of KRAS may be alternatives, including Raf‐MEK‐ERK and PI3K‐AKT‐mTOR pathways.Due to the higher incidence of BRAF‐mutant melanoma, and are recommended for BRAF‐mutant NSCLC.KRAS‐mutant NSCLC, since KRAS and BRAF mutation are usually mutually exclusive. Other Raf inhibitors may be alternatives. Sorafenib is a multikinase inhibitor with a dual antitumor effect enabling it to block the Raf/MEK/ERK pathway and inhibit VEGFR and PDGFR.KRAS mutation, six week DCR was 52.6% and median PFS was 2.3 months.KRAS‐mutant subgroup compared with the placebo in the pretreated nonsquamous NSCLC patients, with OS failed.BRAF plays an important role in regulating the MAPK/ERK signaling pathway, affecting cell division, differentiation and secretion, with a mutation rate of 1%–4% in NSCLC.KRAS mutations.Working as a downstream effector of mitogen‐activated protein kinase (MAPK) pathway, MEK may be a suitable target. Preclinical data has suggested that inhibition of MEK1/2 could be an effective strategy for the treatment of tumors driven by KRAS‐mutant NSCLC patients, compared with docetaxel.KRAS positive and negative NSCLC, 11 patients received selumetinib alone and 30 patients received erlotinib and selumetinib. Unfortunately, in the KRAS‐mutant cohort, the combination did not improve ORR, PFS, and OS. Instead, more serious adverse events (AEs) were found in patients treated with combination therapy. Interestingly, there was an increased level of expression of PD‐1 on CD8+ cells after treatment with selumetinib, suggesting benefits from the combination with PD‐1/L1 antibody.Selumetinib (AZD6244) is a potent and highly selective MEK1/2 inhibitor, showing antitumor activity in xenograft tumors in preclinical studies.KRAS mutation. The median PFS was 4.1 months and median OS was 11.1 months. Subgroup analysis showed that the efficacy of patients with non‐G12C mutations was better, including ORR (37% vs. 26%), PFS (4.1 vs. 3.3 months) and OS (16.3 vs. 8.8 months) (Abstract #9021). In conjunction with therapeutic blockade of the PI3K/mTOR pathway may be another available strategy due to extensive crosstalk between both pathways. However, clinical outcomes showed minimal activity in KRAS‐mutant NSCLC receiving pan‐PI3K inhibitor buparlisib (BKM120) and trametinib.Trametinib was initially approved for the treatment of metastatic melanoma with BRAF V600E or V600K mutations, belonging to the same molecular class as selumetinib. As monotherapy, trametinib has shown limited efficacy and similar survival outcome compared with docetaxel.KRAS‐mutant NSCLC are still underway . In general, emphasis of MEK inhibitors would be combination therapy, especially with chemotherapy, which should be validated in phase III clinical studies.Other MEK inhibitors, such as binimetinib (MEK162), PD‐0325901 and RO4987655, have shown their safety in phase I trials.KRAS‐mutant NSCLC due to preclinical data.KRAS‐mutant population have been reported.The PI3K/Akt/mTOR pathway is a parallel signal transduction pathway, which was thought to be a target for KRAS could cause the activation of tumor suppressor genes INK4a/ARF/p16, leading to hyperactivation of the GTPase RHOA by MEK1/2 and ERK1/2.KRAS NSCLC cells.VS‐6063) is a second‐generation inhibitor of FAK. In a phase 2 clinical trial, KRAS‐mutant NSCLC patients were assigned to defactinib 400 mg orally b.i.d. based on TP53 and CDKN2A mutation status, showing the PFS rate at 12 weeks of 31% after extensive pretreatment with well tolerated side effects.FAK is a downstream effector of KRAS signaling, playing an important role in cell migration. Mutation of KRAS‐mutant cell lines.KRAS‐mutant NSCLC in phase II clinical trials.As a molecular chaperone, HSP90 assists in the folding and maturation of different types of oncoproteins, which play an important role in tumor formation and growth. Inhibition of HSP90 was thought to be another potent therapeutic target by disrupting proper functioning of oncogenic proteins, including EGFR, HER‐2 and EML4‐ALK.KRAS‐mutant NSCLC population. Therefore, drugs targeting the G12C variant could have a major therapeutic impact. The mutant cysteine of KRAS G12C is adjacent to a pocket (P2) of the inactivated KRAS. Thus, many covalent inhibitors have been focused on the development.As previously described, G12C mutations account for almost 50% of the KRAS G12C mutation, ARS‐1620 showed tumor regression, and effectively inhibited the downstream ERK phosphorylation and activated apoptosis.ARS‐853 is a selective, covalent inhibitor of KRAS G12C, being the first direct KRAS inhibitor. In cell models, ARS‐853 and its analogues covalently interact with the GDP‐bound mutant KRAS G12C protein, transforming it into an “inactivated” conformation. However, pharmacokinetics (PK) results have not been verified in vivo due to an adequate drug threshold needed in KRAS cycles.KRAS G12C mutations, most of whom had previously received at least two‐lines of therapy, were enrolled in an open‐label phase I study of AMG 510 (NCT 03600883). Among the 23 NSCLC patients with evaluable efficacy in all dose cohorts, 11 had tumor shrinkage (PR), reaching the ORR of 48% and DCR of 96%, and among the 13 evaluable patients treated with 960 mg AMG 510, seven had tumor shrinkage (PR), reaching the ORR of 54% and DCR of 100%.KRAS G12C mutation. In vitro, AMG 510 combined with RMC‐4550, another SHP2 inhibitor, showed a strong synergistic effect on tumor cells.The surface of KRAS‐G12C has a groove formed by the steering of His95, which could be occupied by aromatic hydrocarbons to promote binding to KRAS G12C protein. Among numerous screening drugs, AMG 510, which is structurally related and overlapped with ARS‐1620, is the preferred candidate for binding to His95 grooves.KRAS G12C mutant solid tumor. In vivo, MRTX 849 has displayed broad‐spectrum antitumor activity in KRAS‐mutant solid tumors, including NSCLC.KRAS G12C mutation. Preliminary clinical data was presented at the 2019 AACR‐NCI‐EORTC meeting, which showed ORR of 60%  at the highest dose of 600 mg b.i.d., with one DLT.MRTX849 is a specifically optimized oral inhibitor, keeping KRAS G12C in its inactive GDP‐bound status and inhibiting KRAS‐dependent signaling pathways in KRAS mutations such as G12D/G12V or concurrent mutation of other genes such as TP53, for whom further clinical decision‐making should be considered.Studies on other new drugs targeting KRAS are still ongoing, including BI 1701963, a pan‐KRAS inhibitor and LY3499446 (NCT #04165031) in phase I clinical trials (Table KRAS‐mutated NSCLC. Faced with numerous choices, future investigation should focus on selecting appropriate drugs for appropriate population and resistance mechanisms of first generation KRAS G12C inhibitors.In conclusion, although KRAS has previously been defined as an untreatable target, especially G12C mutation, clinical data of AMG 510/MRTX 849 targeting KRAS and new combined strategies targeting the downstream signaling pathways of KRAS or related pathways appear promising. In addition, immune checkpoint inhibitors have been proven effective in