The efficacy of perampanel (PER) in pediatric epilepsy with specific etiologies has not been well established. Here, we investigated outcome and predictors of PER treatment in a pediatric cohort with known and presumed genetic etiology.We included pediatric patients with potential genetic epilepsy who received PER treatment and underwent whole‐exome sequencing (WES) from January 2020 to September 2021. All patients were followed up for >12 months.P = 0.042) was a negative predictor of treatment response. However, the seizure onset age, positive WES results, and number of ASMs before PER administration were not significantly. Thirteen carriers with variants in the SCN1A gene showed a better response compared to eight patients with other sodium channels (P = 0.007), and to the other 45 patients with positive WES results . Adverse events were only reported in 23 patients, the most common being emotional problems.A total of 124 patients were included. Overall response rates were 51.6% and 49.6% at 6 months and 12 months, respectively. Pathogenic or likely pathogenic variants in 27 multiple genes were detected among 58 patients (46.8%) by WES. On performing multivariate logistic regression analysis, only developmental delay (OR = 0.406, SCN1A gene.PER is safe and efficacious in pediatric patients with known and presumed genetic etiology. The response rate is comparable to that reported in other pediatric populations, and lower among those with developmental delay. A gene‐specific response to PER is found along with better efficacy links to pathogenic variants in the  SCN1A pathogenic variants and presents with drug‐resistance and neurodevelopmental comorbidities.SCN8A or pathogenic variants in the KCNQ2 gene, traditional sodium channel blockers can reduce seizures.Epilepsy is a common chronic neurologic disorder in children. About one out of 150 children are diagnosed with epilepsy during the first 10 years of their life.Perampanel (PER) is a selective noncompetitive AMPA‐receptor antagonist approved for the treatment of focal onset seizures for patients ≥4 years of age and primary generalized tonic–clonic seizures for patients ≥12 years of age. Several studies demonstrated PER is efficient and safe in patients under 4 years of age with epilepsy.Our study aims to investigate the efficacy and safety of PER in a cohort of pediatric epilepsy with known and presumed genetic etiology. The treatment outcome and its predictors were evaluated after following up for >12 months. The impact of gene‐special etiology on treatment response was also examined for those with definite genetic etiology revealed by the whole‐exome sequencing (WES).This observational, retrospective study was conducted in the second affiliated hospital of Zhejiang university. It was approved by the ethics committee in our hospital (2021‐0605/IR2021398). We extracted clinical characteristics from the medical database of pediatric patients (<18 years of age) with focal or generalized epilepsy who received PER treatment during January, 2020–September, 2021. Patients with insufficient clinical data or who were absent for follow‐up were excluded.Epilepsy with potential genetic etiology was defined according to the International League Against Epilepsy (2017). Inclusion criteria for patients were as follows: (1) neonatal or infantile onset epilepsy (exclude acquired etiologies); (2) have a family history of epilepsy (≥1 first degree relative or ≥2 second degree relatives); (3) unknown causes of developmental and epileptic encephalopathy by routine inspection; (4) combination with developmental delay or autistic phenotype, especially before seizure onset; (5) combination with apparent deformity, growth retardation, or feeding difficulties; (6) combination with cortical malformations, which is evaluated by magnetic resonance imaging (MRI) scan with epilepsy protocol; (7) accordant with particular phenotypes (such as tuberous sclerosis and Dravet). Acquired epilepsy as the etiology of immune, infection, stroke, tumor, trauma, and any other un‐assumed genetic reason were excluded. These patients' sample, with potential genetic etiology, was used for WES.Data retrieved from the electronic database were gender, age, age at onset of seizure, seizure features , number of all ASMs taken so far (including current medication), head MRI, electroencephalogram, and results of WES sequencing according to ACMG guidelines. Initial doses of PER were individualized according to patients' age, weight, and clinical condition: at 2 mg once daily (patients ≥4 years and weights ≥30 kg); at 1 mg once daily ; and at 0.5 mg once daily (patients <4 years and weights <20 kg).PER plasma concentrations were measured in 79 patients using ultra‐performance liquid chromatography. We calculated the concentration‐to‐dose (CD) ratio (ng/ml per mg/kg) to adjust for the body weight. The data were compared between those with versus without enzyme‐inducing anti‐seizure medications (EIASMs). EIASMs included carbamazepine, oxcarbazepine, phenytoin, phenobarbital, and topiramate.SCN1A and other sodium ion channels genes, SCN1A and other ion channel genes, SCN1A and other genes.We evaluated treatment outcomes and tolerability at the last outpatient clinic or through telephone follow‐up because of the COVID‐19 pandemic. We followed the efficacy and tolerability at 6 and 12 months after PER treatment. The responder was defined as ≥50% reduction in seizure frequency. Reasons for drug withdrawal were recorded by the family's reports. For the gene‐specific response to PER, we categorized genes according to the protein function.P < 0.05. We performed multivariate logistic regression to analyze factors influencing the response rate of perampanel treatment (P < 0.1).Statistical analyses were performed with SPSS Version 26 (IBM). Baseline characteristics were given by descriptive statistics. The continuous data were presented as medians, and categorical data were presented as numbers (%). We used the Mann–Whitney U‐test to compare subgroups and continuous variables and the Pearson's chi‐square test or Fisher's exact test for categorical variables. Differences were defined as significant at n = 9), focal seizure without awareness (n = 63), and focal to bilateral tonic–clonic seizures (n = 4). Forty‐eight patients  had generalized seizures, including 15 tonic–clonic seizures, nine myoclonic seizures, six epileptic spasms, six tonic seizures, and two absence seizures. On PER administration, it was often combined mostly with valproate (n = 53), followed by levetiracetam (n = 37), and lamotrigine (n = 16).A total of 124 patients, who were classified as potential genetic etiology and performed WES, were included , and the seizure freedom rate was 24.6% (30/122). Thirty‐five  patients discontinued PER due to lack of efficacy. At 12 months, three patients were further lost to follow‐up. The overall response rate was 49.6% (59/119), and the seizure freedom rate was 26.1% (31/119). Seven additional patients discontinued PER due to a lack of efficacy during 6–12 months after PER administration. The retention rates were 71.3% (87/122) at 6 months and 64.7% (77/119) at 12 months.P = 0.042) showed negative correlation with the treatment response , dizziness (n = 5), fatigue (n = 3), ataxia (n = 3), enuresis (n = 2), and weight gain (n = 2). The mean CD ratio (ng/mL per mg/kg) did not show a statistical difference between patients with adverse events and those without adverse events.Adverse events were reported in 18.5% of patients (23 of 124 patients), including emotional problems , in PER responders versus non‐responders , or in those with versus without adverse effects .PER plasma concentrations were measured for 156 times in 79 patients administering a median perampanel dose of 2 (1–8) mg. The PER plasma concentration was 334.2 ± 218.3 ng/mL , with a CD ratio of 2984.8 ± 2166.1 ng/mL per mg/kg. The CD ratio was significantly different between patients with and without EIASMs. We observed a lower mean CD ratio in patients on EIASMs than in those not on EIASMs .They were divided into six groups: ion channel, enzyme/enzyme modulator, cell adhesion molecule, signal transduction, membrane trafficking, and unclassified Table . HoweverSCN1A), other sodium channels , and other ion channels. Interestingly, the response rates were different between the SCN1A gene and other sodium channel genes (SCN2A and SCN8A). Patients with the SCN1A gene were more likely to respond to PER treatment than those with other ion channel genes (P = 0.018), and those with other sodium channel genes , and the clinical features in these two groups did not differ significantly . Patients with variants in the SCN1A gene displayed marked efficacy. Furthermore, among the 58 patients with positive results of WES, the multivariate logistic regression analysis showed that carriers with variants in the SCN1A gene had a better response compared to those with variants in other genes .We further divided the ion channel group into three subgroups: Nav1.1 .The enzyme/enzyme modulator group was also divided into two subgroups: enzyme and enzyme modulator. No significant between‐subgroup difference was found, but patients in the enzyme subgroup, including those with genes, such as Our real‐world study demonstrated that PER is well‐tolerated and effective in children with known and presumed genetic epilepsy. The response rate and seizure freedom rate reached 49.6% and 26.1% at 12 months, respectively, which is comparable with that reported in other pediatric populations, and adverse events were lower when compared to previous studies.The positive rate by WES in our group was nearly 50%, which was higher than those in previous studies.SCN1A gene had good outcomes after PER treatment more often than patients with other sodium channel genes , and clinical features, such as the age of first seizure onset and developmental delays, had no between‐group statistical significance. For further studies, we found that carriers with variants in the SCN1A gene showed a better response compared to patients with other genes discovered in our group. SCN1A gene variation is a main cause of Dravet syndrome. In a large retrospective survey of 574 patients with Dravet syndrome, only 9.4% were seizure free in the previous 3 months.SCN1A‐related patients were diagnosed with Dravet syndrome, and 63.6% (7/11) of them responded to PER treatment. Previous case series studies displayed a similar response rate.SCN1A pathogenetic variant  was in line with our findings.SCN1A gene with PER treatment, but no discrepant distribution of effective and ineffective variants were found . The expression location of different types of neurons and the functional change of variants between the SCN1A gene and other voltage‐gated sodium channel genes are noted discrepancies. Different effects of different sodium channels on PER might be related to their discrepancies in distribution and functional changes.Interestingly, we found that patients with the GNAO1 gene, reached a 100% seizure reduction. Interestingly, Nissenkorn et alGNAO1 gene. Including ours, there have been six reported cases. The similar findings warrant further investigation for this rare type of DEE.PER partially suppressed seizures and involuntary movements in two patients with early‐onset epileptic encephalopathy caused by the GNAO1 gene encodes the alpha subunit of the heterotrimeric guanine nucleotide‐binding proteins (Gαo), and variants in GNAO1 gene have been demonstrated with two main phenotypes: Epileptic encephalopathy, early infantile, 17  and Neurodevelopmental disorder with involuntary movements . These two phenotypes showed limited response to pharmacological treatments and had poor outcome with severe development delay.GNAO1 pathogenic variants associated with epilepsy result in a loss‐of‐function biochemical behavior related to the control of cAMP levels.GNAO1‐related epilepsy has not been studied before; it needs large samples and further mechanistic research.The Naturally, we should not ignore that PER clearance can be markedly increased by the CYP3A4 enzyme inducers like carbamazepine, oxcarbazepine, phenytoin, phenobarbital, and topiramate (EIASMs).There were several limitations in our study. This was an uncontrolled, individual observational study. Despite having the largest reported sample to date, the heterogeneity of epilepsy phenotypes and genotypes lead to a larger number of patients demonstrating a responder difference among diverse genes. It was also a retrospective study, which lacked some details of medical records such as the accurate seizure frequency of each patient, which limited the ability to test a priori hypotheses further. Prolonged follow‐up and larger samples are needed to determine the gene‐specific response to PER.In conclusion, this long‐time real‐world study supports the use of PER in treatment of children with known and presumed genetic epilepsy. Further analysis based on gene‐specific epilepsy demonstrated a valuable direction for the precision treatment of PER. Therefore, a definite genetic diagnosis is important in PER usage. For more‐profound research, larger samples and longer follow‐up periods for each group of genes are required.Pu Miao, Jianhua Feng, Shuang Wang contributed to the conception of the study; Yanfang Li performed the experiment; Pu Miao, Shuang Wang, Qunyan Su contributed significantly to analysis and manuscript preparation; Pu Miao, Xueying Zhu, Ye Wang performed the data analyses and wrote the manuscript; Wenqin Jin, Lingyan Yu, Sha Xu helped perform the analysis with constructive discussions.The project is supported by the grants from the National Natural Science Foundation of China 82101515 and Public Projects of Zhejiang province (Grant Number: 2021C03104).The authors declare that there is no conflict of interest.Ethics approval and consent to participate. The study was approved by the local ethics committee (2021‐0605/IR2021398), and the informed consent to participate was obtained from participants.Not applicable.Figure S1. Representation of published and our cohort's variants treatment response across the SCN1A protein. The alpha subunit consists of four homologous domains (D1–4) each formed of six transmembrane segments (S1–S6). Segment 4 represents the voltage sensor and segments S5–6 the pore region. Red rhombus denotes effective variants by PER, blue triangle denotes non‐effective variants by PER.Click here for additional data file.Table S1. The phenotype and genotype of patients with positive WES results.Table S2. Gene classification according to protein function.Table S3. The clinical features in these two groups.Click here for additional data file.


Insulin resistance and obesity have been associated with irisin, a protein in fat cells. The levels of irisin in patients with type 2 diabetes mellitus (T2DM) were significantly lower than those in non‐diabetics. This study aimed to examine the relationship between serum irisin levels and endothelial dysfunction in patients with T2DM.There were 90 participants in this study. We matched 65 patients with T2DM with 25 healthy control participants. A series of tests were performed on the participants, including fasting blood glucose, 2 hours postprandial blood glucose, glycated haemoglobin, triglycerides (TG), total cholesterol, high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol (LDL‐C), TG/HDL‐C ratio and albumin/creatinine ratio. In addition to measuring high‐sensitivity C‐reactive protein (hs‐CRP). Enzyme‐linked immunosorbent assay (ELISA) technique was used for estimating irisin concentrations.Flow‐mediated dilation (FMD) was significantly lower in patients with T2DM; however, there was a non‐statistically significant difference between healthy controls and patients with T2DM regarding serum Irisin level. CRP and LDL levels were inversely correlated with circulating irisin levels. In a stepwise regression analysis, only the hs‐CRP and LDL were statistically significant in predicting irisin level.In patients with T2DM, serum levels of irisin were inversely correlated with hyperglycaemia, body mass index and per cent body fat; this suggests that detecting irisin levels early can prevent cardiovascular diseases from progressing. According to the study results, serum irisin serves as a predictive marker for early cardiovascular disease, thus preventing the disease from progressing. There is a need for further research in order to understand how irisin contributes to the development of atherosclerosis and the development of diabetic complications. This study aims to examine the relationship between serum irisin levels and endothelial dysfunction in patients with T2DM. There were 90 participants in this study. We matched 65 patients with T2DM with 25 healthy control participants. In patients with T2DM, serum levels of irisin were significantly correlated with hyperglycemia, BMI, and percent body fat; this suggests that detecting irisin levels early can prevent cardiovascular diseases from progressing. In addition, to determine whether irisin levels in serum could be used as a new indicator for ED.22.1The study was conducted at the Beni‐Suef University Hospital , Internal Medicine Department, Diabetes and Endocrine Clinic. The study included 65 patients with T2DM. The subjects were matched with 25 healthy control subjects. The Ethical Review Committee of the Faculty of Medicine, Beni‐Suef University, approved this study. Participants provided written informed consent.2.2Individuals with T2DM between the ages of 40 and 60, with varying BMIs, and undergoing either oral treatment (sulfonylurea and/or Dipeptidyl peptidase 4 inhibitors (DPP4I)) or insulin therapy. The study excluded patients with congestive heart failure, valvular heart disease, acute coronary syndrome, atrial fibrillation, smokers, nephrotic syndrome, stroke, acute inflammation, liver disease, kidney disease, thyroid illness, pregnant women and those under 40 years of age. In addition, patients with clinical angiopathy, including micro‐ and macroangiopathy, as well as hypertension, were excluded from the study. Furthermore, patients who received statins, diuretics, immunomodulatory agents, metformin and pioglitazone were excluded from the study.2.3The individuals underwent a full medical history and a clinical examination. All recruited individuals were required to have an office blood pressure (BP) of 130/80 mmHg.The following anthropometric measurements were taken: weight, height and body mass index (BMI). Bioelectrical Impedance Analysis (BIA). The BIA was conducted using a body fat analyser model No: BT‐905. The participants were advised to avoid eating or drinking within 4 h of the test, to avoid exercising within 12 h h of the test, to urinate within 30 minutes of the test, to avoid drinking alcohol within 48 h of the test, not to take diuretic medications within 7 days prior to the test, and to avoid testing in a premenstrual period.A routine laboratory investigation was conducted on all participants, including fasting blood glucose (FBG), 2 h postprandial (2hpp) blood glucose, glycated haemoglobin (HbA1c), triglycerides (TG), total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐C), low‐density lipoprotein cholesterol (LDL‐C) and albumin/creatinine (A/C). Analyses were conducted using the Bechman CX5 automated chemistry analyser. As a surrogate marker for ED, small dense LDL (sdLDL) was calculated through the ratio of TG to HDL‐C. High‐sensitivity C‐reactive protein (hs‐CRP) was quantified using chemiluminescent immunoassay.2.4Endothelial function was evaluated by measuring FMD in the right brachial artery with the patient in the supine position and abduction of the right arm. Four experienced technicians conducted evaluations in a dimly lit room for about 30 min. Using B‐mode, the brachial artery diameter was measured continuously for 1 min to obtain the baseline diameter (D1), with the pulsed Doppler signal at a 60 angle to the vessel. Next, a 5 min vascular occlusion period was obtained by inflating a blood pressure cuff on the right forearm up to a pressure of 250 mm Hg. Thereafter, the maximum post‐occlusion vascular diameter (D2) was measured within 3–5 min after deflation of the blood pressure cuff, to avoid the bias of maximum hyperaemia. The FMD value was obtained from the following equation reported by Celermajer et al,2.5Irisin serum concentration was measured using Irisin  – ELISA Assay Kit, with a detection range of Irisin: (0.5–7.8 pg/L), according to manufacture instructions.2.6p‐value was used to evaluate the significance of the results, which can be classified as non‐significant when the p‐value is >.05, significant when the p‐value is ≤.05, and highly significant when the p‐value is ≤.001.The data were analysed using SPSS v. 22  for Windows. Quantitative variables were presented as mean + standard deviation (SD), while qualitative variables were presented as numbers (No.) and percentages (%). Quantitative variables were compared using an independent sample t‐test and a one‐way analysis of variance. Categorical data were compared using chi‐square tests. To determine the relationship between the various quantitative variables, a Pearson correlation test was used. A regression analysis was conducted to identify the predictor factors that may affect the level of FMD and irisin. The quantitative data for each of the study groups were tested for normality using a one‐sample Kolmogorov–Smirnov test before being subjected to inferential statistical tests. A 3p > .05).An overview of the clinical characteristics and biochemical data of diabetic and non‐diabetic subjects can be found in Table p‐values≤.05). Furthermore, circulating levels of irisin were inversely correlated with levels of hs‐CRP and LDL‐C that were sensitive to high levels of irisin   Table .According to simple linear regression analysis, FBG, LDL‐C, TC, TG and HbA1c were statistically significant predictors of FMD concentration (each variable separately).We conducted multiple regression analyses to predict FMD based on age, irisin, hs‐CRP, fasting blood glucose (FBG), 2hpp, creatinine, LDL‐C, TC, TG, HbA1c, BMI and fat percentage. FMD is statistically significantly predicted by HBA1c, BMI and fat percentage only.p‐value <.05).Stepwise regression was used to predict FMD Table  based onp‐value <.05).The level of irisin was predicted using multiple regression using age, FMD, hs‐CRP, FBG, 2hpp, creatinine, LDL‐C, TC, TG, HBA1c, A/C, duration of disease, BMI and BIA. This study found that only hs‐CRP, LDL‐C and A/C variables significantly predicted irisin levels . This study did not include insulin resistance, as it fell outside the scope of its purpose, which was to evaluate serum irisin levels in relation to ED among people with T2DM.The men and women in our study were classified according to their body fat percentage by BIA into the following categories: very low body fat, low body fat, optimal body fat, moderately high body fat and high body fat. As assessed by BIA, we noted a non‐statistically significant difference in body fat percentage between males and females. Most study participants fell into the moderate‐ to high‐fat percentage category. Despite higher irisin levels in patients with high body fat percentages, these differences were not statistically significant . This study found no statistically significant difference in circulating Irisin levels between patients with T2DM and healthy controls, in contrast to previous studies which showed lower levels of Irisin in patients with a new diagnosis of T2DM.Most laboratory and patient criteria were statistically different between patients with T2DM and controls  that occurred in diabetic patients as assessed by FMD with LDL.Regarding the relation between different FMD levels with Irisin, we found that most of the patients who had severe FMD (less than 10) had reduced irisin levels, while other patients with mild or moderate FMD had different ranges of irisin levels, some had reduced irisin level, and others had normal irisin level. Following our results, the reported circulating irisin levels were positively correlated with endothelium dysfunction, and significantly reduced in newly diagnosed T2DM without clinical angiopathy, and also, irisin levels could be a marker for detecting early‐stage of angiopathy in T2DM.In the current study, there was a negative linear correlation between FMD and HbA1c and with FBG, which means that poor glycaemic control is linked to more ED and complicated by atherosclerosis so accordingly decreasing FMD. It had been reported that ED has a positive association between circulating irisin levels, fasting and 2hpp.Liu et al., who observed an inverse relationship between hyperglycaemia and circulating irisin levels.Park et al., reported that circulating irisin levels were negatively correlated with FBG levels.Stengal et al. did not find a correlation between serum irisin and blood glucose levels but found that serum irisin was positively correlated with insulin levels.Serum Irisin level was affected by increasing FBG, which can be agreed with By comparing the serum levels of irisin between T2DM patients with and without MVD (macrovascular diseases), it was found that irisin decreased more significantly when MVD existed. The findings still suggested that irisin would be a potential target for monitoring and intervention of T2DM and its associated vascular complications.Park et al. reported that circulating irisin levels were positively associated with body fat mass in the whole cohort and with BMI in the subgroup of obese individuals.Irisin is positively correlated with triglycerides, TC and LDL‐C. We studied T2DM patients according to BMI and percentage of body fat using bioelectrical impendence analysis and noticed that serum Irisin level increased in obese patients, which was explained by other studies as increasing adipose tissue  in increased irisin level which matched with other studies. Similarly, Liu et al. found a positive correlation between BMI or body fat mass and circulating irisin levels.Irisin levels were correlated with body mass index (BMI), and fat mass and authors described adipose tissue as the main source of circulating irisin in such patients.In obese individuals with other cardiovascular risk factors, higher serum irisin levels were found to be correlated with high BMI.The results showed higher body fat, visceral fat and lower muscle mass in diabetic patients and that circulating irisin was positively associated with muscle mass. Recently, some studies showed that irisin might be associated with the protection of endothelial function.We reported that the obesity prevalence is generally higher in women than in men in all age groups, and there is also a sex difference in body fat distribution. Sex differences in obesity can be explained in part by the influence of gonadal steroids on body composition and appetite; however, behavioural, socio‐cultural and chromosomal factors may also play a role.2, circulating irisin had positive associations with fat‐free mass and a positive trend with BMI.Several studies have investigated the relationship between circulating irisin and BMI. In a study of 117 healthy middle‐aged women with BMI ranging from 20.0 to 47.7 kg/m5In conclusion, the results of the study suggest that serum irisin may have clinical utility as a predictive measure for early cardiovascular disease. Therefore, it may be used as a new early indication of ED that can prevent cardiovascular disease from progressing. As irisin is a relatively new marker of ED, it may be worthwhile to conduct additional studies on irisin that take into account endothelin, prostaglandins, angiotensin II, E selectin and adhesion molecules in the future. A future research study should explore the role of irisin in insulin resistance, atherosclerosis and diabetes complications.Thoraya Mohamed Ahmed: Investigation . Mahmoud Nassar: Writing – original draft . Hanaa Ahmed Abdallah Mohamed: Investigation . Khaled E ElHadidy: Supervision . Hanan Mohamed Farhan: Investigation . Ahmed Sayed Abd El Basset: Investigation . Riem M Elmessiery: Writing – original draft . Mahmoud Farid Kamel: Methodology .No funding for this research.No conflict of interest.The manuscript has been read and approved by all the authors, the requirements for authorship, as stated earlier in this document, have been met and each author believes that the manuscript represents honest work.


Studies on robotic total gastrectomy (RTG) are currently limited. This study aimed to compare the intraoperative performance as well as short‐ and long‐term outcomes of RTG and laparoscopic total gastrectomy (LTG).n = 161) or laparoscopic (n = 636) total gastrectomy between October 2014 and October 2021. The two groups of patients were matched 1:3 using the propensity score matching (PSM) method. The intraoperative performance as well as short‐ and long‐term outcomes of the robotic (n = 147) and the laparoscopic (n = 371) groups were compared.A total of 969 patients underwent robotic (p = 0.008), and the total number of lymph node dissections was higher  in the RTG group compared with the LTG group. More lymph node dissections at the upper edge of the pancreas were performed in the RTG group than in the LTG . Additionally, postoperative recovery indicators and laboratory data were greater in the RTG group than those in the LTG group, while postoperative complications were comparable between the two groups . For overweight or obese patients with body mass indexes (BMIs) ≥25, certain clinical outcomes of the RTG remained advantageous, and no significant differences in three‐year overall survival (OS) or relapse‐free survival (RFS) were observed.After matching, the estimated intraoperative blood loss was lower (80.51 ± 68.77 vs. 89.89 ± 66.12, Robotic total gastrectomy demonstrated better intraoperative performance, could improve the short‐term clinical outcomes of patients, and was more conducive to patient recovery. However, the long‐term efficacies of the two approaches were similar. Robotic surgical systems may reduce surgical stress responses in patients, allowing them to receive postoperative chemotherapy sooner. Robotic total gastrectomy demonstrated better intraoperative performance, could improve the short‐term clinical outcomes of patients, and may reduce surgical stress responses in patients. The long‐term efficacies of the two approaches were similar. D2 lymph node dissection, using Roux‐en‐Y digestive tract reconstruction, is suitable for all advanced patients, including in nodes No. 1–7, No. 8a, 9, 11p, 11d, and 12a.In this retrospective study, we used propensity score matching (PSM) analysis to compare the differences between robotic and laparoscopic total gastrectomy in intraoperative performance as well as short‐ and long‐term outcomes. Focus on the characteristics of robot surgery system in total gastrectomy, explore its safety and effectiveness, and analyze the long‐term oncology results. In addition, further study the advantages of robot surgery for overweight and obese patients. We aimed to investigate whether some underlying mechanisms of robotic total gastrectomy may reduce the surgical stress response and improve tumor prognosis for gastric cancer patients.22.1This was a retrospective study and was reviewed by the appropriate ethics committee, ethics number: QYFY WZLL 27151, all patients signed informed consent. The inclusion criteria included patients who underwent robotic or laparoscopic total gastrectomy at our center from October 2014 to October 2021; aged 18–75 years; diagnosed with gastric adenocarcinoma by gastroscopic biopsy; had cT2‐4aN0/+M0 (patient staging was adjusted according to the 8th edition of the American Joint Commission on Cancer (AJCC) staging systemThe surgical method, either laparoscopic gastrectomy (LG) or robotic gastrectomy (RG), was decided by each patient. Both laparoscopic and robotic surgeries were performed by the same surgical team, and all surgeons had performed either more than 100 laparoscopic total gastrectomy (LTG) or 100 robotic total gastrectomy (RTG) surgeries.As this was a retrospective study, patients were screened according to rigorous inclusion and exclusion criteria. To eliminate confounding factors and resolve possible patient selection biases, the following variables were used for PSM: age, sex, BMI, ASA grade, Nutrition Risk Screening 2002 (NRS‐2002 score), tumor size, tumor location, pathological stage, and tumor differentiation. We performed 1:3 matching using a 0.2 caliper width. Ultimately, 147 and 371 patients were included in the RTG and LTG groups, respectively. After matching, the baseline data of the two groups were balanced.2.2All patients in this study underwent the perioperative Enhanced Recovery after Surgery (ERAS) protocol in our center,All patients received intracorporeal mechanically stapled Roux‐en‐Y anastomosis for gastrointestinal reconstruction combined with π‐shaped esophagojejunostomy or overlap anastomosis after total gastrectomy, as previously described.According to the postoperative pathological and molecular detection of patients, it is recommended that patients with high‐risk stages II and above adopt adjuvant chemotherapy with a 5‐fluorouracil‐based chemotherapy regimen for 6–8 cycles.2.3Clinical data of patients were collected prospectively in our center's database and retrospectively through patient medical records. The following data were obtained: patient characteristics , preoperative physical status , nutritional status , with p < 0.05  indicating statistical significance.The normality of the distribution of continuous variables was assessed using the Kolmogorov–Smirnov method. Quantitative data with normal distributions were compared using t‐tests, while those with non‐normal distributions were compared using the Mann–Whitney U test. Categorical data are expressed using frequencies and percentages, and were compared using χ33.1p < 0.05). After PSM at a ratio of 1:3, 147 and 371 patients were included in the RTG and LTG groups, respectively. The baseline data of the two groups were well‐balanced.The annual number of surgical cases of LTG and RTG between 2014 and 2021 is shown in Figure 3.2p = 0.008), while the actual operation time  showed no significant difference. Thus, a difference in operation time between the RTG and LTG groups was observed in the auxiliary operation time . The estimated intraoperative blood loss in the RTG group was lower than that in the LTG group , and no significant differences were noted in intraoperative blood transfusion, positive margin rate, or conversion to laparotomy between the two groups (p > 0.05).Intraoperative performance is shown in Table p < 0.001). Notably, the number of lymph nodes dissected in the upper border of the pancreas was also significantly different between the two groups . No significant differences in the positive rate of dissected lymph nodes between the two groups were noted .Moreover, a statistically significant difference in the total number of lymph nodes dissected between the RTG and LTG groups was observed , first liquid diet intake , postoperative hospital stays lengths , and postoperative adjuvant chemotherapy intervals  were significantly shorter in the RTG group than in the LTG group. No significant differences were noted in the abdominal drainage volume on the first day after surgery (108.83 ± 56.52 vs. 112.77 ± 54.05 mL), unplanned reoperation rate, or unplanned readmission rate between the two groups (p > 0.05). No postoperative deaths occurred in either group, and the total cost of hospitalization for the RTG group was significantly higher than that for the LTG group .Postoperative recovery outcomes are shown in Table p = 0.962). This study further compared the incidence of specific complications, such as anastomotic fistula, pneumonia, abdominal infection, intra‐abdominal bleeding, gastrointestinal bleeding, pleural effusion, lymphatic fistula, pancreatic fistula, incision problems , and intestinal obstruction. No significant differences in the occurrence of these complications were observed between the two groups (p > 0.05).Postoperative complications are shown in Table 3.4p < 0.05). Notably, the level of amylase in POD1 drainage fluid  was significantly lower in the RTG group than in the LTG group.Figure 3.5p = 0.075), adjuvant operation time , estimated intraoperative blood loss , total number of lymph node dissections , number of lymph node dissections in the upper border of the pancreas , recovery time of bowel function , time of first liquid diet after operation , interval of starting adjuvant chemotherapy after the operation , and total medical expenses . Of note, the procedure for eight patients in the overall cohort was converted to laparotomy, of whom five patients were overweight and all were in the LTG group. Of these, the procedure for one patient was converted to laparotomy due to intraoperative hemorrhage, two due to tumor sites, and two due to obesity. No significant differences were observed between the two groups in terms of postoperative complications (p > 0.05).The data of patients with BMIs ≥25 in the two groups after matching are shown in Table 3.63.6.1p = 0.774, Figure p = 0.905, Figure p = 0.859, Figure p = 0.747, Figure The three‐year overall survival rate (OS) and relapse‐free survival (RFS) rate of the two groups were examined. The three‐year OS rates of the RTG and LTG groups were 78.9% and 79.8%, respectively. Kaplan–Meier analyses of three‐year OS showed that the difference between the two groups was not statistically significant .This study had several limitations. First, this was a retrospective study that lacked subjective indicators of postoperative rehabilitation, and further multicenter, large sample, high‐quality RCT studies to confirm these findings are warranted. Second, the long‐term effects of the two groups were comparable; however, the RTG group had better short‐term outcomes and intraoperative performance, more precise lymph node dissection and damage control, reduced blood loss and transfusion, lower stress responses, faster postoperative recoveries, and earlier initiations of adjuvant chemotherapy. Extended observation periods to assess the importance of these measures in improving the prognoses of patients, such as 5‐year OS and RFS, may be necessary. Third, our center had a large volume of operations, and the operators had a high level of experience in laparoscopic and robotic surgery, which may not be applicable or practical to other centers. In view of the short learning curve of robotic surgery,5Although the long‐term outcomes of the two methods were similar, compared with LTG, RTG may improve short‐term clinical outcomes, reduce surgical trauma, reduce surgeon fatigue, reduce inflammatory reactions, and accelerate postoperative recovery. Robotic surgical systems may also reduce the surgical stress response, which may be an underlying mechanism in improving tumor prognosis in gastric cancer patients. For obese or overweight patients with BMIs ≥25, RTG had clear advantages in visual field exposure, surgical outcomes, postoperative recoveries, and lymph node dissections. Robotic surgery systems may be an improved alternative to traditional laparoscopic surgery and may have broader application prospects.Zhuoyu Jia: Conceptualization ; data curation ; formal analysis ; funding acquisition ; methodology ; project administration ; resources ; software ; supervision ; validation ; visualization ; writing – original draft ; writing – review and editing . Shougen Cao: Conceptualization ; methodology ; project administration ; resources ; supervision . Cheng Meng: Conceptualization ; formal analysis ; methodology ; project administration ; resources ; software . Xiaodong Liu: Data curation ; methodology ; resources ; visualization . Zequn Li: Data curation ; formal analysis ; funding acquisition ; resources ; supervision ; validation . Yulong Tian: Data curation ; methodology ; project administration ; resources ; software ; visualization . Junjian Yu: Methodology ; project administration ; software ; supervision ; writing – original draft . Yuqi sun: Formal analysis ; methodology ; project administration . Jianfei Xu: Data curation ; formal analysis ; methodology ; resources . Gan Liu: Data curation ; formal analysis ; investigation ; methodology ; project administration . Xingqi Zhang: Data curation ; methodology ; resources . Hao Yang: Methodology ; project administration ; visualization . Hao Zhong: Formal analysis ; methodology ; project administration . Qingrui Wang: Methodology ; project administration ; visualization . Yanbing Zhou: Conceptualization ; data curation ; methodology ; project administration .This study was funded by Shandong Provincial Natural Science Foundation, China (No. ZR202103040182); the National Natural Science Youth Foundation of China (No. 82103577).The authors declare that they have no conflict of interest.This study was approved by the ethics committee, ethics number: QYFY WZLL 27151.Figure S5.Figure S6.Click here for additional data file.


Ludwig's angina was first described in 1839 by German physician, Wilhelm Frederick Von Ludwig as a rapidly and fatal progressive gangrenous cellulitis and edema of the soft tissues of the neck and floor of the mouth with rapid spread to other places like anterior mediastinum. However, Type 2 acute myocardial infarction (MI) due to Ludwig's angina has not been documented. A 62‐year‐old male presented to the emergency department with visible anterior neck swelling for 1 week, which was preceded by a tooth arch 1 week prior, the patient presented with a high grade fevers, dysphonia, dysphagia, and facial swelling. No history of trauma. He reported in the past 24 h prior to evaluation, a steady progression of pain intensity with rapid progression and anterior neck skin erythema and swelling. The pain was exacerbated by rotation of the neck, tongue protrusion, and speaking. On examination, there was a visible anterior neck swelling measuring 10.0 × 3.0 cm in widest dimensions, exquisitely tender to palpation with a positive temperature gradient, skin hyperpigmentation and firm in consistency, no crepitus, fluctuance, or induration. Tongue appeared elevated with sublingual edema and pooling of secretions. No stridor. A chest and neck ultrasound scan revealed an extensive abscisic mass from the submandibular, neck, sternal notch, and right clavicular region with the largest pockets measuring 2.11 × 0.8 cm, 2.03 × 0.62 cm, 1.50 × 1.1 cm, with noted submandibular, subclavicular and deep and superficial cervical lymph nodes, the largest measuring 1.23 × 1.63 cm in dimensions. A neck‐CT scan with contrast revealed a pronounced subcutaneous tissue localized collection extending to both submandibular spaces measuring about 5.5 × 12.5 × 9.5 cm with mural enhancement. The upper chest cuts showed moderate pleural effusions and a paracardial hypodense well‐defined lesion measuring 7.5 × 2.5 cm with mild pericardial effusion. The patient was referred to the ear, neck and throat, ENT surgeon for urgent drainage of the abscess, which was done successfully and about 300 mL of hemorrhagic pus was drained. Then transferred to highly dependent unit, (HDU) for IV antibiotic administration and vital observations, prior to that electrocardiogram, ECG showed a normal sinus rhythm. The following day in HDU, the patient started experiencing a chest pain of sudden onset radiating to the upper jaws, left forearm and throbbing in nature, palpitations and started becoming diaphoretic. Blood pressure was 150/70 mmgh and pulse of 120 bpm. ECG readings demonstrated ST‐elevation, at lead 11, V2, and V3, cardiac Troponin I and CK‐MB were elevated 10.0 ng/mL, (<0.4 ng/mL) and 150.0 IU/L, (5‐25 IU/L) respectively. The patient was started on medications to relief acute ischemic pain these included, sublingual nitroglycerin 0.6 mg, morphine 5 mg intravenous slowly, antithrombotic, and beta‐adrenergic blockade. He was kept in HDU later with heparin 80 U/kg bolus and 8 U/kg continuous infusion and was taken for coronary angiogram which demonstrated no any coronary artery occlusion. The patient later on started to register improvement and later discharged on medications for follow‐up. On follow‐up, the subsequent ECG showed persistent atrial fibrillation and patient was discharged on P2Y12 inhibitor, clopidogrel, 75 mg, and beta‐blocker, metoprolol 50 mg. Over the past three decades, mortality rates for acute MI have increased significantly, One common subtype, type 2 MI is noted and driven by a myocardial oxygen supply and demand mismatch in the absence of coronary thrombosis. T2MI can occur with or without obstructive coronary disease like in this patients with angiographically normal coronary arteries. T2MI is increasingly recognized because of various septic pathophyisologies that cause increased myocardia oxygen demand. Evidence of myocardial ischemia especially those with sepsis are likely to develop myocardial injury. T2MI is frequent and explains a significant increase in clinical practice. A consensus is needed about how the diagnosis is established, to facilitate evidence‐based therapies geared toward improving outcomes. Visible anterior neck swelling. Ultrasound scan shows extensive submandibular abscisic mass. Ludwig's is often loosely applied to deep space neck infections but should be limited to those infections which are bilateral and involves the submandibular spaces including both sublingual and sub‐mylohyoid spaces, and has rapid spread to other places like anterior mediastinum. However, Type 2 myocardial infarction (MI) due to Ludwig's angina has not been documented.2A 62‐year‐old male a referral from a peripheral facility presented to the emergency department with visible anterior neck swelling for 1 week, which was preceded by a tooth arch 1 week prior, the patient presented with a high grade fevers, dysphonia, dysphagia, and facial swelling. No any history of facial or neck trauma. The patient however reported a poor dental hygiene. No any history of chronic illnesses like diabetes, hypertension.The patient reported in the past 24 h prior to evaluation, he noted steady progression of pain intensity with rapid progression in the 24 h with anterior neck skin erythema and swelling. He stated that the pain was exacerbated by rotation of the neck, tongue protrusion, and speaking.On examination, there was a visible anterior neck swelling measuring 10.0 × 3.0 cm in widest dimensions, exquisitely tender to palpation with a positive temperature gradient, skin hyperpigmentation and firm in consistency, no crepitus, fluctuance, or induration Figure . Tongue A chest and neck ultrasound scan revealed an extensive abscisic mass from the submandibular, neck, sternal notch and right clavicular region with the largest pockets measuring 2.11 × 0.8 cm, 2.03 × 0.62 cm, 1.50 × 1.1 cm, with noted submandibular, subclavicular and deep and superficial cervical lymph nodes noted, with the largest measuring 1.23 × 1.63 cm in dimensions Figure .A neck‐CT scan with contrast was requested and it revealed a pronounced subcutaneous tissue midline localized collection detected extending to both submandibular spaces measuring about 5.5 × 12.5 × 9.5 cm with mural enhancement. The upper chest cuts showed moderate pleural effusions and a paracardial hypodense well‐defined lesion measuring 7.5 × 2.5 cm with mild pericardial effusion Figure . Preadmistreptococcus pyogenes and staphylococcus aureus bacterial species. The patient was transferred to HDU for intravenous, IV antibiotic administration and vital observations.The patient was referred to the ENT surgeon for urgent drainage of the abscess, which was done successfully and about 300 mL of hemorrhagic pus was drained of about 500 mL. Fluid resuscitations and culture and sensitivity was done and revealed polymicrobial infection with The following day in HDU, the patient started experiencing a chest pain of sudden onset radiating to the upper jaws, left forearm and throbbing in nature, palpitations and started becoming diaphoretic. Blood pressure was 150/70 mmgh and pulse of 120 bpm. Emergency team was consulted, ECG readings demonstrated ST‐elevation, at lead 11, V2, and V3, Figure , serial The patient was started on medication to relief acute ischemic pain these included, nitrates, morphine, antithrombotic likes aspirin and beta‐adrenergic blockade.He was kept in HDU later with heparin 80 U/kg bolus and 8 U/kg continuous infusion and was taken for coronary angiogram which demonstrated no any coronary artery occlusion.The patient later on started to register improvement and later discharged on medications for follow‐up.On follow‐up, the subsequent ECG showed persistent atrial fibrillation, Figure  and pati3There are so many possible complications of Ludwig's angina are airway obstruction, carotid arterial rupture or sheath abscess, thrombophlebitis of the internal jugular vein, mediastinitis, empyema, necrotizing fasciitis, pericardial effusion, osteomyelitis, subphrenic abscess, aspiration pneumonia, and pleural effusion.However acute MI has not been documented and the pathophysiology still not understood. By reporting a case of acute MI due to Ludwig's angina, we hope to raise the awareness in our medical community for this rare clinical entity.Streptococcus viridians and anaerobes like Fusobacterium nucleatum, Peptostreptococcus species, and Actinomyces specie.A simple odontogenic problem can quickly turn fatal because of numerous critical complications, such as airway edema. As represented in this case, patients can present with exquisite pain that could yield profound sepsis if not promptly treated with antibiotics and other critical care measures, such as maintaining the airway and aggressively hydrating, spread from peritonsillar abscesses or suppurative parotitis has been documented. Ludwig's angina is commonly polymicrobial, keeping in mind the normal flora of the oral cavity. Commonly involved organisms are Cardiovascular complications of Ludwig's angina has not fully been documented to raise awareness to the practicing physicians. In this case report, we examine our patient who developed a cardiovascular complication due to systemic complications of Ludwig's angina.Most cases of Type 2 myocardial infarction (T2MI) are triggered by noncoronary etiologies. The response often evokes compensatory mechanisms involving both supply and demand.T2MI can occur in patients with normal coronary arteries or in those with obstructive and nonobstructive coronary artery disease. this patient has no any prior coronary artery disease.Distinguishing mechanisms is difficult. For example, in sepsis like in this patient, despite sufficient alterations in myocardial oxygen demand that ischemia can occur, the toxic effects of tumor necrosis factor (TNF), heat shock proteins and catecholamines, can also cause cardiac troponin, cTn release. T2MI is increasingly recognized because of the increased myocardial oxygen demand and inflammatory mediators released during sepsis.4The investigations confirmed the diagnosis of Ludwig's angina with MI.In this case, it was the detailed history taking, and obvious significant bilateral submandibular swelling, accompanied by dysphonia, that raised concerns regarding the possibility of Ludwig's angina with both efficiency and certainty, ensuring the best possible outcome.There are, however, several potential differential diagnoses to consider when assessing a patient presenting with symptoms such as those above.These include angioneurotic edema, cellulitis, lingual carcinoma, lymphadenitis, peritonsillar abscess, salivary gland tumors, and sublingual haematoma.Due to the rapid and potentially life‐threatening spread of this condition, early diagnosis and interventions are essential to maximize an optimum outcome for patients.5Over the past 3 decades, mortality rates for acute MI have increased significantly, one common subtype, Type 2 MI has been noticed, and defined as an MI driven by a myocardial oxygen supply and demand mismatch in the absence of coronary thrombosis.T2MI can occur with or without obstructive coronary disease like in this patients with angiographically normal coronary arteries.Patients with T2MI have similar or higher all‐cause mortality than patients with T1M1 in part because many studies include critically ill patients with comorbidities. They are at high risk for cardiovascular mortality and major adverse cardiovascular events.Evidence of myocardial ischemia especially those with sepsis are likely to develop myocardial injury. T2MI is frequent and explains a significant increase in clinical practice. The mechanisms are heterogeneous, for which reason, individualized approaches to diagnosis, management, and risk stratifications are needed. A consensus is needed about how the diagnosis is established, to facilitate evidence‐based therapies geared toward improving outcomes.5.1The patient's perception is that the swelling was something that he thought was due to tooth extraction that happened 1 month prior to admission. And he had refused to take the medications that were prescribed.Ronald Kato: Conceptualization; data curation; formal analysis; resources; supervision; validation; writing – original draft; writing – review and editing. Umaru Ssebagala: Investigation; methodology; validation; visualization. Kainembabazi Katrina: Project administration; software.There was no funding or any financial assistance that was contributed toward this manuscript.There is no conflict of interest amongst authors regarding the publication of this article.A written informed consent was obtained from the patient to publish this report in accordance with the Journal's patient consent policy.


In a single‐arm pilot study, we assessed the feasibility and usefulness of an innovative patient‐centered communication tool (UR‐GOAL tool) that addresses aging‐related vulnerabilities, patient values, and prognostic awareness for use in treatment decision making between older adults with newly diagnosed acute myeloid leukemia (AML), their caregivers, and oncologists.α = 0.10.Primary feasibility metric was retention rate; >50% was considered feasible. We collected recruitment rate, usefulness, and outcomes including AML knowledge (range 0–14) and perceived efficacy in communicating with oncologists (range 5–25). Due to the pilot nature and small sample size, hypothesis testing was performed at p = 0.22; caregivers: +1.1, p = 0.05) and perceived greater efficacy in communicating with their oncologists .We included 15 patients , 12 caregivers, and 5 oncologists; enrollment and retention rates for patients were 84% and 73%, respectively. Patients agreed that the UR‐GOAL tool helped them understand their AML diagnosis and treatment options, communicate with their oncologist, and make more informed decisions. From baseline to post‐intervention, patients and caregivers scored numerically higher on AML knowledge  into treatment decision making. For patients and caregivers, AML knowledge scores and perceived efficacy in communicating with the oncologist increased at post‐intervention. In a multicenter prospective observational study, over half of the patients with hematologic malignancies overestimated their chance of cure compared to their oncologists' estimates.Preference elicitation techniques, such as best‐worst scaling (BWS), can be used to assess the relative importance patients place on various aspects or attributes of care.We previously developed and adapted a patient‐centered communication tool [University of Rochester‐Geriatric Oncology Assessment for acute myeloid Leukemia (UR‐GOAL)] in older adults with AML.22.1In this single‐arm pilot study, we recruited older patients with AML, their caregivers, and oncologists from the University of Rochester Medical Center Wilmot Cancer Institute (WCI) and its affiliated oncology practices in upstate New York. Eligible patients were (1) aged ≥60 years; (2) newly diagnosed with AML; (3) English‐speaking; and (4) capable of providing informed consent. Eligible caregivers (if available) were (1) aged ≥21 years and (2) a family member, partner, friend, or caregiver with whom the patient discusses health‐related matters. Patients could enroll without their caregivers, but caregivers could enroll only if their respective patient consented to the study. The inclusion criterion for oncologists was practicing oncologist with at least one of their patients enrolled in the study. Participants were recruited between October 2021 and March 2022. Eligibility was confirmed by the treating physician and the principal investigator (KPL). The study was approved by the University of Rochester Research Subjects Review Board.2.2Once eligibility was confirmed, study personnel approached patients and caregivers face‐to‐face or via telephone. Following consent, patients, and their caregivers completed demographic and clinical measures. Cancer and treatment information for patients was obtained from the electronic medical record. Patients completed the UR‐GOAL intervention (with their caregivers if available) prior to the clinical encounters that involved treatment discussion with their oncologists. At post‐intervention (within 4 weeks after a treatment decision was made), patients and caregivers completed measures as well as a 60‐min semi‐structured interview virtually or in a private space in the hospital. Interviews focused on experience with and feedback on the UR‐GOAL tool. Interviews were transcribed verbatim and uploaded to MAXQDA software (VERBI Software GmbH) for analyses.2.3The UR‐GOAL communication tool has previously been described and has four components Figure : (1) An 2.3.1The 5‐min animated video addresses diagnosis, incidence, symptoms, risk factors, goals of treatment, treatment approaches, and population‐based prognosis. The content was informed by stakeholders in our prior studies.2.3.2To assess aging‐related vulnerabilities, patients completed the self‐report component of a GA that included measures of physical function, nutritional status, social support, and psychological health. Physical function was assessed using the Katz Activities of Daily Living (ADL), Older Americans Resources and Services (OARS) Instrumental ADL, and number of falls in the previous 6 months.Objective tests of physical function [Short Physical Performance Battery (SPPB)] and cognitive function (Mini‐Cog) were performed by study personnel, either in person or over a tele‐video platform .2.3.3Preference elicitation using the BWS technique was performed using Sawtooth Software . The BWS consists of 10 choice tasks, with four attributes  per task Figure . The eig2.3.4Prognostic awareness  and preferences for prognostic information  were assessed. These questions were adapted from previous studies that included more than 1000 older patients with cancer.2.3.5After completion of the UR‐GOAL tool, a summary report was provided to the patient  and the oncologist. Both reports contained attributes from BWS grouped into the four most important and four least important attributes. The patient report included question prompts based on the most important attributes. The oncologist report contained a summary of the GA and the patient's prognostic awareness.2.42.4.1The primary feasibility metric was retention rate. We considered the study feasible if >50% of patients who consented to the study ultimately completed the study intervention and post‐intervention assessment. We captured recruitment rate (percentage of patients who were approached and agreed to enroll) and usefulness. Usefulness was assessed using the Preparation for Decision Making Scale  and a self‐developed survey.2.4.2Measures obtained at baseline and post‐intervention for patients and caregivers included AML knowledge, efficacy in communication, psychological health, and prognostic awareness. Measures obtained at post‐intervention only included patient‐centered communication and shared decision making.2.4.3AML knowledge was assessed by a 14‐item questionnaire developed by the investigators. Scores range from 0–14 (higher scores are better). Efficacy in communication was measured using the 5‐item Perceived Efficacy in Patient‐Physician Interactions (PEPPI) questionnaire. Scores range from 5–25 (higher scores are better).SDM was measured using the Shared Decision‐Making (SDM‐Q‐9) and 3‐item CollaboRATE. We transformed scores to a scale of 0 to 100.2.4.4Similar measures were used for caregivers , AML knowledge, GAD‐7, prognostic awareness, adapted 6‐item Patient‐Centered Communication in Cancer Care, CollaboRATE).2.4.5At post‐intervention, oncologists completed a self‐developed four‐item usefulness survey regarding the UR‐GOAL tool and summary report.2.5t‐tests for measures with normally distributed changes and Wilcoxon signed‐rank tests for measures with non‐normally distributed changes to conduct the comparisons between baseline and post‐intervention. Because of the pilot nature of the study and small sample size, hypothesis testing was performed at α = 0.10 (2‐tailed). All quantitative analyses were conducted using SAS statistical software, version 9.4 .A priori, we chose 15 as our sample size which is considered sufficient based on recommendations from previous feasibility and usability studies.Content analysis was used to analyze the post‐intervention interviews.33.1We approached 19 patients and 16 consented (recruitment rate: 84%). Of the three patients who did not consent, two did not feel well, and one was overwhelmed. One patient withdrew between consent and baseline assessment due to being overwhelmed, resulting in 15 patients. Twelve caregivers and five oncologists were enrolled.Mean age of patients was 76 years ; 47% 7/15) were male, 93% (14/15) were white and non‐Hispanic, and 67% (10/15) were married. At diagnosis, 60% (9/15) had European LeukemiaNet high‐risk AML.5 were maMean age of the 12 caregivers was 69 years ; half were male and all were white. Over half  were the patient's partner, and 33% (4/12) were children of the patient . Of the four patients who did not complete both, three patients completed the study intervention but not the post‐intervention assessments (two transitioned to hospice and one withdrew due to not feeling well). One patient withdrew while completing the study intervention because of distress. Table 3.3p = 0.22) and 6.9  at post‐intervention (Table p = 0.22) and mean change of +1.2 (SD 1.6) among caregivers (p = 0.06)]. GAD‐7 scores decreased numerically in both patients and caregivers [mean change of −1.6 (SD 5.4) among patients (p = 0.34) and mean change of −2.2 (SD 4.8) among caregivers (p = 0.20)]. Other measures available at post‐intervention only are shown in Table Mean AML knowledge scores among patients and caregivers were 6.0 (SD 1.1) and 5.7 (1.3), respectively, which increased to 6.5 . They felt reassured when the range of prognoses based on treatment were discussed with their oncologist. An opportunity to re‐watch the educational video was suggested .Three participants (two patients and one caregiver) felt that the BWS questions in the UR‐GOAL communication tool were repetitive, and one patient found it challenging to select the best and worst attributes.Patient 5 : “I think it's too long…I know you were rephrasing it in a way that makes sure the answer stayed, but the rephrasing could – I just thought it was too long”.Patients found the summary report helpful, and one patient reported using the summary report as a reference during visits with their oncologist. Patients and caregivers appreciated the question prompts provided.Patient 15 : “Yes. In particular, the list of questions on there. We had that thing right in front of us and we used those”.3.4.2Oncologists felt that the UR‐GOAL tool was most useful if used early in the treatment discussion , but that it could also be used to confirm decisions that had already been made.Oncologist 2: “She did really well in the geriatric assessment, and she perceived herself as being very strong, which made me feel better having given her pretty strong chemo to try and get back in remission”.The tool provided oncologists with insight into the patients' understanding (or lack of understanding) regarding their diagnosis and prognosis, as well as their aging‐related vulnerabilities. Oncologists did not perceive the tool to be burdensome and the summary report was easy to interpret. Oncologists suggested adding specific details on aging‐related vulnerabilities .4We found that it was feasible to recruit older patients with AML, their caregivers, and oncologists to a single‐arm pilot study testing a patient‐centered communication tool at diagnosis. Patients reported that the tool helped them to better understand their diagnosis and treatment options, and prepare for decision making. Oncologists found the UR‐GOAL tool to be useful and provided them with valuable insight into the patient's understanding of their diagnosis. The UR‐GOAL tool may improve patient and caregiver knowledge of AML and their perceived efficacy in communicating with their physician.Due to the sudden diagnosis of AML and the high prevalence of aging‐related vulnerabilities, treatment decision making is challenging for older patients.n = 20 patients, mean age = 62.4 years), use of a decision aid (animated videos on AML and treatment) improved knowledge scores from pre‐ to post‐intervention.p = 0.02).Our findings suggest that the UR‐GOAL tool may improve patient and caregiver knowledge of AML as well as patient and caregiver perceived efficacy in interacting with their oncologist, consistent with other studies of decision aids for patients with cancer. A previous systematic review of 87 studies found that use of decision aids for patients with cancer is associated with increased patient knowledge.p = 0.02).We demonstrated that the UR‐GOAL tool may promote SDM, improve patient‐centered communication, and reduce decisional conflict. At post‐intervention, patients reported a mean score of 89.4 (SD 14.4) on SDM‐Q‐9 (a measure of SDM). While we do not have a comparison arm, previous studies exploring SDM for treatment decisions have reported a range of 11–100, with a median score of 84 in a study of patients with hematologic malignancies.Our study has several strengths. First, we included older patients with AML, their caregivers (who are often involved in the decision‐making process), and oncologists. Previous studies on decision aids have not routinely included caregivers. Second, we utilized both quantitative and qualitative methods to better understand the UR‐GOAL tool. Third, we used multiple reliable measures to generate a comprehensive assessment of the tool.This study has limitations. First, this was a single‐arm pilot study without a comparison arm. While we were able to assess some outcomes at baseline and post‐intervention , changes in other outcomes such as SDM and decisional conflict cannot be measured at baseline since the decision‐making process had not yet occurred. Second, our study sample was small, so appropriate caution is needed when extrapolating these findings to other settings. Third, while we attempted to enroll patients prior to the first encounter addressing treatment decisions, some patients may have met with a community oncologist and initiated these discussions. Fourth, the study participants in this group were predominantly white, non‐Hispanic, and English speaking. The results may not be generalizable to patients of other races and ethnicities.In conclusion, we demonstrated that it is feasible to incorporate a patient‐centered communication tool in clinical practice for treatment decision making for older patients with AML, their caregivers, and oncologists. The UR‐GOAL tool may improve patient and caregiver knowledge of AML and perceived efficacy in interacting with the oncologist. Findings have allowed us to adapt our study procedures and the tool, which has informed an ongoing pilot randomized control trial (NCT05335369) to evaluate the preliminary efficacy of the UR‐GOAL tool on SDM and communication. Innovative interventions, such as the UR‐GOAL tool, which address challenges specific to older adults with AML are critical to improve health outcomes for this vulnerable population.Marissa LoCastro: Formal analysis ; writing – original draft (lead); writing – review and editing (lead). Chandrika Sanapala: Data curation ; formal analysis (supporting); project administration ; writing – review and editing (supporting). Ying Wang: Data curation ; formal analysis ; writing – review and editing (supporting). Marielle Jensen‐Battaglia: Data curation (supporting); formal analysis ; writing – review and editing (supporting). Marsha Wittink: Conceptualization (supporting); investigation (supporting); methodology (supporting); writing – review and editing (supporting). Sally A Norton: Conceptualization (supporting); investigation (supporting); methodology (supporting); writing – review and editing (supporting). Heidi Klepin: Conceptualization (supporting); investigation (supporting); methodology (supporting); writing – review and editing (supporting). Daniel R Richardson: Writing – review and editing (supporting). Jason H Mendler: Writing – review and editing (supporting). Jane L. Liesveld: Writing – review and editing (supporting). Eric Huselton: Writing – review and editing (supporting). Kristen O'Dwyer: Writing – review and editing (supporting). Ashley‐Marie Cortes: Formal analysis (supporting); writing – review and editing (supporting). Chrystina Rodriguez: Formal analysis (supporting); writing – review and editing (supporting). William Dale: Writing – review and editing (supporting). Kah Poh Loh: Conceptualization (lead); data curation ; formal analysis ; funding acquisition (lead); investigation (lead); methodology (lead); resources (lead); writing – original draft ; writing – review and editing .This work was supported by the National Cancer Institute at the National Institutes of Health , the National Institute of Aging at the National Institutes of Health (R33AG059206 to HDK), Conquer Cancer American Society of Clinical Oncology, and Walther Cancer Foundation Career Development Award (to KPL), and the Wilmot Research Fellowship Award (to KPL). The content of this report is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.Dr. Loh has served as a consultant to Pfizer and Seattle Genetics and has received honoraria from Pfizer. All other authors have no relevant competing interests to report.Appendix S1.Click here for additional data file.Figure S1.Click here for additional data file.Table S1.Click here for additional data file.


Currently there are no specific recommendations for the use of any particular infant formula in the prevention of cow's milk allergy (CMA). Recently, there has been an increasing interest in alternative infant formulas based on milk proteins from other sources than the cow, including milk from other mammalians such as goat, sheep, donkey, horse, and camel. Whereas these have been studied for their usability in CMA management, there are no studies of their CMA preventive capacity. Thus, the aim of this study is to evaluate whether camel milk can prevent CMA and vice versa.The capacity of camel milk in preventing CMA and vice versa is evaluated in a well‐established prophylactic Brown Norway rat model. IgG1, IgE, and IgA responses, allergy elicitation, intestinal and mLN gene expression, and protein uptake are analyzed. The study demonstrates that camel and cow's milk in general has an insignificant cross‐preventive capacity. Yet, whereas cow's milk is shown to have a low transient capacity to prevent sensitization and clinically active camel milk allergy, camel milk does not show this effect for CMA.This study suggests that due to lack of cross‐tolerance camel milk cannot be used for CMA prevention. Camel milk has gained increasing interest as an alternative protein source for infant formula manufacture. In Brown Norway rats, we investigated the cow's milk allergy preventive capacity of camel milk and vice versa, and demonstrated that camel milk could not prevent cow's milk allergy, while cow's milk had a transient capacity to prevent camel milk allergy.  For CMA management, strict avoidance of intact cow's milk proteins is needed, and for infants not exclusively breastfed the use of hypoallergenic infant formula is recommended. For CMA prevention in infants and small children at high‐risk of developing CMA, there are currently no specific recommendations, neither for the use of particular infant formulas if breastfeeding is not possible nor for when to introduce cow's milk proteins, although delayed introduction of common allergens is discouraged. Yet, in a study by Urashima et al. it was shown that avoidance of cow's milk based formula in the first days of life prevented the development of CMA. In contrast to current guidelines, previous guidelines recommended the use of partially hydrolyzed infant formula (pHF) for the prevention of CMA in infants not exclusively breastfed and at high‐risk of developing CMA, but as current evidence from human studies point to no benefit of pHF in preventing CMA, this recommendation has been omitted.Cow's milk is one of the most common sources of protein causing IgE‐mediated food allergy in infants and small children.1 Cow' Lowe et al. reported no benefit. In line with the study of Lowe et al., three systematic reviews stressed that there is no evidence for a preventive capacity of pHFs. Also animal studies showed different outcomes, where some studies demonstrated no differences in the capacity of intact and hydrolyzed cow's milk products in preventing sensitization to cow's milk proteins, while another study showed that partially hydrolyzed whey proteins could only partly prevent CMA. Thus, based on human as well as animal studies it seems there is no unambiguous evidence for the benefit of using pHF in the prevention of CMA. Whereas pHFs have previously been recommended in the prevention of CMA, infant formulas based on extensively hydrolyzed cow's milk proteins and on amino acids are only recommended for CMA management. Further, pro‐ and prebiotics such as Lactobacillus rhamnosus GG and galacto‐/fructooligisaccharide, respectively, are known to have a positive impact on gut microbiota composition and thus suggested to accelerate development of tolerance towards cow's milk proteins.A few human studies have assessed the preventive capacity of pHF in infants at high‐risk of developing CMA, and while some showed the benefit of pHFs in preventing CMA when compared to conventional formulas,13 Low For example, in a study by Graversen et al., investigating the impact of heat‐treatment on the allergy preventive capacity of whey proteins, it was shown that heat‐treated whey protein and the unmodified counterpart were equally good in inducing tolerance towards whey protein but that the heat‐treated version had a lower allergenicity.There seems to be a growing interest in new types of infant formulas based on non‐hydrolyzed proteins, both as alternatives to conventional infant formulas but also for the prevention and management of CMA.5 For  have gained an increasing interest as alternative protein sources to cow's milk protein. Especially, camel milk has received a growing interest in the recent years for its use in infant formulas, and in particular for its utility in CMA management. This is mainly attributed to the low homology between camel and cow's milk proteins, as well as due to the lack of β‐lactoglobulin (BLG) in camel milk, which is one of the major allergens in cow's milk. In a recent animal study, we demonstrated that cow's and camel milk possessed similar inherent immunogenicity and allergenicity, but that the cross‐reactivity between counterpart proteins was low. In line, several studies analyzing blood samples from cow's milk allergic children showed no or low IgE binding to camel milk proteins confirming low cross‐reactivity between cow's and camel milk proteins. Further, in human trials it has been shown that camel milk is well tolerated by the majority of cow's milk allergic children, stressing its potential in CMA management. However, whether or not early introduction of camel milk could drive a tolerance to cow's milk proteins has to our knowledge not been investigated. Therefore, in the present study, we assessed the capacity of cow's and camel milk to induce cross‐tolerance and investigated whether camel milk could prevent CMA and whether cow's milk could prevent camel milk allergy. For this purpose, a well‐established prophylactic Brown Norway (BN) rat model was used.Infant formulas based on milk proteins from goat, sheep, donkey, horse, and camel32 hav22.12HPO4, 1 mM KH2PO4, pH 7.2) to a protein concentration of 50 mg mL−1 and stored at −20 °C until used. Endotoxin content was measured by Pierce LAL Chromogenic Endotoxin Quantitation Kit  in accordance with the manufacturer's instruction. The endotoxin level of camel milk was <2 endotoxin units (EU) per mg protein, while the endotoxin level of cow's milk was approx. 9 EU per mg of protein.Cow's milk powder  was purchased in a local Polish shop, while camel milk powder was kindly provided by Ausnutria Dairy (China) Co., Ltd., . Solutions of the products were prepared by dissolving cow's and camel milk powders in sterile PBS  were separated under reducing conditions using a 4–20% precast polyacrylamide gel . Proteins were visualized by Bio Safe Coomassie  and photographed using the Imager ChemiDoc XRS+ (Bio‐Rad).In order to evaluate cow's and camel milk protein profiles, SDS‐PAGE was performed as previously described34 wit2.3n = 2 per cage) at 22 ± 1 °C with 55 ± 5% relative humidity and with a 12 h light–dark cycle. Rats were inspected once a day and weighted once a week. Rats were kept on an in‐house prepared diet free from milk proteins, with rice, fish, and potato as protein sources, for >10 generations. Diet and water were given ad libitum.BN rats from the in‐house breeding colony at the National Food Institute, Technical University of Denmark were kept in macrolon cages . For investigating prevention of CMA, groups of rats (Group 1–3) received either water as a control, cow's milk, or camel milk ad libitum in their drinking bottles for 21 days (Intervention phase: Day 0–20) for the purpose of inducing oral tolerance  with either 100 µg of cow's milk proteins (Group 1–3) or 100 µg of camel milk proteins (Group 4–6) in 0.5 mL PBS, once a week for 4 weeks . The animal experiment was completed with two in vivo tests, where an ear swelling test was performed at Day 53, and an oral food challenge (OFC) was performed at Day 56. Rats were sacrificed 1 week after last post‐immunization at Day 56 by exsanguination using carbon dioxide inhalation as anesthesia and blood were collected. Throughout the experiment, blood samples were collected from the sublingual vein; after the intervention phase at Day 28 and 1 week after each post‐immunization at Day 35, 42, 49, and 53. In addition, fecal samples were collected at Day 0, 28, and 56. At sacrifice (Day 56) the following samples were collected; small intestine (SI) content, mesenteric lymph nodes (mLN), pieces of SI, lamina propria (LP), epithelium (EPI), and Peyer's patches (PP). Blood samples were converted into serum, and fecal and SI content samples were converted into fecal and SI content water, respectively, as previously described.To evaluate the capacity of cow's and camel milk in preventing CMA and camel milk allergy, an animal experiment was performed. The animal experiment was divided into two phases; an intervention phase and a post‐immunization phase which was completed with in vivo tests, as displayed in ts Group –3 receivts Group –3 receiv2.5 Briefly, rats were anesthetized with hypnorm/midazolam and the initial ear thickness was measured. Subsequently, rats were intradermally (i.d.) injected with 20 µL of PBS with either 10 µg of cow's milk protein (Group 1–3) or 10 µg of camel milk protein (Group 4–6) into one ear. Ear thickness was measured again 15 min after injection, and delta ear swelling was calculated for each animal. Further, at Day 56, an OFC was performed, where rats from group 1–3 were intragastrically (i.g.) challenged with 1 mL of PBS with 100 mg of cow's milk protein and rats from group 4–6 were i.g. challenged with 1 mL of PBS with 100 mg of camel milk protein. Rats were observed for 10 min in order to monitor number of upper gastro‐intestinal symptoms by means of singultus‐ and emesis‐like behavior, indicating the experience of nausea.At Day 53 an ear swelling test was performed as previously described.44 Bri2.6 Results were expressed as log2 titre values and defined as the interpolated dilution of the given serum sample leading to the mean absorbance for the negative control +3 SD.To detect serum IgG1 specific for either cow's or camel milk, indirect ELISAs were performed, as previously described.34 Res2.7−1 of cow's milk or camel milk in coating buffer , and incubated overnight at 4 °C. Plates were washed five times between each step in PBS with 0.01% w/v Tween 20  (PBS‐T). For all steps that required incubation, plates were incubated for 1 h in the dark at RT with gentle agitation. First, plates were incubated with 50 µL per well of twofold serial dilutions of serum samples v/v in PBS‐T. In each plate, positive and negative control sera were included in order to identify potential plate‐to‐plate variance. For IgA detection, 50 µL per well of HRP‐labeled goat‐anti‐rat IgA  diluted 1:5000 (v/v) in PBS‐T was added to the plates. Next, plates were additionally washed twice with tap water. To visualize the detection of specific IgA, 100 µL per well of TMB‐one  was added and incubated for 12 min at RT. The reaction was stopped by adding 100 µL per well of 0.2 M H2SO4, and the absorbance was measured at 450 nm with a reference wavelength of 630 nm using a microtitre reader . Results were expressed as log2 titre values and defined as the interpolated dilution of the given serum sample leading to the mean absorbance for the negative control +3 SD.To detect serum IgA specific for either cow's milk or camel milk, indirect ELISAs were performed. Maxisorp microtitre plates  were coated with 100 µL/well of 10 µg mL2.8 Results were expressed as log2 titre values and defined as the interpolated dilution of the given serum sample leading to the mean absorbance for the negative control +3 SD.To detect total IgA in serum, fecal water, and SI content water, sandwich ELISA was performed as previously described.28 Res2.9 except of 5% v/v horse serum  being used as blocking agent. Further, for both products, serum samples were twofold diluted in 5% v/v horse serum. DIG‐coupled cow's or camel milk proteins were used with a final concentration of 0.03 µg mL−1 in PBS‐T for specific IgE detection. Results were expressed as the log2 titre values and defined as the interpolated dilution of the given serum sample leading to the mean absorbance for the negative control +3 SD.To detect serum IgE specific for cow's or camel milk, antibody‐capture ELISAs were performed as previously described,34 exc2.10 Serum pools from the day of sacrifice (Day 56) were diluted 1:3000 v/v, whereas the secondary antibody was diluted 1:15,000 and added together with StrepTacin‐HRP conjugate (Bio‐Rad) diluted 1:20,000 for protein standard visualization. All membranes were developed for 15 s for optimal visualization and direct comparison.To detect immune reactive proteins, immunoblotting with serum pools from each group of rats was performed. In brief, SDS‐PAGE with 5 µg of cow's and camel milk proteins were performed, and proteins transferred onto polyvinylidene difluoride (PVDF) membranes as previously described.34 Ser2.11 For RNA extraction from mLN, QIAzol Lysis Reagent  and RNeasy Lipid Tissue Mini Kit  were used in accordance with manufacturers’ protocol. Taqman gene assays  used were: Ocln (occludin Rn00580064_m1), TSLP , IL‐1β , IL‐4 , IL‐10 , INF‐γ , TGF‐β , FoxP3 , and CX3XR1 . The levels of different gene expression were shown as the relative gene expression by means of 2−deltaCT method using B2m (Beta‐2‐microglobulin Rn00560865_m1) and Sdha (Succinate dehydrogenase complex Rn00590475_m1) as normalization genes.To evaluate expression of different genes of interest, mLN and 2 × 0.5 cm pieces of SI, harvested 27 and 37 cm distal from the stomach were collected and stored in RNAlater  at −20 °C. RNA extraction, cDNA synthesis, and RT‐qPCR were performed as previously described.43 For2.12 BLG ELISA kit  was used for determination of concentration of BLG, as a marker for cow's milk protein uptake, in supernatants prepared from tissue homogenates in accordance to manufacturers’ protocol, as previously described.To evaluate protein uptake in the SI compartments, LP, SI content, PP, and EPI of BN rats challenged with cow's milk (Group 1–3) were harvested and homogenized as previously describe.26 BLG2.13t‐test while differences between three or more groups were analyzed using one‐way ANOVA followed by Bonferroni post‐test. If the data did not pass normality test, differences between two groups were analyzed using non‐parametric Mann–Whitney U test while differences between three or more groups were analyzed using Kruskal–Wallis test followed by Dunn's post‐test for multiple comparison. Differences were significant if p ≤ 0.05. Asterisk(s) indicate statistically significant differences between groups: *p ≤ 0.05, **p ≤ 0.01, ***p ≤ 0.001, ****p ≤ 0.0001.Graphs and statistical analyses were made using GraphPad Prism version 9.0.1 . Results from ELISAs were expressed as log2 antibody titre values. All data were initially tested for normal distribution using D'Agostino‐Pearson normality test. If the data passed normality test, differences between two groups were analyzed using parametric 33.1FigureTo evaluate the humoral immune responses developed against cow's or camel milk proteins throughout the study, levels of specific IgG1 were measured at six different time points. At first, it was shown that ad libitum bottle administration of both cow's and camel milk promoted the development of specific IgG1 during the intervention phase, as rats administered with cow's milk developed a statistically significant cow's milk‐specific IgG1 response and rats administered with camel milk developed a statistically significant camel milk‐specific IgG1 response, when comparing with water administered rats Figure2A,B. A Subsequently, the progression of the immune responses upon each of the post‐immunizations with either cow's milk or camel milk was assessed, demonstrating that levels of IgG1 specific for cow's milk Figure  or camel3.2Figurep = 0.0482, Mann–Whitney U test between cow's milk and water intervened groups).To evaluate the capacity of cow's and camel milk in preventing sensitization to both cow's and camel milk, levels of specific IgE were measured throughout the animal experiment. Neither ad libitum bottle administration with cow's nor camel milk induced sensitization in the intervention phase, as specific IgE could not be detected in any of the groups Figure3A,B. Du3.3FigureTo evaluate the capacity of cow's and camel milk in preventing clinical responses towards cow's and camel milk, an ear swelling test and an OFC were performed. In the ear swelling test, groups post‐immunized with cow's milk, and hence tested for prevention of CMA, showed no statistically significant differences in ear swelling after i.d. injection of cow's milk regardless of the oral intervention Figure4A. HoweThe number of symptom episodes was counted after OFC with the product the rats were post‐immunized with. The number of symptom episodes after OFC with cow's milk was statistically significant lower for the group intervened with cow's milk in comparison to the groups intervened with either water or camel milk Figure . Similar3.4In order to evaluate the specificity of IgG1 and the cow's and camel milk protein binding profiles, SDS‐PAGE followed by immunoblotting was performed.FigureFor both cow's and camel milk, caseins were shown as thick bands between 25 and 37 kDa Figure5A. In aThe reactivity of IgG1 for rats post‐immunized with cow's milk and hence tested for prevention against CMA was lower for the group intervened with cow's milk compared to that of the water and camel milk intervened rats Figure . Bands aSimilarly, the reactivity of IgG1 for rats post‐immunised with camel milk and hence tested for prevention against camel milk was slightly lower for the group intervened with camel compared to water and cow's milk intervened rats Figure . Bands a3.5Figurep = 0.0004 and 0.1466, based on one‐way ANOVA) total IgA level was observed for rats intervened with camel milk compared to rats intervened with water and post‐immunized with cow's and camel milk, respectively, indicating an effect of the camel milk intervention revealed upon post‐immunizations  Co., Ltd, Changsha, Hunan, China. The company however did not participate in the study design, data acquisition, data analysis, interpretation, manuscript preparation, or the decision where to publish.Conceptualization: N.Z.M. and K.L.B. Investigation and data curation: N.Z.M., M.H.S., and K.L.B. Methodology: N.Z.M., M.H.S., A.S.R.B., A.I.S., and K.L.B. Data visualization: N.Z.M., M.H.S., and K.L.B. Formal analysis: N.Z.M., M.H.S., and K.L.B. Supervision: K.L.B. Writing – original draft: N.Z.M. Writing – review & editing: N.Z.M., M.H.S., A.S.R.B., A.I.S., E.B.H., and K.L.B. All authors made substantial intellectual contributions to the study, reviewed the manuscript critically, and approved the final version of the manuscript.Supporting InformationClick here for additional data file.