Due to high suspicion of hematologic disease, a bone marrow study was performed. The marrow film showed diffuse infiltration of large and bizarre immature cells with basophilic cytoplasm and cytoplasmic vacuoles (top left), mimicking high‐grade hematologic malignancy. Cytochemical stainings including myeloperoxidase, chloroacetate esterase, and nonspecific esterase were all negative. Flow cytometry showed bright CD56 expression, but negative for CD45 and all other hematopoietic stem/progenitor, myeloid, and lymphoid cell markers. Bone marrow cytogenetics analysis revealed t. The initial histopathologic exam of the bone marrow biopsy specimen revealed malignant round cells infiltration, which were focally positive for desmin, while negative for several other lineage specific markers. No definite diagnosis could be made. Whole body positron emission tomography showed diffused high‐intensity signals over axial and appendicular skeletons and bilateral adnexae (bottom left). Laparoscopic right salpingo‐oophorectomy was carried out for more accurate diagnosis (bottom right), and the histopathological examination confirmed the diagnosis of rhabdomyosarcoma, alveolar type. Fluorescence in situ hybridization study was positive for FOXO1 gene break‐apart, indicating the presence of a translocation (top right), which was specific for rhabdomyosarcoma, alveolar type, in tumor cells. She was transferred to the Oncologic Department for further chemotherapy.A 29‐year‐old female with clinical manifestation of multiple ecchymosis, menorrhagia, bicytopenia, and leukoerythroblastosis was referred to the Hematology Division of this Medical Center from a local hospital. Her hemoglobin level on arrival was 6.0 g/dL, platelet count, 18 × 10


This study aimed to compare the clinical effects of using pedicled double‐barrel fibular transplantation (PDBFT) and bone transport (BT) for the treatment of upper tibial osteomyelitis with bone defects.A total of 83 patients with upper tibial osteomyelitis and bone defects were selected and retrospectively studied in Xi'an Hong Hui Hospital from January 2009 to January 2019. There were 52 males and 31 females, aged 19–72 years. The tibial defect range was 5–12 cm. Patients were divided into two groups, including the PDBFT (40 cases) and the BT group (43 cases). All patients were classified according to Cierny–Mader classification, including 48 cases of type III and 35 cases of type IV. Operation time, blood loss and cure time were compared. Ennecking score was used to evaluate limb functions, including pain, activity function, self‐perception, brace use, walking ability, and gait change, while self‐rating anxiety scale (SAS) was used for postoperative mental and psychological status. In addition, complications were recorded. All patients were followed for at least 2 years. SPSS 23.0 software was used to process data.p > 0.05). Operation time was 182.5 ± 22.7 min in PDBFT group vs, 124.2 ± 15.6 min in BT group, respectively (p < 0.05); intra‐operative blood loss was 286 ± 34 ml vs 45 ± 18 ml (p < 0.05); cure time was 7.3 ± 1.8 months vs 11.6 ± 3.7 months (p < 0.05); and Ennecking score was 87.3% and 76.0%, respectively (p < 0.05). So, the PDBFT group showed longer operation time, more blood loss, shorter cure time, and better Ennecking score than the BT group. Importantly, limb functions of the PDBFT group were better than that of the BT group. Moreover, the PDBFT group presented better postoperative mental status and fewer complications than that in BT group (p < 0.05).There was no significant difference in demographic data between the two groups  and bone transport techniques. The PDBFT technique brought better clinical effects, which could be the first operative choice for the treatment of upper tibial osteomyelitis with bone defects. Soft tissues are weak at the tibia which easily leads to tibial osteomyelitis after a severe open fractureRadical debridement is the most fundamental treatment, including removal of sinus tracts, all infected soft tissues and sequestrumSeveral techniques have been used in long segmental tibial defect reconstruction, such as Ilizarov bone transport, autologous bone transplantation, induced membrane technique, fibular transplantation, and so forthFibular transplantation includes free and pedicled transplantation. It requires good microsurgical skills to perform a free fibular transplantation. A free fibular surgery usually takes a long time and has a lot of blood loss. Unlike free transplantation, the pedicled transplantation surgery is relatively simple with low risk. By breaking the fibula into a parallel double‐barrel shape, the grafted fibular strength will be significantly enhanced. This method has achieved good results in bone reconstruction of the upper tibial defectsThe authors aimed to compare the clinical effects using PDBFT or BT technique for the treatment of upper tibial osteomyelitis with bone defects, and to clarify which method is better for patients with osteomyelitis and bone defects of the upper tibia.(i) Patients over 18 years; (ii) Patients meeting the diagnostic criteria of upper tibial osteomyelitis; (iii) Patients treated by the PDBFT or BT technique and followed for at least 2 years; (iv) Patients with complete medical records; (v) Bone defects ranging from 5–12 cm.(i) Patients with major comorbidities and unable to tolerate anesthesia or surgery; (ii) Uncompleted clinical and follow‐up data; (iii) Patients got amputation treatment finally.A retrospective study was conducted. A total of 83 patients were selected in Xi'an Hong Hui Hospital from January 2009 to 2019. There were 52 males and 31 females, aged 19–72 years. After radical debridement, the upper tibial defects were 5–12 cm. A total of 40 patients were treated using the PDBFT technique and the other 43 cases using the BT technique. All patients were classified according to Cierny–Mader classificationComputed tomography was performed for the injured limb. Blood samples were drawn to detect ESR, C‐reactive protein, and white blood cell count. All patients underwent radical debridement in the first stage. After removing all sequestrum, the residual tibial defects were filled with antibiotic‐loaded bone cement in PDBFT group. When the wounds healed and infection was effectively controlled, bone reconstruction was performed. In BT group, segmental resection method could be used during debridement.The patient was placed in supine position. Combined spinal epidural anesthesia or general anesthesia was taken. An anteromedial incision was taken to remove the bone cement. Then, another incision was made between the fibular head and lateral malleolus. It was entered from the space between the soleus muscle and fibular muscles. One centimeter of medial fibular cuff was retained. The peroneal artery and vein were included in the muscle cuff. The fibula was cut for required length. The peroneal artery and vein were cut off and ligated at distal part of the fibular flap. The proximal pedicle was properly freed for pedicled transfer. The fibular flap length was more than two times of the actual tibial defects, and 2–4 cm longer. According to the design, the fibula was cut into two unequal fragments. One was 2–3 cm longer than the other. Importantly, the continuity of medial muscle cuff was preserved. Distal part of the fibular flap was reversed for 180°. Then, a soft tissue tunnel was prepared and the tibial defect ends were slotted. The pedicled double‐barrel fibular flap was transferred to the defect site through the soft tissue tunnel. Attention was paid not to over twist the pedicle. The fibular flap was inserted vertically and stuck into the medullary cavity. It could be fixed to the tibia with screws. A locking plate was inserted to bridge tibial defects. The foot was kept in neutral position, and the flexor pollicis longus was fixed to the interosseous membrane. A typical case is shown in Figs The patient was placed in supine position and proper anesthesia was given. The injured leg was maintained in the center of the annular fixator with Kirschner wires, parallel to the knee and ankle articular surface, respectively. The transport ring was fixed at a suitable plane of distal tibia. Osteotomy was performed close to the distal tibia. Then, the alignment of bone defect ends was adjusted under a C‐arm image intensifier. One week after operation, the external fixator was adjusted for bone transport and the injured limb began to load partially on the ground. The initial lengthening speed was 1.0 mm per day for six times. When the bone defects were shortened within 4 cm, the speed was adjusted to 0.5–0.75 mm per day, which was completed in 3–4 times. After the two defect ends contacted, it was continued to press properly. This would accelerate the docking site healing. In the transport process, attention was paid to nerve and vessel status. If axial deviation occurred, it was adjusted in time. The fixator was removed when consolidation period finished and docking site firmly healed.Functional exercise was carried out postoperatively, including knee and ankle exercise. Symptomatic treatments were given, such as anti‐inflammatory, detumescence, and pain relief. Moreover, X‐ray films were performed to evaluate healing and bone transport process.Operation time, blood loss, and cure time were compared between the two groups. Cure time was defined as total time from admission to the time that bone defects were fully repaired. At 1 year follow‐up, limb functions were evaluated by Ennecking scoret test was used for comparisons between the two groups. Count data were analyzed using χ2 test. p < 0.05 was defined as statistically significant.SPSS 23.0 software (IBM Company) was used to process data. Measurement data were expressed as mean ± standard deviation. Unpaired Staphylococcus aureus, Pseudomonas aeruginosa or Escherichia coli, was found in 51 cases while two or more kinds of bacteria were found in 32 cases. There was no significant difference in demographic information between the two groups  and the National Natural Science Foundation of Shaanxi Province (2022JQ‐757).The authors declare that they have no competing interests.


Xenopus laevis. Thenceforth, similar gene multiplications were recognized for actin genes in Dictyostelium discoideum,The term pseudogene  was coined by Jacq et alhttps://www.gencodegenes.org/human/stats.html).By the original definition, a pseudogene is a DNA sequence that resembles a gene, but has accumulated (disrupting) variants over the course of evolution. Therefore, pseudogenes, which always derive from functional genes,https://www.gencodegenes.org/human/stats.html). In brief, unprocessed pseudogenes arise from duplication of genomic DNA sequences and lie on the same chromosome as their parental gene. Processed pseudogenes derive from messenger RNA (mRNA) retrotransposition and are usually located on a different chromosome than the parental gene  with the typical phenotype consisting of childhood‐onset, generalized dystonia.PRKRA have undoubtedly been linked to a recessively inherited form of early‐onset generalized dystonia.PRKRAP1 to the parental PRKRA gene.PRKRA variant NM_003690:c.665C>T; p.(Pro222Leu) being present in the heterozygous state only until Sanger sequencing unraveled the variant was actually present homozygously.The high sequence similarity of parental genes, in which mutations can lead to human disease and the non‐coding pseudogene(s), can pose a challenge to genetic testing, especially when using short‐read NGS‐based assessments. In this issue of PRKRA that shows 99.4% sequence identity  to the PRKRAP1 pseudogene including 55 nucleotides upstream and 119 nucleotides downstream of the c.665C>T mutation. In contrast, the intronic sequences of PRKRA do not show sequence similarity to its pseudogene  are generated and can show a perfect match between the parental gene and the pseudogene. This is illustrated in Figure ene Fig.  because PRKRA and PRKRAP1.In a first step, the NGS workflow includes library preparation by fragmenting genomic DNA in short size‐uniform pieces of double‐stranded DNA, followed by ligating technology‐specific adapters to both fragment ends, and subsequent amplification and sequencing of these DNA fragments to generate millions of “reads.” After these steps, reference‐based bioinformatics pipelines include a mandatory “alignment” stage before downstream algorithms can be run. Bioinformatics tools, such as the industry standard “Burrows‐Wheeler Aligner” (BWA),SMN2, which originates from an inverse duplication of the SMN1  locus. Biallelic variants in SMN1 cause spinal muscular atrophy (SMA). SMN2 differs from SMN1 by five nucleotides, none of which changes the encoded protein sequence, but one affects splicing, therefore, resulting in only ~10% of SMN2 transcripts including exon 7 and hence, full‐length SMN protein.SMN2 has become the target of bifunctional antisense oligonucleotides preventing exon 7 skipping and ultimately rescuing SMN synthesis in a licensed disease‐modifying treatment for SMA (nusinersen).Pseudogenes were once regarded as “genomic fossils,” that is, functionless fragments of protein‐coding genes being incorporated into the genome.Pseudogenes can act on their parental genes and alter their sequence at the DNA level, or their expression and functionality on the mRNA and protein level through several mechanisms Fig. .GBA variants, which are recognized as the single largest risk factor for the development of Parkinson's disease. GBA encodes the lysosomal enzyme glucocerebrosidase. Detecting GBA variants is challenging because of its neighboring, unprocessed pseudogene (GBAP1), which has an overall homology of 96% with GBA. In particular, the homology rate peaks at 98% in the region from intron 8 to the 3′‐UTR, where five identical segments >200 bp each are recognized. Homologous recombinations between GBA and GBAP1 have led to the generation of well‐established “complex” structural variants in GBA (termed as Rec1 to Rec7),GBA and GBAP1 also poses challenges on the sequence analysis even when using Sanger sequencing of GBA.At the DNA level, for instance, the high homology between a pseudogene and its parental gene predisposes to non‐allelic homologous recombination leading to a wide range of structural variants Fig. . ImportaAt the mRNA level, pseudogenes are capable to regulate the expression of their parental genes by competitively binding to microRNAs .The definition of a pseudogene has now broadened to include any DNA sequence that is similar to a known gene and has lost some of its original functionality.GBA and PRKRA, a potential role of pseudogenes has not (yet) caught our attention in the field of movement disorders, although several well‐established disease‐linked genes also have pseudogenes. For instance, there is a processed pseudogene of the myoclonus‐dystonia‐linked gene SGCE showing ~80% sequence similarity to SGCE overall and at most ~90% within an exon. Furthermore, the ACTB gene, which encodes β‐actin and in which mutations can cause another form of dystonia, has at least six processed pseudogenes with <93% sequence identity overall, not reaching >95% at the exon level. To cause misalignment in NGS‐based sequence analysis, there should be <3 mismatches per 150‐nucleotide read . Therefore, the sequence identity for these pseudogenes should be too less to seriously trouble sequence analyses.Apart from GBA, but their role might actually be underestimated. As illustrated by the DYT‐PRKRA example,GBA analysis.Overall, pseudogenes have emerged as a hot topic because they can challenge genetic testing and trigger mutational events even in biologically functional parental genes. In the genetics of movement disorders, they have mainly been brought into play regarding (1) Research project: A. Conception, B. Organization, C. Execution; (2) Data Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript Preparation: A. Writing of the First Draft, B. Review and Critique.F.M.: 1A, 1B, 1C, 3A, 3BK.L.: 1A, 1B, 1C, 3A, 3BEthical Compliance Statement: We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. The authors confirm that the approval of an institutional review board was not required for this work. We confirm that no consent for patients was requested for the present article.Funding Sources and Conflicts of Interest: The authors declare that there are no funding sources or conflicts of interest relevant to this work.Financial Disclosures for the Previous 12 Months: F.M. is supported by the Michael J. Fox Foundation (MJFF) and Edmond J. Safra Foundation and was supported by the research grant “Fondo Gianesini” in collaboration with UniCredit Foundation and University of Verona, Italy (February 2021–January 2022). K.L. has been receiving funding from the German Research Foundation (FOR 2488), the Damp foundation, the Parkinson's foundation, and is a member of the GP2 consortium (funded through the MJFF).


Firmicutes and the F/B ratio associated with an HFD, and significantly upregulated the relative abundance of Verrucomicrobia. At the genus level, the downregulation of the relative abundance of Akkermansia and unclassified_Lachnospiraceae groups, and the upregulation of the relative abundance of Romboutsia, Ruminococcus, Corynebacteriume, and Saccharibacteria_genera_incertae_sedis groups brought about by the HFD were significantly reversed. The results of the above experiments were compared favorably with those of a parallel experiment with Bi ‐Sheng ‐Yuan slimming tea . Overall, the findings have provided that WLTT can prevent obesity owing to an HFD by regulating intestinal flora and has a good safety profile, and combinations of Tibetan tea and medicine food homology herbs could be a new option for obesity prevention.Obesity has become a significant global public health problem. Functional drinks have been an essential direction for obesity prevention research. The present study investigated the preventive effect and safety of winter melon and lotus leaf Tibetan tea  on obesity. The rats' hypercaloric high‐fat diet (HFD) obesity model was established to evaluate obesity prevention and explored the mechanism through intestinal flora regulation. The results showed that in obese rats with the intervention of WLTT , the body weight, fat accumulation, adipocyte cell size, serum lipid levels, and antioxidant enzyme activity  were progressively improved. 16S rRNA high‐throughput sequencing showed that WLTT could improve intestinal flora disorders due to HFD, which significantly reversed the relative abundance of  Combinations of Tibetan Tea and Medicine Food Homology Herbs, A new Strategy for Obesity Prevention. According to the latest national prevalence estimates for 2015–2019, 6.8% were overweight and 3.6% obese in children under 6 years old, 11.1% overweight, and 7.9% obese in children and adolescents aged 6–17 years old, 34.3% overweight and 16.4% obese in adults (≥18 years), and with a population base of 1.41 billion, the obesity situation in China is no longer optimistic , formulated with Lotus Leaf, Winter Melon, Cassia Seed, Hawthorn, Chen Pi, Mulberry, Puzzle Nut, and Ginseng, was offered by Sichuan Ya'an Yixing Tibetan Tea Co., Ltd. Bi‐Sheng‐Yen slimming tea (BSY), composed of senna, green tea, cassia seed, lotus leaf, and alisma, was purchased from Beijing Autoshure Health Products Development Co., Ltd. (Lot No. 19201102). Superoxide dismutase (SOD), malondialdehyde (MDA), and glutathione peroxidase (GSH‐Px) kits were purchased from Nanjing Jiancheng Institute of Biological Engineering. Chloral hydrate and formaldehyde were all analytically pure and purchased from Sinopharm Chemical Reagent Co., Ltd.2.2Winter Melon and Lotus Leaf Tibetan Tea was converted to a medium dose of 800 mg/kg in experimental rats based on the recommended daily human dose of 8 g and then designed for a low dose of 400 mg/kg and a high dose of 1600 mg/kg. WLTT was decocted for 20 min at a tea‐to‐water ratio of 1:40 for the first decoction and for 10 min at a tea‐to‐water ratio of 1:20 for the second decoction to obtain the tea broth, which was concentrated to the corresponding raw tea concentration for both decoctions based on a gavage volume of 10 ml/kg for rats. BSY was converted to an experimental dose of 500 mg/kg in rats based on the recommended daily human dose of 5 g. The decoction method is the same as for WLTT and is also concentrated to the corresponding raw tea concentration based on the rats' gavage volume. The above samples were decocted once every day, concentrated, and then refrigerated at 4°C.2.3Seventy SPF grade SD male rats, weighing 200 ± 20 g, were purchased from Chengdu Dashuo Experimental Animal Co. Ltd. (license number: SCXK [Chuan] 2015–030). High‐calorie feed formula: 50% basal feed, 15.0% sucrose, 15.0% lard, 10% casein, 5% whole milk powder, 2% calcium hydrogen phosphate, 1.9% microcrystalline cellulose, 1.1% rock flour. Calories are 4376.4 kcal/kg, of which 19.52% are protein calories, 40.16% are fat calories, and 40.32% are carbohydrate calories‐formulated and supplied by Jiangsu Synergy Pharmaceutical Bioengineering Co., Ltd. (production license: Su Feeding Certificate 2014–01008).According to the method for functional evaluation of healthy food, 70 SPF‐rated SD male rats were taken and fed for 1 week after acclimatization. The rats were randomly divided into two groups according to body weight, 10 of which were normal control (NC) and given maintenance chow, and the remaining 60 were a hypercaloric high‐fat diet model group and given hypercaloric chow. After 2 weeks of feeding, 60 rats given hypercaloric chow were sorted by weight gain, and after eliminating the obese‐resistant rats with lower weight gain, the screened 40 obese‐sensitive rats were again randomly allocated into five experimental groups with 8 rats each according to their body weight range. They were hypercaloric high‐fat diet model group (HFD), Bi‐Sheng‐Yuan slimming tea 500 mg/kg (HFD + BSY), WLTT 400 mg/kg group (HFD + L‐WLTT), WLTT 800 mg/kg group (HFD + M‐WLTT), and WLTT 1600 mg/kg group (HFD + H‐WLTT). Each experimental group was given the corresponding concentration of the test sample, and the NC group and the model group were given double‐distilled water as the control. All rats were oral gavage at a dose of 10 ml/kg once a day, and the dose was adjusted by weighing once a week. All animal experiments were conducted with the Ethics Committee of Zunyi Medical University .2.4body weightg3×10÷ body length (cm). The rat was quickly dissected, and the contents were quickly removed from the same part of the cecum in sterile lyophilization tubes and placed in an insulated box with dry ice for freezing. The liver, kidney, perirenal fat, and epididymal fat tissue were removed and weighed on an electronic balance to calculate the organ index. After weighing, appropriate amounts of liver and epididymal adipose tissue were cut and fixed in formalin fixative and sent to the Department of Pathology, Affiliated Hospital of Sichuan Ya'an Vocational College for pathological analysis. The rat adipose tissue change was observed by H&E staining. Six adipose tissue sections were randomly selected from each group and photographed at 200× field of view to count the number of fat cells in the same area.At the end of the intervention cycle, the rats were fasted without water for 12 h, weighed, anesthetized with 10% chloral hydrate by intraperitoneal injection, and collected blood from the femoral artery. After the plasma was left to stand for 2 h, the serum was separated by centrifugation at 3000 r/min at 4°C for 10 min, and taking a partial serum sample was quickly sent to the Laboratory Department of Ya'an Hospital of Traditional Chinese Medicine in Sichuan Province for biochemical indexes such as TG, TC, HDL‐C, LDL‐C, AST, ALT, BUN, and Cre. According to the kit instructions, another part of the serum sample will be analyzed for the antioxidant enzymes SOD, MDA, and GSH‐Px . After blood collection, the rat's body length was measured, and Lee's index was calculated according to the formula, Lee's index = 2.5The cecum contents of three rats were randomly collected from each group and sent to Sangon Biotech (Shanghai) Co., Ltd. for high‐throughput sequencing library construction and Illumina Mi Seq sequencing. The raw data obtained based on sequencing were stitched according to overlap relationships. The samples were differentiated and then quality‐controlled and filtered for sequence quality, followed by OTU clustering and species annotation, Alpha diversity analysis, Beta diversity analysis, grouping test analysis, and species taxonomic composition analysis.2.6X¯ ± SD. Differences of p < .05 were considered statistically significant.The experimental data were statistically analyzed using GraphPad Prism 8.0 software (GraphPad Prism Software). One‐way analysis of variance was used for comparison between groups, and data are expressed as 33.1p < .05, Figure p < .05, Figure p < .05, Figure p < .05, Figure After 2 weeks on a hypercaloric diet, rats showed significant weight differentiation, thus demonstrating the model's success. However, with the intervention of the experimental samples, the weight of each experimental rat further diverged. The weight‐loss trend was significantly better in each experimental group of WLTT than in the BSY group, showing a dose‐dependent trend  groups provides a more visual representation of the differences in microbial communities between groups  has become one of the leading reference indicators for studying intestinal flora disorders (Indiani et al., Firmicutes and slightly increasing the abundance of Bacteroidetes while upregulating the relative abundance of Verrucomicrobia. However, the group was puzzled by the fact that none of the experimental groups showed high‐abundance values of Bacteroidetes in this experiment, which could be related to the source of the experimental intestinal bacteria samples to the cecum contents.In recent years, intestinal flora has gained much attention as an essential target for chronic metabolic diseases (Cao et al., Akkermansia muciniphila, a normal flora of the human intestine, is the best‐known probiotic in Akkermansia, and numerous studies have shown a negative association between Akkermansia muciniphila and diseases such as obesity, diabetes, cardiovascular disease, and low‐grade inflammation (Higarza et al., Lachnospiraceae has also been shown to reduce obesity and improve inflammation as a potentially beneficial bacterium (Naudhani et al., Akkermansia, unclassified_Lachnospiraceae at the genus level, suggesting that WLTT and BSY can positively regulate probiotic disorders in the intestinal flora caused by a high‐calorie diet. At the same time, studies have confirmed that Romboutsia and Ruminococcus are positively correlated with waist circumference and body mass index, LDL, TG, and TC indicators of blood lipids (Wang, Ablimit, et al., Romboutsia and Ruminococcus was also significantly downregulated by the intervention of WLTT and BSY. In addition, the relative abundance of Saccharibacteria_genera_incertae_sedis and Corynebacterium flora also showed a significant decreasing trend. It can be seen that both WLTT and BSY have an excellent ability to regulate the disturbance of intestinal flora caused by a high‐calorie diet. However, after an in‐depth comparison of the ability of WLTT and BSY to intervene in the intestinal flora, it was found that Psychrobacter and Aerococcus showed a significant upward trend in the BSY intervention group. In contrast, no statistical difference was shown between the experimental groups of WLTT, while Aerococcus was confirmed as a human pathogen in numerous studies (Rasmussen, Probiotics have been shown to combat the development of some chronic metabolic disorders because of their beneficial regulation of the intestinal flora (Ji & Shen, The group compared the species composition obtained from sequencing with the KEGG PATHWAY database and found that the intervention of the WLTT groups led to changes in the functional abundance of microorganisms, and the number of statistically different functional metabolic pathways increased with increasing dose. It mainly causes changes in some metabolic pathways, such as amino acid, insulin, and bile metabolism, in addition to altering the biosynthesis and degradation of some secondary metabolites, which are mostly positively associated with obesity and lipid metabolism.5Akkermansia and unclassified_Lachnospiraceae, and the decreases in the abundance of Romboutsia and Ruminococcuse, thus affecting changes in metabolic pathways such as amino acid, insulin, and bile metabolism and the biosynthesis and degradation of secondary metabolites, may be the key reasons for the effectiveness of WLTT. The combination of Tibetan Tea and medicine food homology herbs may be superior to green tea and medicine food homology herbs in terms of function and safety, which could be a new strategy for obesity prevention.In summary, WLTT has a significant preventive effect on a high‐calorie model of obesity in rats, while the drink also has a good safety profile. The regulation of the intestinal flora significantly, the increase in the abundance of The authors declare no conflicts of interest.


Airway clearance techniques are supposed to be a necessary adjunct for the enhancement of impaired peripheral clearance in cystic fibrosis (CF). The objective was to assess the effect of one physiotherapy session (autogenic drainage: AD) on mucus clearance (sputum wet weight) and impulse oscillometry system (IOS) indices, including those obtained from extended Resistance-Inertance-Compliance (eRIC) modelling, considering the degree of bronchial congestion.Thirty children with CF (median age: 12.7 years) in a stable condition prospectively underwent IOS measurements at baseline and after AD. They were divided in two groups: with  and without  bronchial congestion. Paired-comparison of the effects of AD on airway resistance measurements was done with Wilcoxon test.p < 0.0001, R = 0.66). Ten children had bronchial congestion and 20 were without congestion. In the whole group, R5–20 Hz significantly decreased after AD (P = 0.049), which was related to a decrease in the children with congestion (P = 0.025), whereas it was not significantly modified in the children without congestion (P = 0.327). The eRIC model allowed the calculation of the peripheral resistance of the respiratory system, which also decreased in the children with congestion (P = 0.037), however, not modified in the children without congestion (P = 0.390).The congestion scale correlated with the wet weight of sputum production during the session (Pearson test: One session of autogenic drainage has the ability to decrease peripheral resistance obtained from IOS measurements, more specifically in children with CF with moderate to severe bronchial congestion.ClinicalTrials.gov Identifier: NCT04094441. In 1985, Kirilloff and colleagues posed the question, “Does chest physical therapy work?”, and in their review, they concluded that chest physical therapy has frequently been shown to be of benefit in cystic fibrosis (CF) , suggestAirway clearance techniques are usually commenced as soon as the diagnosis of CF is made. In a systematic review, Warnock and Gates evaluated the different modalities of airway clearance techniques in CF . The resBased on this background, we hypothesised that AD in children with CF could improve peripheral airway indices, depending on the volume of sputum cleared during the session. Sakarya and colleagues showed that the indices obtained from the impulse oscillometry system (IOS) were improved after treatment of an acute exacerbation in children with CF . IOS is This interventional study was registered  on September 19, 2019.The subjects did not perform physical therapy on the morning of the tests and received no bronchodilator or mucolytic treatment in the 12 h preceding the tests. Since forced expiration has been associated with cough, spirometry was not performed at baseline in order not to induce a bias related to expectoration of mucus. The timeline of study procedures is provided in Fig. Children 4–18 years with CF followed at the Cystic Fibrosis Centre (CRCM) at Robert Debré hospital were enrolled during their annual check-ups. All subjects were clinically stable (no antibiotics for an exacerbation in the preceding 4 weeks). This study conformed to the standards set by the latest revision of the Declaration of Helsinki and was approved by an ethics committee . The parents of the children gave written informed consent; assent was also obtained from children.Assessment of AD session: before the session, the degree of bronchial congestion was evaluated by both the child (absence versus presence) and physiotherapist . The children with CF were then divided in two groups according to the visual analogue scale: < 5/10  and ≥ 5/10 . All sputum samples produced during the session were collected and weighed (within 15 min after the end of the session). The sputum weight was determined in the pulmonary function test unit by an independent investigator, who was blinded to the congestion rating.AD was performed by four experienced chest physiotherapists devoted only to children with CF. AD is an airway clearance technique developed by Chevallier that is based on non-forced expiration during controlled breathing at different levels of vital capacity , 10. BriChildren practiced chest physiotherapy on a usual basis (three times a week with a physiotherapist).Impedance of the respiratory system was measured using an IOS , as previously described , 11. ThecentralRS) and peripheral resistance  of the respiratory system, while the peripheral compliance of the respiratory system (CpRS) includes the parenchymal and chest wall compliances. The model was fitted to the impedance data (5–35 Hz) and the minimization of a performance index allowed the calculation of model indices  for continuous data and as frequency (percentage) for categorical data, except when stated. Comparisons between baseline and after AD or between after AD and after salbutamol were performed using the Wilcoxon rank paired test. Comparisons of the continuous variables between the two groups of children were performed using the Mann–Whitney U test . Categorhe study . StatistThe mean (± standard deviation) of the coefficients of variation of Fres, R20Hz, R5Hz, R5–20 Hz, X5Hz and AX were 6 ± 3, 5 ± 4, 6 ± 3, 7 ± 4, 10 ± 10, 12 ± 11; respectively.The intraclass correlation coefficient within-test of Fres, R20Hz, R5Hz, R5–20 Hz, X5Hz and AX were excellent: 0.95 , 0.98 , 0.98 , 0.98 , 0.94 , 0.93 ; respectively.2 s2 L−2, respectively. The corrected Akaike information criterion (appropriateness of the various inverse model topologies) at baseline, after AD and after salbutamol were − 86 , − 91  and − 90 , respectively. Overall, the model adequately fitted the experimental data . There was moderate agreement between the child and the physiotherapist   Table .Table 1CperipheralRS) are described in Fig. The effects of AD on two peripheral markers of resistance , R5–20 Hz significantly decreased after AD .P = 0.010) and RperipheralRS (P = 0.026).When the effects of AD were evaluated based on the opinion of the child , similar results (a significant effect of AD in children with presence of congestion) were evidenced for both R5–20 Hz (P = 0.097) nor in children with (P = 0.138) or without (P = 0.489) bronchial congestion.AD did not significantly modify VD, neither in the whole population . Among the IOS indices, Fres (P = 0.016), AX (P = 0.016), R5Hz (P = 0.034) and X5Hz (P = 0.041) were significantly modified by the bronchodilator. The eRIC model showed significant modifications of IRS and CpRS  and proximal (Rrs11 and Rrs19) airways, but not in the distal compartment (Rrs5–Rrs19) in 30 adult CF subjects [In a similar study, Wallaert et al. performed forced oscillation tests before and after a single AD session , but didsubjects . The autsubjects .1 significantly increased by 2.24% predicted or 80 mL after chest physiotherapy [The eRIC model adequately fitted the experimental data of children with CF, the modeling error was inferior to the error observed in asthmatic children . It emphotherapy . One mayotherapy . This leotherapy –28.Similarly, in a recent study, significant changes were observed in the values of R5–R20Hz and AX, after an oscillatory positive expiratory pressure session and thoracic compression, in the comparison with rest in adult patients with non-CF bronchiectasis, also suggesting peripheral effects of airway clearance techniques . The benAD, despite mucus clearance, was unable to increase the anatomical dead space in our study. This result could be related to the specific distal effect of AD that was evidenced using IOS measurements. Moreover, using functional respiratory imaging, Leemans and colleagues showed that the volume of the airways decreased following high-frequency chest wall oscillation in CF patients, whereas resistance increased . They ex1) after bronchodilator use [The long-term effects of bronchodilator administration in CF remain debated . In the ator use . We obseator use . The incOur study has limitations that are related to its design. Only short-term effects of AD were evaluated in a restricted sample of children with CF. The two-group subdivision may seem artifactual since sputum production during the AD session was a continuum, but similar results were obtained based on the child’s opinion. Moreover, in the whole group, a decrease in R5–R20Hz was demonstrated. Our results were obtained in children with mildly affected lung function and may not be generalizable to all subjects with CF. The predicted values of IOS that have been used were developed in Mexican children , which mSputum elimination was also determined in the present study. For this purpose, the wet sputum weight was measured immediately after the interventions. It is well known that mucus quantity, as volume or weight, cannot represent mucus depuration without considering the possible losses by swallowing or errors in its collection . FurtherIn conclusion, one session of AD performed by a physiotherapist has the ability to decrease peripheral resistance obtained from IOS measurements, more specifically in children with CF with moderate to severe bronchial congestion.


Around 2 million people have migrated from Central and Eastern Europe to the UK since 2004. The UK Central and Eastern European Community (UK‐CEE) are disproportionately exposed to the social determinants of poor physical and mental health. Their health and healthcare beliefs remain under‐researched, particularly regarding primary care.This review explores UK‐CEE community members' use and perceptions of UK general practice.A systematic search of nine bibliographic databases identified 2094 publications that fulfilled the search criteria. Grey literature searches identified 16 additional relevant publications. Screening by title and abstract identified 201 publications of relevance, decreasing to 65 after full‐text screening. Publications were critically appraised, with data extracted and coded. Thematic analysis using constant comparison allowed generation of higher‐order thematic constructs.Full UK‐CEE national representation was achieved. Comparatively low levels of GP registration were described, with ability, desire and need to engage with GP services shaped by the interconnected nature of individual community members' cultural and sociodemographic factors. Difficulties overcoming access and in‐consultation barriers are common, with health expectations frequently unmet. Distrust and dissatisfaction with general practice often persist, promoting alternative health‐seeking approaches including transnational healthcare. Marginalized UK‐CEE community subgroups including Roma, trafficked and homeless individuals have particularly poor GP engagement and outcomes. Limited data on the impact of Brexit and COVID‐19 could be identified.Review findings demonstrate the need for codesigned approaches to remove barriers to engagement, culturally adapt and develop trust in GP care for UK‐CEE individuals.Community members and stakeholders shaped the conceptualisation of the review question and validation of emergent themes. As such, it is unclear where research gaps exist, including the particular needs and experiences of people from distinct countries within our definition of CEE. Primary care staffs' cultural competency towards UK‐CEEs has also received limited attention.Scoping reviews increase the representation of community knowledge, allowing exploration and mapping of the extent, range and nature of scientific literature that may not otherwise be identified.1.2The first author met with community groups, organisations and researchers working with UK‐CEEs in North West England (2016–2020). Community members expressed repeated difficulties and frustration with general practice in the United Kingdom. Community organisations described a paucity of high‐quality research on UK‐CEE health beliefs and general practice engagement but knew of local assessments and reports. Outcomes from community consultation informed the initial conceptualisation and ongoing development of the review.2A systematic literature search was undertaken using established scoping review methodology.2.1The primary review aim was to identify ‘what are UK resident CEE nationals' perceptions of, and engagement with UK General Practice?’ A number of subquestions were also explored, namely, 1) whether barriers and facilitators exist for UK‐CEE community member engagement with UK general practice; (2) whether any identified barriers and/or facilitators vary in their degree and scope for different members of the UK‐CEE community according to gender, age, socioeconomic status, ethnic affiliation or other individual characteristics; and (3) how these barriers and/or facilitators vary over time for the UK‐CEE community, including ‘Brexit’. For the purposes of this review, search terms relating to the UK‐CEE community were defined as nationals from EU member nations in Central or Eastern Europe , location (United Kingdom) and ‘intervention’ . Relevant search terms were identified from Medical Subject Heading codes and peer‐reviewed publications.Supplemental grey literature and publication reference list searches were undertaken.2.3Inclusion and exclusion criteria are presented Table , with ju2.4Database search results were exported to Endnote (version 9.1), merged and deduplicated. In keeping with PRISMA guidelines, search results were screened over two stages  focus on Central and/or Eastern Europeans; (2) healthcare use; and (3) UK context. Full‐text review was undertaken if all criteria were fulfilled or in cases of uncertainty.2.4.21.Key term/s (≥1): ‘general practice’; ‘GP’; ‘family medicine’; ‘family practice’; ‘primary care’; or ‘doctor’ .2.Participants: Central European, Eastern European, A8 or A2 nation migrants.3.Perceptions and/or engagement with healthcare.We rechecked the inclusion and exclusion criteria, and assessed relevance to the primary aim. Articles had to fulfil the following inclusion criteria:Publications focussing solely on European migrants not from Central Europe, Eastern Europe or non‐A8/A2 nations where individuals identified as being from Central and Eastern Europe, or where outcomes relating to UK‐CEEs could not be clearly differentiated, were excluded. Uncertainties regarding study inclusion were cross‐checked by three primary care researchers and resolved through discussion with arbitration by a senior academic. Reasons for noninclusion were documented. Given the nature of the review, statistical inter‐rater agreement was not calculated.2.4.3n = 50), moderate (n = 12) or low (n = 3) critical appraisal scores.Publication quality does not typically influence scoping review inclusion or weighting.A data abstraction chart was developed, piloted on three shortlisted publications, discussed within the team and refined. Concise text‐based information was extracted from included publications and uploaded to NVivo.2.5A representative sample of three transcripts was reread and coded independently by team members. Discussion of the emerging codes formed the basis of a coding scheme for the remaining transcripts. Tabulated coded data were used to explore relationships between study outcomes, enabling inductive and iterative generation of emergent themes, followed by thematic analysis with constant comparison, rather than prior theory, to clarify higher‐order constructs.33.1Database searches identified 2094 publications, decreasing to 1536 after deduplication. Title and abstract screening identified 185 publications that fully (77) or partially (108) fulfilled criteria for full‐text review. Forty‐nine publications fulfilled the criteria for data abstraction. Additional and grey literature searches identified 16 further publications  and local government or third‐sector organisation reports (n = 11), with smaller numbers of academic theses, conference abstracts, magazine articles, oral presentation summaries and letters also fulfilling inclusion criteria (Table n = 28), quantitative (n = 10), mixed methods  and smaller numbers of case reports, case series, audits and other study designs (Table n = 46), during (n = 5) and from (n = 14) the 2016 Brexit referendum (Table The most commonly identified study forms were peer‐reviewed research publications n = 5 and loc3.2.2n = 42), Slovak (n = 18), UK‐CEE (nonspecified) (n = 14) and Romanian (n = 13) were the most commonly described nationalities. Publications frequently considered multiple UK‐CEE nationalities simultaneously and as a single entity, rather than comparatively. Several studies either additionally or exclusively considered the experiences and perceptions of healthcare and community workers working with the UK‐CEEs (n = 8). Publications drew on data from across the United Kingdom (Table n = 42) and Scotland (n = 13). Within England, (n = 13) studies took place in London. Wales and Northern Ireland were less well represented. The setting varied, incorporating urban (n = 27), smaller towns or rural (n = 11) and mixed settings  healthcare frequently substituted or supplemented general practice use.2.Young(er) individuals with higher educational, socioeconomic, social integration and English‐language status. Engagement and acceptance of GP care was comparatively higher.3.Marginalized community subgroups with income and accommodation insecurity, including Roma, homeless, trafficked and unregistered individuals. High levels of (unmet) health needs were compounded by multifactorial barriers to general practice registration and engagement,Rates of general practice registration ranged between 12%3.3.1GP registration was not perceived as straightforward, with community members often lacking knowledge and guidance on the process and requirements, including personal documentation.The ability to gain and maintain practice registration was affected by uncertainty around healthcare entitlements, lack of clarity on GP role and accommodation transiency .3.3.21.Service understanding: Limited awareness and understanding of general practice within the United Kingdom.2.Limited English‐language ability: Affecting understanding of healthcare correspondence, appointment booking and communication with clinicians.3.Medical information: Limited availability or supply of non‐English‐language medical information4.Appointment availability: Both on inquiry and timing in light of other commitments, particularly work.Frequently described and interconnected barriers to access and engagement with UK general practice included the following:Structural barriers were reduced through informal co‐national support networks that provided service knowledge, encouraged healthcare review, supported GP registration and provided translation .3.3.31.Non‐Polish individuals and those living away from urban centres who had fewer culturally familiar health options.2.Individuals with children, where more frequent contact stemmed from health visitor, immunisation and childhood illness appointments (which were perceived as urgent).3.Limited finances for example, individuals without social security coverage to access state or personal finances for private home nation healthcare.4.Acute or perceived severe health needs: Initial health engagement could be tortuous and have avoided general practice.5.Contraception and sexual health: Uptake varied by locality, familiarity with GP services and degree of empowerment,An increased need for care was seen in:3.3.41.Mental health symptoms, despite a high prevalence, rarely led to GP presentation.2.Screening. Accommodation transiency, cyclical migration and requirement for GP registration impacted upon receiving appointment and screening letters.3.Health promotion. GP health promotion strategies were not actively sought out due to more urgent life pressures,4.Vaccination. Low GP registration, language barriers, incomplete medical records and limited parental awareness of UK vaccination schedules led to missed vaccinations.In a number of instances, registration and use of GP services were delayed or not attempted due to a lack of desire or perceived need.3.43.4.11.Cervical smears undertaken by nursing staff every 3 years.2.Primary care in pregnancy and post‐partum undertaken by GPs and ‘non‐doctors’.3.Differing child vaccination schedules, with some vaccination refusal (influenza), missed doses and subsequent infections.4.Health prevention, with low interest and uptake through GP services, for example, smoking, alcohol and dietary advice.5.GP telephone triage and consultations being viewed negatively due to perceived incomplete assessment, time pressure, language difficulties and lack of physical examination.Experiences of state and frequently private healthcare in individuals' home nation shaped healthcare expectations of UK general practice.3.4.2GP appointment availability and timeliness were a frequent concern,Further difficulties included signing in 3.4.3Individuals often delayed presentation until they felt that their needs were serious. GP expertize was sought for specific ‘strong’ treatment or specialist referral.3.4.4Antibiotics were felt to be required rapidly for infections, particularly in children. Recommendation of ‘low‐strength’ ‘nonspecific’ over‐the‐counter medications (particularly paracetamol) and antibiotic nonprescription were frequent points of contention.3.4.5Prior experience of direct specialist access led to dissatisfaction with the gatekeeper model of care. Some perceived GPs to deliberately obstruct their request for referral.3.4.61.The system: To limit resource expenditure due to underfunding.2.The clinician: Undertraining or incompetence,The reason for perceived denial of care was often not explained to or understood by UK‐CEEs. Some individuals reported being told their requests were not safe, indicated or evidence based.Some CEEs felt that their views were confirmed by antibiotic and analgesic prescription or radiological investigation on ED attendance.3.4.71.Universal access, particularly by individuals with low or unstable income and the marginalized, for example, substance misusers.2.Free or lower costs, associated with a wider range of prescriptions, vaccinations and screening compared with home nations .3.Invitation reminders for screening.4.Emergency care services, which were seen as responsive.5.Healthcare facilities and equipment, which were viewed as being of a higher standard than within individuals' home nations.6.Relational care, including clinician politeness, contrasting them with home nation doctors (Poland). Children felt involved in care decisions.7.GP health system guidance, particularly where this allowed efficient navigation of other health services.8.GP promotion of self‐care and avoidance of overtreatment, a view associated with other broader markers of acculturation into UK society.Some positive aspects of general practice and the wider UK health service were reported. These included:3.4.8General practice clinicians' and administrators' perceptions of UK‐CEE community members varied from feeling that health needs were well met,3.53.5.1Dissatisfaction with UK General Practice was commonplace, shaped by misinformation and negative stereotypes. Limited health system understanding and entitlements predisposed individuals to difficulty overcoming structural barriers to care access, unmet health expectations and negative GP experiences.3.5.21.Culturally familiar healthcare facilities within the United Kingdom (Polish clinics and pharmacies) and home nations .2.Self‐sourcing of treatments including purchases within home nations or UK Polish supermarkets.3.Persistence and pressure on GPs, through repeated attendance and treatment or referral insistence.4.Requesting and collecting health documentation, particularly for Roma individuals.5.Community support network and online forum use for health and self‐care advice.Strategies to overcome the perceived power imbalance in accessing GP care included the following:3.5.3Widespread transnational healthcare use was seen as a perceived alternative to GP engagement.3.5.4At a deeper level, the choice between UK and transnational or private healthcare was an outworking of perceived and desired national identity.3.6An initial emphasis on immigration‐related service pressuresThe Brexit referendum created heightened feelings of instability, future uncertainty, being ‘unwelcomed’ by UK nationals and distrust towards UK authorities.44.1This is the first review to focus on CEEs' engagement with and perceptions of UK general practice. Systematic scoping of academic and grey literature allowed consideration of heterogeneous community subgroups. The review identifies general practice under‐registration. Service use is associated with UK‐CEEs' perceived ability, desire and need to engage with general practice. Engagement is characterized by UK‐CEE patients and GP staff failing to comprehend each other's expectations of care. UK‐CEEs' perceived or actual unmet expectations reinforce feelings of distrust and dissatisfaction with general practice, promoting alternative health‐seeking behaviours.4.24.2.1Low levels of GP registration and barriers to service engagement have been reported within other UK migrant and marginalized groups.Rather than being a ‘hard to reach community’,Close working with UK‐CEE community organisations and decision‐makers presents an opportunity to improve care access and empowerment, overcome preconceptions and support alternative approaches to health service provision.4.2.2The current review frequently identified a UK‐CEE reliance on transnational or emergency care. Similar health practices have been described for CEE migrants in other European countries.4.2.3Review findings suggest that UK‐CEE patients and GP staff often fail to comprehend each other's expectations of care. The resultant negative perceptions of general practice affect the degree of service engagement Figure . UK‐CEEsUK‐CEE community members' desire to avoid healthcare disempowerment, inequity and perceived or actual prejudice is understandable.4.2.4We identified culturally tailored approaches to overcome barriers to care access, including different language resources on service use, registration support, community staff and mediators, and collaboration with community organisations.To improve CEE satisfaction with and quality of GP care, service reappraisal will need to consider service provider and UK‐CEEs' expectations, preconceptions and prejudices.Brexit unsettled many UK‐CEE community members, challenging feelings of belonging, entitlement and trust.COVID‐19‐related restrictions, safety concerns and remote consultation will influence UK‐CEEs' engagement with GP services and transnational healthcare.4.3Overcoming UK‐CEE dissatisfaction with general practice is required to increase registration rates and service knowledge.4.4The review provides a comprehensive exploration of academic and grey literature,5A large and increasingly established community of CEE nationals live and work in the United Kingdom. Their ability, desire and need to register and engage with general practice services are shaped by an intersection of individual cultural and sociodemographic factors. Difficulties overcoming structural and in‐consultation barriers to care are common, with health expectations often going unmet. Negative experiences heighten pre‐existing mistrust and dissatisfaction with UK General Practice, while promoting alternative help‐seeking strategies such as self‐care, ED use and private ethnic and transnational healthcare. Marginalized UK‐CEE community subgroups have particularly poor general practice service engagement and outcomes, including Roma, trafficked and homeless individuals. Further primary research is required to identify what is likely to work for which CEEs and in which context. Overcoming barriers to care requires trust between community members and general practice services. Community codesign approaches may support service access, information provision, communication and health management for CEEs. The current review is particularly timely, given the influence of Brexit and the COVID‐19 pandemic on migrant health and health service engagement.Aaron Poppleton, the lead researcher, designed the review protocol and implemented the database searches, data extraction and coding and is also the primary review author. Kelly Howells was involved in title and abstract screening, development of data abstraction template, data extraction, coding and cross‐checking and provided review and feedback on the manuscript. Isabel Adeyemi was involved in title and abstract screening, development of data abstraction template, data extraction, coding and cross‐checking and provided review and feedback on the manuscript. Carolyn Chew‐Graham was responsible for academic supervision of the primary review author, including discussion and formulation of thematic concepts and ideas presented within the discussion, and provided review and feedback on the manuscript. Lisa Dikomitis was responsible for academic supervision of the primary review author, including discussion and formulation of thematic concepts and ideas presented within the discussion, and provided review and feedback on the manuscript. Caroline Sanders was responsible for academic supervision of the primary review author, discussion and feedback of the review protocol, including conceptual and methodological development, oversight of any disagreements relating to publication screening and inclusion and discussion and formulation of thematic concepts and ideas presented within the discussion and also provided review and feedback on the manuscript.The authors have no conflicts of interest to declare. All co‐authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.Supporting information.Click here for additional data file.


Intraductal papillary mucinous neoplasms (IPMNs) are the precursor lesions of pancreatic cancers, requiring active surgical intervention during cancer development. However, the current criteria for predicting malignant IPMNs remain challenging and limited. Hence, this study aimed to assess the discriminatory performance of circulating cytokines, including TNF‐α, IL‐2R, IL‐6, and IL‐8, then build a novel predictive model to improve the diagnostic accuracy.A total of 131 retrospective (from March 2016 to December 2019) and 53 prospective (from March 2020 to January 2021) patients who were histologically confirmed as IPMNs were consecutively collected and analyzed.p < 0.05). Then, a novel score, the circulating cytokine score (CCS), was calculated and demonstrated as an independent predictive indicator with a higher area under the curve (AUC) than each cytokine alone (p < 0.001). Besides the CCS, two high‐risk stigmata features, the presence of solid component (PSC), and main pancreatic duct (MPD) dilation ≥10 mm were also demonstrated as independent indicators for predicting malignant IPMNs. Finally, a novel nomogram incorporating the CCS and these two high‐risk stigmata features presented a remarkable diagnostic performance, both in the training and validation cohorts with AUCs of 0.928 and 0.873, respectively.The circulating levels of TNF‐α, IL‐2R, IL‐6, and IL‐8 were significantly elevated in malignant IPMNs, and were verified as independent factors for malignant IPMNs  was calculated and proved as an independent predictor.A novel nomogram incorporating CCS showed a remarkable diagnostic performance for distinguishing malignant IPMNs. Due to the wide use and development of high‐resolution abdominal imaging, the incidental identification of IPMNs has markedly increased.Increasing circulating biomarkers have been identified for malignant IPMNs. For example, MUC5AC in circulating extracellular vesicles has been identified as a potential and meaningful protein for malignant IPMNs.Therefore, this study aimed to identify the discriminatory performance of circulating TNF‐α, IL‐2R, IL‐6, and IL‐8 for malignant IPMNs, and formulate a novel circulating cytokine score (CCS) for intensified prediction of malignant IPMNs. Meanwhile, a novel diagnostic nomogram with superior discriminatory power including the CCS and imaging features was further established.22.1Between March 2016 and December 2019, 152 consecutive patients preoperatively diagnosed and histologically confirmed as IPMNs of any subtype  were retrospectively enrolled after radical resection at the Zhongshan Hospital, Fudan University. Patients did not have transplantations; human immunodeficiency virus infections; autoimmune diseases; treatments with immunosuppressive agents; and personal history of malignancy. Among these patients, 131 consecutive patients were finally identified and analyzed as a training cohort under the following criteria: complete general and surgical details; preoperative magnetic resonance imaging (MRI) or computed tomography (CT) examinations; and preoperative blood tumor markers and cytokines examinations within 7 days . Twenty‐one patients were excluded due to a lack of preoperative circulating cytokine examinations.Then, another cohort was designed to recruit IPMN patients for validation. The primary endpoint of this study was the sensitivity of the CCS in assessing the malignant transformation of IPMNs. The secondary endpoints included the specificity, positive predictive value (PPV), and negative predictive value (NPV) of the CCS. The validation cohort size was determined using the Power Analysis & Sample Size (PASS) 15 software as follows: the sensitivity of the CCS was 88.7% in the training cohort and was estimated that 47 patients should be analyzed to obtain the sensitivity based on the 95% confidence interval (95% CI) and 10% tolerance error. Finally, 53 consecutive patients with a preoperative diagnosis of IPMNs from March 2020 to January 2021 at the Zhongshan Hospital, Fudan University were prospectively enrolled as the validation cohort. All patients were prospectively examined for these circulating cytokines and pathologically confirmed after radical resection. All surgeries followed the Fukuoka standards.2.2According to the Fukuoka international consensusAll surgical specimens were evaluated by an experienced hepatic‐biliary‐pancreatic pathologist. According to the WGO Practice Guideline and the international consensus for IPMNs, benign IPMNs included LGD and IGD, and malignant IPMNs included HGD and associated invasive carcinomas.2.3t‐test or Mann–Whitney U test. The differences in categorical variables between benign and malignant IPMNs were analyzed by the Pearson χp‐value <0.05.The SPSS 21.0 (IBM) and R software version 4.0.2 (Bell Laboratories) were used for statistical analyses. Continuous variables were depicted by the medians and inter‐quartile ranges (IQRs) and analyzed using the Student's The diagnostic nomogram based on the PSC, MPD, and CCS was formulated by R software. Its diagnostic power was further assessed by calibration curves, concordance index (C‐index), decision curve analysis (DCA), and clinical impact curve (CIC) as previously described.33.1According to the retrospective criteria, 131 IPMN patients after surgical resection were enrolled in the training cohort. In this cohort, 53 (40.5%) patients had malignant IPMNs, including 30 patients with invasive carcinoma. The median age was 65.0  years, and the median diameter of cyst and MPD was 2.5  cm and 5.0  mm, respectively. High‐risk stigmata and worrisome features are summarized in Table Following the prospective inclusion and exclusion criteria, 53 patients with IPMNs were included in the validation cohort. In this cohort, 21 (39.6%) patients had malignant IPMNs, including 11 patients with invasive carcinoma. The median age was 66.0  years, and the median diameter of cyst and MPD was 2.5  cm and 6.2  mm, respectively. Meanwhile, no significant differences in clinical, pathologic, and radiographic characteristics were detected between the validation and training cohorts Table .3.2p = 0.044), jaundice (p = 0.044), surgery type of Whipple (p = 0.003), main‐duct IPMN subtype (p = 0.004), larger cyst diameter (p = 0.041), larger MPD dilation (p = 0.001), and higher serum Ca19‐9 levels (p < 0.001) were more common in malignant IPMN patients. Considering the high‐risk stigmata and worrisome features, obstructive jaundice (p = 0.044), PSC (p < 0.001), MPD dilation ≥10 mm (p = 0.002), and lymphadenopathy (p = 0.029) were significantly different in malignant IPMNs. Meanwhile, the circulating cytokines TNF‐α, IL‐2R, IL‐6, and IL‐8 were remarkably higher in malignant IPMNs and were positively correlated , IL‐6 , IL‐8 , and TNF‐α  ‐ were independent risk indicators for malignant IPMNs , obstructive jaundice (p = 0.033), PSC (p < 0.001), MPD dilation ≥10 mm (p = 0.003), lymphadenopathy (p = 0.033), Ca19‐9 ≥ 37 U/mL (p < 0.001), and CCS (p < 0.001) were significant predictors for malignant IPMNs in the training cohort. Additionally, the multivariable analysis demonstrated that the PSC , MPD dilation ≥10 mm , and CCS  were independent predictive indicators for malignant IPMNs , MPD dilation ≥10 mm (p = 0.005), thickened enhancing cyst walls (p = 0.018), Ca19‐9 ≥ 37 U/mL (p = 0.039), and CCS (p < 0.001) were potential predictive indicators for the presence of malignant IPMNs in the validation cohort. In the subsequent multivariate analysis, the PSC , MPD dilation ≥10 mm , thickened enhancing cyst walls , Ca19‐9 ≥ 37 U/mL , and CCS  were independent predictors for malignant IPMNs. Altoghther, these results demonstrated the robust predictive role of the PSC, MPD dilation ≥10 mm, and CCS , the C‐index of the nomogram model was significantly higher . Additionally, the calibration curves presented good agreement in the actual‐observed and nomogram‐predicted values in the validation cohort Figure .Considering the predictive accuracy and clinical net benefit for predicting malignant IPMNs, the formulated nomogram was further verified as superior compared to each indicator alone by the DCA and CIC in the validation cohort Figures B and S3B4Once IPMNs, a known radiologically identifiable precursor of pancreatic cancers, develop into invasive diseases, the prognosis of patients is significantly poorer compared to those without invasion. Therefore, accurately distinguishing benign and malignant IPMNs is crucial to determining the appropriate management of patients. Ideally, surgical resection would be recommended for patients with malignant IPMNs, while those with benign diseases should be conservatively monitored to avoid perioperative morbidity until the disease develops. However, the exact identification of benign or malignant lesions in preoperative clinical practice can be challeging.Recently, the incorporation of cyst fluid markers into clinical and radiographic models has improved the diagnostic discrimination of malignant IPMNs.The proinflammatory cytokine TNF‐α exerts an essential role within the host's immune response,In addition to the CCS, two other imaging characteristics from the Fukuoka standards were identified as independent predictive indicators for malignant IPMNs, the PSC and MPD ≥10 mm. Both are high‐risk stigmata of IPMNs and have been validated as powerful independent predictors for malignant IPMNs in various studies.Currently, few studies have established a nomogram based on multiple indicators to predict malignant IPMNs.However, this study also has some limitations. First, it was a single‐center study with finite enrolled cases. Only patients with histologically confirmed IPMNs were included to develop the model, which might difficult its applications to patients with suspected IPMNs under surveillance. Thus, longitudinal analysis of these circulating cytokines and high‐risk imaging features during surveillance in the future can be used to validate its clinical value. Second, the cut‐off value of the CCS might not be appropriate for other patient cohorts. Thus, further large‐scale, multi‐center, prospective clinical trials and meta‐analyses including various CCS studies are required for validation and to determine the most suitable cut‐off. Third, the circulating cytokine levels in patients with immunological function disorder, synchronous malignant diseases, or even viral infections, can result in false positives. In these cases, the circulating cytokine model would be not applicable. Therefore, we adopted the exclusion criteria mentioned above, and other potential influences need to be further evaluated in clinical practice.5In summary, the serum levels of TNF‐α, IL‐2R, IL‐6, and IL‐8 were significantly higher in patients with malignant IPMNs compared to those with benign IPMNs. The CCS was further verified as an independent predictive indicator for the malignant transformation of IPMNs, as well as two high‐risk stigmata features, the PSC and MPD ≥10 mm. Furthermore, a novel predictive nomogram, integrating the CCS, PSC, and MPD ≥10 mm, was established and validated, and remarkably enhanced the predictive power to discriminate malignant IPMNs from benign lesions. Therefore, it can be a valuable and promising tool for predicting the probability of malignant IPMNs in clinical practice and allow timely and accurate surgical decisions.NP, WW and WL had the idea for and designed the study and had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. NP, QC, WW and WL drafted the paper. NP, QC, JZ, HY and WL did the analysis, and all authors critically revised the manuscript for important intellectual content and gave final approval for the version to be published. NP, QC, JZ, HY, DW, YJ, SR, TK, XX, WW and WL collected the data. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.This study was funded by the National Natural Science Foundation of China (82103409), China Postdoctoral Science Foundation (2021M690037), Shanghai Sailing Program (21YF1407100), National Key R&D Program of China (2019YFC1315902), Youth Fund of Zhongshan Hospital Fudan University (LCBSHZX003) and Shanghai ShenKang Hospital Development Centre Project (SHDC2020CR2017B).The authors have no conflict of interest.The protocol of this study was conducted according to the ethical policies and procedures approved by the Ethics Committee of Zhongshan Hospital, Fudan University and the protocol was registered in Research Registry (researchregistry7046). All candidate subjects have signed written informed consent.Figure S1Click here for additional data file.Figure S2Click here for additional data file.Figure S3Click here for additional data file.Table S1Click here for additional data file.Table S2Click here for additional data file.Table S3Click here for additional data file.Table S4Click here for additional data file.


Hand eczema (HE) is the most frequently occurring occupational skin disease. However, studies on non‐occupational wet exposure, occupations not considered as high‐risk, and socioeconomic factors regarding HE are scarce.To investigate the association between HE and occupational and non‐occupational wet exposure and work‐related factors in the Dutch general population.Within the Lifelines Cohort Study, participants with HE were identified by a digital, add‐on questionnaire that included questions regarding exposure. Data on work‐related and socioeconomic factors were collected from baseline.Overall, 57 046 participants (42.0%) were included. Occupational and non‐occupational wet exposure were positively associated with HE in the past year (odds ratios (ORs) 1.35, [95% confidence interval (CI): 1.22–1.49] and 1.34, [95%CI: 1.17‐1.53], respectively). Positive associations for high‐risk occupations , occupations not considered as high‐risk  and higher levels of education were found .Preventive strategies for HE should focus on avoidance of all wet exposure, regardless of origin. In addition, job tasks instead of job title should be taken into account. As previous results on the association between HE and socioeconomic factors differ, future research should focus on a uniform definition of socioeconomic status. Preventive strategies for hand eczema should focus on avoidance of all exposure to wet activities, regardless of origin.Job tasks instead of job title should be considered when counseling patients with hand eczema.Future research on the association between hand eczema and socioeconomic factors should focus on a uniform definition of socioeconomic status. The questionnaire was available until May 15, 2020. The lifetime and 1‐year prevalence of HE were identified by the questions “Have you ever (now or in the past) had hand eczema?” and “Have you had hand eczema in the past 12 months?”, respectively ).2.3Occupational wet exposure was determined according to the German “Technische Regeln für Gefahrstoffe” (TRGS) 401 criteria.2.4Participants’ professions at baseline were coded according to the International Standard Classification of Occupations, version 2008 (ISCO‐08) and aggregated into major and minor groups, based on the three‐digit level.2.5Educational level was classified according to the International Standard Classification of Education2.6Socioeconomic status was based on neighbourhood SES scores according to Statistics Netherlands and the Netherlands Institute for Social Research, which were linked to the postal codes of the participants of the Lifelines cohort. The status scores for each postal code within the Netherlands are based on the inhabitants' average income, educational level, and job perspective. Scores given to postal codes range from −8 to +3, with a score of ~ 0 representing an average SES in the Netherlands.2.7Net household income was classified into eight categories: less than 750; 750–1000; 1000–1500; 1500–2000; 2000–2500; 2500–3000; 3000–3500, and ˃ 3500 euros per month.2.8Employment status was divided in four categories: unemployed, retired (including early retirement), unfit for work, and employed. Individual participants were placed in only one category.2.9The number of working hours per week was reported as a discrete variable and was divided into six categories: 1‐8; 9‐16; 17‐24; 25‐32; 33‐40, and > 40 work hours per week. Values exceeding ≥ 80 hours per week were considered invalid and were excluded for further analysis.2.10U tests. Probability was recognized as significant in where the P‐value was < .05. Prevalence is presented as ‘n’ and ‘%’ with corresponding 95% confidence intervals (95%CI). The association between HE in the past year and sex, age, physician diagnosed AD, contact allergy, occupational and non‐occupational wet exposure, overall wet exposure, and work‐related and socioeconomic factors are described using odds ratios (ORs) with corresponding 95%CIs. ORs were calculated by means of univariate and multivariate logistic regression models. In the first multivariate logistic regression model, ORs were adjusted for predefined confounders . In the second model ORs were adjusted for all predefined confounders of model 1, plus the socioeconomic and work‐related factors that were statistically significant in the univariate analysis.Data analysis was performed using the Statistical Products and Service Solutions package version 25 . Characteristics of the individuals who responded to the question regarding lifetime prevalence of HE are presented as numbers (n) and proportions (%). Differences between the sexes, and between responders and non‐responders were assessed using chi‐square tests, independent t‐tests, or Mann–Whitney P‐values of the interaction terms were < .05.The potential presence of effect modification, in which a specific independent variable has a different effect on the main outcome depending on another independent variable, was assessed by including interaction terms in the final model. Interaction terms were defined as all combinations of a specific socioeconomic or work‐related factor multiplied by one of the other socioeconomic or work‐related factors. Effect modification was considered present when 33.1Descriptive data regarding potential confounders, socioeconomic, and work‐related factors are presented in Table In the non‐responder analysis, there was a statistically significantly increased proportion of female responders compared to male responders. Responders were also more likely to be older, higher educated, with a higher SES, higher income, a tendency to report psoriasis and eczema more often, and differed in employment status Appendix .3.2The results of the logistic regression analyses to assess different risk factors for HE are shown in Table 3.3The univariate analysis showed a positive association between HE in the past year and both occupational wet exposure and non‐occupational wet exposure . After adjustment (model 1 and 2) a positive association with HE remained .When looking further into the specific factors contributing to wet exposure, contact with fluids, use of gloves and frequency of hand washing contributed to occupational wet exposure, and use of gloves and frequency of hand washing contributed to non‐occupational wet exposure.3.4Table 3.5Regarding socioeconomic factors, the univariate analysis Table  showed a4The main findings of this study were a positive association between HE in the past year and occupational as well as non‐occupational wet exposure. Specific factors contributing to occupational wet exposure included direct contact with fluids, use of gloves, and frequency of hand washing. Specific factors for non‐occupational wet exposure included use of gloves and frequency of hand washing. Apart from a positive association between HE and certain high‐risk occupations, a positive association was found for occupations not considered as high‐risk occupations as well. In addition, a positive association between reporting HE in the past year and higher levels of education was found. No association was found for SES, income, employment status, or number of working hours.4.1The association between HE and wet work exposure has been studied previously. However, most studies only focus on occupational exposure and not on non‐occupational exposure.4.2In the current study, a higher 1‐year prevalence of HE among healthcare workers, including personal care workers and nursing and midwifery professionals was found. Previous studies have shown that healthcare workers are at an increased risk of developing HE.4.3The association between HE and socioeconomic factors, such as income and educational attainment, has been studied previously.Some limitations to this study should be taken into account. First, the cross‐sectional data regarding HE is insufficient to determine causality between HE and socioeconomic and work‐related factors. Moreover, the data could have changed between baseline and the current add‐on study. This further complicates comparison with other studies because of variations in the study design. Furthermore, this may, for example, have led to the overestimation of HE prevalence in low income and low SES categories, underestimation in higher income categories, and distortion of HE prevalence among different occupational groups as a result of salary increases and/or changing of occupation over time. However, this was partly avoided by asking participants to report whether the onset of HE took place in certain high‐risk occupations.The question regarding the 1‐year prevalence of HE used in the current study was validated by Meding et al., with a sensitivity and specificity of 65% and 93%, respectively.In conclusion, the most important findings of the current study were the association between HE and occupational as well as non‐occupational wet exposure. Positive associations for high‐risk occupations and occupations not considered as high‐risk  were found, as well as for higher levels of education. In daily practice, preventive strategies should focus on avoidance of all exposure to wet activities, regardless of origin. Special attention to occupations considered as high‐risk remains necessary, however, occupations not considered as high‐risk occupations should not be overlooked. Furthermore, to determine whether an individual is working in a high‐risk occupation, job tasks instead of job title should be considered. As previous results on the association between HE and socioeconomic factors differ between studies, future research should focus on a validated definition of SES for investigating the association with HE.Marjolein Brands: Conceptualization ; data curation (lead); formal analysis (lead); investigation ; methodology ; project administration (lead); resources ; validation ; visualization (lead); writing – original draft (lead); writing – review and editing . Laura Loman: Conceptualization (supporting); data curation (supporting); investigation ; methodology ; resources ; supervision (supporting); validation ; writing – review and editing . Marie L.A. Schuttelaar: Conceptualization ; investigation ; methodology ; resources ; supervision (lead); validation ; writing – review and editing .M.L.A. Schuttelaar received consultancy fees from Sanofi Genzyme and Regeneron Pharmaceuticals and is an advisory board member for Sanofi Genzyme, Regeneron Pharmaceuticals, Pfizer, LEO Pharma, Lilly. The other authors report no conflicts of interest.Appendix S1. Questions and response options including referencesClick here for additional data file.Appendix S2. Non‐responder analysisClick here for additional data file.Appendix S3.Data of missing valuesClick here for additional data file.


Anaplastic lymphoma kinase (ALK) fusion is a prognostic indicator for patients with non‐small cell lung cancer (NSCLC) receiving tyrosine kinase inhibitors (TKIs). The real‐world data of ALK TKIs remain a major concern.Patients with ALK‐positive advanced NSCLC, who received crizotinib or alectinib treatment in first line, were retrospectively reviewed. ALK status was detected using immunohistochemistry (IHC) or next‐generation sequencing (NGS). Clinical outcomes have been comprehensively analyzed between TKIs, ALK fusions, EML4‐ALK variants, and next‐generation TKIs after crizotinib failure.n = 109; alctinib, n = 59). Alectinib showed consistent superiority in progressive‐free survival (PFS) over crizotinib . Multivariate Cox regression showed chemotherapy (CT) prior to TKIs or synchronous chemotherapy seemed not to improve PFS compared to ALK inhibitors alone (p > 0.05). And, alectinib was superior to crizotinib in prolonging intracranial PFS . Patients in EML4 group had a better prognosis than those in non‐EML4 group after alectinib administration . TP53 co‐mutations were relatively common (34.0%) and associated with adverse outcome in ALK‐positive patients . After crizotinib failure, 33 patients received a sequential application of next‐generation ALK TKIs. Compared to ceritinib and brigatinib, alectinib might have better PFS (p = 0.043).One hundred sixty‐eight patients were successively enrolled (crizotinib, Our results revealed alectinib had better PFS and higher intracranial efficacy compared to crizotinib in ALK‐positive NSCLC, and might improve PFS by comparison with ceritinib and brigatinib after crizotinib failure. 1. Chemotherapy prior to TKI or in combination with TKI showed no improvements in PFS compared to ALK inhibitors alone. 2. Alectinib showed better PFS and higher intracranial efficacy by comparison with crizotinib, especially in patients with fusion involving EML4‐ALK. 3. After failure of crizotinib, alectinib might have better PFS compared to ceritinib and brigatinib. 4. TP53 co‐mutations were relatively common and associated with adverse outcome of ALK‐positive NSCLC.  What about their data in real‐world? Given that, we performed this retrospective study and analyzed the clinical outcomes between crizotinib and alectinib, and the survival benefits among the subsequent ALK TKIs when failed to crizotinib treatment. In addition, the efficacy of TKIs among different ALK fusions, EML4‐ALK variants, as well as the impact of TP53 co‐mutation on survival of ALK‐positive patients was also explored.22.1One hundred and sixty‐eight ALK‐positive local advanced or metastatic NSCLC patients were retrospectively reviewed and enrolled successively from our hospital between March 2017 and September 2020. The inclusion criteria were as follows: (1) ALK rearrangement confirmed by Ventana ALK (D5F3) CDx IHC assay or NGS; (2) stage IIIB, IIIC, and IV disease according to the 8th American Joint Committee on Cancer Staging System; (3) administration of crizotinib 250 mg (from March 2017 to August 2020) or alectinib 600 mg (from November 2018 to September 2020), twice daily, including those received prior or synchronous chemotherapy; (4) radiographic data available for evaluation. The exclusion criteria were as follows: (1) patients with other actionable driver alterations; (2) patients receiving systemic treatment other than TKIs and chemotherapy.The baseline characteristics were reviewed and collected from the electronic records, including age, sex, histology, diagnosis, ALK status by IHC or NGS, treatment process, radiographic document, and so on. The best changes in tumor from baseline, response rates, and progression‐free survival (PFS) were analyzed according to Response Evaluation Criteria in Solid Tumors (version 1.1). The Ethics Committee of the First Affiliated Hospital of Zhengzhou University approved this retrospective analysis and waived informed consent.2.2The expression of ALK protein of FFRE sections was evaluated by Ventana ALK (D5F3) CDx IHC assay (Roche Diagnostics) according to the manufacturer's protocols. Tumor cells presented with strong granular cytoplasmic staining are defined as ALK‐positive case, while tumor cells without strong cytoplasmic staining are defined as ALK‐negative case.The NGS details were described in our previous reports.2.3p values <0.05 were considered statistically significant. Data were also analyzed by SPSS (version 19).The baseline features and response rates were compared by chi‐square test or fisher‐exact test when chi‐square test was unsuitable. The survival analysis was performed using Kaplan–Meier method and Log‐rank test. Multivariate Cox regression model was performed for the analysis of prognostic factors. Two‐sided 33.1p < 0.001. Patients with 1 cycle of chemotherapy before ALK TKI accounted for 20.2% (22/109) in crizotinib group and 47.5% (28/59) in alectinib group. The proportion of CT cycles more than 2 was similar between the two groups (25.7% vs. 25.4%). The other clinical baseline characteristics such as age, sex, ECOG PS, smoke history, histology, TNM stage, extrathoracic metastases , ALK detection method, brain radiotherapy at preliminary diagnosis were not significantly different between crizotinib and alectinib group  cases were treatment‐naive in crizotinib group, more than that in alectinib group with 27.1% (16/59), 3.2p = 0.306; DCR 95.4% vs. 98.3%, p = 0.666).The objective response rate (ORR) and disease control rate (DCR) to crizotinib and alectinib were estimated Table . And no p = 0.004, Figure n = 125) receiving no or only 1 cycle of chemotherapy prior to TKI use , extrathoracic metastases , non‐adenocarcinoma  were the independent prognostic factors for PFS  and 67.9% (74/109) events of disease progression were observed in alectinib and crizotinib group for the whole TKI‐naive population Table . AlectinS Figure .3.3p = 0.003; Figure p = 0.002), brain metastases , and CT more than 2 cycles .It is universally acknowledged that alectinib was superior to crizotinib in BBB penetration, but is it also more effective on extracranial metastases? Consistent with the previous studies, alectinib was still better than crizotinib in prolonging intracranial PFS , which was confirmed by multivariate cox‐regression analysis   and tended to have a poorer survival than those without  is the gold standard for gene fusion detection with the disadvantage of poor repeatability requires professional interpretation. IHC is also approved for detecting ALK status due to its good reproducibility and sensitivity. Despite its extensive clinical application, Ventana IHC platform still has some limitations: (1) risk of false negativity; (2) difficulty in distinguishing the fusion partner and concurrent gene mutations. And the above issues can be resolved by NGS.The results of phase III trial, NEJ009, showed that EGFR‐TKI combined with platinum‐based chemotherapy significantly improved PFS and OS in EGFR‐positive NSCLC patients compared with targeted therapy.Similar to the previous clinical trials and real‐world studies, we also observed that alectinib was superior to crizotinib in prolonging survival of ALK‐positive and TKI‐naive NSCLC, and still had satisfactory effects in patients who progressed to crizotinib treatment. Compared to crizotinib, administration of alectinib also showed better intracranial protection. After the failure of crizotinib treatment, which one works better among next‐generation TKIs? There were no randomized controlled studies for head‐to‐head comparison of next‐generation TKIs in ALK‐positive patients. A retrospective study from China demonstrated that alectinib treatment showed better PFS and higher intracranial efficacy in patients failed to crizotinib treatment. Consistent with it, we also observed that alectinib was better for prolonging PFS than ceritinib and brigatinib in ALK‐positive patients failed to crizotinib treatment. This may be partly attributed to the less BBB penetration of ceritinib than alectinib.p = 0.071). All the above studies indicated the efficacy prediction of ALK inhibitors and more precise treatment strategies for differential ALK fusions and variants in the future.Do ALK fusion types and EML4‐ALK variants really matter? The landmark study by Heuckman et al proved that differential types of ALK fusion caused differential protein stability and resulted in differential responses to ALK TKIs.Compared with specific variants, concurrent genetic mutations, such as TP53, MYC copy, or CCND1 copy, may yield a negative impact on prognosis.5This retrospective analysis showed that alectinib was superior to crizotinib in ALK‐positive, TKI‐naïve NSCLC with better PFS and higher intracranial penetration. After failure of crizotinib, alectinib might have a better prognosis compared to ceritinib and brigatinib. TP53 co‐mutation had an adverse effect on the survival of ALK‐positive patients. It was worthy to note that the chemotherapy combination seemed unable to improve PFS or reduce the resistance to TKI.YW, RZ, and XL contributed to the conception. YW, PH, and DG contributed to data collection. YW and RZ contributed to data analysis, interpretation, and graphics presentation. YW, RZ, and SS contributed to constructive discussions and manuscript writing. All authors read and approved the final version of the manuscript.The authors have no conflicts of interest to declare.This work was supported by the Youth Innovation Fund of the First Affiliated Hospital of Zhengzhou University (LHGJ20190018 and LHGJ20190030). The funding source had no role in the study design, data collection, analysis, results interpretation, manuscript drafting, and decision to submit the paper for publication.The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the ethics committee of The First Affiliated Hospital of Zhengzhou University and individual consent for this retrospective analysis was waived.Figure S1Click here for additional data file.Table S1–S3Click here for additional data file.