We investigated the effect of statin intensity on the development of new onset diabetes mellitus (NODM) in Korean patients after percutaneous coronary intervention (PCI). A total of 1013 consecutive patients without diabetes mellitus were retrospectively analyzed. All study patients received high- or moderate-intensity statin . The primary endpoint was development of NODM, and the secondary one was the composite of cardiac death, non-fatal myocardial infarction, and any revascularization. In 264 pairs (528 patients) of propensity score-matched patient, NODM developed in 34 patients (6.4%) and composite cardiac events occurred in 73 patients (13.8%) during a median follow-up of 36.7 months. The incidence rate of NODM was significantly higher in patients with high-intensity statin than with moderate-intensity statin . The incidence rate of composite events was not significantly different between the two groups . The use of high-intensity statins was associated with NODM after adjustment for multiple risk factors . High-intensity statin therapy is associated with a higher incidence of NODM, but not with better cardiovascular outcomes, in Korean patients undergoing PCI. A new cholesterol lowering intensity-based approach rather than stain intensity-based approach to the high-risk patients without diabetes mellitus may be helpful in maximal treatment effect without safety concern of NODM in Asian patients. The elevated low-density lipoprotein cholesterol (LDL-C) level has been considered one of the major causes of coronary heart disease, and clinical guidelines emphasize LDL-C as the primary target of cholesterol-lowering therapy3. Statin blocks endogenous synthesis of cholesterol and reduces LDL-C concentration by inhibiting 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which catalyzes the rate-limiting step in cholesterol biosynthesis4. In addition, statins inhibit HMG-CoA reductase within endothelial cells, vascular smooth muscle cells, and inflammatory cells, which results in the inhibition of the important signaling pathways of atherosclerosis as pleiotropic effects5. Consequently, many previous trials with statins have consistently shown significant reductions in cardiovascular mortality and morbidity9. Furthermore, high-intensity statin therapy has shown further reductions in cardiovascular events compared with low-intensity or moderate-intensity statin therapy10.Coronary heart disease is a leading cause of mortality and morbidity worldwide14. It has been suggested that the risk of developing NODM during statin therapy is associated with statin intensity16. In meta-analysis of data from 5 statin trials, high-intensity statin therapy more increased the incidence of NODM by 12% than moderate-intensity statin therapy12.However, recent emerging evidence has suggested that statins confer increased risk of developing new-onset diabetes mellitus (NODM)3. However, it is well known that Asians achieve more cholesterol reductions and experience more side effects with the same statin intensity than Caucasians18. Therefore, in Asian countries, it is common for clinicians to use moderate- or low-intensity statin therapy rather than high-intensity statin therapy, even if they are at high risk19. In spite of these ethnic differences, most studies on the association between statin use and development of NODM have been conducted in Western countries22. Asian data on the association between statin intensity and NODM in high-risk patients are needed. The data will be very helpful for many clinicians treating Asian patients. Therefore, this study was conducted to investigate the occurrence of NODM and clinical outcomes according to statin intensity in high-risk Korean patients who underwent percutaneous coronary intervention (PCI) for which high-intensity statin is recommended.Clinical lipid guidelines recommend high-intensity statins for the patients with established CVDThis retrospective, observational, single-center study was conducted at Seoul Boramae hospital in a big city . Between January 2010 and December 2015, a total of 5080 consecutive patients who received PCI with drug-eluting stents (DES) as well as statin therapy were initially screened. Patients with the following conditions were excluded sequentially: (1) prior history of diabetes mellitus, (2) newly diagnosed diabetes mellitus during the admission for index PCI, (3) loss of clinical follow-up for more than 6 months after PCI, (4) no information on key data for the study analysis such as glucose, glycated hemoglobin and LDL-C levels, and (5) changes in statin intensity during the first year. Finally, medical records of 1014 patients were analyzed in this study. Our study was conducted according to the Declaration of Helsinki. The Institutional Review Board (IRB) of our hospital approved the study protocol . Informed consent was waived by the IRB due to retrospective study design and to the routine nature of information collected.2). Previous history of cardiovascular risk factors, including hypertension, dyslipidemia, myocardial infarction, angina, heart failure, ischemic stroke, and smoking status were reviewed. A patient was classified as a current smoker, unless sustained abstinence from cigarettes and/or other tobacco products for at least 12 months. Biochemical parameters, including white blood cell count, hemoglobin, plasma glucose, glycated hemoglobin, total cholesterol, LDL-C, high-density lipoprotein cholesterol, triglyceride, and C-reactive protein, were measured after overnight fasting during index hospitalization. Blood samples for biochemical parameters were collected on the next morning after PCI from patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) who exhibited unstable vital signs who required emergency PCI. Blood samples for biochemical parameters were collected on the morning of PCI from patients with angina pectoris and NSTEMI with stable vital signs who did not require emergency PCI. Estimated glomerular filtration rate was calculated with the Modification of Diet in Renal Disease Study (MDRD) equation.Patients’ demographic parameters, underlying disease, smoking status, and concomitant medications were reviewed. Body mass index (BMI) was calculated by dividing body weight in kilograms by the square of the height in meters  were classified as the high-intensity statin group, those with 30% to 49% reduction  were classified as the moderate-intensity statin group. The type and dose of statin were prescribed according to clinical guidelines whenever possible, and the final decision was left to the judgement of the attending physician.The intensity of statin therapy was divided into 2 categories according to the current American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelineThe primary endpoint of this study was development of NODM during the follow-up period. The secondary endpoint was the major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven coronary revascularization. NODM was defined as newly detected glycated hemoglobin A1c (HbA1c) of 6.5% or more, fasting plasma glucose of 126 mg/dL or more, random plasma glucose of 200 mg/dL or more, and medical records of type 2 diabetes mellitus or prescription of one or more antidiabetic medication during the follow-up period. Cardiac death was defined as death from acute coronary syndrome, ventricular arrhythmia, and pump failure. Unexplained sudden death was also considered cardiac death. Myocardial infarction was defined as elevation in cardiac troponin values with at least 1 value above the 99th percentile upper reference limit, with symptoms of myocardial ischemia, new ischemic change of electrocardiography, development of pathologic Q waves, or imaging evidence of myocardial infarction. Ischemia-driven coronary revascularization indicates PCI or coronary artery bypass graft surgery in patients with ≥ 70% diameter stenosis on coronary angiography accompanied by recurrent symptoms, new electrocardiographic changes indicating ischemia, or positive functional study results suggesting ischemia. Clinical follow-up was done every 3–6 months and whenever a clinical event took place. All events were identified by the physician in charge and confirmed by the principal investigator.t-test, and categorical variable using Pearson’s chi-square test between the 2 groups. As statin intensity was not randomized, a propensity score was used to adjust for potential selection or predisposition bias. The propensity score was estimated using multiple logistic regression analysis, with all variables shown in Supplementary Table P < 0.05. All statistical analyses were performed using statistical package SPSS V.22.0  and R programming language V.3.5.3 .The data are presented as the mean ± standard deviation (SD) for continuous variables and as numbers with percentages for categorical variables. Continuous variables were compared using Student’s The mean age of the patients in the study was 66.1 ± 11.9 years, and 68.3% were men. A diagnosis of acute coronary syndrome was made in 89% of the study subjects. According to statin intensity, patients were divided into 2 groups: 283 (27.9%) patients received high-intensity statin therapy and 730 (72.1%) patients received moderate-intensity statin therapy. The specific baseline clinical characteristics of the whole study patients according to statin intensity are shown in Supplementary Table Propensity score matching was performed to adjust for differences of baseline characteristics. A total of 264 pairs of propensity score-matched patients were analyzed in this study. The p value of Hosmer–Lemeshow goodness of fit for the propensity score model was 0.978. There were no significant differences in the baseline clinical characteristics between the two groups. The baseline clinical characteristics of the propensity score-matched patients are shown in Table P = 0.035)  . However, the incidence of MACE was not associated with statin intensity  (Supplementary Table The median follow-up duration was 1098 days (interquartile range: 628–1825 days). During the follow-up period, 61 (6.0%) patients developed NODM as a primary outcome. The incidence of NODM was significantly higher in the high-intensity statin group than in the moderate-intensity statin group   . However, the incidence of MACE was not associated with statin intensity   patients developed NODM as a primary outcome. The incidence of NODM was significantly higher in the high-intensity statin group than in the moderate-intensity statin group  Fig. A. MACE o95) Fig. B. Event In this study, we investigated the effect of statin intensity on the development of NODM and composite cardiovascular events in Korean patients who received PCI with DES. The use of high-intensity statins was associated with higher incidence of NODM, than those with moderate-intensity statins. The incidence rate of composite of cardiac death, non-fatal myocardial infarction, and ischemia-driven revascularization was not significantly different between the 2 groups.9. However, there is concern about development of NODM associated with statin use. In the Anglo Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA) trial, treatment with atorvastatin 10 mg numerically increased risk of NODM , albeit without statistical significance20. In the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial, NODM developed much more frequently in patients with atorvastatin 80 mg than with placebo . In the analysis of Justification for Use of statins in Prevention, an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial, rosuvastatin therapy more increased risk of developing NODM than placebo especially in patients with risk factors for diabetes mellitus 25. Sattar et al.14. conducted meta-analysis to figure out relationships between statin use and development of NODM, and concluded that statin was associated with slightly increased risk of developing NODM . Furthermore, along with our study results, several previous studies have shown that high-intensity statin therapy more increased risk of NODM than moderate-intensity statin therapy27.Statin decreases intracellular cholesterol synthesis by inhibiting rate-limiting enzymes of cholesterol biosynthesis. By lowering LDL-C and with pleiotropic effects, statins significantly reduce cardiovascular mortality and morbidity28. In an efficacy study with Japanese subjects, 5 mg of rosuvastatin lowered LDL-C by 52.7% than baseline29. On the other hand, in Western trails, 5 mg of rosuvastatin lowed LDL by approximately 40%, and 20 mg of rosuvastatin was needed to achieve 52% reduction in LDL-C31. The magnitude of LDL-C reduction with low- to moderate-intensity statin therapy varies in many clinical outcomes, not simply in laboratory results. In the Management of Elevated Cholesterol in the Primary Prevention Group of Adult Japanese (MEGA) study conducted in Japan, even low-intensity statin therapy significantly reduced cardiovascular outcome 32. High-intensity statin therapy not only reduces cardiovascular events, but also increases side effects, such as statin induced myopathy, and elevation of liver enzyme34. In line with these findings, other studies also demonstrated that Asians achieved more cholesterol reductions and experienced more side effects than Caucasians after receiving the same intensity statin therapy18. These results suggest that special attention must be paid to the efficacy-side effect ratio for specific statin treatment strategy in Asians.There are racial differences in responses to statin. Plasma exposure to rosuvastatin and its metabolites was significantly higher in Asians than in Caucasians3. However, diabetes mellitus increases the risk of cardiovascular disease and other complications, such as retinopathy, nephropathy, neuropathy, diabetic foot, and dementia, during a long-term follow-up39. Therefore, we consider appropriate lipid lowering therapy to have the best clinical prognosis with minimal adverse effects, including NODM development with life-long statin therapy. In recent study by Abbasi et al., showed that high intensity statin increased insulin resistance40. And, study by Dormuth et al. showed that high intensity statin was associated with 15% increased risk of development of NODM compared with lower potency statins41. Similar to previous study, in this study, high-intensity statin therapy was significantly associated with higher risk of NODM than moderate-intensity statin therapy in very-high-risk Korean patients who had undergone PCI. Furthermore, high-intensity statin therapy was not more beneficial than moderate-intensity statin therapy in terms of the prevention of cardiovascular events, including cardiac death, non-fatal myocardial infarction, and ischemia-driven revascularization. Although, statin is known to have pleiotropic effects such as anti-inflammatory effects in addition to LDL-C lowering effect, there was no statistically significant difference in clinical events according to statin intensity when LDL-C was lowered to a similar level in this study. It is obvious that the lower LDL-C, the lower CVD event for both primary and secondary prevention42. In recent study, the addition of ezetimibe to statin significantly lowered LDL-C level and CVD events without significant increase in side effects43. Similarly, recent clinical trials with proprotein convertase subtilisin/Kexin 9 (PCSK9) monoclonal antibodies reported no increase in NODM risk at very low LDL-C levels, it is conceivable that the low LDL-C level is not associated with NODM development44. Current cholesterol clinical practice guidelines recommend using maximally tolerated statin first, followed by adding ezetimibe or PCSK9 inhibitor3. However, in this study, high intensity statin was associated with significant increase of NODM in Asian patients. Therefore, we should consider potent cholesterol lowering therapy rather than high intensity statin therapy to very-high-risk Asian patients who do not have diabetes mellitus before statin therapy. If patients cannot reach therapeutic goal with moderate intensity statin therapy, we are able to add ezetimibe or PCSK9 inhibitor to moderate intensity statin therapy rather than increasing statin dose to reduce risk of NODM. As previously described, there is a racial difference in efficacy and safety by statin therapy. Due to differences in pharmacodynamics and pharmacokinetics of statins, adjustment of cholesterol lowering therapy rather than increase statin intensity might be helpful to increase efficacy and safety in Asian patients.The benefits of statins outweigh numerous side effects, and current clinical guidelines recommend high-intensity statin therapy in patients at high risk, regardless of the presence of diabetes mellitus44.There are several limitations in this study. First, this is observational study, so the results may have been subjected to bias, even though propensity score matching method was used and multiple potential variables were adjusted in the analysis. Second, all subjects in this study were Korean, and ethnicity may have affected the risk of developing NODM. Thus, generalization of our study results to other ethnic groups may be difficult. Third, the incidence of cardiovascular events was relatively lower than expected. One plausible explanation is that all the diabetic patients were excluded in the analysis. In addition, a relatively well controlled LDL-C level may have lowered the patients’ risk of developing cardiovascular events. Fourth, although patients whose satin intensity changed within the first 1 year were excluded in the study, there is a possibility that statin intensity was altered in some patients during the follow-up period after 1 year; however, it was not adequately reflected in this study. Fifth, it is not clear what type and dose of statins the patients had been using prior to the study, or whether the patients had never used statins. An individual history of statin use prior to the study may also have influenced the physician's decision to select the appropriate statin type and dosage. In fact, in this study, it is unclear whether it was an effect of previous statin use, but the LDL-C reduction did not exceed 50% compared to baseline in patients who received high-intensity statin therapy. This suggests that the reduction in LDL-C was less than expected, compared to the 45.6% LDL-C reduction in the moderate intensity statin group. Duration of statin use is also an important factor in affecting the incidence of NODM, so the duration of each subject's statin use before the study may have influenced the results. Based on the LDL-C reduction rate, patients prescribed high intensity statins were more likely to have taken statins previously than those prescribed moderate intensity statins. Therefore, the effects of previously used statins may not have been adjusted, which may have affected the study results. Sixth, lifestyle factors such as diet and exercise are also important factors contributing to the development of NODM. In crude patients, the high intensity statin group showed higher smoking rate compared with the moderate statin group. Since, lifestyle factors were not assessed in this study, lifestyle factor could have influenced study results. Seventh, contemporary drug eluting stent and wide usage of intracoronary imaging and optimal stent technique could have influenced development of MACE. Eighth, side effects related to statin use other than diabetes were not assessed in this study. Contrary to expectations, the occurrence of cardiac death and myocardial infarction was higher in the high-intensity statin group. It is speculated that the cardiac event occurred when the patient arbitrarily stopped taking the statin due to side effects. Finally, it is unknown whether the lowered LDL-C level itself, rather than statin intensity, caused NODM. However, as previously described, recent clinical trials with PCSK9 inhibitor reported no increase in NODM risk at very low LDL-C levels, it is conceivable that the low LDL-C level is not associated with NODM developmentHigh-intensity statin therapy, rather than moderate-intensity statin therapy, is associated with a higher incidence of NODM and was not associated with better cardiovascular outcomes in patients who received PCI. A new cholesterol lowering intensity-based approach to the treatment of high-risk patients should be considered in achieving the maximal treatment effect without safety concern of NODM. More detailed guidelines for statin therapy are needed to maintain efficacy and to increase safety for Asian populations. Larger-scaled, prospective, randomized controlled trials may be helpful in clarifying the effect and safety of a new cholesterol lowering intensity-based approach rather than statin intensity-based approach for the treatment of high-risk patients without diabetes mellitus.Supplementary Information.


In all international medical student (IMS) programs in China, language barriers between IMSs and Chinese patients greatly reduced the learning in clinical practice and brought great challenges to IMSs in their transition from preclinical to clinical practice. This study aimed to investigate the role of bilingual simulated patients (B-SPs) in IMSs learning of medical history collection in China.48 IMSs of grade 4 between October 2020 to Jan 2021 were enrolled in this study. During the training of medical history collection, students were randomly arranged into two groups trained with either B-SPs (B-SP group) or English-speaking SP (E-SP group). All SPs in Objective Structured Clinical Exam station (OSCE) were trained in the Affiliated Hospital of Wuhan University. Clinical skills in medical history collection were assessed by instructors during pre-clinical, post-clinical OSCE and clinical rotations.P < 0.05) compared to E-SP group, while obtaining significantly higher score improvements between pre- and post-OSCE (17.22 (95% CI 12.74 to 21.70) vs 10.84 (95% CI 3.53 to 18.15), P = 0.0007).The scores of IMSs in each group were analyzed in terms of medical history collection including the ability to effectively consult for information and key communication skills related to patient care. Our results indicated that IMS in B-SP group obtained similar scores in preclinical training for history collection (67.3 ± 8.46 vs 67.69 ± 8.86, B-SPs are more conducive to doctor-patient communication and actually improve IMSs learning in medical history collection in China. One of the consequences of globalization is the changing landscape of international higher education. The past two decades have seen a significant increase in the number of international students, that is, those who cross national borders in order to study. However, for these international those students always face a number of challenges including language and communication difficulties, cultural and educational barriers that affect their adjustment, socialization, and learning experience , psycholLanguage barriers for international medical students (IMSs) may be more prominent because of the specialized and complex nature of medical vocabulary and higher requirements on the flexible use of language in doctor-patient communications. In the last two decades, China has experienced a dramatic rise in the enrolment of international students to its institutions of higher education, and clinical medicine is the most popular program for academic studies . Most ChComprehensive and systematic medical history collection is one of the most important parts of clinical diagnosis, which is closely related to diagnostic strategy and provides unignorable safety information for clinical treatment. During the consultation, effective communication determines the harmonious start of patient-doctor interactions, which is related to patient satisfaction, compliance, and ultimately clinical outcomes –8. MedicSimulation patients (SPs) are a widely accepted tool for teaching communication skills with evidence of effective transfer into real life skills . ThroughIn recent years, there has been a dramatical increase in the number of IMSs receiving higher education, including clinical medicine, in China, especially from developing countries . In theiIn October 2020, 48 fifth-year IMSs from 7 countries including Pakistan, Somalia, Kenya, Thailand, the United Kingdom, and South Korea from Wuhan University's six-year medical (English-taught) program were enrolled in this study. These IMSs attended a medical history collection lecture by the junior faculties. 3 B-SPs and 3 E-SPs without medical background attended a training seminar for SPs and the other 6 SPs attended the Objective Structured Clinical Examination Station (OSCE) and were qualified by the Wuhan University Affiliated Hospital. Two qualified OSCE examiners were also from Wuhan University. All study subjects consented and signed up to this study and all authors had access to the study data, reviewed and approved the final manuscript. This study protocol was approved by the Ethics Committee of the Wuhan University People's Hospital.After lectures on medical history collection, all IMSs were randomized into two groups (B-SP group or E-SP group) in training workshops. The training sessions were conducted by a faculty member and assisted by 6 previously trained senior and chief residents. In E-SP group, English was used in the training. In B-SP group, SPs communicated with the IMSs in Chinese, and if IMSs found it difficult or unclear to understand, the Chinese was translated into English. All workshops were scheduled once a week and four simulation scenarios were applied. Each SP was given the same scenario description and learning objectives to interact in both groups.After 1-month SP training, IMSs were randomly assigned to the OSCE , which were conducted by two qualified examiners from Wuhan University.All IMSs then underwent a 3-month clinical rotation in the inpatient units . The clinical faculties assessed the IMSs' performance in patient history collection and their ability to communicate verbally and nonverbally in clinical practice. Scores represent the average assessment of the three rotations.After clinical rotations, IMSs attended a second clinical skills OSCE administered by the same examiners as in the first OSCE assessment. English was used in both OSCE assessments. A flowchart of the researcher's tasks is shown in Fig. Simulation scenarios were designed by senior physicians with extensive clinical and teaching experience in Renmin Hospital of Wuhan University. The scenarios were set up to take into account the culture differences between east and west and the actual situation of Chinese patients, simulating outpatient and ward situations as much as possible. The training programs focused on IMSs’ clinical analysis skills, communication skills and verbal and non-verbal humanistic care during the medical history-taking consultation process. All cases were discussed by experts and then officially allowed to be used in the training.SPs should be “standardized” in their performances so students could get the same testing experience . SPs werThe evaluation criteria for medical history collection included pre- and post-clinical OSCE evaluations. Ten aspects include self-introduction, appearance and etiquette, organizational arrangements, consultation content, information collection, respect for understanding, communication skills, citation verification, summary and end of consultation. The full score was 100 points. Each examiner used the same scoring criteria to assess IMSs performance.For evaluation of the 3-month clinical rotation, clinicians from each of the 3 departments evaluated IMSs skills of medical history collection with Chinese patients at the end of rotations.p < 0.05 indicates that the difference is statistically significant.SPSS19.0 statistical software was used for data analysis. The data were expressed as mean ± standard deviation. After testing for normal distribution and homogeneity of variance, comparison between groups were analyzed by paired t-test. As for the differences of score changes between pre- and post-clinical OSCE, independent t-test was used. In this study, 48 IMSs were trained in B-SP- or E-SP-based training of medical history collection through evaluation by pre- and post-clinical OSCE and clinical instructors in clinical rotations. The undergraduate medical students were statistically balanced in terms of mean age, gender, and HSK level in Chinese Table .Table 1BIMSs medical history collection skills were assessed based on the ability to effectively consult for information and competency in key communication skills related to patient care: self-introduction, appearance and etiquette, organization, obtaining information with effective questioning skills, consultation content, behaviors that demonstrate caring and humility, communication skills, providing evidence through effective skills, summarization, and consultation closure.P = 0.8767].We first analyzed the effect of preclinical training by B-SPs or E-SPs on IMS learning for medical history collection . In this preclinical OSCE, no significant differences between two groups were found regarding to scores of skills in gathering information from patients, communication skills, organization, and summarization after the preclinical session trained with B-SPs and E-SPs Table . Similarp < 0.01]  vs 70.97 (95% CI 67.4 to 74.5), P = 0.0007). These results clearly indicated that bilingual history collection training is a practical way to address the learning problems of IMSs in clinical practice and thus improve their clinical skills competency.Medical history collection is one of the most important parts of clinical skills and requires students to obtain important history data through effective communication with patients in a limited time. Students should train to establish a good doctor-patient relationship and to fully reflect humanistic care in their communication. After clinical rotations, IMSs in both B-SP and E-SP groups improved their ability to collect medical history [84.52 (95% CI 81.5 to 87.6) vs 67.3 (95% CI 63.9 to 70.7)] in the B-SP group; 78.53 (95% CI 75.5 to 81.6) vs 67.69 (95% CI 64.1 to 71.2) in the E-SP group, when compared with preclinical OSCE, respectively]  evaluation. There was no significant difference between E-SP and B-SP groups in the skills of collecting patient information in terms of counseling, doctor-patient communication skills, organization and summarization. These findings suggested that preclinical use of B-SPs had not a prominent impacts for IMS in medical history collection before their clinical rotations. Its role in clinical rotations and clinical practice required further exploration.For Chinese patients, they do not use English. This language barrier clearly limits the learning of IMSs when it comes to actual communication with our clinical patients. Even though IMSs have lived in China for 3–4 years and have studied Chinese for a long time, they still find it difficult to communicate with Chinese patients. The main reasons for this include: (1) IMS were not familiar with Chinese patients' expression habits and logical ways of thinking; and (2) IMS lacked Chinese communication training when collecting medical histories. In our study, IMSs trained with B-SPs rather than E-SPs during clinical rotations were better suited to communicate with Chinese patients. IMSs in B-SP group had significantly fewer difficulties due to language barriers than E-SP group. Clinical instructors also rated history collection significantly higher for IMSs in B-SP group than that in E-SP group. IMSs in B-SP group appeared to be more interested in communicating with Chinese patients. In contrast, for IMSs in E-SP group, they were usually unable to communicate effectively with Chinese patients. Clinical instructors, IMSs, and Chinese patients often had to communicate repeatedly, and the language barrier brought more difficulties for IMSs. The training of bilingual SPs helped IMSs overcome the language barrier to benefit their clinical studies.The higher levels of medical history taking skills of IMSs in B-SP group were further confirmed by the second OSCE . Although IMSs in both B-SP and E-SP groups improved their ability to collect medical history compared with their scores in the first OSCE, respectively, the score changes between two OSCEs for IMSs in B-SP group were much higher than that in E-SP group. These results further verified that B-SPs-based preclinical training was a feasible solution to the learning problems of IMSs in clinical practice, thus facilitating the improvement of their clinical skills.Our results and conclusions have important implications for the clinical teaching for international medical students in other countries. The following aspects should be noted in clinical bilingual teaching for international medical students. Firstly, B-SPs who are native English speakers should have good communication skills in Chinese, especially in medical Chinese, and have more familiar knowledge of Chinese culture. Secondly, B-SPs and E-SPs should not have related medical background which will guarantee the real situation of patient scenarios. All qualified SPs should attend a training seminar for this SP training. Furthermore, B-SPs and E-SPs in preclinical training should not attend OSCEs. Finally, SPs for twice OSCEs should be the same batch which could ensure the consistency of same assessment criteria.In conclusion, the application of B-SPs has improved the medical history collection ability of IMSs. It not only alleviates the language barrier for medical students in learning and training, but also improves students' clinical practice and facilitates their clinical skills in history taking, thus improving the quality of teaching and providing a good method for bilingual courses in other medical majors. The training of B-SPs has high requirements for teachers and students, including good language skills, performance and imitation skills, short training basic medical knowledge afterwards. All these need to be further explored and improved in the future.Not commissioned; externally peer-reviewed.


Stress urine incontinence (SUI) is most common in middle-aged women and the second most common in those over 75. SUI causes significant discomfort and suffering for patients and has a considerable financial impact on the healthcare system. Conservative approaches are recommended as the first step in treatment. However, surgery is often necessary to improve a patient's quality of life due to the high failure rate of conservative treatments. A thorough literature review of studies published before March 2023 was conducted on the safety and effectiveness of single-incision mini slings (SIMS) and standard mid-urethral slings (MUS). PubMed, Embase, Cochrane Library, and Elsevier's ScienceDirect were used to retrieve the studies. Two reviewers independently searched and evaluated the data based on inclusion and exclusion criteria. Review Manager 5.4 software was used for meta-analysis. Included were seventeen studies involving 3,503 female SUI patients without intrinsic sphincter deficiency (ISD) or mixed urinary incontinence. According to the results of our meta-analysis, the clinical efficacy of SIMS is comparable to that of MUS in terms of objective cure rate . In contrast, it increases the post-procedure International Consultation on Incontinence Questionnaire (ICIQ) score . CI: -0.02 to 0.18, p: 0.11, I2: 55%) and improves the PGI-I score to a greater extent . In contrast, there is no difference between the two groups regarding patient satisfaction  and Sandvik score reduction . In conclusion, single-incision mid-urethral slings (SIMS) are as effective as mid-urethral slings (MUS) for treating pure stress urinary incontinence (SUI) without intrinsic sphincter deficiency (ISD), with a shorter operation time. However, the SIMS procedure has a higher incidence of dyspareunia. At the same time, bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), worsening urgency, dysuria, and pain score are less likely to occur with SIMS. Only the decrease in pelvic/groin pain was statistically significant. Urinary incontinence (UI) is a prevalent illness affecting 30-50% of women throughout their lives . IndividThe development of single-incision mid-urethral slings (SIMS) aimed to reduce complications by shortening the insertion trajectory. Additionally, SIMS offer potential benefits such as a shorter polypropylene tape, insertion through a single vaginal incision, and the ability to perform the procedure under local anesthesia . The MinLimited research has been conducted on the effectiveness and safety of single-incision mid-urethral slings (SIMS) compared to traditional mid-urethral slings. Existing studies have provided conflicting results, with only a few randomized controlled trials and observational studies available. Therefore, we conducted a systematic review and meta-analysis to determine which surgical procedure is superior for treating stress urinary incontinence. As far as we know, this is the first recently updated meta-analysis to compare SIMS versus mid-urethral slings for treating this condition.Methods The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines  were folSearch StrategyElectronic searches without language constraints were conducted on PubMed, Embase, the Cochrane Library, and Elsevier's ScienceDirect databases for clinical research (updated in March 2023). For literature retrieval, simple keyword and medical subject heading (MeSH) term combinations  were utilized. In addition, thorough searches of each pertinent review's references and citation lists were conducted. The population, intervention, comparison, and outcome (PICO) methodology was followed. Women with stress urinary incontinence represented the population of interest (SUI). Three researchers  assessed the titles and abstracts of possibly eligible studies separately. Inclusion And Exclusion CriteriaThe included studies met the following criteria: The studies must be either randomized controlled trials (RCTs) or observational studies (cohort or case-control). The researchers compared the efficacy and safety of single-incision mini-slings (SIMS) to traditional synthetic mid-urethral slings (MUS). Participants were SUI-positive females, and there was no statistically significant difference in the fundamental characteristics of the participants. The outcomes included the cure rate, surgery-related data, and postoperative sequelae.The following criteria were used to exclude studies: Studies or articles that do not provide sufficient data for meta-analysis, studies that are not original research such as conference abstracts, case reports, case series studies, editorials, or review articles, studies with a follow-up time of less than one year, and studies that focus on patients diagnosed with intrinsic urethral sphincter deficiency (ISD). The exclusion of studies with ISD is necessary as it is a distinct condition from stress urinary incontinence, which is the focus of this meta-analysis.Data Extraction And DefinitionsThe literature selection was completed according to the inclusion and exclusion criteria. Two reviewers (T.P and F.S) independently extracted data and appraised quality and content. The following items were extracted from each available study: first author, year of publication, country, study design, intervention, sample size, follow-up data, baseline variables , parity), and relative outcome  and overall complications. The primary outcomes were objective cure rate and subjective cure rate. The negative cough stress test analyzed the objective cure rate, whereas the subjective cure rate comprised of patient global impression of improvement scale (PGI-I), patient satisfaction, postoperative Sandvik score, and international consultation on incontinence score (ICIQ). The secondary outcomes included adverse events related to the two procedures, the need for revision surgery/re-surgery, operative time, and length of hospital stay. Cough stress test: The patient was supine/lithotomy and had 200-400 mL of fluid in the bladder. The examiner directly visualized the urethral meatus for the presence of leaking after she coughed 1-4 times. Fluid leakage from the urethral meatus that occurs concurrently with/simultaneously with the cough(s) is considered a positive test. The subjective cure rate was defined as "very much better" or "much better" based on the PGI-I, postoperative ICIQ-SF cut-off score (of 6/21) that is likely to be associated with a patient-reported successful outcome on the PGI-I following surgical therapy. Sandvik score: The score range is 0 to 8, with 0 being the lowest and 8 being the highest (or 12 for the fourth level). The greater the score, the more severe the incontinence. Quality Of Included StudiesQuality assessment of all the included RCTs and observational studies was done by using the Cochrane risk of bias tool  and NewcStatistical AnalysisOnly comparative studies were statistically analyzed with Review Manager 5.4.1. . This meta-analysis calculates a pooled effect of relative risks (RRs) for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes using the generic-inverse variance with a random-effects model. The findings of the pooled analysis were illustrated using forest plots. Funnel plots of primary outcomes were produced for each primary outcome to evaluate publication bias. Using Higgin's I2 test , levels Since the data were acquired and analyzed from previous clinical studies for which the researchers had already obtained informed consent, no approval from an ethical committee was necessary for this investigation.ResultsCharacteristics OF The Eligible Studies The literature review initially yielded 1750 articles. After removing duplicates and screening studies based on their titles and abstracts, seventeen -29 studiBaseline Characteristics Of The Patients The overall number of participants was 3503 (1773 in the SIMS group and 1730 in the MUS group), with mean ages ranging from 44.1 ± 7.0 to 62.5 ± 10.4. All the patients included in the study were females with SUI. Most patients included were overweight, with an average parity of 3 ± 1.1. Tables Quality Assessment And Publication BiasAs determined by the New Castle-Ottawa scale, observational studies have a low probability of bias, a technique for assessing study quality, as shown in Table Primary Outcomes The objective cure rate and the subjective cure rate characterized the primary outcomes. The subjective cure rate was determined by patient satisfaction, PGI-I (better or very much better), Sandvik score < than the pre-operative score, and ICIQ score. The objective cure rate was determined primarily by analyzing patients with a negative cough stress test. Objective cure rate: Thirteen of 17 studies provided the objective cure rate, which was predominantly a negative cough stress test, and the pooled analysis revealed that the rate of the negative cough stress test was comparable across the two groups  as shown in Figure Subjective cure rate: The subjective cure rate was analyzed by assessing four outcomes: PGI-I score, Sandvik score, postoperative ICIQ score, and patient satisfaction, which are described as follows: Six of 17 studies provided PGI-I score, and the pooled analysis revealed that patients in the SIMS group had a non-significantly increased rate of PGI-I score better than baseline compared to placebo  as shown in Figure Secondary Outcomes The secondary outcomes were the length of the operation, the length of the hospital stay, the necessity for revision or surgery, and adverse events. A list of secondary outcomes is included in Table Operative time: The operative time was provided by 7 of the 17 studies, and the pooled analysis revealed that the SIMS procedure required much less time than the MUS treatment. Owing to the significant level of heterogeneity, a leave-one-out sensitivity analysis was conducted, which revealed that a single study did not influence the results of this outcome. Length of hospital stay: Seven of the 17 studies recorded the length of hospital stay. The pooled analysis revealed that the SIMS technique was related to a non-significantly shortened length of hospital stay. Due to the considerable heterogeneity, a leave-one-out sensitivity analysis was performed, which demonstrated that any single study did not affect the results of this outcome. Need for revision/re-surgery: Five of 15 studies provided the rate of revision surgery or re-surgery, and the pooled analysis revealed that the SIMS procedure was associated with a non-significantly lower risk of revision/re-surgery than the MUS approach. Adverse events: The pooled analysis of adverse events revealed that the SIMS procedure was linked with a significantly higher risk of dyspareunia when compared with the conventional MUS procedure. On the other hand, it was linked to a lower risk of bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), urgency worsening, dysuria, and a pain score < 5 on the visual analog scale (VAS). Still, only the reduction in pelvic/groin pain was statistically significant. The rate of urine retention did not differ between the two groups. Univariate Meta-Regression The study used univariate linear meta-regression analysis to investigate the correlation between adverse cough stress test outcomes and Sandvik scores less than the pre-operative scores and baseline variables, including age, BMI, and parity. The results indicated that the negative cough stress test rate decreased with age but increased with parity and BMI, although these results did not reach statistical significance. On the other hand, the rate of Sandvik score being less than the pre-operative score decreased with increasing BMI but increased with age and parity. Table Discussion Petros and Ulmsten introduced the tension-free vaginal tape (TVT) in 1995 as a simple and highly effective surgical method for treating female stress urinary incontinence (SUI). In recent years, there have been significant advancements in treating female SUI, and TVT has become a popular procedure due to its excellent efficacy and short learning curve. This popularity has also led to the development of various procedure modifications . The intThis comprehensive systematic review and meta-analysis of 17 studies included 3503 participants. They aimed to analyze and compare the safety and effectiveness of two surgical techniques: single incision mini-sling (SIMS) and Mid-urethral sling. In addition, it was essential to evaluate intraoperative and postoperative problems. Regarding demographic and pre-operative factors, the groups were comparable clinically before surgery. Considering primary outcomes, the objective cure rate was almost similar in both groups. According to Bakas et al.2's research, the TVT procedure effectively treats SUI in women with pure SUI and a cystocele of no more than grade 1. The study showed that the procedure has an 83.9% objective cure rate and a 78.6% subjective cure rate at a 17-year follow-up and has a minimal risk of complications . The subFurthermore, there were no significant differences in patient-reported and objective cure rates between the currently used SIMS during midterm follow-up . HoweverThe secondary outcomes of the study comprised the duration of the operation, hospitalization period, requirement for revision or surgery, and any unfavorable incidents. The SIMS procedure had a significantly shorter operative time than the MUS treatment, and the other factors were discovered to be almost insignificant. In contrast, adverse events associated with the SIMS procedure were significantly linked with a higher risk of dyspareunia than the conventional MUS procedure. The combination of design features in the Altis procedure is distinctive. While direct comparisons with other SIMS have yet to be conducted, it is crucial to comprehend the theoretical principles of each design. Given the many surgical options available to surgeons, the advantages of SIMS should be considered from a patient's viewpoint. SIMS generally has shorter operation times, reduced postoperative pain, and faster recovery. Furthermore, apart from TVT-Secur, the effectiveness of SIMS is not inferior to conventional mid-urethral slings .Our study had several advantages (1). A total of seventeen studies, comprising both randomized controlled trials and observational cohorts, reinforced the meta-analysis we conducted. This significantly impacted the overall sample size and increased the study's power. (2) To examine how various studies influenced the overall estimate, a sensitivity analysis was conducted to assess PGI-I (better or very much better), operative time, and length of hospital stay to check for high heterogeneity. (3) To assess publication biases, a range of tests and plots, such as funnel plots, were employed, and none were significant. (4) Furthermore, the Newcastle-Ottawa Scale was used to identify any publication bias in the additional observational study included in our meta-analysis. (5) This study used a univariate linear meta-regression analysis to examine the relationship between adverse cough stress test outcomes and Sandvik scores and baseline variables, including age, BMI, and parity. While the negative cough stress test rate decreased with age, it increased with parity and BMI. However, these findings were not statistically significant. Conversely, the rate of Sandvik scores being less than pre-operative scores decreased with increasing BMI. In contrast, it increased with age and parity.While our study produced significant statistical data, it is vital to recognize its limitations. (1) Firstly, most studies' follow-up durations varied significantly, with some indicating longer durations. In evaluating any surgical procedures, longitudinal follow-up studies are preferred; thus, a longer follow-up period would have been preferable. (2) The observed clinical heterogeneity may have been caused by variations in study designs, interventions, and patient factors . (3) The lack of a clear and detailed description of blinding procedures in the included RCTs may have resulted in conclusion bias. The occurrence of potential biases resulting from CCTs is inevitable. (4) Furthermore, assessing technical equipment and surgical proficiency is imperative for evaluating the efficacy of the two approaches. Yet, it was not feasible to appraise them in the current review. (5) An additional constraint of this study is the inclusion of unselected populations in some of the studies (patients with pelvic organ prolapse and varying degrees of stress urinary incontinence) and the possibility that some patients were duplicated across two studies.To summarize, single-incision mid-urethral slings (SIMS) exhibit comparable short-term efficacy to mid-urethral slings (MUS) in treating patients with pure stress urinary incontinence (SUI) and no signs of intrinsic sphincter deficiency (ISD). Compared to mid-urethral slings, the SIMS procedure demonstrated a shorter operative time and a significantly higher incidence of dyspareunia. Conversely, it was associated with a decreased risk of bladder perforation, mesh-related complications, pelvic/groin pain, urinary tract infection (UTI), worsening urgency, dysuria, and a pain score of less than five on the visual analog scale (VAS). However, only the decrease in pelvic/groin pain showed statistical significance. Consideration of the identified limitations is essential when interpreting the results. Large, well-designed prospective randomized controlled trials with extensive follow-up are necessary to confirm the long-term efficacy and safety of the intervention.


Rectal colonisation with carbapenem-resistant Gram-negative bacilli (CR-GNB) may cause CR-GNB infection in children with haematological malignancies (HMs) haematological. To date, information on its epidemiology is limited. This study aimed to assess the the risk factors for rectal colonisation with CR-GNB in children with HMs.A case–control study in a tertiary children’s hospital in Hangzhou City, was conducted between July 2019, and September 2021. Based on the hospitalisation date, children in the CR-GNB colonisation group and control groups were matched at a ratio of 1:2. Conditional logistic regression models were used to compute the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the risk factors for CR-GNB rectal colonisation in children with HMs.P = 0.020).colonisation In the conditional logistic regression model, the aORs were 6.84 (95% CI 1.86–25.20) for acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL), 4.16 (95% CI 1.17–14.84) for prior concomitant infections within the last 1 month, 2.33 (95% CI 1.16–4.69) for prior carbapenems usage within the last 1 month and 7.46 (95% CI 1.81–30.67) for prior hematopoietic stem-cell transplantation (HSCT).A total of 85 non-duplicated CR-GNB isolates were collected from rectal swab samples of 69 children with HMs. The 30-day mortality rates were 5.8% in the CR-GNB colonisation group and 0% in the control group (AML/ALL, prior concomitant infections within the last 1 month, prior carbapenems usage within the last 1 month, and prior HSCT are associated with an increased risk of rectal colonisation with CR-GNB in children with HMs. Pseudomonas aeruginosa, carbapenem-resistant Acinetobacter baumannii and have become serious threats to public health, causing serious infection and high mortality rates ) was also significantly higher than that of the control group . The demographic characteristics of the children in this study are shown in Table CR-GNB infections seriously threaten the survival of patients, especially those with chronic granulocytopenia after chemotherapy, in HM treatment units –19. CR-GTherefore, CR-GNB intestinal colonisation in patients with HMs, especially in children, must be studied to prevent CR-GNB infections. This case–control study was conducted to identify the risk factors for CR-GNB rectal colonisation in children with HMs. The rate of CR-GNB rectal colonisation reached 18.4% during the study period, an alarming finding. The top three bacteria were all Enterobacteriaceae  and accounted for three-quarters of CR-GNB isolates. This suggests that Enterobacteriaceae is the main force of CR-GNB colonisation in children with HMs, which may be because Enterobacteriaceae is the main component of gut microbiota. From the demographic characteristics, no significant difference in age and sex was found between the CR-GNB colonisation group and the control group, which indicated that the two groups were relatively matched in terms of grouping. CR-GNB rectal colonisation significantly affected the outcomes of children with HMs. Significant differences were found in both CR-GNB infections and 30-day mortality between the two groups of children with HMs. In other words, the incidence of CR-GNB infections and 30-day mortality were significantly higher in the CR-GNB colonisation group than in the control group. However, this significant difference may be underestimated because clinicians may have adopted more aggressive management measures to prevent CR-GNB infections after receiving news of CR-GNB rectal colonisation, which may have prevented some cases from progressing to CR-GNB infections or even death. The incidence of CR-GNB infections and the 30-day mortality in the CR-GNB colonisation group were higher than those calculated in this study if clinicians did not adopt more aggressive management measures.The logistic regression analysis showed that AML/ALL, prior concomitant infections within the last 1 month, prior carbapenem use within the last 1 month and prior HSCT are associated with an increased risk of rectal colonisation with CR-GNB in children with HMs. In children with AML or ALL, the immune balance is often disrupted, and this disruption is exacerbated by agranulocytosis caused by chemotherapy. The incidence of infectious diseases in children with AML or ALL will be far greater than that in other populations, and the use of antibiotics will be unavoidable. Frequent, heavy and persistent use of antibiotics, especially carbapenems, leads to further screening for CR-GNB. Currently, HSCT is a curative option for many HMs in children; however, the probability of infection will be greatly increased during immunosuppression and even lead to death , 22. TheThe limitations of this study should be considered. First, As this was a retrospective case-control study, resistance genes were not analyzed. Second, As a single-center study, the conclusion might not apply to other hospitals because the cases included were all solely from the same hospital Third, the sample size was limited because the patients were from the same ward of the same hospital, and the study period was limited. Although the requirements for sample size estimation were met, the representativeness of the study results may be limited. Additional study with expanded scope and large sample sizes is needed. Finally, further subgroup analysis is needed because of differences in the mechanisms by which Enterobacteriaceae and Pseudomonas develop resistance. However, given the limited sample size of other GNBs, further subgroup analyses were not included in this study.The risk factors for CR-GNB rectal colonisation in children with HMs include AML/ALL, prior concomitant infections within the last 1 month, prior carbapenems usage within the last 1 monthand prior HSCT. Therefore, clinicians should strengthen the detection of CR-GNB rectal colonisation in children with HMs and adjust the management measures to prevent CR-GNB infections promptly in the presence of the four risk factors, such as strengthening the monitoring of infectious indicators and adjusting the use of prophylactic or therapeutic antibiotics.


Since its introduction in 2000, the TILLING strategy has been widely used in plant research to create novel genetic diversity. TILLING is based on chemical or physical mutagenesis followed by the rapid identification of mutations within genes of interest. TILLING mutants may be used for functional analysis of genes and being nontransgenic, they may be directly used in pre-breeding programs. Nevertheless, classical mutagenesis is a random process, giving rise to mutations all over the genome. Therefore TILLING mutants carry background mutations, some of which may affect the phenotype and should be eliminated, which is often time-consuming. Recently, new strategies of targeted genome editing, including CRISPR/Cas9-based methods, have been developed and optimized for many plant species. These methods precisely target only genes of interest and produce very few off-targets. Thus, the question arises: is it the end of TILLING era in plant studies? In this review, we recap the basics of the TILLING strategy, summarize the current status of plant TILLING research and present recent TILLING achievements. Based on these reports, we conclude that TILLING still plays an important role in plant research as a valuable tool for generating genetic variation for genomics and breeding projects. Howeverinterest . At the 1 plants. The most popular mutagen used for the creation of TILLING populations is EMS (Ethyl methanesulphonate) which is an alkylating agent causing mainly G/C to A/T transitions , peppermint (Mentha L.) or sugarcane (Saccharum officinarum), the generation of stable mutants is more problematic. The meristematic buds  or cell or tissue cultures in vitro are usually target materials for mutagenesis (1 plant should be propagated into the next generation (M2) in order to avoid the repetitions of the same mutations during screening. A very important aspect is the maintenance of mutagenized generations – each M2 plant and its M3 progeny should be assigned a unique code and seeds from each plant should be collected separately.The goal of mutagenesis for TILLING is to obtain a highly mutagenized population to increase the probability of finding a mutation in every gene. Thus, it is crucial to select a proper mutagen and its dose. The sensitivity for mutagen treatment varies between plant species and even between various genotypes of the same species. In general, the lower the mutation frequency, the larger population is needed, which leads to higher costs and labor efforts. On the other hand, too high mutation frequency may cause lethality or sterility of Mnsitions . The mutnsitions . Once thnsitions . This isagenesis . The chiagenesis . For gen2 generation, because of the chimerism of the M1 generation owing to the fact that seeds are multi-cellular and only a subset of the mutagenized cells are responsible for germline development. The DNA should be isolated from each M2 plant individually (one M2 plant per M1 parent) and is usually pooled prior to screening for mutations. There are many screening methods aimed at mutation identification - they differ in sensitivity, capacity, difficulty, and costs. These methods are briefly described in the following section. Depending on the methods of mutation screening used, there is a different schema of DNA sample pooling. The M2 plants (and further generation) may be also directly phenotypically characterized for a forward genetic approach. Importantly, the proper maintenance of seeds from all generations (in a seed bank) and DNA stocks isolated individually from M2 plants are crucial to make the TILLING platform long-lasting. In order to make a TILLING platform publicly available, it is indispensable to create a database where all data about phenotypes, mutations identified and seed availability is collected.The mutation screening is performed on the MArabidopsis thaliana in 2000. Because TILLING is a method that can be easily applied to most organisms, shortly afterwards new TILLING populations for other plant species were produced. Examples of TILLING platforms created for various, diploid and polyploid, plant species are presented in The first TILLING population was developed for 2The discovery that mutations can be induced revolutionized plant breeding. The first crop mutant variety (‘Chlorina’ – a variety of tobacco) was introduced in the 1930s  and methArabidopsis thaliana the method of point mutation identification was based on DHPLC (Denaturing High-Performance Liquid Chromatography)  the DHPLC method was used. This method allows the detection of heteroduplex in a pool as an additional peak in the chromatogram, because of differential melting kinetics of homo- and heteroduplexes of DNA. After the identification of the potential mutations in particular M2 plants, the mutant PCR products were sequenced to confirm the mutation. The DHPCL method is very sensitive, however, it is relatively low throughput. Another method used for direct analysis of heteroduplex appearance is HRM (High-Resolution Melting) which is very fast but restricted only to fragments of max. 400 bp length (In the first TILLING experiments performed on ography) . Arabidop length . In ordep length . The mosp length . For thep length .Currently, the rapid identification of all mutations present in the mutant genome may be done through the NGS approach (‘TILLING by Sequencing’), either directly or using different strategies of sample pooling  e.g. . The hugAnother new approach used to screen mutagenized populations is called FIND-IT  . It prov3https://sdgs.un.org). The newest achievements generated through the TILLING approach are illustrated in Even though the first TILLING service was developed more than 20 years ago, this strategy is still broadly used in plant research studies, especially for agronomically important species. TILLING mutants are used to study the genetic bases of many important traits related to plant development and response to various biotic and abiotic stresses. TILLING is also used to create genotypes with improved important agronomic traits e.g. related to climate change, and hence it holds great promise for addressing global challenges in agriculture and food security and may be helpful in achieving some of the Sustainable Development Goals (SDGs) adopted by the United Nations General Assembly in 2015 as part of the 2030 Agenda for Sustainable Development , rice , maize , and soybean   . The TILHordeum vulgare L.), a number of mutants in different genes encoding proteins engaged in response to drought e.g. bZIP transcription factor HvABI5 (ABA Insensitive 5), a protein involved in RNA metabolism - HvCBP20 (Cap-Binding Protein 20), or a subunit of farnesyltransferase HvERA1 (Enhanced Response to ABA1) have been developed. Some of induced alleles led to the increased tolerance to drought stress and influenced such physiological traits as stomata closure, relative water content (RWC), photosynthesis performance, membrane permeability, pigment content in leaves, and wax deposition (Brassica rapa ssp. trilocularis) mutant carrying a substitution in a gene encoding Ca2+ cation exchanger transporter (CAX) showed a higher biomass, better photosynthetic performance, higher water use efficiency, and increased accumulation of a myo-inositol, which influenced osmotic protection under salt treatment and increased tolerance to salt stress (Medicago truncatula) (SRLK (Surface Receptor-like Protein Kinase) gene showed insensitivity to the salt stress treatment in terms of root growth. This gene encodes a membrane-located receptor kinase, which plays an important role in stress signal transduction (OsAKT1 (Similar to AKT1-like potassium channel), OsHKT6 (Oryza sativa high-affinity K+ transporter), OsNSCC2 (Translocation protein Sec62 family protein), OsCAX2 , OsHAK11 (Potassium transporter), OsP5CS1 (Delta-1-pyrroline-5-carboxylate synthetase), OsNHX (Sodium/hydrogen Exchanger), OsNAC60 (Similar to NAM/CUC2-like protein), OsSOS1 (Similar to Na+/H+ Antiporter) were subjected for TILLING analysis  of nine investigated genes exhibited higher tolerance to salt treatment compared to the wild type, in regards to root and shoot growth.Drought belongs to abiotic stresses that affect crop productivity most strongly. Drought stress tolerance is a complex trait, therefore a great number and variety of genes can be selected for analysis by TILLING and both, drought-tolerant and drought-sensitive mutants have been created . In barlposition . Tolerant stress . Anotherncatula) . Two mutsduction . In riceanalysis . In tota3+) toxicity in acid soils. Decreased heavy metal accumulation in tobacco (Nicotiana tabacum) was achieved by TILLING analysis of two genes – HMA2S and HMA4T, which encode heavy metal transporters: cadmium (Cd) and zinc (Zn). They play a role in root-to-shoot metal transport. In the identified mutants, compared to the wild type, the levels of Cd and Zn in leaves decreased by 39-97% and 35-48%, respectively . The mutant with higher tolerance to Cd and Zn was identified, which may be used in Cd phytoremediation programs  pathway, which leads to cell cycle inhibition and activation of DNA repair mechanisms , mutants in genes encoding four fatty acid desaturases that control saturated/unsaturated fatty acid ratio were isolated in a TILLING population that was used to decipher the oil biosynthesis pathway. Among these mutants, there were lines with improved seed oil composition – elevated oleic acid and lower polyunsaturated fatty acids contents , a polyploid species. Phytic acid is the major phosphorous storage compound in seeds of this species (2-4%), but due to the fact that it cannot be metabolized, similarly to glucosinolates, tannins, and phenolic acids, it is considered to be an antinutritive compound (Bn2-PGK2 (2-Phosphoglyceric Acid Kinase) genes. The double mutant for Bn2-PGK2 had significantly reduced phytic acid contents, which is potentially beneficial for the human diet  in oilseed rape . The TILLING strategy has been used to identify wheat genotypes with reduced content of immunogenic gluten proteins . Double Triticum durum) grain is another example of the use of TILLING strategy to modify genes responsible for nutritional value. Vitamin A deficiency (VAD) is a public health problem in more than half of all countries, especially those in Africa and South-East Asia. The most severe effects of this deficiency are seen in young children and pregnant women in low-income countries. The transgenic approach to address VAD problem has been undertaken in rice (Oryza sativa L.) and genetically engineered ‘Golden Rice’ with enhanced provitamin A content was finally approved for cultivation in 2021 in The Philippines, after almost 20 years of studies (www.isaaa.org). In durum wheat, the increase of β-carotene content by more than 70% was achieved by TILLING of two genes, HYD1 (β-carotene hydroxylase 1) and LcyE (Lycopene ϵ-cyclase) (Enrichment of provitamin A content in durum wheat (cyclase) . Owing tEPSPS (5-enolpyruvylshiki-mate-3-phosphate synthase) showed enhanced tolerance to this herbicide (www.isaaa.org).A spectacular example of breeding success with the use of TILLING strategy also comes from wheat (in this case common wheat). For this species, tolerance to herbicide glyphosate (N-phosphonomethyl-glycine) was introduced through a nontransgenic approach . The douerbicide . Taking Solanum lycopersicum L.), the improvement of fruit shelf-life has been a frequently studied trait, modified by TILLING for breeding purposes (SlACO1 (ACC oxidase 1) gene. The mutants exhibited decreased ethylene production and conductivity, which led to enhanced shelf-life and firmness. Another study aimed at the development of TILLING mutants with changed ethylene metabolism, shelf-life duration and fruit softening was performed for the Ethylene Receptor gene (SlETR1) (Expansin 1 (SlExp1) involved in cell wall expansions and loosening. The improvement of fruit shelf-life in these mutants was attributed to altered cell wall polysaccharide composition (In tomato (purposes . One exa(SlETR1) . TILLINGposition .4HvHox1 (homeodomain-leucine-zipper1) gene, which controls the row-type character of a spike, showed that three forms carrying missense mutation presented different phenotypes compared with the parent cultivar ‘Barke’. It reflects the different influences of substitutions on the protein function. Two mutants presented intermediate phenotypes, another one a six-row type spike, while cultivar ‘Barke’ was two-rowed (ABP (Auxin Binding Protein 1) gene - abp1-5 (Nicotiana tabacum). The low level of Cd might be „beneficial” for smokers because it leads to lower Cd accumulation in their bodies. The study conducted on inhabitants of the Upper Silesia region in Poland indicated that smokers accumulated a twice higher level of Cd compared with non-smokers (HMA4.1 and HMA4.2 were silenced using an RNAi (RNA interference) approach. This was successful for Cd reduction in tobacco leaves, however negative effects on plant development, including retarded growth, necrotic lesions, altered leaf morphology, and increased water content have been observed. Application of the TILLING strategy led to removing this impact, and mutants with both, a lower content of Cd in leaves and no negative developmental effects have been identified. In order to minimize the phenotypic effects, the different mutation combinations in analyzed genes have been investigated. It has been proven, that complete functional loss obtained by induction of nonsense mutation in one homeologous HMA4 gene and the functional reduction in the other HMA4 gene obtained by induction of missense mutation led to the best results and these mutation combinations are the best choice for breeding programs in tobacco , not only knock-outs. It is of special importance, especially for genes that are crucial for plants to survive, whose total inactivation may be lethal. For them, the sublethal alleles may be required for phenotypic analysis. Advantage from the reduction of protein activity obtained with TILLING-mutants vs. total turn off of the gene function using RNAi technique can rely also on avoiding some disruption during plant growth and development, which was indicated e.g. in research in tobacco, where RNAi mutants were characterized by necrotic lesions or increased water content in leaves . Importawo-rowed . Another- abp1-5 . This mu- abp1-5 . TILLING-smokers . First,  tobacco .https://github.com/bjtill/Mutation-Finder-Annotator-CLI) that can be used for TILLING by sequencing. It is noteworthy that TILLING can also be conducted without any sophisticated apparatus, utilizing only basic laboratory equipment . Such a low-cost approach is suitable for implementation in developing countries with limited laboratory infrastructure, however, it is important to acknowledge that it may result in reduced sensitivity when it comes to identifying mutations.The TILLING strategy has been used for more than 20 years, during which it was modified and improved. In general, as described in previous sections, the screening methods keep getting better, faster, and cheaper, which makes TILLING a robust tool for functional genomics. This can be seen especially in terms of sequencing technology, but currently, the use of TILLING-by-sequencing is limited to species for which reference genomes are available. The software for mutation analysis is also evolving together with TILLING. As an example, the PARSESNP tool  was veryA significant advantage of TILLING is that once established, a TILLING platform is long-lasting and may be used for both, forward and reverse screening. Finally, most important from an agronomic point of view, non-GMO mutants are created, as in TILLING strategy there is no need for transformation. Hence, new TILLING alleles may be used not only for functional analysis of genes but also serve as a valuable resource for crop improvement because they can be directly used in breeding programs without regulatory restrictions that exist in some countries for the material labeled as GMO.abp1-5 mutant carrying change in the ABP (Auxin Binding Protein 1) gene of Arabidopsis, which was identified by TILLING approach, after whole-genome sequencing the additional 8,000 single nucleotide polymorphisms were identified  in previously reported plant TILLING populations . The bottleneck is usually the characterization of identified mutants – determining the phenotypic consequence of the mutation, but this is a problem of each mutation technology, including gene editing by CRISPR/Cas9. In terms of functional genetics studies, it is always an added value to combine different approaches that complement each other, e. g. TILLING and CRISPR/Cas9 strategies that produce different types of mutants. It is also worth reminding that TILLING mutants are not GMOs so they can be directly used, without regulations, in pre-breeding programs around the world to improve crop performance.MS-Z and IS conceive the manuscript. MS-Z and MK wrote the manuscript; MK generated tables; BT and IS revised and edited manuscript. All authors approved the submitted version.


The COVID-19 pandemic has had a devastating impact on a global scale, causing significant morbidity and mortality. The virus affects multiple organ systems, including the respiratory, cardiovascular, and coagulation systems, leading to severe pneumonia in some patients. Moreover, COVID-19 patients with severe pneumonia have a high incidence of thrombotic events, which can result in significant morbidity and mortality. Given the potential benefits of anticoagulation therapy in COVID-19 patients with thrombotic complications, recent studies have proposed high-dose prophylactic anticoagulation (HD-PA) therapy as a potential treatment option. In fact, some studies have suggested that HD-PA therapy may be more effective in reducing thrombotic events and mortality rates than other treatment options. This review aims to provide a comprehensive overview of the benefits and risks of HD-PA therapy for COVID-19 pneumonia patients. By synthesizing and analyzing the latest available research, we highlight patient selection criteria and discuss the optimal dosage, duration, and timing of therapy. Additionally, we review the potential risks associated with HD-PA therapy and provide recommendations for clinical practice. Ultimately, this review provides valuable insights into the use of HD-PA therapy in COVID-19 pneumonia patients and paves the way for further research in this critical area. By exploring the benefits and risks of this treatment option, we hope to provide healthcare professionals with the information they need to make informed decisions about the best course of treatment for their patients. COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had a devastating impact worldwide, leading to high levels of morbidity and mortality. While the disease primarily affects the respiratory system, much research has revealed that COVID-19 can also cause damage to other vital organs, including the cardiovascular and coagulation systems. Among COVID-19 patients, those with severe pneumonia have a higher risk of developing thrombotic complications (TCs), such as deep vein thrombosis and pulmonary embolism, which can result in severe morbidity and mortality [Given the high incidence of thrombotic events among COVID-19 pneumonia patients, anticoagulation therapy has emerged as a potential treatment option. While standard prophylactic anticoagulation therapy has been shown to lower the risk of venous thromboembolism in COVID-19 patients, high-dose prophylactic anticoagulation (HD-PA) therapy may be a more effective approach for these patients, with a greater reduction in thrombotic events and mortality rates . Labbé eThe purpose of this review article is to provide a comprehensive overview of the benefits and risks associated with HD-PA therapy for COVID-19 pneumonia patients. By studying and considering the up-to-date existing studies, we aim to assist healthcare professionals in making informed decisions about the use of this therapy for their patients.Material and methodIn our literature search on HD-PA therapy for COVID-19 pneumonia, we used keywords like "risks and benefits," "patient selection," "thrombotic events," "pneumonia," "prophylactic anticoagulation," and "COVID-19." We searched various electronic databases and manually screened reference lists of relevant articles. We selected high-quality studies focusing on HD-PA therapy in COVID-19 pneumonia patients while excluding studies on other types of anticoagulation therapy or non-COVID-19 patients. Two independent authors assessed the studies for relevance, and disagreements were resolved through discussion and consensus.A brief history of anticoagulation therapy in COVID-19Anticoagulation therapy has become a crucial treatment approach for COVID-19 since the early stages of the pandemic, primarily due to the high incidence of TCs observed in infected patients. As understanding of the disease and its complications has evolved, anticoagulation therapy has expanded beyond critically ill patients, which was the initial focus of studies . FurtherThe use of prophylactic anticoagulation therapy in COVID-19 patients has shown promising results in reducing the incidence of TCs, which are a significant cause of morbidity and mortality in COVID-19 patients. The pro-thrombotic state observed in these patients results from a complex interplay between the virus, the immune system, and the coagulation system. Studies have shown that the use of prophylactic anticoagulation therapy in COVID-19 patients significantly reduces the risk of venous thromboembolism, arterial thrombosis, and overall mortality . HoweverOverview of standard prophylactic anticoagulation therapyStandard prophylactic anticoagulation therapy for COVID-19 patients typically involves using low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). LMWH is usually dosed based on the patient's weight, while UFH dose is monitored through activated partial thromboplastin time levels. This approach helps to ensure that patients receive appropriate anticoagulation therapy while minimizing the likelihood of adverse events .Determining the duration of prophylactic anticoagulation therapy involves various factors, such as the patient's risk of thrombosis and bleeding and their clinical course. By adopting an individualized approach to determine the appropriate duration of therapy, healthcare providers can ensure that patients receive the necessary duration of anticoagulation therapy based on their specific circumstances. This tailored approach allows healthcare providers to optimize the benefits of anticoagulation therapy while minimizing the risk of adverse events. By administering LMWH or UFH and tailoring dosing and duration based on patient-specific factors, healthcare providers can help reduce the risk of thrombosis in patients with COVID-19 pneumonia. Additionally, an individualized approach can help minimize the risk of adverse events associated with anticoagulation therapy -9.Benefits of HD-PA therapyHD-PA therapy is a potential treatment option for COVID-19 pneumonia patients at an increased risk of developing thrombotic events. This therapy involves the administration of a higher dose of anticoagulant medication than the standard prophylactic therapy. For instance, 334 patients were randomly assigned to SD-PA and HD-PA, using LMWH for 14 days or until hospital discharge or weaning from supplemental oxygen for 48 consecutive hours outcome occurred first. The HD-PA patients received double the dose of SD-PA [The mechanisms of action of HD-PA therapy are similar to those of standard prophylactic therapy. Anticoagulants work by inhibiting the coagulation cascade. Some act directly by binding and inhibiting the enzyme, while others act indirectly by binding to antithrombin or by preventing their synthesis from the liver (vitamin K-dependent factors). In this way, they prevent the formation of blood clots. However, high-dose prophylactic therapy is believed to be more effective in preventing thrombotic events than standard prophylactic therapy because it provides more anticoagulation .Research has indicated that administering HD-PA therapy can lower the incidence of thrombotic events like venous thromboembolism (VTE) and others in patients with COVID-19 pneumonia. The evidence suggests that HD-PA therapy is a viable treatment option for COVID-19 pneumonia patients at a high risk of developing thrombotic events. A randomized controlled trial conducted by Tacquard et al. included 538 patients; 104 patients experienced 122 TCs with an incidence of 22.7%. Pulmonary embolism accounted for 52% of the recorded TCs. HD-PA was associated with a significantly reduced risk of TC without increasing the risk of hemorrhages or excessive bleeding .Risks of HD-PA therapyHD-PA therapy is associated with an increased risk of bleeding as a potential adverse effect. This risk is particularly relevant in patients with an underlying bleeding disorder or who have recently undergone major surgery. Bleeding can occur in various locations, including the gastrointestinal tract, urinary tract, and the brain, and may be life-threatening in some cases .Another potential risk associated with HD-PA therapy is the development of heparin-induced thrombocytopenia (HIT). HIT is an immune-mediated disorder that can occur in response to exposure to heparin, which leads to a decrease in platelet counts and an increased risk of thrombosis -14. HIT Patient selection for HD-PA therapyThe use of HD-PA therapy in COVID-19 pneumonia patients has demonstrated a promising effect in reducing the incidence of VTE and other thrombotic events. However, it is crucial to carefully identify the patients most likely to benefit from this therapy while also considering those at high risk of bleeding .Selecting patients is a critical step in administering HD-PA therapy. Identifying patients at the highest risk of developing VTE and other thrombotic events is vital, as they are the most likely to benefit from the therapy. These patients may include those with pre-existing risk factors for thromboembolism, such as obesity, advanced age, and comorbidities like heart disease or cancer. Additionally, patients admitted to the ICU or requiring mechanical ventilation may also be at high risk for thrombotic events and would benefit from prophylactic anticoagulation therapy ,15.On the other hand, it is essential to consider patients at high risk of bleeding when considering HD-PA therapy. Such patients include those with a history of bleeding disorders or taking medications that increase the risk of bleeding. Patients who have undergone recent surgery or have experienced recent trauma are also at high risk for bleeding and may not be suitable candidates for this therapy . TherefoIdentification of Patients at High Risk of VTE and Thrombotic EventsNumerous risk factors have been identified as significant for developing VTE and other thrombotic events in COVID-19 pneumonia patients. Advanced age, obesity, immobility, prolonged hospitalization, and co-morbidities, such as diabetes, hypertension, and cardiovascular diseases, are associated with an increased risk of developing thrombotic events . AdvanceOther co-morbidities associated with an increased risk of VTE and thrombotic events in COVID-19 pneumonia patients include diabetes, hypertension, and cardiovascular diseases. These conditions are known to increase the risk of clotting events and can exacerbate the effects of COVID-19, leading to a greater likelihood of developing TCs . Lastly,Identification of Patients at High Risk of BleedingPatients at a high risk of bleeding may be at an increased risk of experiencing adverse events if they receive HD-PA therapy. Factors contributing to the likelihood of bleeding in COVID-19 pneumonia patients include having a history of bleeding disorders, renal impairment, liver dysfunction, and concurrently using other medications such as nonsteroidal anti-inflammatory drugs and antiplatelet agents that can increase bleeding risk .Given this potential risk, it is crucial to carefully consider patient selection for HD-PA therapy and evaluate the balance between the risks and benefits of the treatment for each patient. In certain instances, alternative therapies or administering lower doses of anticoagulation may be more appropriate to minimize the potential for adverse events.HD-PA therapy has been shown to have potential benefits in reducing thrombotic events and lowering mortality rates in COVID-19 pneumonia patients. However, the therapy carries a higher risk of bleeding and HIT in some patients, necessitating carefully considering patient selection to balance the risks and benefits. Although the therapy shows promise, further research is needed to determine the optimal dosing, duration, and patient selection for HD-PA therapy in COVID-19 patients. Future studies should focus on identifying patients who are most likely to benefit from the therapy and assessing the long-term effects of the therapy and the risks of bleeding and HIT. Such research may refine HD-PA therapy in COVID-19 pneumonia patients and improve patient outcomes.


Background: Endoscopic-ultrasound-guided gastrojejunostomy (EUS-GJ) can be a new alternative for patients with malignant afferent loop syndrome (MALS). However, a fully covered self-expandable metal stent (FCSEMS) has not been well investigated in this setting. Methods: This is a multicenter retrospective cohort study. Consecutive patients that underwent EUS-GJ using a FCSEMS for MALS between April 2017 and November 2022 were enrolled. Primary outcomes were technical and clinical success rates. Secondary outcomes were adverse events, recurrent symptoms, and overall survival. Results: Twelve patients (median age: 67.5 years (interquartile range: 58–74.8); 50% male) were included. The most common primary disease and type of previous surgery were pancreatic cancer (67%) and pancreatoduodenectomy (75%), respectively. Technical success and clinical success were achieved in all patients. Procedure-related adverse events occurred in one patient (8%) with mild peritonitis. During a median follow-up of 96.5 days, one patient (8%) had recurrent symptoms due to the EUS-GJ stent dysfunction; including biliary events unrelated to the EUS-GJ stent, five patients (42%) had recurrent events. The median overall survival was 137 days. Nine patients (75%) died due to disease progression. Conclusions: EUS-GJ with a FCSEMS seems safe and effective for MALS with high technical and clinical success rates and an acceptable recurrence rate. Malignant afferent loop syndrome (MALS) is a rare late complication after surgery for upper abdominal malignancies caused by mechanical obstruction of the afferent loop after Billroth II or Roux-en-Y reconstruction due to local recurrence or peritoneal dissemination . The dilRecently, minimally invasive endoscopic procedures  have been reported . Of thesLAMSs with an electrocautery tip (Hot LAMSs) can be placed in a single step without device exchange, which reduces the procedure time and leakage of gastrointestinal fluid. In addition, leakage of gastrointestinal fluid after stent placement is virtually prevented because the gastrointestinal tracts are firmly adhered to each other. These features are thought to be highly effective in preventing peritonitis . HoweverGiven these facts, FCSEMSs can be suitable stents for EUS-guided MALS treatment, but only a few reports have been published using FCSEMSs. Therefore, a multicenter study was conducted to evaluate the usefulness of FCSEMSs on EUS-guided gastrojejunostomy (EUS-GJ) in patients with MALS.This was a retrospective cohort study performed at three tertiary centers. The study protocol was collectively reviewed and approved by the institutional review board of Saitama Medical Center, Saitama Medical University , then permission to conduct the study was obtained at each institution. The medical records were queried for all consecutive patients who underwent EUS-GJ with a FCSEMS for relief of symptoms of MALS between April 2017 and November 2022. MALS was diagnosed when computed tomography (CT) showed obstruction and proximal dilatation of the afferent loop due to local recurrence or peritoneal dissemination of the previously resected tumor with symptoms such as abdominal pain, fever, cholangitis/jaundice, or nausea/vomiting. Considering the effect on bile excretion, the site of afferent loop obstruction was classified according to the previous report .EUS-GJ was performed using an oblique-viewing curved-linear array echoendoscope  and a dedicated processor . Patients were sedated in the prone position with midazolam and pethidine hydrochloride. The dilated afferent loop was punctured with a 19-gauge needle  under ultrasound guidance avoiding the intervening vessels evaluated in Doppler mode. After aspirating the intestinal fluid and confirming needle entry, a small amount of contrast medium was injected to depict the afferent loop. A 0.025-inch guidewire  was passed through the needle and coiled in the afferent loop. The needle was removed, leaving the guidewire in situ, then the tract was dilated. Dilation was performed using a bougie , balloon dilator , or diathermic dilator . Following the tract dilation, a dumbbell-shaped FCSEMS with a 10 or 12 mm diameter  or a conventional tubular-type FCSEMS with a 10 mm diameter  was placed between the afferent loop and stomach. The HILZO stent has dumbbell-shaped flares at both ends that are 4 mm larger in diameter than the stent body, which are expected to prevent stent migration. Therefore, this stent was preferentially used, but at one institution , this stent became available in the middle of the study period, so the WallFlex was used in the beginning. The dilatation method, stent diameter, and stent length (6 or 8 cm) were selected by the endoscopist. An additional 7-Fr double pigtail plastic stent (DPPS)  was coaxially placed through the metal stent to prevent migration at the discretion of the endoscopist .All patients underwent plain CT and laboratory tests on the next day of the procedure. An oral diet was started when clinical symptoms improved without any severe adverse event.Primary outcomes were technical and clinical success. Technical success was defined as the appropriate placement of a FCSEMS as intended. Clinical success was defined as relief of MALS-related symptoms and decompression of the dilated afferent loop on CT findings within one week. Secondary outcomes were early (up to 14 days) and late adverse events, recurrent symptoms, and overall survival (OS). Adverse events were described in accordance with the American Society for GI Endoscopy lexicon .Descriptive continuous variables were presented as number (percentage) or median (interquartile range (IQR)). The Kaplan–Meier method was used to estimate recurrent symptom-free survival (RFS) and OS. Deaths without recurrent symptoms were treated as censored at the time of death in RFS. The follow-up data were gathered until March 2023. All statistical analyses were performed with EZR Ver. 1.52  [Twelve patients (median age: 67.5 years (IQR: 58–74.8); 50% male) were enrolled in this study. Baseline characteristics are shown in Prior afferent loop drainage had been attempted in three cases (25%) . The transluminal approach was performed using a double-balloon endoscope , with one case unsuccessful because the guidewire could not pass through the stricture, and in the other case, a nasal tube was placed. The percutaneous approach was performed transhepatically with the placement of an external tube. The nasal and percutaneous tubes were removed after conversion to EUS-GJ later. Prior biliary drainage had been performed in four cases (endoscopic retrograde cholangiopancreatography (ERCP) using a double-balloon endoscope in two cases, EUS-guided hepaticogastrostomy (EUS-HGS) in one case, and the combination of both in one case), all of which were Type 2 cases.Technical success was achieved in 12 cases (100%). Details and outcomes of procedures are shown in Long-term outcomes after EUS-GJ procedures are shown in The median RFS ) was 112 days (72-not applicable (NA)), and the recurrence-free probability at 90 days (95% CI) was 0.764 (0.309–0.940). When recurrent events were limited to those due to EUS-GJ-stent dysfunction, recurrence occurred in one case (8%), with a median RFS (95% CI) of NA (72-NA) and recurrence-free probability at 90 days (95% CI) of 0.857 (0.334–0.979) . Median In the present study, both technical and clinical success rates of EUS-GJ with a FCSEMS for MALS were excellent at 100%, with an acceptable adverse events rate of 8%. Recurrence of symptoms developed in 42%, but most were biliary events unrelated to the EUS-GJ-stent; when recurrent events were limited to those due to EUS-GJ-stent dysfunction, symptom recurrence was only 8%, and the recurrence-free probability at 90 days was 0.857. To the best of our knowledge, this study represents the largest series of patients that underwent EUS-GJ with a FCSEMS for MALS.p < 0.001) [p < 0.001) [Currently, minimally invasive endoscopic procedures are the mainstay for MALS. There are two types of endoscopic procedures: transluminal and EUS-guided transmural approaches ,5. The t< 0.001) . Similar< 0.001) . FurtherThere are two reports of EUS-GJ with a LAMS for MALS involving more than 10 cases: Gutierrez et al. reported a technical success rate of 100%, clinical success rate of 89%, adverse events rate of 17%, and reintervention rate of 17% during a median follow-up of 120 days in 18 patients [The advantage of the LAMS is its large diameter. However, as the contents of the afferent loop are liquid, a large diameter is not necessary. In fact, there was no difference in efficacy according to the diameter of the LAMS . NeverthAnother advantage of the LAMS  is that the one-step placement and the adherent effect of the gastrointestinal tracts minimize leakage of gastrointestinal fluids, preventing peritonitis. The FCSEMS requires multiple device exchanges to dilate the tract, increasing the risk of peritonitis. Although a 6-Fr cystotome is the most reliably insertable dilation device, a balloon was used by endoscopists who were concerned about bleeding due to the cystotome in this study. The balloon has the risk of pushing on the afferent loop and dislodging the guidewire, so a bougie dilatation followed by balloon dilatation was often used. As a result, peritonitis developed in one of the 12 cases (8%). In this case, the insertion of a dumbbell-type FCSEMS was attempted after dilatation with a 6-Fr cystotome but failed. The stent could be inserted by changing the guidewire from 0.025 inches to 0.035 inches with the use of an ERCP catheter. Because the FCSEMS introducer is as thick as 8.5-Fr, it could not fit in the 6-Fr cystotome dilation. In addition, the patient had a high fever immediately before the procedure and was considered to have had an active infection in the afferent loop. Multiple device exchanges in the presence of an active infection caused peritonitis. The optimal dilation method for FCSEMS placement is unclear and remains an issue for future study.Migration is the major drawback of the FCSEMS and was observed in 1/12 (8%) of the patients in the present study. Fortunately, the coaxial DPPS could maintain the anastomosis, which facilitates reintervention. Migration was observed in 1/2 (50%) of the tubular type, but 0/10 (0%) of the dumbbell-shaped type, suggesting that the anti-migration function of the dumbbell-shaped FCSEMS was effective. A DPPS should be added when using a tubular-type FCSEMS. LAMSs are short in length and have large flanges at both ends that firmly adhere the digestive tract to each other, making migration unlikely. On the other hand, “buried LAMS” can occur, in which the stent is buried within the gastrointestinal wall.Obstructive jaundice and cholangitis are common manifestations in Type 1 and 2 MALS. In Type 1, EUS-GJ alone is sufficient because the biliojejunal anastomosis is spared, whereas biliary drainage is usually required in Type 2. Biliary drainage may be necessary even in Type 1 and 3 patients with disease progression , as in tThe present study has several limitations. First, this was a retrospective study with a limited number of patients, so selection bias and reporting bias could not be eliminated. Second, the patient characteristics such as the primary disease and surgical method, as well as the procedure details such as the dilation method, the type and size of FCSEMS used, and the combination with a DPPS, were disparate and not standardized. Third, it was a single-arm study with no comparison arm. The strengths of this study are its largest patient population in this setting and its multicenter design.In conclusion, EUS-GJ with a FCSEMS seems safe and effective for MALS with high technical and clinical success rates and an acceptable recurrence rate. Further investigations including comparative studies with EUS-GJ with a LAMS are warranted in the near future.