Network pharmacology analysis demonstrated that both PX and XH targets were enriched in cancers and inflammatory responses. RNA sequencing confirmed that PX treatment induced cancer cell apoptosis and inhibited inflammatory reactions within the tumor. Moreover, the PX formula considerably restored homeostasis of the gut microbiota, which was not observed in the XH group. PX targets, those associated with the survival probability of CRC patients, correlated with macrophage (Mφ) infiltration, which presented an independent risk factor for the CRC outcome. PX treatment promoted the transition of alternatively activated Mφs (M2 Mφs) to classically activated Mφs (M1 Mφs). Moreover, the peritoneal Mφs from the PX group inhibited the migration of CW26.WT cells, as evidenced by the wound healing experiment and transwell assay, which was consistent with the decreased expression of the vascular endothelial growth factor (VEGF). Furthermore, the coculturing system confirmed that PX-treated Mφs suppressed colorectal tumor-derived organoid proliferation. PX formula exhibits a potential antitumor effect against CRC by suppressing the colonization of pathological microorganisms, reshaping Mφ effector functions and hence inhibiting cancer cell proliferation.Colorectal cancer (CRC) is the most common cancer worldwide and develops due to a broad range of causative factors. Pingxiao (PX) formula and Xihuang (XH) formula are two commonly used drugs to treat CRC, especially as an alternative therapy for those patients who could not suffer surgery, chemotherapy, or immunotherapy, namely, elder or advanced CRC patients. However, the pertinent pharmacological mechanisms are still elusive. The investigation was designed to explain the pharmacological mechanisms of the PX formula. A murine model of CRC was established by injecting CT26.WT cells into the caecum of 4-week-old male Balb/c mice, following PX or XH treatment for 30 days. Network pharmacology analysis combined with weighted gene coexpression network analysis (WGCNA) predicted the pharmacological mechanisms and therapeutic value. High-throughput 16S rRNA sequencing determined the alterations in the gut microbiota communities. Western blotting, immunofluorescence, and flow cytometry examined the influence of PX on the tumor microenvironment (TME). Injection of CT26.WT-induced CRC in Balb/c mice was markedly attenuated by PX treatment. Compared with XH administration, PX exhibited a stronger antitumor effect, such as smaller tumor volume, lower interleukin 17 (IL-17), IL-6 and tumor necrosis factor-alpha (TNF Colorectal cancer (CRC) is one of the most common cancers and the third most frequent cause of cancer-related deaths, and CRC-caused mortality has increased by 40% with the development of economics during the decades. Despite the access to specialists and effective therapy in recent years, it has been projected that there has been a rise in the number of young patients as well as subsequent deaths –3. The pToxicodendron vernicifluum (Stokes) F. A. Barkley (TV), Strychnos nux-vomica L. (SS), nitre, Agrimonia pilosa Ledeb (AL); Curcuma aromatica Salisb. (CR), Citrus × aurantium L. (CL), Feces trogopterus (FT)  . The PX https://www.theplantlist.org. Component-target networks were computed by the active components according to the following criteria: 0.18 drug-likeness and 30% oral bioavailability. The associated genes of CRC were collected from five databases: GeneCards, Online Mendelian Inheritance in Man (OMIM), DrugBank, PharmGkb, and Statistics of Therapeutic Target Database (TTD). The targets of active components were obtained from PubChem and the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform [All the plant names have been checked with Platform . The ingPlatform , sortingλ). Based on the optimal lambda value as well as the corresponding coefficients, the risk signature genes were obtained and samples were clustered into low-risk and high-risk groups. The receiving operating characteristic (ROC) curve with the area under the curve (AUC) representing the degree or measure of separability was constructed by “pROC” and “ggplot2” packages to determine the discrimination ability. The closer to 1 means the validity. Single-sample gene set enrichment analysis (ssGSEA) was performed to identify the influenced immune cells by PX treatment.The mRNA expression profile and clinical information of 426 patients with colon adenocarcinoma (COAD) were downloaded from The Cancer Genome Atlas (TCGA) database, and weighted gene coexpression network analysis (WGCNA) was performed. The tumor samples were clustered into two groups based on the mRNA levels of the PX targets by the “limma” and “ConsensusClusterPlus” packages. The Kaplan–Meier (KM) plotter was plotted to utilize “survival” and “survminer”  packagesExperiments were conducted under the supervision of the guidelines of the Institutional Animal Care and Use Committee of Jining Medical University in China (SYXK-Shandong province 2018-0002).2O): 25 min (A:20%:B:80%), 50 min (A:35%:B:65%), 9 min (A:90%:B:10%), and 7 min (A:20%:B:90%). Data were processed in information-dependent acquisition (IDA) with a high sensitivity mode. XH Wan was bought from the Beijing Tong Ren Tang drug company.In the PX formula, the weight ratio of CL, SS, nitre, AL, CR, alunite, FT, and TV is 5 : 3:3 : 3:3 : 2.5 : 1. Mixed CL, nitre, CR, alunite, FT, and TV powder were extracted by 70% ethanol, and the leftover and AL were boiled and concentrated. AL was added to the dried mixture. A total of 405 g of powder was obtained about 230 g of PX drug. To validate the components, a connected system of the LC-30 (Shimadzu)-hybrid quadruple time-of-flight mass spectrometer (TOF-MS) with an electrospray ionization source (ESI) was used. The mobile phase system had solution A (acetonitrile) and equate B  , and on the same day, the mice were treated with PX or XH by oral for the next 30 days. The dose for a human being is 300 mg/kg per day based on the Chinese Pharmacopoeia 2020, and the correspondingly murine is 3.6 g/kg calculated by the Meeh Rubner formula: skin surface area = mass coefficient∗weight∗2/3∗10−4. The positive control of the study is cyclophosphamide (CTX)  which facilitates antitumor immunity and suppresses CRC progression [10gression . 90 mg (The feces and mucus within the colon were collected and mixed and processed by 16S rRNA sequencing. Raw data were filtered  and prodm/z) values, and peak intensity . According to the In-house MS2 database, substances were identified and determined by orthogonal projections to latent structures-discriminant analysis (OPLS-DA). The cut-off is fold change (FC) > 1, P value <0.05, and variable importance in the projection (VIP) > 1 [The feces and mucus sample was treated with methanol and standard internal substances. After the ultrasound and frozen treatment, the samples were centrifugated. The supernatant was subjected to ultrahigh-performance liquid chromatography (UHPLC) coupled with TOF-MS . Acquisition software  was utilized to assess the full scan survey MS data, which were then converted by ProteoWizard and generated the retention time (RT), mass-to-charge ratio (VIP) > 1 .FastQ files were processed for primary quality control. Read pairs that contain more than 3 or the proportion of bases with a quality value below 5 were removed. All the downstream analyses were completed on the clean data obtained. Differentially expressed genes (DEGs) were identified using the DEGSeq R package (PRJNA820958).After 3.6 g/kg PX treatment, we collected the serum from CRC mice in two hours. To examine the toxicity, CT26.WT cells were treated with the serum and subjected to an MTT assay  , 4 week-old male mice were sacrificed and bone marrow from femurs was incubated with blood cell lysis buffer  for 5 minutes. Filtered cells were cultured with the 1640 medium in the presence of the granulocyte-macrophagecolony-stimulating factor  at a concentration of 55 ng/ml. M5 Mφs were cultured with prepared microparticle solution  for 2 hours at 37°C and then mounted at the fluorescein isothiocyanate (FITC) wavelength (488 nm).10φs. After 24 hours, cTDOs were incubated at 37°C with propidium iodide (PI)/Hoechst33342 (480 nm/630 nm) for 20 minutes. For Ki67 staining, the Ki67 eFluor™ 660 eBioscience™  (1 : 1000) antibody was incubated for 24 hours and examined by using a fluorescent microscope .The solid tumor was cut into small pieces and washed with cold PBS until the PBS solution became transparent and clear. After 35 minutes of digestion by digestive solution , the filμg) was subjected to SDS-PAGE (sodium dodecyl sulfate-polyacrylamide gel electrophoresis) and transferred. After blockage, diluted antibodies (1 : 1000)  were incubated with the membrane for 24 hours. After washing with PBS, secondary antibodies conjugated with horseradish peroxidase (HRP) were utilized and an enhanced chemiluminescence (ECL) substrate was added to visualize the protein bands. All chemicals were bought from Invitrogen, USA.The total protein  in the presence of PX serum for 24 hours. After the fixation by 4% paraformaldehyde (PFA), the cut insert membrane was subjected to DAPI  staining and examined by using the microscope.CT26.WT cells were added to a transwell insert  , and tumor necrosis factorα (TNFα) .ELISA kits were bought from Abcam and utilized to examine the cytokine concentrations in the serum: interleukin (IL)-17 , IL-6 , interferont-test was used to compare the difference between the two groups. A Cox proportional hazard model was established to indicate PX targets associated with the survival probability in COAD patients. A hazard ratio (HR) with 95% confidence intervals and a log-rank P value were calculated via univariate survival analysis, and a P value of <0.05 was considered statistically significant.Data are means ± SEM. An unpaired Student's The PX ingredients had 171 active compounds (Supplementary Commiphora myrrha (Nees) Engl., Bovis calculus, and Boswellia sacra Flueck., shared 179 genes with CRC, and Myrrha was responsible for 78% of the targets  were cultured as a model to examine the proliferation capacity of cancer stem cells, which recapitulates the neoplastic progression within TME. An  Figures . Moreovegures φs .In the present study, we provide evidence of the anticancer efficacy of the PX formula against CRC and demonstrate the underlying mechanisms. As the third most common cancer worldwide, CRC develops in the setting of hereditary cancer syndromes or from inflammatory bowel disease (IBD) , and itsin-vivo experiments demonstrated that the PX formula exhibited a stronger antitumor effect than XH treatment, as evidenced by the suppressed tumor size and inhibited levels of IL-17, IL-6, and TNFα, which are the best characterized independent risk factors for CRC [γ expression that inhibits the expansion of disseminated colorectal cancer cells [PX and XH are widely used in China to treat cancers . In the  for CRC –24 and ier cells . KEGG anφs and Th17 cells, both of which are protumorigenic in CRC [φs are immune cells with high plasticity and can transit to different phenotypes in response to diverse stimuli. The classically activated (M1) Mφs are proinflammatory and induce antitumor immunity, while the alternatively activated (M2) Mφs contribute to wound healing and facilitate cancer cells escaping from the host immune reactions [φs (TAMs) mostly take on an M2-like phenotype and contribute to immune escape, allowing the transformation of neoplastic cells. Herewith, changing M2 Mφs toward M1 Mφs is one of the prospective aims of cancer immunotherapy [φs, which in turn instigated the apoptosis of cancer stem cells and inhibited neoplastic cell migration. Collectively, the PX formula is able to reverse the tumor-promoting phenotype of TAMs and thus reshape the communication between TAMs and other cell populations or microbes, which has also been considered a causal factor for neoplastic processes and influences the responsiveness to cancer therapeutics [Reestablishing the immune status within the tumor: in developed cancers, immune surveillance is mostly missing and the immune-suppressive TME is established. TME is critical for carcinogenesis and cancer maintenance by supporting tumor growth, invasion, metastasis, and hiding from T-cell detection and traditional anticancer therapy. However, not all the immune cells within the TME represent an attempt to impair tumor immune surveillance and enable tumor cells to proliferate rapidly. The combination of AF, CR, AL, and TV tends to induce immunity and eradicate neoplastic cells by shaping the plasticity potentials of Mc in CRC –28, as eeactions , 29. Tumotherapy . Based oapeutics .φs from the PX mice suppressed the migration capacity of cancer cells shown in the transwell experiments and wound healing assays and inhibited the expression of VEGF in cancer cells, indicating decreased metastatic dissemination [φs from the PX mice induced apoptosis as evidenced by the increased PI level and BAX protein abundance and reduced proliferation-related Ki67 expression [Induction of metastatic cancer cells apoptosis: in our in vitro experiments, we observed that the peritoneal Mmination . Moreovepression  of cTDOspression . Altogetpression , 36.genus Clostridium, Escherichia, and Enterococcus, which are considered human pathogens and associated with colorectal carcinogenesis by inducing colonic inflammation and stimulating neoplastic signaling pathways [genus Alloprevotella and Prevotellaceae UCG 001. Based on KEGG analysis and RNA sequencing, PX exhibits a strong microbicidal effect by using AF, CR, AL, and TV, as well as white alunite, which is a natural product with a potential antivirus [Altering the pathological microbiota communities: perturbations of the colonic microorganism communities are conducive to the carcinogenesis and metastasis of CRC, which exacerbate the colonization of pathogenic taxa at the expense of probiotics and hence produce cancer-promoting metabolites . PX treapathways –40. Morepathways  such as ntivirus  and antintivirus . CompareReversing drug resistance: cancer-related mortality is mainly attributed to the development of drug resistance. Platinum-based drugs and epidermal growth factor receptor (EGFR) inhibitors have been used widely against human tumors , 45, andReprogramming of amino acid metabolism and nervous and humoral regulation: to suffice the biosynthetic demands of unlimited proliferated cancer cells from nutrient-poor TME, an abundant supply of amino acids is pivotal . As a maMalignancy forms a thrombophilic state by increasing venous stasis, which portends a poor prognosis . FT promLast but not least, the multiple components might raise a concern about the absorption and bioavailability of the PX formula. Lines of evidence have demonstrated that mirabilite could alter the pharmacokinetic behaviors of herb components by orchestrating the absorption of each compound . ConsistGiven the high complexity of CRC pathogenesis, we delineated the pharmacological logic of the PX formula from seven aspects:Collectively, these herbs in the PX formula work synergistically to instigate the host anticancer immunity and thus stimulate cancer cell apoptosis, suppress infections, and reshape microbiota communities, establishing a tumor-eradicating TME, and restore the homeostasis of humoral. Although the 179 XH targets are also enriched in various cancers, inflammation, apoptotic signaling, nervous and humoral regulation, and estrogen signaling pathways, the shortcomings of the XH formula might be attributed to the neglect of drug metabolism and resistance, humoral circulation, energy consumption, and microbiota composition. In short, the PX formula exerts a more successful therapeutic effect than XH and might be administered either as an adjuvant in combination with other therapeutic strategies or as a monotherapy for those patients who could not suffer surgery as well as chemotherapy. Especially, the combined utilization of the PX formula with other treatment modalities in traditional Chinese medicine such as acupuncture , 59, whiWe posit that the antineoplastic mechanism of PX involves the induction of anticancer immunity, the establishment of healthy microbiota composition, and the improvement of drug metabolism.


A growing body of literature has shown that maternal diet during pregnancy is associated with infant gut bacterial composition. However, whether maternal diet during lactation affects the exclusively breastfed infant gut microbiome remains understudied. This study sets out to determine whether a two-week of a reduced fat and sugar maternal dietary intervention during lactation is associated with changes in the infant gut microbiome composition and function.n = 10) infants immediately before and after the intervention. Maternal baseline diet from healthy mothers aged 22–37 was assessed using 24-h dietary recall. During the 2-week dietary intervention, mothers were provided with meals and their dietary intake was calculated using FoodWorks 10 Software. Shotgun metagenomic sequencing was used to characterize the infant gut microbiome composition and function.Stool samples were collected from four female and six male (p = 0.003), amino acids (p = 0.005), carbohydrates (p = 0.01), and fatty acids and lipids (p = 0.01). Although the dietary intervention did not affect the bacterial composition of the infant gut microbiome, relative difference in maternal fiber intake was positively associated with increased abundance of genes involved in biosynthesis of storage compounds (p = 0.016), such as cyanophycin. Relative difference in maternal protein intake was negatively associated with Veillonella parvula (p = 0.006), while positively associated with Klebsiella michiganensis (p = 0.047). Relative difference in maternal sugar intake was positively associated with Lactobacillus paracasei (p = 0.022). Relative difference in maternal fat intake was positively associated with genes involved in the biosynthesis of storage compounds (p = 0.015), fatty acid and lipid (p = 0.039), and metabolic regulator (p = 0.038) metabolic pathways.In all but one participant, maternal fat and sugar intake during the intervention were significantly lower than at baseline. The functional capacity of the infant gut microbiome was significantly altered by the intervention, with increased levels of genes associated with 28 bacterial metabolic pathways involved in biosynthesis of vitamins . The early postnatal period is a critical window for the development of the infant gut microbiome , which hSeveral studies have investigated maternal contributions to infant health. Maternal diet during pregnancy has been associated with infant health outcomes, including allergic diseases , 2013; dThe most likely mechanisms by which maternal diet affects the infant gut microbiome and for which the most robust evidence exists is the entero-mammary pathway , whereinThe aim of this study was to determine the effect of a 2-week of a reduced fat and sugar maternal dietary intervention on infant gut microbiome composition and function using shotgun metagenomic sequencing in 10 healthy infants.n = 10). All infants included in our study were healthy, exclusively breastfed, and aged 1.8–4.9 months. Six of the infants were born vaginally, two by emergency caesarean section, two by elective caesarean section, and four were female. During the study period, there was no consumption of antibiotic by infants and mothers. Exclusion criteria were pre-existing maternal diabetes, maternal diseases known to affect gastric absorption (such as gastric ulcers), dietary restrictions , pregnancy complications , multiple pregnancies, known congenital abnormalities or health issues in the infant that could significantly affect feeding behavior, and solid food introduction before the first study session. The study was approved by The University of Western Australia Human Research Ethics Committee (RA/4/20/4953) and registered on the Australian New Zealand Clinical Trials Registry (ACTRN12619000606189). All mothers provided informed consent and answered a background health and lifestyle questionnaire on enrolment.Healthy, Caucasian, primiparous mothers with ages ranging from 22 to 37 years were invited to participate in the study . Maternal height was measured using a Stadiometer (accurate to 0.01 m). Maternal body composition was measured using bioimpedance spectroscopy (Impedimed SFB-7). Infant weight was measured using calibrated electronic scales . Infant length was measured using a Stadiometer (accurate to 0.01 m). Head circumference was measured using flexible, non-stretchable measuring tape with increments of 0.1 cm and checked against a static measure. Infant body composition was measured using bioimpedance spectroscopy (Impedimed SFB-7).Baseline dietary intake (for 1 week prior to the dietary intervention) was assessed using the Automated Self-Administered 24-Hour Dietary Recall (ASA24) system . MothersParticipants serve as their own controls. Infant stool samples were collected immediately before and after the intervention. Due to variations in infant bowel habits, some samples were collected before or after the intended sampling day. Pre-diet samples were collected up to 3 days before, while for post-diet samples, all were collected within 2 days prior to 5 days after the intended sampling day, with the exception of one infant stool sample that was collected 11 days after .Participants self-collected infant stool samples by taking E-swabs of diapers. Stool swabs in 1 ml liquid Amies media were stored in the participant’s home freezer (-20°C) before being collected at the next home visit and transferred to the laboratory where they were defrosted and vortexed for 5 s to release the sample from the swab into the liquid transport medium. Samples were then aliquoted and stored at −800°C until analysis.DNA was extracted from pre-and post-diet stool samples using the QIAamp 96 PowerFecal QIAcube HT Kit (Qiagen) on the QIAcube HT system (Qiagen). The resulting DNA was quantitated using a high sensitivity dsDNA fluorometric assay . Samples needed to reach a minimum of 0.2 ng/μl to pass quality control requirements. Libraries were prepared using a modified protocol, using the Illumina® DNA Prep, (M) Tagmentation (96 Samples) kit (Illumina #20018705), to allow for reduced reaction volumes. Libraries were indexed with IDT® for Illumina Nextera DNA Unique Dual Indexes Set A-D (Illumina #20027213–16). Pooled libraries were prepared for sequencing on the NovaSeq6000 (Illumina) with 2 × 150 bp paired-end chemistry. Sequencing was performed to a target depth of 3 Gbp  raw read generation before quality filtering. Data quality was guaranteed at 75% and above for reads >Q30 at the completion of the sequencing run. All sample preparation and sequencing was performed at Microba Life Sciences Limited.Shotgun metagenomic sequencing data quality control was performed at Microba Life Sciences Limited (see footnote 1). Paired-end DNA sequencing data were demultiplexed and adaptor trimmed using Illumina BaseSpace Bcl2fastq2 (v2.20) accepting one mismatch in index sequences. Reads were then quality trimmed and residual adaptors removed using the software Trimmomatic v0.39  with thevia UniProt 2019/09) and Transporter Classification Database  using ABRicatevs post-diet comparison analyses, paired t-tests were used for comparisons of paired measurements of square root-transformed microbial and gene abundance data. Rare taxonomic reads present in less than three samples and low abundance reads with a mean relative abundance within infants positive for that taxa of less than 0.5% were excluded. Rare functional reads present in less than three samples and low abundance reads with a maximum sample count less than 2 were excluded. Pearson correlation tests were used to compare continuous variables for analyses of associations between the difference in individual maternal dietary factors and square root-transformed microbial and gene abundance data. Square root transformation was used to normalize data distribution. Rare taxonomic features (species) where read counts were 0 in all samples and low abundance features with a maximum sample count of less than 100 reads were excluded. Rare functional features where read counts were 0 in all samples and low abundance features with a maximum sample count of less than two reads were excluded. p values were corrected for multiple hypothesis testing using the Benjamini and Hochberg false discovery rate correction. Corrected values of p < 0.05 are considered statistically significant. No confounders were included in the analysis due to the within individual design and the homogeneity of the group. Redundancy Analysis (RDA) was used to visualize relationships between samples in two-dimensions for identifying sample clusters based on the maternal fiber, protein, sugar, and fat intake.Univariate statistical tests were applied to a filtered set of features. In general, different criteria were applied for taxonomic data and functional data. For pre- Maternal and infant characteristics of the study participants are shown in p = 0.049), maternal fat mass (p = 0.005), fat mass index (p = 0.004), percentage of fat mass (p = 0.036), and maternal fat mass to fat-free mass ratio (p = 0.022).During the intervention, compared to baseline values, maternal fat, saturated fat, and sugar intake decreased significantly by 59.6, 67.5, and 32.9%, respectively. However, for one participant sugar intake increased during the intervention . There wBifidobacterium spp. (24.3%), Bacteroides spp. (17.5%), and Clostridium spp. , Bifidobacterium longum (10.4%), and Bifidobacterium infantis , B. infantis (8.04%), and Bifidobacterium breve (4.5%). Bifidobacterium infantis was present in only one infant stool sample (at 80.3% relative abundance) and its’ relative abundance did not change after the dietary intervention (80.4%). Other identified Bifidobacterium spp. were Bifidobacterium bifidum, Bifidobacterium dentium, Bifidobacterium adolescentis, and Bifidobacterium animalis, with relative abundances ranging from 0.05 to 10.6% and being present in both pre- and post-diet samples of at least one infant.Number of reads that passed QC as well as the number of reads that mapped for each of the protocols for all samples are reported in . The mos. 11.5%; . At the s 8.04%; . Seven Bt-tests to identify any differences in infant gut microbial composition within each infant. No statistically significant differences were identified in the relative abundance of any bacterial species between pre-vs post-diet samples, potentially due to the low participant numbers and high level of inter-individual variation. However, some microbial compositional changes were identified within each infant. For example, B. breve was present in three pre-diet samples , and its relative abundance increased in post-diet samples . It is also worth noting that one infant, whose mother had an increased sugar intake during the intervention, showed the greatest difference in gut microbiome composition between pre- and post-diet, with decreased relative abundance of Klebsiella grimontii (32.2 vs. 0%), Escherichia flexneri (34.4 vs. 7.6%), and Clostridium neonatale (12.3 vs. 4.3%), and increased relative abundance of Klebsiella pneumoniae . Nor was there any difference in Bray–Curtis distances between pre-vs post-diet samples (p = 0.99).Pre- and post-diet samples were statistically compared using paired p = 0.003), metabolic regulators (p = 0.003), amino acids (p = 0.005), aromatic compounds (p = 0.008), carbohydrates (p = 0.01), and fatty acids and lipids (p = 0.01). However, while all gene clusters and metabolic pathways that were significantly different post-intervention were rendered insignificant after adjustment for FDR. p-values ranged from 0.06 to 0.078, indicating a strong trend toward significance , B. breve (3.3 vs. 5.7%), B. longum (7.8% vs. 13%), and Klebsiella variicola (0.24 vs. 2.4%), and a decrease in the mean abundances of Bacteroides vulgatus (6.8 vs. 3.7%), B. adolescentis (1.1 vs. 0.28%), C. neonatale (13 vs. 9.1%), E. flexneri (4.1 vs. 1.8%), and K. grimontii (3.5 vs. 1.1%). The functional potential of these organisms are shown in . One mother-infant dyad was excluded from this analysis due to a lack of baseline dietary intake data.Although infant gut microbiome composition did not differ significantly in pre-p = 0.018; p = 0.025). Cyanophycin acts as a temporary nitrogen reserve and accumulates in the form of granules in the cytoplasm during phosphate or sulfur starvation , while positively correlated with the relative abundance of Klebsiella michiganensis , responsible for thiamin synthesis. The mechanism by which the maternal dietary intervention generated these alterations is unclear, since no significant changes in the infant gut microbiome composition were detected after the intervention, and HM macronutrient content was not affected by the intervention  samples to establish a baseline microbiome, combined with use of strict inclusion criteria where all participants with factors that have been shown to impact maternal gut, HM, and infant gut microbiomes were excluded, including probiotic and antibiotic use. A number of limitations do, however, need to be acknowledged. The sample size is small, and the duration of the intervention is relatively short; thus, is it unknown whether the same results may be obtained if a similar dietary intervention were applied on a larger cohort and/or for a longer period. Additionally, time of sampling might be a confounding variable, as maternal weight/BMI typically decreases in the early months postpartum, and the infant gut microbiome develops temporally. The effects of other potential confounders such as infant sex and mode of delivery were minimized by including an equal number of these variables. In analyses of relative abundances, every increase or decrease in a certain microbe’s abundance can lead to changes in that from other community members. This is an inherent limitation of using relative abundances to compare between different samples, however, despite this, this method is still well-accepted as an effective way to document the microbial composition of different sample types. Metabolic pathway analyses were not conducted, instead, all reference to these is based on the relative abundance of associated genes, which may or may not have been actively expressed.This pilot study is the first to report the effect of a controlled maternal dietary intervention during lactation on the breastfed infant gut microbiome. While the effect of maternal diet during pregnancy on the composition of the infant gut microbiome has been previously investigated , here, wThe data presented in the study are deposited in the SRA repository, accession number PRJNA819247.The studies involving human participants were reviewed and approved by The University of Western Australia Human Research Ethics Committee (RA/4/20/4953). The patients/participants provided their written informed consent to participate in this study.LS, DG, MW, BM, and MP: study design. AS: sample collection and processing, statistical analyses, and writing original draft. AS, LS, DG, and MP: interpretation. SL: detection of antibiotic resistance genes. GL, MN, LS, DG, MW, BM, and MP: writing review and editing. All authors contributed to the article and approved the submitted version.AS, LS, and DG are supported by an unrestricted research grant from Medela AG, administered by The University of Western Australia. MP is supported by a National Health and Medical Research Council Project grant (APP1144040). Umm Al-Qura University, Saudi Arabia provides a PhD scholarship for AS. The funding bodies were not involved in the design of the study, collection/analysis/interpretation of data, writing of the manuscript, or in the decision to publish the results.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Previous articles reported on the tip–apex distance, lag screw placement, fracture pattern, reduction quality, osteoporosis and other factors associated with second surgery. The current study focused on investigating the association of the matching degree between proximal femoral intramedullary nail and femoral medullary cavity on reoperation rate.A retrospective cohort study was conducted. It included patients with intertrochanteric fracture who were treated with proximal femoral anti-rotatory intramedullary nail (PFNA) between January 2016 and April 2021. The gap between the intramedullary nail and the femoral medullary cavity was equal to the difference in diameter between the two. According to the gap size, all patients were divided into three groups, as follows: high-matching group: gap ≤ 2 mm; middle-matching group: 2 < gap < 4 mm; and low-matching group: gap ≥ 4 mm. The mean gap was measured through standard images. The primary observational index was whether the reoperation was needed, and secondary observational indexes included operative time, length of hospital stay. Patient characteristics were recorded, as follows: age, sex, follow-up time, fracture pattern, reduction grade and length of intramedullary nail.P = 0.002). The three groups had 11 cases (13.7%), 12 cases (13.8%) and 4 cases (11.1%) of reoperation, respectively, and logistic regression showed no significant association was noted between matching degree of intramedullary nail and reoperation rate.A total of 203 eligible patients were recorded, including 78 males (38.4%) and 125 females (61.6%). They had a mean age of 77.8 ± 9.9 years old and an average follow-up time of 58.1 ± 24.0 weeks. Twenty-seven patients (13.3%) needed a second operation. Coxa varus combined with screw cutting was the most common reason for reoperation (11 cases). Unstable fracture pattern with poor reduction grade tended to contribute to reoperation, whose odds ratio (OR) was 6.61 (95% confidence interval [CI], 1.98–22.09; The matching degree between proximal femoral intramedullary nail and femoral medullary cavity did not seem to be an important factor for reoperation, which offered more options of intramedullary nail size intraoperatively and reduced implants stock from inventory. Intertrochanteric fracture occurs in elderly commonly, and most patients lose part of the hip function, which brings great burden to their families and constitutes a large part of the healthcare burden , 2. IntrAfter obtaining the approval of the Ethics Committee of the First Affiliated Hospital of Harbin Medical University, a retrospective cohort study was conducted on patients with intertrochanteric fracture who were treated with proximal femoral anti-rotatory intramedullary nail (PFNA) between January 2016 and April 2021. Inclusion criteria included patients who were older than 60 years old and followed up for at least 24 weeks. Exclusion criteria included patients who had tumor-induced fracture, had serious medical disease and had to undergo long-term bed rest had postoperative cognitive impairment and were unable to provide complete radiological image. The primary observational index was whether the reoperation was needed, and secondary observational indexes included operative time and length of hospital stay. Patient characteristics were recorded, as follows: age, sex, follow-up time, fracture pattern, reduction grade and length of intramedullary nail. The causes of reoperation were recorded, including coxa varus, screw cutting , screw cutting-out , screw backing-out, prosthesis peripheral fracture, non-union and complications associated with internal fixation  at least three cortices showing continuous callus formation on standard anteroposterior and lateral radiographs; 2) absence of obvious pain on palpation and percussion at original fracture site; and (3) ability to walk without auxiliary devices , 18. The absence The statistical analysis was performed using R version 4.0.3. A chi-square test was used to compare homogeneous distribution among categorical variables by evaluating frequencies within the groups. A one-way analysis of variance (ANOVA) test was used for comparing homogeneous distribution among numerical variables. Logistic regression was performed to analyze the relationships of reoperation with age, sex, fracture pattern and reduction quality, nail length and matching degree.A total of 203 patients were finally enrolled Table . Eighty P = 0.925).Twenty-seven patients (13.3%) required additional surgery. The most common cause of reoperation is coxa varus combined with cutting of screw (11 cases). Other causes of reoperation include coxa varus combined with cutting-out of screw (two cases), coxa varus combined with back nail (three cases), simple coxa varus (two cases); non-union (four cases), pain associated with intramedullary nail stimulation (five cases). The three groups had 11 cases (13.7%), 12 cases (13.8%) and 4 cases (11.1%) of reoperation, respectively, and no statistically significant difference was found among the groups (P = 0.049). The differences of operative time among the three groups were also analyzed, and significant differences were not observed .Statistically significant differences were not observed among the three groups in age, gender, follow-up time, length of hospital stay, fracture patterns and reduction quality, as shown in Table P = 0.002). Result showed matching degree was not an important factor of reoperation.Logistic regression analysis was conducted Table . Age, seThe matching degree between the nail and femoral medullary cavity might affect fracture healing . Millar P > 0.05) [P = 0.925, Table Whether a nail–bone system can meet the need for fracture healing depends on a variety of factors, not merely biomechanics . More cl > 0.05) ; howeverThe choice of intramedullary nail size remains controversial, which is often associated with complications resulting from the mismatch between the intramedullary nail and the femur, such as anterior cortical penetration and secondary fractures , 24. ChaIn our research, the cutting of the screw was the most common failure pattern of internal fixation, with a total of 11 cases, all of which were accompanied by varying degrees of coxa varus. Differing from the report of Zhang et al., the most common failure mode was cutting-out of screw instead of cutting .P = 0.002). There were 20 cases (9.85%) of OTA/AO 31A3 fractures, as follows: “Good” reduction grade in 0 case (0%); “Acceptable” in 7 cases (35%); and “Poor” in 13 cases (65%). The reduction quality of OTA/AO 31A3 fractures tended to be identified as “poor.” Six cases (30%) of OTA/AO 31A3 fractures required second surgery, and this reoperation rate was higher than in other studies [Fracture reduction quality is one of the most important predictors to consider when preventing a second operation, because cortical buttress improves cortical resistance to collapse. Poor reduction, especially with head–neck fragment varus, increases the risk of cortical collapse . Pressur studies . OTA/AO  studies . Hao et  studies .P > 0.05, Table The effect of nail length on reoperation rate was analyzed. In our study, nails with lengths of 170, 200 and 240 mm were used. Logistic regression analysis showed that the length of nail was not significantly associated with reoperation (In summary, our studies found that the matching degree between proximal femoral intramedullary nail and femoral medullary cavity did not seem to be an important factor for reoperation, which offered more options of intramedullary nail size intraoperatively, reduced implants stock from inventory and costs to the healthcare systems and allowed orthopedic surgeons to used small-diameter nails in lieu of large-diameter ones for decreasing complications resulting from the mismatch between nail and bone.This study has some deficiencies. Different surgeons operated on the patients. These surgeons received standardized training on the surgical approach, posture management, pre- and postoperative management. However, due to individual differences of surgeons, varying degrees of impact were bound to be made on pre- and postoperative management, fracture reduction quality, operative incision size, operative time, intraoperative posture and postoperative rehabilitation plans. Such differences affected the postoperative results, especially the reoperation rate. In addition, the diameter of femoral marrow cavity was not uniform, and thereby, the diameter was measured at the level where the medullary cavity is most fully filled with distal nail considering the feasibility of the study.


To explore the effect of pre-pregnancy body mass index (BMI) on neonatal outcomes among singletons born after frozen embryo transfer (FET).This large retrospective cohort study included 18,683 singleton infants born after FET during the period from Jan 1, 2007 to Dec 31, 2019. The main outcomes were large for gestational age (LGA) and preterm birth. Logistic regression models with generalized estimating equations for clustering by patients to estimate odds ratios of LGA and preterm birth.Overweight was positively associated with LGA overall (adjusted OR 1.78 [95%CI 1.60-1.98]), and this association was consistent across age categories. The underweight was inversely associated with LGA among mothers younger than 35 years , but this association was no significant among mothers 35 years or older. Overweight was positively and significantly associated with preterm birth overall (adjusted OR 1.52 [95%CI 1.30-1.77]) and consistently across age categories. The underweight mothers younger than 30 years had a decreased risk of preterm birth (adjusted OR 0.70 [95%CI 0.51-0.97]), but the underweight was no significantly associated with preterm birth among women aged 30 years of older.The risks of LGA and preterm birth were increased in singletons born to overweight mothers, regardless of the maternal age. Underweight decreased the risk of LGA and preterm birth for younger mothers. These findings are important for providing preconceptional counseling to specifically targeted women at high risk of LGA and preterm birth.The online version contains supplementary material available at 10.1186/s12958-022-00957-8. Since the birth of the first in vitro fertilization (IVF) baby in 1978, more than seven million babies have been born worldwide through assisted reproductive technologies (ART). With the tremendous advancements in the field of ART over the past 40 years, the ultimate goal of ART has changed from achieving successful pregnancy to having a healthy baby , 3. The The gestation age and birth weight are two important indicators evaluating neonatal health. Excessive fetal growth can result in birth weight of large for gestational age , which substantially increases the risk of short-term and long-term morbidities and mortality –7. In thThe extensive literature showed the increased risk of adverse neonatal outcomes in FET singletons comparing with singletons following spontaneous conception –11. ManyPre-pregnancy body mass index (BMI) is a potentially modifiable and preventable lifestyle-related factor related with neonatal outcomes . HoweverWith the increasing use of FET worldwide, clinical study on the association of pre-pregnancy BMI and neonatal outcomes resulting from FET is very important to provide crucial advice to specifically target women at high risk of adverse neonatal outcomes before ART or during pregnancy. The objective of the current study was to assess the effect of pre-pregnancy BMI on adverse neonatal outcomes including LGA and preterm birth among singletons born after FET. Previous studies have reported the association between pre-pregnancy BMI and neonatal outcomes would differ by maternal age. A population-based cohort study including 7,141,630 singletons reported a crossover effect of maternal age (a change from an inverse association to a positive association) for the association between pre-pregnancy obesity and preterm birth . Sever sAll data used in this study were obtained from the ART database at the Department of Assisted Reproduction of the Shanghai Ninth People’s Hospital, affiliated with Jiao tong University, School of Medicine . Cycle-level information on patient characteristics, details of clinical treatment with ART procedure, and pregnancy outcomes and neonatal outcomes resulting from ART were recorded in this database, which was required by the Technical Standard for Human Assisted Reproduction issued by the Chinese Ministry of Health (CMOH) , 23. Qua2), normal weight (18.5-24.9 kg/m2), and overweight (25.0-29.9 kg/m2). In our population, the number of patients conforming to the WHO class I or higher obesity classes (BMI > 30 kg/m2) was small, so we did not analyze the data from these patients with a BMI > 30 kg/m2. The small number of obese women can be explained by the following reasons. The Asian population in general has a lower BMI than that observed for non-Asian populations ) as mothers with overweight (4.24% [n = 90]). For mothers with underweight, 10.09% (n = 216) of singletons were LGA, whereas for mothers with normal weight, the percentage was 17.24% (n = 2486); for mothers with overweight, the proportion of LGA infant was 26.35% (n = 560). The proportion of preterm birth was 5.65% (n = 121), 7.38% (n = 1064), and 10.87% (231) for mothers with underweight, normal weight, or overweight, respectively.The proportion of singletons with SGA, AGA, LGA, and preterm birth across BMI categories stratifying by maternal age was presented in Table Using the normal weight as the reference, overweight was positively associated with LGA overall (adjusted OR 1.78 [95%CI 1.60-1.98]), and this association was consistent across age categories, whereas the underweight was inversely associated with the risk of LGA among the overall mothers (adjusted OR 0.53 95%CI 0.46-0.62]) (Table 6-0.62) (p-interaction< 0.001). Stratification by maternal age and using birth to normal weight mothers as the reference, the underweight mothers younger than 30 years had a decreased risk of preterm birth (adjusted OR 0.70 [95%CI 0.51-0.97]). To further assess the relationship between pre-pregnancy BMI and preterm birth, we evaluated the joint effects of maternal age with pre-pregnancy BMI on the risk of preterm birth , whereas overweight was positively and significantly associated with preterm birth overall (adjusted OR 1.52 [95%CI 1.30-1.77]) and consistently across age categories (Table -0.93), wIn this large observation study of more than eighteen thousand singletons born after frozen embryo transfer, we found that overweight women, irrespective of age, had significantly increased risk of LGA and preterm birth compared with normal weight women. Compared with normal weight women, a significantly decreased risk of LGA was found among underweight women younger than 35 years, and a significantly lower risk of preterm birth was found among underweight women aged less than 30 years. To our knowledge, this is the first study to explore the relation of pre-pregnancy BMI with the LGA or preterm birth, stratified by maternal age, among singletons born after FET.The primary strength of our study is that we focused on women conceived by FET. To our knowledge, this is the first and the largest study to explore the joint association of maternal pre-pregnancy BMI and age with the risk of LGA and preterm birth among FET offspring. Results from this study could enrich existing research on evaluating the effect of pre-pregnancy BMI on neonatal outcomes. The dataset was obtained from the single center, which reduced the potential confounding effects of differences in ART technique and laboratory environment between centers.2 were not included in this study, which limited the generalizability to other populations with BMI > 30 kg/m2.However, several limitations need to be considered in interpreting our findings. First, although we had a large sample size, the number was small for subjects older than 38 years with underweight when we stratified by LGA or preterm birth. Second, we did not explore the association of obesity and preterm or LGA in this study owing to the small numbers of obese subjects. Third, as an observational study, we could not adjust for some potential confounders, such as endometrial preparation protocol, smoking status, a history of preterm delivery, nutrition conditions and educational status. Finally, patients with a BMI > 30 kg/mThe data from Global Burden of Disease Study showed the proportion of overweight has reached 38% globally for women aged 20 years or older . In ChinPreterm birth is related with the high risk of neonatal mortality and morbidity . SurvivoAlthough both developed and developing countries face a growing burden of overweight and obesity, underweight also remains a significant health public concern among women of childbearing age. By contrasting with previous studies finding that pre-pregnancy underweight was not related with LGA, our results suggest the pre-pregnancy underweight was a protective factor against LGA in women younger than 35 years . HoweverExisting evidences on whether lower maternal BMI influences the risk of preterm birth is debated. Han et al. performed a systematic and comprehensive summary of all studies between 1950 and 2009 including 78 studies and 1,025,794 women in developing and developed countries to elucidate the direction and magnitude of the relation between maternal underweight and preterm birth in singleton pregnancies . The resIn this, the first and largest study evaluating the effects of pre-pregnancy BMI and maternal age on risks of LGA and preterm birth for singletons born after FET to our knowledge, to date, we observed an increased risk of LGA and preterm birth in singletons born to overweight mothers, regardless of the maternal age. Underweight decreased the risk of LGA and preterm birth for younger mothers. These findings are important for clinicians who provide pre-conceptional counseling to specifically targeted women at high risk of LGA and preterm birth. Overweight women should be informed of the perinatal risks and take some measures including dietary adjustment, physical exercise, and behavioral intervention, to optimize their BMI before fertility treatment.Additional file 1: Supplementary table 1. Odds ratios (95%CI) for the relationship of pre-pregnancy body mass index with SGA, by maternal age.Additional file 2: Supplementary table 2. Joint association of maternal age and pre-pregnancy body mass index with risk of SGA.


Laparoscopic gastrectomy and robotic gastrectomy are the most widely adopted treatment of choice for gastric cancer. To systematically assess the safety and effectiveness of robotic gastrectomy for gastric cancer, we carried out a systematic review and meta-analysis on short-term and long-term outcomes of robotic gastrectomy.In order to find relevant studies on the efficacy and safety of robotic gastrectomy (RG) and laparoscopic gastrectomy (LG) in the treatment of gastric cancer, numerous medical databases including PubMed, Medline, Cochrane Library, Embase, Google Scholar, and China Journal Full-text Database (CNKI) were consulted, and Chinese and English studies on the efficacy and safety of RG and LG in the treatment of gastric cancer published from 2012 to 2022 were screened according to inclusion and exclusion criteria, and a meta-analysis was conducted using RevMan 5.4 software.WMD = 35.72, 95% CI = 28.59–42.86, P < 0.05) , reduced blood loss  , higher number of harvested lymph nodes  , time to first postoperative food intake shortened  , and lower length of postoperative hospital stay   in comparison to the LG group. While the other variables, for example, time to first postoperative flatus, postoperative complications, proximal and distal mar gin, R0 resection rate, mortality rate, conversion rate, and 3-year overall survival rate were all found to be statistically similar at P > 0.05.The meta-analysis inlcuded 48 literatures, with 20,151 gastric cancer patients, including 6,175 in the RG group and 13,976 in the LG group, respectively. Results of our meta-analysis showed that RG group had prololonged operative time (In the treatment of gastric cancer, robotic gastrectomy is a safe and effective procedure that has both short- and long-term effects. To properly evaluate the advantages of robotic surgery in gastric cancer, more randomised controlled studies with rigorous research methodologies are needed. Gastric cancer is the most common malignant tumor of the digestive tract in far-eastern countries. The global incidence of gastric cancer has declined steadily in recent years, but Asia still has the highest incidence of gastric cancer . Due to In order to search PubMed, Medline, Cochrane Library, Embase, Google Scholar, and China Journal Full-text Database (CNKI) and other databases according to clinical comparison studies of RG and LG, the search strings “Robotic OR da Vinci OR Robot-Assisted”, “Gastrectomy”, “Gastric “, “Cancer OR Carcinoma OR Tumor OR Neoplasm”, “Laparoscopic OR Laparoscopic-Assisted “ and “Robotic”, Searches were limited to the period 2012–2021, with the “related search” feature being utilized further to exclude omissions.Inclusion criteria: (1) published randomized or non-randomized controlled trials comparing RG with LG; (2) patients diagnosed with gastric cancer who have undergone their first surgical procedure; (3) provide clear criteria for the selection of study cases and methods for grouping; (4) provide evidence of clinical efficacy comparison between RG and LG; (5) include data studies of superior quality and detail; (6) describe the raw data, including continuous variables such as mean and standard deviation, and count information such as the number of events and the number of samples. For dichotomous variables, the combined odds ratio (OR) and 95% confidence interval (CI) should be provided, as well as a regression coefficient that can be converted to the combined OR and 95% CI and standard error. Exclusion criteria: (1) comparisons of non-LG and RG cases; (2) study cases containing other benign gastrointestinal diseases; (3) study cases having only undergone palliative major gastrectomy, tumor reduction, or short-circuit surgery; (4) study cases involving emergency surgery; (5) no reliable comparisons could be drawn from the literature; (6) duplicate published studies; (7) no controlled studies conducted simultaneously; and (8) no clear grouping tendency in terms of the extent of lymph node dissection or stage of the disease.0 resection rate, postoperative hospital stay, immediate postoperative gas and food intake, complication rate, 3-year survival rate, and morbidity and mortality rate.Extractions are made by two investigators independently, and if a dispute occurs, it is resolved through mutual discussion or by a third party. The following data types can be identified: (1) General information, including the names of the authors, the dates of literature publication, the type of study, the sample size, the tumor site and its size, and the TNM stage; (2) outcome indicators, such as operative time and blood loss, lymph node dissection, transit rate, distal margin length, RWe used the MINORS scoring criteria  to assesWMD) for efficacy analysis for count data. The 95% confidence interval (CI) for the effect sizes was calculated. It was checked for heterogeneity between the studies using the χ2 test and I2 values, and in case of heterogeneity , a random-effects model was applied; if there was no heterogeneity , a fixed-effects model was applied. The differences were considered statistically significant at P < 0.05.We performed the meta-analysis using RevMan 5.4 software, using odds ratio (OR) values for measurement data and weighted mean differences   . The meaI2 = 93%, P < 0.05, and analysis using a random effects model showed that intraoperative bleeding was significantly less in the RG group than in the LG group  (Intraoperative bleeding was reported in 43 publications with homogeneity test  < 0.05) . The meaI2 = 87%, P < 0.05, and analysis using a random effects model showed that the number of lymph node dissections was higher in the RG group than in the LG group  using random effects model analysis  (Time to first postoperative flatus 26 publications reported time to first postoperative flatus with homogeneity test  > 0.05) . The meaI2 = 53%, P < 0.05, and analysis using a random effects model showed that time to first postoperative food intake was significantly shorter in the RG group than in the LG group  (Time to first postoperative food intake 26 publications reported time to first postoperative food intake with homogeneity test  < 0.05) . The meaI2 = 80%, P < 0.05, and a random effects model analysis showed significantly lower length of hospital stay in the RG group than in the LG group   . The meaI2 = 22%, P > 0.05, and a random effects model analysis showed no statistically significant difference in complication rates between the two groups  (Postoperative Complication rates 47 publications reported complication rates with homogeneity test  < 0.05) . The aveI2 = 57%, P < 0.05, and analysis using a random effects model analysis showed no statistically significant difference in proximal margin distance between the two groups   . The meaI2 = 71%, P < 0.05, and a random effects model analysis showed not statistically significant in distal margin distance between the two groups   . The mea0 resection rates 48 publications reported R0 resection rates with homogeneity test I2 = 0%, P > 0.05, and analysis using a fixed effect model showed no statistically significant difference in R0 resection rates between the two groups  (0 resection rate was 128.52 in RG group and 290.81 in LG group.R > 0.05) . The aveI2 = 95%, P < 0.05, and analysis using a random effects model analysis showed no statistically significant difference in tumor size between the two groups  (Tumor size 22 publications reported tumor size with homogeneity test  > 0.05) . The meaI2 = 0%, P > 0.05, and analysis using a fixed effect model showed no statistically significant difference in mortality rate between the two groups   . The aveI2 = 0%, P > 0.05, and a fixed effect model analysis showed no statistically significant difference in conversion rate between the two groups  (Conversion rate 14 publications reported conversion rate with homogeneity test  > 0.05) . The aveI2 = 0%, P > 0.05, and a fixed effect model analysis showed no statistically significant difference in reoperation rate between the two groups  (Reoperation rate 13 publications reported reoperation rate with homogeneity test  > 0.05) . The aveI2 = 88%, P < 0.05, and a random effects model analysis showed no statistically significant difference in 3-year survival between the two groups   . The aveI2 > 50% and P < 0.05. Our results suggest that there was heterogeneity in the time to first flatus, proximal margin, distal margin, tumor size, and overall survival   (Heterogeneity is considered to be significant when  > 0.05) . Further < 0.05) . AccordiEvaluation of publication bias was accomplished using a funnel plot of intraoperative blood loss, lymph node dissection, and postoperative complications. There was no evidence of publication bias in the bilaterally symmetrical funnel plots of overall complications .In most cases of gastric cancer, gastrostomies are the mainstay of treatment. Almost thirty years ago, minimally invasive gastrostomies were introduced to reduce patient burden. As a result of the increasing availability of surgical robots, a robotic-assisted gastrectomy was performed for the first time in Japan in 2002 . CurrentRobotic surgery has become increasingly popular in a variety of surgeries due to its increased surgical precision and safety. Since the earliest application of robotics in surgery, it has evolved in five distinct categories: endoscopic, stereotactic, bioinspired, millimeter-scale microbots, and autonomous systems. Robotic surgery has shown to have dramatically superior clinical results when compared to laprascopic and open surgical techniques. In our study, of the 48 publications examined, 38 researches employed the Da Vinci surgical systems while the other 10 did not specify the surgical systems used . Accordiet al. .A patient's prognosis and degree of surgical cure are affected by the number of lymph nodes dissected at the time of surgery for early gastric cancer. As a treatment for intermediate and advanced gastric cancer, D2 lymph node dissection remains the standard procedure. Nonetheless, it is difficult to dissect D2 lymph nodes in LG. The included studies , 24, 28 et al. , and the rest of the results remained unchanged, indicating that systematic analysis results are relatively reliable.A meta-analysis of the data revealed that there was no difference in the rest of the data between the RG and LG group. Despite this, there is heterogeneity in first postoperative flatus time, postoperative complications, proximal incision margin distance, distal incision margin distance, tumor size, and 3-year survival rate. There may be a variety of reasons for this: (1) The operators included in the study may be in different stages of their RG development, and the indicators are heterogeneous. (2) The tumor size, location, and stage of included studies are different; (3) Preoperative management and surgical methods are also different, contributing to varying results. The findings of a high-quality non-randomized controlled trial, however, were also convincing when evaluating the short-term effects of surgery, as shown by Abraham et al. . After rThis study has some limitations (1) the inclusion of the most recent literature and exclusion of studies with duplicate cases; (2) the inclusion of a relatively large number of studies, which increased the number of relevant cases; and (3) the systematic analysis of long-term survival information, such as the 3-year survival rate. Several limitations exist in this meta-analysis, including: (1) the included literature was retrospective, lacking high-quality randomized controlled trials, some of which had a small number of patients, which may have contributed to publication bias, and (2) the recurrence rate was not examined.Based on our meta-analysis, RG appears to have superior therapeutic effects than traditional LG for treating gastric cancer and both are safe and practical. Its future application opportunities will improve as more experience is gathered. In the future, large-scale, multi-sampled multicenter randomised controlled studies will be required to increase the reliability of RG in clinical therapy.


Lactobacillus acidophilus, Lactobacillus plantarum, and Lactobacillus rhamnosus GG), and evaluated the growth, physiochemical, and aroma characteristics. All three strains exhibited excellent growth potential in the sweet cherry juice; however, Lactobacillus acidophilus and Lactobacillus plantarum demonstrated more robust acid production capacity and higher microbial viability than Lactobacillus rhamnosus GG. Lactic acid was the primary fermentation product, and malic acid was significantly metabolized by LAB, indicating a transition in microbial metabolism from using carbohydrates to organic acids. The aroma profile was identified through integrated analysis of electronic nose (E-nose) and headspace gas chromatography–ion mobility spectrometry (HS-GC–IMS) data. A total of 50 volatile compounds characterized the aromatic profiles of the fermented juices by HS-GC–IMS. The flavor of sweet cherry juice changed after LAB fermentation and the fruity odor decreased overall. Lactobacillus acidophilus and Lactobacillus plantarum significantly increased 2-heptanone, ethyl acetate, and acetone contents, bringing about a creamy and rummy-like favor, whereas Lactobacillus rhamnosus GG significantly increased 2-heptanone, 3-hydroxybutan-2-one, and 2-pentanone contents, generating cheesy and buttery-like odors. Principal component analysis of GC–IMS data and linear discriminant analysis of E-nose results could effectively differentiate non-fermented sweet cherry juice and the sweet cherry juice separately inoculated with different LAB strains. Furthermore, there was a high correlation between the E-nose and GC–IMS results, providing a theoretical basis to identify different sweet cherry juice formulations and appropriate starter culture selection for fermentation. This study enables more extensive utilization of sweet cherry in the food industry and helps to improve the flavor of sweet cherry products.Sweet cherries are popular among consumers, with a recent explosion in sweet cherry production in China. However, the fragility of these fruits poses a challenge for expanding production and transport. With the aim of expanding the product categories of sweet cherries that can bypass these challenges, in this study, we prepared sweet cherry juice fermented by three different lactic acid bacteria (LAB;  In parth of LAB . LAB-ferh of LAB . Szutowsh of LAB . Cherry h of LAB . Liu et Lactobacillus paracasei and analyzed the change in volatile compounds using GC–MS. The fermented chokeberry juice was characterized by aromatically desirable volatile compounds such as alcohols and esters. Lactobacillus rhamnosus GG-fermented sour cherry juice by headspace (HS)-GC–IMS and found a huge change in the levels of most volatile compounds during the fermentation. Additionally, an electronic nose (E-nose) is a device designed to mimic the human olfactory system .Analytical standards of citric acid, succinic acid, malic acid, ascorbic acid, and lactic acid were purchased from Aladdin Technology Co., Ltd. . Shikimic acid and fumaric acid were obtained from Solabiao Technology Co., Ltd. . Other reagents such as De Man, Rogosa, Sharpe (MRS) medium; 3,5-dinitrosalicylic acid; and Na2.2.Lactobacillus acidophilus JYLA-16, Lactobacillus plantarum JYLP-375, and Lactobacillus rhamnosus GG JYLR-005 were obtained in lyophilized form from Zhongke Jia-yi Bioengineering Co., Ltd. . These strains were stored as a freeze-dried powder at −80°C. The culture was incubated at 37°C for 16 h with 100 ml MRS medium for activation. Subsequently, the activated cells were centrifuged and washed with sterile water to prepare for fermentation.2.3.7 LAB cells/ml was allotted into the pasteurized sweet cherry juice and incubated under a static condition at 37°C for 48 h. All fermentation and analyses were employed in triplicate. The experimental samples were divided into the following four groups for comparison: sweet cherry juice without LAB (CJ), sweet cherry juice fermented with Lactobacillus acidophilus JYLA-16 (LAFCJ), sweet cherry juice fermented with Lactobacillus plantarum JYLP-375 (LPFCJ), and sweet cherry juice fermented with Lactobacillus rhamnosus GG JYLR-005 (LRFCJ).Fully ripened and frozen sweet cherries were obtained from a cherry farm in Shandong, China. The sweet cherries were cleaned and the pulps were removed with a pitter. The obtained pulps were squeezed by a juicer , filtered through four-layer gauze, and centrifuged to obtain clear sweet cherry juice. The obtained juice was pasteurized  and stored at −80°C before fermentation. An initial concentration of 1 × 102.4.2.4.1.Viable counts of fermented sweet cherry juice were conducted based on the spread-plate method as reported previously . In brie2.4.2.2O was added and the absorbance was recorded at 540 nm on an ultraviolet-spectrophotometer ; d-glucose was used as a standard. The pH was determined by a digital pH meter . To prevent contamination of the samples, 50 ml of the sample was removed and placed into a 100 ml flask, and then the pH was detected in the flask.The SSC of fermented sweet cherry juice was evaluated in units of °Brix using a digital refractometer . The reducing sugar content was determined according to the 3,5-dinitrosalicylic acid (DNS) colorimetric method, as described previously . In brie2.4.3.2), 150 l/h; capillary voltage, 3 kV; and collision gas, argon (99.99%). Compounds were identified by their retention times and ion pair strength. The samples were quantified based on their peak areas using calibration curves for the different standard concentrations.To identify the organic acids of fermented sweet cherry juice, a UPLC coupled with linear trap quadrupole–Orbitrap mass spectrometry system  was utilized according to the manufacturer instructions. Briefly, 1 ml of each sample was centrifuged at 12000 rpm for 10 min. The obtained supernatant was filtered through a 0.22 μm membrane for UPLC-MS/MS analysis. The separation of analytes was carried out on a Hypercarb column  at 40°C. Linear-gradient elution was performed at a flow rate of 0.25 ml/min. The gradient elution consisted of water (phase A) and acetonitrile (phase B) as mobile phases varying as follows: 0–6 min, 95% B; 6–6.1 min, 55% B; 6.1–10 min, 95% B. An electrospray ion source was used to scan in multiple reaction monitoring positive- and negative-ion modes. The MS conditions were as follows: source temperature, 130°C; desolvation temperature, 500°C; flow rate of the desolvation gas, 800 l/h; flow rate of the cone gas . Sample analysis was performed according to a previously reported method . To assess the correlation between E-nose sensor responses and volatile compound levels detected by GC–IMS, Spearman’s correlation analysis was performed with Origin Pro 2021 software .The results are presented as mean ± standard deviation of three independent experiments. One-way analysis of variance and Duncan’s test were applied in SPSS 18 , and 3.3.1.Lactobacillus acidophilus , whereas LRFCJ had the lowest lactic acid content (4295.89 ± 56.62 mg/l). Numerous studies have demonstrated lactic acid as the primary fermentation product, including in the LAB fermentation of elderberry, black chokeberry, and sea buckthorn juices . The lacMalic acid is one of the primary organic acids in sweet cherry that provides the characteristic sourness and acts as a flavor blender to create a strong and sharp taste . The CJ Lactobacillus acidophilus and Lactobacillus plantarum utilize citric acid and malic acid as carbon sources. Previous studies have shown that LAB can use citric acid and malic acid simultaneously, even though their relative conversion rates differ. In general, citric acid metabolism is accompanied by the use of carbohydrates or other energy sources. LAB can convert citric acid into acetate and oxaloacetate by ATP-citrate lyase  and LPFCJ (35.62 ± 2.7 mg/l) samples showed lower citric acid levels than the unfermented (CJ) samples (57.91 ± 25.72 mg/l). This is possibly because te lyase . The resot juice . The incot juice .l-Ascorbic acid (vitamin C) is one of the primary hydrosoluble antioxidants of the fruit and is an essential component of human nutrition , which was almost double that of the control group. The increase in l-ascorbic acid in the fermented sweet cherry juice might be attributed to the fact that ascorbic acid can be produced by these LABs  is a classical supervised data dimension reduction method, which can be utilized to identify perceptible olfactory differences between different sources, narrowing the differences between similar sources and widening the differences between distinct sources, with more considerable distances between groups indicating more significant variability . As show3.4.3.4.1.The differences in volatile compounds in sweet cherry juice fermented by different LAB were further analyzed by HS-GC–IMS. 3.4.2.Tricholoma matsutake Singer. Additionally, a newly formed dimer exhibits a much greater molecular weight than the monomer and produces multiple signals.The qualitative results of the volatile compounds of fermented sweet cherry juice with the three LAB strains are presented in 3.4.3.For a more intuitive presentation of the distinction of volatile compounds among samples, fingerprint analysis was conducted . The resLactobacillus rhamnosus GG  was performed to highlight the variations in volatile compounds among different LAB-fermented sweet cherry juices. The most significant variable was the first principal component (PC1), which accounted for 60.2% of the total variance. PC1 negatively correlated with most aldehydes . The unf3.5.The E-nose analysis and GC–IMS data could both effectively categorize the sweet cherry juices fermented with different LAB strains but to varying degrees. In contrast to the general volatile chemical data provided by E-nose, GC–IMS can detect individual volatile chemicals in samples. Thus, the combination of the two strategies may enhance the overall performance of characterization of fermented juice. 4.Lactobacillus acidophilus, Lactobacillus plantarum, and Lactobacillus rhamnosus GG). This work indicated that all three strains could grow well in the sweet cherry juice, although their fermentation resulted in different flavor and aroma features. Higher acid production and rapid growth in the juice were found in LAFCJ and LPFCJ samples compared with those of LRFCJ samples. This study thus established the volatile compound fingerprint of sweet cherry fermented by these three LAB strains. Furthermore, the characteristic volatile compounds in different sweet cherry juice formulations were identified. PCA of GC–IMS data and LDA of E-nose results revealed that the aroma profile in LRFCJ was substantially different from that of the others. Furthermore, there was strong correlation between the E-nose and GC–IMS results. Overall, our study provides the first data on the aroma profile of sweet cherry juice according to the correlation and integration of E-nose and GC–IMS data. The results highlight the significant diversity in the aroma of fermented sweet cherry juice and confirm the potential applicability of both E-nose and GC–IMS in studying the industrial applications of fruit starter cultures.This study shows that sweet cherry is an outstanding fruit substrate for fermentation-based biotransformation into higher-value volatile compounds using the three selected LAB strains , and funding acquisition. YZ and XW: investigation, conceptualization, and validation. Y-JG: writing (review and editing). B-CW: software and formal analysis. All authors contributed to the article and approved the submitted version.This study was supported by the University Natural Sciences Research Project of Anhui Province (KJ2021A1009), the Hefei University Scientific Research and Development Fund (20ZR09ZDB), and the talent fund of Hefei University (20RC48).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The aim of the study was to compare the chemical and fatty acid composition, colour, and sensory quality of wild and farmed pikeperch. Raw wild pikeperch had a higher moisture and ash contents, as well as pH value, but lower fat and protein contents than farmed pikeperch. In sous-vide fillets, a higher fat and a lower protein content were noted in farmed fish. Slight differences in colour attributes between farmed and wild fish affected neither chroma nor hue in raw and sous-vide fillets. Wild and farmed fish fillets prepared using sous-vide were scored similarly in the sensory assessment. Although wild fish had a more beneficial fatty acid composition demonstrated by a higher proportion of polyunsaturated fatty acids, including eicosapentaenoic and docosahexaenoic, a higher fat concentration in farmed pikeperch resulted in obtaining similar or even higher concentration of these fatty acids in sous-vide fillets. Regardless of the origin of pikeperch it might be recommended as a valuable part of a daily diet. Sander lucioperca) have remained fairly stable at approximately 20,000 tons annually over the past 40 years [Catches of pikeperch  or salting and acid marinating. Each of these processes results in products with distinct sensory properties and nutritional value. In households and restaurants, most commonly used thermal processes are cooking and frying. However, a high-temperature treatment might negatively affect the nutritional profile of fish products. Bouriga et al. , who app3. After the fish obtained a body weight of 25 g, they were moved to larger rearing tanks of approximately 2 m3. In the last 12 months (fattening phase), fish were fed Aller Rep Ex . The composition of the feeds was: crude protein—53.0%, crude fats—14.0%, nitrogen free extract (NFE)—14.5%, crude fibre—1.3%, and gross energy—20.9 MJ kg−1 feed. Fatty acid composition of the feed is presented in −1. Water temperature during fattening phase ranged from 16.8 °C to 22.7 °C. The oxygen concentrations at the rearing tank’s outflow did not fall below 6.1 mg O2 L−1. The concentration of total ammonia nitrogen (TAN = NH4+-N + NH3-N) measured at the rearing tank outflows did not exceed 0.4 mg TAN L−1 and that of nitrites (NO2-N) did not exceed 0.2 mg NO2-N L−1. The water pH was within the range of 7.78–8.08. The stocking density in the last months of rearing was approximately 30 kg m−3.Effect of pikeperch origin (farmed vs. wild) was analysed using 12 farmed  and 12 wild fish  were captured at the same time . They were ground together, and their composition was determined as: 4.8% ash, 0.6% fat, and 76.5% moisture. Immediately following capture, the pikeperch were killed and kept on ice until processing (not longer than 6 h). Fillets for the study were obtained after gutting the wild and farmed pikeperch, de-heading with a simple cut, fin removal, filleting, and skinning the fillets . Gill nets were used . The water temperature was 6.0 °C when the fish were caught. The prey fish of wild pikeperch . Samples for thermal treatment were weighted and individually vacuum packed in plastic punches suitable for sous-vide cooking, and then they were heated in a sous-vide device at a temperature of 65 °C for 40 min. After that, the samples for sensory analysis were evaluated, whereas the remaining were chilled in cold water with ice and refrigerated at a temperature of 4 °C overnight and then used in chemical analyses.2 + b*2)0.5 and h = atan (b*/a*)·360°/(2·Π) [Colour parameters (CIE L*a*b*) were measured on the surface of the muscle tissue of raw and cooked fillets using Konica Minolta CR-400  . CIE L* a* and b* values were measured in triplicate in the dorsal part of the fillets on their inner side. L* values indicate the lightness (from 0 black to 100 white), a* the proportion of red (a* > 0) or green (a* < 0) hues and b* the proportion of yellow (b* > 0) or blue (b* < 0) hues. Using the following equations, values of chroma (C) and hue angle (h) were calculated: C = (a*0°/(2·Π) .Values of pH and expressible water content were determined in the raw muscle tissue of fish. Values of pH were measured directly in three different locations of each raw fillet with a HI 8314 pH-meter equipped with an FC 200 combined electrode . Prior to measurements, the pH-meter was calibrated (pH 7 and pH 4 buffers). Expressible moisture was determined in triplicate for each sample according to the method described by Benjakul et al.  with a sRaw and sous-vide fillets were individually ground twice through a 4 mm mesh. To determine the moisture content, samples were dried at a temperature of 103 ± 2 °C . After dv/v). Methylation of fatty acids was conducted using a chloroform–methanol–sulphuric acid (100:100:1) mixture [Fatty acid proportions and contents were determined using the method described in detail in Modzelewska-Kapituła et al. . Briefly mixture . Chromat mixture .The analysis was carried out according to Modzelewska-Kapituła et al. . ImmediaNormal distribution of data and variance homogeneity were tested using Shapiro–Wilk’s and Leven’s tests, respectively. Data showed a normal distribution and variance homogeneity; therefore, to compare mean values, one-way variance analysis was applied .Parameters of wild and farmed pikeperch are shown in A higher proportion of skinned fillets in relation to body weight was found in wild pikeperch, which might indicate their higher economic efficiency and might result from a longer body. Nevertheless, it should be highlighted that farmed pikeperch at the age of approx. 2 years reached a similar body weight to wild 4-year-old pikeperch. This resulted from differences in feed composition  and water temperatures (lake vs. RAS). The feed also differed in fatty acid composition .Significant differences were noted in each fatty acid proportion, as well as the sum of particular fatty acid groups. The wild pikeperch fodder had higher saturated and polyunsaturated fatty acid  and n-3 fatty acids proportions but lower monounsaturated fatty acids (MUFA) and n-6 fatty acids than farmed fish fodder.The chemical composition of raw fillets obtained from wild and farmed pikeperch is shown in The fillets from wild pikeperch had a higher moisture 78.9%) and ash (1.2%) contents and pH (6.7), but a lower fat (0.4%) and protein (19.3%) content than farmed pikeperch . These differences in the chemical composition resulted from differences in the feed of wild and farmed fish, including the fat content which was 0.6% and 14% in wild and farmed pikeperch fodder, respectively. Similar to results of the present study, a higher fat content in farmed vs. wild pikeperch was noted by Jankowska et al. . This mi8.9% and Perca flavescens) and might be attributed to multiple factors such as lower fat content, blood vasculature, higher deposition of melanin due to dietary effects, or enzymatic reactions from tyrosine. Despite differences in pH values, there were no differences in expressible water contents (Esox lucius) [In terms of colour, wild and farmed fish differ only in redness (a*), which was higher in wild pikeperch . Higher contents . Similar lucius) . The exp lucius) . Both th lucius) ,29. The Significant differences in fatty acid composition and concentration in the muscle tissue of wild and farmed pikeperch were noted. Generally, the proportions of SFA, MUFA, and PUFA in the wild pikeperch were similar and accounted for 32 to 35% of total fatty acids. The most prevailing fatty acids were C16:0  and C18:1cis9 (oleic acid), which accounted for 22% and 17% of total fatty acids, respectively. In farmed fish, a higher proportion of MUFA was noted in comparison to SFA and PUFA . The most abundant fatty acids were similar to those noted in wild pikeperch, but in different proportions—C16:0 accounted for only 15% and C18:1cis9 for as much as 36% of total fatty acids . The abuJankowska et al.  showed tDifferences in fatty acid proportions and a higher content of fat in farmed pikeperch produced differences in the concentration of particular fatty acids in fresh fillets . AlthougThere were slight differences in the quality of cooked fillets between wild and farmed pikeperch. In terms of the chemical composition, the fish differed in fat content, which was higher in farmed pikeperch, and protein content, which was higher in wild fish fillets . The moiFillets differed also in colour—those obtained from farmed pikeperch were lighter and had a higher redness . A higher lightness of sous-vide farmed pikeperch fillets corresponded with a significantly higher fat content in those samples, which is a known factor affecting muscle tissue . HoweverAs was noted in the raw fillets, the sous-vide cooked fillets obtained from wild and farmed pikeperch differed in fatty acid composition  and concentration (mg/100 g). Although wild pikeperch fillets had a higher proportion of the sum of PUFA and n-3 fatty acids, sous-vide cooked fillets obtained from farmed fish were a better source of those fatty acids in the human diet due to higher concentrations of these components . GeneralIn this study, wild and farmed pikeperch were compared in terms of yields, pH, colour, and chemical composition of raw muscle tissue, as well as chemical composition, colour, and sensory quality of fillets after sous-vide cooking. The weight of wild and farmed pikeperch was similar, but wild pikeperch had a longer body and showed a significantly higher skinned fillet yield. Differences in the fodder chemical composition as well as life environment resulted in differences in raw fillet colour (wild pikeperch fillets had more red hues), proximate chemical composition, and fatty acid profile. Raw wild pikeperch fillets had lower fat and protein contents than farmed counterparts; however, after sous-vide, fillets from wild pikeperch showed lower fat and higher protein contents than those from farmed pikeperch. Wild fish had a more beneficial fatty acid composition manifested by a higher proportion of EPA and DHA. Nevertheless, due to a higher fat concentration in farmed pikeperch, a similar content of those fatty acids in sous-vide fillets was noted in wild and farmed pikeperch. Moreover, sous-vide fillets from farmed pikeperch had a higher amount of PUFA, including n-3; therefore, they were more beneficial from a nutritional perspective. The colour of sous-vide fillets produced from wild pikeperch were darker and less red than fillets produced from farmed fish; however, this did not affect the results of the sensory colour evaluation. There were no differences in the aroma, texture, juiciness, or taste of sous-vide fillets obtained from wild and farmed pikeperch. High results obtained in the sensory assessment indicate a good eating quality of both sous-vide products regardless of the fish origin. The results of the present study clearly indicate the good quality and high nutritional value of farmed pikeperch; therefore, fish producers might be encouraged to produce pikeperch in RAS as an alternative to wild pikeperch, whose population in the environment is limited.


Due to staff shortages and reports of high work stress, work conditions of hospital physicians and nurses receive wide attention. Additionally, sociocultural diversity of the workforce and patient population is increasing. Our study aim is to analyze how individual and organizational diversity-related factors are associated with the experience of staff’s work stress.A cross-sectional online survey was conducted with healthcare staff from 22 acute hospitals operated by two healthcare organizations in Germany in 2018. Sociodemographic, occupational and organizational factors were surveyed. Participants further reported work conditions related to the sociocultural diversity of colleagues and patients. Effort-reward imbalance (ERI) was measured with the German short version. Multivariable regression models were calculated with ER ratio as an outcome.N = 800 healthcare staff were included. Variables associated with higher ERI were longer work experience , not holding a leading position , being a witness  or victim  of discrimination at one’s own ward, reporting frequent burden due to language barriers with patients  and colleagues , and having restricted access to translators at work . Factors associated with lower ERI were having a first generation migration background  and being a physician .Catering to the needs of healthcare personnel in dealing with the additional effort related to language barriers at work, e.g., readily available translator services, and creating non-discriminatory work environments might be one cornerstone for the prevention of work-related ill health and retention of qualified hospital staff.The online version contains supplementary material available at 10.1007/s00420-022-01947-4. Healthcare professionals frequently experience work stress stemming from adverse psychosocial work conditions  theoretical underpinning, focus on specific work aspects and their evaluation, availability of measurement instruments in different languages, psychometric properties of these instruments and their capability to explain the health of employees  and organizational factors  in healthcare professionals  in organization A and n = 7039 (n = 1254 physicians and n = 5785 nurses) in organization B. Due to low participation rates of physicians, a paper-and-pencil survey was offered to physicians of two randomly selected hospitals of organization B. The final sample size after data correction amounted to n = 800 participants for this analysis .A complete survey was pursued with an approximate target population of The online questionnaire included questions on the following characteristics of participants: gender , age and job experience (in years), job role (nurse or physician), leading position (yes or no), employment status (temporary or permanent), and work status (full time or part time). Participants further reported their respective affiliation to one of the two study organizations (subsequently anonymized into institution A and institution B for data protection reasons).We asked participants about their personal migration experience and the migration experience of their parents, which we subsequently categorized into no migration experience, first generation and second generation migration background as suggested by Schenk et al. . Particiα = 0.724), reward (α = 0.709) and overcommitment (α = 0.767). For statistical analyses, the ratio between effort and reward was calculated as a separate variable, by building the ratio between the sum score of effort (E) and the reward sum score (R) corrected by the ratio of items in each subscale (c), i.e., ER ratio = E/(R × c). Occupational stress is assumed to occur when the ER ratio is above 1, indicating an imbalance between efforts spent and rewards received in return  plot, since available analytical tests, e.g., the Shapiro–Wilk test, are highly sensitive with regard to sample size. Relationships between participants’ effort, reward, overcommitment and ER ratio and categorical variables were tested using independent t-tests or one-way ANOVA with post-hoc tests, respectively. Equivalently, we used Spearman correlation tests to test the latter relationships with continuous variables. As one precondition for multivariable analyses, normal distribution of residuals was plotted and assessed in histograms. Finally, multiple regression analyses were applied to determine variables associated with ER ratio, which was measured on a continuous scale as recommended by Montano et al.  as well as means and standard deviations (for continuous variables) were generated as applicable. Missing values in variables ranged between o et al.  and van o et al. . SupplemDescriptive results of the study population are displayed in Table Respondents estimated that a mean of 22.1% (SD: 17.5) of employees on their ward had a migration background, while a mean of 30.5% (SD: 20.5) of patients were assigned a migration background. Thirty-eight percent of participants reported witnessing an act of discrimination on their ward and 13.5% of respondents reported an own experience of discrimination. Participants described frequent burden due to language barriers in interactions with patients, but rather infrequent burden due to respective barriers in colleague and supervisor interactions. Respondents described average possibilities to consult interpreters in case of language barriers. Mean cultural competence was 3.5 (SD: 0.55) without considerable variance in the subscales of cultural knowledge, skills and metacognition.n = 174) of respondents had ratios equal to or under 1 implying a favorable relationship between effort and reward spent at work. However, 77.2% (n = 590) of participants reported an imbalance between effort and reward.The mean ER ratio was 1.33 (SD: 0.42), whereby mean effort was 9.72 (SD: 1.75), mean reward 17.90 (SD: 3.36) and mean overcommitment 14.73 (SD: 3.31). When ERI scores were dichotomized, 22.8% , not holding a leading position , having been a witness  or victim of discrimination  and reporting frequent burden due to language barriers with patients  and colleagues . Higher ERI was further associated with lacking possibilities to consult interpreters in case of language barriers . However, lower ER ratios were related to a first generation migration background  and being a physician . In comparison to bivariate analyses, the associations of ERI with the employment status, work status and proportion of patients with a migration background on one’s ward were no longer statistically significant. This model explained 17.2% of the variance in the outcome ER ratio (adjusted R2 = 0.172). Additional calculations containing effort, reward, and overcommitment as dependent variables in multiple linear regression analyses are displayed in Online Resource Tables S1, S2, and S3.Multivariable analyses controlled for the simultaneous effects of individual and organizational characteristics on the ER ratio Supplementary file2 (PDF 192 KB)Supplementary file3 (PDF 192 KB)Below is the link to the electronic supplementary material.