Stress-related health problems have increased sharply over the last two decades and have become a serious issue at all levels of society. In the Jönköping Region in southern Sweden, a nature-based rehabilitation (NBR) program for adults with Exhaustion Syndrome has been developed and then implemented into the Swedish National Healthcare System. The main aim of this study was to investigate the effectiveness of this NBR-program. This was achieved by examining patients’ quality of life, exhaustion symptoms and overall health using self-assessment instruments, comparing the results before participation to immediately after, three months after and six months after. With a sample size of 67 participants, the results show a statistically significant improvement for all points. From a public health perspective, and with background knowledge of the nature of the patient group under treatment, the studied program would appear to be effective and economic, having a satisfied patient group as well as a favourable comparison with the outcomes of other research programs. Although the results are promising, as this is a naturalistic field study, there is no control group, and further research is encouraged. We suggest randomised controlled studies, longitudinal studies and investigation of mediators. The concept of stress was introduced into main-stream medical thinking in the 1930s by Hans Selye and is defined as an individual’s reaction to excessive strains or overloading ,3,4,5,6.Stress-related health issues are categorised as psychosomatic and have become increasingly more common ,9,10. SiStress-related health problems affect individuals who have been exposed continuously to high levels of stress over a long time without having the possibility to recover and recuperate. This, in turn, can lead to the onset of Exhaustion Syndrome, which is a serious and long-lasting state. Exhaustion Syndrome is a fatigue-dominated diagnosis , which iBeginning in the 1990s, in Sweden, there has been a significant increase in long-term sick-leave that has a psychological basis , and, byStress-related health issues are, thus, not only a burden for more and more individuals, but have also become a significant socio-economic factor as well as an increasing strain on the healthcare system. Initially, research tended to focus on why people developed stress-related symptoms, but, since 2000, more time has also been spent on examining the consequences of contracting such problems ,25,26. RThere exists a long tradition of seeking both the assistance of nature to support health development  as well Studies, both quantitative and qualitative, have found that NBR can be helpful for decreasing symptoms of exhaustion, severe stress, depression and anxiety, increasing general psychological wellbeing and overall health, having a positive impact on restarting stalled rehabilitation processes and functioning in everyday life as well as increasing likelihood to return to work ,41,51,54The Attention Restoration Theory (ART) is relevant when it comes to cognitive recovery from stress and focuses on two types of human attention [Directed attention helps us to stay focused on a task, as “unnecessary” stimuli in the environment are disregarded and intense concentration is used. Soft fascination describes a form of effortless, spontaneous attention not controlled by will, but rather lands on things in the surroundings that do not demand our effort. Directed attention is seen as a limited resource that needs to be recharged, which is promoted in restorative environments—such as nature—where soft fascination occurs unconsciously [The Psycho-Evolutionary Theory states that humans have adapted to surviving in nature and, therefore, have positive reactions in such an environment [The Savanna Hypothesis argues that habitat preferences such as open landscape and closeness to water were formed during evolution as these facilitated survival, which is why these features are appealing to us still today [The Prospect Refuge Theory describes the optimal natural environment to be a protected area with a view. Such a place would have been advantageous in human evolution by providing both shelter with a possibility to hide and a lookout point to identify different kinds of danger or opportunities [The Biophilia Hypothesis, that states that humans have an innate ability and tendency to connect with nature and its inhabitants which has helped human survival [Theory of Supportive Environments (SET), that describes a connection between how the individual is feeling and what her needs are for the surrounding physical and social environment, especially in different stages of stress-related health issues [Common to the theories and hypotheses that underlie NRB is the assumption that being present, using all of our senses, in nature and interacting with animals can be of help in the promotion of health ,60,61,62ttention ,65. Diresciously ,66. The ironment ,67,68. Nironment ,67. The tunities . “Biophisurvival . A theorh issues ,71. The h issues ,73,74,75h issues ,76,77. Patients between the ages of 18 and 65 were referred to the program by their doctor from local healthcare centres, psychiatric outpatient units or occupational healthcare units. Referred patients were then invited for an assessment interview with a psychologist and an occupational therapist. The interview had two major aims: firstly, to inform the potential participant about the program to see if she was interested and, secondly, for the clinicians to assess if the patient and the program seemed to suit each other. The primary criterion to be admitted to the program was that the individual’s main problem was the presence of stress-related mental health issues (not including traumatic stress as a primary diagnosis), even if accompanied by secondary or simultaneous illnesses such as depression, anxiety or long-term pain. The level of illness had to be assessed to match the level of intensity in the program.The professional team consisted of a gardener , a licenced psychologist and a licensed occupational therapist, all of whom were knowledgeable about nature-based intervention and rehabilitation. The occupational therapist’s dog was also considered a member of the team and joined the group at the start of each day, during the breaks and at other times deemed suitable by the occupational therapist. As the team included licenced healthcare professionals, the program was classified as an MNBR-program, but is often referred to herein as simply NBR.The facility consisted of a house and a garden located beside a nature reserve. The house had the space needed for group sessions, a large work bench for nature-assisted activities, a room where the participants could retreat if they so wished, a kitchen and rooms for the staff.The nature incorporated in the program was chosen and designed with previous research in mind. The garden satisfied the suggestions offered by Grahn and Ottosson , containThe NBR-program was designed to help adults with stress-related mental health issues by providing a structured group intervention that aimed to improve their health in two major ways: through improving their ability to cope with the demands of their daily lives and through the experience generated by the consequences of their impaired resources. The program goals were to improve general health and quality of life for the patients; to reduce exhaustion symptoms; to improve mental and emotional health and to promote the ability to cope with the demands of everyday life. Group size varied between six and eight patients and the program was ten weeks in length. The participants came to the facility twice per week for three hours each time. These three hours were typically divided into two treatment modules, with a tea and coffee break in between. Three months after finishing the program, the group was invited back for a reunion around the fireplace in the facility’s garden. This can be thought of as a booster session that offered the patients an opportunity to meet and reflect upon their progress. The NBR-program was started in 2012 within the Swedish Healthcare System of the Jönköping Region in southern Sweden. As a consequence of staff changes in 2015, new structure and content were designed (described below). One of the changes was the introduction of self-assessment evaluation scales. These changes marked the starting point of this study’s timeframe. The programs’ psychological treatment was based on Cognitive Behavioural Therapy (CBT), which integrates cognitive psychotherapy and behavioural therapy based on the conception that we can increase our well-being by changing our thought and behaviour patterns ; AcceptaDuring the program, a group meets twice per week. Typically, Day 1 begins with a semi-structured group treatment followed by a walk in the surrounding nature, that includes a time for stillness and silence. Day 2 normally includes a nature-based activity and a walk in the surrounding nature, again including time for stillness in silence. During the coffee break between the two sets of activities, the patients can choose to socialise with the other group members, the leaders or the dog, or to find their own space and sit by themselves. The group treatment consists of eight semi-structured sessions led by the psychologist . The very first day is designed as an introduction to the program and the time is used by the occupational therapist to introduce theories underlying occupational therapy. Self-assessment scales, described below, are filled in on this first day. The occupational therapist and the psychologist share responsibility for Day 1 and both are always present for the activities that follow the group treatment sessions. The nature-based activities typically consist of gardening, activities in the forest, animal-assisted activities led by the gardener or nature-assisted occupational therapy led by the occupational therapist, which will often reflect the different seasons. Some examples are picking apples, making apple juice, carving pumpkins, making Christmas decorations out of pine branches, planting seeds or cuttings, digging in flower beds or vegetable plots, wood carving, hiking and gathering around a fire, dry-felting and meeting horses, calves or guinea pigs. Depending on the group’s needs, the occupational therapist may use one of these days or parts thereof to discuss theoretical aspects of occupational theory with the group. The occupational therapist and the gardener together have responsibility for Day 2 and are both always with the group, while the psychologist is often on hand and ready to assist. The aspect of nature chosen each time for activities and walks was decided using Grahn’s pyramid, coupled with the information that the team gathered from the participants concerning their current state ,71. For At the end of the rehabilitation program, each patient, the occupational therapist and/or the psychologist met with the patient’s referring doctor and other relevant agents such as their employer, Social Insurance Agency Officer or Employment Agency Officer to participate in discussions concerning possible rehabilitation plans. The self-assessment scales were filled in again by the patients on the last day of the program, together with an evaluation form that included a patient satisfaction Likert scale. At the booster session, the same scales were once again filled in, and a six-month follow-up was sent to the patients via mail.The main aim of this study is to investigate the effect of a specific NBR-program for adults with Exhaustion Syndrome. This was achieved by investigating patients’ quality of life, exhaustion symptoms and overall health using self-assessment instruments, comparing the results before participation to immediately after, three months after and six months after. A further aim is to find out to what extent the patients were satisfied with the program. To determine this, results from a client satisfaction survey were studied. The participant were patients that attended the NRB-program as part as their healthcare for Exhaustion Syndrome. The age span was between 27 and 63 years, with a mean age of 43.9 years. In all, 68% (SD = 9.7) of the participants were between 33 and 53 years of age; 91% of the participants identified as female and 9% as male. To be included in the study, the patient had to have attended at least half of the program/scheduled sessions and filled in the self-assessment scales at the start and the end of the program.On the whole, 113 patients attended the first 16 groups, which were chosen to be included in the study. Of these, 93 had attended at least half of the scheduled sessions and completed the self-assessment scales both at the beginning and at the end of the program and were, therefore, considered eligible for the study. The 93 patients were given written information about the study as well as a consent form and were asked if they wanted to participate. Of the eligible participants who were asked for their informed consent, 5 declined and 21 did not reply; 67 of the patients gave their informed consent and are included in this study. Further to this, 61 participants had completed at least one of the self- assessment scales at the three-month follow-up and at 44 had completed at least one of the self-assessment scales at the six-month follow-up.When the NRB-program was first started, a decision was made to include validated self-assessment scales as part of the clinical routine in order to continuously monitor patient health, to obtain feedback on the clinical work and to help to evaluate and improve the program. The first group was used as a pilot project. The scales were distributed four times: on the first and last days of the rehabilitation program and three and six months after completion of the program. Participants were asked to complete the evaluation form on the last day of the program. The scales chosen were EQ-VAS , BrunnsvShirom–Melamed Burnout Questionnaire (SMBQ) is a quantitative self-rating scale that is designed to explore the incidence and degree of a burnout syndrome. It consists of 22 items, divided into 4 sub-scales: Physical Fatigue (8 items); Cognitive weariness (6 items); Tension (4 items) and Listlessness (4 items). Each item is rated using a seven-point scale ranging from 1  to 7 . Five of the items have a reversed scoring . For each sub-domain, the average is calculated by dividing the score by the number of items. The average for all 22 items is called the SMBQ-Global. The cut-off point for SMBQ-Global is 3.75, where high  burnout is indicated by a score ≥ 4.47 and low  burnout by a score of ≤2.75. The cut-off point for the non-clinical population is 3.75; Cronbach’s alfa: a = 0.91 [a = 0.91 . The vala = 0.91  and it wa = 0.91 . SMBQ haa = 0.91 . SMBQ haa = 0.91 ,88,89.Brunnsviken Brief Quality of Life Scale (BBQ) is a self-rating scale designed to quantify the individual’s subjective experience of her life-quality. It was developed from the more extensive self-rating questionnaire “Quality of Life (QOLI)” [ (QOLI)” , to make (QOLI)” . Maximis (QOLI)” .EQ-VAS is a self-rating scale where the respondent judges the quality of her present health by making a cross on a vertical scale that starts at the bottom with 0  and goes up to 100 at the top  [ health) . In this health) . Studies health) .In addition, the patients were asked to fill in an evaluation form, created within the program, that asked questions regarding how they had experienced the program, what they thought was of value and not of value, what they thought could have been different and what they appreciated. A Likert scale regarding client satisfaction with the program was added to the evaluation and the four choices offered were “completely satisfied”; “mostly satisfied”; “mostly dissatisfied” and “completely dissatisfied”. The Likert scale was included in this study.Some of the data from the self-assessment scales and the client satisfaction Likert scale were collected before a decision was made to analyse it, and consent was sought by mail from these patients. After the formal decision was taken, those patients who subsequently applied to participate in the program were given both the relevant information and the consent form by hand. The 26 patients that declined or did not reply all belonged to the group where consent was sought retrospectively. p-value and effect size (Cohen’s D) were calculated [t-test analysis is performed on these kinds of instruments instead of a Wilcoxon analysis, it could be argued that it would be favourable here as well to be able to make easier comparisons. For this reason, a t-test was also carried out for each of the calculations. For each operation, answers from each set of questionnaires were compared, showing how many of the scores went up or down or remained the same between measurement times. Age was correlated with outcome, using Spearman’s rho [For each of the three instruments used, a Wilcoxon analysis was carried out using SPSS version 27. The Wilcoxon analysis was chosen, as the instruments consisted of ordinal scales, meaning the participant estimates an experience and equidistance between the options cannot be guaranteed. For each of the instruments, the results from the first questionnaire (before starting participation) were compared with the results from the second questionnaire (at the end of the program), then the third (three months after the end of the program) and then the fourth (six months after the end of the program). Comparisons were also made between the results of time 2 and times 3 and 4; in the same way, the results of time 3 were compared to time 4. Median with the statistical dispersion of quartiles, lculated . As it ian’s rho . Gender p < 0.01. Considering the number of tests performed, to avoid mass significance, it was decided to sharpen the level of significance to The evaluation form was designed to obtain feedback regarding the clinical work and anonymity was guaranteed. Using the Likert scale, the patients made a qualitative assessment of the NBR-program. Calculations were made of how many answers were received for each category. However, anonymity meant that we could not match specific answers with specific patients; thus, from the total number of replies (93), there were 26 forms we did not receive permission to use. Therefore, we could not analyse the results in great detail.When the self-reported data obtained from the participants before they began the program are compared to the data obtained directly after the 10-week program, statistically significant improvements regarding their overall health, their quality of life and their exhaustion symptoms are revealed. We could also see a statistically significant improvement in those same areas when comparing the data from before joining the program to that obtained three months after completion of the program. The same held true when comparing the data from before attending the program to data collected six months after finishing the program, which suggests that the improvement lasted over time. Below, we present our findings in more detail.p < 0.01) are presented in Improved score, No change in score and Worsened score were used, with Improved score having the highest percentage for all comparisons.A significant difference in result scores was found when comparing the results of VAS from the first day of the program to the last day of the program, three months after the program and six months after the program. Comparisons of median values at different measurement times and statistical significance (p < 0.01) are presented in Improved score, No change in score and Worsened score were used, with Improved score having the highest percentage for all comparisons.A significant difference in result scores was found when comparing the results of BBQ from the first day of the program to the last day of the program, three months after the program and six months after the program. Comparisons of median values at different measurement times and statistical significance (p < 0.01) are presented in Improved score, No change in score and Worsened score were used, with Improved score having the highest percentage for all comparisons. Even though a large part of the participants improved in health, we could also see that some did not experience any difference in measured health aspects, while some even experienced worse health.A significant difference in result scores was found when comparing the results of SMBQ from the first day of the program compared to the last day of the program, three months after the program and six months after the program. Comparisons of median values at different measurement times and statistical significance  and six months after the program (SMBQ6), where the Wilcoxon analysis shows a statistically significant decrease in symptoms but the t-test analysis only shows a strong trend in the same direction. The No significant correlations between outcome and age were found regarding overall health (VAS), as presented in Results obtained from the first day of the program, regarding quality of life (BBQ1) and six months after completion of the program (BBQ6), show a significant correlation between lower age and higher life-quality six months after finishing the program, as presented in No significant correlations between outcome and age were found regarding exhaustion symptoms (SMBQ), as presented in The Likert scale used to measure patient satisfaction with the program showed that all patients reported that they were either “completely satisfied” or “mostly satisfied”. As stated above, we had no way to accurately determine which answers came from which patient. Therefore, we cannot accurately state how many in each answer category were generated from the group of patients who had given their permission, but, as all of the forms reported that they were either “completely satisfied” or “mostly satisfied”, this was also true for those patients who gave permission.The study shows positive results, but, even though a large percentage of the participants had improved in health, we could also see that some did not experience any difference in measured health aspects, while some even experienced worse health. There are many possible ways of considering these results; they could, for example, indicate a poor match regarding the level of illness in invited patients and intensity of the program, or even that other important mediators were influential. One factor that could influence these results is that the program partially focuses on recognising one’s symptoms and accepting the reality of the illness—which could actually indicate progress from a clinical perspective. Though the results show that the health of the participants improved, because of the study design, we cannot isolate the causal factors responsible for change. As previously mentioned, the setting was not controlled for strict scientific research. Therefore, unknown factors can play a role both in improvement to and decline in the measured health variables, as in the general clinical population. As we did not have a control group, we cannot know how the results would compare to no treatment or treatment as usual.A significant correlation between outcome and age was found. This suggests that the age factor might play a role in the positive outcome of higher life-quality, but this needs to be investigated further for any conclusions to be drawn. With a larger study sample and more participants in different age groups, as well as gender groups, we could possibly obtain more correlations. As this is an actual clinical setting, it is interesting to observe what age and gender groups are referred to this kind of program. It raises questions concerning the onset of stress-related illness, as well as whom is identified as a candidate for the program in the healthcare system. The results from the evaluation form shows that all participants were completely satisfied, or mostly satisfied, with participation in the program. Due to the study design, we cannot present how many were in each category, which would have been desirable.Although Exhaustion Syndrome can vary in severity, rehabilitation often takes a relative long time. The results in this study measure change after participation in a 10-week program where patients take part 2 times per week for 3 h. Previous studies show that three of the documented and better-known programs in Sweden included the following variations: 28 weeks (16 weeks with the possibility of 12 more weeks) at 4 half-days per week ; 14 weekThe study was carried out as an examination of an established real-world clinical setting, a naturalistic field study, as opposed to a program designed for research. From a pure methodological perspective, this involves certain limitations in comparison to the “gold standard” for research, as the study had no control group or randomisation. Also, there was a broad criterion for patient group selection in the already existing program, which, by extension, was also true for the participants in the present study. On the other hand, it is of interest for, amongst others, caregivers, consumers, politicians and taxpayers to look at clinical programs that are established parts of the existing healthcare system. The idea to study the program was introduced by one of the team members after six patient groups had participated, which can be seen as a possible source of bias, even though that team member then stopped working with the program to carry out the research. The instruments were chosen to examine the effectiveness of the clinical setting, with no future study in mind. Afterwards, it is obvious that, for research purposes, it would have been interesting to collect more data. When it comes to the qualitative method, limitations occurred when using the data for research purposes rather than clinical purposes as the material was collected anonymously and, therefore, could not be very precisely presented. It would have been desirable to be able to present the number of answers in each Likert category rather than presenting them in broader terms; if it would have been designed for study purposes to begin with, this could have been solved. The three instruments used in this study all have satisfying validity and reliability. The reliability for BBQ is on the lower side, but, as it is considered to be as good as its widely used predecessor QOLI, we felt comfortable including it in the study.It would have been interesting to include more qualitative results from the questionnaire in the study and/or to complement them with interviews. This would have given a deeper insight into the participants’ experience and might have shed some light on perceived mediators. For example, the participants reported that it was of benefit to meet people in similar situations to their own, to participate in a structured activity while on sick-leave and to learn how they themselves could incorporate elements of nature into their everyday life to continue to improve their own health.This research shows that participation in the program led to a higher quality of life, lesser exhaustion symptoms and improved overall health. The results were still statistically significant three and six months after finishing the program. From a public health perspective, and with background knowledge of the nature of the patient group under treatment, the studied program would appear to be both economical and effective. It has both a satisfied patient group and favourable comparison with the outcomes of other research programs. Nature-based programs are, in a modern sense, in their infancy, but the kinds of results shown in this study are promising and would seem to justify further investigation. The three major areas suggested for future research are the need for randomised controlled studies to establish if this kind of program is superior to no treatment and/or superior to or as good as treatment as usual treatment; investigation of what variables contribute to the positive change; longitudinal studies to investigate if the positive outcomes stand the test of time beyond six months after finishing such a program. It would be beneficial to, in addition to self-assessment scales and interviews, measure brain activity and cortisol levels.


Pharmaceutical care in community pharmacies has been shown to improve adherence to chronic therapies. Long-term impact on clinical outcomes or medical cost savings, however, remains understudied.To estimate the cost-effectiveness of a pharmaceutical care intervention program in Dutch community pharmacies that improved patients’ adherence to lipid-lowering therapy.An economic evaluation was performed using a time-dependent Markov model from the health care payer perspective. Participants were patients initiating lipid-lowering therapy for primary prevention (40%) or secondary prevention (60%) of cardiovascular events (CVEs). The intervention was the pharmaceutical care program MeMO (Medication Monitoring and Optimisation) in 9 community pharmacies in the Netherlands, based on continuous monitoring and optimization of lipid-lowering therapy in new patients. The follow-up period of the program was 1 year. The main outcome of the intervention program was discontinuation of lipid-lowering therapy. This outcome was extrapolated in the economic model to lifelong costs, quality of life, reductions in cardiovascular events, and incremental cost-effectiveness ratios.Patients in the MeMO program had a lower risk for therapy discontinuation, RR = 0.49 (0.37 to 0.66); the effectiveness was similar in primary and secondary prevention. In a cohort of 1,000 primary and secondary prevention patients, the MeMO program resulted in a reduction of 7 nonfatal strokes, 2 fatal strokes, 16 nonfatal myocardial infarctions (MIs), 7 fatal MIs, and 16 revascularizations over patients’ lifetime. Additional medication, disease management, and intervention costs in the MeMO program were €411,000; the cost savings due to reduced CVEs were €443,000. The MeMO program resulted in 84 quality-adjusted life-years (QALYs) gained and net cost savings of €32,000. Clinical benefits and cost savings were highest in the secondary prevention population.Pharmaceutical care in community pharmacies can improve statin therapy adherence, resulting in better prevention of CVEs. The MeMO program resulted in considerable clinical benefits and net cost savings. Programs by community pharmacies targeted at improving adherence may provide good value for money, and health care insurers should consider reimbursing these activities.


Statistical analysis using the t-student and Wilcoxon signed-rank tests for paired data is performed with SPSS 26 and R Statistical software. The significance level is established at p < 0.05; (3) Results: cryobiopsies were valid for diagnosis in 25 of 27 patients, with a maximum average size of 3.5 ± 0.7 mm. A total of 18 samples (66.67%) were positive for malignancy and 9 (33.33%) were benign. The tumor percentage measured in all neoplastic samples was greater than 30%. The average DNA and RNA extracted in nine non-small cell lung cancer cases was 97.2 ± 22.4 ng/µL and 26.6 ± 4.9 ng/µL, respectively; (4) Conclusions: the sample size obtained from an endobronchial ultrasound-guided mediastinal transbronchial cryo-node biopsy facilitates the morphological and histo-architectural assessment of inflammatory and neoplastic pathology. It optimizes molecular tests in the latter due to more tumor cells, DNA, and RNA.(1) Background: endobronchial ultrasound-guided mediastinal transbronchial cryo-node biopsy, previously assisted by fine-needle aspiration, is a novel technique of particular interest in the field of lung cancer diagnosis and is of great utility for extrathoracic tumor metastases, lymphomas, and granulomatous diseases. An integrated histological and molecular diagnosis of small samples implies additional difficulty for the pathologist. Additionally, emerging tumor biomarkers create the need to search for new approaches to better manage the tissue sample; (2) Methods: An analytical observational study of 32 mediastinal node cryobiopsies is carried out in 27 patients ( Different conditions can cause mediastinal lymphadenopathies. Malignant pathology is commonly attributed to lymphomas and metastatic lesions associated with primary thoracic tumors, particularly lung and esophagus, which can spread to the mediastinal nodes . EndobroSeventy percent of non-small cell lung cancer (NSCLC) patients are diagnosed in advanced stages without any surgical options, and diagnosis is usually established through cytological samples and small biopsies ,5. The pEGFR, BRAF, KRAS, and MET, as well as ALK, ROS1, NTRK, and RET translocations and PD-L1 expression levels. If NGS is available, the detection of emerging immunomarkers such as HER2, MSI, STK11, KEAP1, or TMB should be considered. Therefore, pathologists need to handle samples obtained from patients with lung cancer in a specialized, systematic, and directed way to make them profitable for diagnosis while preserving tissue for molecular determinations  . NGS was performed with “Panel Archer FusionPlex Sarcoma” . Detection of t was performed using break-apart FISH.The molecular biomarkers  and SPSS version 26 .A descriptive study was conducted to examine the characteristics of the population and technical parameters of the biopsy, namely, needle size, sample size, number of fragments, diagnoses made, percentage of tumor cells, and DNA and RNA quantification. Measures of central tendency, including mean and standard deviation, were used for quantitative variables, while frequencies and proportions were utilized for qualitative variables. Student’s The study was conducted following the Helsinki Declaration guidelines. The participants were given informed consent, and their data were pseudonymized for biomedical research purposes. The study has been approved by the provincial research ethics committee of Almería (code: 25/2023).The study analyzed 27 patients and conducted 32 mediastinal lymph node cryobiopsies, and 29 were valid for diagnosis. The remaining three were limited to the lymph node capsule corresponding to perinodal soft tissues, with two biopsies belonging to the same patient. All lymph nodes were larger than 10 mm.Eighteen (66.67%) patients had malignant neoplasms: twelve had primary lung tumors and six had extrathoracic malignancies. The remaining nine patients (33.33%) were diagnosed with inflammatory conditions . All malignant neoplasms had a tumor cell percentage exceeding 30%. The histological diagnoses in the cryobiopsies and the diagnostic categories assigned in the EBUS-TBNA  are listThe histo-architectural characterization in the 29 cryobiopsies had higher definition and resolution than in the cell blocks produced through the associated EBUS-TBNAs .Out of the 12 cryobiopsies conducted for lung malignancies, nine NSCLC (eight adenocarcinomas and one large cell neuroendocrine carcinoma) were valid for RT-PCR and PD-L1 IHC testing, leaving the EBUS-TBNA material for IHC determinations (p40 and TTF1). Only PD-L1 was determined in one squamous NSCLC, as age did not require other biomarkers to be tested. No ancillary biomarker determination was tested in the two small-cell neuroendocrine carcinomas.The associated bivariate analysis in EGFR mutation  with remaining native biomarkers; one adenocarcinoma with NTRK mutation (NTRK3ex15) with remaining native biomarkers; six adenocarcinomas and one large cell neuroendocrine carcinoma with native EGFR, BRAF, ALK, ROS1, RET, MET, and NTRK. PD-L1 immunohistochemical expression levels in the 10 NSCLCs, including one squamous cell carcinoma, were 80% (1), 20% (1), 15% (1), 5% (3), and <1% (4). Other molecular results included three melanomas: two with a BRAF V600 mutation and one with native BRAF V600 and one sarcoma. NGS was targeted to simultaneously detect and identify the fusions of 26 genes  associated with soft tissue cancers from negative patient RNA. SYT FISH   translocation was used for synovial sarcoma along with a break-apart probe (negative). Cryobiopsies performed on small cell lymphocytic lymphoma and urothelial carcinoma metastasis were combined with EBUS-TBNA samples for flow cytometry (only for lymphoma cases) and IHC (in both cases). EBUS-TBCNB samples in all non-tumor lesions allowed for the planning of IHCs and histochemical (HCs) studies. The needle size did not affect the measurements. No complications were detected in the 32 EBUS-TBCNBs.Molecular results were as follows: one adenocarcinoma with This study shows the results of 32 cryobiopsies performed in different mediastinal lymph node stations in 27 patients for one year, highlighting the pathologist’s assistance with interventional pulmonologists during EBUS-TBNA with EBUS-TBCNB procedures and emphasizing the relevance of adequate management and the optimization of the samples obtained in both methods. In lung cancer diagnosis, the pathologist usually handles cytology or small biopsies wherein the tumor fraction and percentage of viable tumor components are limited for a comprehensive morphophysiological and molecular diagnosis ,6. AdvanQuality samples become essential for obtaining histological and molecular guarantees in cases of lung cancer ,5. In thTransbronchial cryobiopsy samples, due to their larger size, allow the pathologist to recognize the histoarchitecture and better interpret histological patterns in an adequate clinical-radiological context. Additionally, in malignant neoplasms, they help obtain a percentage of tumor cells valid for molecular tests ,17.Our EBUS-TBCNB series is one of the largest published ,11,13. TDepending on the diagnostic suspicion, the need for complementary studies for molecular studies is assessed, especially in the second approach: the pathologist assesses the validity of the EBUS-TBNA samples. Together with the pulmonologists, they decide whether EBUS-TBCNB favors a more precise and comprehensive diagnosis. In our series, the same pathologist managed the EBUS-TBNA study and the cryobiopsy fragments.In 22 patients, the pathologist assisted in ROSE, and cryobiopsy was decided when the possible diagnostic limitations were verified to determine if they exclusively handled the material obtained in EBUS-TBNA. Within the five cryobiopsies without previous ROSE, two had a high suspicion of small cell neuroendocrine carcinoma, wherein the molecular needs were not so demanding, and three cases already had a previous diagnosis (two NSCLC and one inflammatory), directing the EBUS-TBCNB for molecular determinations and histological diagnosis.EBUS-TBNA is a minimally invasive technique that achieves good results and diagnostic yield in lung cancer and malignant neoplasms in hilar and mediastinal nodes > 95% and 80% of the samples that are suitable for IHC and molecular testing ,18,21. FThe diversity of samples combining EBUS-TBNA and EBUS-TBCNB allows the pathologist to manage and make the material profitable in a targeted manner. In lung cancer, it facilitates the application of the recommended molecular test guidelines. In other pathologies, it favors the planning of complementary studies . These dCryobiopsies in cases of granulomatous diseases versus EBUS-TBNA cellblocks offer a more complete architectural morphological histological study. In neoplasms, morphologic and IHC diagnosis could be approximated on EBUS-TBNA cellblocks and cytology samples. EBUS-TBCNB better defined histologic patterns, secured tissue for expanded IHC panels, and warranted molecular studies. High-grade sarcoma was diagnosed using EBUS-TBCNB; EBUS-TBNA oriented toward mesenchymal neoplasm, category VI . Using IEBUS-TBCNB did not generate any relevant complications, which aligns with the literature ,16,17,19Applying cold with the cryoprobe (3–4 s) probably poses a challenge in preanalytical DNA and RNA extraction and analysis. However, the biomarker determinations in our series, which were based on RT-PCR and NGS, have not been compromised, as in previously published series ,17,18,19It is also important to consider that EBUS-TBNA and EBUS-TBCNB obtain samples from the same patient; therefore, they complement each other. Cryobiopsies, being larger and having a higher percentage of tumors (>30%), are especially valuable for molecular studies. If the percentage of tumors exceeds 30% in cryobiopsies, it makes them valid even for NGS, which is sometimes difficult to ensure in cell blocks.On the one hand, the most relevant limitation of this study is the potential selection bias. The available data guarantee no clear confounding bias if results are extrapolated to populations with inclusion criteria superimposable to those cited. On the other hand, this is the first study to compare EBUS-TBCNB versus EBUS-TBNA from the pathologist’s point of view. It is worth noting that the findings presented in this report should be approached with caution due to the limited number of available samples, mainly due to the novelty of the technique. Nevertheless, given that this study has demonstrated promising results, it would be interesting for future research to compare their findings with ours to further validate the techniques used.EBUS-TBCNB can be a complementary technique to EBUS-TBNA. A larger sample size allows a histo-architectural reading that facilitates the pathologist’s diagnosis of mediastinal neoplastic and inflammatory nodal disease. A higher percentage of tumor cells in cryobiopsy with high-quality DNA and increased RNA quantities ensures greater cost-effectiveness for molecular studies, adding value to NSCLC that can be used to address emerging biomarkers. This procedure is fast, minimally invasive, and avoids the need for re-biopsies.The pathologist’s management of samples in situ in EBUS-TBNA facilitates the decision of whether a patient benefits from EBUS-TBCNB. Our results, obtained from the pathologist’s perspective, something that has been previously undocumented, support the incorporation and standardization of this technique to optimize morphologic and molecular diagnoses in cases of mediastinal adenopathies. Future studies could compare their findings with ours.


Significant increased knowledge scores were reported for all specified subdomains after the course with an increase in academic interest in cardiology (p = < .001) and cardiothoracic surgery (p = < .001). Students revealed that clinical responsibilities and a healthy work-life balance were considered most important when deciding upon their future career. This study highlights the benefit of an extracurricular education program in cardiothoracic surgery and cardiology for undergraduates and could possibly aid students in preparing for clinical practice.Medical students in the Netherlands have a relatively low exposure to cardiothoracic surgery and cardiology. This results in discrepancies between starting levels of medical residents and expected standards in clinical practice. Another side effect is the international decline in interest in a career in these cardiovascular fields. To compensate for this, extracurricular education programs focused on cardiothoracic surgery and cardiology have been set up. This study aims to evaluate the impact and benefits of an extracurricular education program on students' knowledge of cardiothoracic surgery and cardiology and to explore possible factors involved in (academic) career decision making. 66 participants were enrolled in the extracurricular education program VECTOR and were included in a cross-sectional cohort study. All participants scored their familiarity with different aspects of cardiothoracic surgery and cardiology prior to and after the course. Data was analyzed using Linear regression and Wilcoxon Signed Rank testing. Participants demonstrated a significant trend towards improved familiarity with cardiothoracic surgery and cardiology after the program (The online version contains supplementary material available at 10.1007/s10916-023-01988-3. Starting medical residents are amongst the first healthcare professionals to provide initial hospital care in the challenging medical specialties of cardiothoracic surgery and cardiology. Therefore, adequate basic knowledge of this population is essential to guarantee quality of care.In the Netherlands, medical training starts with 6 years of study in medicine. The first 3 years are focused on foundational knowledge of all medical specialties. The last 3 years consist of clinical rotations and research. In the whole curriculum of medical school, only 5% of all training is spend on cardiovascular medicine . FurtherThis affects both the interest of students in cardiovascular medicine and the starting level of beginning medical residents. For example, student interest in pursuing a career in cardiothoracic surgery has been declining internationally for several years now , 3, and To fill the gap between knowledge provided in medical school and the obvious higher standards in clinical practice, several initiatives have been taken by students and young physicians facilitating extracurricular education in cardiothoracic surgery and cardiology. One of these initiatives is VECTOR . VECTOR Earlier studies have shown the benefits of extracurricular courses in plastic surgery, medical anatomy programs and nursing education –9. HowevThis is a cross-sectional study. 66 participants were included, that attended the VECTOR extracurricular course during the academic year 2021–2022. All participants were asked to fill in a custom questionnaire at the end of the program, consisting of 10 statements. This non-validated questionnaire can be found in p < 0.05.Statistical analyses were performed using IBM SPSS Statistics 28.0 software for Windows. Categorical demographic data is reported as frequencies and percentages, whilst non-normally distributed continuous variables are displayed as a median with corresponding interquartile range. Using the Likert-scale, students indicated their familiarity with the topics in the course. Data from the questionnaire was considered ordinal with each category representing a different value ranging from 1 to 6 . The higher the score, the greater the student’s insight in this topic. The overall effect of the extracurricular program was evaluated using a Linear Regression analysis. In addition, sub-analyses were performed using Wilcoxon Signed Rank testing. For all analyses, results were considered statistically significant if Written informed consent was collected from all patients. All data remained anonymous and participation was completely voluntary.Data from 66 participants taking part in the VECTOR program was collected. Baseline characteristics can be found in Table B = 6.89 [5.80 – 7.99]; p =  < 0.001; R^2 = 0.55).For all participants, cumulative scores for all statements were calculated prior to and after the course. This included scores related to student’s knowledge about cardiothoracic anatomy, common cardiovascular diseases, ECG interpretation, clinical duties of cardiovascular specialists and relevant (scientific) developments within the field of cardiothoracic surgery and cardiology. Participants demonstrated significantly increased scores after participating in the program (p = 0.348).Linear regression analysis with adjustments for sex revealed no significant difference in overall scoring between males and females (p = 0.29). After adjusting for sex and study-year, participants still demonstrated a significant trend towards improved knowledge standards after the program , implying that the program contributed to a significant increase in cardiovascular knowledge regardless of study year at baseline.To investigate if study year was a significant effect modifier in this association, participants were dichotomized into two groups: Bachelor students  and Master students (year 4 and 5). Based on the p-value of the corresponding interaction term, discrepancies in study year did not result in significant differences in Likert-scale values after the course (Mdn = 4), common cardiovascular disease (Mdn = 4) and clinical duties of cardiovascular specialists (Mdn = 4) appeared to be more familiar topics prior to the program compared to interpretation of ECG’s (Mdn = 3). and relevant developments within cardiovascular medicine (Mdn = 2).Cumulative scores for all aspects of the program are visualized in Fig. r > 0.50). Largest improvement was shown in awareness of relevant developments within the field  followed by knowledge on common cardiovascular diseases and their appropriate diagnostics and management . Students also significantly improved their ability to interpret ECG’s  and showed similar advancements in knowledge about cardiothoracic anatomy  and clinical duties of medical specialists .Differences in student’s knowledge prior to and after the program are presented in Table Mdn = 5 and total score = 329; Mdn = 5).Differences between interest in scientific research prior to and after the program are visualized in Fig. Wilcoxon Signed Rank testing demonstrated that Likert-scale scores related to pursuing an academic career had significantly increased for both cardiothoracic surgery (effect size r = 0.45) and cardiology (effect size r = 0.53) after the program . Whether the profession would offer an appropriate salary (14%) or whether it was possible to pursue an academic career (15%) seemed less important. Social status (9%) and difficulty of being accepted into a residency program 13%) were considered least important in decision-making. Results are displayed in Fig. % were coThis study shows the benefits of an extracurricular education program in cardiothoracic surgery and cardiology for undergraduates. A significant increase was seen in all specified course topics after following the program, ranging from anatomical knowledge to etiology, diagnostic methods and (scientific) developments in the respective fields. Linear regression analysis showed that the increase in score was universal when stratified by study phase , highlighting the benefit of this program regardless of study year at baseline. There were no significant differences in scores between men and women.Students reported a significant increased interest in scientific research in cardiothoracic surgery and cardiology after following the program. This showcases a potential advantage for departments of cardiothoracic surgery and cardiology to attract talented and ambitious undergraduates for clinical research.With regards to declining interest in cardiothoracic surgery in the past years, medical departments might be interested to learn what factors influence students to choose a career path. Our findings show a strong preference towards clinical duties and a healthy work-life balance. This suggests that departments might benefit from diverting their recruiting efforts by providing students with a clearer understanding of what their specialty entails. Also, students may be more interested in pursuing a career in cardiothoracic surgery or cardiology when a decent work-life balance can be attained. Salary and academic opportunities also seem to be of importance in career-decision, but to a lesser extent than the aforementioned factors.The most important limitation in this study is the limited number of participants. For this reason, regression analysis was performed using dichotomized variables for study year to decrease the margin of error and increase the study power. Another limitation involves the self-reported outcome measures by participants which might have influenced results. Participants completed the questionnaire after following the course. As this questionnaire contained elements of the participants’ own perceived knowledge prior to the course, it is likely that this bias affected scores at baseline. However, the cross-sectional design of our study might have improved score accuracy, as students gained better insight of what they did not know prior to the course. This cognitive bias phenomenon is known as the Dunning-Kruger effect . This miMoreover, this study employed a non-validated questionnaire to gather data about participants' engagement in the extracurricular program. The goal was to assess the program's effects on students' knowledge, practical skills, and interest in cardiology and cardiothoracic surgery. Although the questionnaire was customized to address the relevant research questions, this approach could have introduced limitations with regards to result interpretation. It's worth noting that validated questionnaires tailored for medical education are currently lacking. To improve the robustness of findings, future investigations could bolster methodological precision by formulating and validating a questionnaire aligned with specific study parameters in this context.In the future, a longitudinal study is needed with a larger number of participants that explores students’ interest in cardiothoracic surgery and cardiology over the years and follows their career choices. This will display long term results and confirm potential benefits of an extracurricular educational program in cardiothoracic surgery and cardiology.In conclusion, our findings suggest a beneficial effect of an extracurricular education program in cardiothoracic surgery and cardiology for undergraduates. We recommend departments of cardiothoracic surgery and cardiology and university faculties to implement a comparable program in their standard curriculum to motivate talented and ambitious students towards the field of cardiovascular medicine and improve the starting level of clinical care in cardiothoracic surgery and cardiology among beginning medical residents.Supplementary file1 (PDF 113 KB)Below is the link to the electronic supplementary material.


ARID1A mutation status had an impact on therapeutic responsiveness in gastric cancer (GC), especially combinatory chemo-immunotherapy.AT-rich interaction domain 1A (ARID1A) encodes a vital component of switch/sucrose non-fermentable chromatin-remodeling complex. Given its association with genomic instability, we conducted this study to determine whether ARID1A-mutant GC based on tissue samples and sequencing data, respectively. MSKCC Cohort, mGC Cohort, and Melanoma Cohort were utilized to interrogate the predictive efficacy of ARID1A mutation to programmed cell death protein 1 (PD-1) blockade.We retrospectively enrolled a total of 1162 patients from five independent cohorts. ZSHS Cohort and TCGA Cohort were designed to inform chemotherapeutic relevance and immunobiology of ARID1A mutation was enriched in EBV-positive, hypermutated-single nucleotide variant and microsatellite-unstable subtype GC, and was predictive of responsiveness to both fluorouracil-based chemotherapy and PD-1 blockade. Specifically, ARID1A mutation score was a highly sensitive indicator (91%) of response to pembrolizumab. Mechanistically, ARID1A mutation correlated with extensive DNA damage repair deficiency and immunogenic tumor microenvironment (TME) featured by elevated activated subsets of CD8+ T cells, CD4+ T cells, and NK cells. Type 17T helper cells were typically abundant in ARID1A-mutant GC and might be a precondition for chemosensitivity conferred by ARID1A mutation. Furthermore, ARID1A mutation indicated elevated expression of VEGFA and CLDN18, as well as over-representation of ERBB2 and FGFR2 signaling pathway.ARID1A-mutant GC displayed immunogenic TME and might be a candidate for both monotherapy and the combination of frontline chemotherapy and PD-1 blockade.The online version contains supplementary material available at 10.1007/s00262-022-03326-x. Currently, surgical resection and conventional chemotherapy remain the standard-of-care treatment for gastric cancer (GC) patients Only patients with coordinated tumor genomics and immune microenvironment (TME) may gain maximum benefits from either chemotherapy or immunotherapy ARID1A, ARID2 and PBRM1 are crucial in maintaining genome fidelity and orderly gene expression, whereas they frequently mutate across human malignancies ARID1A (AT-rich interaction domain 1A) mutation affects around 25% of GC patients ARID1A generally promotes tumor progression ARID1A mutation is predictive of response to immunotherapy in metastatic urothelial carcinoma and even performs better when combined with CXCL13, a chemokine for B cell recruitment ARID1A deficiency is associated with flawed DNA damage repair (DDR) processes ARID1A mutation in GC.A chromosome is a reservoir where genetic information resides on. Any tiny modification in the chromatin structure may impact on the cell behavior. Assembled by diverse subunits, switch/sucrose non-fermentable (SWI/SNF) chromatin-remodeling complexes take the responsibility to determine the positions of nucleosomes ARID1A mutation predicted improved efficacy of both fluorouracil-based chemotherapy and PD-1 blockade in GC. ARID1A-MUT tumors were highly immunogenic and abundant in activated immune infiltrates. More interestingly, Th17 cells functioned as a precondition for chemosensitivity conferred by ARID1A mutation. Therefore, by upregulating Th17 infiltration, PD-1 inhibitors might plausibly sensitize previously unresponsive GC to chemotherapy. Conclusively, somatic ARID1A mutation should be recognized as a crucial molecular parameter to guide treatment selection, especially for screening GC patients that are potentially responsive to combinatory chemo-immunotherapy.In this study, we found that This study recruited overall 1162 patients from five cohorts , included one tissue-sample-based ZSHS Cohort (Supplementary Table S1), and four sequencing-based cohorts. The ZSHS Cohort originally enrolled 496 GC patients under the approvement of the Clinical Research Ethics Committee of Zhongshan Hospital, Fudan University . Between August 2007 and December 2008, the aforementioned patients, median aged 60 at surgery, underwent radical gastrectomy and standard D2 lymphadenectomy in Zhongshan Hospital. After surgery, resected fresh tissue samples were constructed as tumor microarrays  as previous described + cells in TMAs of ZSHS Cohort. Anti-ARID1A antibody  and anti-IL17A antibody  used in this study were purchased from Abcam. For deparaffinage, TMA slides were first baked in an oven at 60 °C for 6 h and then immersed in three washes of xylene. After that, TMAs were sequentially placed in graded alcohol from 100%, 95%, 85%, to 75% for rehydrating and then dipped into blockers buffer (ZSGB-BIO) to inhibit endogenous peroxidase. For antigen retrieval, slides were immersed in corresponding buffer solution and heated for 3 min as soon as the pressure cooker had reached full pressure. After blocked with 10% goat serum (ZSGB-BIO) at 37 °C for 2 h, the slides were subsequently incubated with prediluted primary antibody  at 4 °C overnight. Subsequent to reaction with HRP-labeled secondary antibody (ZSGB-BIO) for 30 min at 37 °C, slides were incubated with diaminobenzidine for color rendering . Next, TMAs were immersed into hematoxylin (Servicebio) for counterstaining. Ultimately, slides were washed in xylene for three times and mounted with coverslip and mounting medium (ZSGB-BIO). Detailed information of antibodies and other reagents used for immunohistochemistry was provided (Supplementary Table S2).IHC assay was conducted to evaluate ARID1A expression pattern and count intratumoral IL17AARID1A mutational status was performed according to several previous publications ARID1A mutation and reduced protein expression . Consequently, positive intranuclear staining of ARID1A in tumor cells was regarded as normal ARID1A expression , in corresponding to ARID1A wildtype (WT). In contrast, negative intratumoral ARID1A expression with positive staining of stromal cells was defined as deficient ARID1A expression , pointing to ARID1A mutation. Stromal cells were regarded as internal positive control + cells were defined as the average number of positive stained cells per HPF in three representative areas. Cut-off value of intratumoral IL17A+ cells, which was 46, was defined according to our previous study IHC images were evaluated by two experienced pathologists under a microscope at high-power field , both of whom were blinded to corresponding patient outcome. Evaluation of http://www.r-project.org/). All used software and R packages were listed (Supplementary Table S4). Briefly, TCGA (The Cancer Genome Atlas) Cohort with clinical, transcriptomic, genomic and pathway activity data were obtained from http://www.cbioportal.org and https://xenabrowser.net/ in August 2020 ARID1A mutational status or lack of vital status. Clinical and genomic data of Memorial Sloan-Kettering Cancer Center (MSKCC) Cohort were obtained from http://www.cbioportal.org in August 2021, baseline, treatment and survival data of which were presented in Supplementary Table S5 http://tide.dfci.harvard.edu/download/ in March 2021, baseline and treatment data of which were presented in a published study Inclusion and exclusion criteria along with key study procedures of the four sequencing-based cohorts were provided . Bioinformatic analyses performed in this study were generally based on R-4.0.3  and multivariate (adjusted) Cox proportional hazard regression were applied to discover the clinical significance. Patients with missing data were excluded from each statistical model.Chi-square and Fisher’s exact test were conducted with MedCalc Statistical Software version 15.6.1 . Remaining statistical analyses included in this study were performed by SPSS software version 23.0 (IBM SPSS). All conducted analyses were two sided, and N = 431), FAT4 mutation was the only one that conferred prolonged overall survival (OS) in both univariate  and multivariate Cox regression model . Nevertheless, when merely focused on patients with known chemotherapy information , the presence of FAT4 mutation no longer implied a trend toward improved OS.Existing molecular subtyping of gastric cancer is primarily based on overall genomic features including mutation density and chromosomal instability (CIN) ARID1A-MUT GC patients showed favorable OS compared with WT tumors when receiving chemotherapy . IHC staining of ARID1A was performed in our internal ZSHS Cohort to validate this finding . Consistently, deficient ARID1A predicted superior OS in patients with fluorouracil-based adjuvant chemotherapy , but not in patients who merely received surgical resection (Without Chemotherapy). Exactly, ARID1A mutation affected around 25% of GC patients and took the fourth place of top mutated genes. ARID1A mutation was generally co-occurrent with other mutations except TP53, while frameshift insertion or deletion consisted of a large proportion of ARID1A mutants .Instead, ARID1A mutation through differential gene expression and pathway analysis. Consequently, ARID1A-MUT GC showed a remarkable upregulation in IFN-gamma signaling related genes, including IFNG, CXCL9, CXCL10, CXCL11 and CD274 . Meanwhile, pathways reflecting cell cycle activity were also over-represented .We sought to characterize the underlying biological process affected by ARID1A mutation acted on DDR machinery ARID1A mutants suffered from extensive DDR deficiency, which included the deficiency of base excision repair (BER), nucleotide excision repair (NER), mismatch repair (MMR), homology-dependent recombination (HR), etc.  correlated with improved OS in GC patients with chemotherapy . Our prior study has uncovered the antitumor role of IL17 producing cells and its relation with chemotherapeutic sensitivity in gastric cancer ARID1A mutation and Th17 infiltration , but not in Th17low tumors. Similarly, when patients with top 30% Th17 infiltration were removed, ARID1A mutation was no longer predictive of chemotherapeutic sensitivity in GC  resulted in elevated Th17 infiltration , which encouraged us to uncover the linkage between ARID1A mutation and response to PD-1 inhibitor.We sought to elucidate the association between Th17 infiltration and chemotherapeutic sensitivity of sly Fig. A and consly Fig. B. As a rARID1A mutations were mainly enriched in EBV-positive (EBV+), microsatellite-unstable (MSI), and POLE-MUT  tumors   minus Z-score of downregulated genes (Log2 FC < − 2) ARID1A mutation score could not only mimic ARID1A mutational status with RNA-seq data, but also reflect the functional status of ARID1A mutants. In mGC Cohort, when combining ARID1A mutation score with TMB and MSI, there was superior sensitivity (91%) to capture ICB responders  Fig. B. To valARID1A mutation and known targetable alterations ARID1A mutants displayed significantly elevated VEGFA expression, ERBB2 signaling, FGFR2 signaling, and CLDN18 expression, yet equal EGFR signaling and c-Met signaling to WT GC tumors. Collectively, those findings might provide a roadmap for targeted therapy selection in GC patients.Additionally, we assessed the association between ARID1A mutation has been explored as a predictor of immunotherapeutic responsiveness in metastatic urothelial carcinoma and pan-cancer analysis ARID1A-MUT GC as a molecularly distinct subtype with immunogenic TME and broad therapeutic targets.ARID1A-MUT GC patients could benefit from both chemotherapy and PD-1 blockade. ARID1A mutation affected almost 25% of GC patients and was the only one to inform chemotherapeutic responsiveness across the top ten mutated genes. This finding strongly encourages us to supplement ARID1A mutation as a crucial parameter in future molecular subtyping of GC. Notably, when combining ARID1A mutation score with TMB and MSI, 11 out of 12 responders in mGC Cohort were successfully predicted. If confirmed in larger-scaled prospective clinical trials, ARID1A mutation score may function as a highly sensitive indicator to screen possible ICB responders.Several insights were gained from our research. First, we showed that ARID1A mutation might serve as a novel biomarker for chemotherapy plus PD-1 blockade. ARID1A mutation was prevalent in all five TCGA molecular subtypes. While MSI subtype GC and POLE-MUT patients with high TMB were likely to benefit from immunotherapy, existing evidence suggests they may not be suitable for chemotherapy ARID1A mutational status might be a solid mean to enable beneficial chemo-immunotherapy. Moreover, given PD-1 blockade resulted in elevated Th17 infiltration, prior immunotherapy to shape a “chemotherapy friendly” TME might augment chemotherapeutic benefits for ARID1A-MUT patients. Thus, our study even implied the feasibility of executing PD-1 blockade—chemotherapy sequential treatment in ARID1A-MUT GC patients.Second, our study indicated that ARID1A mutation—DDR deficiency—immune activation” axis in GC and provided a feasible explanation for chemosensitivity conferred by genomic alterations. Intratumoral immune infiltrates are key determinants of patient outcome and therapeutic vulnerability ARID1A mutation. Although thoroughly elucidating chemotherapeutic effect remains a challenge, our results again recognized immune cells as key players, and underscored the interplay between tumor genomics and immune contexture in determining patient outcomes. Moreover, given ARID1A-MUT held a highly unstable genome, ATR inhibitors Third, we profiled an “ARID1A-MUT GC was not assessed. Therefore, our suggestion of ARID1A mutation as a biomarker for multimodality treatment needs to be validated in preclinical experiments or prospective clinical trials.Limitations were presented. First, our results were primarily based on observations of retrospective cohorts. Moreover, the safety of combinatory therapy for Supplementary file 1 (DOC 13260 kb)Below is the link to the electronic supplementary material.