Non‐small cell lung cancer (NSCLC) is the leading cause of cancer‐related mortality worldwide. It is advisable to select the appropriate treatment based on characteristics of the cancer such as pathology, mutations, and programmed death‐ligand 1 (PD‐L1) levels. In this study, by remarking squamous NSCLC with low PD‐L1 expression without mutations, we investigated the efficacy and safety of regimens that included molecularly targeted drugs such as immune checkpoint inhibitors (ICIs) through a network meta‐analysis.Databases were searched systematically to identify appropriate articles, in which randomized trials with incurable squamous NSCLC were described. Suitable studies were manually checked by two reviewers. A random model network meta‐analysis was conducted, in which the primary outcome was the overall survival rate.p = 0.016) followed by the platinum regimen + nivolumab (Niv) + ipilimumab (Ipi) . However, the efficacy of ICI monotherapy was not statistically different from that of the platinum regimen.We identified 48 studies, which included 16 391 patients. When a platinum + third‐generation cytotoxic agent regimen (platinum regimen) was a reference, the platinum regimen + pembrolizumab (Pemb) yielded the best results in regard to the overall survival rate when compared with chemotherapy .Clinicians wonder which treatment is best for patients with squamous lung cancer expressing low programmed death‐ligand 1 and no mutations. This study presents the comparison of regimens including immune checkpoint inhibitors using network meta‐analysis with 48 studies and 16 391 patients. The primary outcome was overall survival. Our main result was that the platinum regimen + pembrolizumab was the best regimen (hazard ratio = 0.57, 95% confidence interval = 0.36–0.90,  Non‐small cell lung cancer (NSCLC) is the leading cause of mortality in the world.The superiority of regimens is often determined in randomized clinical trials (RCTs), however, all regimens, especially ICI regimens, are not compared. Understanding the differences between ICI regimens is important during the process of choosing a treatment. Network meta‐analysis is an optimal analytical method that allows for indirect comparisons among multiple regimens. In 2017, we conducted a network meta‐analysis of cytotoxic regimens for first‐line incurable NSCLC.The protocol of our analysis conformed to the Preferred Reporting Items for Systematic Reviews reporting checklistTo identify eligible articles, the MEDLINE, Web of Science Core Collection, Embase, and Cochrane Central Register of Controlled Trials databases were searched systematically on October 15, 2020. The equations used in MEDLINE are listed in Text The published sources had to be written in English. RCTs that enrolled patients with advanced NSCLC were included in this study. Trials that focused on NSCLC with oncogenic mutations were excluded. Conference abstracts were allowed. Studies that included treatment only in the form of first‐line chemotherapy were included. Studies that included maintenance therapy, second‐line therapy, and later‐line therapy were excluded.Appropriate treatments included platinum doublet chemotherapy, ICIs, and molecularly targeted therapies. Clinical studies on platinum plus an angiogenesis inhibitor have also been conducted. ICI can be administered alone or in combination with platinum‐based treatments.There is a controversy regarding the difference between cisplatin (CDDP) and carboplatin (CBDCA),A network meta‐analysis based on individual regimens cannot evaluate the physicians' choice regimens. Two models were established to assay these items. The “main model” did not make a distinction between CDDP or CBDCA plus third‐generation cytotoxic drug regimen (platinum regimen). The “separate model” evaluated each platinum regimen differently.Because the use of kinase inhibitors in patients without driver‐gene mutations is not standardized, they were excluded from the study.RCTs enrolled patients with advanced or recurrent squamous NSCLC. Regardless of whether classification of the tumor‐lesion‐metastasis was revised in the past, we adopted the stage described in the article. Patients with a history of surgery or radiotherapy were included in the study. Studies that focused on those with a low performance status or the elderly were excluded.NSCLCs with a low or high PD‐L1 level (<1% or >50%) were excluded because recent guidelines have used the cut‐off of PD‐L1 levels at 1% or 50%.Trials focusing on non‐squamous carcinoma, oncogenic mutations, and patients with a TPS ≥50% were excluded. However, we accepted studies that did not clearly describe the pathological classification, oncogenic mutations, and PD‐L1 expression. This was necessary, because the majority of studies related to NSCLC would have been excluded otherwise. It has been reported that there are differences in PD‐L1 assay positivity.The quality of each incorporated study was checked using the Cochrane risk of bias tool. This judgment tool evaluated selection, performance, detection, attrition, reporting, and other biases.The primary outcome was overall survival (OS); the secondary endpoints were progression‐free survival (PFS), adverse events based on the Common Terminology Criteria for Adverse Events grade III or higher,The data of studies including the first author name, publication year, phase, primary outcome, pathology, stage, performance status, regimens, sample size , and trial outcomes were independently extracted by two reviewers (N.F. andK.S.). Discrepancies were resolved through mediation by a third reviewer (N.H.). Parmar's method was used to analyze survival data.p value of <0.05 was considered statistically significant.Our study applied the frequentist weighted least‐squares approach random‐model network meta‐analysis.There were 1386 articles retrieved by electronic and hand searches. There were 897 articles that met the inclusion criteria. There were 489 articles removed because they were duplicate studies; 719 articles were removed during the process of screening title/abstract, and 130 articles were removed after reviewing the full article. Finally, 48 appropriate studies were identified Figure .There were 19 studies and 39 arms, of which 11 included ICIs, in the main model and 42 studies and 89 arms, of which four included ICIs, in the separate model. The average age of the patients ranged from 51 to 67 years. A total of 16 391 patients were enrolled; the number of participants in the respective studies ranged from 50 to 1218 with a median of 261 participants Table . The Coc2 = 0%; total p = 0.394; within designs, p = 0.394) , followed by the platinum regimen + nivolumab (Niv) + ipilimumab (Ipi) , and the platinum regimen + necitumumab (Nctm)  . The additional analysis including only studies in which PD‐L1 was explicitly mentioned was conducted. The results did not conflict with the main analysis  ranked first. The effect of this regimen was significantly different between the separate models  were evaluated in 19 studies with 6785 total patients  Figure . Atezolis Figure . In the s Figure .p = 0.040). The platinum regimen + dulanermin regimen showed the best PFS   than the platinum regimen alone  Figure .p < 0.001), followed by Niv and durvalumab  Figure . In the For squamous lung cancer with PD‐L1 TPS of 1%–49%, platinum + Atz is recommended by the guidelines of the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the European Society for Medical Oncology. However, the results of Impower 130,Our analysis had some limitations. First, although there were differences in the drug, amount, and period, the platinum regimen in the main model was identified to be the same. Complementarily, we conducted a separate model, and the result was similar to that of the main model. Second, according to the Cochrane tool criteria, all incorporated papers had a high risk of bias. Unfortunately, it is difficult to conduct a double‐blind study without a sponsor. We believe that these factors did not significantly reduce the reliability of this study.In summary, we performed a systematic review and network meta‐analysis of patients with squamous NSCLC with a PD‐L1 TPS of 1%–49%. For the 16 391 patients diagnosed with NSCLC and part of 48 RCTs, the platinum regimen + Pemb and the platinum regimen + Niv + Ipi were considered appropriate first‐line agents for treating squamous NSCLC with low PD‐L1.All authors have completed the ICMJE uniform disclosure form. N.H. has received personal fee from Taiho Pharmaceutical and a research grant from Taiho Pharmaceutical outside of the work. K.W. has received personal fees from AstraZeneca, Ono Pharmaceutical, and Boehringer Ingelheim outside of the work. Y.H. has received personal fees from AstraZeneca and Boehringer Ingelheim outside of the work. N.K. has received personal fees from Chugai Pharmaceutical, AstraZeneca, Boehringer Ingelheim, Sanofi, Ono Pharmaceutical, MSD, Bristol Myers Squibb, Eli Lilly, and Kyowa Kirin; and research grants from Chugai Pharmaceutical, Boehringer Ingelheim, MSD, Eli Lilly, Kyowa Kirin, Daiichi Sankyo, and Pfizer outside of the work. T.K. has received personal fees from Chugai Pharmaceutical, AstraZeneca, Bristol Myers Squibb, Eli Lilly, Taiho Pharmaceutical, Chugai Pharmaceutical, Daiichi Sankyo, Sanofi, and Pfizer; and research grants from MSD, Chugai Pharmaceutical, Eli Lilly, Taiho Pharmaceutical, Chugai Pharmaceutical, Daiichi Sankyo, Pfizer, and Shionogi outside of the work. The other authors have no conflicts of interest to declare.Appendix S1 Supporting InformationClick here for additional data file.


The correlation between perioperative changes in nutritional status during esophagectomy and prognosis remains unclear. This study aimed to evaluate the impact of changes in prognostic nutritional index levels during the perioperative period on esophageal cancer patient survivals.From January 2009 to May 2019, 158 patients with esophageal squamous cell carcinoma were enrolled. From the time-dependent ROC analysis, the cutoff values of preoperative and postoperative prognostic nutritional index levels were 46.9 and 40.9. Patients were divided into preoperative-high group (Group H) and preoperative-low group (Group L). Then, patients in Group L were divided into preoperative-low and postoperative-high group (Group L–H) and preoperative-low and postoperative-low group (Group L–L). Long-term outcomes and prognostic factors were evaluated.p = 0.001). Patients in Group L–L had significantly worse overall survival than those in Group L–H (p = 0.023). However, there was no significant difference in overall survival between Groups H and L–H (p = 0.224). In multivariable analysis, advanced pathological stage  and Group L–L  were independent predictors of poor overall survival.Patients in Group L had significantly worse overall survival than those in Group H (Patients in Group L–H had a good prognosis, similar to those in Group H. This result indicated that increasing the postoperative prognostic nutritional index level sufficiently using various intensive perioperative support methods could improve prognosis after esophagectomy in patients with poor preoperative nutritional status.The online version contains supplementary material available at 10.1007/s10388-021-00883-5. Esophageal cancer is the sixth leading cause of death from cancer worldwide . DespiteRecently, nutritional or inflammatory status markers have been identified , 11. TheIn this study, we hypothesized that the recovery of PNI level after esophagectomy may improve patient prognosis. The correlation between nutritional and immunological status during esophagectomy and prognosis was investigated using PNI in patients with ESCC.From January 2009 to May 2019, 188 patients with ESCC at the Department of Surgery, Hamamatsu University School of Medicine, were retrospectively reviewed. All patients underwent esophagogastroduodenoscopy (EGD) and computed tomography (CT) from the neck to the pelvis to determine the clinical stage. The clinical stage was diagnosed based on the Union for International Cancer Control TNM classification of malignant tumors, 8th edition .n = 2), double cancer (n = 10), salvage surgery (n = 12), and interruption of follow-up within 2 years (n = 6). Finally, 158 patients were included in the study  age > 20 years, (2) Eastern Cooperative Oncology Group performance status of 0–1, (3) histological diagnosis of ESCC by endoscopic biopsy, (4) no double cancer, (5) radical esophagectomy, (6) survival for at least 90 days after surgery, and (7) patients who survived and were followed up for more than 2 years. Patient ineligible for study enrollment was based on the following exclusion criteria: death within 90 days after surgery ( age > 203) [PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte counts (per mm3) . PreoperNeoadjuvant chemotherapy was performed as a standard treatment for patients with non-stage I ESCC. The treatment regimen was a combination of cisplatin and 5-fluorouracil or a combination of docetaxel, cisplatin, and 5-fluorouracil. Transthoracic esophagectomy with 2- or 3-field lymph node (LN) dissection and gastric conduit reconstruction via the posterior mediastinal route was performed as a standard surgical procedure at our institution . In the According to our protocol, patients were instructed to abstain from smoking and alcohol consumption for at least 4 weeks before surgery. Physiotherapists commenced respiratory rehabilitation using an incentive spirometer. Following the surgery, early ambulation and restart of respiratory rehabilitation were encouraged. An elemental diet was started at 10 kcal/h from the day of surgery via a jejunostomy tube for patients with a jejunostomy. The tube-feeding dose was gradually increased to 1200 kcal/day. Enteral nutrition through jejunostomy was continued in the patients, even after the hospital discharge until there were satisfactory results in oral intake .At the time of oral feeding initiation, the rehabilitation physician and the speech–language–hearing therapists performed videofluoroscopic (VF) and videoendoscopic (VE) examinations, especially for the patients receiving multidisciplinary team support. The meals were started with a dysphagia diet. The diet was changed to liquids in accordance with the improvement in the swallowing function. Furthermore, the total calorie intakes were based on decisions made by the multidisciplinary team conference. The calorie intake at the time of discharge was approximately 1500 kcal/day after introduction of multidisciplinary team support . After tPostoperative follow-up was performed using CT every 6 months and EGD every year for 5 years after surgery. Recurrence-free survival (RFS) was calculated from the operation to the day of recurrence of esophageal cancer. Overall survival (OS) was calculated from the operation to the day of death due to esophageal cancer. Patients were followed up until death or until the end of the study . Patients who died of an illness unrelated to esophageal cancer, interrupted follow-up, or under following up were recognized as censored, and RFS and OS were calculated based on the days until censoring.t test. The Mann–Whitney U test was used for non-parametric analyses. Differences between each category were identified using the Chi-square test or Fisher’s exact test, and the Kruskal–Wallis test was used to identify the differences in continuous variables. Survival curves were produced using the Kaplan–Meier survival method and log-rank test. Hazard ratios (HRs) were calculated, and univariate and multivariate analyses were performed using Cox proportional hazards regression models. The threshold for significance was set up at p < 0.05.The time-dependent ROC analysis was performed using R software v 4.0.5 . The tip < 0.001) and, thus, the rate of patients who received neoadjuvant chemotherapy was higher in Group L (p = 0.004). The rate of multidisciplinary team support was similar in both groups (p = 0.736) (Table p = 0.338). Moreover, no significant difference was observed in terms of LN dissection, operation time, and jejunostomy (Table p = 0.038). There was no significant difference in AL and SSI between Groups L and H . Pathological study showed that the patients in Group L were diagnosed at an advanced stage (p = 0.002). The rate of patients who received either adjuvant chemotherapy or radiation was higher in Group L than those in Group H (p = 0.012). There was no significant difference in the proportion of local recurrence between the groups. However, the rates of patients who had regional LN and distant organ recurrence were significantly higher in Group L than in Group H    Fig. .Fig. 2Kap = 0.132). The proportion of multidisciplinary team support in Group L-L tended to be lower than that in Group L–H . The incidence of postoperative infectious complications  was higher in Group L–L than in Group L–H (p = 0.032). The prevalence of AL and SSI was significantly higher in Group L–L than those in Group L–H . The rate of patients who received enteral nutrition in the early postoperative phase was similar between the groups . There was no difference in the population of patients with death unrelated to esophageal cancer (p = 1.000). The proportion of patients who received adjuvant chemotherapy was similar between the two groups (p = 0.336). However, adjuvant therapy was suspended in two patients from Group L–L due to adverse events . Furthermore, patients in Group L–H had significantly better OS than those in Group L–L (p = 0.023) . However, there was no significant difference in OS and RFS between Groups L–H and H  p = 0.077p = 0.004, p < 0.001, and p < 0.001, respectively) (Table p = 0.548) (Table p = 0.001) and Group L-L  were independent predictors of worse OS (Table All of the variables shown in Table y) Table . Postope8) Table . In multA stratified analysis before and after introduction of multidisciplinary team support was performed. The proportion of patients in Group L–H increased markedly from 17.1% before initiation of the multidisciplinary team support to 22.6% after initiation of the multidisciplinary team support (Online Resource 3). Before introduction of multidisciplinary team support, patients in Group L–H showed significantly better OS and RFS than those in Group L–L ; OS: 61.1 months vs. 35.4 months; RFS: 61.1 months vs. 24.4 months). Furthermore, there was no difference in the OS and RFS between Groups L–H and H. Although the number of patients who received multidisciplinary team support was small, after it was initiated, patients in Group L–H also tended to have a good OS than those in Group L–L (MST of OS: 36.2 months vs. 23.7 months). Moreover, the survival curves were also similar between Groups L–H and H (Online Resource 3).To investigate the survival impact postoperative nutritional support, the long-term outcomes of patients with postoperative infectious complications  were assessed using a stratified analysis which patients were divided into groups based on whether they developed postoperative infectious complications (Online Resource 4). In the stratified analysis, either with or without postoperative infectious complications, patients in Group L–H were tended to have better OS and RFS than those in Group L–L (Online Resource 4).This study demonstrated that preoperative-low PNI patients who did not sufficiently recover in terms of postoperative PNI level had a significantly worse OS. In contrast, preoperative-low PNI patients who sufficiently recovered in terms of postoperative PNI levels had similar OS to those with preoperative-high PNI levels. These results suggested that the changes in PNI levels from the pre- to postoperative phase may predict the prognosis in patients with ESCC, and successful recovery of PNI level after transthoracic esophagectomy can improve the OS in preoperative-low PNI patients to match that of preoperative-high PNI patients.PNI was initially proposed by Buzby  and modiThe controlling nutritional status (CONUT) score is another representative nutritional index which reported as an independent predictor of prognosis of esophageal cancer . EvaluatIn this study, patients in Group L–L tended to have more frequent postoperative complications than those in Group L–H. Postoperative complications reportedly induced the suppression of albumin production and elevation of white blood cells, particularly neutrophils, resulting in insufficient PNI recovery . InteresThe proportion of patients in Group L–H increased after introduction of multidisciplinary team support. In the stratified analysis, patients in Group L–L were tended to have poor OS than those in Group L–H both before and after introduction of multidisciplinary team support. These results indicated that intensive postoperative care with a multidisciplinary team support could contribute not only to the prevention of postoperative complications and maintenance of PNI levels, but also to the prolongation of prognosis, especially in preoperative-low PNI level patients. Moreover, two patients in Group L-L stopped adjuvant chemotherapy. These cases suggested that sufficient PNI recovery after esophagectomy improved tolerance to adjuvant chemotherapy. In multidisciplinary team support, team conference in which the members could share the patients’ nutritional status, swallowing function from VF and VE, and calorie intake could have contributed to the enhanced nutritional support . MoreovePatients in Group L–L had significantly worse RFS than the others did, and patients in Group L–H had similar RFS to those in Group H. However, when limited to the first year after esophagectomy, the decline in RFS rate was similar between Groups L–H and L–L. After a year, the RFS rate continued to decline in Group L–L, but that in Group L–H was relatively stable. These results suggested that postoperative PNI reflected tumor immunity. Okadome et al. reported that the systemic nutritional and immunological status in patients may be associated with local tumor immunity by evaluating the relationship between PNI and tumor-infiltrating lymphocyte status .The study had some limitations. First, this was a retrospective study conducted in a single institution. However, this study reviewed consecutive patients at our institution, which reduced selection bias. Another limitation is that the study period was relatively long. Consequently, the treatment of patients with ESCC, including the maturation of surgical techniques, regimen of neoadjuvant chemotherapy, and perioperative management, could have changed over this period. There were some biases in the operation and perioperative interventions. Hence, a multi-institutional prospective study must be conducted to validate the current results.In conclusion, the recovery of PNI levels after esophagectomy could improve the prognosis in patients with preoperative malnutrition. Further studies are warranted to validate this classification and investigate the survival benefit of PNI changes during esophagectomy.Supplementary file1 (PDF 132 kb)Supplementary file2 (PDF 126 kb)Supplementary file3 (PDF 264 kb)Supplementary file4 (PDF 235 kb)Below is the link to the electronic supplementary material.


Endoscopic sleeve gastroplasty (ESG) is an alternative nonsurgical treatment option for obesity. However, most studies on the utility and efficacy of ESG are derived from the Western population. It is unknown if ESG elicits similar results in Asians with different fat distribution, sociocultural customs, and dietary practices. Our study aims to assess the safety and efficacy of ESG among a multi‐ethnic Asian population.We reviewed 35 patient records who underwent primary ESG for obesity at our unit. We followed a U‐shaped suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage total body weight loss (TBWL) at the last follow‐up.2, respectively. The majority were female (57%) and of Chinese ethnicity (51%). The procedure was technically successful in all patients. We used an average of five sutures , and the mean ± SD procedure time was 65 ± 10 min. No major complications occurred, and the average length of stay was 1 day. Twenty‐one patients completed 3 months of follow‐up, and 10 patients 6 months. The mean ± SD TBWL at 3 and 6 months were 14.5 ± 4.8% and 16.2 ± 4.9%, respectively. We observed improvement in diabetes mellitus (87%), fatty liver (86%), and hypertension (58%) during the follow‐up.The mean ± SD age and body mass index were 43.6 ± 11.3 years and 34 ± 4.9 kg/mESG is a safe and effective option for promoting weight loss in a multi‐ethnic Asian population. ESG‐induced weight loss may improve obesity‐related comorbidities. Endoscopic sleeve gastroplasty (ESG) is an effective treatment option for Asian patients with obesity. ESG is a short‐stay procedure with an excellent safety profile, and the weight loss achieved leads to improvement in comorbidities. Obesity is a chronic, relapsing, multifactorial, and neuro‐behavioral disease associated with multiple metabolic comorbidities, including diabetes mellitus and hypertension.Several public health policies and measures have been introduced to combat the obesity pandemic. However, no single treatment is shown to cure obesity permanently and maintain weight loss over the long term. The current treatment options available for obese patients include diet and lifestyle changes, pharmacotherapy, and, the most effective, bariatric surgery. The number of patients seeking bariatric surgery has remained low despite its effectiveness. A survey conducted in 2018 by the Asia–Pacific Metabolic and Bariatric Surgery Society involving 18 Asia–Pacific countries showed a low frequency of bariatric surgery  even with a large population of eligible obese patients.2) is lower than for Western populations because of the higher body fat percentage at lower BMI.Novel, less invasive approaches are required to overcome this disparity and to encourage more obese patients to seek treatment. Recently, endoscopic sleeve gastroplasty (ESG), a minimally invasive and reversible endoscopic procedure, was developed with a premise to reduce the size of the stomach, similar to laparoscopic sleeve gastrectomy.We retrospectively reviewed the records of patients who underwent ESG at the Obesity Center at Singapore General Hospital between November 2020 and August 2021. The institutional review board approved the study. All authors had access to the study data and reviewed and approved the final conclusions. The study was conducted following the ethical principles detailed in the Declaration of Helsinki and was consistent with the Good Clinical Practices recommendation. Informed consent was obtained from all the patients before the procedure.2, and (iii) be able to comply with instructions and provide informed consent. We excluded those with: (i) severe systemic illnesses, (ii) substance abuse, (iii) uncontrolled eating disorder, (iv) pregnancy, and (v) coagulopathy. We did not pre‐select our patients, and all eligible candidates who committed to long‐term follow‐up were offered ESG. We collected information on technical outcomes, length of stay, complication rates, and early weight loss outcomes.We reviewed the records of patients who underwent primary ESG at our unit. All the patients referred for ESG had declined surgery and failed in diet and lifestyle therapy. The inclusion criteria for ESG were (i) age ≥17 years, (ii) BMI ≥27.5 kg/mAll ESG procedures  were done by one endoscopist (R.A.) with extensive experience in endoscopic suturing. We performed the procedure with the patient under general anesthesia. We assessed the stomach first with an upper endoscopy to identify any contra‐indication for ESG. We then advanced the endoscope fitted with the suturing device to commence the ESG Fig. . We admiThe patients were followed up at regular intervals by dieticians, gastroenterologists, and physiotherapists. The energy requirement was calculated from the Harris–Benedict formula, taking into account the patients' physical activity status. An energy deficit of about 2.6 MJ/day was prescribed to induce an approximate loss of between 0.5 and 1 kg/week. In the first month, we maintained the patients on a strict liquid diet (4 weeks), which included commercial meal replacement options or homemade soups. We subsequently escalated intake to semi‐solid and solid food as tolerated. To prevent lean muscle mass loss, we encouraged patients to eat animal‐derived proteins such as eggs, fish, chicken, and red meat. Depending on the patient's capacity, we devised an individualized exercise plan, such as treadmill, stair‐climbing, jumping jacks, and squats (~30–45 min/day).The primary objective of this study was to assess the safety and complication rate of ESG in a multi‐ethnic Asian cohort. We graded the adverse events according to the Clavien–Dindo classification, where a higher grade represents greater severity of complication.t‐test to compare weight loss outcomes at baseline and last follow‐up after the procedure. We measured the percentage of patients achieving more than 5%, 10%, and 20% TBWL. A P‐value of <0.05 was considered to be significant.We expressed the continuous variables as mean ± SD or median (range), and categorical variables as percentages. We assessed for normality using the Shapiro–Wilk test. We used the paired 2. The mean age was 43.6 ± 11.3 years, and the initial weight was 93.2 ± 16 kg. Most of the patients were female (57%) and of Chinese ethnicity (51%). Obesity‐related comorbidities were present in 85% of patients. Six patients (17%) were on antiplatelet therapy before the procedure. We continued aspirin but stopped clopidogrel 1 week before and restarted 3 days after the procedure.We reviewed the records of 35 patients who received ESG for obesity during the study period. The characteristics of our patients are shown in Table The procedure was technically successful in all the patients Table . We usedNo major complications occurred in our cohort. In two patients, intra‐procedure bleeding was noted. The bleeding occurred at the helix puncture site in the proximal stomach. In the first case, the oozing was persistent even after cinching the tissues together. In the second case, active spurting was seen. We treated both the patients with hemoclips and adrenaline injection and achieved hemostasis. We discharged them within 24 h; no blood transfusion was required. None presented again with re‐bleeding or intractable vomiting. In our group, the average decline in hemoglobin after the procedure was 0.9 ± 2.4 g/dL.2, respectively. Similarly, the mean ± SD TBWL, %TBWL, and BMI loss at 6 months was 14.1 ± 5.9 kg, 16.2 ± 4.9%, and 5.7 ± 1.5 kg/m2, respectively.Among the study cohort, 10 (29%) patients completed 6 months of follow‐up, and 21 (60%) 3 months , we observed improvement in HbA1c or reduction in medication dosage in seven (87%) patients. The decline in HbA1c, compared to baseline, was seen within the first 3 months of follow‐up post ESG (8 ± 0.9% vs 7 ± 0.9%). In six (75%) patients, the dosage of the diabetic drugs was reduced, and in two (25%) patients insulin was stopped completely. A decrease in the pill burden was noticed at 3 months after ESG . Likewise, elevated transaminases and fatty liver were seen in 14 patients at baseline. We observed improvement in liver tests in 12 (86%) patients. ESG, as compared to baseline, resulted in remarkable improvement in ALT (68.2 ± 38.2 vs 30 ± 11.9 IU/L) and AST (54.6 ± 27.4 vs 32.8 ± 7.4 IU/L), respectively. In 10 of the 17 cases (59%), we observed improvement in systolic blood pressure and medication reduction for hypertension. The mean difference in the systolic blood pressure was 7.7 mmHg. In two cases, all the medications were stopped altogether.We observed improvement in comorbidities within the short follow‐up duration. Among the patients with type 2 diabetes (Our study showed that ESG was safe in a Southeast Asian cohort irrespective of their BMI. There were no severe complications. All the patients recovered rapidly and required only an overnight hospital stay. ESG induced significant weight loss in our patients, albeit over a short follow‐up duration, resulting in improvement in obesity‐related comorbidities.versus no suturing of the gastric fundus in ESG found no added benefit and lower efficacy with fundal suturing.Endoscopic suturing in bariatrics was first introduced in 2004, and since then significant advancement has occurred.et al., in a meta‐analysis involving 1772 ESG patients, showed the pooled rate of adverse events to be 2.2%.Multiple studies primarily involving mainly the Western population have established the safety and efficacy of ESG. Hedjoudje et al. demonstrated that ESG prolonged gastric emptying of solids by 90 min and resulted in a 59% decrease in caloric intake.ESG delivers its weight loss effect predominantly by achieving gastric restriction and altering gastric motility.et al. showed that the weight loss achieved could be maintained for 5 years with a good multidisciplinary follow‐up.A weight loss of 5–15% improves all obesity‐related comorbidities, enhances the quality of life, and decreases mortality.Our study has several strengths and certain limitations. We present the first experience investigating the safety and utility of ESG in a relatively large group of multi‐ethnic Asian patients. It is essential and relevant to show such results, as different patient populations might respond variably to weight loss treatment. Additionally, the dietary habits, physical activity pattern, sociocultural beliefs, and outlook toward obesity management diverge significantly between the East and the West.In conclusion, ESG delivers acceptable early weight loss results with an excellent safety profile in this cohort of Southeast Asian patients with obesity. The expectation of rapid recovery and the reversible and repeatable nature of the procedure may encourage patients to seek treatment, including those who decline or are not suitable for bariatric surgery. Future studies of durability, long‐term efficacy, and cost effectiveness of ESG are required.


This study provides the first representative analysis of error estimations and willingness to accept errors in a Western country (Germany) with regards to algorithmic decision-making systems (ADM). We examine people’s expectations about the accuracy of algorithms that predict credit default, recidivism of an offender, suitability of a job applicant, and health behavior. Also, we ask whether expectations about algorithm errors vary between these domains and how they differ from expectations about errors made by human experts. In a nationwide representative study (N = 3086) we find that most respondents underestimated the actual errors made by algorithms and are willing to accept even fewer errors than estimated. Error estimates and error acceptance did not differ consistently for predictions made by algorithms or human experts, but people’s living conditions  affected domain-specific acceptance  of misses and false alarms. We conclude that people have unwarranted expectations about the performance of ADM systems and evaluate errors in terms of potential personal consequences. Given the general public’s low willingness to accept errors, we further conclude that acceptance of ADM appears to be conditional to strict accuracy requirements. This study provides the first representative analysis of error estimations and willingness to accept errors in a Western population (in Germany) with regards to specific algorithmic decision-making (ADM) systems. We examine how accurately algorithms are expected to perform in predicting credit defaults, recidivism of an offender, suitability of a job applicant, and health behavior.1) continues to spread into everyday life. At the same time, claims, risks4, and implementations related to ADM are under debate, e.g. in criminal risk assessment7 or allocation of public resources8. Despite these controversies, it is unclear how the general public perceives ADM quality. Representative studies focus on attitudes11 and on perceived understanding and application of ADM and artificial intelligence15, but rarely on perceptions of the systems’ reliability and validity . The public debate centers on laypeople’s trust in and fear of algorithms16, e.g. in media coverage of hopes and concerns regarding artificial intelligence17. Research on algorithm aversion and appreciation18 examines both the circumstances under which people trust algorithmic advice19—for instance, because they perceive the decision problem in question to be objective or to require mechanical skills20 or because they lack confidence in their own expertise—and the circumstances under which they are mistrustful, for instance22, in response to slow algorithm responses or to observing algorithm errors.Algorithmic decision-making . To the best of our knowledge , this is the first representative study comparing error estimates and the willingness to accept errors for ADM.Surprisingly, the expected level of accuracy of algorithms and the perceived competence28; cost-sensitive error management29), and the degree to which errors are accepted may differ in the legal30 and in the medical domain31, e.g. if the consequences of medical errors are irreversible. From the perspective of an unemployed person, for instance, mistakenly being overlooked for a job by an ADM  is likely more costly than being hired in spite of being unsuitable . In our analysis, we therefore relate error acceptance to critical factors such as unemployment phases. Also, we compare the willingness to accept errors with the typical error preference of exemplary stakeholders . We additionally explore factors underlying attitudes toward technology, that may influence both algorithm error estimation and acceptance, such as risk preference32, gender33, and age34. For instance, only one third of US-Americans above 50 years of age compared with half of those 18 to 29 years of age believe that algorithms can be free of human biases16. Because algorithm appreciation was shown to be lower among less numerate people18, we compare different educational groups.Classifying ADM systems balance two different types of errors, misses and false alarms, each associated with different consequences (costs). Thinking about types of decision errors and related costs can affect acceptance of errors . However, results from earlier studies indicate that in the medical domain, people actually prefer human experts over automated care because, among others, they believe that machines disregard individual circumstances38. People were also found to trust recommendations of computers less than those made by physicians39 and, crucial for error perception, to consider algorithm-based advice as being less accurate than clinicians’ advice40. In the domain of people analytics—algorithm-based planning, recruitment, development, and promotion in human resources—human interviewers are also assumed to be more accurate and useful than algorithmic decision aids41. At least for those two domains, the few existing studies thus indicate that people perceive algorithms to make more errors than human experts do. Accordingly, we compare error estimation and error acceptance for algorithmic and expert advice across domains.Best-selling authors and commercial companies have promoted “AI” as being superior to human expertsWe conducted a survey of a large population-representative sample of members of private households in Germany . In the survey, 3086 respondents were questioned about estimated and accepted error rates in current credit scoring before being randomly assigned to decision scenarios either on algorithms or on experts (between-subjects). Respondents were requested to provide estimated and accepted error rates in a people analytics problem (predicting a suitable job candidate), a legal problem (predicting recidivism of an offender), and a health problem . For instance, respondents were asked with respect to credit scoring: “You have probably heard of the Schufa. The Schufa estimates the solvency of all persons in Germany. This helps entrepreneurs and landlords decide whether someone gets a cell phone contract, an apartment, or a loan, for example. Now please imagine a group of 100 people who are actually insolvent: How many of them do you think are mistakenly assessed by the Schufa as being solvent? [estimating false negatives]; What would be acceptable to you: At most, how many of these 100 people could be mistakenly assessed by the Schufa as being solvent? [accepting false negatives].Across domains and types of errors, about one in every four algorithmic decisions was estimated to be wrong Fig. a–d, withF = 15.75, P < 0.001, ηp2 = 0.01), but false negatives were considered less acceptable  = 4.32, P = 0.038, ηp2 < 0.01). For the algorithmic evaluation of health behavior  = 39.17, P < 0.001, ηp2 = 0.03) and considered acceptable  = 22.76, P < 0.001, ηp2 = 0.02).Minimally more false negatives than false positives were estimated for the algorithmic prediction of recidivism , for recidivism , for health behavior , and for credit scoring .Notably, there is a consistent and large difference between the estimated and maximally accepted rates of algorithm error across all four domains. Expressed in percentage points, the differences in false positives (FP) and false negatives (FN) are for application suitability . Figure 42. This appears to be similar to the AUCWeightedMean = 0.80 (SD = 0.17) that we calculated  based on each respondent’s error estimates. However, 45.5% of participants  overestimated AUC (> 0.85), while 33.0%  underestimated it (< 0.76). Underestimations were more extreme than overestimations.The credit agency SCHUFA reports an accuracy of 0.81 of its (banking) credit score in terms of the value of the area under the receiver operating curve (AUC)Participants who underestimated or overestimated the accuracy of credit scoring algorithms differed in several respects from those who gave approximately correct estimates (Supplementary Table 43. This is lower than the AUCWeightedMean = 0.75 (SD = 0.19) that we calculated based on each respondent’s error estimates. Moreover, 61.0% of participants  overestimated AUC (> 0.73), while 24.9%  underestimated it (< 0.63). Participants who underestimated the accuracy of the recidivism algorithm  and of 2.1% for credit defaulting (occurring within one year44). Figure To interpret the absolute figures of accepted errors, the base rates of the targets of the algorithms (e.g. how many people default within one year) need to be taken into consideration. What directly counts for a person affected by an algorithm are the posterior probabilities (how likely a certain prediction is correct or incorrect), not the false negative rates (how many of the targets are missed) and false alarm rates . In a first step, we calculated implied posterior probabilities with the rates of accepted algorithms errors (weighted for representativeness) and the reported base rates of 30.6% for recidivism . In contrast to offenders at risk, those not at risk have an interest in not being falsely diagnosed as at risk of recidivism . Finally, potential victims of defenders on bail will desire tests that maximize the negative predictive value (NPV) toward 100%, that is, the probability that offenders will not commit another crime if they are tested negative and are released. The comparison showed that people’s preferences for recidivism prediction overlap with performance ideals of developers, of potential victims, and of non-recidivizing offenders, but not with recidivizing offenders: False negatives were considered less acceptable than false positives.In a second step, we compared the calculated posterior probabilities of error acceptance with ideal posteriors according to different stakeholders’ goals Fig. b. For alFigure Different posteriors lie in different stakeholders’ interest, because they expect personal consequences from different types of errors. Hence, it is examined in the following how error acceptance could depend on personal consequences from errors in specific domains.FFP = 38.38, P < 0.001, Rcorr2 = 0.29) that controlled for error estimations, age, income, and gender showed that respondents who were unemployed within the past ten years (std. β = 0.15) showed increased acceptance of falsely assessed suitability by algorithms. Noteworthy, this was not predictive in a parallel analysis of expert assessments (P = 0.826). Overlooking suitable job candidates  = 31.33, P < 0.001, Rcorr2 = 0.26) by algorithms was less accepted by older people (std. β = − 0.15). Again a relationship that could be not indicated for experts (P = 0.256).A linear regression  = 15.41, P < 0.001, Rcorr2 = 0.09) revealed that misses  of recidivizing offenders were less accepted by people with higher income (std. β = − 0.07), and women (std. β = − 0.07). False positives by algorithms  = 17.08, P < 0.001, Rcorr2 = 0.10) were less accepted with increasing age (std. β = − 0.12) and income (std. β = − 0.10). We could neither confirm for false negatives  nor false positives by experts  the listed factors.Furthermore, a linear regression  = 21.43, P < 0.001, Rcorr2 = 0.18)—corresponding to overlooking unhealthy behavior—was less often accepted by older people (std. β = − 0.11); also for human advisors (std. β = − 0.07). Acceptance of false negatives  was not influenced by the factors that we considered  = 30.93, P < 0.001, Rcorr2 = 0.24).If additionally controlling for body mass index, health, and insurance status, a false positive algorithmic evaluation of health behavior  = 112.72, P < 0.001, Rcorr2 = 0.25) by older respondents (std. β = − 0.06) and those reporting higher household income (std. β = − 0.07). The latter also accepted fewer false positives (std. β = − 0.06),  = 88.59, P < 0.001, Rcorr2 = 0.21).With regards to errors in credit scoring, fewer false negatives were accepted , health domain , and crime domain (recidivism) we analyzed in this section whether estimated and accepted errors vary for ADM and human experts in the role of the advisor  = 0.14, P = 0.707) between expert and algorithm error estimations but that these differed depending on the domain  = 11.79, P < 0.001, ηp2 = 0.01) and on the type of error within the domain  = 32.81, P < 0.001, ηp2 = 0.01). Lower rates of false negatives (minus 4.6 out of 100 suitable applicants) were estimated for job algorithms  = 78.50, P < 0.001, ηp2 = 0.03). In recidivism prediction, there was a statistical interaction of type of error and advisor  = 4.12, P = 0.042, ηp2 < 0.01), though there were no meaningful differences  = 8.87, P < 0.001, ηp2 < 0.01).A 3 × 2 × 2 ANOVA (advisor x type of error x domain) indicated no general difference  = 3.08, P = 0.046, ηp2 < 0.01) and on the type of error within the domain  = 3.45, P = 0.032, ηp2 = 0.01)  = 4.92, P = 0.027, ηp2 < 0.01); false negatives were also considered less acceptable than false positives in the case of algorithms  = 12.06, P = 0.001, ηp2 = 0.01). For recidivism prediction, in contrast, differences in acceptance are limited. False positives seem to be considered less acceptable when caused by algorithms than by experts. Mistakenly predicting false recidivism was generally less accepted  = 4.24, P = 0.040, ηp2 < 0.01). Notably, it was generally considered less acceptable to falsely diagnose unhealthy behavior than to overlook it  = 37.63, P < 0.001, ηp2 = 0.01).Differences in acceptance of errors made by algorithms or experts depended on the domain  = 9.01, P < 0.001, ηp2 = 0.01) accept a higher number of human than algorithm errors (about 1 to 2 more per 100 predictions), while those younger than 29 accept fewer human errors and more algorithm errors (a difference of about 4 in 100 predictions). Similar distinctions could not be confirmed for gender or for monthly household net income.An analysis of factors that lead to ADM-specific acceptance of errors confirms that people above the age of 29 (r = 0.27 and 0.43), indicated that error acceptance grows with increasing perception of errors, regardless whether algorithms or experts are presented as advisors . Less numerate people are less likely to appreciate algorithms18. Also, we cannot exclude a domain-independent general expectation about algorithm accuracy that could explain the larger differential for the less accurate algorithm (recidivism prediction) than for the more accurate algorithm (credit scoring). This calls for research on first-hand experience and training with ADM systems that have to be accessible and comprehensible to people of lower education and that could help adjust performance expectations toward the ground truths, e.g. ballpark correctness of estimated errors.Lower expectations about algorithm accuracy were found among respondents with lower education, less employment, and lower income. Overly negative expectations could indicate total absence of any familiarity and knowledge but may also reflect somewhat justified distrust of new technologies that could affect vulnerable citizen’s everyday life in unwelcome ways  of different types of error appear to influence one’s willingness to accept algorithm errors. People with higher household income accept fewer errors in credit scoring. A higher willingness to accept false positives than false negatives in predicting defaulting is noteworthy, given that 98% of inhabitants in Germany are non-defaulters in the credit scoring system and thus can only end up as a false positive, not as a miss. This puzzling result suggests that people fear harms to the economy more than to themselves, given that the proportion of lenders, landlords, and entrepreneurs among the general population is quite limited. People who experienced phases of unemployment in the past ten years appear to be more open for errors in their favor, namely false positives in predicting suitable job candidates. Older people were less accepting of overlooking suitable candidates. Overlooking recidivizing offenders was less accepted by women and people with higher income. Further investigation is needed to clarify why those plausible associations were limited exclusively to ADM perception. One could hypothesize, for instance, that we could detect the associations because algorithms as advisors had amplified the respondent’s preferences to avoid certain consequences.51. Exceptions are indicated for the better algorithmic prediction of average academic grade points and job and training performance ratings52. Akin to that, our participants expected that algorithms detect suitable job candidates better than experts. In contrast, doctors were perceived to make slightly fewer errors of both types in evaluating health behavior, a perception that is not found elsewhere in the literature. Perceived harm of errors may contribute to domain-specific algorithm aversion in healthcare53.Furthermore, ADM systems in our study were estimated to perform roughly at par with experts. Here, people’s expectations appear to be in line with meta-analytic results, according to which algorithms were not found to perform better than experts in prediction tasks54 , and people accordingly choose algorithms when making decisions under risk55. At the same time, algorithms perform better on problems of risk than on problems of uncertainty such as in forecasting human behavior (high epistemic uncertainty). It needs to be experimentally confirmed whether laypeople accordingly accept more errors by ADM systems with increasing epistemic uncertainty.Because the respondents were willing to accept fewer errors by ADM than by human experts at least in some domains (e.g. disregarding suitable job applicants), the public may likely expect some ADM systems to be more error-free than humans in order to accept these. Here, the uncertainty of a decision problem may play a role. Algorithms perform better under certainty (e.g. geometry) than with problems of risk56, our representative study did not find any indications of a relationship between risk preference and the acceptance of algorithm errors across three domains. An additional analysis of the asymptomatic growth in error acceptance  with credit scoring were not noticeable. This points to the question of how the general population, which applies for jobs, flats, and credits, will instead develop a sufficient understanding of ADM systems. Providing information about their accuracy and reliability could reduce algorithm aversion19, in particular competitive performance information 57. Both observed and inferred accuracy of predictive algorithms59, even if it is low60, along with confidence information for each prediction61, may correct performance expectations and could improve trust in algorithms . Alternatively, more frugal algorithms63 could be used. Opposed to just using interpretable models64 and explaining complex models65, frugal algorithms assure both transparency and understandability (e.g. explaining a prediction60 or an error), which are potential measures to correct performance expectations and to increase trust in ADM systems66.Finally, the lack of familiarity with domain-specific algorithmsLimitations. Although we used an experimental manipulation (between-subjects) within a household survey, the limited time and attention within a period of eight minutes restricted the possibilities to provide more details for the decision-support problems in question. For instance, “being suitable for a job” in applicant screening, which meant that an applicant fulfils the requirements of a job, could have been misconstrued as meaning that the applicant is among the top candidates. To improve valid understanding of the problems, a large-scale experiment with scenarios or videos would be necessary, ideally with repeated measurements of perceptions of expert and algorithm performance within-subjects.67. This contrasts with their actual use for individual classification5, as we applied them for our decision-support problem. However, we introduced the developers’ terminology of “predicting the risk of recidivism” (instead of “predicting recidivism”), which may have hampered item comprehension by inviting participants to conclude that not all offenders will (not) recidivize according to the prediction. In that case, participants would have expected and likely accepted more errors. This would imply that our assessment in fact underestimated error expectations and acceptance regarding the prediction of actual recidivism.The developers of COMPAS state that the risk scales were designed to identify risk groups, “not a particular high-risk individual” (p. 31)Another limitation to the present study is that the estimates for the actual accuracy of the credit scoring algorithm are self-reported by the SCHUFA. The accuracy estimates for COMPAS, in contrast, stem from independent scientific studies. The SCHUFA being a commercial company, one could argue that their estimates of their own algorithms might be inflated. We have no evidence of this possibility, but if it were the case, that would mean that the public overestimates the accuracy of the algorithm to an even greater extent than what we show in Fig. Nor can we exclude the possibility that people in Germany have a more precise sense of the accuracy of other ADM systems, as we could only compare respondents’ estimates to the available accuracies for the domains of credit scoring and recidivism prediction. However, given the lack of further learning possibilities or transparent information available for other ADM systems, we have no reason to assume that the overestimates are unique to recidivism and credit scoring.68, including the ability to evaluate the performance of predictive algorithms. Accordingly, schools need to teach students the requisite concepts to understand ADM systems, including input, output, consequences, features, feature weights, fairness, and performance-related properties such as false alarm rate, miss rate, positive predictive value, and cross-validation, along with the skills to locate the relevant information.Currently, ADM systems are spreading across most life domains, including personalized medicine, consumer scoring, credit scoring, insurers’ customer classification, people analytics, learning analytics, and predictive policing. This cultural change requires digital risk literacy on the part of citizens69.Yet knowledge of the actual performance that is delivered by credit scoring and recidivism prediction does not suffice. With regards to both algorithms and experts it is important to keep in mind that people are sensitive to different types of error because these present different costs for them and others. Laypeople consider these potential costs when confronted with algorithmic decision support. Educational materials on decision-support systems should thus inform readers about the performance of algorithms. Facilitating this understanding, however, also requires a culture of transparency and trust, cultivated by commercial firms or imposed by regulators, in which people gain easy access to relevant information about the reliability of algorithms in credit scoring, people scoring, and other critical domains70 because it is a high-quality sample of the population in Germany, including immigrants and resident foreigners, randomly selected from a set of randomly selected places in Germany. Within this longitudinal survey, which started in 2011, all household members 16 years of age and up are interviewed in person annually, mitigating usual sampling biases due to high age, low affinity for technologies, or vulnerable status. The panel’s representativeness relies on interviewing split-offs (younger panel members founding their own families). Informed consent was obtained from all respondents. Our sample with 3086 respondents ) is representative of the adult population in Germany71 (Supplementary Table The study data were collected as a part of the “Innovation Sample” of the German Socio-Economic Panel Study (SOEP IS)In accordance with an experimental between-subjects design, after responding to credit scoring items, respondents were randomly assigned to either algorithm or expert predictions . The study was approved by the Institutional Ethics Board of the Max Planck Institute for Human Development . It was carried out in accordance with the guidelines and regulations of the Max Planck Society for the Advancement of Science in Germany and in accordance with the Declaration of Helsinki.We used four partially known scenarios to introduce ADM systems, of which credit scoring is fully established in Germany, recidivism prediction is established outside Germany, and suitability prediction is currently being established in Germany; the evaluation of healthy behavior was derived from established health bonus programs.Error rates for each algorithm and each expert were assessed with a normalized frequency format for both types of errors: missing targets and false alarms. The algorithms described in the items . Standard demographic variables from the SOEP survey that we used (see an overview in Supplementary Table A validated self-report item about risk attitudeOur segment of the household survey began with an introductory example about security scanners that illustrated the types of errors in classification (Supplementary Table Data were analyzed with regression techniques. All data were weighted on the person level to fine-tune for representativeness.Supplementary Information.


To address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, and were included in assessment of eating disorder symptom presentation.All cisgender male youths who presented for specialized eating disorder treatment at one of two sites were invited to participate, along with a group of matched cisgender females, and all youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment.A total of 27 males, 28 females and 6 trans youths took part in the study. At baseline, Kruskal–Wallis tests demonstrated that trans youths reported higher scores than cisgender male and female youths on measures of eating pathology (Eating disorder examination-questionnaire (EDE-Q) and the body fat subscale of the male body attitudes scale (MBAS)). These analyses demonstrated that there were no differences between cisgender male and female youths on eating disorder symptoms at baseline. However, repeated measures ANOVA demonstrated that males had greater decreases in eating pathology at discharge than did females, based on self-reported scores on the EDE-Q, MBAS, and Body Change Inventory.Gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths, though no differences between cisgender males and females emerged at baseline for eating disorder symptom presentation. Contrary to expectations, there were no gender differences in measures of muscularity concerns. Males demonstrated greater eating disorder symptom improvements than females, suggesting that male adolescents may have better treatment outcomes than females in some domains. Research in the field of eating disorders has focused on females, and less is known about the symptom presentation and treatment outcomes in males and gender minority youths. This prospective study set out to assess gender differences in eating pathology and treatment outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, yet there is limited research on gender differences in muscularity concerns in treatment-seeking youths with eating disorders. Participants include cisgender male youths, matched cisgender females, and gender diverse youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment. Some gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths. There were no differences between cisgender males and females in eating disorder symptom presentation at baseline, and contrary to expectations, there were no gender differences in measures of muscularity concerns. However, males demonstrated greater eating disorder symptom improvements than females. The predominance of research on females with eating disorders has led to gaps in knowledge about eating disorder symptom presentation in males and gender minorities. Murray and colleagues  highlighWithin the limited literature on male eating disorders, there appears to be a higher proportion of pediatric males seeking eating disorders services in comparison to adult males. Adult eating disorders services report that males represent as little as 5% of referrals , with a There are some demographic and clinical differences between male and female children and adolescents who present to eating disorder services. Male youths are typically younger than females at admission, are more likely to identify with an ethnic minority group, and have a higher likelihood of having an “atypical” or “other” eating disorder diagnosis , 26, 44.There are also differences in the eating disorder symptoms reported by males compared to females. Male adolescents with eating disorders report lower scores on the Eating Disorder Examination in comparison to females , 44. A rMuscularity-related concerns are not captured in the most common validated questionnaires in eating disorders, which tend to focus on thinness, and body parts that may be more relevant to females . MusculThe research on sex and gender differences in treatment outcome for eating disorders generally suggests that males and females respond similarly to treatment. A recent secondary analysis of randomized controlled trials investigated gender differences in treatment outcome, which demonstrated that boys with anorexia nervosa respond similarly to girls . In a laMany of the papers examining differences between males and females do not indicate whether they were assessing sex assigned to participants at birth, or gender, and whether there were any participants who did not identify with the sex assigned to them at birth. Gorrell and colleagues  indicateTo address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. The current study also examined symptoms of depression and obsessive–compulsive disorder, given research on adults reporting differences in both these symptoms among males and females . MeasureAll cisgender male youths who were admitted to the Provincial Specialized Eating Disorders Program for Children and Adolescents at the British Columbia (BC) Children’s Hospital or Looking Glass Residence between September 2015 and February 2019 were invited to participate. Male participants were matched with the next cisgender female who met matching criteria outlined by the research team and was admitted to the program.Potential participants  who provided permission to be approached by the research team were provided with information about the study around the time of their admission to the program. Participants who were receiving treatment at the Looking Glass Residence who had reached the age of majority (19 years) provided signed consent, as did parents/caregivers. Children and adolescents ages 18 and under provided signed assent. Participants were asked to complete measures at baseline (at assessment/admission to the program), discharge,BC Children’s Hospital Provincial Specialized Eating Disorders Program for Children and Adolescents typically offers treatment for those between 7 and 18 years, while Looking Glass Residence offers specialized eating disorders treatment for those between 16 and 24 years. An overview of the clinical programs offered in the Provincial Specialized Eating Disorders Program at BC Children’s Hospital and the Looking Glass Residence are reported by Coelho and colleagues .Upon obtaining assent and consent, participants were provided with a link to complete study measures online via Research Electronic Data Capture (REDCap), which is hosted at the BC Children’s Hospital Research Institute. REDCap is a secure, web-based application designed to support data capture for research studies . FamilieData in the current report focus on data from the youths, parent data will be reported separately. Data from interviews with parent participants in the study have been previously reported , and bodYouths were asked to complete a demographics questionnaire, which included questions about the sex assigned to them at birth, gender identity, and ethnicity. Participants were also provided with questionnaires that assessed both eating disorder and general psychiatric symptoms.Eating disorder examination-questionnaire : This escents, , which hescents, , with a escents, , and a uescents, . CronbacBody change inventory : This 1ry : This 1d : This iCentre for epidemiological studies-depression scale (revised) : This b : This 2p < 0.05. Descriptive statistics, including mean and standard deviation , and median and interquartile range  are also reported.Scores on self-report questionnaires were calculated if less than 10% of items were missing, with averaging of available items employed to generate subscale and total scores if there was missing data. Non-parametric tests  were conducted to assess differences between male, female, and trans youths at Time 1 for continuous measures, given unequal sample sizes across groups and violations of normality for some measures based on Kolmogorov–Smirnov test . Chi-square analyses were employed to test group differences for categorical measures. The alpha level was set at n = 19 males, 18 females had scores at both Time 1 and Time 2 for EDE-Q, no missing total scores for other 3 primary eating disorder measures, and for psychiatric symptoms, 19 males had data available for OCI-CV at both time points, data were available at both time points on the OCI-CV for all females, with no missing scores for the CES-D). There were violations of the assumption of normality for some of the measures at Time 2 , but given that sample size was similar across groups, and values for skewness and kurtosis were less than 2 for all measures, repeated measures ANOVA was considered to be an acceptable approach. Given the small sample of trans youths, there was insufficient power to analyze changes in this group. Means and percentage change are presented for comparative purposes. None of the measures for trans youths had violations of normality at Time 2. Analyses were conducted using SPSS Statistics version 26.Treatment outcome data in male and female youths (changes from Time 1 to Time 2) were analyzed with repeated measures analysis of variance (ANOVA). A decision was made to conduct an available case analysis, given the small sample of male youths, and the fact that data were available for all participants for the majority of the primary measures for the 20 male and 20 female participants who completed both Time 1 and Time 2 measures (n = 1), transgender female (n = 1), and transgender male (n = 4). There were an additional four males who were admitted to BC Children’s Hospital or the Looking Glass Residence during the study period who declined to participate, representing a 87% participation rate for males. Consent and assent were obtained for one male participant who subsequently disengaged from treatment and did not complete questionnaires. Five females declined to participate (85% participation rate), and one female participant completed only one measure at Time 1. No trans youths declined to participate. Eating disorder diagnoses and other demographic and clinical information for the sample are presented in Table p = 0.79). Differences in age across male, female and trans youths did not reach statistical significance, H(2) = 4.86, p = 0.088. No significant group differences emerged for ethnicity ,H(2) = 0.63, p = 0.73).A total of 27 males, 28 females, and 6 trans youths participated in the study. Trans youths included those who identified as non-binary/genderqueer n = , transgemale n = . There wH(2) = 9.12, p = 0.010. Pairwise comparisons demonstrated that trans youths reported higher scores than did male youths (p = 0.003) or female youths (p = 0.037). No differences emerged between male and female youths (p = 0.149). Scores on symptom measures at Time 1 are presented in Table Group differences emerged for EDE-Q global scores, H(2) = 9.71, p = 0.008. Pairwise comparisons demonstrated that trans youths reported higher scores than did either male (p = 0.002) or female (p = 0.008) youths. No differences emerged between male and female youths on the body fat subscale. Group differences on the muscle subscale (H(2) = 2.69, p = 0.26) and height subscale (H(2) = 6.36, p = 0.042) did not reach Bonferroni-corrected significance.Scores on the MBAS subscales were examined separately, given problems with the internal consistency of total scores on this measure. Bonferroni correction (0.05/3) was applied for the subscale analysis, to control for alpha inflation given that the a priori analytic plan was to examine the total score on this measure. Group differences emerged on the body fat subscale score, H(2) = 3.59, p = 0.167, or the OEQ, H(2) = 1.03, p = 0.598.No group differences emerged on scores on either the BCI, Given the relatively large proportion of participants who did not report body image concerns, follow-up analyses were performed in which only those who endorsed body image concerns were included. The pattern of results did not change with this subanalysis.5H(2) = 13.50, p = 0.001. Pairwise comparisons demonstrated that male youths reported lower scores than did either female (p = 0.002) or trans (p = 0.004) youths. No differences emerged between female and trans youths (p = 0.31). Significant group differences also emerged on the CES-D, H(2) = 13.75, p = 0.001. Trans youths reported higher scores than did females (p = 0.04), who in turn reported higher scores than males (p = 0.02). The difference between males and trans youths also reached significance (p = 0.001).Group differences emerged on the OCI-CV, χ2  = 0.05, p = 0.83, Phi = 0.03], nor were there significant differences in the proportion of youths who reported body image concerns who took part at Time 2 . No differences in length of treatment for males and females emerged for the sample of 40 participants who completed measures at Time 1 and Time 2, U = 249.50, p = 0.18. Details of the cisgender male and female participants who completed both Time 1 and Time 2 are provided in Table A chi-square analysis was performed to examine if there were any predictors of attrition at Time 2. All trans youths (n = 6) completed Time 2 measures, and were not part of the repeated measures analyses so were not included in analyses of predictors of attrition. There were no differences in the proportion of males  and females n = 20, 71.4% of initial sample) who completed measures at Time 2 [F = 121.85, p < 0.001, partial η2 = 0.76, with the mean mBMI of the sample increasing from 86.80% (SD = 12.09) to 99.35% (SD = 11.32). There was not a significant interaction with gender, F = 1.28, p = 0.26, partial η2 = 0.03.There was a significant effect of time on participants’ percentage median Body Mass Index (mBMI) from Time 1 to Time 2, F = 20.97, p < 0.001, partial η2 = 0.38, as well as a significant interaction between time and gender, F = 4.24, p = 0.047, partial η2 = 0.11. Paired t-tests on raw EDE-Q scores were conducted to further examine the interaction, which demonstrated that males had a significant decrease in EDE-Q scores from Time 1 to Time 2 (t(18) = 4.59, p < 0.001, d = 1.15), whereas females did not demonstrate a significant change in scores (t(17) = 1.39, p = 0.18, d = 0.34). A similar pattern of results was obtained for MBAS total scores, F = 5.23, p = 0.028, partial η2 = 0.12, as well as a significant interaction between time and gender, F = 4.24, p = 0.046, partial η2 = 0.10. Paired t-tests were conducted to examine the interaction, which demonstrated that males had a significant decrease in MBAS scores from Time 1 to Time 2 (t(19) = 2.92, p = 0.009, d = 0.61), whereas females did not demonstrate a significant change in scores (t(19) = 0.17, p = 0.86, d = 0.03).Mean scores across treatment for males, females, and trans youths are reported in Table p = 0.054) total scores on the BCI were log transformed. Repeated measures analyses demonstrated a significant effect of time on BCI scores, F = 20.16, p < 0.001, partial η2 = 0.35, as well as a significant interaction between time and gender, F = 4.82, p = 0.034, partial η2 = 0.11. Paired t-tests on raw BCI scores were conducted to examine the interaction, which demonstrated that males had a significant decrease in scores from Time 1 to Time 2 (t(19) = 5.51, p < 0.001, d = 1.13), whereas females did not demonstrate a significant change, t(19) = 1.71 p = 0.10, d = 0.35.Due to a violation of equality of error variance, and a marginally significant violation of equality of covariance  = 11.61, p = 0.002, partial η2 = 0.23, with scores decreasing from Time 1 to Time 2, but no significant interaction between time and gender, F = 1.98, p = 0.17, partial η2 = 0.05.Due to a violation of equality of covariance and equality of error variance, total scores on the OEQ were transformed. Log transformation corrected the violation of equality of covariance . Repeated measures analyses demonstrated that there was a significant effect of time on OEQ scores, Trans youths reported decreases of 20% on the EDE-Q global scores from Time 1 to Time 2, 11% on the OEQ, and 16% on the BCI. Cisgender female youths reported similar reductions on the EDE-Q (28%), OEQ (9%), and BCI (14%). The percentage reductions for cisgender males were 69% on the EDE-Q, 25% on the OEQ, and 32% on the BCI.F = 10.35, p = 0.003, partial η2 = 0.22, but no significant interaction between time and gender, F = 1.06, p = 0.31, partial η2 = 0.03. Similarly, there was a significant effect of time on CES-D scores, F = 9.91, p = 0.003, partial η2 = 0.21, but no significant interaction between time and gender, F = 2.14, p = 0.15, partial η2 = 0.05.Due to a violation of equality of covariance and equality of error variance, total scores on the OCI-CV and CES-D were log transformed. Repeated measures analyses demonstrated that there was a significant effect of time on OCI-CV scores, Trans youths reported decreases of 11% on the CES-D and 14% on the OCI-CV from Time 1 to Time 2. In contrast, cisgender female youths reported reductions of 21% on the CES-D and 4% on the OCI-CV, while cisgender male youths reported 49% reduction on the CES-D and 27% reduction on the OCI-CV.Trans youths reported higher levels of eating pathology on the EDE-Q, as well as the body fat subscale of the MBAS at Time 1, relative to cisgender males and females. Contrary to expectations, no differences between males and females emerged on the MBAS or the BCI, which assess male-relevant concerns including muscularity and strategies to increase body size/muscle size. No group differences emerged on the OEQ, a measure of obligatory exercise. In line with hypotheses, males reported lower levels of depression and obsessive–compulsive symptoms than did females, and also lower scores than trans youths. The lower levels of psychiatric symptoms reported by males in the current study aligns with previous reports that adult males have lower depressive and obsessive–compulsive symptoms . The lacAs expected, there were significant decreases in both eating disorder and psychiatric symptoms over the course of treatment. There were no differences in treatment outcome between males and females on the psychiatric measures of depressive and obsessive–compulsive symptoms, nor were there differences on measures of obligatory exercise. Similarly, both males and females demonstrated an increase in percentage body mass index over the course of treatment. However, males demonstrated a better outcome than females on some of the eating disorder symptom measures, including the EDE-Q, MBAS, and BCI. The better outcomes in males than females aligns with some previous reports e.g., , 45, 47), 4745, 4Given the inclusion of children and young adolescents in the current study, some differences in muscularity concerns may have been obscured. A large study of male adolescents and young adults demonstrated that muscularity concerns emerge in mid to late adolescence . SimilarThis study is one of the first to report on treatment-related changes in measures of eating disorder and other psychiatric symptoms in a sample of trans youths. It is noteworthy that trans youths reported significantly higher eating disorder symptoms than did cisgender males or females at Time 1 as measured by the EDE-Q. Trans youths who participated in large surveys in Youth Health or College Assessment surveys in public schools and colleges also reported higher levels of eating disorder symptoms relative to cisgender youths  is needed to assess whether gender differences persist over time. There were also challenges in matching some males to females, including delays in finding females who met matching criteria, meaning that youths did not always overlap in the timing of their treatment. The matching also did not account for changes in treatment plan and intensity or the course of treatment . The timing of participants’ completion of Time 1 and Time 2 measures also did not always align with the dates of their admission and discharge, with some participants requiring several reminders to complete the measures. Furthermore, the small sample of trans youths, and differing sample sizes across cisgender and trans youths, led to non-parametric tests being conducted to assess gender differences at Time 1 and precluded the inclusion of trans youths in repeated measures analyses.The current study demonstrates that there are limited differences between cisgender males and females in eating disorder symptom presentation at baseline. However, males demonstrated greater eating disorder symptom improvements than females, in alignment with some previous reports. Longer-term follow-up is needed to establish whether these improvements persist over time. Trans youths demonstrated higher scores on measures of eating pathology relative to cisgender youths. There was a lack of gender differences in measures of muscularity concerns, and a lack of treatment-related changes on measures that assessed muscularity and other male-relevant concerns in cisgender females. Future research elucidating the nature of muscularity concerns in cisgender females with eating disorders, and how these concerns may differ from those of males, is warranted. Additional research establishing the psychometric properties of eating disorder symptom measures in trans youths is also warranted.


Herbaria are invaluable sources for understanding the natural world, and in recent years there has been a concerted effort to digitize these collections. To organize such efforts, a method for estimating the necessary labor is desired. This work analyzes digitization productivity reports of 105 participants from eight herbaria, deriving generalized labor estimates that account for human experience.Individuals’ rates of digitization were grouped based on cumulative time performing each task and then used to estimate a series of generalized labor projection models. In most cases, productivity was shown to improve with experience, suggesting longer technician retention can reduce labor requirements by 20%.Using student labor is a common tactic for digitization efforts, and the resulting outreach exposes future professionals to natural history collections. However, overcoming the learning curve should be considered when estimating the labor necessary to digitize a collection. During the digitization of eight herbaria Table  affiliatFactors such as location, space, specimen organization, and scope of digitization tasks make every digitization effort unique and difficult to generalize. Due to this uncertainty, the pre‐digitization curation necessary to prepare for such a project  is not examined in detail. Tasks that ultimately follow pre‐digitization curation  include: affixing barcode labels (referred to herein as “barcoding”), imaging, and transcribing label data .Few works have published digitization rates from which to reference  determine the average rate of worker improvement as a function of experience, and (2) derive labor estimates across a range of specimen counts for barcoding, skeletal databasing, and imaging tasks. Additionally, we attempt to characterize the nature and impact of the unexpected setbacks experienced throughout the project.https://sernecportal.org), which was built on the Symbiota platform .Technicians from each collection were trained on digitization tasks and provided stepwise workflows consistent with those proposed by Nelson et al. . TraininGoogle Forms was used as a reporting tool whereby any workers on this project, whether volunteers, hourly workers, work‐study students paid by a university, or students working for academic credit on independent study, were required to report minutes spent, tasks performed, and any setbacks experienced during each work session. For consistency, pulldown or selection menus were created for student name, date, and host herbarium. Additionally, data validation was enforced for numeric inputs . Workers were instructed to never round time beyond the nearest five minutes and to report as precisely as possible the exact number of specimens barcoded, imaged, or skeletally databased. A free‐entry field was provided to describe any setbacks or problems that may have occurred that were not representative of a typical workflow .https://www.python.org/), using the Pandas library . Any setback description not matching an acceptable phrase was identified as a non‐typical measurement resulting from a significant setback. These setback entries were set aside for separate evaluation and omitted from subsequent task rate analyses. Phrases indicating “training” were not among the acceptable phrases; therefore, the time invested during initial training of new technicians is not accounted for in the task rate analyses. Extreme outliers were defined as entries with any numeric values exceeding five standard deviations within that field. A total of 5158 hours across 2475 entries remained in the post‐cleaning data set following these cleaning operations.After cleaning, session report data were grouped by technician name and sorted by ascending date of work session. Additional fields were calculated to track individuals’ cumulative time performing each task at the time the report was submitted. All technicians’ cumulative task times were then grouped into shared two‐hour bins. The mean rate of performance  for each task was calculated among all entries present in each two‐hour bin. This allowed non‐contemporary technicians to be compared at times when they had achieved approximately equal experience. The task rates per bin were then fit to a regression scatterplot using the Python Seaborn library  among setback descriptions were as follows: “specimen(s)” (68), “training” or “blitz” (59), “sernec” (43), “skeletal” (31), “slow” (25), “barcode(s)” (17), “imaging” (15), “folders” (14), “computer” (14), “label” (14), “missing” (13), “camera” (11), “collector” (11), “setting” (11), ”repair” (11), “internet” (9), “species” (9).Reporting a project‐wide digitization rate based on these data will depend on how one defines a specimen as being digitized and which hours are included as contributing to that effort. Here, three project‐wide rates are reported using various methods to determine both total specimens digitized and total hours contributing to the effort Box . Using tBOX 1Across all tasks and collections, 7808 hours were recorded; after cleaning, 5023 total hours remained. Of the post‐cleaning hours, 3493 were spent on the primary digitization tasks  with the remaining 1530 hours spread across other tasks . Across all collections, post‐cleaning, primary digitization task rates were as follows: 229,333 specimens were imaged at 2.30 per minute over 1660 hours, while 231,307 specimens were skeletally databased at 3.14 per minute over 1228 hours, and 180,949 barcodes were applied at 4.07 per minute over 740 hours.y = 1.95170 + 0.02118x. Skeletal databasing rate as a function of cumulative time is estimated as y = 2.55659 + 0.02760x. Although average barcode application rates initially improved with cumulative time, they exhibited an inflection point after which rates began to decrease following additional time performing the task. Therefore, barcode application rates were fit to a second‐order polynomial , the derived estimation formulas assume unrealistically ideal scenarios. From the 7808 total pre‐cleaning hours documented, approximately 12% (946 hours) contained significant setbacks. The mean session duration  increased by 32% when a setback was present. Subjectively, the majority of the setbacks documented were of a technical nature . In addition to the setbacks, nearly 12% of pre‐cleaning hours (918 hours) were identified as having been from non‐representative reporters. Labor estimates derived from these formulas using 45‐hour contract durations underestimate the actual labor expenditures of the participating collections by 25%. In light of these caveats, we recommend efforts using these data include a similar session‐rate tracking system and add an appropriately sized “unanticipated setbacks” buffer  to the labor budget.Labor estimations based on Table We evaluated 7808 hours of herbaria‐digitizing activities spanning 34 months across a workforce of 105 people. These data were assessed and presented in a way that highlights the average rate of worker improvement as a function of cumulative experience and to provide labor estimates for common digitization tasks; thus, they may be used by differently sized collections or projects to estimate labor costs. We believe the estimations presented are achievable when using similar workflows and incorporating individual session‐rate tracking tools into the digitization effort. Because these estimates represent the rates possible when no unforeseen delays are present, we recommend an additional 20–30% of labor funding be included to account for setbacks such as those discussed here.C.P. designed and performed the analysis, produced figures and tables, wrote the original draft, and assisted J.S. in data curation and project supervision. A.K., R.F., E.R., E.G., S.K., B.R., A.B.M., and J.S. substantially contributed to data curation, project administration, and supervision, as well as draft review and editing. A.B.M., J.S., E.G., and B.R. secured funding for the work. All authors approved the final version of the manuscript.


This study aimed to culturally adapt and psychometrically validate the PROMIS Social Relationships Short Forms (PROMIS‐SR) among Chinese patients with breast cancer.A cross‐sectional study.N = 965). Eligible patients filled out the demographic information questionnaire, the PROMIS‐SR, and the Functional Assessment of Cancer Therapy‐Breast.The PROMIS‐SR was translated into simplified Chinese by strictly adhering to the Functional Assessment of Chronic Illness Therapy translation method and was subsequently tested among patients with breast cancer  provided support for the original structure of the PROMIS‐SR. All instruments reported strong known‐group, cross‐cultural and convergent validity, as hypothesized. Correlation coefficients ranged from 0.67 to 0.85, and Cronbach's α of all items were high (0.90–0.94). Patients with breast cancer require constant care and support from others. Social health is a critical domain of breast cancer care related to clinical health outcomes  assess patients’ experience and priorities and may thereby promote individual care provision  supports the increased usage of PROs in guiding clinical decisions  Educational qualification of master's degree or higher;2) Linguistic and healthcare experts;3) Working as Chinese–Canadian nursing researchers or researchers who are native Chinese speakers.N = 50).Once the translators reached a consensus about the final version of the translated PROMIS‐SR, cognitive interviews were conducted among native Chinese‐speaking adolescents to evaluate their interpretation and response to each item in the PROMIS‐SR. The PROMIS‐SR are brief and accurate instruments for assessing different types of social relationships among patients with enduring disease and the general population. Therefore, both patients with breast cancer and the general population were included in the cognitive interview. These interviews were conducted with five patients with breast cancer and five healthy participants for each item. Furthermore, participants were asked to reframe the items that were confusing or difficult to understand. The PROMIS‐SR was later modified, pilot‐tested and revised with samples of patients with breast cancer  female, 2) received a diagnosis of breast cancer, 3) received medical treatment for breast cancer, 4) aged 18 years or older, and 5) able to speak, read and write Mandarin Chinese. Patients with mental disorders or critical conditions were excluded from this study. Socio‐demographic data and the questionnaires were self‐reported by the patients. On the contrary, clinical data were obtained and reviewed from their medical records by trained nursing researchers. After given written consent to participate, the patients completed the demographic information questionnaire, the PROMIS‐SR, and the Functional Assessment of Cancer Therapy‐Breast.3.2.3Demographic information was collected from participants, using questionnaires inquiring participants’ age, religious affiliation, marital status, children, educational background, current employment, monthly family income and stage of cancer treatment.never, 2 = rarely, 3 = sometimes, 4 = usually, 5 = always)  = 10). The PROMIS‐SR has been translated and psychometrically validated in different languages with satisfactory results , was validated in this study. All items were answered using a 5‐point Likert‐type scale . The total score was computed as the sum of all subscale scores, where higher scores indicated higher degrees of quality of life  and a subscale designed specifically for patients with breast cancer (BCS) . The patients were invited to participate in the survey with the help of their nurses during hospitalization. The data were collected by trained nurse researchers in the Department of Breast Surgery from each study site. The patients were informed about the purpose, necessity, process, confidentiality, and voluntary participation requirements of the study prior to the interviews by trained nurse researchers. Signed informed consent was obtained from all patients before completing the questionnaires.3.4The SPSS Statistics 23 for Windows, Mplus 7.4 and AMOS version 23.0 were used to analyse the obtained data. Demographic characteristics, clinical characteristics, and scale scores were presented using descriptive statistics, wherein categorical and continuous variables were described using frequency, mean values, and standard deviations.2/df <3), comparative fit index (CFI >0.90), goodness‐of‐fit index (GFI >0.90), Tucker‐Lewis index (TLI >0.90), and Root Means Square Error of Approximation (RMSEA <0.08) . The sample sizes were sufficient to perform a stable model estimation by CFA  indicated that respondents with the same trait from groups with different age, education background, gender have differed probabilities of giving certain response to items , Guttman's Split‐half coefficient (> 0.70: acceptable), and item‐to‐total correlations (r > 0.30: acceptable), where higher values indicate higher item reliability . Statistical significance was set at 44.1M±SD =49.03 ± 10.34). The data showed that 92.5% of the respondents were married, 97.0% had children, 87.8% were without religious affiliation, 32.5% had received secondary school education, 63.5% were unemployed, 52.3% had a monthly family income of less than ¥6,000 (approximately $900). As for clinical information, 66.6% had crossed the stage of chemotherapy treatment and most of them were in stage Ⅱ and Ⅲ of cancer.Table 4.24.2.12/df =2.133, p <.05, GFI =0.920, CFI =0.926, TLI =0.931, RMSEA =0.038). All factor loadings were high (ranging from 0.77 to 0.87), which indicated statistically significant correlations among the items. These findings provided evidence for a good model fit of the PROMIS‐SR and provided support for the original structure.The factorial validity of the instruments was tested by performing a three‐factor CFA model Figure . The mod4.2.2In the current study, age  and educational backgrounds  were the two socio‐demographic variables tested for DIF. Table 4.2.3p <.05), followed by the PROMIS Emotional Support and FACT‐B , and lastly, the PROMIS Instrumental Support . Therefore, these results provided evidence for the convergent validity of the PROMIS‐SR.Spearman correlation coefficients reported moderate correlations between the PROMIS‐SR and FACT‐B. The highest correlation emerged between the PROMIS Informational Support and the FACT‐B   Table . Employe5) Table .4.4The PROMIS‐SR demonstrated acceptable Cronbach's α and Guttman Split‐half coefficients above the standard of 0.70 Table . All ite5Measures of social relationships play an important role in emphasizing how patients’ social environments influence their health status. To the best of our knowledge, this is the first study to conduct a translation and psychometric validation of the PROMIS‐SR in the Chinese population of enduring diseases. Additionally, the study evaluates the PROMIS‐SR in a vulnerable population—patients with breast cancer, aiming to aid nurses to satisfy the patients’ unmet social relationship needs. Findings from this work provided evidence for the reliability and validity of the PROMIS‐SR in this population.The CFA results provided evidence for the factorial validity of the PROMIS‐SR. There was no evidence for DIF concerning age and educational background; this indicates that all items were unbiased measures and reported satisfactory cross‐cultural validity. These findings were consistent with a previous study, which suggested that the English version of the PROMIS‐SR did not report any local dependency on gender, age, education, and ethnicity among adults in the US  the need for more language translation and revision, and 2) the social relationships of patients with breast cancer with different age and treatment characteristics.5.1This study had certain limitations. First, the current study sample may not be entirely representative of all Chinese patients with breast cancer because they were recruited from only three tertiary hospitals, and most of them were middle‐aged. Second, the sample only included female patients due to the lack of male patients suffering from breast cancer. Thus, future studies should include patients with different age groups and male patients to ensure the generalizability of these results. Additionally, the current study followed a cross‐sectional design and did not evaluate test–retest reliability. However, our findings provide a clinical foundation for using the Chinese version of the PROMIS‐SR among different populations and settings.6An accurate and brief social relationship needs evaluation may enable nurses to screen patients who require tailored social support. The current study findings provided evidence of adequate reliability and validity of the Chinese version of the PROMIS‐SR to perform routine assessments of social relationship needs among Chinese patients with breast cancer. Future studies are needed to draw more firm conclusions about its applicability.The authors declare that there is no conflict of interest.TC and CR: Study design, data analysis and wrote manuscript. TC, QH and CR: Analysed and interpreted the data. FW and HX: Acquired the data, revised the manuscript for important intellectual content. All authors read and approved the final manuscript.Data are available upon reasonable request.