Segmentation is a crucial step in treatment planning that directly impacts dose distribution and optimization. The aim of this study was to evaluate the inter-individual variability of common cranial organs at risk (OAR) delineation in neurooncology practice.Anonymized simulation contrast-enhanced CT and MR scans of one patient with a solitary brain metastasis was used for delineation and analysis. Expert professionals from 16 radiotherapy centers involved in brain structures delineation were asked to segment 9 OAR on their own treatment planning system. As reference, two experts in neurooncology, produced a unique consensual contour set according to guidelines. Overlap ratio, Kappa index (KI), volumetric ratio, Commonly Contoured Volume, Supplementary Contoured Volume were evaluated using Artiview™ v 2.8.2—according to occupation, seniority and level of expertise of all participants.p < 0.01). The radiation oncologists, members of Association des Neuro-Oncologue d’Expression Française society performed better in all indicators compared to non-members (p < 0.01). Our exercise was effective in separating the different participating centers with 3 of the reported indicators (p < 0.01).For the most frequently delineated and largest OAR, the mean KI are often good (0.8 for the parotid and the brainstem); however, for the smaller OAR, KI degrade , with a significant discrimination (Our study illustrates the heterogeneity in normal structures contouring between professionals. We emphasize the need for cerebral OAR delineation harmonization—that is a major determinant of therapeutic ratio and clinical trials evaluation. Howeverructures . Segmentructures –11. HoweAssociation des Neuro-Oncologue d’Expression Française (ANOCEF).This was a multicenter study endorsed by GRANOCEF, the Radiation Group of the Anonymized contrast-enhanced CT scans in treatment position of one patient treated for a solitary brain metastasis in intent of Stereotactic body radiation therapy was used for delineation and analysis. CT scans encompassing the whole brain were performed according to the following procedure: acquisition extended from the vertex to C7 with 1 mm slices every 1 mm; max 500 slices, FOV: 350 mm, image resolution: 512 × 512 (pixel size: 1.46 pxl/mm), 120 kV, 370 mAs mean (auto modulation). Mean estimated CTDI vol = 45 mGy; iodinated contrast medium injected 10 min prior acquisition at the concentration of 1.5 mL/kg—maxi 100 mL.All images were then transferred to Isogray™ treatment planning system  in DICOM format. According to published international recommendations, two referent senior radiation oncologists expert in neuro-oncology  produced a unique consensual contour set for the following 9 OAR: left parotid, left optic nerve (LON), optic chiasm, brainstem, pituitary, left cochlea, left internal acoustic meatus (LIAM), left hippocampus and anterior segment of the left eyeball (ASLE) –16. We uIn France notably, OAR delineation can be delegated to other professionals under the supervision of the radiation oncologist. Therefore, we solicited the professionals involved in cranial OAR delineation in their daily activity in eight RT centers in north-eastern France—academic and private. Professionals could be radiotherapy technologists (RTT) or dosimetrists, residents or senior radiation oncologists (RO). These so called “observers” were stratified according to their seniority: less than 3 years, between 3 and 10 years and more than 10 years of practice.European Greater Region Radiation Oncology Consortium .In addition, in December 2017, we solicited the expert radiation oncologists involved in ANOCEF (Association of French-speaking Neuro-oncologists) in France as well as those participating in our AQUILAB made available a dedicated secured website to download the pre-mentioned anonymized DICOM imaging as well as a procedure to delineate the set of OAR (procedure available upon request) and upload the contours. Each participant had to register with personal ID and password prior to the exercise. The participants (observers) delineated the set of OAR, on all slices, blind to other contours, using their own segmentation tools and according to their daily practice. The resulting set of OAR was labeled with an anonymous ID. In parallel, we collected the occupation, seniority and level of expertise in the position of all participants.The variability and the differences in the delineated volumes were quantified using Artiview™ v2.8.2 software .The comparative analysis was performed by using specific metrics  is defined as the ratio between the intersection of Cn with CR and their union . (OptimaDice similarity coefficient or Kappa Index (KI) or Cohen’s Kappa was used to determine the agreement between the reference contour and the user’s contour, as described elsewhere . Kappa vThe volumetric ratio (VR) defined as the ratio between Cn and CR; The Commonly Contoured Volume (VCC) is defined as the ratio between the intersection of Cn with CR and CR; The Supplementary Contoured Volume (SCV) is defined as the ratio between the difference of Cn with From Receiver Operating Characteristics (ROC) we can also measure the following indexes:In order to study the human factor separately, it appeared necessary to evaluate three types of contouring uncertainties that could be linked to the technology with a second study: (1) inaccuracy of the manual contouring tools of the TPS used by the observers, (2) imprecision of the thresholding automatic when used to contour, (3) uncertainties related to the import–export of structures from the local TPS to the centralized analyze interface.Contour manually with its own tools 4 imposed left structures made hyperdense: left parotid, LON, left hippocampus and L-ASLE.Contour these same 4 left structures with automatic thresholding (3000 HU).To address these three points, the experts delineated the contralateral (right) structures. AQUILAB then sent back the observers the reference contrast-enhanced CT scans as well as a RT-STRUCT file containing the right OARs and additional structures to be contoured. One radiation oncologist per center had then to carry out 2 additional tasks, ideally using the same station as during the first exercise.The RT-STRUCT files enriched with the contours produced were then centralized back for analysis with the previously described metrics.A descriptive analysis of original contours was performed on all variables. Quantiles, mean and standard deviation were evaluated for quantitative variables. Qualitative variables were summarized with their levels’ frequencies. For statistical purposes, centers with only one professional were pooled within center #6. Comparisons between different groups was assessed by a one-way analysis of variance (ANOVA). When a significant difference was found, we used a Tukey’s post-hoc test, which was corrected for multiple comparison, to perform individual comparisons.In the second study, to assess the three potential technical interferences a Mann–Whitney test was used. Comparisons of organ delineation performances for each exercise were assessed by a Kruskal–Wallis test. When a significant difference was found, we used a Mann–Whitney test, which was corrected for multiple comparison, to perform individual comparisons.p < 0.05. All statistical analyses were performed on R version 3.5.3 .Significance threshold was set to The database was frozen on April 2018.Professionals from sixteen centers uploaded their sets of structures representing overall 57 professionals: 33 senior radiation oncologists (including 11 ANOCEF members), 18 residents training in radiation oncology (out of whom one—AQ21—was excluded due to an aberrant contour set) and 6 “specialized” RTT ; however, for the smaller OAR, KI degrade  Fig. .Fig. 1Kap < 2.0 × 10–16), VSC (p < 2.0 × 10–16) and KI (p < 2.0 × 10–16). The VCC, OV and KI of the largest organs (i.e. parotid and brainstem) were significantly greater than those of the smaller structures—i.e. Chiasm, Cochlea, Pituitary, LON, LIAM, ASLE.  .All the RTT who participated in the study represented only one center, so we analyzed only the RO and residents’ populations.p = 2.0 × 10–5). The RO performed better than the residents . There is no significant difference for any of the other performance parameters studied.There is a significant difference in the VCC between occupations (We did not find any significant difference in the performance parameters studied based on the experience of the subjects.p < 0.01 except for VCC with p = 0.06) , the VCC (p = 3.1 × 10–8), and the KI (p = 6.1 × 10–4) and a trend for the VSC (p = 1.5 × 10–2)  avoid deviations from the treatment plan at the individual level, and (2) collectively not introduce bias in the results of radiotherapy clinical trials.Additional file 1: Figure S1. Surface metrics used in the study. CR: Reference contour delineated by the experts according to published recommendations (red disk); Cn: Observer(s) contour(s) (blue disk).Additional file 2: Figure S2. KI according to ANOCEF membership, **p < 0.01.Additional file 3: Table S1. Investigation of organ effect on the technical uncertainties ; shaded cells = lack of statistical significance.


Z‐score < –2.0). In transwomen lumbar spine BMD did not change , but lumbar spine Z‐score increased by +0.22  after 10 years of HT. Also in transmen lumbar spine BMD did not change , but lumbar spine Z‐score increased by +0.34  after 10 years of HT. This study showed that HT does not have negative effects on BMD, indicating that regularly assessing BMD during HT is not necessary. However, a high percentage of low BMD was found prior to HT, especially in transwomen. Therefore, evaluation of BMD before start of HT may be considered. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals, Inc.Concerns about the effects of gender‐affirming hormonal treatment (HT) on bone mineral density (BMD) in transgender people exist, particularly regarding the decrease in estrogen concentrations in transmen. Although it is known that HT is safe for BMD in the short term, long‐term follow‐up studies are lacking. Therefore this study aimed to investigate the change in BMD during the first 10 years of HT, to determine whether HT is safe and if assessing BMD during HT is necessary. A follow‐up study was performed in adult transgender people receiving HT at the VU University Medical Center Amsterdam between 1998 and 2016. People were included if they were HT naive and had a dual‐energy X‐ray absorptiometry (DXA) scan at the start of HT. Follow‐up DXA scans performed after 2, 5, and/or 10 years of HT were used for analyses. The course of BMD of the lumbar spine during the first 10 years of HT was analyzed using multilevel analyses. A total of 711 transwomen  and 543 transmen  were included. Prior to the start of HT, 21.9% of transwomen and 4.3% of transmen had low BMD for age ( Sex hormones influence bone acquisition and metabolism. Men develop wider bones and greater cortical bone size than women due to periosteal apposition.Gender‐affirming hormonal treatment (HT) in transgender people influences bone metabolism. After 1 year of HT the BMD increases in transwomen ,n < 50) cross‐sectional case‐control studies, with contradictory results. In transwomen compared with control men, higher,Z‐scores after 7.6 years of HT.The long‐term effects of HT on BMD have been investigated using small‐sample  did not apply to this study, and necessity for informed consent was waived due to the retrospective design.This study is part of the retrospective Amsterdam Cohort of Gender Dysphoria (ACOG) study, including all 6793 people who once presented themselves at the gender identity clinic of the VU University Medical Center (VUmc), Amsterdam, the Netherlands, between 1972 and 2016. Study design has been described.2. Absolute BMD values (g/cm2) were obtained and were converted into T‐scores (standard deviation [SD] difference between the person's BMD and the BMD of a young‐adult reference population of the same birth‐sex and ethnicity) and Z‐scores (SD difference between the person's BMD and an age‐matched BMD of the same birth‐sex and ethnicity), based on the National Health and Nutrition Examination Survey (NHANES). In addition, T‐scores and Z‐scores on baseline were also calculated using the identified sex as reference population. Osteoporosis was defined as a T‐score below –2.5, and a Z‐score below –2.0 was classified as low bone density for age.BMD measurements were performed during regular patient care before the start of HT and were usually repeated every 2 to 5 years during HT. BMD of the lumbar spine (LS), total hip (TH), and femoral neck (FN) were measured using a DXA Hologic Delphi, which was updated in July 2004 and replaced by a Hologic Discovery A in February 2011 . Phantom calibration allowed for comparison of BMD values with a difference of <1.0% between the densitometers. Coefficients of variation were <1.0% for both densitometers and least significant change was 0.022 g/cmBlood samples were obtained during regular patient care before the start of HT, after 3 months of HT, and thereafter usually every 1 to 2 years. Higher‐quality assays were implemented when available, and conversion formulas were generated to allow for comparison of the old and new values.Estradiol was measured using a radioimmunoassay  with a lower limit of quantitation (LOQ) of 18 pmol/L and an interassay coefficient of variation (CV) of 10% until January 2010, after which a competitive immunoassay  was used until July 2014 . The formula Delfia = 1.267 × Diasorin–28.87 was used for conversion. After July 2014, LC‐MS/MS  was used . For conversion, the formula LC‐MS/MS = 1.60 × Delfia–29 was used.Testosterone was measured using a radioimmunoassay  until January 2013 . Thereafter, a competitive immunoassay  was used . For conversion, two formulas were used: Architect = 1.1 × RIA+0.2 for testosterone concentrations <8 nmol/L; Architect = 1.34 × RIA–1.65 for testosterone concentrations >8 nmol/L.Luteinizing hormone (LH) was measured using an immunometric assay  until June 2011 . Thereafter, an immunometric assay  was used . For conversion, the formula Architect = 0.91 × Delfia–0.01 was used.t tests  or chi‐square tests were used to analyze the differences in baseline characteristics between people with at least one follow‐up measurement and people without a follow‐up measurement.Baseline characteristics are reported as mean ± SD, median (interquartile range [IQR]), or percentages. Independent Z‐scores during the first 10 years of HT. Time was analyzed as a categorical variable with set time points at baseline , after 2 years of HT , after 5 years of HT , or after 10 years of HT  using dummy variables. Next, stratified analyses were performed to investigate the change in BMD over time for different age groups , sex hormone concentrations during HT, and baseline BMD. The mean estradiol, testosterone, and LH concentrations during HT were calculated by averaging the results from the laboratory measurements after 1, 2, 5, and 10 years of HT . Because no linear associations existed between change in BMD and hormone concentrations, estradiol concentrations were divided into tertiles, LH concentrations into suppressed (<1 U/L) or not suppressed (>1 U/L), and testosterone concentrations into suppressed (<2 nmol/L) or not suppressed (>2 nmol/L) for transwomen, and tertiles for transmen. Baseline BMD was divided into tertiles. Last, the multilevel analyses were repeated by adding age, estradiol, testosterone, and LH concentrations as interactions with time to the model.Linear multilevel analyses with measurements clustered within people were performed to analyze the course of absolute BMD values and For all analyses, STATA Statistical Software  version 13.1 was used.Z‐score of the LS, estradiol, testosterone, LH, and 25 (OH)D concentrations at baseline between people with and without follow‐up BMD measurements (data not shown). The baseline characteristics of the study population are shown in Table The flowchart of the inclusion of participants is shown in Fig. Z‐score of −0.93 ± 1.32 before start of HT. At baseline, 14.2% of the transwomen were classified as having osteoporosis (T‐score ≤ –2.5), and 21.9% had low bone density (Z‐score < –2.0) for age.Transwomen had a mean LS 2; 95% CI, –0.005 to +0.017 g/cm2), but LS Z‐score was +0.22  higher compared with baseline , whereas it decreased in those in the lowest tertile . There was no difference in change in LS BMD between suppressed versus not suppressed testosterone and LH. Transwomen in the lowest baseline BMD tertile  increased by +0.026 , whereas no change was observed in those in the middle  or highest tertile .After 10 years of HT, LS BMD was not different from baseline  was found in 2.4%, and low bone density for age (Z‐score < –2.0) in 4.3% at baseline.The baseline LS 2; 95% CI, –0.004 to +0.019 g/cm2), but LS Z‐score increased by +0.34  from baseline to 10 years , whereas it did not change in the younger two age groups. Baseline estradiol concentrations were lower in transmen ≥40 years  than younger transmen . No change in LS BMD was found in transmen who were categorized in the two lowest estradiol tertiles , but it increased in those who were categorized in the highest estradiol tertile  increased in BMD , whereas it did not change in the middle tertile  or highest tertile .LS BMD after 10 years of HT was similar to baseline  and 10 years (n = 4) of HT. In the overall analyses, no changes in TH BMD  and FN BMD  were found in transwomen. Also in transmen, no changes in TH BMD  and FN BMD  were found. No subgroup analyses could be performed due to the limited number of people in each of the subgroups.Only a small number of BMD measurements of TH and FN were performed after 5 years  compared with younger age groups. This finding was also described in a prospective 1‐year follow‐up study.In transwomen with higher estradiol concentrations during HT an increase in LS BMD was found, whereas low estradiol concentrations were associated with a decrease in LS BMD. Testosterone concentrations were suppressed in the majority of the population and were not associated with the change in LS BMD. LH concentrations were not associated with change in LS BMD, but were also suppressed by the use of cyproterone acetate and is therefore not indicative of adequate estrogen substitution. In transmen, estradiol and testosterone concentrations were not associated with change in LS BMD. In transmen with low LH concentrations the LS BMD increased, whereas it did not change in those with higher LH concentrations. These results indicate that in transmen, LH concentrations may be used to evaluate the adequacy of testosterone dosing for bone health, whereas in transwomen estradiol concentrations may be used to evaluate the adequacy of estradiol dosing. In addition, because LS BMD decreased in transwomen with low estradiol concentrations, therapy compliance should be stimulated.Our study was performed in the largest gender identity clinic of the Netherlands, including a large population of transwomen and transmen with a wide age range. Previous studies investigated the long‐term effects of HT on BMD in cross‐sectional studies, without baseline differences taken into account. In this study, long‐term follow‐up analyses were performed, also looking at the influence of age and sex hormone concentrations. However, there are also some limitations. First, because this study is a retrospective study, data were collected during regular patient care. Clinical data, such as smoking habits, alcohol intake, and body weight, were usually only assessed at baseline but not structurally during medical checkups and could not be reliably analyzed. Also, data about calcium intake, vitamin D supplementation, or physical activity were not available, which could also influence BMD. It might be possible that trans people gain a healthier lifestyle during HT, for example more exercising, quit smoking, and using vitamin D supplementation. Because a control group was lacking, the change in BMD cannot only be contributed to the use of HT. Although this study is retrospective, LS BMD measurements and sex hormone concentrations were regularly assessed as this was part of the treatment protocol. For this study, people were included for analyses if they had a DXA scan prior to the start of HT. No differences in baseline characteristics were observed between people with and without follow‐up LS BMD measurements, which decreases the risk of selection bias. Second, differences in change in BMD for different treatment regimens were not analyzed. Because trans people often change the type of HT they use, it could not be analyzed whether the change in BMD differs for people who use transdermal, oral, or intramuscular estrogen or testosterone. In addition, the majority of the population underwent gonadectomy during the first 10 years of HT,Z‐score was found. However, because prior to HT a high percentage of low bone density was found in transwomen, bone health should be an important topic, especially if therapy noncompliance is suspected. The results of this study support the statements of the Endocrine Society GuidelineIn clinical practice, concerns about the safety of HT on bone health are present, probably because earlier studies found low BMD after long‐term HT in transwomen compared with control men, and because of fear that HT decreases estradiol concentrations in transmen, which could have negative effects on BMD. The current results may indicate that HT does not have negative effects on bone health in trans people, because no change in LS BMD and an increase in LS The authors have no relevant disclosures to declare.


Taraxacum officinale is a distributed weedy plant used as a traditional medicinal herb belonging to the family Asteraceae. The complete chloroplast genome of T. officinale was generated by de novo assembly with whole genome sequence data. The chloroplast genome was 151 324 bp in length, which consisted of a large single copy region of 83 895 bp and a short single copy region of 18 549 bp separated by a pair of inverted repeat regions of 24 440 bp. The chloroplast genome contained 79 protein-coding genes, 29 tRNA genes and four rRNA genes. Phylogenetic analysis revealed that T. officinale was closely related to Lactuca sativa. Taraxacum, known as dandelion, belongs to the family Asteraceae and widely distributed in the temperate areas of the Northern Hemisphere. More than 2500 species are known in the genus Taraxacum , Yongin, Korea, using a modified cetyltrimethylammonium bromide protocol , Seoul, Korea. Whole genome sequence data of 1.3 Gb were generated, trimmed, and assembled by a CLC genome assembler , as described in Kim et al. (Panax ginseng (GenBank accession no. NC_006290) as a guidance. The draft sequence was validated and manually corrected by PE read mapping. The protein-coding, tRNA and rRNA genes in the chloroplast genome were annotated using the DOGMA program  was 151 324 bp in length and showed a typical quadripartite chloroplast genome structure consisting of a large single copy region of 83 895 bp, a short single copy region of 18 549 bp, and a pair of inverted repeats regions of 24 440 bp. The chloroplast genome contained a total of 112 genes including 79 protein-coding genes, 29 tRNA genes and 4 rRNA genes. The GC content of the whole chloroplast genome was 37.7%.The complete chloroplast genome of T. officinale and other 14 species belonging to the family Asteraceae, using a maximum likelihood analysis of MEGA 6.0 (Tamura et al. T. officinale was most closely related to Lactuca sativa belonging to the subfamily Cichorioideae, as expected (Phylogenetic analysis was conducted with common 68 chloroplast protein coding sequences of expected .


Antioxidants located in both the hydrophilic and lipophilic compartments of plasma act as a defence system against reactive oxygen species (ROS). Excessive production of ROS during anaesthesia affects the antioxidant capacity of plasma and may result in oxidative stress. The aim of this study was to evaluate the antioxidant capacity of lipid- (ACL) and water-soluble (ACW) antioxidants in client-owned dogs diagnosed with periodontal disease and early-stage myxomatous mitral valve degeneration (MMVD) and anaesthetised for a dental procedure with propofol and sevoflurane or with propofol only.n = 8) or with propofol only . Dogs with no evidence of MMVD  were anaesthetised with propofol and sevoflurane. Blood samples for determination of ACL and ACW were collected before and 5 min, 60 min and 6 h after induction to anaesthesia. In MMVD/PS dogs, ACL was significantly higher at all sampling times when compared to PS dogs. Compared to basal values, only anaesthesia maintained with propofol significantly increased ACL at 60 min in dogs with MMVD. In MMVD/P dogs, ACW increased after induction to anaesthesia and remained elevated up to 6 h after anaesthesia. Compared to basal values, anaesthesia maintained with sevoflurane significantly increased ACW only at 60 min in both dogs with and without MMVD. The only difference between propofol and propofol/sevoflurane anaesthesia in dogs with MMVD was significantly higher ACW at 60 min after induction to anaesthesia in the propofol group.Dogs with MMVD were anaesthetised with propofol and sevoflurane (MMVD/PS, Regarding antioxidant capacity, propofol could be a better choice than sevoflurane for anaesthesia of dogs with early-stage MMVD, although further studies are necessary to clarify the advantage of this antioxidant capacity. The heart is constantly subjected to ROS formation due to the high rate of aerobic metabolism . AntioxiPropofol and sevoflurane are commonly used anaesthetics in dogs. Propofol has a structural feature, the phenolic hydroxyl group, like vitamin E, and is believed to act as a ROS scavenger , 11. SevIn order to determine the most appropriate anaesthesia protocol for the dogs with early-stage MMVD, we determined the antioxidant capacity of lipid- and water-soluble antioxidants in dogs with MMVD which were anaesthetised with propofol alone, or in combination with sevoflurane, for a dental procedure. We hypothesised that total intravenous anaesthesia with propofol increases ACL and ACW compared with anaesthesia induced with propofol and maintained with sevoflurane in dogs with MMVD.Eighteen dogs diagnosed with MMVD ACVIM class B1 and B2, 7 females  and 11 males , weighing 17.52 ± 8.86 kg and aged 8.65 ± 3.05 years were included in the study. The control group (PS) consisted of 12 dogs with no cardiac disease, 6 females  and 6 males , weighing 23.11 ± 9.08 kg and aged 5.88 ± 2.45 years.Some samples for determination of ACW were excluded from the study due to technical problems with latent fibrin formation and the results are reported only for 7 dogs in the MMVD/PS group, 10 dogs in the PS group and 8 dogs in the MMVD/P group.p = 0.443), antibiotic administration (p = 0.443), use of regional nerve blocks (p = 0.054), age of dogs (p = 0.054) and duration of anaesthesia (p = 0.254). Ketamine was administered significantly more frequently (p = 0.017) in dogs with MMVD compared to dogs with no cardiac disease.There were no differences between the groups in periodontal/dental disease status , while a power coefficient for ACW measurements  almost reached the recommended value of 0.80 [The limitation of this study is that the dogs were client-owned, and thus the environmental and nutritional backgrounds of the dogs differed, which may have influenced the antioxidant parameters . In fact of 0.80 .Compared to basal values, ACW was significantly increased 60 min after induction to anaesthesia in both dogs with and without MMVD regardless of the anaesthesia protocol. In dogs with MMVD, ACW was significantly higher in the propofol group. In dogs with MMVD, only anaesthesia with propofol significantly increased ACL. These results suggest that regarding antioxidant capacity, propofol could be a better choice than sevoflurane for anaesthesia, although further studies are necessary to clarify the advantage of this antioxidant capacity in dogs with non-severe MMVD.This prospective clinical study was evaluated and approved by the National Ethics Committee and written informed client consent was obtained before the dogs were included in the study. All procedures complied with the relevant Slovenian  and European regulations. Client-owned dogs receiving no medication 1 month prior to anaesthesia were recruited from the University of Ljubljana Veterinary Faculty subject pool. Their health status was evaluated based on history, physical examination and blood tests including complete blood count with white cell differential count and serum biochemical analyses . Cardiovascular disease was confirmed by history, clinical examination, standard electrocardiogram and echocardiography using two-dimensional, M-mode, and colour and spectral Doppler modes .n = 30. The dogs were diagnosed with periodontal disease and scheduled for a dental procedure under general anaesthesia. Eighteen dogs were diagnosed with MMVD class B1 or B2 according to the American College of Veterinary Internal Medicine (ACVIM) classification [n = 10) or sevoflurane . The control group consisted of 12 dogs with no evidence of MMVD.All eligible dogs that were presented between June 2016 and January 2017 were included. The final sample size was fication . They weDogs were premedicated with morphine 0.3 mg/kg administered subcutaneously (SC) 20 min before induction to anaesthesia. An intravenous catheter was placed into the cephalic vein, and after 5 min of preoxygenation , anaesthesia was induced with propofol (3–6 mg/kg) intravenously (IV) and titrated to effect. The dogs were intubated endotracheally within 30 to 60 s, connected to a circle breathing system and allowed to breathe oxygen spontaneously. In dogs with MMVD, anaesthesia was maintained with propofol at 0.3–0.6 mg/kg/min IV (MMVD/P group) or with sevoflurane at an end-tidal sevoflurane concentration of 2 to 3% (MMVD/PS group). Dogs with no evidence of MMVD (PS group) were anaesthetised the same way as the MMVD/PS group. Hartmann’s solution was infused at 5 mL/kg/h IV during anaesthesia. Perioperative analgesia was supported with oral regional nerve blocks with levobupivacaine 1 to 2 mg/kg and/or IV boluses of ketamine 0.5 mg/kg. Ketamin was administered when the heart rate increased by 20% or if signs of nociceptive responses occurred during anaesthesia. Perioperative antibiotic management was carried out with cefazolin 20 mg/kg IV if clinically indicated.2 tension, respiratory rate, ECG, blood pressure (non-invasively) and rectal temperature were monitored during anaesthesia.The dogs were placed in dorsal recumbency and warmed with bags filled with warm water. End-tidal sevoflurane concentration, end-tidal CODogs with the majority of teeth present were included in the study, and a detailed oral examination  was performed prior to periodontal treatment. Dogs were divided into two groups based on their oral/dental disease for statistical analysis: ≤ 25% of the teeth affected with periodontitis and/or dental fractures and > 25% of the teeth affected with periodontitis and/or dental fractures.During recovery, the dogs were administered Hartmann’s solution at 2 mL/kg/h IV and morphine 0.3 mg/kg SC every 3 h, depending on the invasiveness of the procedure. Carprofen 4 mg/kg IV was administered after the last blood sampling. All dogs were released to home care the same day, with analgesics and antibiotics prescribed as clinically indicated. They were prescribed carprofen 2 mg/kg orally twice daily for 4 to 6 days. In case of severe acute pain, a transdermal fentanyl patch (3 to 4 μg/kg/h) was placed on the skin of the lateral thoracic region at the end of anaesthesia.Venous blood samples were collected from the jugular vein before premedication  and 5 min (immediate post induction period), 60 min (intraoperative period) and 6 h after induction to anaesthesia (postoperative period).Blood samples for determination of ACL and ACW concentrations  were collected in lithium heparin containing tubes . Samples were immediately centrifuged at 1500×g for 15 min at 4 °C and plasma immediately frozen at − 80 °C until analysis.The method is based on the chemiluminometric detection of photochemically generated superoxide anion radicals from a photosensitizer (luminol), which are partially eliminated from the sample by reaction with antioxidants present in the sample. The remaining radicals react with luminol to produce luminescence, which is measured with a PHOTOCHEM analyser  using supplied reagent kits. After defrosting and vortexing, 100 μL of plasma sample and 100 μL of methanol were pipetted in a 1.5 mL plastic container with a cap. Samples were then vortexed for 10 min and centrifuged at 25,000 rpm for 10 min at 4 °C. Sample preparation steps were performed in a dark place. Until analysis , prepared samples were held in the dark at a temperature below 4 °C. Plasma ACL and ACW were measured in accordance with the manufacturer instructions, using reagent kits  with the PHOTOCHEM analyser. The results of the ACW measurements are expressed in nmol equivalents of ascorbic acid in mL of the sample, and the results of the ACL measurements in nmol equivalents of trolox  in mL of the sample.To assess whether the propofol formulation used in the study has antioxidative properties, we also measured ACL in a sample of propofol formulation, using the same method as described above.p = 0.05, 30 dogs would be enough to achieve more than 80% power of the study. Statistical analysis was supported by the R statistical software program (version 3.2.2) with the nlme package [p < 0.05 was considered significant.An a priori sample size calculation was not performed as no comparable data from the literature regarding ACW and ACL were available to enable calculation. Post-hoc sample size calculation indicated that with an effect size of 0.5 and significance level  package . The Kru


Paravertabral blocks (PVB) are in use to adequately manage pain arising from a variety of operations on the thorax, abdomen or pelvis. PVB is straightforward, efficacious in operations performed. This study was undertaken to evaluate how efficacious ultrasound-guided thoracic paravertebral block is when used in patients undergoing percutaneous nephrolithotomy (PCN).A total of 44 patients, falling in categories I to III of the American Society of Anesthesiologists, and aged between 18 and 65 years, who were scheduled for PCN, were randomly distributed into two groups. The anaesthetic intervention group (PVB) contained 22 individuals, who were injected at level T8-T9 with 20 mL 0.25% bupivacaine as a single administration. In the control group C, also containing 22 individuals, the intervention was not carried out. The groups were compared after PCN in terms of opioid use, pain score, opioid adverse effects profile and the need for supplemental analgesia.p < 0.05). The controls used more opioid relief than the PVB group and had lower scores for satisfaction (p < 0.05).Visual analogue scale pain scores whilst at rest or moving were lower at the level of statistical significance in the PVB group compared to controls at 2 and 4 h post-surgery. At 6 and 8 h post-surgery, the control group had a lower VAS score when moving, and this result reached statistical significance (Ultrasound-guided PVB using bupivacaine and an in-plane technique provides effective analgesia in PNL. It is associated with high scores on patient satisfaction and minimal complications.ClinicalTrials.gov, NCT04406012. Registered retrospectively, on 27 May 2020. PCN (percutaneous nephrolithotomy) is a frequently employed, minimally invasive operative technique technique used to remove renal calculi . The tecThe study’s main aim was evaluating analgesic efficacy in PVB-US to the thorax, whilst the secondary aim was assessment of how satisfied patients were with the procedure and how much rescue analgesia was needed in such cases.ClinicalTrials.gov database under registration number NCT04406012. The inclusion criteria of this study were an age of 18–65 years and an American Society of Anesthesiologists classification of I or III scheduled for PCN from February 2016 to july 2016. Patients participating the study is shown in the CONSORT diagram ; previous pneumothorax; phrenic nerve paralysis; stenotic aorta of severe degree. The participants in the trial were allocated into one of two groups – those receiving the anaesthetic intervention  and control subjects – using the closed envelope randomisation technique 1 h prior to surgery before admission to the operating room by the nurse of urology yard. Monitoring electrocardiogram (ECG), peripheral pulse oximetry and external blood pressure measurement) was set up at 5 min intervals.Ethical approval was obtained from the Local Ethics Committee of Kırıkkale University, Kırıkkale, Turkey (No.04/03) and registered retrospectively on the Postoperative analgesia requirements were evaluated using the visual analogue scale (VAS), which ranges in value from 0, indicating an absence of pain, to 10, indicating pain of high severity. The evaluations were performed at 1, 2, 4, 6, 8, 10, 12 and 24 h post-surgery. The score was checked when the patient was resting and when moving (such as when deeply inspiring or coughing). A VAS score above 4 was taken to indicate a need for extra pain relief. The control group were given a standard post-surgical analgesia regime, i.e. dexketoprofen 50 mg i.v. Where administering dexketoprofen did not result in a VAS score below 4, tramadol was co-administered at a dosage of 1 mg per kg body weight.The individuals in the PVB group all received paravertebral blocks. This group all underwent monitoring via ECG, external BP measurement and pulse oximetry within theatre before PVB was undertaken. Anaesthetic induction occurred after PVB placement. The patient assumed a seated position and a linear 10–18 MHz ultrasound probe  was positioned paramedially over the space between two transverse processes. The transverse processes of the T9 and T10 vertebrae and the superior pleura and costotransverse ligament were visualised. An 80 mm long needle of 22 gauge  was inserted under ultrasonic guidance and 10 mL bupivacaine hydrochloride  dissolved in 20 ml solution was infiltrated into the paravertebral space. The needle is advanced to the point where the superior costotransverse ligament crosses the space. The dispersal of the local anaesthetic agent over the pleura was observed, along with its displacement. All PVBs were undertaken by the same, experienced anaesthetist.− 1 propofol, 0.6 mg kg− 1 rocuronium, 1–2 mcg kg− 1 fentanyl and anesthesia was maintained with sevoflurane and oxygen-air mixture. Intraoperative dose of additional opioid was different and noted in anesthesia follow-up form.After the paravertebral block was performed, all patients received standardized general anesthetic technique with 2–2.5 mg kgThe pain scores using VAS were noted in both groups post-procedure. The degree of patient comfort was also noted. The occurrence of nausea and vomiting and any need for further pain relief was noted. At 24 h post surgery patient satisfaction was noted. A scale of 1 to 5 was employed for this, ranging from 1 (very unsatisfied) to 5 (very satisfied). The same urologist performed the surgery in all cases.p value below 0.05 was taken to indicate statistical significance.A power calculation was performed with the G * Power 3.1.9.4 statistical package application using the following parameters: n1 = 22, n2 = 22, α = 0.05, (effect size) d = 0.9; (power (1-β)) = 0.83. The data obtained were evaluated using the IBM SPSS 25.0 statistical application. The Chi-Square statistic was used in comparisons. Descriptive statistics were obtained for the data , both continuous and categorical. The data were tested for normal distribution using the Shapiro-Wilk test. The independent samples t Test was employed for comparisons involving normally distributed quantitative data in the groups, and the Mann–Whitney U test was used in the analysis of non-normally distributed data. The paired samples t test (t test in dependent groups) was employed for within-group comparisons. A p > 0.05). Both groups were the same from a statistical point of view in terms of opioid use during the surgery and in post-surgical satisfaction score (p > 0.05). In the post-surgical period, group C used a greater amount of opioid for pain relief than group PVB, and they were less satisfied with the procedure overall (p < 0.05). See Table The groups did not differ at the level of statistical significance in terms of sex, age, weight, BMI or classification under the ASA rubric .At 1 h post-operatively, the VAS score was higher during movement  than at rest and this differnce attained statistical significance. In group C, VAS was higher during movement than at rest  but the VAS score “moving” was significantly higher in group C (p < 0.05). Additionally, the VAS scores differed significantly within the C group when “at rest” and “moving” scores were compared (p < 0.05), with the latter being higher, i.e. indicating more discomfort.At 6 and 8 h post-operatively, the VAS “at rest” score did not differ significantly between groups (p < 0.05).At 10 and 12 h post-operatively, the VAS “moving” scores were significantly higher in group C (p > 0.05). See Table At 24 h post-operatively, both dynamic and resting VAS scores did not differ at the level of statistical significance, neither resting nor moving (p < 0.05). See Table There was a statistical difference found in the rate of requiring extra pain relief at 1, 2, 4, 8 10, 12 and 24 h post-surgically. In all cases, group C had greater need for analgesia (p > 0.05).The two groups did not differ at the level of statistical significance for nausea and vomiting at any point . In that study, two treatments were compared: ropivacaine 0.5% in a volume of 30 mL with adjuvant dexmedetomidine 50 microgram or ropivacaine 0.5% in 30 mL alone. The level of injection was between T3 and T5. Two injections were given in the lateral decubitus position. The treatment was post-surgical but before the patient recovered consciousness. Adjuvant dexmedetomidine lengthened the duration of analgesia obtainable with bupivacaine alone. The pain score at rest (assessed using VAS) did not differ significantly at any point postoperatively, with the exception of 4 h post-surgery. In the adjuvant therapy group, the maximum VAS pain scores for the 24 h post-operative period while resting or when coughing were lower than those seen in the group receiving ropivacaine alone. This result attained statistical significance . It seemOur study showed that patient satisfaction was higher in the PVB group than group C. If PVB is performed in awake patients, a single injection may be preferable to multiple injections. Research on cadavers demonstrated that the spread of infiltrated anaesthetic was no different, whether injection occurred singly or at two levels. This study also employed ultrasonic guidance . AdditioWhilst PVB has become the de facto Gold Standard in chest surgery, this has yet to be acknowledged in the literature on the subject . A numben = 3), one vasovagal attack (n = 1), and a potentially toxic reaction to the local anaesthetic (n = 2). Neither inadvertent rupture of the pleura nor a pneumothorax leading to symptoms occurred [The reports published so far about the occurrence of complications mention a risk of inadvertent epidural or intrathecal injection in approaching 1% of cases. Ultrasound was not used for guidance where this occurred. Total spinal anaesthesia has occurred on some occasions . Total soccurred .Both in this study and in the authors’ routine practice, the authors have a preference for the in-plane anaesthetic technique. Complications of the technique, including bleeding or technical issues, did not occur.This study suffers from certain limitations. For example, we were unable to assess precisely the tramadol dosage needed, since patient-controlled analgesia, which would give a clear picture, was not used. In addition, the area of block achieved was not precisely delineated by performing a sensory neurological examination.Ultrasound-guided PVB using bupivacaine and an in-plane technique provides effective analgesia in PNL. It is associated with high scores on patient satisfaction and minimal complications.


This study aimed to investigate the effect of Xuefu Zhuyu decoction on preventing contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI). n = 126) and Group B (n = 130). Before and after PCI, all patients routinely received antiplatelet aggregation therapy, antilipidemic therapy, and hydration therapy. Besides routine therapy, patients in Group B received Xuefu Zhuyu decoction from 3 days before PCI to 3 days after PCI. Serum creatinine (Scr), estimated glomerular filtration rate (eGFR), superoxide dismutase (SOD), and malondialdehyde (MDA) were measured, respectively, at baseline (72 h before PCI) and at 24, 48, and 72 h after PCI.  A total of 256 patients undergoing selective PCI for coronary artery disease were consecutively enrolled and randomly divided into two groups: Group A (P < 0.01). The incidence of CIN was less in Group B. According to the definition, CIN occurred in 5 patients (2.0%) in the intervention group and 5 (4.0%) in the control group (P=0.167). In terms of oxidative stress, Group B had a lower MDA (P < 0.05), but a higher SOD (P < 0.05).  Compared with Group A, Group B presented a lower fluctuation of SCr and eGFR ( Compared with the control group, Xuefu Zhuyu decoction intervention therapy increased the level of SOD and reduced MDA. The Xuefu Zhuyu decoction intervention group presented a higher level of eGFR at 24, 48, and 72 h after PCI in patients with coronary heart disease and a lower level of Scr. The results are propitious to prove that Xuefu Zhuyu decoction might play an antioxidative stress role in the prevention of CIN after PCI. In reμmol/L 0. mg/dl or factors . CIN is  factors . Besides factors , 10, it  factors . TherefoHowever, the pathogenesis of CIN is still unclear. There is no effective treatment for CIN nowadays. Several perioperative preventions have been developed , 13, inc−1·1.73−2 or creatinine clearance rate <30 ml/min or ALT/AST >3 times the normal value); and (10) antithrombotic intolerance. The protocol was approved by the Ethics Committee of Shaoxing People's Hospital , and all participants gave written informed consent.Patients with coronary heart disease undergoing selective PCI in our hospital were continuously enrolled from June 2014 to May 2017. Exclusion criteria were as follows: (1) receiving other Chinese medicines one month before PCI; (2) allergic to the contrast medium; (3) using the contrast medium in the last week; (4) undergoing coronary artery bypass grafting; (5) malignant tumor; (6) acute and chronic infection; (7) emergency PCI; (8) severe cardiac dysfunction (left ventricular ejection fraction <30%); (9) severe hepatic and renal dysfunction (estimated glomerular filtration rate <30 ml·minn = 126) and the intervention group (n = 130). Before PCI, all patients were given aspirin , clopidogrel (loading dose of 300 mg/day), and atorvastatin (20 mg/night). After PCI, all patients continued to take aspirin and clopidogrel (75 mg/day) for at least 12 months and were injected subcutaneously low molecular weight heparin 0.4 ml/day for 3 days. Atorvastatin was continued if no contraindication existed.We planned to recruit 300 patients, but we actually recruited 256 patients. Patients were randomly 1 : 1 divided into two groups (control group and intervention group) by using table of random number. After treatment plan communications with patients, a total of 256 patients undergoing selective PCI for coronary artery disease were divided into two groups: the control group . The hydration rate was reduced appropriately for patients with left ventricular ejection fraction (LVEF) <50%. Patients in the intervention group (Group B) received Xuefu Zhuyu decoction from 3 days before PCI to 3 days after PCI, and the control group (Group A) did not.Angelica (9 g), raw rehmannia (9 g), sichuan dome (5 g), red peony (6 g), Achyranthes bidentata (9 g), Platycodon (5 g), Bupleurum (3 g), fructus aurantii (6 g), and liquorice (3 g). The decocting methods are (1) soaking in warm water for 1 hour, (2) decocting in gentle fire for 45 minutes, (3) extracting the juice and then decocting the two juices, (4) decocting about 400 ml twice, and (5) taking two times in the morning and evening after mixing, at 1 dose a day.Xuefu Zhuyu decoction is provided by the preparation room of Shaoxing People's Hospital. The formula of Xuefu Zhuyu decoction contains peach kernel (13.7 g), safflower (10.3 g), The study was a randomised, controlled, single-blinded clinical trial. The physicians performing the angiographic procedure were blinded to the assignment group. The same nonionic, low-osmolar contrast medium  was used in all cases.−1·1.73−2) = 175 × SCr (mg/dl) −1.154 × age − 0.203 . All tests were performed in our center laboratory blinded to assignment.Serum creatinine (Scr), superoxide dismutase (SOD), and malondialdehyde (MDA) were measured at baseline (72 h before PCI) and at 24, 48, and 72 h after PCI by collecting fasting venous blood. The estimated glomerular filtration rate (eGFR) was calculated according to the modified MDRD formula which is suitable for Chinese: eGFR (ml·minμmol/L (0.5 mg/dl) or 25% of the baseline within 72 h after contrast medium administration without other factors.CIN is defined as an increase in serum creatinine beyond 44.2 t-test. Holm–Sidak test was used to perform multiple comparisons. Chi-square was applied to compare categorical variables between groups. Univariate and multivariate linear regression analyses were performed to investigate the factors associated with renal function. All data were analyzed through SPSS 24. A P value less than 0.05 was considered significant (2 sided).Continuous variables were indicated as mean ± SD and categorical variables as percentages. The differences for continuous variables between the two groups were estimated through the independent sample A total of 256 patients with coronary heart disease undergoing selective PCI at our hospital were continuously enrolled from June 2014 to May 2017. After random allocation, 126 patients only received routine treatments as mentioned above (Group A). The remaining 130 patients were classified as Group B and received intervention treatment of Xuefu Zhuyu decoction in addition to routine treatments.∗ 1.73 m2. Mean volume of the contrast medium was 31.98 ml. There were no significant differences between the two groups in sex, LVEF, hypertension, clinical presentation, and laboratory variables at baseline (P > 0.05).Demographic characteristics and clinical, biochemical, and procedural variables are presented in 24h vs SCrbaseline: 78.1 µmol/l vs 75.6 µmol/l, P=0.0014; SCr48h vs SCrbaseline: 83.6 µmol/l vs 75.6 µmol/l, P < 0.0001; SCr72h vs SCrbaseline: 88.5 µmol/l vs 75.6 µmol/l, P < 0.0001) and accordingly eGFR reduced significantly in Group A . However, no significant difference was identified between baseline and postprocedural SCr and eGFR in Group B, except for eGFR at 24 h which was significantly higher than baseline . When compared between the two groups, Group B presented a higher level of eGFR at 24, 48, and 72 h after PCI , and accordingly the level of SCr was significantly lower in Group B . The results are summarized in P=0.167).In Group A, compared with baseline, SCr increased significantly after PCI  and MDA increased significantly . However, no significant difference was identified between baseline and postprocedural SOD and MDA in Group B, except for SOD at 72 h which was significantly higher than baseline  and MDA at 24 h was significantly higher than baseline . When compared between the two groups, Group B presented a higher level of SOD at 24, 48, and 72 h after PCI , and accordingly the level of MDA was significantly lower in Group B . The results are summarized in In Group A, compared with baseline, SOD reduced significantly after PCI  was indicated in linear regression analysis. Similarly, detaSCr was linearly correlated to detaMDA . Moreover, detaGFR had significant linear correlation with detaSOD , and detaGFR was linearly related to detaMDA .The term “deta” represents the change value of an indicator. Significant linear relation between detaSCr and detaSOD , lower SCr (P < 0.01), higher SOD (P < 0.01), and lower MDA (P < 0.01).To explore the factor influencing the results of eGFR, SCr, SOD, and MDA at 72 h, univariate linear regression analyses were performed. P value less 0.1 during univariate analyses were tested in the multivariate model. The results are presented in P < 0.01), lower SCr (P < 0.01), higher SOD (P < 0.01), and lower MDA (P < 0.01).Stepwise multivariate regression analysis was used to explore independent factors associated with measurement indexes. Potential confounders based on a known relevant clinical factor and factors with a P < 0.01) in stepwise multivariate regression analysis.When adding detaSOD and detaMDA into independent variables, we observed that intervention measures still significantly contributed to detaSCr/eGFR  Xuefu Zhuyu decoction was associated with less SCr and higher eGFR after PCI; (ii) Xuefu Zhuyu decoction contributed to higher SOD and lower MDA, which are the markers of oxidative stress that might play an important role in CIN; (iii) oxidative stress played an important role in the pathogenesis of CIN.Multiple mechanisms may be involved in the development of CIN, including decreased renal blood flow, renal tubular microembolization, apoptosis, oxidative stress, and contrast agents' direct toxicity to renal tubular epithelial cells –23. It hAt present, hydration therapy is generally recognized as the routine measure to prevent CIN. Although adequate hydration therapy reduces the concentration and hyperosmotic state of the contrast media , the incXuefu Zhuyu decoction is a well-known traditional Chinese medicine for treating cardiovascular diseases, and the findings of our study suggested its effects on antioxidative stress and contributions to prevent CIN after PCI; the findings might improve prognosis of patients receiving PCI. The specific mechanism of CIN is not fully understood, and the results of our study might provide a theoretical and practical basis for the pathogenesis of CIN, a possible new perspective for prevention and treatment of CIN, and a clearer picture for subsequent research on the treatment of CIN. Then, if our research results could be put into practice, the potential possibility of long-term renal insufficiency would greatly be decreased, the hospitalization time and cost of patients might remarkably be reduced, and the postoperative quality of life of patients would well be improved.The current study presented several limitations. Firstly, due to small sample size and rare incidence of CIN in our study, the current study was underpowered to demonstrate that Xuefu Zhuyu decoction could reduce CIN. However, we found that Xuefu Zhuyu decoction was associated with higher level of eGFR and lower SCr after PCI. The results may provide a theoretical basis to conduct larger studies to explore the relationship between Xuefu Zhuyu decoction and CIN. Secondly, the conclusion of this study was based only on the results of clinical tests, and no in-depth study of histopathological and molecular mechanism changes of CIN before and after the intervention was done. Thirdly, this study only observed one of the mechanisms of Xuefu Zhuyu decoction on renal protection, and deeper antioxidant stress and other mechanisms of CIN remain to be explored.Compared with the control group, Xuefu Zhuyu decoction intervention therapy increased the level of SOD and reduced MDA. The Xuefu Zhuyu decoction intervention group presented a higher level of eGFR at 24 h, 48 h, and 72 h after PCI in patients with coronary heart disease, and the level of SCr was significantly lower. The results are propitious to prove that Xuefu Zhuyu decoction might play an antioxidative stress role in the prevention of CIN after PCI.


When protease inhibitor (PI)‐based second‐line ART fails, guidelines recommend drug resistance testing and individualized third‐line treatment. However, PI‐resistant viral strains are rare and drug resistance testing is costly. We investigated whether less costly PI‐exposure testing can be used to select those patients who would benefit most from drug resistance testing.pol region was performed on plasma and DBS using standard clinical protocols.We performed a retrospective analysis of South African adults living with HIV experiencing failure of ritonavir‐boosted‐lopinavir (LPV/r)‐based second‐line ART for whom drug resistance testing results were available. We included patients who received plasma‐based drug resistance testing at a central South African reference laboratory in 2017 and patients who received dried blood spots (DBS)‐based drug resistance testing at a rural South African clinic between 2009 and 2017. PI‐exposure testing was performed on remnant plasma or DBS using liquid chromatography mass spectrometry (LCMS). Additionally, a low‐cost immunoassay was used on plasma. Population genotypic drug resistance testing of the Samples from 544 patients (494 plasma samples and 50 DBS) were included. Median age was 41.0 years (IQR: 33.3 to 48.5) and 58.6% were women. Median HIV‐RNA load was 4.9 log10 copies/mL (4.3 to 5.4). Prevalence of resistance to the NRTI‐backbone was 70.6% (349/494) in plasma samples and 56.0% (28/50) in DBS. Major PI‐resistance mutations conferring high‐level resistance to LPV/r were observed in 26.7% (132/494) of plasma samples and 12% (6/50) of DBS. PI‐exposure testing revealed undetectable LPV levels in 47.0% (232/494) of plasma samples and in 60.0% (30/50) of DBS. In pooled analysis of plasma and DBS samples, detectable LPV levels had a sensitivity of 90% (84% to 94%) and a negative predictive failure of 95% (91% to 97%) for the presence of major LPV/r resistance.PI‐exposure testing revealed non‐adherence in half of patients experiencing failure on second‐line ART and accurately predicted the presence or absence of clinically relevant PI resistance. PI‐exposure testing constitutes a novel screening strategy in patients with virological failure of ART that can differentiate between different underlying causes of therapy failure and may allow for more effective use of limited resources available for drug resistance testing. First‐line ART treatment results in high on‐treatment virological suppression rates in these settings. , 2 In caDespite the dosing complexity and potential toxicity of these regimens, several studies have reported good virological response to programmatic second‐line treatment in LMIC. , 6, 7 NoDrug resistance testing is costly, has a long turn‐around time, and requires extensive laboratory infrastructure and specialist interpretation. Due to these factors, capacity for resistance testing is limited in most LMIC.  The low Accurate screening tests for adherence to treatment would enable preselection of adherent patients for drug resistance testing. Moreover, this approach would also provide a point of entry into intensified adherence counselling for non‐adherent patients. While currently used surrogate adherence measures such as patient‐reported adherence and pharmacy refill data generally correlate with treatment outcomes, these tests are either subjective or vulnerable to manipulation. , 16, 17 We studied the value of recent PI‐exposure measured by qualitative plasma LPV level testing as an objective adherence marker and screening tool for PI drug resistance in patients with virological failure on second‐line ART. We report the accuracy of this novel treatment monitoring strategy on plasma samples as well as on dried blood spots (DBS), the predominant sample types in use for HIV‐RNA viral load and HIV drug resistance testing.22.1This is a retrospective analysis of adult ≥18 years) people living with HIV attending public healthcare facilities. Patients were included if (1) they were receiving treatment with LPV/r‐based second‐line ART, (2) if they experienced confirmed virological failure according to South African guidelines, defined as viraemia ≥1000 copies/mL for at least six months, after at least one year of PI‐based second‐line ART, [ years peThis study was conducted with ethical clearance from the Research on Human Subjects  Committee at the University of the Witwatersrand (Clearance certificate number M180332). In accordance with the Committee policy, no informed consent was obtained from the patients due to the retrospective nature of the study. No additional samples were taken from patients for the purposes of this study.2.2Plasma samples were analysed at the National Health Laboratory Services (NHLS) laboratory at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa, a referral laboratory for HIV drug resistance testing that services public healthcare facilities across four provinces, covering approximately 40% of the South African national treatment programme. Out of a total of 786 eligible patients who received HIV drug resistance testing in 2017 for virological failure on second‐line ART, a computer‐generated random selection of 500 patients was made. Patients received drug resistance testing on EDTA‐derived plasma as part of clinical care. Remaining plasma was stored at a temperature monitored facility at −80°C. Drug exposure testing was performed batchwise on these stored samples.In addition, to demonstrate the feasibility of the approach using alternative sampling materials, the study was also implemented at a large rural primary healthcare facility based in Limpopo, South Africa, which provides ART to a large and well‐described cohort of over 3600 people living with HIV. Between December 2009 and August 2017, 50 patients with virological failure on second‐line ART received DBS‐based genotypic drug resistance testing as part of routine clinical management. Per patient, five drops of 50 µL of EDTA‐derived whole blood were spotted on a Protein Saver 903 card  and were left to dry overnight prior to packaging in a zip‐lock bag containing desiccant. Samples were shipped on room temperature to the Translational Virology Laboratory of the University Medical Center Utrecht (UMCU), Utrecht, The Netherlands, where all analyses were performed. Drug resistance testing was performed within three weeks of sample collection using two spots as input and results were reported back to the treating clinician. The remaining spots were subsequently stored at a temperature monitored facility at −20°C. Drug exposure testing was performed batchwise on thawed DBS, using one spot as input.2.3Population‐based genotypic drug resistance testing was performed using previously described methods for plasma  and for Drug resistance to LPV/r was defined as the presence of at least one of the following IAS‐USA defined LPV/r resistance‐associated mutations in protease: V32I, I47V/A, I50V, I54V/L/M, L76V, V82A/F/T/S and I84V.  Drug sus2.4PI‐exposure testing was primarily performed using high performance liquid chromatography‐tandem mass spectrometry (LCMS).2 = 0.995) in the range of 0.03 to 11.16 mg/L. The coefficient of variance of low and high quality control samples (mean concentrations of 2.34 and 8.10 mg/L respectively) was below 10%. Plasma LPV levels above the assay limit of detection (LOD) of 0.01 mg/L were considered detectable. Screening for detectable levels of other antiretroviral anchor drugs  was also performed to exclude any unreported use of other antiretroviral drugs.For plasma‐based drug level testing, LCMS was performed on EDTA‐derived plasma using a validated clinical protocol for quantitative plasma drug level measurement that is subjected to regular external quality assurance.  For LPV,In addition to LCMS‐based testing, PI‐exposure testing was repeated on a rapid automated enzyme immunoassay (EIA) for detection of lopinavir  that was implemented on the Indiko™ Plus benchtop chemistry system . Assay validation is described elsewhere.  Plasma L2 = 0.98) in the range of 0.25 mg/L to 8.00 mg/L, with quality control sample results  within 20% of the reference range. Plasma LPV concentrations were estimated from dried blood spot LPV concentrations according to a previously validated formula: DBS concentration/(1‐haematocrit). [For DBS‐based testing, an in‐house LCMS procedure optimized for the detection of LPV in DBS was used. The assay proved linear (Rtocrit).  Estimate2.5t‐test or Mann‐Whitney U‐test for continuous data, and χ2‐test or Fisher’s exact test for categorical data. Multivariable analysis of predictors of LPV/r‐resistance was performed using logistic regression. Age, sex, second‐line NRTI‐backbone, HIV‐RNA load at second‐line failure and study group (DBS vs. plasma) were entered as covariables. In a sensitivity analysis, stepwise backward selection of covariables to the models based on Akaike information criterion was used. The randomization list for the random sample of patient plasma samples was generated using stratified random sampling without replacement, where strata reflect the proportional sample contribution of each province to the dataset. All statistical data analysis was performed using R version 3.4.1  and Rstudio version 1.0.153, the epiR (version 0.9‐99) and pROC (version 0.13.0) statistical packages, and the publicly available stratified function (https://www.rdocumentation.org/packages/fifer/versions/1.0/topics/stratified) for random sampling.Diagnostic accuracy of LPV exposure testing as a marker for LPV/r resistance was reported as sensitivity, specificity, and positive/negative predictive value (PPV/NPV). Accuracy at varying threshold levels was assessed using receiver‐operated characteristic (ROC) analysis. For ROC analysis, levels above the upper limit of quantification (LOQ) and below the lower LOQ were censored at the respective LOQ. Univariate comparisons were performed using the unpaired Student’s 33.1From 500 patients selected for plasma‐based testing, 494 patients were included, originating from 72 healthcare facilities see . Fifty p58.6% (319/544) of patients were female, with a median age of 41.0 years (interquartile range (IQR): 33.3 to 48.5). Median HIV‐RNA load at time of failure was 4.9 log copies/mL (IQR: 4.3 to 5.4). Patients were infected with HIV‐1 subtype C in 98.9% (538/544) of cases.  of plasma samples and in 54.0% (27/50) of DBS. Mutations conferring resistance to NRTIs were detected in 70.6% (349/494) of plasma samples and 56.0% (28/50) of DBS. LPV/r‐resistant viral strains were only detected in 26.7% (132/494) of plasma samples and 12.0% (6/50) of DBS  of patients using LCMS and 45.4% (221/487) of patients using EIA. For LCMS, sensitivity of LPV level for LPV/r resistance was 89% (95% CI: 83% to 94%), and NPV was 94% (90% to 97%). For EIA, sensitivity of LPV level for LPV/r resistance was 88% (82% to 93%), and NPV was 93% (89% to 96%) (Table 32/494 ofp < 0.001). Patients with detectable LPV also had a significantly lower plasma HIV‐RNA load when compared to patients with undetectable LPV .In combined analysis of plasma and DBS results (n = 544), detectable LPV had a high sensitivity of 90% (84% to 94%) and NPV of 95% (91% to 97%) for LPV/r resistance Table . A detecAssessment of different LPV detection thresholds in quantitative testing performed on plasma samples revealed that sensitivity was 83% (76% to 89%) at the minimum recommended LPV trough level of 1 mg/L. In ROC analysis, LPV drug level had an area under the curve of 75.6% for prediction of LPV/r resistance (95% CI: 71.2% to 80.0%). Optimal sensitivity was attained at a threshold of 0.01 mg/L, confirming the benefit of a low threshold for application as a screening test , and M184V was less prevalent (78.6% (11/14) versus 94.9% (112/118); Fisher’s exact p = 0.055).In fourteen cases an undetectable LPV level was encountered in the presence of LPV/r resistance. In‐depth analysis of viral genetic profiles revealed that when compared to cases of LPV/r resistance with detectable LPV levels, major PI drug resistance mutations were more likely present in mixtures with wild type (42.9% (6/14) vs. 16.9% (20/118); Fisher’s exact 3.3Of predefined LPV/r resistance mutations, a single LPV/r resistance mutation was detected in 16.7% 23/138), two mutations in 42.8% (59/138) and three or more in 40.6% (56/138) of cases in combined analysis of plasma and DBS results . A trend of less LPV/r resistance in patients on non‐standard backbones versus AZT/3TC‐backbone was observed, but this was not statistically significant (p = 0.067). In the DBS group we observed that patients with LPV/r‐resistant virus had a longer median duration of second‐line ART (64.4 (36.2 to 75.7) vs. 30.8 (16.2 to 51.7) months), a trend that bordered on statistical significance (Mann‐Whitney p = 0.052). HIV‐RNA load and sex were not significantly correlated with LPV/r resistance , ce Table .4In this largest‐to‐date analysis of patients with virological failure on second‐line ART in LMIC, LPV plasma levels were not detected in half of patients. An undetectable LPV level excluded the presence of PI‐resistant viral strains with a high degree of certainty. Results were consistent between DBS‐based testing in a rural healthcare facility and plasma‐based testing at a reference laboratory.In this analysis, only a minority of patients with virological failure harboured PI‐resistant virus. This finding is in line with previous observations from LMIC.  The low The low prevalence of PI resistance necessitates further investigation of the underlying cause of failure, which is currently based solely on drug resistance testing. Population‐based drug resistance testing can be unreliable in case of non‐adherence, as drug sensitive strains may reemerge as the dominant viral population in plasma under these circumstances. , 29, 30 Qualitative testing for recent drug exposure in patients with virological failure of second‐line ART constitutes a novel approach to treatment monitoring in resource‐limited settings. Implementation of this approach would allow for targeted use of expensive resistance testing in patients at high risk of harbouring PI‐resistant viral strains. If PI‐exposure testing would have been used to determine eligibility for drug resistance testing in this study, approximately half of all requested drug resistance tests could have been avoided. The routine implementation of such a two‐tiered approach holds the potential to simplify clinical management of patients experiencing virological failure.Our study further demonstrates that this approach can be implemented in various different settings. The use of DBS facilitates implementation of drug exposure testing in settings where laboratory infrastructure and cold‐chain transport are unavailable and allows for subsequent drug resistance testing on the same DBS card. Moreover, successful use of a low‐cost immunoassay on plasma samples in this study shows that PI‐exposure testing can also be decentralized to settings with limited laboratory infrastructure. Immunoassays are easily implemented on standard chemistry analyzers at a fraction of the cost of drug resistance testing, and enable rapid feedback of results. The development of point‐of‐care (POC) technology for viral load measurement and drug resistance testing is set to change current ART monitoring algorithms. The recent development of POC tests for the detection of antiretroviral drugs in urine may pave the way for future implementation of drug level testing in POC ART monitoring strategies. , 34 MoreTo our knowledge, this is the first demonstration of diagnostic accuracy of qualitative PI‐exposure testing in patients with viraemia during PI‐based second‐line ART. We identified one previous study which retrospectively assessed quantitative lopinavir plasma concentrations and LPV/r‐resistance in 134 adult and paediatric patients experiencing failure of PI‐based second‐line ART.  AccuracyA small number of patients harboured LPV/r‐resistant virus in the absence of detectable LPV levels. The misclassification of these patients by PI exposure testing is likely indicative of intermittent non‐adherence or recent interruption of treatment. After treatment interruption, LPV levels will drop below detectable levels within one or two days,  while PIMore sensitive next‐generation sequencing techniques may be able to detect PI‐resistant viral subpopulations below the detection threshold of population‐based sequencing. The impact of these minority variants on treatment success has not been conclusively established, but is an area of ongoing research interest.  Next‐genIn patients with PI resistance, mutational patterns of PI resistance were extensive. This likely reflects the long duration of virological failure on PI‐based ART, which is inherent to annual viral load testing, and may be further aggravated by long turn‐around times and limited access to drug resistance testing and third‐line treatment. Accumulation of PI drug resistance mutations resulted in cross‐resistance to darunavir, a crucial component of third‐line regimens, in a substantial amount of cases. These findings further highlight the need for novel strategies to enable fast and informed decision‐making in case of failure on second‐line ART.This study has several important limitations. Data on treatment history and duration were not available for patients in the plasma sample group. These factors may have explained the difference in prevalence of PI resistance between the plasma and DBS group. While the study results can likely be generalized to other Southern African countries, they may be less relevant to settings where different second‐line regimens, notably atazanavir‐based regimens are used. In addition, the results may be less applicable to settings were different HIV subtypes predominate or where patients were previously exposed to unboosted PI treatment. Strengths of this study include the use of samples obtained in routine clinical practice at various levels of healthcare, enabling a realistic assessment of the accuracy of PI exposure testing in standard clinical care. The use of routine clinical data also enabled us to perform the largest analysis to date of PI drug resistance prevalence in patients expressing virological failure of programmatic LPV/r‐based second‐line ART and to identify the most prevalent resistance pathways in HIV‐1 subtype C.5Although access to ART is rapidly scaling up in LMIC, access to laboratory monitoring is lagging behind. Novel diagnostic approaches using simple and low‐cost technologies may bridge this gap. This study demonstrates that PI‐exposure testing has the potential to improve and simplify clinical management in case of virological failure, by directing rationalized drug resistance testing in patients failing second‐line ART. Implementation of this strategy should be considered to enable more efficient use of limited resources.The authors report no conflicts of interest.AMJW, SC, HAT, RS and LEH designed the study. LEH, RH, EM, MN, TP, DL, TS, AMJW and DMB were involved in drug level testing experiments. KS, RS, SC, and AMJW were involved in drug resistance testing experiments. RM, LEH and HAT were involved in the clinical care of patients in the study. LEH performed the statistical analyses. JMS, DMB and AMJW gave feedback on the analyses and reviewed preliminary results. LEH and AMJW drafted the first version of the manuscript. All authors provided feedback on the manuscript. All authors have read and approved the final manuscript.Data S1. Random selection of participants in the plasma group.Table S1. Breakdown of patients in study per facility type and province.Table S2. Stepwise backward automatic variable selection.Figure S1. A‐C, Linearity of continuous variables against the logit.Click here for additional data file.


The authors of a previous study proposed a statistically based approach to denote treatment outcome, translating pretest and posttest scores into clinically relevant categories, such as recovery and reliable improvement. We assessed the convergent validity of the Jacobson–Truax (JT) approach, using T‐score based cutoff values, with ratings by an independent evaluator.Pretest and retest scores on the Brief Symptom Inventory (BSI) and clinical global impression improvement (CGI‐I) ratings were collected repeatedly through routine outcome monitoring from 5,900 outpatients with common mental disorders. Data were collected in everyday practice in a large mental health care provider.D) ranging from D = .50 to .56. Discordance was predominantly due to a more positive outcome according to JT than on CGI‐I ratings.Continuous pretest‐to‐retest BSI change scores had a stronger association with CGI‐I than the categorical variable based on JT. However, JT categorization and improvement according to CGI converged substantially with association indices (Somers' Converting continuous outcome variables into clinically meaningful categories comes at the price of somewhat diminished concurrent validity with CGI‐I. Nevertheless, support was found for the proposed threshold values for reliable change and recovery, and the outcome denoted in these terms corresponded with CGI improvement for most patients. They proposed several cutoff values: two standard deviations below the dysfunctional mean, two standard deviations above the functional mean or the point where the frequency distribution of scores of the functional and dysfunctional population cross lines. When normative data of the dysfunctional and the functional population are available, the last operationalization is preferred.RCI). This is the amount of change required to be 95% certain that change is statistically reliable and not due to measurement error of the instrument used. Combining both indices results in five categories: recovered , reliably improved , unchanged (not reliably changed), reliably deteriorated (reliably changed towards worsening of the condition), and relapsed . The last category is usually small  and is sometimes merged with reliable deterioration.A well‐established method to translate measurements of outcome into clinical meaningful terms is the Jacobson–Truax (JT) approach to clinical significant change  and (2) a value to distinguish clinical significantly changed (or recovered) patients from merely improved patients (JTCS). Previously, we proposed generic cutoff values for these indices to be used when raw scores on measures have been transformed to T‐scores: JTRCI > 5.0 (or JTRCI < −5.0) and JTCS = 55  to distinguish a T‐score within normal limits from a mild level of problems (T > 55). Other categories for T‐scores proposed by PROMIS are mild (T = 55 to 60), moderate (T = 61 to 70), and severe (T > 70).Several cutoff values are required to categorize patients into the five categories of JT: (1) a positive and negative value for statistical reliable change to distinguish improved and deteriorated patients from unchanged patients (JTRCI) and  a value RCI criterion can yield a quite conservative indicator of change . Furthermore, the method requires normative data for the outcome instrument used, preferably from dysfunctional and from functional or general population samples. Also, the method is of limited use with patients who enter treatment scoring in the functional range  project , all referred to GGZ Rivierduinen . According to a semistructured diagnostic interview, the Mini‐International Neuropsychiatric Interview , and this is the reverse for anxiety disorders (23% and 59%). For both conditions, the remaining minority is treated with combinations or with other treatments . A comprehensive protocol (Psychiatric Academic Registration Leiden database) was used, which safeguarded the anonymity of participants and ensured proper handling of the data. All participants gave permission for use of their coded data for scientific research.33.1The CGI is a well‐established instrument for the standardized global assessment of outcome by a rater Guy, . The sca3.2y = 66 * (x + 0.01)0.21 and calibrated on the general population. This implies a mean score of M = 50 (SD = 10) for the general population; most patients score between T = 60 and T = 70.The BSI , from baseline to the last reassessment M = 411 days (SD = 391). In particular, for the last reassessment, there was a wide range in the length of intervals from 3 months to 6 years .Patients were reassessed every 4 to 6 months, which included the CGI improvement rating (CGI‐I). Per sampling round, the number of patients decreased with 45%, partly due to the completion of treatment, partly because of no‐show (after repeatedly being contacted) of the patient at the reassessment session. Thus, at the first assessment, Research nurses were thoroughly trained in administration of the MINI‐plus, the CGI and disorder specific rating scales in biweekly group sessions by rating video‐taped assessment sessions with patients and vignettes describing cases and discussing their assessment until consensus was reached.4.1D; Somers, First, in order to get information on the consistency/validity of the Clinical Global Impression scale, we compared change in CGI‐severity score from baseline to the first and from baseline to the last reassessment with the CGI‐improvement score by means of a measure of ordinal association . ROC curves were calculated to investigate the sensitivity and specificity of threshold values on the BSI‐TOT T‐scores for reliable improved (JTRCI > 5) with dichotomized CGI‐I as “very much” or “much improved” (1 and 2) versus “minimally improved” or a less favorable CGI‐I score (3–7) as criterion. Likewise, we evaluated the cutoff score (JTCS = 55) for recovery with CGI‐S as criterion, dichotomizing CGI‐I as “very much worse” or “much worse” (6 and 7) versus minimally worse or a better outcome (1–5). Finally, we compared change scores for statistically reliable deterioration with dichotomized CGI deterioration, now dichotomizing CGI‐I as “very much worse” or “much worse” (6 and 7) versus minimally worse or a better outcome (1–5). Subsequently, outcome was categorized according to JTRCI, JTCS, and JTRCICS.Furthermore, threshold values for JTD  at baseline, M = 0.88 (SD = 0.69) at the first reassessment, and M = 0.77 (SD = 0.68) at the last reassessment. In normalized T‐scores, this corresponds to M = 66.7 (SD = 9.3) at baseline, M = 60.7 (SD = 11.8) at the first reassessment, and M = 58.2 (SD = 12.6) at the last reassessment. Outcomes at the first reassessment categorized according to the JT approach showed that 19.6% were recovered, 29.3% were improved, 42.8% were unchanged, 6.5% were deteriorated, and 1.8% became ill. At the last available reassessment, outcomes were more favorable with 31.9% of the sample recovered, 26.9% improved, 35.5% unchanged, 5.5% deteriorated, and 2.1% became ill. As Table r = .61 to r = .67).Mean score of patients on the BSI was 5.2D = .55 for the first reassessment and Somers' D = .54 for the last reassessment; both p < .001; see Tables M = 0.34 BSI‐scale points (SD = 0.58) towards a lower severity (6.0 T‐score points or a medium effect size of ES = 0.60) and the average CGI‐I score corresponded with M = 3.00, (SD = 0.99), one scale point below the midpoint (“no change”), indicating “minimally improved.” For the last reassessment, BSI‐change was M = 0.45 (8.6 T‐score points), CGI‐S change was M = 0.95 (SD = 1.23) and CGI‐I was M = 2.78 (SD = 1.05), a lower mean score indicating more improvement compared with the first reassessment. Finally, more patients have convergent scores on both CGI variables than divergent scores (see Tables The correspondence between change in CGI‐S scores and the rating on the CGI‐I was significant: Somers' p < .001). Figure The association between the BSI total score and CGI‐S was also substantial: ICC = .50, ICC = .68, and ICC = .70, for the baseline assessment, first, and last reassessment, respectively . The area under the ROC curve was AUC = .82  and AUC = .89  for the first and the last reassessment, respectively. The findings suggest JTCS = 56.0 as optimum threshold value for clinical significance.Figure RCI < −5 in both curves, probably due to the few patients that were considered deteriorated on the CGI‐I.Finally, Figure 5.4p < .05) and also substantial, as indicated by the index of association for ordered variables . These results indicate that the CGI‐I gave a somewhat more conservative estimate of treatment outcome than JTRCI: the largest off‐diagonal group  had “minimal or no change” according to the CGI‐I but were reliably improved according to JTRCI .The agreement between outcome according to the JT approach and according to the CGI‐I was statistically significant  much improved”  than in the opposite categories “recovered” but “minimal or no change” (n = 358 and n = 406). Finally, comparing the outcome according to the full JTRCICS categorization with CGI‐I revealed a pattern similar to what was found for JTRCI: the CGI‐I being a somewhat more conservative estimate of treatment success than the JTRCICS index, due to recovered and reliable improved patients according to JTRCICS, who are merely improved or not changed according to the CGI‐I. Changing the cutoff values for JTRCI or JTCS did not improve the association between CGI‐I and JTRCICS.In contrast, JT66.1The findings of the present study revealed that CGI scores were more strongly associated with the continuous BSI‐TOT change and residual change scores than with JT indices. As has been argued before . This low number may actually be an underestimation due to selection bias, as patients who deteriorate are more likely to drop out from treatment and/or may be less inclined to comply with a reassessment appointment. Consequently, they are probably not fully represented in the current dataset.6.2D = .55 and .54 for the first and last reassessment). Few patients who were deemed improved were deteriorated in the preceding interval according to their CGI‐S scores (n = 192), and even less who had worsened were improved according to CGI‐S scores (n = 30). Comparable numbers were found at the last reassessment (see Tables r = .71). These findings boost our confidence in the suitability of the CGI‐I as criterion to evaluate JT threshold values.The CGI has been criticized on semantical, logical, and psychometric grounds , but this did not yield a higher association with CGI‐I. Alternatively, an outcome measure with higher measurement precision  loss of data. In particular, the latter is a point of concern as this may have influenced the outcome data in opposite ways. On the one hand, selection bias may have inflated estimated treatment outcome, as unsuccessfully treated patients are more likely to decline participation in reassessments. On the other hand, there were also many patients who continued treatment and continued to improve but declined further reassessments. For these patients, no endpoint assessment was available, which may have deflated the overall outcome estimates. This precludes the use of the present results for definitive statements about what is achieved with mental health care in everyday clinical practice. However, for the purpose of comparing two indicators of treatment outcome—JT and CGI‐I—the present data are still quite suitable.Future research into the appropriateness of the JT criteria for categorization of treatment outcome may focus on other, more objective indicators of treatment outcome, such as ensuing treatment or readmission to mental health care later on. In particular, long‐term follow‐up data could provide relevant information on the aptness of the JT categorization with the proposed cutoff values.7The results revealed support for the validity of the JT method and the proposed cutoff values for reliable change (RCI > 5 and CS = 55) associated with the JT method. The JT method appeared somewhat more optimistic about what had been achieved compared with the CGI‐improvement ratings. There was less support for the distinction between unchanged from deteriorated patients among patients with an unfavorable treatment outcome. The JT method translates pretest‐to‐posttest change scores into clinically relevant outcome categories with immediate appeal to the clinician. The categories correspond reasonably well with improvement ratings by an independent rater.The author(s) declare that they have no competing interests.E. de. B. contributed to conception and design of the study, conducted the statistical analysis, and wrote the manuscript. I. V. E. C. participated in the design of the study, coordinated the study and data acquisition, and revised the manuscript. A. M. v. H. has been involved in revising the manuscript. All authors read and approved the final manuscript.st reassessmentTable S1. Change in CGI severity scores by CGI improvement scores at 1Table S2. Change in CGI severity scores by CGI improvement scores at the last reassessmentClick here for additional data file.