Up to 20% of patients with cerebellar infarcts will develop malignant edema and deteriorate clinically. Radiologic measures, such as initial infarct size, aid in identifying individuals at risk. Studies of anterior circulation stroke suggest that mapping early edema formation improves the ability to predict deterioration; however, the kinetics of edema in the posterior fossa have not been well characterized. We hypothesized that faster edema growth within the first hours after acute cerebellar stroke would be an indicator for individuals requiring surgical intervention and those with worse neurological outcomes.Consecutive patients admitted to the neurological intensive care unit with acute cerebellar infarction were retrospectively identified. Hypodense regions of infarct and associated edema, “infarct–edema”, were delineated by using ABC/2 for all computed tomography (CT) scans up to 14 days from last known well. To examine how rate of infarct–edema growth varied across clinical variables and surgical intervention status, nonlinear and linear mixed-effect models were performed over 2 weeks and 2 days, respectively. In patients with at least two CT scans, multivariable logistic regression examined clinical and radiological predictors of surgical intervention (defined as extraventricular drainage and/or posterior fossa decompression) and poor clinical outcome .p < 0.001) in the surgical group than that in the medical intervention group. On 410 serial CTs, infarct–edema volume progressed rapidly over the first 2 days, followed by a subsequent plateau. Of 112 patients who presented within two days, infarct–edema growth rate was greater in the surgical group . Of 67 patients with at least two scans, after adjusting for baseline infarct–edema volume, vascular territory, and NIHSS, infarct–edema growth rate over the first 2 days  was an independent, and the strongest, predictor of surgical intervention. Further, early infarct–edema growth rate predicted poor clinical outcome , independent of baseline infarct–edema volume, brainstem infarct, and NIHSS.Of 150 patients with acute cerebellar infarction, 38 (25%) received surgical intervention and 45 (30%) had poor clinical outcome. Age, admission National Institutes of Health Stroke Scale (NIHSS) score, and baseline infarct–edema volume did not differ, but bilateral/multiple vascular territory involvement was more frequent (87% vs. 50%, Early infarct–edema growth rate, measured via ABC/2, is a promising biomarker for identifying the need for surgical intervention in patients with acute cerebellar infarction. Additionally, it may be used to facilitate discussions regarding patient prognosis.The online version contains supplementary material available at 10.1007/s12028-021-01414-x. The development of life-threatening edema occurs in up to 20% of patients with large cerebellar infarction , 2. GivePredicting which patients will deteriorate from cerebellar edema is challenging because of nonspecific symptoms and imaging pitfalls . Early iMuch of the work mapping stroke edema formation and growth over time has only been explored in the anterior circulation. The absolute change in infarct–edema volume in the first 3–5 days after anterior circulation stroke has been associated with poor short-term and long-term outcomes . MoreoveConsecutive admissions to a neurological/neurosurgical intensive care unit (ICU) with acute cerebellar infarction from January 2006 through May 2019 were retrospectively identified. At our institution, the decision for ICU admission is made at the discretion of vascular neurologists and neurocritical care physicians. Patients are automatically admitted to the ICU if osmotic is delivered or if mechanical thrombectomy is performed within the past 24 h. Inclusion criteria for the study population were age ≥ 18 and ischemic stroke involving the cerebellum, confirmed by using CT imaging. Patients with isolated brainstem infarcts without visible cerebellar involvement on CT were not included in the initial database. Exclusion criteria included prior cerebellar stroke, concurrent cerebral ischemic stroke greater than 50% of the MCA territory, symptomatic hemorrhagic transformation  , and decClinical and radiological variables were abstracted retrospectively from medical records. Clinical and demographic information included age, sex, time of last known well (LKW), thrombolytic treatment, NIHSS score and Glasgow Coma Scale (GCS) score at admission to ICU, admission lab values , chart documented medical history , time of medical and/or surgical intervention, discharge NIHSS score, discharge GCS score, and discharge location. For patients who were deceased at the time of discharge, an NIHSS of 42 and GCS of 3 were used.Radiological data extracted from CT imaging included time of acquisition, vascular territory involvement, presence of brainstem infarct, and cerebellar infarct–edema volume. For simplicity, infarct territory classification was collapsed into binary categories: infarcts involving either bilateral or multiple cerebellar vascular territories versus infarcts involving one vascular territory . We alsoThe treatment end point was defined by intervention type. Patients who remained stable on conservative medical management with or without osmotic  therapy were included in the “medical group”. Patients who underwent surgical interventions (EVD and/or SDC), in addition to medical management, were included in the “surgical group”. In our institutional practice, osmotic therapy is not used prophylactically, but it is initiated at the time of level of consciousness worsening in association with edema with mass effect on CT scan. Patients who had a decline in neurological status, despite maximal medical therapy, underwent surgical decompression based on previously published guidelines , 18.The clinical outcome end point was defined by hospital discharge location. “Good outcome” was defined as discharge to acute inpatient rehabilitation hospital or discharge to home, whereas “poor outcome” was defined as discharge to a skilled nursing facility, long-term acute care facility, hospice, or morgue. Although 30-day and 90-day modified Rankin Scale scores were not uniformly available because of the retrospective nature of our clinical database, discharge destination has been used as a reliable surrogate for modified Rankin Scale in stroke survivors .Imaging interpreters were blinded to surgical and clinical outcomes. Infarct-related hypodensity volume was manually measured on clinical CT scans. Visible regions of infarct-related hypodensity in the cerebellum likely represented a combination of infarct core and edematous tissue. This region is referred to as “infarct–edema” throughout the article, with the understanding that the delineated lesion may include both injured brain tissue and reactive fluid components. The ABC/2 formula was used to measure volume, where A is the longest lesion axis of any image slice, B is the line perpendicular to A at the widest dimension, and C is the height, obtained by multiplying number of CT slices by individual slice thickness. In cases of bilateral cerebellar hemispheric infarcts, individual hypodensity volumes were measured separately and added. It provides the best simple geometric estimate of hemorrhagic stroke volume and infarct volume , 21.n) × H, where n indicates the number of image sections showing region of interest, A indicates the area (cm2), manually delineated for each image slice, and H indicates the height (cm) defined by slice thickness. The concordance between the ABC/2 method and the volumetric method was assessed by using Lin’s concordance coefficient (ρc), revealing a good concordance of 0.87 .First, to validate the ABC/2 formula as a representative estimate of infarct–edema volume in our study population, two neurologists (Y.W. and A.P.) measured infarct–edema volume on 15% of sample CTs by using the ABC/2 method and a volumetric method. The volumetric method was defined as volume (ml) =  used the more pragmatic ABC/2 method to measure infarct–edema volume for all remaining CTs. A randomly selected 9% sample of CT scans yielded an intraclass correlation of 0.92 (95% CI 0.86–0.96), indicating excellent interrater reliability.2 test or Fisher’s exact test and Mann–Whitney U-test for categorical and continuous variables, respectively. Using the univariate results, two multivariable logistic regression models were constructed to determine baseline clinical and radiological predictors of surgical intervention, with forward stepwise entry for variables with p value < 0.3, and p value < 0.05 to be retained. Logistic regression collinearity and final model validity were checked. Collinearity between variables was assessed by using the variance inflation factor. None of our variables exhibited a variance inflation factor > 10 or |r|> 0.6, which would have required exclusion from the model. Fit of logistic regression models was assessed by using the Hosmer–Lemeshow test. The variance explained by the model was calculated using R2. Statistical analyses were performed using SAS software version 9.4 .Descriptive statistics of baseline variables were reported as percentages for categorical data and as medians with interquartile ranges for continuous data. Statistical analyses for group comparisons and univariate analysis were performed using the χTo model the trajectory of infarct–edema growth, infarct–edema volume as a function of time from LKW was plotted as a spaghetti plot for the 410 head CTs over the 14-day period. Differences in rate of infarct–edema growth between individuals who received conservative medical management and individuals who required treatment escalation and underwent surgical intervention were compared by using two models: (1) a nonlinear (logistic curve) model to capture the steep rise and long plateau over 2 weeks and (2) a linear mixed-effects model to fit the linear rate of growth over the first 2 days. The former nonlinear mixed-effect model allowed for estimation of infarct–edema growth rates and asymptotic (plateau) volumes of patients who received medical management vs. patients who received surgical intervention while accounting for repeated measures , 23. It p value < 0.3 and a p value < 0.05 to be retained. The logistic regression analyses were then adjusted for covariates . Additionally, we adjusted for concurrent brainstem infarct as a covariate in clinical outcome. Receiver operating characteristic analysis was performed with and without infarct–edema growth rate and area under the curve was calculated.Lastly, to determine whether infarct–edema growth rate predicted surgical intervention or poor clinical outcome , we first calculated growth rate as the change in infarct–edema volume over the change in time. We used a subgroup of patients who had at least two scans within the first 2 days. In patients with three or more CT scans, the two scans performed closest to LKW and closest to 48 h from LKW were selected. On sensitivity analysis, there were no differences in demographics, admission NIHSS, past medical history, and surgical intervention frequency between participants who were included in and those who were excluded from the subanalysis (data not shown). We used two multivariable logistic regression models to determine whether early infarct–edema growth rate was predictive of surgical intervention and clinical outcome, independent of baseline infarct–edema volume. We used forward stepwise entry for variables with a p = 0.65). As a result, only 9.8% and 5.3% of patients received a tissue plasminogen activator in the medical and surgical groups, respectively (p = 0.52). One hundred twenty-five patients were admitted directly to the ICU from the ED, whereas 25 patients were transferred from an inpatient ward to the ICU after clinical decline. Only one patient had an EVD inserted prior to the transfer. On admission to the ICU, compared with the medical group, the surgical group had (nonsignificantly) more severe neurological impairment measured by GCS (p = 0.06) and by NIHSS (p = 0.09). In the surgical group, EVD and SDC occurred on day 2.5  and 2.6 , respectively.From 2006 to 2019, 198 patients were admitted to the neurological ICU with primary cerebellar infarction confirmed at imaging. Of these, 150 met final eligibility criteria . As a result, baseline infarct–edema volume was not different between the two groups . However, in the group of patients with visible infarct–edema on initial CT, the surgical group had greater baseline infarct–edema volume . Patients in the surgical group were more likely to have infarct–edema involving bilateral or multiple vascular territories that those in the medical group  and 26 (68%) of the initial CTs in the medical and surgical groups, respectively (p = 0.85), whereas more patients from the surgical group were discharged to skilled nursing facilities, trending significance (p = 0.09).At the time of discharge, more than half of patients from both intervention groups were discharged to inpatient rehabilitation facilities , bilateral or multiple vascular territories , and hemorrhagic transformation on admission CT  were associated with surgical intervention. On multivariable logistic regression analysis, baseline infarct–edema volume and bilateral or multiple vascular territories remained independent predictors of surgical intervention (Table p = 0.005). The final predicted mean plateau volume was 24.9 ml (95% CI 21.5–28.3) and 43.6 ml (95% CI 38.3–48.8) for the medical and surgical groups, respectively (p < 0.0001).Because of the low variance explained by baseline infarct–edema volume and infarct territory involvement at predicting patients requiring surgical intervention, we examined the added value of infarct–edema growth rate, as measured on serial CTs. First, to describe the temporal evolution of infarct–edema over the first 14 days, we plotted infarct–edema volume as a function of time from LKW across all 410 scans in 150 patients Fig. b. In botp = 0.002, Fig. Although infarct–edema growth followed a logistic growth pattern over the 2-week period, we observed a steep linear growth pattern over the first 2 days. Thus, we further characterized the infarct–edema growth pattern during this early criterial period. One hundred twelve patients had at least one CT scan  over the first 2 days of LKW. Compared with the medical group, the surgical group was associated with greater infarct–edema volume by day 0.5 and onward  who had at least two CT scans  in the first 2 days since LKW . The calculated infarct–edema growth rates of the medical and surgical groups were consistent with the growth rates modeled in Fig. p = 0.02) to 0.91  (p = 0.0002). The final multivariable model explained 49% of the variance in the intervention end point, relative to 20% variance explained in the previous model including only baseline variables.Next, we evaluated if the addition of early infarct–edema growth rate improved the ability to predict individuals requiring surgical intervention. We first calculated the rate of growth on the subset of patients , admission NIHSS , and brainstem infarct  were associated with poor outcome, whereas baseline infarct–edema volume and bilateral or multiple vascular territories were not. On multivariable logistic regression, infarct–edema growth rate remained a significant predictor of poor outcome, independent of baseline infarct–edema volume, NIHSS, brainstem infarct, and vascular territories Supplementary file2 (DOCX 95 kb)Below is the link to the electronic supplementary material.


The TaOx:N–based device significantly enhanced the RS characteristics compared with a TaOx–based device in terms of resistance variability. It achieved lower device–to–device variability in both low-resistance state (LRS) and high–resistance state (HRS), 8.7% and 48.3% rather than undoped device of 35% and 60.7%. Furthermore, the N–doped device showed a centralized set distribution with a 9.4% variability, while the undoped device exhibited a wider distribution with a 17.2% variability. Concerning pulse endurance, nitrogen doping prevented durability from being degraded. Finally, for synaptic properties, the potentiation and depression of the TaOx:N–based device exhibited a more stable cycle–to–cycle variability of 4.9%, compared with only 13.7% for the TaOx–based device. The proposed nitrogen–doped device is more suitable for neuromorphic systems because, unlike the undoped device, uniformity of conductance can be obtained.Resistive random–access memory (RRAM) for neuromorphic systems has received significant attention because of its advantages, such as low power consumption, high–density structure, and high–speed switching. However, variability occurs because of the stochastic nature of conductive filaments (CFs), producing inaccurate results in neuromorphic systems. In this article, we fabricated nitrogen–doped tantalum oxide (TaO New technologies such as artificial intelligence (AI) and the Internet of Things (IoT) are gaining attention, so rapid processing of vast amounts of data and information is required. However, in traditional digital computing—the von Neumann architecture—operation and storage devices are separated. Accordingly, bottlenecks occur when transferring complex data between devices ,2. Therex/Pt enhances the reliability effect on neuromorphic systems. Refs. [o to Vo2+, so the leakage path can be reduced. Another important effect of nitrogen in the oxide layer is the restriction of oxygen ions’ diffusion. Y. E. Syu et al., [x improves uniformity at a low operating current. The performance of N–doped memory devices compared with undoped memory device in previous reports is summarized in Despite these advantages, the filament–type RRAM cannot avoid large variations in conductance because the formation and rupture of filaments occur randomly, a drawback for use in neuromorphic systems . Severals. Refs. ,21,22,23s. Refs.  stated t et al.,  stated t et al.,  reportedx. Therefore, we investigated enhancing RS and synaptic properties in TaOx films with nitrogen doping.In this study, the effect of nitrogen doping on synaptic properties and DC properties was also examined, in contrast with previous studies . By incox/Pt and Ta/TaOx:N/Pt devices were fabricated using the following process. First, we deposited the platinum (Pt) bottom electrode (BE) with a thickness of 100 nm using a thermal evaporator on a silicon oxide–silicon (SiO2/Si) substrate. The substrate was cleaned with acetone, isopropyl alcohol (IPA), and deionized (DI) water under ultra-sonication for 5 min each. The tantalum oxide (TaOx) and nitrogen–doped tantalum oxide (TaOx:N) switching layers were deposited with a thickness of 50 nm at room temperature. We applied a radiofrequency (RF) sputtering power of 240 W with the 3–inch tantalum metal target.The Ta/TaO2 gas, and an additional 1 sccm of N2 gas for the TaOx:N device. We then coated the negative PR and patterned it with a square pattern size of 100 μm. Then, the Ta top electrode (TE) was deposited by DC sputtering with a thickness of 100 nm.The pressure in the main chamber was maintained at 5 mTorr, and the gas flow rate was set to 20 sccm of Ar gas, 6 sccm of Ox films. x/Pt and Ta/TaOx:N/Pt memristors were measured. A preliminary forming process was required to produce a low–resistance state (LRS) from the initial state [First, the electrical properties of the Ta/TaOal state ,28. Bothread) during a cyclic test, as depicted in x–based memristor exhibited a significant difference in resistance in the set and reset operations with cycle–to–cycle resistance variabilities (σ/μ) of 27.8% (LRS) and 23.7% (HRS). However, the TaOx:N–based memristor exhibited a stable RS characteristic with relatively small cycle–to–cycle resistance variabilities of 15.7% (LRS) and 13.2% (HRS). A retention characteristic test was performed to confirm the performance of the TaOx–based and TaOx:N–based memristors, as depicted in 5 s without any degradation.The detailed distribution of HRS and LRS values were extracted from the I−V characteristics measured at 0.2 V  and long–term depression (LTD), are crucial aspects of the application of neuromorphic systems . The LTPx–based memristor. Ten cycles of potentiation and depression were conducted with these consecutive pulses. x–based memristor and −1 and 0.81 V for the TaOx:N–based memristor; the pulse width was set to 100 nS. Even for nitrogen–doped devices (4.9%), cycle–to–cycle variability occurred, as depicted in x–based device. The conductance of the last point of a cycle does not match the first point of a subsequent cycle. In contrast, x:N–based memristor, which has higher cycle–to–cycle uniformity, is suitable for neuromorphic computing applications. Key performance indicators achieved in the present study are summarized in As depicted in x/Pt and Ta/TaOx:N/Pt devices. The TaOx:N–based memristor exhibited uniformity of resistance state and set voltages and a 105 pulse endurance. Furthermore, synaptic properties such as potentiation and depression were conducted with a pulse train. The TaOx:N–based memristor exhibited more stable conductance modulation when measuring potentiation first and depression first. In contrast, the TaOx–based memristor produces variability in the I–V curves, set voltages, and device-to-device resistance. It also degrades when pulse endurance, potentiation, and depression are measured. When we use RRAM as a neuromorphic system, the device should have low resistance variability. Therefore, a TaOx:N–based device is more suitable for an artificial synapse than an undoped–TaOx device.In this study, we investigated the role of nitrogen doping on resistive and synaptic characteristics while comparing the Ta/TaO


This study aimed to examine the safety of fixed‐dose nivolumab.We retrospectively reviewed the medical records of 113 Japanese patients with gastric cancer who were previously treated with cytotoxic chemotherapy and initiated nivolumab. The endpoints were the incidence of Grade 2 or higher immune‐related adverse events (irAEs) in the conventional dose (3 mg/kg) and fixed‐dose groups (240 mg).The incidence rates of irAEs in the conventional‐dose and fixed‐dose groups were 29.9% and 19.4%, respectively, and the rates of Grade 2 or higher irAEs were 23.3% and 19.4%, respectively, with no significant difference between the two groups, suggesting that nivolumab at 240 mg is as safe as the 3 mg/kg dose.This is the first report on the safety of nivolumab at 240 mg in Japanese patients. As this was a retrospective study, informed consent was not sought from the patients. All patient data were anonymized and deidentified before analysis.We reviewed the medical records of patients with gastric cancer for whom nivolumab treatment was initiated at our hospital between September 2017 and August 2019. Patients who had previously received immune checkpoint inhibitors and those who received both 3 mg/kg and fixed doses of nivolumab were excluded from the study.2.1Nivolumab was administered every 2 weeks until treatment discontinuation or the end of follow‐up, as previously described.Surviving patients were confirmed on the last follow‐up date. We defined immune‐related adverse events (irAEs) as events with an immunological rationale requiring frequent monitoring and possible intervention with immunosuppressive therapy. These included endocrine, hepatic, cutaneous, lymphatic, neurological, gastrointestinal, renal, pulmonary, pancreatic, and optic irAEs. We did not consider symptomatic factors with transient abnormal laboratory values, such as elevations in the levels of alanine aminotransferase, aspartate aminotransferase, and thyroid‐stimulating hormone, as irAEs. All adverse events were graded according to the Common Terminology Criteria for Adverse Events, version 4.0.2.2The study endpoints were the incidence of Grade 2 or higher irAEs and the number of patients who discontinued nivolumab due to adverse events in the conventional‐ and fixed‐dose groups. The study endpoints were based on Grade 2 irAEs as these irAEs would result in nivolumab withdrawal.2.3U test and Fisher's exact test. Statistical significance was set at p < 0.05. Statistical analyses were performed using JMP version 13 software (SAS Institute Japan).The differences in patient background, irAEs grading (Grade 2 or higher), and frequency of irAEs between the groups were analyzed using Mann–Whitney 33.1n = 77) or 240 mg (n = 36) nivolumab, as shown in Figure p < 0.01) was significantly higher in the 3 mg/kg group than in the 240 mg group. The drugs used previously in the treatment of these patients included S‐1, cisplatin, irinotecan, trastuzumab, capecitabine, oxaliplatin, paclitaxel, ramucirumab, and docetaxel.Between September 2017 and August 2019, we screened 134 patients for eligibility; among them, 113 had received 3 mg/kg (3.2p = 0.264) in the 3 mg/kg and 240 mg groups, respectively. Furthermore, the number of patients with Grade 2 or higher irAEs was 18 (23.3%) and 7 (19.4%) in the 3 mg/kg and 240 mg groups, respectively  and 7 , pneumonitis (p = 0.550), diarrhea/colitis (p = 0.176), liver dysfunction (p = 1.000), nephritis and renal dysfunction (p = 0.538), and other (p = 0.538) were not significantly related to the drug treatment groups. Furthermore, the frequency of rash (p = 0.028) was higher in the 240 mg group than in the 3 mg/kg group.The incidence of other irAEs of Grade 2 or higher in the 3 mg/kg group was as follows: six patients with hypothyroidism, three with pneumonitis, five with diarrhea/colitis, three with liver dysfunction, one with nephritis and renal dysfunction, three with rashes, and one with an event designated as “other.” In the 240 mg group, the incidence of irAEs of Grade 2 or higher was as follows: One patient with hypothyroidism, one with liver dysfunction, one with nephritis and renal dysfunction, six with rashes, and one with an event designated as “other” , and short observation period (in the 240 mg group). The median duration of treatment was 42 days for the 3 mg/kg group and 56 days for the 240 mg group, and the median follow‐up intervals were 124 and 284 days, respectively. Six patients (16.7%) in the 240 mg group did not complete the treatment; however, as the incidence of irAEs was high in the early stages of the administration, and none of the patients developed irAEs after the end of treatment in the 3 mg/kg group, we believe that the effect on the results is small. Overall, considering that there are no previous studies on low‐weight patients with gastric cancer treated with a fixed dose of 240 mg, we believe that this safety assessment is significant. Correlation analysis between variables alone is not sufficient to draw conclusions from this study, and the results need to be confirmed in future studies involving more patients and more robust statistical analysis. In the next study, we plan to increase the number of patients and conduct multivariate analysis; therefore, we conducted this study in an exploratory manner to extract important factors for the subsequent study.5The administration of nivolumab at a fixed dose of 240 mg to patients with gastric cancer is as safe as the weight‐based 3 mg/kg dose, based on the findings from a small group of patients. To the best of our knowledge, this is the first report comparing the safety of nivolumab at 240 and 3 mg/kg in Japanese patients with gastric cancer, and we believe these findings will be useful for future studies.Yusuke Iikura and Takeshi Aoyama: Conceptualization. Yusuke Iikura and Makoto Hiraide: Formal analysis. Takeru Wakatsuki, Izuma Nakayama, Mariko Ogura, Akira Ooki, Daisuke Takahari, Keisho Chin, Kensei Yamaguchi, and Toshihiro Hama: Writing – review and editing. Yusuke Iikura and Takeshi Aoyama: Writing – original draft.Kensei Yamaguchi has received speaking honoraria from Merck Serono, Takeda Pharmaceutical, Taiho Pharmaceutical, Chugai Pharmaceutical, Ono Pharmaceutical, Eli Lilly, Yakult, Sanofi, Bristol‐Myers Squibb, and Bayer, and research grants from Ono Pharmaceutical, MSD, Taiho Pharmaceutical, Sumitomo Dainippon Pharma, Eli Lilly, Daiichi Sankyo, Yakult, and Gilead Sciences. He also plays consulting and advisory roles for Bristol‐Myers Squibb. The other authors declare no conflict of interest.The corresponding author confirms that the manuscript is an honest, accurate, and transparent account of the study being reported, no important aspects of the study have been omitted, and any discrepancies from the study as planned have been explained.


Z‐score <−2) than those without HIV (33% versus 7%). Both male and female CWH in later puberty had lower trabecular vBMD, CSA (4% and 38%), and SSI than those without HIV, whereas cortical density was similar. Adjustment explained some of these differences; however, deficits in bone size persisted in CWH in later puberty . Similarly, puberty further worsened the inverse association between HIV and bone strength (SSI) in both males (interaction p = 0.008) and females (interaction p = 0.004). Despite long‐term ART, we identified deficits in predicted bone strength in those living with HIV, which were more overt in the later stages of puberty. This is concerning, as this may translate to higher fracture risk later in life. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).HIV infection has multi‐system adverse effects in children, including on the growing skeleton. We aimed to determine the association between chronic HIV infection and bone architecture  in peripubertal children. We conducted a cross‐sectional study of children aged 8 to 16 years with HIV (CWH) on antiretroviral therapy (ART) and children without HIV (CWOH) recruited from schools and frequency‐matched for age strata and sex. Outcomes, measured by tibial peripheral quantitative computed tomography (pQCT), included 4% trabecular and 38% cortical volumetric bone mineral density (vBMD), 4% and 38% cross‐sectional area (CSA), and 38% stress–strain index (SSI). Multivariable linear regression tested associations between HIV status and outcomes, stratified by sex and puberty (Tanner 1–2 versus 3–5), adjusting for age, height, fat mass, physical activity, and socioeconomic and orphanhood statuses. We recruited 303 CWH and 306 CWOH; 50% were female. Although CWH were similar in age to CWOH , more were prepubertal . Median age at ART initiation was 4 (IQR 2–7) years, whereas median ART duration was 8 (IQR 6–10) years. CWH were more often stunted (height‐for‐age  The global decline in HIV‐associated child and adult deaths has largely been achieved in Eastern and Southern Africa, home to 89.2% (2.5 million of 2.8 million) of the world's CWH. There is increasing recognition that, despite ART, HIV has adverse effects on multiple organ systems in children resulting in long‐term multisystem comorbidities. These are of growing concern as the improved survival attributable to ART means that increasing numbers of CWH are now entering adolescence and adulthood. In sub‐Saharan Africa (SSA), CWH are commonly underweight (weight‐for‐age Z‐score <−2) and/or stunted (height‐for‐age Z‐score <−2), with the prevalence of stunting varying from 23% to 73%. Linear growth continues through adolescence as bone accrues to achieve peak bone mass (PBM). PBM is a critical determinant of adult osteoporotic fracture risk; a 10% reduction can double fracture risk in adulthood . The long‐term impact of exposure to both HIV infection and ART in perinatally infected children is of concern because impaired linear growth may be associated with suboptimal PBM accrual, with implications for adult fracture risk.Improved access and earlier antiretroviral therapy (ART) initiation in children with HIV (CWH) has markedly increased survival, enabling many children to now reach puberty and adulthood.1 The LBM) and lumbar spine bone mineral apparent density (LS‐BMAD) in CWH than in children without HIV (CWOH), which was more overt in later adolescence. Tenofovir disproxil fumarate (TDF) exposure has been associated with low BMD in adults living with HIV. Recently, among CWH, both TDF exposure and orphanhood were associated with lower TBLH‐BMCLBMZ‐score.We recently reported lower dual‐energy X‐ray absorptiometry (DXA)‐measured bone outcomes of total‐body less‐head (TBLH) bone mineral content (BMC) for lean mass adjusted for height  offers an opportunity to study bone architecture, quantifying volumetric bone mineral density (vBMD) and bone size, which enables prediction of bone strength. A recent South African study compared pQCT‐measured bone architecture among 172 CWH and 98 CWOH aged 7 to 14 years, reporting lower trabecular vBMD in male CWH and generally lower bone strength in CWH than in CWOH.In a smaller cross‐sectional study in Zimbabwe, age at ART initiation was strongly negatively correlated with both LS‐BMAD and TBLH‐BMCWe hypothesized that HIV infection would be associated with adverse effects on bone architecture, leading to compromised pQCT bone outcomes, ie, vBMD, bone size, and predicted strength  from HIV clinics at Parirenyatwa and/or Sally Mugabe Hospitals in Harare, Zimbabwe. These are the two large public hospitals in Harare, providing HIV care services to more than 2000 children. CWOH were randomly recruited, using school registers, from three primary and three secondary schools within the same community suburbs served by the hospitals providing HIV care, and were frequency‐matched by sex and age strata. Inclusion criteria were age 8 to 16 years, living in Harare. CWH were included if they were aware of their HIV status and had been taking ART for at least 2 years. At the time of enrollment into the study, CWOH underwent HIV testing to confirm their status. Children with acute illness requiring hospitalization, those lacking guardian consent, and those who were recently diagnosed with HIV were excluded from this study.A cross‐sectional study was conducted using baseline pQCT measurements from the IMpact of Vertical HIV infection on child and Adolescent Skeletal development (IMVASK) study, as per published protocol (ISRCTN12266984).20 CWH combining details including number in household, head of household age, highest maternal and paternal education levels, household ownership, monthly household income, access to electricity, water, a flush toilet and/or pit latrine, and ownership of a fridge, bicycle, car, television, and/or radio and was split into tertiles for analysis. The International Physical Activity Questionnaire (IPAQ) short version classified intensity of physical activity as low (metabolic rate [MET] minutes <600 per week), moderate (MET minutes = 600 to 3000 per week), and vigorous (MET minutes >3000 per week). Diet was assessed using a tool developed for the Zimbabwean context based on a validated dietary diversity and food‐frequency tool from India and Malawi and international guidelines applicable to SSA. Daily dietary calcium (Ca) intake was classified as very low (<150 mg/d), low (150–299 mg/d), and moderate (300–450 mg/d). Daily dietary vitamin D intake was classified as very low (<4.0 μg/d), low (4.0–5.9 μg/d), and moderate (6.0–8.0 μg/d).Data were collected between May 2018 and January 2020. Demographic and clinical data were collected using an interviewer‐administered questionnaire together with handheld medical records. Demographic and clinical data collected included age, sex, socioeconomic status (SES), guardianship, orphanhood, age at HIV diagnosis, age at ART initiation, ART regimen, diet, and physical activity. SES was derived using the first component from a principal component analysis21 com Where there was a discordance between the stages for males and females, testicular and breast development stage, respectively, were used to assign Tanner stage. Participants were grouped into Tanner stages 1 and 2 (pre‐ to early puberty) and Tanner stages 3 to 5 (mid/late puberty). Three standing height measurements were obtained to the nearest 0.1 cm using a Seca 213 stadiometer , and three weight measurements were obtained to the nearest 0.1 kg with a Seca 875 weight scale, with means calculated. Equipment was calibrated annually. Using British 1990 growth references, height‐for‐age Z‐score <−2, weight‐for‐age Z‐score <−2, and low weight‐for‐height body mass index (BMI) Z‐score <−2 were used to define stunting, underweight, and wasting, respectively. Fat mass and fat‐free soft tissue (lean) mass were measured by whole‐body DXA scan, using a Hologic QDR Wi machine with Apex software version 4.5 . CD4 cell count was measured using a PIMA CD4 machine . HIV viral load was measured using the GeneXpert HIV‐1 viral load platform .Puberty was Tanner staged by a trained study nurse and/or doctor. For males, testicular volume, penile size (length and circumference), and pubic hair growth  were assessed. For females, breast growth (size and contour) as well as pubic hair growth and age of menarche were assessed. Testicular, breast, and penile growth were graded from I to V based on Tanner descriptions.27 Whe As long bones grow in length, the growth plate moves upward and the wider metaphysis is reshaped into a diaphysis by continuous resorption by osteoclasts beneath the periosteum. To allow for consistency of a scan site, the reference line was placed at the growth plate in those children whose end plate and growth plate were not yet fused. vBMD was measured in mg/cm3 at the 4%  site for trabecular bone and the 38%  site for cortical bone. Bone size measures included 4% and 38% total cross‐sectional area  and 38% cortical thickness (mm). Predicted bone strength was measured as 38% stress–strain index , indicating the bending and torsional strength of bone. The manufacturer's software (version 6.20) was used for image processing and analysis. At the 4% tibia, CALCBD was used to calculate total CSA and trabecular vBMD. CALCBD contour mode 1  was used to exclude pixels in defined regions of interest (ROI) that fell below a threshold of 180 mg/cm3, peel mode 1  peeled away the outer 55% of the total bone CSA, leaving an inner 45% CSA considered as the trabecular region of interest. At the 38% tibial site, CORTBD was used to define cortical vBMD and area; this algorithm removes all voxels within ROIs with an attenuation coefficient below a 710 mg/cm3 threshold (with separation mode 1). Total CSA was defined at the 38% tibia using a 180 mg/cm3 threshold. Cortical thickness was calculated using a circular ring model. A phantom was scanned daily for quality assurance. Thirty participants were scanned twice, with repositioning, to assess reproducibility. Coefficients of variation were calculated from the results of the 30 rescanned participants. The short‐term precision (root mean square % CV) was 1.26% for trabecular vBMD, 0.37% for cortical vBMD, 2.08% for 4% total CSA, and 0.93% for 38% CSA. All pQCT scan slices and scout views were qualitatively graded by a single radiographer. Movement artifacts were graded 0 to 3: 0 = none; 1 = slight; 2 = medium streaking; and 3 = scan unusable. Grade 3 images were excluded from analysis.Non‐dominant tibial pQCT scans were performed using an XCT 2000 , with voxel size 0.5 × 0.5 mm and slice thickness 2 mm . Tibial length was measured from the distal medial malleolus to the tibial plateau with a metal ruler. Scan sites were determined as a percentage of tibia length, with the exact position determined by scout view placement of a reference line on the growth plate or on the end plate for those with fused growth plates.30 As Trained research assistants and/or a study nurse explained the study information to participants and guardians. Guardians gave written informed consent and participants gave age‐appropriate written assent. This study was approved by the Parirenyatwa Hospital and College of Health Sciences joint research ethics committee (JREC/123/19), the Biomedical Research and Training Institute Institutional Review Board (AP150/2019), the London School of Hygiene and Tropical Medicine (17154) Ethics Committee, and the Medical Research Council of Zimbabwe (MRCZ/A2494).3), 4% and 38% CSA (mm2), 38% cortical thickness (mm), and 38% SSI (mm4). We used independent sample t tests to compare continuous data between groups and percentages and chi‐square tests for categorical data. We determined differences between CWH and CWOH, stratified by sex  in separate regression models, by comparing means using linear regression and generating mean differences and 95% confidence intervals. We compared an unadjusted model with a model adjusting for a priori confounders; age (years), height (cm), binary pubertal status , fat mass, physical activity, SES, and orphanhood , lean mass adjustment was not made to avoid collinearity. If lean mass was included in linear regression, the variance inflation factors exceeded a value of 8. We assessed modification of the association of HIV with bone outcomes by pubertal stage by incorporating a binary interaction term for puberty (pre/early versus mid/late). In further analyses, restricted to CWH, we compared those who were exposed to TDF with those who were not. To account for missing data assumed missing at random, multiple imputation by chained equations (with 7 imputed data sets), allowing for imputation of categorical and continuous data simultaneously was performed. Imputation models included all pQCT bone outcomes, variables associated with missingness (Tanner stage only), and factors determined in complete case analysis to be associated with HIV . Imputation models were run on males and females combined, with regression analysis models using the imputed data run stratified by sex.Statistical analyses were performed using Stata version 16.0 . Data were cleaned and checked for consistency and outliers. Outcomes included 4% trabecular and 38% cortical vBMD (mg/cml power),33 fatThe study recruited 610 participants, of whom 578 (94.8%) (276 with and 302 without HIV) had a pQCT scan Fig. .p = 0.009) and females  , with corresponding lower fat and lean mass.Of the participants with a pQCT scan, CWH were similar in age to those without HIV. However, CWH were more likely to be in Tanner stages 1 and 2 compared with their uninfected counterparts; this was the case for both males  Table . Compare3. Among CWH 21% (n = 63/303) were taking TDF at the time of the study. However, 33.6% (n = 102) reported ever using TDF as part of their ART regimen, of whom 13.2% (n = 40) reported taking it for more than 4 years. The average age at TDF initiation was 10 years.Overall CWH had been diagnosed with HIV when aged 3.9 ± 3.2 (mean ± SD) years and started on ART at a median age of 3.7 (IQR 1.8–6.9) years, so that at the time of participation in this study, median ART duration was 8.1 (IQR 6.2–9.5) years. The majority (79%) had a suppressed viral load (<1000 copies/mL), and only 2.3% had a CD4 count <200 cells/mmCWH were more likely to have a lower SES than children without HIV. Compared with children without HIV, both male and female CWH were more likely to be orphans or to have only one surviving parent Table . In both3 (6.2%) and 11.7 mg/cm3 (5.2%) lower in male and female CWH than in children without HIV, whereas no such differences were found for cortical vBMD  had smaller metaphyseal and diaphyseal tibial bone size (CSA) than CWOH Table . These sIn both males and females, before any adjustment, SSI was lower in CWH than those without HIV; however, this was explained by adjustment for age, height, and puberty Table .We next investigated the potential interaction between HIV infection and pubertal stage (pre/early [Tanner 1–2] versus mid/late [Tanner 3–5]) on bone outcomes.Differences in trabecular vBMD between children with and without HIV were similarly small, in both pre/early and mid/later puberty, with no evidence of interaction for males or females Fig. . HoweverBefore adjustment, clear evidence was detected to suggest that pubertal stage was modifying the effect of HIV on bone size, such that in both males and females, CWH in mid/late puberty had substantially smaller CSA than children without HIV, at the metaphysis and diaphysis, whereas this difference was not apparent in pre/early puberty Fig. . Althougp = 0.008) and females (interaction p = 0.004), such that HIV‐associated bone deficits appear worse toward the end of puberty  found in CWH, compared with those without HIV, was most overt in mid/late puberty in both males and females Fig. . After fty Table .In further analyses, restricted to CWH, those who were and were not exposed to TDF were similar in terms of sex, SES, physical activity, and dietary intake of calcium and vitamin D , which suggested CWH have smaller bone size and lower predicted bone strength than CWOH, although this association was not adjusted for fat mass, physical activity, or any indicator of SES. Our larger study was able to both stratify by pubertal stage and adjust for a number of relevant confounders and showed how differences in size and strength become more pronounced in later puberty. A longitudinal Canadian study of 9‐ to 18‐year‐old CWH with diverse ethnic backgrounds reported no change in pQCT bone outcomes over 2 years. However, this study was small (n = 31 CWH) across sex and ethnic strata, suggesting insufficient power to detect change over time. Although notably, as found in our study, Canadian CWH in early puberty had higher cortical BMD compared with CWOH. An extensive literature has established a higher prevalence of stunting and underweight in CWH than in CWOH, which has been confirmed by our study and our earlier studies in Zimbabwean children. By adjusting for body size however, we have shown that the lower bone size in female CWH, especially in later puberty, is independent of lower height and weight.To date, only two studies have reported using pQCT in children living with HIV.38 OurLBM, such that children exposed to TDF for 4 or more years had on average a 0.5 SD lower TBLH‐BMCLBMZ‐score compared with CWH who had not received TDF. This effect size is clinically important, as a 0.5 SD reduction in bone density increases by 50% both childhood and, if sustained, future adult fracture risk. Here we show, after accounting for multiple confounders, that TDF use is particularly associated with trabecular bone loss. Whether this translates to increased fracture risk at trabecular‐rich skeletal sites, such as the wrist and vertebra, is currently unknown.This is the first study to use pQCT to examine the effects of TDF use on bone architecture in CWH. Our previous DXA findings in the same Zimbabwean cohort identified a strong association between TDF use and bone deficits, particularly affecting TBLH‐BMCLBMZ‐score, a cortical‐rich region of interest  and LS‐BMAD Z‐score, a trabecular‐rich site  in CWH compared with their uninfected counterparts. Further earlier work in a smaller, slightly younger (6 to 16 years) Zimbabwean population identified similar prevalence of low LS‐BMAD and TBLH‐BMCLBM in CWH . Although DXA‐measured areal BMD does not differentiate trabecular and cortical compartments, the lower LS‐BMAD previously reported indicates the possibility of a greater deficit in trabecular bone. This aligns with our unadjusted analysis that showed that trabecular vBMD and not cortical density was lower in CWH than in CWOH. However, this is inconsistent with our adjusted analysis, as we report no differences in both trabecular and cortical density in CWH and CWOH after full adjustment.Our reported pQCT results further extend our previous DXA findings in the same Zimbabwean cohort, where we found a higher prevalence of low TBLH‐BMC and a risk factor for poor bone growth. Hence, as expected, we saw a greater number of CWH were prepubertal than children without HIV. Pubertal delay could be the reason for compromised bone accrual in CWH. Without stratifying by pre/early versus mid/late puberty, we would have missed important interactions between HIV and pubertal stage. In our study, male CWH in mid/late puberty demonstrated the most adverse skeletal profile. The importance of stratifying by puberty was also demonstrated by a cross‐sectional study in the US of 7‐ to 24‐year‐olds, which similarly reported an HIV*puberty interaction on DXA‐measured spine and total body bone mineral content and density; the lower bone mass in participants with HIV was more pronounced with advancing puberty. However, in this study, the differences were more evident in males, whereas in our study, we demonstrated differences in both males and females. It is not clear to what extent the difference in the source population , study sampling , and/or the age studied might account for these different findings.Pubertal delay is both a common consequence of HIV infection11 and lactation, and menopause. Lactation is a known risk factor for bone loss in African women, and 83% of Zimbabwean women continue to breastfeed beyond 1 year postpartum. Coupled with HIV infection and ongoing ART, the risk of adult osteoporosis is high. Recent data from rural South Africa identified a 37% prevalence of femoral neck osteoporosis in women aged ≥50 years living with HIV. Understanding fracture risk in African women living with HIV is an important research priority.Our results suggesting females living with HIV particularly may be entering adulthood with bone‐size deficits is a concern. Women often experience periods of bone loss, eg, pregnancy,45 lacThe major strength of this study is the novel use of pQCT in a large population of children in an understudied African population. The comparison with children without HIV and the fact that the study sample is likely representative of children living in Harare are study strengths. Our study has several limitations. The analysis is cross‐sectional; therefore, we cannot infer causality. Further, pQCT is not a technique used in clinical practice, which limits the ability to relate findings to routine clinical practice. We were unable to compare findings to normative pQCT reference data because there are no established normative pQCT data for children living in sub‐Saharan Africa. The study was not powered to stratify by pubertal stage; therefore, because males appeared to be transitioning through puberty more slowly than females, the study may not have included sufficient males at more advanced stages of puberty. Small numbers within Tanner stage categories limited our ability to test for interaction, as we needed to group participants in different pubertal stages based on numbers with each stage, rather than pubertal biology. Further follow‐up may be helpful in assessing both the male and female children further.Our results suggest the effect of HIV on bone size and strength differs by pubertal status. We report deficits in bone size and strength associated with HIV infection, which are found more clearly toward the end of puberty in both male and female children. We further show, for the first time, an indication of attenuated trabecular bone accrual in those using TDF. We expect our findings to be broadly generalizable across populations living in southern Africa, where HIV prevalence is high. Hence, these findings have implications for fracture risk in adulthood. The study of fracture incidence, in people living with HIV in sub‐Saharan Africa, is now a research priority.The authors declare no conflicts of interest.Cynthia Mukwasi‐Kahari: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; writing – original draft; writing – review and editing. Andrea M Rehman: Conceptualization; data curation; formal analysis; methodology; supervision; writing – original draft; writing – review and editing. Mícheál Ó Breasail: Data curation; investigation; writing – review and editing. Ruramayi Rukuni: Data curation; investigation; project administration; writing – review and editing. Tafadzwa Madanhire: Data curation; formal analysis; writing – review and editing. Joseph Chipanga: Data curation; project administration; writing – review and editing. Lynda Stranix‐Chibanda: Supervision; writing – review and editing. Lisa K Micklesfield: Supervision; writing – review and editing. Rashida A Ferrand: Project administration; supervision; writing – review and editing. Kate A Ward: Conceptualization; data curation; methodology; resources; supervision; writing – original draft; writing – review and editing. Celia L Gregson: Conceptualization; methodology; project administration; resources; supervision; writing – original draft; writing – review and editing.https://publons.com/publon/10.1002/jbmr.4752.The peer review history for this article is available at The authors declare no conflicts of interest.Appendix S1. Supporting Information.Click here for additional data file.


N = 221) of elderly spousally bereaved people. The aim was twofold. First, we aimed to establish the optimal measurement model of SOC, evaluating the fit of different factor solutions for the 29‐item SOC‐29 scale and 13‐item SOC‐13 scale, using confirmatory factor analysis. Second, we sought to examine associations of emerging SOC factors with symptoms levels of prolonged grief disorder (PGD) and depression, and with satisfaction with life, assessed concurrently (at 6 months post‐loss) and at two consecutive time points, 13 and 18 months post‐loss. Results showed that the three‐factor model of the SOC‐13  provided a good fit to our data. With respect to our second aim, analyses showed that the three SOC factors were associated with concurrently assessed PGD, depression, and satisfaction with life. In the analyses predicting outcomes at Wave 2 and Wave 3, meaningfulness (but not manageability and comprehensibility) predicted some of the outcomes, above and beyond baseline scores of the outcomes. Findings suggest that meaningfulness may increase healthy and attenuate unhealthy responses to loss. Helping bereaved people to experience life's demands as worthy of investment and engagement is likely an important target for bereavement care.There is growing interest in psychological factors maintaining healthy functioning following adverse events. One such variable is a sense of coherence (SOC), an orientation to life comprising manageability, comprehensibility, and meaningfulness. Little research has examined the role of SOC in adjustment to bereavement. The present longitudinal study examined the role of SOC in recovery from loss, in a Danish sample ( Among elderly spousally bereaved people, a sense of coherence was found to encompass three distinguishable elements of manageability, comprehensibility, and meaningfulness.The three elements of a sense of coherence were associated with concurrently assessed reactions to loss.Baseline increased meaningfulness (but not manageability and comprehensibility) predicted decreased unhealthy and increased healthy bereavement‐responses later in time.Helping bereaved people to experience life's demands as worthy of investment and engagement and empowering them to identify resources needed to adjust are important targets for bereavement care.1manageability , comprehensibility , and meaningfulness (the basic sense that life's demands are worthy of investment and engagement). To measure SOC, Antonovsky , a concept central to the salutogenic theory of health  and the association of SOC at W1 with these outcomes at W2 and W3 (13 and 18 months post‐loss). We focused on negative and positive outcomes, considering that adjustment to loss involves both mitigating negative emotions and maintaining positive psychological functioning. Assuming that the analyses would show that, in our sample, SOC consists of multiple, distinguishable components, we intended to investigate both the association of the distinct components with the outcomes as well as the association of the SOC factors with outcomes when controlling for the shared variance between SOC factors. Considering the lack of knowledge on the role of SOC in recovery from loss, examining both the distinct and combined impact of SOC factors on bereavement outcomes was deemed both clinically and theoretically relevant, by elucidating potential underlying mechanisms of problems in recovery from loss and targets for interventions.We had no hypotheses about the factor structure of the SOC items, considering that prior work has supported different factorial structures. With respect to our second aim, we anticipated that SOC would be negatively related with PGD and depression symptoms and positively with satisfaction with life. Again, because of the lack of research in bereaved samples, we had no specific hypotheses about the strengths of these relationships nor about the relative importance of SOC factors emerging from our analyses.22.1N = 221, N = 176, and N = 169 were available at 6 months (W1), 13 months (W2), and 18 months post‐loss (W3), respectively. In the W1 sample (N = 221), participants had a mean age of 72.19 (SD = 4.23) years: 130 (58.8%) were female, 88 (39.8%) were male (gender was unknown for n = 3). They had a mean of 8.19 years of public schooling . All had lost a spouse or partner. As noted, for all participants, the time elapsed since the loss was 6 months (at W1). Participants had cohabited with their partner 45.34 (SD = 10.73) years before the partner's death, on average. They had 2.61  children on average; n = 190  had faced a period of the spouse's illness before the partner died. The self‐reported cause of death was cancer in 91 (41.2%) cases, cardio vascular disease in 34 (15.4%) cases, dementia in five (2.3%) cases, an accident in three (1.4%) cases, diabetes in three (1.4%) cases, other causes  in 74 (33.5%) cases, and unknown in 11 (5%) cases.Of 296 participants included at the 2‐month assessment, in the current study, data from 2.2Data were gathered using self‐report questionnaires. The first part contained questions on socio‐demographics and loss‐related variables. The second part included different standardized questionnaires measuring PGD symptoms, depression symptoms, satisfaction with life, and SOC. As described elsewhere . As noted above, evidence supported psychometric properties of the SOC‐29 and SOC‐13 but the factor structure of both scales has been debated , we successively evaluated the fit of a one‐factor solution and three‐factor solution of the SOC‐29 and one‐factor, two‐factor, and three‐factor solutions of the SOC‐13.  As estimation method, maximum likelihood with robust standard errors (MLR) was used. To evaluate model fit, we considered the comparative fit index (CFI) and Tucker–Lewis index (TLI) with values >.90 indicating adequate fit, and the root‐mean‐square error of approximation (RMSEA) and standardized root mean square residual (SRMR) with values <.08 indicating acceptable fit  implemented in MPlus  and PGD, depression, and functional impairment (at W1–W3). In addition, we examined whether scores on these indices differed as a function of the socio‐demographic and loss‐related variables we assessed, using analysis of variance and Pearson correlations. As a third step, we examined whether participants who discontinued participation at W2 differed from those continuing participation in terms of all variables assessed at W1 using analysis of variance for continues variables and Fisher's exact tests for dichotomous variables. Similar analyses were done to compare people who continued vs. discontinued participation at W3.As a fourth step and to address our second aim, we performed a series of multiple regression analyses to examine associations of emerging SOC factors with symptom‐levels of PGD and depression, and satisfaction with life, at W1, W2, and W3. In examining concurrent associations, we planned to examine the association of each distinct emerging SOC factor with the outcomes ; next, we planned to examine associations of emerging SOC factors with the outcomes, while controlling for the shared variance between the SOC factors. In examining associations of SOC factors with outcomes at W2 and W3, a similar procedure was used, albeit that W1 scores of the outcome variables were controlled in the analyses, to examine if SOC factors predicted outcomes at W2 and W3, beyond outcomes at W1. There were occasional missing values on some items. For aim 1, full information maximum likelihood was used to deal with these missings. For the analyses that included the measures of SOC, PGD, depression, and functional impairment, listwise deletion was employed when participants had >20% missing variables on the items of the measure under consideration and the remaining occasional missing variables of questionnaire items were handled using mean imputation. This resulted in slightly varying sample sizes across analyses.33.1Fit indices for the models that we tested are shown in Table χ2 = 22.15, ∆df = 1, p < .001), but also did not provide good fit estimates . Modification indices pointed out that errors of the same two items that had correlated errors in the SOC‐29 were correlated in the SOC‐13. In addition, errors terms of one of the manageability items (Have you felt like a loser?) and one of the comprehensibility (Have you overestimated/underestimated the importance of things happening?) were also correlated; this was also potentially due to content overlap, considering that these items both represented critical self‐evaluation. The adjusted two‐factor model, with correlations between these two pairs of error terms fit better than the one‐factor model  and the two‐factor model  and had good fit estimates , but did not have good fit estimates. Again, modification indices pointed at correlations between the errors of the two aforementioned item pairs. The adjusted three‐factor model, with correlations between these error terms, fit better than the one‐factor model  and the three‐factor model  and had good fit estimates . Because research on SOC in grief is sparse, it was deemed informative to retain the three‐factor model, distinguishing the three factors put forth by Antonovsky (ps < .001).The two‐factor model with correlated errors and the three‐factor model with correlated errors had similar fit estimates and—accordingly—the tonovsky , in subs3.2F = 3.96, p = .048. This variable was also associated with satisfaction with life scores at W1, W2, and W3: significantly higher satisfaction with life scores were reported when a period of illness preceded the death, W1: M = 26.03, SD = 5.63 vs. M = 22.52, SD = 5.92, F = 7.25; W2: M = 26.32, SD = 5.35 vs. M = 22.85, SD = 5.69, F = 5.96; W3: M = 26.49, SD = 5.69 vs. M = 23.55, SD = 5.56, F = 4.27; all ps < .05. Moreover, dichotomized cause of death was associated with PGD severity at W1, W2, and W3, with significantly higher scores reported by those who lost a spouse to cancer, W1: M = 34.67, SD = 10.41 vs. M = 31.63, SD = 10.81, F = 3.97; W2: M = 34.18, SD = 10.14 vs. M = 29.86, SD = 11.24, F = 6.38; W3: M = 32.61, SD = 10.75 vs. M = 28.35, SD = 10.18, F = 6.59, all ps < .05. Finally, having more children was associated with stronger satisfaction with life at W2 .Zero‐order correlations between the three SOC factors at W1 and PGD severity, depression severity, and satisfaction with life at W1, W2, and W3 are shown in Table 3.3Of all 221 participants at Wave 1, the 176 who still participated at Wave 2 did not differ from the 45 discontinuing their participation on any of the variables assessed at Wave 1 . Of all participants at Wave 1, the 169 people who still participated at Wave 3 did not differ from the 52 discontinuing their participation on all variables assessed at Wave 1.3.4Table Table Table 3.5p = .14). The association of meaningfulness with W3 PGD, controlling W1 PGD at the other SOC factors, passed the threshold for significance . All other significant findings remained significant and all other nonsignificant findings remained nonsignificant. Thus, associations of SOC factors with outcomes reported in Tables We examined if the outcomes of the regressions summarized in Tables As noted, the two‐factor model (with one factor including the comprehensibility and manageability items and a second factor spanning meaningfulness items) fit the data equally well as the three‐factor model Table . For exp4A gradually growing evidence base shows that a sense of coherence (SOC), encompassing a sense that one's internal and external world are comprehensible, manageable, and meaningful, offers protection against the negative impact of stressful life events  the threshold for acceptable model fit. In our examination of the factor structure of the SOC‐13, the two‐factor and three‐factor models fit the data better than the one‐factor model but did not pass the threshold for good fit. Modification indices revealed that error terms of two items referring to critical views on other people and two other items referring to a critical self‐evaluation were correlated. When allowing residual correlations for these two item‐pairs, both the two‐factor and three‐factor models fit the data well; the fit of these models did not differ significantly.The findings indicate that, in our sample, the more parsimonious set of 13 items yielded a better measurement of SOC than the combination of 29 items. Our findings are generally consistent with research findings showing that the two‐factor model represents a good model of the SOC‐13 (Grevenstein & Bluemke, Considering that Antonovsky  originalThe importance of meaningfulness in affecting responses to loss was also clear when considering the longitudinal analyses. SOC factors were unrelated to PGD severity at W2 and W3, when controlling W1 PGD albeit that the association of meaningfulness with PGD at W3 trended toward significance in the regression including all three SOC factors. SOC factors did not predict W2 depression beyond W1 depression. Meaningfulness predicted W3 depression, beyond W1 depression, when considered alone and together with the other SOC factors. When considered in distinct analyses, the three SOC factors were associated with W2 and W3 satisfaction with life, when controlling W1 satisfaction with life. Meaningfulness was the only SOC factor predicting satisfaction with life at W2 and W3 when all three SOC factors were considered together.stressors are worth facing attenuates the emotional pain of bereavement. Notable too is that increased meaningfulness was associated with increased satisfaction with life and, albeit to a lower degree, decreased levels of PGD and depression. This is consistent with prior theorizing and research indicating that elevated SOC both acts as buffer between negative events and distress and directly inflates positive outcomes in the face of these events (Schäfer et al., Considering these findings, the following stands out. Meaningfulness consistently turned out to be the most important element of SOC in predicting consequences of bereavement. This is consistent with Antonovsky's  originalStrengths of this study include its longitudinal design, multiple follow‐up assessments, and relatively homogeneous sample. The study also has some limitations. First, the use of self‐report measures to assess all the variables may have inflated associations between variables because of shared method variance. Second, although the ICG is still commonly used, it was constructed way before recent conceptualizations of PGD emerged, including those now included in DSM‐5‐TR APA,  and ICD‐the first study showing that, in the face of losing a spouse at older age, SOC, and particularly its element of meaningfulness, may function as a buffer for the psychological impact of bereavement. More research is needed to examine the role of SOC in recovery from loss across different subgroups of bereaved people and variables mediating the impact SOC. Studying SOC and other factors protecting against negative health outcomes of bereavement seems all the more pertinent now that PGD is included in the main bodies of both the ICD‐11 (WHO, Notwithstanding these considerations, this is one of the, if not ‐11 WHO,  and DSM‐‐11 WHO, . If futu‐11 WHO, . Psychol‐11 WHO, , narrati‐11 WHO, , and thi‐11 WHO,  or mindf‐11 WHO, .The authors declare to have no conflict of interest.Table S1. Factor loadings of the three‐factor model of the SOC‐13Table S2. Summary of regression analyses with comprehensibility/manageability and meaningfulness predicting concurrent prolonged grief, depression, and satisfaction with lifeTable S3. Summary of regression analyses with comprehensibility/manageability and meaningfulness predicting prolonged grief, depression, and satisfaction with life at W2Table S4. Summary of regression analyses with comprehensibility/manageability and meaningfulness predicting prolonged grief, depression, and satisfaction with life at W3Click here for additional data file.


Escherichia coli and Shigella spp. using MALDI‐TOF MS in the negative ion mode for lipid profiling coupled with machine learning. Both E. coli and Shigella species are closely related; they share high sequence homology, reported for 16S rRNA gene sequence similarities between E. coli and Shigella spp. exceeding 99%, and a similar protein expression pattern but are epidemiologically distinct. A bacterial collection of 45 E. coli, 48 Shigella flexneri, and 62 Shigella sonnei clinical isolates were submitted to lipid profiling in negative ion mode using the MALDI Biotyper Sirius® system after treatment with mild‐acid hydrolysis (acetic acid 1% v/v for 15 min at 98°C). Spectra were then analyzed using our in‐house machine learning algorithm and top‐ranked features used for the discrimination of the bacterial species. Here, as a proof‐of‐concept, we showed that lipid profiling might have the potential to differentiate E. coli from Shigella species using the analysis of the top five ranked features obtained by MALDI‐TOF MS in the negative ion mode of the MALDI Biotyper Sirius® system. Based on this new approach, MALDI‐TOF MS analysis of lipids might help pave the way toward these goals.Matrix‐assisted laser desorption/ionization‐time of flight mass spectrometry (MALDI‐TOF MS) has become a staple in clinical microbiology laboratories. Protein‐profiling of bacteria using this technique has accelerated the identification of pathogens in diagnostic workflows. Recently, lipid profiling has emerged as a way to complement bacterial identification where protein‐based methods fail to provide accurate results. This study aimed to address the challenge of rapid discrimination between  Escherichia coli from Shigella species.Workflows for the identification of shigellosis in a clinical microbiology laboratory. The routine workflow is represented by a black arrow while the lipid profiling identification workflow is represented by green arrows. Combined with a machine learning algorithm, lipid profiling by routine MALDI in the negative ion mode might have the potential to differentiate  Unfortunately, both Shigella and E. coli can grow on screening media. Currently, methods based on biochemical tests and serotyping are preferred for the discrimination of these species. However, these approaches may have suboptimal diagnostic performance as they are slow, relying on multiple‐step methods of culturing on selective agar, slide agglutination tests, and the use of commercial biochemical identification kits. In addition, Shigella species and E. coli are undistinguishable using molecular methods such as sequencing the 16S rRNA gene or molecular syndromic panel  . Then, serotyping can be performed to definitively discriminate between the four species: S. boydii, S. dysenteriae, S. flexneri, and S. sonnei , for which speed of diagnostics is crucial to treat the patient and prevent and control outbreaks. Analysis using MALDI‐TOF MS in the negative‐ion mode combined with a machine learning algorithm demonstrated that it is possible to tell apart E. coli, S. flexneri, and S. sonnei using lipid profiles.This study aims to accelerate the application of routine MALDI‐TOF MS to address the public health challenge of the rapid discrimination between 22.1E. coli strains, 48 S. flexneri strains, and 62 S. sonnei strains was analyzed. These clinical isolates were recovered from stool samples of diarrheic patients who were admitted or hospitalized in eight different French hospitals. Before the analysis conducted in this study, isolates had been classified into species by standard biochemical and serotyping methods. These methods involved multiplex PCR (Seegene) on patient stool samples to search for the most common pathogens responsible for febrile diarrhea such as Salmonella spp., Campylobacter spp., enteroinvasive E. coli/Shigella spp., Aeromonas spp., and Clostridium difficile. For positive results, stool samples were isolated on adequate screening medium. Accordingly, if a positive signal was obtained by multiplex PCR for enteroinvasive E. coli/Shigella spp., a Salmonella/Shigella agar  and a Hecktoen agar (bioMérieux) were used for culture. On colonies that cultured after 24 h incubation, identification was performed using an API20E biochemical strip (bioMérieux) or Vitek®2 GN identification card (bioMérieux), allowing discrimination between E. coli and Shigella spp. Then, serotyping was performed to definitively discriminate between the four species: S. boydii, S. dysenteriae, S. flexneri, and S. sonnei. In the routine workflow, if the API20E biochemical strip or the Vitek2 identified a sample as E. coli, multiplex PCR (syndromic molecular panel) might be performed on the bacterial colony to verify if this E. coli isolate corresponds to an enteroinvasive strain (acquisition of the Shigella invasin gene inv).A bacterial collection of 45 2.2g for 10 min, then washed twice with 200 µL ddH2O. The pellet was resuspended in 100 µL of acetic acid 1% v/v and incubated in a PCR machine  at 98°C for 15 min. After incubation, the pellet was washed twice with 200 µL ddH2O and then resuspended in 20 µL ddH2O. A volume of 0.4 µL of the hydrolyzed sample was mixed with a 1.2 µL Norharmane matrix  on a MALDI target plate named MSP 96 target polished steel BC (Bruker Part‐No. 8280800). The bacterial suspension and matrix were mixed directly on the target by pipetting and then dried gently under a stream of air.One bacterial colony was resuspended in 100 µL of water. This bacterial suspension was centrifuged at ×10002.3m/z 1000 to m/z 2500. The spectra obtained were processed with default parameters using FlexAnalysis v.3.4 software .The spectra were recorded in the linear negative‐ion mode  using MALDI Biotyper Sirius® system . Each spectrum corresponded to an ion accumulation of 5000 laser shots randomly distributed on the spot for the range 2.4E. coli, S. sonnei, and S. flexneri samples. First, a square root transformation (sqrt) was performed on the intensities of the spectra. The intensity values were then smoothed using the Savitzky–Golay method , a threshold is determined by considering true labels. Intensities above that threshold will be set to 1, otherwise 0, via R packages “binda” [version 1.0.4] [Gibb & Strimmer, After the above pre‐processing workflow, the feature matrix was converted into both a naïve binary absence‐presence matrix  and a dichotomized binary matrix  and the pooled mean (across species). The top‐ranked peaks were used to test their class prediction ability. Data were further split into training and testing data  to study the robustness of the top‐ranked features in terms of classification of the three species.Binary discriminant analysis was then applied to the dichotomized binary feature matrix to identify and rank the most differentially expressed peaks across the spectra and ascertain whether any of these peaks from the lipid profiles could be used for cla184‐ss prediction, i.e., to determine whether the spectra belonged to a sample of 33.1E. coli, S. sonnei, and S. flexneri in a routine MALDI Biotyper Sirius® system, we tested a panel of 45 E. coli, 48 S. flexneri, and 62 S. sonnei clinical isolates. The samples were prepared to enrich membrane lipids as described earlier and the mass spectra were recorded in the linear negative ion mode. The range m/z 1000 to m/z 2500 was chosen as it gave spectra with the highest signal‐to‐noise (S/N) (>3) and mass resolution (>200), suitable for following data analyses. The range of interest (m/z 1000 to m/z 2500) in the E. coli spectrum  . The random separation of training and testing data was repeated 100 times. Various numbers of top‐ranked peaks including all peaks  and one set of randomly selected 15 peaks were used as controls. Consistent with a previous report from Tang et al.  only min3) Table .4E. coli and Shigella spp.MALDI‐TOF‐MS is a valuable tool already in use in many clinical microbiology laboratories for rapid species identification directly from bacterial colonies. This project used lipid profiling to investigate whether lipid typing can help to discriminate between the closely related species E. coli from Shigella, including protein‐based MALDI‐TOF MS and molecular methods, but due to their close relationship, these assays are not reliable. Currently, identification methods that are routinely used in clinical microbiology laboratories rely on a biochemical characterization using an API20E strip that induces 24 h delay to discriminate E. coli from Shigella spp. and on subsequent serotyping for Shigella , favoring the on‐target extraction and ionization of apolar molecules such as phospholipids and glycolipids. We cannot rule out that the peaks we observed are degradation products of larger molecules allowing the actual discrimination between Shigella and E. coli despite the high level of similarity between their O‐antigens.Other methods have been attempted to accurately discriminate In this context, our results suggested that MALDI‐TOF MS profiling of lipids could provide a straightforward alternative method of species discrimination using the existing routine MALDI mass spectrometer system compared to serotyping which could lead to cross‐reactivity and error in the interpretation of the bacterial strain identification. Indeed, MALDI‐TOF MS is a technique that uses inexpensive reagents and produces robust and reproducible results in a short timeframe. Lipid profiling of bacterial species is an emerging field of research that has already been developed for the rapid identification of antimicrobial resistance traits such as polymyxin resistance using the MALDI‐TOF negative mode ; Investigation ; Methodology . Wenhao Tang: Data curation ; Methodology ; Software ; Visualization . Sandrine Bernabeu: Resources (supporting). Rémy A. Bonnin: Resources (supporting). Emmanuelle Bille: Resources (supporting). Eric Farfour: Resources (supporting). Thomas Guillard: Resources (supporting). Olivier Barraud: Resources (supporting). Vincent Cattoir: Resources (supporting). Chloe Plouzeau: Resources (supporting). Stéphane Corvec: Resources (supporting). Vahid Shahrezaei: Software (supporting). Laurent Dortet: Conceptualization ; Resources (supporting); Writing – review & editing (supporting). Gerald Larrouy‐Maumus: Conceptualization (lead); Funding acquisition (lead); Methodology (supporting); Project administration (supporting); Resources (lead); Writing – original draft (lead); Writing – review & editing (lead).None declared.None required.


Sardinella maderensis, Dentex angolensis, Sphyraena sphyraena and Penaeus notialis caught from the coastal waters of Ghana using inductively coupled plasma mass spectrometry method. Penaeus notialis recorded the highest concentrations of all the metals  except Hg. Mercury was relatively high in D. angolensis (0.14 ± 0.03 µg/g). Apart from As, all metals were within globally permissible daily limits for consumption by human per meal. The estimated Target Hazard Quotient due to the intake of Hg through D. angolensis consumption exceeded the threshold value across all age categories. Carcinogenic risks due to As intake through P. notialis consumption far exceeded the 10−6 threshold for all age groups in Ghana. It is recommended that the consumption of these fish species particularly, the shrimp P. notialis be done cautiously to avoid possible future health challenges.Heavy metal pollution of the marine environment has toxic implications for both the aquatic biota and human health. We examined the levels of Zinc (Zn), Lead (Pb), Copper (Cu), Cadmium (Cd), Arsenic (As) and Mercury (Hg) in muscles of   Meanwhile, Kumar et al. Globally, studies have been conducted to assess the potential health risks associated with heavy metals in foods consumed by humans, with some revealing negative health implications while others revealing no adverse health effects. For example, to establish the safety of baby foods and milk powders in Iran, Kiani et al. 22.1S. maderensis (Madeiran sardinella), S. sphyraena (Mediterranean barracuda), D. angolensis (Angolan Dentex) and P. notialis (Southern pink shrimp) from Ghanaian coastal waters were obtained from five (5) major fish landing beaches between June and September 2017 for the study  of the samples. Approximately 300 mg of each composite sample was digested with concentrated nitric acid  and hydrogen peroxide  followed by inductively coupled plasma mass spectrometry . The Hg content of each composite sample was analyzed directly without any treatment using an AMA254 mercury analyzer . Method validation was carried out by analyzing certified reference materials , spiked samples and performing method blanks . Typical2.4The data obtained were statistically analyzed using the statistical package, IBM SPSS 24.0 . The means and standard deviations of metal concentrations in fish species were recorded. One Way Analysis of Variance (ANOVA) and Multivariate post hoc Tukey tests was used in examining the statistical significance of the differences in mean concentrations of trace metals among different fish species. The level of significance was set at p < 0.05.2.52.5.1C is the metal concentration in fish [ug/g w.w)] and BW is the average body weight of the different age groups ranging from 21 kg to 70 kg.The dietary exposures to trace metals for children, adolescents, and adults were estimated using the average trace metal concentrations determined for each fish species. For EDI and other health risk parameter estimations, the established average body weights for the three different age categories were 21 kg for children aged 6 years, 51 kg for adolescents aged 14 years, and 70 kg for adults aged 70 years 2.5.2−1 mg kg−1d−1 for Hg, 4.0 × 10−2 mg kg−1d−1 for Cu, 3.0 × 10−1 mg kg−1d−1 for Zn, 3.0 × 10−4 mg kg−1d−1 for As and 1.0 × 10−3 mg kg−1d−1 for Cu The non-carcinogenic health risk was estimated using the Target Hazard Quotient equation developed by the USEPA. The Target Hazard Quotient (THQ) is defined as the ratio of the lifetime average daily dose to the reference dose (RfD) 2.5.3−1 for inorganic arsenic For carcinogens, risks were estimated as the incremental probability of individuals developing cancer over a lifetime due to exposure to a potential carcinogen The THQ and CR risk calculations for As were made on the assumption that the toxic inorganic arsenic was 3% of total As 33.1The mean concentrations and standard deviations of trace metals in S. maderensis, D. angolensis, S. sphyraena, and P. notialis from Ghanaian coastal waters are presented in S. sphyreana < D. angolensis < S. maderensis < P. notialis. These levels were within the FAO recommended permissible seafood intake level of 30 µg/g, implying no immediate adverse health effect. Arsenic concentrations in the fish species ranged from 0.8 μg/g to 8.5 μg/g and followed the order: S.sphyreana < S.maderensis < D. angolensis < P. notialis. Arsenic levels in P. notialis largely exceeded the permissible seafood intake levels of 2.0 μg/g and 1.3 µg/g set by both the Food Standard Australia New Zealand- −1) in groundwater with values ranging up to 10,000 μg L−1 in surface water from different parts of Africa Copper levels in the fish species ranged from 0.31 μg/g to 12.08 μg/g. The levels are below the FAO 3.2Although the levels of all trace metals, except for As, did not exceed permissible seafood intake limits, their actual toxicity depends on exposure doses, frequencies, and durations. Exposure doses, frequencies, and durations vary from individual to individual and according to age. Therefore, estimating daily consumption is considered a tool for evaluating the balance between benefits and risks. The EDIs calculated in this study were compared to the provisional maximum tolerable daily intake (PTDI) (g/person/day) established by the FAO/WHO Expert Committee on Food and Additives. Except for As, which exceeded the set limit in all age groups , all metP. notialis and D. angolensis  derived from the intake of As were computed because the consumption of As may promote both non-carcinogenic and carcinogenic effects depending on the exposure dose. The CRs were computed using the concentration of inorganic As because this form of the metal is a classified known carcinogen (USEPA Group A). Although Hg (methylmercury) and Cd are categorized in USEPA groups C  and B1 (probable carcinogen due to human studies), respectively, their CRs were not computed because Ingestion Slope Factors (CSFo) are not established yet for these elements ge group  as well Despite the health implications associated with the consumption of the assessed fish from the coast of Ghana, we acknowledge that the sample size is relatively small, and so it is recommended that further studies be undertaken to confirm these findings.4Heavy metal pollution is a global problem that has implications for ecosystem functioning, global food safety and security. While extensive studies on trace metal levels in seafood have been carried out in many parts of the world to guide seafood consumption, little or no studies exist from other parts of the world including the Gulf of Guinea Region. The study, therefore, comes to fill an important gap in knowledge by providing information on heavy metal levels in four (4) commonly consumed fish species from the Gulf of Guinea and their possible implications to human health.S. sphyreana. Even though, the concentrations of Cu and Hg, and their computed EDIs pose no apparent health threats, the THQs due to exposures to these metals and As implied possible manifestations of significant non-cancer related health risks in children and adolescents. Non-cancer risks due to As and Cu intake are higher for the consumption P. notialis while those due to Hg intake are higher for D. angolensis and S. sphreana consumption. The study further reports significant carcinogenic risks due to As intake from S. maderensis and D. angolensis in most and in all age categories for P. notialis.Except for As, the levels of all the metals studied were below the permissible limits set by various regulatory authorities in the world. Arsenic levels were above permissible limits in all fish species except P. notialis to avoid likely carcinogenic risks in children, adolescent, and adult populations.We therefore strongly recommend that to avoid the manifestations of non-carcinogenic risks, the consumption of these fish species by adolescents, children, pregnant women, and nursing mothers is done with caution while measures are taken to reduce their levels in the marine environment. While further studies are recommended to corroborate these conclusions, caution should be taken in the consumption of Elvis Nyarko: Conceptualization, Writing – review & editing, Supervision, Funding acquisition. Charles Mario Boateng: Conceptualization, Methodology, Investigation, Writing – original draft, Visualization. Maurice Oti Edusei: Conceptualization, Methodology, Writing. Obed Asamoah: Conceptualization, Writing – review & editing. Edem Mahu: Conceptualization, Methodology, Writing – review & editing, Supervision, Formal analysis.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Adrenal cysts are relatively rare and often asymptomatic. Surgical treatment is indicated for symptomatic cases with cysts >6 cm, suspected bleeding, and those that cannot be distinguished from malignant illness based on imaging findings. There have often been cases of giant cysts that were difficult to treat using laparoscopic surgery.A 39‐year‐old woman presented with fever and upper abdominal pain. Abdominal computed tomography and magnetic resonance imaging revealed a 95 × 80‐mm left adrenal cyst. As malignant disease could not be ruled out, and the patient was symptomatic, we opted for robot‐assisted left adrenalectomy. The pathological findings indicated an adrenal pseudocyst.This is the second report of the successful robot‐assisted removal of a giant adrenal cyst. CRPC‐reactive proteinCTcomputed tomographyHEhematoxylin eosinMRImagnetic resonance imagingNo consensus exists on the surgical approach to giant adrenal tumors. Robot‐assisted adrenalectomy has significant advantages for adrenal cysts and tumors >6 cm where malignancy cannot be ruled out.Adrenal cysts are relatively rare. A large population‐based study on adrenal tumors in 2017 reported a sex‐ and age‐standardized prevalence rate of patients with adrenal tumors of 532/100 000 inhabitants, with most adrenal tumors being incidental adrenocortical adenomas <40 mm in patients aged >40 years.A 39‐year‐old woman sought medical attention in April 2022 for the chief complaint of dull upper abdominal pain and fever up to 38°C lasting approximately 5 days. She had a medical history of Graves' disease without other complications and a family history. Abdominal ultrasound findings suggested a left upper abdominal cyst, and she was admitted for close examination and treatment.Patient condition at admission was as follows: Height, 165 cm; weight, 50 kg; body mass index, 18.4; blood pressure, 145/54 mmHg; heart rate, 87 bpm; body temperature, 38.8°C. The abdomen was flat and soft, with tenderness in the upper abdomen. However, the mass was not palpable. Endocrinological and hematological examinations revealed no abnormalities except a mildly elevated CRP level (5.9 mg/dL).Plain abdominal CT revealed a 95 × 80‐mm cyst in the left adrenal gland; the left kidney was largely displaced to the caudal side. The cyst interior was uniform with high water density Fig. . The cysThe patient was diagnosed with an adrenal cyst, and abdominal MRI findings could not rule out primary‐onset malignancy. Therefore, we decided to resect the mass surgically. The DaVinci Xi system (Intuitive Surgical; 4 ports, and 2 assistant ports, Fig. A gross pathological examination of the resected specimen revealed unilocular cyst formation with no solid tumors. Accumulation of a dark red‐like substance was noted on the inner surface Fig. . PatholoAdrenal cysts, including pseudocysts, are rare tumors, often found as incidentalomas.In this case, blood pressure was normal, with no evidence of an endocrinologically suspected functional tumor. We preoperatively diagnosed the patient with an adrenal cyst based on MRI and multi‐slice CT results. Differential diagnoses included retroperitoneal liposarcoma, cystic pheochromocytoma, and adrenal metastases. Around 7% of adrenal cysts are suspected to be malignant; therefore, differentiation from benign cysts is important.Surgical approaches are mainly laparotomy or laparoscopy. Since giant cysts often adhere to surrounding tissues, they are difficult to approach laparoscopically.Because preoperative images could not rule out malignancy, we decided that total resection was needed. Generally, the difficulty of laparoscopic surgery for adrenal tumors increases with tumor size due to poor visibility and maneuverability. Comparatively, robot‐assisted surgery has great merits because it provides a clearer close‐up view, finer operation, and countertraction with the third arm. However, in the absence of a sense of touch, robotic surgery requires constant forceps manipulation awareness based on visually obtained information to avoid rupturing the cyst. We believe these merits are significant for cases in which malignancy cannot be ruled out or for adrenal cysts and tumors >6 cm. Following the adrenal myelolipoma removal by robot‐assisted surgery,The classification developed by FosterWe report a case of a giant adrenal pseudocyst successfully removed by robot‐assisted surgery. The merits of robot‐assisted adrenalectomy are considered significant for adrenal cysts and tumors >6 cm, for which malignancy cannot be ruled out.Takayuki Ohzeki: Writing – original draft; writing – review and editing. Hiroyuki Kita: Supervision. Remon Kunishige: Supervision. Taiji Hayashi: Supervision. Tsukasa Nishioka: Supervision.The authors declare no conflict of interest.No ethical approval was required for this case report.Verbal informed consent has been obtained and is documented in the medical record.Not applicable.