Preoperative evaluation of aggressiveness, including tumor histological subtype, grade of differentiation, Federation International of Gynecology and Obstetrics (FIGO) stage, and depth of myometrial invasion, is significant for treatment planning and prognosis in endometrial carcinoma (EC). The purpose of this study was to evaluate whether three-dimensional (3D) magnetic resonance elastography (MRE) can help predict the aggressiveness of EC.From August 2015 to January 2019, 82 consecutive patients with suspected uterine tumors underwent pelvic MRI and MRE scans, and 15 patients with confirmed EC after surgical resection were enrolled. According to pathological results , the patients were divided into two subgroups. The independent-samples t-test or Mann-Whitney U test was used to compare the stiffness between different groups. The diagnostic performance was determined with receiver operating characteristic (ROC) curve analysis.n = 6) myometrial invasion was significantly higher than that with < 50 % (n = 9) myometrial invasion . Using a stiffness of 3.04 kPa as a cutoff value resulted in 100 % sensitivity and 77.8 % specificity for differentiating ≥ 50 % myometrial invasion from < 50 % myometrial invasion of EC. The stiffness of poorly differentiated EC (n = 8) was significantly higher than that of well/moderately differentiated EC (n = 7) . Using a stiffness of 3.04 kPa as a cutoff value resulted in 75 % sensitivity and 71.4 % specificity for differentiating poorly differentiated from well/moderately differentiated EC. The stiffness of FIGO stage II/III EC was significantly higher than that of FIGO stage I EC . Using a stiffness of 3.04 kPa as a cutoff value resulted in 100 % sensitivity and 70 % specificity for differentiating FIGO stage I EC from FIGO stage II/III EC. The tumor stiffness value in type II (n = 3) EC was higher than that in type I (n = 12) EC (3.67 ± 0.59 kPa vs. 2.88 ± 0.85 kPa), but the difference was not significant (p = 0.136).The stiffness of EC with ≥ 50 % (Tumor stiffness measured by 3D MRE may be potentially useful for predicting tumor grade, FIGO stage and myometrial invasion of EC and can aid in the preoperative risk stratification of EC. Endometrial carcinoma (EC) is one of the most common primary malignant tumors in women, and its incidence is steadily rising worldwide . PreoperRecently, magnetic resonance elastography (MRE) has emerged as a noninvasive technique for evaluating tissue viscoelastic properties by measuring the shear waves produced by a vibrating mechanical transducer. As an alternative to biopsy and to enable noninvasive visualization and quantification of stiffness, MRE has been used successfully to estimate the stage of hepatic fibrosis . RecentlTherefore, the purpose of this study was to evaluate the feasibility of transpelvic 3D MRE of the uterus and to assess the diagnostic performance of 3D MRE in predicting tumor aggressiveness, including histological subtype, tumor grade, FIGO stage, and myometrial invasion of EC.This retrospective study was approved by our institutional review board, and all patients provided informed consent. From August 2015 to January 2019, 82 consecutive patients with suspected uterine tumors underwent pelvic MRI and MRE scans. Among them, 22 patients who had histopathological confirmation of EC after surgery were selected. Seven patients were excluded because (1) the MRE examination failed (n = 1) due to obesity (thickness of subcutaneous fat was 3.75 cm), and the images could not be used for quantitative analysis; (2) they had a history of previous radiotherapy/chemotherapy (n = 2); and (3) their lesion had a maximum diameter of < 2 cm (n = 4). Finally, 15 patients with EC were enrolled in this cohort study. Figure b values (b = 0 and 800 s/mm2).MRI was performed on a 3.0T scanner  with 8-channel phased-array torso coils  for signal acquisition. MRE was performed with a pneumatic driver developed by Mayo Clinic . The driver was placed above the pelvis. Continuous acoustic vibrations at 60 Hz, which were transmitted from an active driver to the passive driver via a flexible vinyl tube, were used separately to produce propagating shear waves in the cervix. A test vibration was first applied to allow the patient to become familiar with the vibration. A free-breathing, multislice, EPI, 3D-MRE sequence was used. The acquisition parameters included repetition time = 1334 msec, echo time = 52 msec, slice thickness = 3 mm, interslice gap = 0 mm, number of slices = 20, FOV = 240 mm, acquisition matrix = 80 × 80, superior-inferior spatial saturation bands, and parallel imaging acceleration factor = 2. The total imaging time for MRE was approximately 80 s. Diffusion-weighted imaging (DWI) was performed using a respiratory-triggered single-shot spin echo echoplanar imaging sequence in the transverse plane before contrast-enhanced imaging, with 2 The MRE-acquired displacement fields were processed using a 3D direct inversion (DI) of the Helmholtz wave equation after applying the curl operator to calculate a stiffness map over the uterine volume. The reconstruction matrix was 256 × 256 × 20. The processing steps were applied automatically to generate quantitative images of tissue shear stiffness maps in units of kilopascals (kPa).In each case, the mean stiffness of the EC was calculated using a manually specified region of interest (ROI). The ROIs were drawn by two radiologists , both of whom were highly experienced in pelvic MRI with more than 5 years of experience. The ROIs excluded tumor edges, areas of significant wave interference and any other artifacts seen in the magnitude and wave images. The tumor ROI was drawn on the magnitude images with reference to conventional MR images. Then, the ROIs were copied to the stiffness map, which gave the stiffness values in kPa. The mean stiffness in kPa within the ROIs was reported. Apparent diffusion coefficient (ADC) maps were automatically generated from each DWI image by MRI system software .Patients were staged on the basis of the histopathological findings following surgical resection, according to the revised FIGO staging system (2009) . All oriU test was used to compare the stiffness value between different groups with abnormal distribution. To characterize the diagnostic accuracy of tumor stiffness in the assessment of tumor aggressiveness, receiver operating characteristic (ROC) curves were implemented. By maximizing the Youden index, we determined the optimal cutoff values and corresponding sensitivities and specificities for distinguishing between different groups. Statistical analysis was performed with SPSS 22.0 . p-values < 0.05 were considered statistically significant.Interobserver reproducibility for the ROI measurements of the two readers was assessed by using the interclass correlation coefficient . The independent-samples t-test was used to compare the stiffness value between different groups with a normal distribution. The Mann-Whitney n = 15) was 50.20 ± 9.03 years (range 35–65 years). Among these patients, 6  were premenopausal and 9  were postmenopausal. Patient characteristics are detailed in Table The mean patient age in the study sample n = 5 was 50.p = 0.136). The stiffness value of EC with ≥ 50 % myometrial invasion was significantly higher than that of EC with < 50 % myometrial invasion , but there were no significant differences in tumor size between the other subgroups . For DWI, the ADC value showed no significant differences between any subgroups.The categorizations of endometrial cancer with corresponding stiffness values are detailed in Table In addition, the interobserver variability of tumor stiffness was low, with intraclass correlation coefficients of 0.89 to 0.94 and a minimum detectable change of 0.01 to 0.2 kPa for the different tumor stiffness measurements.To our knowledge, this is the first study to use 3D MRE to assess the aggressiveness of EC. In our preliminary study, we demonstrated that preoperative tumor stiffness as measured by 3D MRE could predict tumor aggressiveness, including grade of differentiation, FIGO stage, and depth of myometrial invasion of EC, suggesting that this parameter may serve as a noninvasive imaging biomarker for preoperative risk stratification to guide surgical treatment and adjuvant therapy.In our series, we found that the stiffness value of EC with deep myometrial invasion was significantly higher than that of EC with superficial myometrial invasion, with a cutoff value of 3.04 kPa to distinguish EC with deep myometrial invasion from EC with superficial myometrial invasion. However, the role of stiffness in modulating the growth and progression of EC remains poorly defined. Previous studies have demonstrated that several factors may contribute to increased malignant stiffness, including collagen deposition in the extracellular matrix, high cellularity, abnormal perfusion, and increased interstitial fluid pressure from the altered vasculature , 23. CurEarly-stage EC shows a good prognosis, and the 5-y survival rate is reported to be more than 90 % in patients with stage Ia or Ib disease . HoweverTwo distinct types of EC based on histological and molecular characteristics have been described in a previous study, and type II EC is usually less differentiated than type I EC and is more prone to infiltration and metastasis , 32. OurDespite our promising results, our preliminary study does have several limitations. First, this was a retrospective study performed at a single institution, and the sample size was relatively small. Thus, our findings need to be reproduced in larger patient series with longer follow-up and evaluation of prognostic information to confirm the possible value of MRE as a preoperative biomarker in EC. Second, as a confounding factor of bias, menopausal status may influence our results. In our small cohort study, 40 % of the patients were premenopausal. A previous study showed that stiffness changed in the uterine corpus during the menstrual cycle, which was related to the anatomic and functional alteration of both the myometrium and the endometrium . Future In conclusion, preoperative tumor stiffness as measured by 3D MRE could predict tumor aggressiveness and may be a strong prognostic factor in EC. Preoperative 3D MRE as part of a multiparametric MR protocol may, thus, serve as a noninvasive imaging biomarker for diagnosis and appropriate therapeutic strategy determination for patients with EC.


IL‐6, which could be involved in the pathophysiology of the GI involvement in COVID‐19. Further investigation with more clinical data, including endoscopic findings and molecular analyses, will contribute to a comprehensive understanding of COVID‐19‐associated GI injury.Patients with coronavirus disease 2019 (COVID‐19) primarily cause respiratory symptoms. However, gastrointestinal (GI) symptoms can also occur. The endoscopic characteristics of the GI tract in COVID‐19 patients remain unclear. We herein report a 62‐year‐old male with severe COVID‐19 who needed multidisciplinary treatment, including extracorporeal membrane oxygenation (ECMO). Despite the improvement in his respiratory status, GI bleeding developed. Capsule endoscopy and colonoscopy revealed extensive mucosal sloughing in the lower intestinal tract. Additionally, we performed a comprehensive analysis of the mRNA expression levels of various proinflammatory cytokines in the intestinal mucosal tissues. The results suggested a significant elevation of  IL‐6, which could be involved in the pathophysiology of the GI involvement in COVID‐19.Patients with coronavirus disease 2019 (COVID‐19) primarily causes respiratory symptoms. However, gastrointestinal (GI) symptoms can also occur. Although several reports have indicated an association between the severity of COVID‐19 and the frequency of GI symptoms, such as diarrhea and abdominal pain,A 62‐year‐old male with a history of hypertension and diabetes mellitus was transferred from another hospital to the emergency department of our hospital with a 2‐day history of fever, chills, and fatigue. A nasopharyngeal swab tested positive for SARS‐CoV‐2. A chest CT scan showed diffuse ground‐glass opacities in the bilateral lobes. Despite the administration of favipiravir (AVIGAN) and tocilizumab (ACTEMRA), his respiratory condition gradually deteriorated over the course of 2 weeks; therefore, he was transferred to our hospital for treatment with extracorporeal membrane oxygenation (ECMO). Although his pneumonia gradually improved on ECMO, he had a significant amount of watery stool with bleeding. His abdomen was soft, with no tenderness. Routine blood tests showed a white blood cell count of 4900/μl, hemoglobin level of 12.4 g/dl, platelet count of 45,000/μl, C‐reactive protein level of 3.59 mg/dl, fibrinogen level of 129 mg/dl (200‐400 mg/dl), and D‐dimer level of 26.2 μg/ml (< 1.0 μg/ml). The stool culture and tests for pathogens were all negative. Contrast‐enhanced CT showed submucosal edema in both the small intestine and colon without any decreased contrast effect of the gut suspect of ischemic change or thrombi in the abdominal vessels  for 3 days led to temporary improvements in his diarrhea and hematochezia, these GI symptoms returned to previous levels after the cessation of treatment. Next, we administered 5 mg/kg infliximab (Remicade) twice with an intervening interval of 2 weeks; however, he did not respond to the treatment. Finally, he died of multiple organ failure  A viral cytopathic effect, (2) viral‐induced inflammation, (3) hypo‐perfusion due to microthrombosis or life‐threatening condition itself, (4) altered gut microbiota, and (5) secondary infections. Among these mechanisms, there is a possibility that the severe mucosal damage in both the small intestine and colon, in this case, was due to the coexistence of hypo‐perfusion and viral‐induced inflammation.Generally, SARS‐CoV‐2 enters enterocyte, and then viral synthesis and replication occur, which leads to a cytopathic effect .IL‐6 in both the small intestine and the colon, which suggested an IL‐6 dominant cytokine reaction in the GI tract . We used a colonic mucosa in patients with ulcerative colitis (UC) in remission as control. The results showed increased expression levels of t Figure .IL‐6 is a proinflammatory cytokine produced by macrophages, T cells, B cells, fibroblasts, and vascular endothelial cells. In patients with severe COVID‐19 requiring intensive care, higher blood plasma levels of several proinflammatory cytokines have been observed.TNFα expression in colorectal mucosa and both clinical and endoscopic response of infliximab in UC patients.On the other hand, the patient was negative for SARS‐CoV‐2 PCR test using stool sample. Additionally, a previous report demonstrated that IL‐6 is essential for the proliferation and regeneration of epithelial cells.As experience with COVID‐19 has expanded, it has been reported that patients with COVID‐19 have thrombotic microvascular injury of a systemic nature and that the lung, skin, kidney, GI tract, and other organs are affected.In conclusion, we present the case of a COVID‐19 patient with severe mucosal damage in both the small intestine and colon. The pathophysiology of COVID‐19‐associated GI mucosal injury has not yet been clarified. Further investigation with more clinical data, including endoscopic findings and molecular analyses, will contribute to a comprehensive understanding of COVID‐19‐associated GI injury.No authors have any conflict of interest to declare.None.Written informed consent based on the Helsinki Declaration  was obtained from all patients. The Review Board of Sapporo Medical University reviewed and approved the study protocol.


Clostridioides difficile causes nosocomial diarrhoea associated with antibiotic use and immunodeficiency. Although the number of paediatric C. difficile infections (CDIs) has increased worldwide, there are few studies on the molecular characterization of strains causing CDIs among children. We report the clinical features and strain molecular characterization of a CDI in a female child with a history of liver transplantation at 7 months of age. This is the first report of the 046 ribotype causing paediatric diarrhoea. Clostridioides difficile is an anaerobic Gram-positive spore-forming bacillus that is usually spread via the faecal–oral route, and is a primary cause of antibitioc-associated diarrhoea in hospitalized patients [patients .C. difficile has increasingly been reported as an important pathogen in children in recent years [C. difficile infections (CDIs) are not completely understood in this population [nt years . This pant years . Neverthpulation . Some repulation .C. difficile strain.The literature has few reports on the occurrence of CDI in transplant paediatric patients, despite the fact that transplant recipients should be more susceptible to CDI because of multiple hospitalizations and immunosupression . A retroA 2.5-year-old girl with a history of liver transplantation at 7 months of age was admitted with diarrhoea at Albert Sabin Children’s Hospital in Fortaleza, Brazil. The stool was bloody and mucoid, with an average frequency of six bowel movements per day, which was unrelated to diet, but was associated with diffuse abdominal pain. There was no vomiting. Physical examination revealed that the patient was in good general condition and afebrile, eupneic, hydrated, anicteric, acyanotic and without cardiopulmonary alterations. Her abdomen was distended but soft and non-tender, with the liver edge 3 cm below the right costal border and the spleen 4 cm below the left costal border. Thorax percussion gave normal results on auscultation.−3, neutrophils 24 % and lymphocytes 53 %), low haemoglobin (10.5 g dl−1), normal platelets (191 600 mm−3) and normal renal function (urea 26 ml dl−1 and creatinine 0.2 mg dl−1). We did not detect intestinal parasites (i.e. protozoa and helminths), gastrointestinal viruses, gastrointestinal viruses, or enteric pathogens in the patient’s stool sample.The compete blood count revealed leukocytosis with neutropenia and lymphocytosis  since that time. No proton pump inhibitor was prescribed.C. difficile toxins is performed for all patients with diarrhoea who have risk factors. A stool sample was examined on the third day of the onset of diarrhoea that was positive for C. difficile toxin A/B (we used ProSpecT Clostridium difficile Toxin A/B Microplate Remel). We cultured the sample on selective CCFA media  as well as on fastidious anaerobe broth (FAB), over 5 and 15 days, respectively. We incubated the samples in anaerobic conditions . The FAB-positive broth was inoculated onto another CCFA media plate. Characteristic C. difficile colonies appeared on CCFA [Brucella agar with 5 % lysed sheep blood and vitamin K (5 mg ml−1) to identify them further and to perform molecular tests.At our hospital, an initial screen for  on CCFA . These wC. difficile isolates were confirmed using the RapID ANAII system (Remel) and by PCR amplification [tpi gene (C. difficile housekeeping gene).The fication of the tptcdA and tcdB gene fragments of PaLoc. By contrast, we obtained negative results for the binary toxin gene cdtB as well as the putative regulatory gene tcdC. We conducted molecular strain typing by amplification of the 16S–23S rRNA intergenic spacer sequences [SmaI genomic DNA digestion, as described previously [http://webribo.ages.at). We compared DNA fragment patterns to those in the database of the National Microbiology Laboratory, Canada, using BioNumerics software (version 5.1. Applied Maths). We designated the isolate as PCR ribotype 046 and the new pulsotype as 1174 .Using a previously reported method , we obtaequences  and pulseviously . PCR ribBrucella agar supplemented with vitamin K (5 mg ml−1) and 5 % defibrinated sheep blood. The isolate was resistant to levofloxacin (4 µg ml−1) and susceptible to vancomycin (1.5 µg ml−1), metronidazole (0.38 µg ml−1), rifampicin (<0.002 µg ml−1), moxifloxacin (1.0 µg ml−1) and clindamycin (1.0 µg ml−1). Resistance breakpoints were set in agreement with the guidelines of the Clinical Laboratory Standard Institute (CLSI) (M11-A8). For levofloxacin, we used the moxifloxacin breakpoint; for vancomycin, we used the EUCAST guidelines ; and for rifampicin, we used the breakpoint given by O'Conner et al. [We determined the antibiotic susceptibility profile using the E-test (bioMérieux) on r et al. .−1 three times a day for 14 days). No probiotic therapy was used.The diarrhoea ceased on the fourth or fifth day after the initiation of therapy with metronidazole  accounted for 20 % of all detected CDIs in immunocompromised paediatric patients in Germany . These dtcdA and tcdB gene fragments of PaLoc were positive), which explains the diarrhoea. PCR ribotype 046 has previously been isolated from neonatal pigs and humans in Sweden, indicating its zoonotic potential [The isolated 046 ribotype strain was toxigenic (otential , and in otential . PCR ribotential . Despiteotential , ours isThe isolation and identification of strains has been a crucial practice in hospital services to provide a better understanding of the severity, recurrence and antibiotic resistance of CDIs. Although some studies have shown that ribotype 046 is resistant to antibiotics such as amoxicillin, rifaximin and erythromycin , the strThis case shows the importance of considering CDI in children following SOT in developing countries. The case highlights the relevance of strain molecular characterization to understand epidemiological spread as well as clinical features. Because CDI prolongs hospitalization time, increases healthcare costs, and can cause death, vigilance in health care units for CDI in the paediatric population, notably in immunosuppressed children after SOT, should be emphasized.


T60 = 700 ms) or anechoic room. Farthest distance judgments and room size judgments (volume and area) were obtained from blindfolded participants  for speech, music, and noise stimuli. With sighted participants, the judged room volume and farthest sound source distance estimates were positively correlated (p < 0.05) for all conditions. Participants with visual losses showed no significant correlations for any of the conditions tested. A similar pattern of results was observed for the correlations between farthest distance and room floor area estimates. Results demonstrate that partial visual loss disrupts the relationship between judged room size and sound source distance that is shown by sighted participants.Visual spatial information plays an important role in calibrating auditory space. Blindness results in deficits in a number of auditory abilities, which have been explained in terms of the hypothesis that visual information is needed to calibrate audition. When judging the size of a novel room when only auditory cues are available, normally sighted participants may use the location of the farthest sound source to infer the nearest possible distance of the far wall. However, for people with partial visual loss (distinct from blindness in that some vision is present), such a strategy may not be reliable if vision is needed to calibrate auditory cues for distance. In the current study, participants were presented with sounds at different distances (ranging from 1.2 to 13.8 m) in a simulated reverberant ( Estimation of the three-dimensional characteristics of a room, such as its layout and its size, plays an important role in orientation  and fully blind participants  were correlated for sighted participants but not for participants with any severity of VI. We also investigated whether the hypothesized effect of VI on the relationship between judged room size and farthest sound source distance generalized across different room environments and stimuli. Participants were tested in anechoic and reverberant rooms, using speech, music and noise stimuli. Participants made spatial judgments in simulated anechoic and reverberant rooms, to investigate whether the room reflections influenced the relationship between auditory distance estimates and room size judgments in participants with a range of severities of VI.The virtualization methods, stimuli tested, and procedures were similar to those used in our previous experiments that investigated auditory distance estimation , and for the groups with VI, there was no significant difference in duration of VI (p > 0.05).56 Participants in total  took part in the experiments. Participants were divided into groups based on their visual acuities, which were used as an indicator of the severity of their VI . The category boundaries were chosen so as to include participants with a wide range of visual losses, where the boundaries were approximately equivalent to WHO classifications of visual loss: mild , mid-range , and severe . Participants with mild VI were able to see light, colors and shapes, but vision might be unclear or hazy or areas of the visual field might be compromised, leading to difficulties in tasks such as recognizing street signs or faces. Individuals with mid-range VI had some useable form vision, shape recognition and the ability to perceive some movement. Those with severe VI had light perception only. The current category boundaries were chosen to distinguish different severities of VI (where usable vision is present) from total blindness. This is distinct from the WHO classification of “blindness”, where categories 3–5 are labeled as “blindness,” despite usable vision being available within this range. Sample sizes were dictated by the availability of the VI participants. Information about the groups is shown in Table Previous studies of fully blind individuals have shown that there is a critical period (birth to approximately 14 years of age) for plasticity of the occipital cortex  and classrooms (400–1200 ms)  was used to produce the stimuli. Participant responses were recorded using a response interface on an Asus AA185 computer. The stimuli were produced using procedures detailed in our previous work  due to frequency-dependent absorption of the sound by the walls might be a reverberation-related distance cue  and condition (anechoic or reverberant) were fixed. Sounds at different distances were presented in a pseudo-random order. In each block, there were 80 trials with 10 repetitions of each virtual distance. After each presentation, the participant gave a verbal report of the apparent distance, with no time limitations for their response. Responses were recorded by the experimenter using a response interface. No training or feedback was given. The geometric mean of the 10 judgments for a given virtual distance was taken as the final estimate for that distance. After a block of trials was completed, participants gave judgments of the length, width, and height of the room for that block. There were 6 blocks [3 stimulus types  and 2 room conditions (anechoic and reverberant)] and the order of presentation of the blocks was randomized . The experiment was completed in a single sitting of approximately 1 h and 40 min with as many breaks as required.Data were analyzed using Pearson and Spearman correlations, mixed-model ANOVAs, and Kolmogorov–Smirnov normality tests.s in tables and plots.For correlational analyses, in the majority of cases, the data were found to be normally distributed and Pearson correlations are reported. In cases where Kolmogorov–Smirnov tests indicated that the data did not follow a normal distribution, non-parametric Spearman correlations are reported, indicated by https://osf.io/).Accuracy was assessed using a mixed-model ANOVA on the ratio of the judged distance to the simulated distance. To assess variability, a mixed-model ANOVA was run on the standard deviation (SD) of the ratio of the judged distance to the mean judged distance. Distance , reverberation time (two levels: anechoic and reverberant rooms) and stimulus  were within-subjects factors and visual status  was a between-subject factor. For statistical analysis, data were grouped into near (1.22–1.72 m), middle (2.44–4.88 m), and far (6.90–13.79 m) distances. This procedure was similar to that used by Kolarik et al. , which f3 and the farthest simulated sound distance was 13.8 m  between room size and farthest distance estimates were found for all stimuli and experimental conditions for the normally sighted group (group 1). No significant correlations were found for any of the VI groups.Figure p < 0.05) between room floor area estimates and farthest distance estimates were found for all conditions for the normally sighted participants (group 1). No significant correlations were found for any VI groups.If the farthest judged sound source distance is used to infer room size, the farthest judged distance may be more highly correlated with room floor area than with volume estimates, as distance judgements provide no information about room height. Figure p < 0.05). For the sighted group, significant correlations were observed in almost all conditions for the length dimension and some conditions for the width dimensions, but not for the height dimension  = 5.5, p = 0.002, η2 = 0.24), distance  = 122.4, p = 0.001, η2 = 0.70), and stimulus  = 43.2, p = 0.001, η2 = 0.45), and significant interactions between stimulus and visual status  = 9.0, p = 0.001, η2 = 0.34), stimulus and distance  = 6.6, p = 0.001, η2 = 0.11), stimulus and reverberation time  = 9.2, p = 0.001, η2 = 0.15), and stimulus, distance and visual status  = 4.46, p = 0.001, η2 = 0.21). No other significant main effects or interactions were observed . Post hoc t-tests with Bonferroni correction showed significant differences between the the sighted group and the severe VI group for middle and far distances for the speech stimuli, and for all distances for the music stimuli. Significant differences between the sighted group, and the mid-range and severe VI groups were observed for anechoic noise stimuli at middle distances.To assess the accuracy of the distance judgments, for each participant, condition and simulated distance, the ratio of the judged distance to the simulated distance was calculated. The mean ratios for the normally sighted group and VI groups are shown in Fig. Table F = 9.8, p = 0.001, η2 = 0.16) and distance  = 112.3, p = 0.001, η2 = 0.68), and a significant interaction between stimulus and distance  = 4.0, p = 0.009, η2 = 0.07). No other significant main effects or interactions were observed  including visual status, indicating no significant differences in the variability of the distance judgments between sighted controls and VI participants.To assess the variability of the distance judgments, for each participant, condition and simulated distance we determined the standard deviation (SD) of the ratio of the judged distance to the mean judged distance. The mean and individual ratios are shown in Fig. p > 0.05). A mixed-model ANOVA on the accuracy of distance judgements showed main effects of visual status  = 5.6, p = 0.002, η2 = 0.27), distance  = 109.8, p = 0.001, η2 = 0.71), and stimulus  = 39.3, p = 0.001, η2 = 0.47), and significant interactions between stimulus and visual status  = 8.2, p = 0.001, η2 = 0.35), stimulus and distance  = 6.9, p = 0.001, η2 = 0.13), stimulus and reverberation time  = 11.1, p = 0.001, η2 = 0.2), and stimulus, distance and visual status  = 4.98, p = 0.001, η2 = 0.25). No other significant main effects or interactions were observed . A mixed-model ANOVA on the variability of the distance judgments showed significant main effects of stimulus  = 8.9, p = 0.001, η2 = 0.17) and distance  = 118.4, p = 0.001, η2 = 0.76), and a significant interaction between stimulus and distance  = 4.7, p = 0.004, η2 = 0.09). No other significant main effects or interactions were observed . These results show that similar findings were observed whether or not late-onset VI participants were included in the analyses, suggesting that age of onset of VI did not affect the results.To investigate whether age of visual loss onset affected performance, additional analyses were run on data for early-onset VI participants only, so that five late-onset participants were excluded from group 2 and two from group 3 . Our current data support this hypothesis. The strategy of using farthest distance estimates to judge room size is particularly useful when first entering an unfamiliar room to gain insights regarding its dimensions. Although such a strategy results in a conservative estimate of room size unless the farthest sound source is close to the far wall, it at least allows an initial internal representation to be formed to support path planning and navigation that can be updated later when further spatial cues become available.When both auditory and visual information are available to normally sighted participants, judgments of room size are primarily based on visual information (Maempel and Jentsch T60 = 700 ms) used. Longer reverberation times might provide more salient cues for room size. Previous studies using reverberation times of 1700 ms or more have shown that rooms with long reverberation times are judged to be larger than rooms with short reverberation times  between auditory judgments of farthest distance and room size than observed for sighted controls (r = 0.46), a finding consistent with the perceptual enhancement hypothesis (Kolarik et al. Previous work from our laboratory showed that for fully blind participants, for whom visual calibration information was completely absent, there was a stronger correlation (Although the current findings and those of previous work that tested VI participants (Lessard et al. In the current experiment, participants reported estimates in cm, m or feet if they preferred. If VI participants did not use such units in their daily lives, they might have inaccurate internal estimates of what constitutes cm, m or feet. However, discussion with the VI participants indicated that they did use cm, m or feet to report distances in their daily lives, as do sighted individuals. We previously conducted a control experiment with fully blind individuals to check that their perception of what a meter constitutes does not differ significantly from that for sighted controls (Kolarik et al. Changes in auditory localization abilities in fully blind individuals have been linked to plasticity of the occipital cortex that occurs during a critical period (Cohen et al. The present results add to the growing body of evidence that full blindness is not necessary for significant changes in hearing to become manifest. The World Health Organization estimates that across the world 188.5 million people have mild visual loss, 217 million have moderate to severe losses, and 36 million have full blindness (Bourne et al. In conclusion, the findings show that partial visual loss disrupts the relationship between judged room size and sound source distance that is evident in participants with full vision. Consistent with the perceptual deficiency hypothesis, the results support the idea that using a degraded visual signal to calibrate auditory space interferes with the relationship between the estimated room size, and the farthest sound distance.


Five-year survival increased from 80% in 1990–94 to 91% in 2010–15 (p < 0.01). Mortality decreased by 4% annually (p < 0.01). Patients 15–17 years were increasingly treated in a paediatric oncology centre, from 35% in 1990–94 to 87% in 2010–15 and experienced a 70% reduction of risk of death compared to those treated outside such a centre (p < 0.01). Significant progress against childhood ALL has been made in the Netherlands, visible by improved survival rates coinciding with declining mortality rates. These outcomes were accompanied by stable incidence rates, despite increases for BCP-ALL at age 10–14 years and T-cell ALL at age 15–17 years.We assessed the epidemiologic progress against childhood and adolescent acute lymphoblastic leukaemia (ALL) in the Netherlands over a 26 year period. ALL patients <18 years were selected from the Netherlands Cancer Registry and the Dutch Childhood Oncology Group. Trend analyses were performed over time and by age group and ALL subtype. Between 1990 and 2015, 2997 ALL patients were diagnosed, i.e. 115 patients (range 87–147) per year. Overall incidence remained stable at 37 per million children, despite increases for B-cell precursor ALL (BCP-ALL) at age 10–14 years (AAPC + 1.4%,  Increases in incidence of childhood acute lymphoblastic leukaemia (ALL) have been reported at the beginning of the 21st century . No cleaSince the early 1970s, treatment of children with ALL has been organised with national treatment protocols in the Netherlands. At that time the Dutch Childhood Leukemia Study Group  was established. The DCLSG/DCOG has a trial and data centre, with a reference diagnostic laboratory for leukaemias, and it also coordinates clinical trials, since 2003 also for solid tumours. Most recent changes in therapy were improvements in chemotherapy and better ways to stratify patients to receive less or more intensive therapy . Trends The overall aim of this study was to assess the progress made for children and young adolescents with ALL in the Netherlands since 1990 by analysing trends in incidence and survival against the background of subsequent treatment regimens. Data from the Netherlands Cancer Registry (NCR) were combined with detailed leukaemia and treatment characteristics from the DCOG registry. Mortality data on cause of death were derived from the website of Statistics Netherlands. In addition, detailed analyses were made regarding ALL subtype and site of treatment.Patients aged <18 years and diagnosed with ALL (ICD-O-3 M9811-9818 and M9835-9837) from January 1990 to December 2015 were extracted from the NCR. For completeness a linkage with DCOG was performed and after this linkage the ALL subtype, site of treatment and treatment protocol could be determined for patients known at the DCOG registry. A total of 2947 patients with ALL from the NCR were linked with 2882 patients from the DCOG, yielding 2997 patients eligible for inclusion  and has a national coverage since 1989 with a completeness of at least 96% of all newly diagnosed malignancies in the Netherlands . The NCRThe centrally reviewed results of bone marrow, peripheral blood and spinal fluid samples taken at diagnosis are registered at the DCOG database. ALL diagnosis is based on a combination of cytomorphology, immunophenotyping and –increasingly– (molecular) cytogenetics . BaselinDisease-specific mortality rates from 1980 to 2016 were derived from Statistics Netherlands (CBS). Because of privacy regulations, linkage between the NCR and CBS is not allowed in the Netherlands on a routine base. The lymphoid leukaemia (LL) specific ICD-9 code “204” and ICD-10 code “C91” were used to identify the number of persons who died from LL. Mortality data by age at death were presented by 5-year age groups .Characteristics of the study population were described as percentages in relation to the following five periods of diagnosis: 1990–94, 1995–99, 2000–04, 2005–09, and 2010–15. Differences among categorical variables were tested with the χ2 tests.p values.Annual incidence and mortality rates were calculated per million person years, using the annual mid-year population size as obtained from Statistics Netherlands. Rates were age-standardised according to the age structure of the World standard population for age ranges 0–14 year, 0–17 year for estimation of incidence rates, and 0–19 year for mortality rates . Linear Survival time was calculated as the time elapsed between the date of diagnosis and the date of death due to any cause (event) or date at last follow-up . Traditional actuarial survival analysis was used to calculate overall survival (OS) at 5 and 10 years after diagnosis. Changes over time in observed 5-and 10-year survival were evaluated with a p-trend analysis for period of diagnosis, sex, age at diagnosis, ALL subtype, and site of treatment by using parametric survival models (streg), adjusted for follow-up time (in years). To evaluate their effect on the risk of dying per period of diagnosis, these parameters were entered in a multivariable analysis model. For survival analyses according to treatment protocol, patients eligible and treated according to the protocol were included (DCOG patients only).p value < 0.05 was considered statistically significant.All analyses were performed with STATA/SE 14.1 . Joinpoint regression program (version 4.5.0.1) was used to check for incidence trend transitions during the study period . A p valThe funding source had no role in the study design, data collection, analyses and interpretation of the results, nor in writing of this manuscript.Between 1990 and 2015, 2997 children and adolescents aged <18 years were diagnosed with ALL in the Netherlands and analysed in this study. The majority of patients had a diagnosis confirmed by the reference laboratory of the DCOG (96%). Median age at diagnosis was 5 years (interquartile range 3–9 years). More boys than girls were diagnosed with ALL  being 1.4) (Table p < 0.01) (Table n = 4), treatment at an adult ward (n = 9) or death at first presentation at a hospital (n = 3).Over time patients were increasingly treated at a paediatric oncology centre, 94% in the period 1990–94 compared to 98% in the period 2010–15 (p = 0.05), from 30 per million person-years in 1990–94 to 37 in 2010–15. This increase did not pertain to any age group , from 26 per million person-years in 1990–94 to 32 in 2010–15 (Supplementary Table p = 0.04). T-cell ALL only showed an increasing trend for young adolescents (15–17 years) from two patients per year on average in the 1990s to four in 2010–15   were diagnosed with ALL annually. The world standardised incidence rate for patients aged 0–17 years (WSR 0–17) increased over time by 0.6% per year   ; for patients aged 1–4 years from 86% in 1990–94 to 95% in 2010–15 (p < 0.01); for patients aged 5–9 years from 86% in 1990–94 to 96% in 2010–15 (p < 0.01); for patients aged 10–14 years from 72% in 1990–94 to 85% in 2010–15 (p < 0.01); for patients aged 15–17 years from 57% in 1990–94 to 74% in 2010–15 (p = 0.02)  in 1990–94 to 91% (SE 1%) in 2010–15 (% in 199002) Fig. . The 10-02) Fig. .Fig. 2Tip < 0.01); for girls from 86% to 91% (p = 0.04) (Supplementary Table p < 0.01). Five- and 10-year overall survival significantly increased for BCP-ALL, from 81% in 1990–94 to 93% in 2010–15 (p < 0.01) and from 77% in 1990–94 to 89% in 2005–09 (p < 0.01), respectively. Five and 10-year overall survival for T-cell ALL did not improve  compared to 1990–94 . Patients with a T-cell ALL were at higher risk of dying compared to patients with BCP-ALL   during the periods 2005–09 and 2010–15  over time, being 87% (n = 59) during 2010–15 compared with 35% (n = 14) during 1990–94  . Addition of site of treatment, i.e. adult oncology versus paediatric oncology resulted in the loss of significance for the HRs of the recent periods of diagnosis . In this second model, site of treatment appeared to be the most discriminative factor for reduced risk of death, i.e. an HR 0.3 for patients treated at a paediatric oncology centre compared to treatment outside a paediatric oncology centre . In the first period on average 40 young people died per year compared to 11 per year in 2010–16  of ALL increased with a modest 0.6% per year. For the last period the WSR was 37 cases per million children aged 0–17 years. This incidence rate is similar to other western countries , 24, altOur population-based survival data demonstrated increasing rates over time, with 5-year overall survival of 80% in 1990–94 versus 91% in 2010–15. The population-based study from the CONCORD working group showed similar results for patients aged 0–14 years and year of diagnosis between 1995 and 2009 for north-western European countries comparable with the Netherlands . The COGFive and 10-year overall survival rates for adolescents aged 15–17 years increased from <60% in 1990–94 to ~75% in 2010–15. The better hospital-based survival rates for adolescents (and young adults) were attained when adolescents were treated on paediatric ALL protocols compared to adult protocols about 15 years ago –31. The In agreement with other studies, mortality rates declined constantly over time at each age group , 35. IncAlthough detailed information on treatment schemes , risk group or response status are lacking in the NCR for individual patients, we did not have the intention with this descriptive epidemiological study to study outcome by treatment protocol or risk group. We just wanted to show whether there was progress. Strengths of our study include the linkage with the DCOG clinical registry over the whole study period. We could thus obtain morphology codes of almost all patients by centralised expert haemato-pathology review and determine the proportion of patients treated in a paediatric oncology centre. The latter improvement may be a stimulus for other groups.All in all, by combining incidence, survival and mortality data we attained a comprehensive picture of the progress against ALL in children and young adolescents in the Netherlands by showing improved survival, especially improved survival of adolescents treated in a paediatric oncology centre, and supported by steadily declining mortality rates. The overall incidence rate was stable, despite two age and type-specific increases.Supplementary figures and tables


Neurosurgical ablation of Forel's field H1 for cervical dystonia, which is currently abandoned, was formerly used in the 1960s–1970s. Regardless of the lack of neuroimaging modalities and objective evaluation scales, the reported efficacy was significant. Although recent studies have reappraised the ablation of the pallidothalamic tract at Forel's field H1 for Parkinson's disease, the efficacy for cervical dystonia has not been investigated well.Data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at Forel's field H1 were retrospectively analyzed. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores, the neck score of the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS), and adverse events were evaluated preoperatively and at the last available follow‐up period.p < 0.0001). The BFMDRS neck score also improved significantly from 6.2 ± 2.9 preoperatively to 2.8 ± 2.8 at the last available follow‐up period . Reduced hand dexterity in seven patients, hypophonia in five patients, dysarthria in four patients, and executive dysfunction in one patient were confirmed as adverse events at the last available follow‐up evaluation. One patient had postoperative hemorrhage.The mean clinical follow‐up period was 13.9 ± 6.5 months. The mean TWSTRS total scores were 34.3 ± 14.0 preoperatively and 18.4 ± 16.5 at the last available follow‐up period (46.4% improvement, The current study confirmed significant improvement in TWSTRS total scores and BFMDRS neck scores at the 13.9‐month follow‐up after unilateral pallidothalamic tractotomy. The pallidothalamic tract in Forel's field H1 is expected to be an alternative treatment target for cervical dystonia. The pallidothalamic tract (PTT), including the ansa lenticularis and lenticular fasciculus, is composed of fiber bundle relay of the basal ganglia–thalamo–cortical circuit, which connects the globus pallidus internus (GPi) with thalamic subnuclei including the ventrolateral and ventroanterior nuclei, and centromedian–parafascicular complex nucleus.Ablation of Forel's field is called campotomy or Forel H‐tomy, which was used to treat Parkinson's disease (PD), epilepsy, and cervical dystonia in the 1960s–1970s.The data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at the Tokyo Women's Medical University Hospital between January 2019 and January 2021 were retrospectively collected and analyzed. All patients were refractory to botulinum toxin injections. Deep brain stimulation (DBS) was rejected for the following reasons: refuse to have a mechanical device implanted and difficulty accessing hospitals that manage DBS from the remote area.Toronto Western Spasmodic Dysphonia Rating Scale (TWSTRS) scores, BFMDRS scores, and adverse events were evaluated preoperatively and at the last available follow‐up period. The TWSTRS is a validated rating scale for cervical dystonia, consisting of three subscales including severity (0–35), disability (0–30), and pain (0–20), with higher scores indicating greater impairment. The TWSTRS total score ranges from 0 to 85, with the three subscales' sum. The BFMDRS has a 0–20 score (higher score indicating greater impairment) consisting of subscales for eyes (0–8), speech/swallowing (0–16), mouth (0–8), neck (0–8), trunk (0–16), right arm (0–16), left arm (0–16), right leg (0–16), and left leg (0–16). The subscales for the arms and legs were divided into contralateral and ipsilateral surgical sides. Head MRI scans were performed before and immediately after surgery, and 3 months postoperatively.Stereotactic planning was performed using the Leksell SurgiPlan  and Brainlab Elements software . Under local anesthesia, a Leksell stereotactic frame  was fixed to the patient's skull. T1‐weighted axial and T2‐weighted axial, and coronal MRI (1‐mm slice) were used to determine the target and CT scans (1‐mm slice) for correcting MRI distortion were used. Our tentative target of PTT was intended to be located in Forel's field H1, where the ansa lenticularis and lenticular fasciculus merge, corresponding to the thalamic fasciculus on the Morel atlas.The contralateral side to the direction of head deviation was chosen for torticollis as the surgical side. For laterocollis, the contralateral side to the direction of neck tilting was chosen as the surgical side. For anterocollis and retrocollis, the contralateral hemisphere to the symptomatic dominant side, which was the more affected side of dystonia, including limb dystonia, was chosen as the surgical side.Lesion evaluation was confirmed using the Brainlab Elements software . The distances from the center of the medial and lateral lesions created to the midline , midcommissural point (anteroposterior), and the AC–PC plane  were measured by postoperative T1/T2‐weighted MRI on the day of surgery. Lesion volume  was calculated using the low‐intensity area of the T2‐weighted MRI on the day of surgery.p < 0.05.For non‐normally distributed data, the Wilcoxon signed‐rank test was used to compare the preoperative TWSTRS total and subscale scores, and the BFMDRS total and neck scores with those at the last available follow‐up. All statistical analyses were performed using SPSS . All statistical tests were two‐tailed, and significance was set at The ethics committee of the Tokyo Women's Medical University approved this study, and patient consent was waived owing to the study's observational nature.Table p < 0.0001) at the last available follow‐up period  at the last available follow‐up period . The total and neck scores of the BFMDRS also significantly decreased by 50.5% and 55.0%, respectively. Prolonged neurological deficits were found in five patients with hypophonia, seven patients with reduced hand dexterity, four patients with dysarthria, and one with executive dysfunction resulting from hemorrhagic complications.Before the advent of the DBS era, there were several stereotactic lesioning targets for the treatment of cervical dystonia, including ZI, GPi, Forel's field H1, ventro‐oral internus (VOI), and the interstitial nucleus of Cajal (INC).In 1970, Hassler and Dieckmann used ablation of Forel's field H1 and VOI unilaterally in 21 patients with cervical dystonia.Pallidotomy or pallidal DBS targets the posteroventrolateral part of GPi which is strongly associated with the origins of pallidothalamic fibers.l‐dopa , fatigue , and transient somnolence  in 10 patients with PD after unilateral pallidothalamic tractotomy.Recent studies of pallidothalamic tractotomy have been reported only from three centers, including Switzerland, Brazil, and Japan.The most frequently available stereotactic surgical target for cervical dystonia is GPi. A recent pooled meta‐analysis study has revealed that bilateral GPi‐DBS improved cervical dystonia by 60.4%, 54.8%, 67.7%, and 55.9% reduction of TWSTRS total, severity, disability, and pain score, respectively.This study had several limitations. In the retrospective analysis, subtle adverse events were likely overlooked. One of the major concerns associated with lesioning surgery is the recurrence or temporary benefits. Because of the relatively short‐term follow‐up, long‐term efficacy could not be concluded in this study. Lastly, due to the lack of evaluations of cognitive and mood states, the safety profile of psychiatric or behavioral function is unknown.This study confirmed significant improvement in TWSTRS (46.4% reduction) and neck subscore of BFMDRS (55.0% reduction) at the 13.8‐month follow‐up after unilateral pallidothalamic tractotomy at Forel's field H1. The PTT in Forel's field H1 may be an alternative lesioning target for cervical dystonia.The authors report no conflict of interest relative to the research covered in this manuscript.SH: study design, patient selection, analysis of imaging data, interpretation and acquisition of data, writing, and revising the manuscript; KK: acquisition of data; TN: acquisition of data; AF: statistical analysis; TM: acquisition of data; MI: interpretation and acquisition of data; TK: study design; TT: study design, patient selection, acquisition, and interpretation of data.The Institutional Review Board at the Tokyo Women's Medical University approved this study (No.3576).Video S1. Pre‐post operative condition with excellent result.Click here for additional data file.Video S2. Pre‐post operative condition with poor result.Click here for additional data file.


Hypertension is a major risk factor of cardiovascular diseases (CVDs), which attributes to one‐third of all deaths worldwide. It is also considered as a key feature of metabolic syndrome (MetS). The aim of the present study was to compare the presence of characteristic features of MetS in hypertensive and non‐hypertensive males and females and find out the percentages of MetS in hypertensive and non‐hypertensive adults.This was a cross‐sectional study, involving 120 participants that included 60 hypertensives and 60 non‐hypertensives (35‐55 years). Data were obtained through an interviewer‐administered questionnaire. Fasting blood sugar (FBS) and lipid parameters  were analyzed, and waist circumference (WC) was measured. Percentages of MetS among hypertensive and non‐hypertensive groups were determined according to both modified Adult Treatment Panel III (ATP III) and new International Diabetes Federation (IDF) criteria. Results were analyzed using SPSS version 21.P < .001 and P = .002 respectively), while mean value of TG was significantly higher (P = .005) in hypertensive females compared with non‐hypertensive females. Further, the percentage of subjects in the total hypertensive group with increased FBS and increased WC was significantly higher than the non‐ hypertensive group. The percentage of subjects with MetS was significantly (P < .001) higher in hypertensive group (68%) compared with non‐hypertensive group (20%) according to modified ATP III criteria. When compared with new IDF criteria, it was 63% and 20%, respectively.Among the characteristic features of MetS, mean FBS and WC were significantly higher in hypertensive males compared with non‐hypertensive males (The percentage of subjects with increased FBS, WC, and MetS was significantly higher in the hypertensive group compared with non‐hypertensives group. These findings emphasize the urgent need to develop national strategies for early detection, and to take preventive measures to make people aware of the impact of metabolic syndrome. Studies have shown approximately 20% to 25% of the world's adult population have MetS and they are prone to have a threefold greater risk for CVD morbidity and fivefold greater risk of developing type 2 diabetes mellitus (T2DM).As hypertension is a key feature of MetS and could be measured easily, this could be used as an important measure to predict the development of MetS. As no studies have been carried out to identify MetS among hypertensives in Sri Lanka, this study would provide an insight to compare the characteristic features of MetS in hypertensive and non‐hypertensive males and females and to find out the percentage of MetS in hypertensive and non‐hypertensive groups. Many studies have pointed out the importance of preventing MetS in order to reduce morbidity and mortality due to CVD and T2DM.22.1A cross‐sectional study was carried out at the Family Practice Centre of University of Sri Jayewardenepura, Nugegoda, Sri Lanka during September 2015‐January 2016. The study was approved by the Ethics review committee of Faculty of Medical Sciences, University of Sri Jayewardenepura . This study involved 120 participants between the age range of 35 to 55 years, including 60 hypertensives and 60 non‐hypertensives.Informed written consent was obtained from all the participants before the study. Hypertensive adults (diagnosed as hypertension >140/90 mmHg and/or on hypertensive drugs) were included in the “Test” group and non‐hypertensive adults who were not diagnosed for hypertension and with normal blood pressure <120/80 mmHg, were included in “Control” group. Subjects who were pregnant, having severe diseases, physical impairments, and who did not like to participate in the study were excluded. The female and male distribution in each hypertensive and non‐hypertensive group were similar (n = 30). Socioeconomic data, lifestyle information, and medical information were obtained through an interviewer‐administered questionnaire.Large waistline : WC ≥90 cm for South Asian male and ≥ 80 cm for South Asian female, plus any two of the following four features:High triglyceride level: ≥150 mg/dL (1.7 mmol/L), or obtaining treatment for high TGDecreased high density lipoprotein cholesterol: <40 mg/dL for male, <50 for female, or obtaining treatment for low HDL cholesterol.Raised blood pressure: systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg, or obtaining treatment for hypertension.Increased fasting blood sugar (glucose) level: ≥100 mg/dL (5.6 mmol/L) or obtaining treatment for high blood sugarFor the analysis of FBS, 10 hours of overnight fast was considered, and for triglycerides and HDL cholesterol, 12 hours of overnight fast was considered. FBS analysis was done using Biorex diagnostics, glucose kit where FBS <100 mg/dL was considered as normal. For lipid profile, separated serum was analyzed using Stanbio cholesterol LiquiColor kit, where TG < 150 mg/dL, HDL > 40 mg/dL  and > 50 mg/dL  were considered as normal. WC < 90 cm for South Asian males and <80 cm for South Asian females were considered normal.According to modified ATP ΙΙΙ (2005) criteria, MetS is defined as the presence of at least three of the above‐mentioned five features. All five components were taken into account in this study.2.2t‐test. For Means ± SD and frequencies, descriptive analysis was done. Fisher's exact test (two‐tailed) was used to determine the significance of association between two categorical variables . P value was used to measure the significance. If P < .05, the observed difference or association was considered as significant.Data were analyzed using statistical package for social sciences (SPSS) version 21. Significance of mean differences of MetS related characteristics between hypertensive and non‐hypertensive groups was done using independent sample 3P < .001) than non‐hypertensives (45.25±6.6 years). Medical information and lifestyle information of the study subjects are presented in Table The mean age of total, male, and female subjects were 47.6±6.2, 47.03±6.4, and 48.35±6.15 years, respectively. The mean age of hypertensive subjects (50.13±4.9 years) was significantly higher (P < .001) higher FBS was observed only in male hypertensive subjects compared with non‐hypertensive males. Mean TG was significantly (P = .005) higher in hypertensive females compared with non‐hypertensive females. The mean WC was higher than the normal reference level in both hypertensive females and non‐hypertensive females, but the value was significantly (P = .002) higher in hypertensive males compared with non‐hypertensive males.Mean values of assessed biochemical parameters are presented in Table P < .001) higher in the hypertensive group compared with the non‐hypertensive group according to both modified ATP III and new IDF criteria.The presence of MetS in this study population was assessed using modified ATP III and new IDF criteria, and the data are given in Table P = .025) higher in the total hypertensive group and hypertensive males compared with respective non‐hypertensive groups (Table P = .002) higher in hypertensive males than non‐hypertensive males, while a significant difference between female hypertensives and non‐hypertensives was not observed. The percentage of subjects with increased FBS, WC, TG were significantly higher in MetS subjects than non‐MetS individuals.The percentage of subjects with FBS, TG, HDL, and WC beyond the risk cutoff values are given in Table ps Table . The maj4MetS is a health burden that has become a challenging problem worldwide. This study aimed to identify whether a normal routine measurement of blood pressure would pave way to detect development of MetS early. Supporting the hypothesis, the key finding of the present study was the significantly higher percentage of subjects with MetS in patients with hypertension compared with their non‐hypertensive counterparts according to both methods of diagnosis of MetS (modified ATP III and new IDF criteria). Further, the MetS subjects with hypertension presented with raised FBS and WC. A study done in Brazil has observed the prevalence of MetS in hypertensives as 71.6% and 82.4% according to ATPIII (2001) and IDF (2005) criteria, respectively.Supporting the findings of the present study, a study conducted in Europe has reported that 66.5% of uncontrolled hypertensive patients had MetS and 35.5% of patients with controlled blood pressure had MetS.Central obesity, which is depicted by increased WC, is considered as one of the main underlying factors and one of the main features of MetS.According to a report of ATP III, MetS is associated with elevated triglycerides.In summary, the percentage of subjects with increased FBS, WC, and MetS was significantly higher in the hypertensive group compared with the non‐hypertensive group.Hence, the findings of the present study not only indicate that hypertensive subjects are more prone to have MetS but also emphasize the urgent need to develop national strategies for the early detection and preventive measures to make people aware of the metabolic syndrome.The authors declare that they have no conflict of interests.Conceptualization: Usha Hettiaratchi, Lohini AthiththanData Curation: Roshali Senarathne, Usha Hettiaratchi, Lohini AthiththanFormal Analysis: Roshali SenarathneFunding Acquisition: Lohini AthiththanInvestigation: Roshali Senarathne, Nirodha Dissanayake, Riyaza Hafiz, Sumara ZaleemMethodology: Usha Hettiaratchi, Lohini Athiththan, Roshali Senarathne, Nirodha DissanayakeRecourses: Usha Hettiaratchi, Lohini AthiththanSoftware: Roshali Senarathne, Lohini AthiththanSupervision: Usha Hettiaratchi, Lohini AthiththanValidation: Usha Hettiaratchi, Lohini AthiththanWriting—Original Draft: Roshali SenarathneWriting—Review and Editing: Usha Hettiaratchi, Lohini AthiththanAll authors have read and approved the final version of the manuscript.Lohini Athiththan had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.Lohini Athiththan affirms that this manuscript is an honest, accurate, and transparent account of the study that is being reported; and no important aspects of the study have been omitted; and that any discrepancies from the study as planned  have been explained.Approval for the present work was obtained from the Ethics review committee of Faculty of Medical Sciences, University of Sri Lanka, Sri Lanka .


The diagnosis of systemic autoimmune rheumatic diseases (SARD) is based on the detection of serum antinuclear antibodies (ANA) for which indirect immunofluorescence (IIF) is the golden standard. New solid‐phase immunoassays have been developed to be used alone or in combination with the detection of extractable antinuclear antibodies (ENA) to improve SARD diagnosis. The purpose of this study was to compare the clinical performances of different ANA screening methods alone or in combination with ENA screening methods for SARD diagnosis.A total of 323 patients were screened for ANA by IIF, EliA™ CTD Screen, and ELISA methods. Agreements were calculated between the methods. Then, EliA™ CTD Screen positive samples were screened for ENA by line immunoassay (LIA) and fluorescence enzyme immunoassay (FEIA).The diagnostic accuracy of EliA™ CTD Screen (79% sensitivity and 91% specificity) was better than that of ELISA or IIF. The combination of EliA™ CTD plus IIF had the highest sensitivity (93%). ENA determination revealed that Ro52 and Ro60 were the most prevalent specificities. The use of IIF alone was not able of detecting up to 36% of samples positive for Ro52, and 41% for Ro60.EliA™ CTD Screen has a better diagnostic performance when compared to IIF and ELISA. The combined use of EliA™ CTD Screen and IIF clearly improves the rate and accuracy of SARD diagnosis. The use of EliA™ CTD Screen as first‐line screening technique allows the detection of antibodies, which could not be detected by IIF alone. There is still room for improvement in ANA screening testing. Currently there are different methods available for systemic autoimmune rheumathic disease sift, but the optimization of screening protocols does not only rely on the selection of the best method–there is no perfect test‐ but in the detection of the optimal combination for the specific laboratory routine. In our study we compared the performance of two protocols in our routine samples: solid phase test+IIF and ELISA+IIF. IIF together with EliA CTD Screen (solid phase test) resulted in the highest sensitivity, while EliA CTD Screen showed the best sensitivity/specificity balance. Moreover, it has been widely demonstrated that a combination of these two techniques may improve the diagnostic accuracy of ANA screening.In routine laboratory testing, after a positive result is obtained on a screening platform, it is useful to determine the specificity of the antibody using different ENA testing platforms due to their prognostic and diagnostic power. Taking into account, the availability of different methods for SARD diagnosis, it is important to evaluate the performance of different tests in order to determine which ANA and ENA combination performs best and is more sustainable.The aim of this study was the comparative analysis of three different ANA screening methods . An analysis was carried out considering single or combination tests (EliA™ CTD Screen plus IIF vs. ELISA plus IIF). We also evaluated the potential ANA plus ENA combination testing in SARD diagnosis using two different ENA screening methods (LIA and FEIA).22.1N = 147 ; Organ‐specific autoimmune disease group, N = 31; Malignancies group, N = 12 and Non‐autoimmune diseases, N = 147). This study was approved by the local Ethics Committee of the Virgen Macarena University Hospital.Cross‐sectional study including samples referred for ANA testing from April to August 2019. A total of 323 patients from the primary care, rheumatology, nephrology, and internal medicine services of the Virgen Macarena University Hospital  were evaluated. The samples were collected randomly, including just one sample per patient. The samples were retrospectively classified, according to patients final clinical diagnosis, into the following groups: SARD group, 2.2ANA screening was performed with the following three techniques:IIF: ANA was performed using HEp‐2® cells (Immunoconcepts) (screening dilution 1:80) using ≥1:80 cut‐off which allows the detection of antibodies against a wide variety of nuclear molecules and antigens located in the cytoplasm, including those in mitotic cells. ANA IIF were carried out by Dr. González and Dr. Pérez, who have 30 and 7 years of experience, respectively; using an automated microscope  and SIExpert software .FEIA: The EliA™ CTD Screen (Thermo Fisher Scientific) was performed using the Phadia 250 instrument. This assay contains a mixture of the following antigens: dsDNA, Ro52, Ro60, SSB, Sm, U1RNP , Jo‐1, Scl‐70, CENP‐B, Mi‐2, RNA Pol III, PM‐Scl, PCNA, Ribosomal P, and Fibrillarin. The ratios of test sample to calibrator (cut‐off) recommended by the manufacturer were used: <0.7, negative; 0.7–1, equivocal; >1, positive.ELISA: RELISA (Immunoconcepts) a qualitative indirect enzyme immunoassay was used. Stabilized antigens  and other antigens from HEp‐2 nucleus and cytoplasm are coated onto the surface of the microwells to serve as antigenic substrates. Cut‐off values recommended by the manufacturer were used: <10 U/ml, negative; 10–15 U/ml, borderline; >15 U/ml, positive.For combined testing , patients with a positive result in one of the tests were considered positive, and patients with negative results in both tests were considered negative.2.3™ CTD Screen positive samples (n = 123) were analyzed for the following ENA specificities using two different methods:EliALIA: Euroline (Euroimmun), including RNP‐U 1(70 kDa+A+C), Sm, SSA/Ro60, SSA/Ro52, SSB, Scl70, Jo‐1, CENP‐B, PCNA, Histones, Ribosomal P proteins, PM‐Scl, Mitochondrial, and Nucleosomes. The intensity of the resulting staining is proportional to the antibody concentration in the sample. Therefore, semi‐quantitative cut‐off values recommended by the manufacturer were used as follows: negative (0–10 intensity of the resulting staining); weak positive (11–25); moderate positive (26–50), and strong positive (>50).FEIA: EliA specificities (Thermo Fisher Scientific), including SmDP, Rib P, PCNA, U1RNP, Ro, Ro52, Ro60, La, CENP, Scl‐70s, Fibrillarin, RNA Pol III, PM‐Scl, Jo‐1, and Mi‐1. Cut‐off values recommended by the manufacturer were used: ≤1.0 U/ml, negative; >1 U/ml, positive.2.4The differences between the results obtained from different methods were analyzed by chi‐square, phi coefficient, and contingency coefficient tests. Cohen's kappa coefficients were used to estimate the measuring agreement among methods. Statistical analyses were performed using the software SPSS Statistics v25.33.1In this patient cohort, the prevalence of SARD was 41.2% . The median age of the patients was 56 ± 16 years. Table 3.2The results of ANA screening with IIF, ELISA, and EliA™ CTD Screen were obtained and compared. As shown in Table p < 0.05)  Table . Phi coe™ CTD Screen, sensitivity was 79% (95% CI: 72%–86%), specificity was 91% (95% CI: 86–95%), and positive and negative likelihood ratios (LR) values were 8.33 (2.05–3.50) and 0.23 (0.32–0.55), respectively. IIF had the following values: sensitivity 69% (95% CI: 61%‐77%), specificity 56% (95% CI: 49%‐63%), positive LR 1.58 (1.30–1.93), and negative LR 0.55 (0.41–0.73); while ELISA showed a sensitivity of 69% (95% CI: 61%–77%), a specificity of 74% (95% CI: 68%‐80%), positive LR 2.68 (2.05–3.50), and negative LR 0.42 (0.32–0.55). Therefore, it can be concluded that EliA™ CTD Screen had higher sensitivity, specificity, and positive LR, and better negative LR compared to both IIF and ELISA.Next, SARD diagnosis performances of three screening platforms were compared Table . For EliMoreover, when the performance of EliA™ CTD Screen plus IIF was compared to ELISA plus IIF screening, EliA™ CTD Screen plus IIF screening showed higher sensitivity (93% vs. 89%) and specificity (50% vs 45%), and higher positive LR (1.86 vs. 1.63) and lower negative LR (0.14 vs. 0.23) values.3.3The antigenic specificities were assessed using two methods: EliA™ and LIA. Both platforms displayed the highest positivity rates for Ro60 and Ro52 antibodies that are most commonly reported in the literature for SARD diagnosis. Therefore, the percentage of these antigens  was assessed in systemic autoimmune diseases  and positive for SARD . As shown in Table 4n = 175) were similar to those obtained in the routine work of our laboratory and in other studies such as Bizzaro et al.This study included patients with suspicion of SARD referred from primary care, rheumatology, nephrology, and internal medicine departments. It is important to distinguish these different groups of patients which generally are referred to as SARD or ANA‐associated rheumatic diseases (AARD) as there is considerable variability among them.The comparative analysis of the three screening methods revealed that the sensitivities and specificities of the IIF and ELISA methods were more similar to each other , while EliA™ CTD Screen had higher sensitivity and specificity levels for SARD . Positive and negative LRs  were also better than IIF and ELISA. The sensitivity and specificity values for IIF were lower than reported by Orme et al.When the diagnostic efficiency of combined tests was evaluated , sensitivity and negative LR values were observed to be increased compared to EliA™ CTD Screen or ELISA alone measurements. In particular, EliA™ CTD Screen plus IIF combination results were highly promising with high sensitivity and low negative LR (sensitivity = 93% and negative LR = 0.14). Although combination tests had lower specificity and positive LR values compared to individual tests, sensitivity was higher and negative LR was below the limits considered clinically significant.Higher measuring agreement has been observed between EliA™ CTD Screen and ELISA compared to EliA™ CTD Screen and IIF, most likely due to the fact that EliA includes all the antigens with enhanced expression in ELISA. In EliA™ CTD Screen a mixture of 17 ANAs associated with SARD was present, while in ELISA there were 12. On the other hand, IIF uses a much wider range of antigens. As assessed by Pearson's chi‐square test, although there were statistically significant differences between the results of the methods , when EliA™ CTD Screen or ELISA were combined with IIF, sensitivity, specificity, and measure agreement improved. The meta‐analysis by Orme et al.For EliA™ CTD Screen positive samples, specific antibodies associated with SARD have been tested, using LIA and EliA™ (FEIA). However, dsDNA has not been considered for the study, since it would not be used for comparing LIA and FEIA, as it is not recommended to analyze anti‐dsDNA autoantibodies by LIA.n = 323) was limited; however, it can be considered representative of the routine work of a laboratory specialized in the diagnosis of SARD. The second relies on the fact that the analysis of antibodies against the different antigenic specificities associated with SARD was performed exclusively in patients with positive EliA™ CTD Screen following the usual protocol of the laboratory. Finally, neither disease duration nor concurrent therapies and disease activity were considered for the analysis, so its impact on the results has not been evaluated.The study has three main limitations. The first is sample size. The cohort size . Furthermore, the use of EliA™ CTD Screen as first‐line screening technique allows the detection of Ro52 and Ro60 antibodies  which would not be detected by IIF alone, thus increasing the false‐negative rate.Dr. González has received a speaker honorarium from Thermo Fisher Scientific.All authors confirmed they have contributed to the intellectual content of this paper and have met the following 3 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; and (c) final approval of the published article.This study was approved by the Ethics Committee of the University of Virgen Macarena Hospital . Authors declare that the manuscript has not been submitted to any other journal for simultaneous consideration, has not been published previously and data have not been manipulated or copied from other authors.


Event‐driven pre‐exposure prophylaxis (edPrEP) with oral tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) is highly effective for preventing HIV acquisition in men who have sex with men (MSM) and is preferred over daily PrEP by some MSM. However, it is largely unknown how well MSM adhere to edPrEP. We then aimed to assess PrEP protection during CAS among MSM using edPrEP and participating in the Amsterdam PrEP demonstration project (AMPrEP).We analysed data from participants enrolled in AMPrEP who were taking edPrEP. We measured adherence through (1) a mobile application in which sexual behaviour and PrEP‐use were recorded daily, (2) three‐monthly self‐completed questionnaires and (3) dried blood spot (DBS) samples collected around six, twelve and twenty‐four months after PrEP initiation. We assessed the proportion of days with condomless anal sex (CAS) acts that were protected by PrEP, per partner type , and the proportion of three‐month periods during which PrEP was correctly used. Intracellular TFV‐diphosphate (TFV‐DP) concentrations were determined from DBS. Good adherence was defined as at least one tablet before and one tablet within 48 hours after a CAS act.Between 11 September 2015 and 6 October 2019, 182 of 376 MSM (48.4%) used edPrEP for at least one three‐month period. Of the 8224 CAS days that were reported in the app during edPrEP‐use, we observed good protection for most CAS days involving steady partners , known casual partners  and unknown casual partners . Men reported consistently correct PrEP‐use in 851 (81.4%) of the 1046 three‐month periods of edPrEP‐use. The median TFV‐DP concentration was 591 fmol/sample (interquartile range = 270 to 896).Adherence to edPrEP was high as determined from the online app and questionnaire. DBS measurements were consistent with two to three tablets per week on average. The Adherence is pivotal to the effectiveness of PrEP . HoweverTo gain insight into edPrEP adherence, we aimed to assess PrEP use during CAS among MSM using edPrEP and participating in the Amsterdam PrEP observational cohort study (AMPrEP). Specifically, we aimed to quantify the number of CAS acts which were poorly or not protected by PrEP, stratified by partner type, to obtain an indication of risk for HIV acquisition during CAS. We also assessed determinants of poor or no PrEP protection and variation in protection over time. Lastly, we aimed to assess whether intracellular TFV‐DP from DBS could be used to measure adherence for edPrEP users. We used data from (1) a mobile diary‐based application (app), (2) three‐monthly questionnaires and (3) DBS to study these aims.22.1The AMPrEP project was a demonstration project that aimed to assess the uptake and feasibility of daily and edPrEP among MSM and transgender persons in Amsterdam, the Netherlands. Full study procedures have been published . In brieWritten informed consent was obtained from all participants. The AMPrEP study was approved by the ethics board of the Amsterdam University Medical Centers, location Academic Medical Center, the Netherlands (NL49504.018.14) and is registered with the Netherlands trial registration (NTR5411).2.2We developed an app for Android and iOS to collect daily information on PrEP‐use and sexual behaviour. The design and use of the app have been described elsewhere . We restAt baseline and three‐monthly study visits, we tested participants for HIV and STI and asked participants to complete a self‐administered computer‐assisted questionnaire on sexual behaviour and PrEP‐use, as described previously . We askeTM Protein Saver Cards . Blood was allowed to dry for ≥2 hours at room temperature, after which the cards were sealed in plastic bags containing a desiccant with a humidity indicator  and stored at −20°C. DBS samples were shipped in batches for analysis at Skaggs School of Pharmacy and Pharmaceutical Sciences . We sent 12‐ and 24‐month samples and if the former sample was unavailable, we sent the 3‐, 6‐ or 9‐month sample instead. The procedure to measure TFV‐DP and FTC‐TP in DBS has been described previously [For DBS, we used whole blood collected through phlebotomy conducted at three time points after PrEP initiation: three, six or nine; twelve; and twenty‐four months. Blood was spotted onto Whatman 903eviously . Lower l2.3Based on data recorded in the app, we evaluated PrEP protection per day on which CAS was reported (henceforth “CAS days”). We categorized edPrEP protection as excellent, good, poor or none Table . If no dBased on data from questionnaires, we evaluated PrEP protection as consistently correct edPrEP‐use  in an initial multivariable model. We sequentially removed all determinants with a p < 0.05 to arrive at a final multivariable model. We assessed model fit using a Pearson’s χ2 goodness‐of‐fit test. In a sensitivity analysis, we assessed PrEP protection among participants who reported data in the app ≥90% of days per month (henceforth “high app usage”). We also assessed comparability between app and questionnaire data , which was dichotomized into no/poor and good/excellent coverage. We estimated odds ratios (ORs) comparing odds of no/poor PrEP protection across levels of determinants and their 95% confidence intervals (CIs) using logistic regression with a random‐intercept to account for between‐participant variability at baseline. We forced follow‐up time and time‐updated age, and included all determinants with a Analysis .Undetectable TFV‐DP were assigned half the value of the lower limit of quantification. We plotted log‐transformed TFV‐DP against the log‐transformed number of PrEP pills and log‐transformed number of CAS acts in the preceding six weeks, as reported in the app. In addition, we plotted log‐transformed TFV‐DP concentrations against the number of pills taken, as reported in the questionnaire, in the preceding 30 days. We regressed log‐transformed TFV‐DP concentrations on log‐transformed number of PrEP pills used, from the app and questionnaire, and log‐transformed number of CAS acts, from the app, using tobit models that account for left‐censored concentrations, while including a random‐intercept for participants. For FTC‐TP concentrations, we assessed the proportion of DBS samples with detectable FTC‐TP. In a sensitivity analysis, we restricted analysis to participants with high app usage before DBS‐collection.We carried out analyses using Stata .2.5The funders of this study had no role in the study design, data collection, data analysis, data interpretation and writing of the manuscript. All authors had full access to the data used in this study. The last author had final responsibility for the decision to submit for publication.3p = 0.0114), were less often in a steady relationship (p = 0.0152), and more often identified as non‐exclusively homosexual (p = 0.0345) compared to those recording app data. Baseline sexual behaviour did not differ between app users and non‐users. The majority of edPrEP users continued recording data in the app at least once a month until 42 months after PrEP initiation  used edPrEP during at least one three‐month period Figure . These in Figure .In the app, 2455 (29.9%) CAS days with steady partners, 3472 (42.1%) with known casual partners, and 2297 (27.9%) with unknown casual partners were reported. Excellent PrEP protection was observed in the majority of CAS days with steady partners (56.9%), known casual partners (84.0%) and unknown casual partners (81.6%) Table . Over tip = 0.98; known casual partners: p = 0.99; unknown casual partners: p = 0.97).Univariable analysis of determinants of no/poor PrEP protection is shown in Table Of the 182 PrEP users who used edPrEP during at least one three‐month period, 171 94.0%) completed at least one questionnaire . When asked which pill(s) they forgot most often, 24.1% of men mentioned the pills before sex, 22.6% the first pill after sex and 31.3% the second pill after sex.One hundred and eighty‐one DBS‐measurements from 98 individuals were collected after periods of edPrEP‐use Figure . The medp < 0.0001) and pills used (p < 0.0001) reported during the six weeks before DBS‐measurements in the app  did differ. Second, we saw a decrease over time in the number of reported sex days in the app, which may have influenced changes in adherence over time. Third, as this study was the first PrEP demonstration study in the Netherlands, participants were likely to be more highly motivated to use PrEP; and they were mostly white, middle‐aged and highly‐educated. Thus, studies on adherence to edPrEP in other settings are needed to assess whether our results may be generalized to the broader MSM population. Fourth, statistical power may not have been sufficient to establish significance for some risk‐factors. Lastly, edPrEP usage is nuanced and quantitative data cannot fully explain why PrEP users at times use edPrEP suboptimally. Qualitative studies are needed to provide more insight into this and further explore possible areas for interventions.5In this PrEP demonstration project, the large majority of CAS days was protected by good or excellent adherence to edPrEP, especially CAS days with known and unknown casual partners. The difference in PrEP protection between partner types could be a reflection of PrEP‐use as it aligns with perceived HIV risk. Given that the low observed TFV‐DP concentrations are the result of fewer pills taken, adherence interpretations must be customized for edPrEP. DBS can be useful as a research tool, but its use in monitoring adherence to edPrEP in clinical practice may be limited.The Public Health Service of Amsterdam received the drugs for the Amsterdam PrEP study from Gilead Sciences based on an unconditional grant. UD received unrestricted research grants and speaker’s fees from Gilead Sciences, paid to his institute. PLA received research grants and personal fees from Gilead Sciences. HJCdV received grants from Medigene, and advisory board and speaker fees from Gilead Sciences, Medigene, Abbvie, Janssen‐Cilag and Willpharma, all paid to his institute. MP received unrestricted research grants and speaker’s fees from Gilead Sciences, Roche, Abbvie and MSD, all paid to her institute. All other authors declare no competing interest.EH, MP, HJVdV, UD and MFSvdL conceptualized and designed the AMPrEP demonstration project. VJ, EH, MvdE and MFSvdL contributed to the study design of this study. VJ, EH, MvdE, AB, HZ, LC, UD, PA, HJVdV, MP and MFSvdL were involved in data acquisition, data analysis or interpretation of the data. VJ drafted the manuscript. All authors read and approved the final manuscript.amprep@ggd.amsterdam.nl. Request for further information can also be submitted through the same email address. The AMPrEP steering committee verifies each proposal for compatibility with general objectives, ethical approval and informed consent forms of the AMPrEP study, and potential overlap with ongoing studies. There are no restrictions to obtaining the data and all data requests will be processed in a similar way.The AMPrEP data are owned by the Public Health Service of Amsterdam. Original data can be requested by submitting a study proposal to the steering committee of AMPrEP. The proposal format can be obtained from Analysis S1. Determinants of monthly app use.Analysis S2. Comparability of app and questionnaire data.Table S1. Determinants of monthly app use (1 to 26 days vs 0 days and use of at least 27 days vs 0 days). Results of univariable and multivariable multinomial logistic regression analysis, AMPrEP observational cohort study, September 2015 to October 2019, Amsterdam, the NetherlandsTable S2. Comparison of the numbers of PrEP pills taken and unknown casual partners reported in the AMPrEP mobile diary app and the 3‐monthly questionnaires, AMPrEP observational cohort study, September 2015 to October 2019, Amsterdam, the NetherlandsTable S3. Socio‐demographic and sexual behaviour characteristics at baseline of event‐driven PrEP users who ever used the app (n = 141) and never used the app (n = 41), AMPrEP observational cohort study, August 2015 to June 2016, Amsterdam, the NetherlandsTable S4. PrEP protection of condomless anal sex acts by edPrEP users per partner type as reported in the daily app by participants who reported data in the app at least 27 days within a month (n = 108), AMPrEP observational cohort study, September 2015 to October 2019, Amsterdam, the NetherlandsTable S5. Determinants of poor/no adherence to PrEP per sex partner type among event‐driven PrEP users (n = 141); results of univariable multi‐level logistic regression, AMPrEP observational cohort study, Septebmber 2015 to October 2019, Amsterdam, the NetherlandsFigure S1. App use after PrEP initiation among event‐driven PrEP users (n = 182), AMPrEP observational cohort study, September 2015 to October 2019, Amsterdam, the Netherlands.Figure S2. Association between log transformed TFV‐DP concentrations from dried blood spots (DBS) and log transformed number of pills taken as reported in the 3‐monthly questionnaires, AMPrEP observational cohort study, September 2015 to October 2019, Amsterdam, the Netherlands. Number of pills was transformed as follows: ln(1+number of pills taken).Click here for additional data file.