Records of beach morphologic change and concurrent hydrodynamic forcing are needed to understand how coastlines in different environments change over time. This submission contains data for the period 2006 to 2021, for two contrasting macrotidal environments in southwest England: (i) cross-shore dominated, dissipative, sandy Perranporth Beach, Cornwall; and (ii) longshore-dominated, reflective gravel beaches within Start Bay, Devon. Data comprise monthly to annual beach profile surveys, annual merged topo-bathymetries, in addition to observed and numerically modelled wave and water levels. These data provide a valuable resource for modelling the behaviour of coastal types not covered by other currently available datasets. Such data are vital for understanding and predicting shoreline response to changes in hydrodynamic forcing at various timescales, including short-term storm erosion and recovery, and longer-term shoreline change due to sediment budget imbalances and sea level rise5. Of the few available long-term coastal survey datasets, most observe intermediate, sandy beaches, in micro-meso tidal climates. Dissipative and reflective beaches, as well as gravel beaches, are poorly represented or absent from the data. Furthermore, few available datasets contain repeat surveys of the entire sedimentary compartment, a necessary element for determining a total sediment budget, which may be used to understand long-term coastal change processes6.A small number of long-term beach survey datasets have been made available for broader use , University of Plymouth. Complimentary data are provided by the South West Regional Monitoring Programme, one of six such programmes operating in England, supplying information for strategic coastal management. The Programme is run by the Plymouth Coastal Observatory , which collects and makes available a spectrum of coastal data. Numerically modelled wave and water levels were obtained from the Copernicus Marine Environment Monitoring Service .The datasets include monthly to annual beach topographic surveys, merged annual topo-bathymetric digital elevation models (DEMs), and hourly nearshore directional wave data and water levels, completed by hourly output from regional wave and water level numerical models. Primary data, including beach profiles and topo-bathymetric DEMs, were collected by the Coastal Processes Research Group , aimed at covering the entire sedimentary compartment to determine a ‘total sediment budget’. This approach provided unprecedented insights into embayed beach morphodynamics30. A detailed description of the methods and datasets for Perranporth are provided in the next section.Field research at Perranporth commenced in 1998 with a focus on dissipative beach swash dynamicsach Fig. . Survey 33. Regular monthly surveys of Slapton Sands began in 2006, along with installation of an ARGUS video station34, revealing that beach changes took place over seasonal to annual time scales, driven primarily by longshore sediment transport35. The beaches of Start Bay were also much affected by the extreme 2013/14 winter, with subsequent monitoring extended across all beaches of Start Bay , sediment characteristics (sand versus gravel) and morphodynamic state (dissipative versus reflective). The data sets are comprehensive, with information of supra-, inter- and sub-tidal morphological change, as well as wave forcing and water levels. As such, the datasets are suitable for testing, validating and developing morphodynamic models, as well as of interest in their own right for studying beach morphodynamics.The objective of this contribution is to make available two unique beach survey datasets, from coastline types poorly represented in the available data, from the same geographic region, but with differing wave exposure and contrasting dominant sediment transport pathways  is medium sand, with an average D50 of 0.33 mm, and with the coarsest sediments found around low tide level42.Perranporth Beach is a 3.5-km long sandy beach located on the north coast of Cornwall, SW England Fig. . The beaHs of 1.6 m and average peak period Tp of 10–11 s from the W-WNW. The wave climate is strongly seasonal with moderate-energy summers , high-energy winters , and extreme wave heights exceeding Hs = 8 m, Tp = 19 s occurring at a frequency of less than once per year23. The beach is macrotidal, with a spring range of 6.3 m and a neap range of 2.7 m. Maximum ebb and flood velocity range from 0.1 ms−1 to 0.4 ms−1 at depths between 10 and 30 m with the tidal flows predominantly parallel to the shoreline, and with speeds significantly increasing around the headlands, to c. 0.7 m s−1 during spring tides27. The strong flood-ebb asymmetry in the current magnitude during a tidal cycle results in a northward residual current along the coast of 0.05–0.2 ms−1 24.Perranporth is fully exposed to North Atlantic swells, with the wave buoy . The beach is constrained at both ends by headlands: Droskyn Point in the south and Ligger Point in the north  between the upper shoreface and the shallow sub-tidal at 5 to 7 m depthrth Fig. . IsolateHuman interventions at Perranporth are primarily limited to the southern section of the beach .A full list of profile names used by Plymouth Coastal Observatory (PCO) are provided for Perranporth Table . These cet al.29.An uncommon aspect of this data submission is the inclusion of digital elevation models (DEM) of the full nearshore, beach and dune systems Table , DS03 foσ) of 0.04 m.Drone-based, or Uncrewed Aerial Vehicle (UAV), photogrammetric data were collected for the dune area of the full length of the beach, using a DJI Phantom 4 (RTK) quadcopter for 2016–2018 and 2021. Coverage includes the supratidal to an elevation of >30 m ODN. For each flight 20–30 ground control points (GCPs) were distributed evenly throughout the survey volume (except for 2021 where RTK UAV used reduced GCP requirements). GCPs were surveyed using an RTK-GNSS Trimble 5800/R10. Images were processed using a Structure-from-Motion/Multi-View Stereo workflow (Agisoft MetaShape Pro) to produce a 1-m DEM, with vertical uncertainty (σ) is 0.05 m.All-Terrain Vehicle (ATV) mounted RTK-GNSS surveys were conducted over inter-tidal and supratidal (z = −2 to 4 m) for the full extent of the beach, employing a Trimble 5800/R10, running alongshore lines with cross-shore line spacing 20–25 m, for years 2016–2019 and 2021. ATV data were collected concurrently with single-beam echosounder (SBE) bathymetry, and combined to a merged data product (see next section). Mean uncertainty for ATV surveys (σ) of 0.05 m.Single-beam echosounder (SBE) surveys covering the shallow sub-tidal, for the full alongshore extent of the beach, to c. 18 m water depth, were collected using a Valeport Midas Surveyor echosounder , pole-mounted on an inflatable surf rescue vessel, with external Trimble RTK-GNSS positioning , for years 2016–2018. Tidal reduction was performed using accurate GNSS heighting and local geoid separation model. Cross-shore transects were spaced 50-m for inshore lines (<10 m depth) and at 100-m spacing for offshore lines (>10 m depth), with vertical measurement uncertainty  were used for the 2011 merged DEM. Lidar coverage includes the intertidal, supratidal and dune system, with vertical uncertainty (σ) of 0.15 m.Airborne Lidar data collected in Jan 2011 by the Environment Agency and obtained from PCO , collected to survey specification International Hydrographic Organization Order 1a,between April 2009 and March 2011. The 2011 UKHO bathymetry was initially provided vertically referenced to Chart Datum, and then converted to ODN (consistent with other datasets), using the Vertical Offshore Reference Frame separation model (VORF), facilitated by the UKHO.Multibeam echosounder (MBE) bathymetric surveys were derived from multiple sources, covering the area around Perran Bay, extending 2–3-km offshore, to a depth of ≥ 30 m. UK Hydrographic Office (UKHO) MBE bathymetric data were used for 2011  and Norbit iWBMs 400 kHz MBE (2021), with motion data provided by GNSS-aided Applanix POSMV MRU and primary positioning provided by a Trimble RTK-GNSS system. Sound velocity data were provided by Valeport Swift SVP and mini SVS. CPRG MBE data were collected in 2016–2018 and 2021, with point data interpolated to a 2-m grid using the nearest neighbour method, with variable vertical uncertainty (95% C.l.) of 0.06–0.3 m, with most values <0.1 m. MBE data were processed using QPS Qimera and variable uncertainty grids were computed using the CUBE algorithm29. For 2011  of 2-m merged DEMs were constructed Fig.  from the11 Table , the merDEMs of Difference . The greatest time mismatches occur for surveys prior to the 2013/14 storm season  and the intertidal and supra tidal beach. These critical surveys have minimal temporal mismatch. Greatest mismatch is with MBE data, typically used in areas of >15 m water depth, where less change is expected. Methods for validating all survey data, including determination of offsets between surveys, are described in the “Technical Validation” section. For users calculating difference between DEMs, it is recommended to apply thresholding based on combined uncertainty38.Due to the difficulties in obtaining complex, multi-method survey data, there are instances where the constituent datasets for the merged DEM were obtained over different months or years. This introduces a degree of uncertainty, as bed level change may occur between surveys. Additionally with merged DEMs, there may be offsets between datasets that may represent either measurement error and/or morphologic change between surveys. These sources of uncertainty are acknowledged, though are inherently difficult to quantify. Best-practice standards have been followed in determining variable uncertainty mapsWave and water level data are provided from observations and regional numerical models Table ; Fig. 5.https://southwest.coastalmonitoring.org/), moored in c. 18 m of water depth at mid-tide, directly offshore of the study site  for the nearest available tide gauge, an Etrometa Step Gauge, at Port Isaac, 35 km northeast of Perranporth . Variables include water level (Ordnance Datum Newlyn and Chart Datum) and residual , recorded at 10-min intervals for 2006 – 2021. It is not recommended that the observed Port Isaac water levels be used directly for Perranporth, as there are significant water level variations in tidal range and timing of high/low water between these points, due to a steep tidal range gradient in the region. However, the Port Isaac tidal gauge data are included as they provide the nearest available observations of water level residual, and may be useful for numerical model validation.Water level observations Table  were obthttps://marine.copernicus.eu), from the Atlantic-European North West Shelf-Wave Physics Reanalysis, using the spectral wave model WAVEWATCH III, produced by the UK Met Office, at c. 1.5 km grid resolution, with a 3-hourly timestep, for 1980–present. Included with this data submission is a single wave model node offshore of south Perranporth Beach ; Tp ; and peak direction Dp . Overall there is good agreement between observations and model, noting the output points are not co-located , and Root Mean Square (RMS) difference. Results include ted Fig. , therefohttps://marine.copernicus.eu) from the Atlantic - European North West Shelf - Ocean Physics Reanalysis, using the hydrodynamic model NEMO, produced by the UK Met Office at 7-km grid resolution, at a 1-hour timestep, for 1993 to present. Included with the dataset is a single model node offshore southwest of Perranporth Beach  and the transition to a low-gradient sandy bottom occurs around a depth of 8–10 m depth47, relative to ODN.Start Bay is a 12-km long embayment aligned SSW-NNE and located on the south coast of Devon, SW England Fig. . The emb35. The easterly waves are locally generated in the English Channel, but the southerly waves generally refract into the Channel from the Atlantic from an initial westerly direction. The wave climate is strongly seasonal, with summer and winter significant wave heights of Hs = 0.5–0.6 m and Hs = 1–1.3 m, respectively38. Maximum wave heights during storms in Start Bay can attain Hs = 5 m. These extreme waves occur less frequently than once a year, and may arrive from the east  or the south . The tidal regime is macro-tidal with a spring and neap tidal range of 4.3 m and 1.8 m, respectively. The tidal water motion in Start Bay can be described as a large scale anti-clockwise eddy39, where the eddy is at the same time the result of and the cause for the large subtidal banner bank, called Skerries, located in the southwest part of the bay. Skerries comprises medium shelly sand48 and extends across almost half of Start Bay with the crest only a few meters below low tide level; therefore, it exerts a significant influence on the inshore wave climate and affects both the wave height and direction along the coast, especially for waves from the south39.The bay is impacted by a bi-modal wave climate Fig. , with a 23. The Start Bay embayment as a whole is a closed system38, bounded by significant northern and southern headlands; however, beach rotation and exchange of sediment between the individual sub-embayments occur through headland bypassing under extreme wave conditions37 and sustained periods of a particular wave direction38. Based on a total sediment budget approach, the northward sediment transport during the 2013/14 extreme winter along Slapton Sands is estimated38 at 500,000 m3, while the southward sediment transport during one of the most energetic easterly storms in 2018 is estimated37 at 200,000 m3.The southerly and easterly wave directions drive northward and southward sediment transport, respectively, and the beaches in the embayment are continually in a state of dynamic equilibrium, with the planform shape rotating in response to the current wave approach36. The southern end of Hallsands is backed by a rock armour revetment, in poor condition. The southern third of Beesands features compound rock armour and seawall, protecting a small number of residential and commercial buildings. A short section of rock gabions is present at north Beesands. Torcross, at the southern end of Slapton Sands is heavily protected by compound revetment and seawall, protecting properties behind the wall, extending northward into a rock revetment protecting the road along the crest of the barrier. The middle section of Slapton Sands, comprising a narrow dune backed by the road, has seen a number of damaging storm events, with a 2018 event destroying a section of road and carpark37. The northern section of Slapton Sands is cliffed-backed and has minimal interventions, while at the far north of the bay, Blackpool Sands is largely unprotected apart from a small section of wall fronting a retail premises behind the mid-point of the beach.A range of human interventions are located across Start Bay; with some areas heavily engineered, and other sections in a more natural state. The positioning of protection structures toward the southern end of the southern sub-embayments reflects the long-term trend of northward sediment transport and clockwise rotation. At the far southern end of the bay . Both CPRG and PCO profiles are sampled at irregular distances cross-shore, with higher resolution around changes in slope; data are provided at the original sample points, without interpolation.PCO transects at Start Bay include 37 lines covering the extent of Hallsands, Beesands, Slapton Sands and Blackpool Sands, with varying alongshore spacing Fig. , surveyehttps://southwest.coastalmonitoring.org/).A full list of profile names used by Plymouth Coastal Observatory (PCO) are provided for Start Bay Table . These c38. MBE bathymetric surveys for Start Bay were obtained from UKHO for the 2013 epoch and by CPRG for subsequent years. Additional to these methods, the Start Bay merged DEMs include isolated areas of pole-mounted RTK-GNSS coverage, obtained by CPRG, typically used in areas where UAV flights were not permitted. In this instance, full coverage was achieved by having a surveyor walk closely-spaced (c. 5-m) alongshore lines38. A sample Start Bay full embayment survey is provided for 2018 , and numerical modelling data via CMEMS (https://marine.copernicus.eu). Extended data sets may be freely accessed via these portals.Waves and water levels for Start Bay are provided using a combination of observations and regional numerical model observations, summarised in Table Wave buoy data for Start Bay Table  were colWave model outputs Table  are provHs ; Tp ; and Dp . Agreement between wave model and observations is reasonably good, noting the model node and wave buoy are not co-located, and also that wave direction may be more reliably predicted during high wave events37.A statistical comparison between the Start Bay wave model node and wave buoy was conducted, using the methods previously described for Perranporth, determining values for 49. A summary of all 13 datasets is provided in Table The full data record is available through an open access data repositoryThis submission represents a comprehensive long-term hydro-morphodynamic data for a macro-tidal beach (Perranporth) and a gravel beach (Start Bay). Furthermore, these are amongst the few available datasets containing time series of full embayment DEMs, which capture the entire active zone of sediment transport (to the depth of closure) at both sites. For these reasons, these data are highly valuable in modelling how coastlines such as these will respond to future changes in sea level and wave climate.38 (their Appendix A). A multi-method validation was conducted in 2017, comparing various surveying methods used to generate the Start Bay merged DEM against appropriate reference surfaces.Extended descriptions of validation of survey methods are provided in ref. 38).Topographic surveying methods (UAV and RTK-GNSS) were compared against a high-precision survey reference surface, obtained by surveying a section of beach with a Leica terrestrial laser scanner, using reference control points measured with a total station. This method accounts for total uncertainty and/or bias for each survey method. UAV survey comparison with the reference surface resulted in a mean difference (bias) of 0.02 m and root-mean-square-error (RMSE) of 0.04 m. The RTK-GNSS recorded a mean difference of −0.008 m and RMSE of 0.05 m  was determined for MBE surveying by applying a combined statistical and error budget modelling approach, based on prior estimates of uncertainty and total propagated uncertainty for each sounding. The uncertainty estimates were gridded using the Combined Uncertainty and Bathymetric Estimator (CUBE) algorithm, commonly used for generating spatially variable uncertaintyhttps://southwest.coastalmonitoring.org/). Wave data accuracy (uncertainty) is reported as wave height (3%) and wave direction (1.5 degrees). Water level uncertainty from tide gauges is reported as 0.01 m.Wave and water level observations were obtained through the Plymouth Coastal Observatory (PCO). Documentation on quality control is available through PCO (https://marine.copernicus.eu). Technical reports on validation of the wave model50 and hydrodynamic model51 are available through CMEMS.Wave and hydrodynamic modelling outputs were obtained through the Copernicus Marine Environment Monitoring Service (CMEMS;


Mycoplasma pneumoniae is a common causative pathogen of community-acquired pneumonia. An accurate and sensitive detection method is important for evaluating disease severity and treatment efficacy. Digital droplet PCR (ddPCR) is a competent method enabling the absolute quantification of DNA copy number with high precision and sensitivity. We established ddPCR for M. pneumoniae detection, using clinical specimens for validation, and this showed excellent specificity for M. pneumoniae. The limit of detection of ddPCR was 2.9 copies/reaction, while that for real-time PCR was 10.8 copies/reaction. In total, 178 clinical samples were used to evaluate the ddPCR assay, which correctly identified and differentiated 80 positive samples, whereas the real-time PCR tested 79 samples as positive. One sample that tested negative in real-time PCR was positive in ddPCR, with a bacterial load of three copies/test. For samples that tested positive in both methods, the cycle threshold of real-time PCR was highly correlated with the copy number of ddPCR. Bacterial loads in patients with severe M. pneumoniae pneumonia were significantly higher than those in patients with general M. pneumoniae pneumonia. The ddPCR showed that bacterial loads were significantly decreased after macrolide treatment, which could have reflected the treatment efficacy. The proposed ddPCR assay was sensitive and specific for the detection of M. pneumoniae. Quantitative monitoring of bacterial load in clinical samples could help clinicians to evaluate treatment efficacy. Mycoplasma pneumoniae is a causative pathogen of respiratory infections in humans. It is a small, cell-wall-deficient bacterium that belongs to the class Mollicutes. M. pneumoniae is a significant cause of community-acquired pneumonia, especially in children and young adults  is an absolute quantification method that does not involve the generation of a standard curve, and it shows robust detection efficiency for various pathogens such as SARS-CoV-2, hepatitis B virus, human immunodeficiency virus, and rculosis . Severalrculosis . Most imM. pneumoniae and compared its clinical advantages with real-time PCR. We evaluated the ability of the assay to obtain results from samples taken from different periods of M. pneumoniae infection, and to measure treatment efficacy based on bacterial load in infected patients.In this study, we developed a ddPCR method for the accurate quantification of M. pneumoniae infection without any co-infection, based on a commercial real-time PCR assay . The other 99 specimens were negative for M. pneumoniae when tested with the same kit. Six patients were sampled two- or three-times during hospital treatment, and these additional eight samples were also used to measure treatment efficacy. Clinical information was also collected, including sex, age, duration of fever, length of stay, white blood cell count, neutrophil ratio, and C-reactive protein level.In total, 186 clinical respiratory specimens, including 99 sputum samples, 46 throat swabs and 41 bronchoalveolar lavage fluid, were obtained from pediatric pneumonia patients between January and December 2019. Seventy-nine specimens were collected from patients diagnosed with M. pneumoniae pneumonia (SMPP) group and a general M. pneumoniae pneumonia (GMPP) group based on the guidelines for management of pediatric community-acquired pneumonia . The extracts were eluted in 150 μL of nuclease-free water and stored at −80°C until use. The concentration of nucleic acids was determined with a NanoDrop 2000 Spectrophotometer .M. pneumoniae detection with ddPCR is shown in Digital PCR was conducted by dividing the samples into many droplets and counting the number of droplets in which a reaction occurred. The sample preparation in this assay was the same as for real-time PCR. The workflow of in silico cross-reactivity. All primers showed high specificity for M. pneumoniae. This conserved region was cloned into vector pUC57 to obtain recombinant plasmid for further use. The master mix for the ddPCR was composed of 15 μL of reaction buffer, 6.45 μL of DNase-free water, 2.4 μL of each forward and reverse primer (10 μM), and 0.75 μL of the probe (10 μM) to form a final volume of 20 μL. A no-template control was used in every ddPCR batch. The generation of droplets was performed with a Targeting One Droplet Generator. PCR amplification was carried out using an Applied Biosystems Veriti 96-Well Thermal Cycler with the following conditions: 95°C for 10 min followed by 40 cycles of denaturation at 94°C for 30 s and 60°C for 1 min. The plate was stored at 4°C until the droplets were analyzed with a Targeting One Droplet Reader and Chip Reader R1 software.Digital droplet PCR was performed with a TargetingOne Digital PCR System . The primers and probe  were desReal-time PCR was conducted in parallel with the same primers and probes used for ddPCR on ABI 7500 Software Version 2.3 (Applied Biosystems). The reaction system included 15 μL of PCR Master Mix Reagents , 0.9 μL of forward primer (10 μM), 0.9 μL of reverse primer (10 μM), 0.6 μL of probe (10 μM), and 9.6 μL of DNase-free water, and the same amount of DNA template as was used for ddPCR. The cycling conditions were as follows: 94°C for 10 min, followed by 40 cycles of denaturation at 94°C for 10 s and annealing/extension at 60°C for 45 s. The result was considered positive when the cycle threshold (Ct) for the P1 gene was ≤38 and negative when Ct was >38.Mycoplasma and common bacteria of the respiratory tract: M. pneumoniae type 1 strain (ATCC 29342), M. pneumoniae type 2 strain (ATCC 15531), Streptococcus pneumoniae (ATCC 49619), Haemophilus influenzae (ATCC 43065), Staphylococcus aureus (ATCC 25923), Staphylococcus epidermidis (ATCC 12228), Klebsiella pneumoniae (ATCC 27736), Escherichia coli (ATCC 25922), Mycoplasma fermentans (ATCC 19989), Legionella pneumophila (ATCC 33152), Mycobacterium tuberculosis (ATCC 25618/H37Rv), Pseudomonas aeruginosa (ATCC27853), Mycoplasma genitalium (ATCC 33530), Ureaplasma parvum (ATCC 27813), Mycoplasma hominis (ATCC 23114), adenovirus , herpes simplex virus , and varicella zoster virus . The linear dynamic range of the ddPCR assay was determined using 10-fold serial dilutions of the recombinant plasmid. For the reproducibility of ddPCR, five independent experiments were performed with these recombinant plasmid dilutions across 5 days, then the inter-assay coefficient of variance (CV) was calculated. The limit of detection (LoD) of both real-time PCR and ddPCR was obtained using serial dilutions of spiked samples of concentrations close to the detection limits. For all concentrations, tests were performed on 20 replicates.The specificity was evaluated by testing for other M. pneumoniae detection, 178 clinical samples were tested. The performance was compared with that of real-time PCR in parallel, using the same primers and probes.To evaluate the performance of the ddPCR assay for p value <0.05 (two sided) was considered statistically significant. The above-mentioned analyses were performed using either Prism 8.0  or SPSS 19.0  software.Categorical variables (Sex) are expressed as count/percentages, and between-group comparison was done using the Chi-squared test. The distributions of continuous variables were assessed for normality using the Shapiro–Wilk W test. Continuous variables are expressed as mean (standard deviation) in the case of Gaussian distributions or median (interquartile range) in the case of skewed distributions. Comparison of continuous variables between two groups was performed using the independent samples t-test or nonparametric Mann–Whitney U test, where appropriate. Correlations between the Ct values of real-time PCR and the bacterial load determined by ddPCR were analyzed with the Pearson correlation test. A M. pneumoniae detection. Among the 12 common respiratory pathogen controls and four mollicutes species, only two M. pneumoniae samples (types 1 and 2) produced positive signals, while the other control samples were negative. Therefore, ddPCR showed high specificity for M. pneumoniae, with no cross-reaction with other pathogens  were 0.068, 0.094, 0.116, 0.159, and 0.197, respectively, suggesting that the ddPCR assay had good reproducibility.The linear dynamic range was evaluated by ddPCR and compared with that of real-time PCR. Both methods showed a good linear range, and ddPCR achieved results comparable to those of real-time PCR: plasmids  The inteWe used serial dilutions of the recombinant plasmid to determine the detection limit of ddPCR and compared it with that of the real-time PCR assay. The linear series DNA standards were diluted to the detection limit with cDNA from negative throat swab samples from healthy people to concentrations below the minimum detection range of ddPCR or real-time PCR. Each concentration was analyzed for 20 replicates. The LoD of ddPCR was 2.9 (95% CI: 1.8–4.4) copies/reaction while the real-time PCR was 10.8 (95% CI: 7.1–14.5) copies/reaction. The LoD of ddPCR and real-time PCR were comparable, ddPCR was probably three times below that of the real-time PCR.M. pneumoniae with ddPCR and real-time PCR. For ddPCR, 80 samples were positive and 98 were negative. For real-time PCR, 79 samples were positive and 99 were negative. The correlation coefficient between ddPCR and real-time PCR was 0.8784 . White blood cell count, neutrophil ratio and C-reactive protein level were higher in the SMPP group than in the GMPP group (p < 0.001). The bacterial loads tested by ddPCR in the SMPP group were significantly higher than those in the GMPP group  with macrolide antibiotic treatment were sampled two or three times before or during admission. These additional eight samples were included for testing. Detailly, three swab samples which collected at 2 days prior to admission (2d PTA), day 1 of azithromycin treatment (AZM 1d), day 3 of azithromycin treatment (AZM 3d) were from Patient A. Three swab samples collected at AZM 1d, AZM 3d and day 5 of azithromycin treatment (AZM 5d) were from Patient B. For the rest four patient, two swab samples collected at AZM 1d and AZM 3d were collected separately. When tested by ddPCR, the bacterial loads of all patients dramatically decreased after azithromycin treatment (p = 0.014), which could have reflected the efficacy of antibiotic treatment. Patient A showed fluctuation in bacterial load, which initially increased and then decreased after macrolide treatment.Digital droplet PCR provided accurate detection of M. pneumoniae has substantially reduced its genome during its adaptive evolution, and thus it has limited metabolic capabilities and relies on its host to provide most of the nutrients it needs  of M. pneumoniae genes determined using quantitative PCR, and showed that PCR loading was associated with clinical severity and inflammatory indicators. The high bacterial load group had high fever, high thermal peak, long duration of fever, and elevated levels of C-reactive protein. Many studies have also suggested that high macrolide resistance is related to clinical features , National Natural Science Foundation for Key Programs of China Grants (82130065), Beijing Natural Science Foundation (7222014), FENG foundation (FFBR 202103), the Research Foundation of Capital Institute of Pediatrics (CXYJ-2021-04), and Beijing high-level public health technical talent project-02-08.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To analyze the efficacy and safety of Bifidobacterium quadruple viable tablets combined with mosapride citrate for the treatment of constipation.A systematic review was performed on studies published until July 2022 in PubMed, Embase, China National Knowledge Infrastructure, and Wanfang. The efficacy rate, adverse reaction rate, recurrence rate, and clinical symptoms were included in the measured outcomes.P < 0.001; I2 = 0.0%, P = 0.645). There was no significant difference in the incidence of adverse reactions between the two groups , Z = 0.11, P = 0.911; I2 = 0.0%, P = 0.958). The recurrence rate of constipation in patients receiving the combination treatment was lower than that of patients treated with mosapride citrate alone , Z = 3.38, P = 0.001; I2 = 29.8%, P = 0.200).The efficacy of Bifidobacterium quadruple viable tablets combined with mosapride citrate in the treatment of constipation was higher than that of mosapride citrate alone , Z = 8.19, Bifidobacterium quadruple viable tablets combined with mosapride citrate demonstrated efficacy and safety in treating constipation. Probiotics have the potential to positively influence gut health and microbial profiles in patients with functional constipation.The online version contains supplementary material available at 10.1186/s12876-023-02884-3. Functional constipation (FC), also referred to as chronic idiopathic constipation, is a prevalent gastrointestinal disorder caused by abnormal functioning of the colon, rectum and anus . PatientBifidobacterium, Enterococcus faecalis, Lactobacillus acidophilus, and other components that can lower intestinal PH 4, promote the restoration of normal flora, enhance immune function, avoid the invasion of pathogenic bacteria, and facilitate the recovery of gastrointestinal motility [Fiber and osmotic laxatives are usually as the first-line treatment for FC. However, recurrence of symptoms is often observed following this treatment. Recently, there has been an increase in the use of gastrointestinal motility drugs, such as mosapride citrate (mosapride), in clinical practice. Mosapride is a selective 5-hydroxytryptamine 4 (5-HT4) receptor agonist that promotes the release of acetylcholine and enhances the peristaltic function of the gastrointestinal tract by activating cholinergic interneurons and 5-HT4 receptors in the muscular plexus , 9. Mosamotility –14. In pmotility .The efficacy of a single drug is often limited, and prolonged use can lead to drug resistance and dependence, affecting the compliance of patients to treatment and the long-term effectiveness of the drug. Although Bifidobacterium quadruple viable tablets regulate human microecology and have a notable impact on the intestine, they do not affect gastrointestinal motility. In contrast, mosapride can increase gastrointestinal motility but cannot effectively improve the intestinal microenvironment. In recent years, combining these two drugs has shown improved therapeutic outcomes in patients with FC . HoweverThe meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search was performed by two reviewers in two English-language databases (PubMed and Embase) and two Chinese-language databases  from database inception through July 2022. The search terms used were as follows: (bifidobacterium), AND , AND (idiopathic constipation), AND (chronic constipation), AND (slow transit). The full text of the included articles was carefully reviewed.The inclusion criteria were as follows: (1) prospective or retrospective studies or clinical research; (2) enrollment of patients with constipation; (3) the control group receiving treatment with mosapride citrate tablets, and the experimental group receiving treatment with Bifidobacterium quadruple viable tablets on the basis of the control group; and (4) primary outcome measures focused on the effectiveness in the treatment of constipation, while secondary outcomes included adverse event rate, recurrence rate, and clinical symptoms. The following criteria resulted in the exclusion of identified articles: (1) duplicate publications; (2) conference summaries, comments, letters, existing meta-analyses, and systematic reviews; (3) non-randomized controlled trials; and (4) studies investigating abnormal index values.The following information was extracted from the included studies: author’s name(s), publication date, sample size, patient age, outcome indicators, and details of intervention and control group treatments (treatment type and method of administration). The first reviewer extracted data from the literature, and the second reviewer confirmed the accuracy.I2 test, and sensitivity analysis was conducted to evaluate the stability of the main indicators. Funnel plots and Egger’s and Begg’s statistics were utilized to examine publication bias. The risk of bias in the included studies was evaluated using the Cochrane Collaboration tool.Statistical analyses were performed using Stata 15.0 software. The efficacy rate, adverse reaction rate, and recurrence rate of the two drug groups used to treat constipation were estimated using the odds ratio (OR) with a confidence interval (CI) of 95%. The clinical symptom scores were estimated using the Standardized Mean Difference (SMD) with a CI of 95%. A random effects model was utilized to estimate the overall effect of the two drug groups. Heterogeneity was estimated using the A total of 367 studies were identified through the database searches. Of these, 38 studies were duplicate studies and therefore excluded. Following screening of the titles and abstracts, 308 studies were deemed irrelevant and were also excluded. Based on the inclusion and exclusion criteria, 8 studies were excluded, leaving 13 studies that met the inclusion criteria  . The result of the publication bias analysis is presented in Fig. P > 0.05). Sensitivity analysis was performed to evaluate the stability of the combined effects of the two drugs, and the results are shown in Fig. Of the 13 selected articles, 11 analyzed the effectiveness rate of treatments. The results of the random effects model revealed that the combination of Bifidobacterium quadruple viable tablets with mosapride citrate exhibited a higher efficacy rate in treating constipation than that of mosapride citrate tablets alone , Z = 8.19, P < 0.001; I2 = 0.0%, P = 0.396, Fig. P < 0.001; I2 = 0.0%, P = 0.690, Fig. P < 0.001; I2 = 0.0%, P = 0.902), Fig. P < 0.001; I2 = 0.0%, P = 0.999, Fig. Four articles analyzed changes in clinical symptoms, including difficulty in defecation, fecal character, defecation frequency, and defecation interval. The analysis revealed that patients treated with Bifidobacterium quadruple viable tablets combined with mosapride citrate showed lower scores for defecation difficulty [SMD=-1.28, 95% CI , Z = 10.75, 2 = 29.8%, P = 0.200, Fig. Seven articles analyzed the recurrence rate of constipation after treatment. The random effects model showed that the recurrence rate was significantly lower in patients treated with Bifidobacterium quadruple viable tablets combined with mosapride citrate compared to the control group, which showed statistically significant differences [OR = 0.48, 95% CI , Z = 3.38, P = 0.001; I2 = 0.0%, P = 0.958, Fig. Ten articles were analyzed for adverse reaction rates. The results of the random effects model showed no significant difference in the incidence of adverse reactions between patients treated with Bifidobacterium quadruple viable tablets combined with mosapride citrate and that of the control group [OR = 0.97, 95% CI , Z = 0.11, P = 0.911; IFC is one of the most prevalent gastrointestinal disorders encountered in clinical practice . Its etiA recent systematic review and meta-analysis concluded that probiotics may improve overall intestinal transit time and defecation frequency in adults with FC, despite a large amount of heterogeneity among studies . The conL. acidophilus and Bifidobacterium contributed to the normalization of intestinal transit [As first-line treatments for FC, fiber and osmotic laxatives can increase stool frequency by an average of 1.4 total bowel movements per week . Further transit , 29. SimBifidobacterium and L. plantarum) interventions were significantly superior to a placebo in the treatment of FC, showing improved efficacy and reducing the recurrence rate of constipation, thereby enhancing clinical effectiveness [Consistent with our findings, a meta-analysis demonstrated that probiotic (tiveness . RegardiThe efficacy rate of Bifidobacterium quadruple viable tablets combined with mosapride citrate demonstrated higher efficacy in the treatment of patients with constipation compared to mosapride citrate alone. Furthermore, this treatment proved safe for managing constipation. The findings of this study highlight the potential of probiotics to positively influence gut health and microbial profiles in patients with FC.Additional file 1.


This study relates to emerging concepts of appropriate trial designs to evaluate effects of intervention on the accumulation of irreversible disability in multiple sclerosis (MS). Major starting points of our study are the known limitations of current definitions of disability progression by rater-based clinical assessment and the high relevance of gait and balance dysfunctions in MS. The study aims to explore a novel definition of disease progression using repeated instrumental assessment of relevant motor functions performed by patients in their home setting.The study is a prospective single-center observational cohort study with the primary outcome acquired by participants themselves, a home-based assessment of motor functions based on an RGB-Depth (RGB-D) camera, a camera that provides both depth (D) and color (RGB) data. Participants are instructed to perform and record a set of simple motor tasks twice a day over a one-week period every 6 months. Assessments are complemented by a set of questionnaires. Annual research grade assessments are acquired at dedicated study visits and include clinical ratings as well as structural imaging . In addition, clinical data from routine visits is provided semiannually by treating neurologists. The observation period is 24 months for the primary endpoint with an additional clinical assessment at 27 month to confirm progression defined by the Expanded Disability Status Scale (EDSS). Secondary analyses aim to explore the time course of changes in motor parameters and performance of the novel definition against different alternative definitions of progression in MS. The study was registered at Deutsches Register für Klinische Studien (DRKS00027042).The study design presented here investigates disease progression defined by marker-less home-based assessment of motor functions against 3-month confirmed disease progression (3 m-CDP) defined by the EDSS. The technical approach was chosen due to previous experience in lab-based settings. The observation time per participant of 24, respectively, 27 months is commonly conceived as the lower limit needed to study disability progression. Defining a valid digital motor outcome for disease progression in MS may help to reduce observation times in clinical trials and add confidence to the detection of progression events in MS. Accumulation of disability in multiple sclerosis may occur as relapse-associated worsening (RAW) or steady progression independent of relapse activity (PIRA) . While aA recent review reported on outcomes in phase III clinical trials of secondary progressive multiple sclerosis since 1990 . Among tWithin this concept events of CDP or lack thereof within a given timeframe, respectively, represent one component. Other components are the absence of clinical relapses and absence of radiological signs of inflammatory disease activity. Recently, predictive value has been shown for total brain volume loss (BVL) on disability progression. Thus, measures of decline in brain volume have been added as a fourth component (NEDA-4) . Still, At a time when chronic disease processes represent the target for future interventions in MS, improving the operational definitions of disability progression remains a key priority of MS research . TechnicFollowing this strategy, this investigation aims to devise and evaluate an instrumental definition of CDP in early RRMS by episodic patient self-assessment of motor symptoms at home. Among the various technologies available, we chose a visual-perceptive technology based on commercial RGB-D cameras. As a marker-free method this study applies a consumer-grade RGB-Depth (RGB-D) camera (Microsoft Azure Kinect®) combined with customized software (Motognosis Amsa) for motion capture at home as the primary outcome. As a marker-free method, it has high potential for clinical utility and RGB-D technology has been explored for the purpose of task-based motor assessment in various neurological conditions in research settings . As a noPrimary endpoint is the accuracy of detection of progression events at 24 month compared to progression events defined as 3-month CDP in EDSS. Relation of such definitions to patients’ reports of function and impairment as well as structural change on MR imaging and optical coherence tomography (OCT) will complement the final analysis.2.2.1.The study is a single-center prospective observational cohort study. Study data combines observations from different sources: patients’ remote self-assessment, data from treating neurologists obtained in routine clinical care—both performed semiannually—and data from annual in-person study visits at an academic clinical research center. The primary outcome consists of home-based recordings of short motor tests  performed twice a day for a period of 1 week every 6 months. Patient-reported outcomes is acquired every 6 months using validated questionnaires on specific functions, impairments and quality of life.Data requested from treating neurologists comprise the Multiple Sclerosis Functional Composite (MSFC-3) , the gloAnnual study visits at the research site comprise clinical and functional assessment including Motognosis Labs as well as imaging of brain (MRI) and retina (OCT) detailed below.The observation period is 24 months for the primary endpoint with an additional clinical assessment at 27 months to confirm progression defined by EDSS.2.2.The study targets a sample size of 150 people with a diagnosis of relapsing–remitting MS according to revised McDonald criteria  in theirInclusion further allows use of any intervention for MS or other morbidity as long as this is not considered to affect compliance with the study protocol. Comorbidities are not excluded as long as not considered to interfere with motor performance.Prior disease activity or other known predictors of disease progression were implemented as additional inclusion criteria to increase expected CDP observations at 24 months while at the same time trying to maintain generalizability of our findings for the target population of early RRMS.2.2.1.Written informed consent to participate in this study.Participant’s age is ≥18 years.Participant resides within reasonable range from study center to allow supervision of technical set-up at home and provision of technical back-up.Diagnosis of relapsing–remitting multiple sclerosis according to 2017 diagnostic criteria .ANDDisease duration of <10 years since diagnosis.ANDEDSS ≤ 6.0 .ANDfulfillment of one or more of the following criteria:history of recent disease activity: ≥ 1 relapse or ≥ 1 new T2 lesion or ≥ 1 Gd + enhancing lesion on MRI over the past 2 years.ORFindings on routine brain MRI from within 6 months prior to screening: total T2 lesion load of ≥10.ORFindings on routine brain MRI from within 6 months prior to screening: any Gd + enhancing lesion.ORFindings on routine MRI from within 6 months prior to screening: ≥ 1 spinal or brainstem lesion.ORFinding on optical coherence tomography performed at screening: Peripapillary retinal nerve fiber layer (pRNFL) < 92 μm in a non-optic neuritis eye.2.2.2.Relapse within 3 months prior to baseline visit.Other disease or condition with suspected effect on motor performance.Any condition foreseen to prevent compliance with protocol.The patient is pregnant at screening.Any contra-indications for MRI investigation at screening.2.3.An overview of the visit schedule is provided in 2.3.1.Measurements are recorded with a markerless motion analysis system consisting of the measurement software  running on an All-in-One PC  and a single RGB-Depth camera .The device is delivered to the patient’s home and set-up appropriately by qualified staff along with oral instruction of the testing protocol which includes assessment of six specified short motor tasks within the recording space of the camera. All data are stored on the system hardware only.Participants are instructed to use Motognosis Amsa twice a day—preferably morning and later afternoon/evening—for a period of 7 days for each visit. Participants start by preparing the measuring area . When the measurement area is cleared, they can start the software. The software can be controlled with gestures, i.e., lifting of the left or right arm. Assessments start with a positioning phase, where participants will see themselves on the computer screen and will be guided to the correct starting location with visual and auditory cues. Subsequently assessment-specific video instructions are provided. After execution of an assessment a result page is shown. If a measurement error occurred, a notification will be shown with the request to rerecord. Otherwise, the participant can proceed to the next assessment. If a specific task was not recorded, the participant is supposed to enter the reason for the omission in a free text field.Stance with open and closed eyes and closed feet : angular sway speed 3D (°/s) separately for phases of stance with open and closed eyes.Stepping in place (40 s): knee amplitude (m) and arrhythmicity (%).Short walk in comfortable speed : Short walk in comfortable speed: comfortable walk speed (m/s) and step width (cm).Short walk in maximum speed : maximum walking speed (m/s).Line walk : mean trunk roll deflection (°).Standing up and sitting down from a chair: up time (s) and down time (s).Assessments and their motor outcomes for this study include:Performing the whole set of assessments, including in-between system operation, positioning, instructions and conduction takes at maximum 10 min. If particular assessments are deemed too risky for an individual participant by the investigator, the participant may be instructed to record only a subset of the assessments.On each day of home-based assessment of motor function, participants are asked to answer three simple questions as potential determinants for day-to-day fluctuations: (1) about the severity of pain on a 0–10 numerical analog scale pain (painNAS), (2) about the current health status on a 0–100 visual analog scale (EQ-VAS)  and (3) 2.3.2.PROs listed below were applied in validated translations—except for PGIC, for which own translation was used—and completed directly in eCRF via individualized links.2.3.2.1.The Patients’ Global Impression of Change (PGIC) scale was first developed in context of patients’ perception of changes after intervention . It is a 7-point verbal scale, with the options “very much improved,” “much improved,” “minimally improved,” “no change,” “minimally worsened,” “much worsened,” and “very much worsened.” The PGIC is commonly used in clinical trials for treatments of pain, but it has also been applied as a generic measure applicable to a wide variety of conditions and treatments. Worsening of any grade is considered clinically meaningful .2.3.2.2.The Multiple Sclerosis Walking Scale-12 (MSWS-12) is a patient-rated measure assessing the extent to which a person’s ability to walk is affected by MS., i.e., it is conceived to capture the impairment level. It has been developed from patients’ experience and has undergone psychometric validation and translations . The 12 2.3.2.3.The fatigue scale for motor and cognitive functions (FSMC) is a patient questionnaire to assess MS-related cognitive and motor fatigue , 46. A L2.3.2.4.The clinical rating of spasticity will be performed using a patient-rated measure of the perceived severity of spasticity, employing a numeric rating scale , 48 for 2.3.2.5.The Hamburg Quality of Life Questionnaire for Multiple Sclerosis (HAQUAMS) is a health-related quality of life measure designed for pwMS . The HAQ2.3.2.6.The 9-item Patient Health Questionnaire-9 (PHQ-9) was devised to screen for depressive disorders in primary care and the setting. It is based on the DSM-IV diagnostic criteria for a major depression episode. The PHQ-9 can be used both as a screening instrument for a depressive episode and can be used to provide information about the severity of a depressive episode. Each question in the scale has four response choices: “not at all,” “several days,” “more than half the days,” and “nearly every day” and classifications of no/possibly relevant depressive disorder are made according to manual , 53.2.3.2.7.The Godin leisure-time exercise questionnaire (GLTEQ) is applied here to assess physical activity levels in MS. It contains three core items regarding the frequency of strenuous, moderate, and mild physical activity for bouts of 15 or more minutes during a 7-day period . The sco2.3.2.8.EQ-5D is a generic and widely used measure of health status developed by the EuroQol Group.Participants are asked to classify and rate their own health according to five dimensions. These dimensions comprise mobility, self-care, usual activities, pain/discomfort and anxiety. Each dimension is divided into five levels, i.e., 1 “no problems,” 2 “slight problems,” 3 “moderate problems,” 4 “severe problems,” and 5 “extreme problems.” . While a2.3.2.9.Given the high prevalence and clinical relevance of pain, the Brief Pain Inventory (BPI) was developed as a brief instrument with low respondent burden that can be easily administered by large numbers of patients . The BPI2.3.3.Information from routine care is retrieved repeatedly throughout the observation period from treating neurologists. The baseline data set comprises information on diagnosis and comorbidities, most recent relapse including its treatment and clinical outcome and full list of current medication as well as EDSS and MSFC-3, if performed routinely. Follow-up data are requested from any clinical visit throughout the observation period, at least semiannually, and comprise clinician’s global ratings of change, information on relapses since last visit in medication or comorbidities, as well as EDSS and MSFC-3.2.3.4.2.3.4.1.Time since diagnosis of multiple sclerosis, prior manifestations of disease, current symptoms, prior and current disease modifying therapy, supportive therapy and relapses in past 24 months as well as comorbidities and changes thereof are acquired by the clinical investigator.Current therapy will be documented at baseline and changes thereof will be reported at each visit. This also extends to rehabilitative interventions.2.3.4.2.The expanded disability status scale (EDSS) is used to quantify disability in MS. The scale was first developed by Kurtzke in 1955 and then expanded in 1983. It is usually referred to as a measure which is scaled on 10 steps from 0 (no disability) to 10 (death from MS). Scoring is based on an examination by a neurologist. EDSS steps 1.0 to 3.5 refer to people with MS who are able to walk without any limitation, while EDSS steps 4.0 and higher are defined by decrease in walking capacity. Assessment of EDSS will follow instructions of Neurostatus for functional systems scores and EDSS step  by certi2.3.4.3.The MSFC was developed by a special Task Force on Clinical Outcomes Assessment as a clinically applicable standardized, quantitative assessment instrument for use in MS trials . The MSFThe MSFC will be performed and analyzed in accordance with the respective testing manual issued by.the National Multiple Sclerosis Society. Cut-offs for clinically meaningful change in MSFC and component Z-scores have been defined as >20% worsening .12.3.4.4.The 6-min walk (6 MW) is applied here to measure of walking endurance/ walking capacity in pwMS . The tes2.3.4.5.in camera version used (Microsoft Kinect v2 for Motognosis Labs vs. Azure Kinect for Motognosis Amsa) and test set-up, as Motognosis Labs uses a camera plugged in to a laptop and participants are guided through assessments by a trained operator according to standard instructions.Our group developed a clinically applicable assessment protocol (PASS-MS) for usage with the Motognosis Labs system . Motognosis Labs functions similar to Amsa in terms of technology. It differs PASS-MS consists of 10 short motor tasks performed in front of the RGB-D camera and parameters for the description of performance are generated by custom scripts. In operator-based application, this system proved acceptable to patients and was easily applied. Previous validation showed accuracy of derived parameters against gold standard multi-camera motion capture  and suffStance with open and closed eyes and closed feet .Dual Task Stance with open and closed eyes and closed feet.Stepping on place (40s).Short walk in comfortable speed.Short walk in maximum speed.Line walk.Standing up and sitting down from a chair.Pronator drift test.Finger-to-nose-test.Finger tapping.Assessment of PASS-MS includes:2.3.4.6.In this study a standardized MR protocol was performed consisting of: a 3D-T1-weighted sequence (MPRAGE), a 3D T2-SPACE, a 3D fluid attenuated inversion recovery (FLAIR), a Diffusion Weighted Imaging sequence (DWI) and a resting state functional MRI (rsfMRI). To define progression, we use operational cut-offs for brain volume loss known to increase with age. Mean BVL per year amounts to by 0.15, 0.30, 0.46, and 0.61% of baseline brain volume at ages 45, 55, 65, and 75 years, respectively . The cor2.3.4.7.Optical coherence tomography (OCT) is a suitable high-resolution imaging method for the assessment of retinal integrity with good reproducibility. Peripapillary retinal nerve fiber layer thickness and macular volume are the most reported indicators to measure retinal atrophy on OCT. It has been shown that pwMS with a pRNFL thickness of less than or equal to 87 μm (88 μm) measured with Spectralis (Cirrus) OCT devices had double the risk of disability worsening in the follow-up .which led us to consider this measure as a component of the inclusion criteria. With respect to progression of structural abnormalities of the retina, an absolute thinning of pRNFL of more than 1.25 μm at 24 months against baseline is considered clinically meaningful. This threshold has been established previously as the upper limit to define stability in multiple sclerosis .2.3.5.See 2.4.All study data will undergo plausibility checks including description of missings prior to further analysis. Definitions of progression events by EDSS or alternative definitions for secondary outcomes are applied as provided in section 2.3.Data from technical recordings  are continuously monitored by trained users to check usability and plausibility according to standard operating procedures for quality control (QC). Specifically, for Amsa and PASS-MS, presentations of all assessments are systematically inspected and evaluated for quality concerns following the QC pipeline developed by Röhling et al. .For RGB-D camera based motion capture, both Amsa and PASS-MS, a list of task-specific kinematic parameters is generated according to custom scripts by the provider. Kinematic parameters include for example gait speed for the short walking tasks. Primary analysis will consider only one parameter per test condition, i.e., seven parameters.2.5.Data flow is shown in For the technical assessments performed in this study , test results  are only transferred into REDCap system after pre-processing as described in section 2.4 along with results of QC.All pseudonymized raw data are digitally stored in separate archives on local platforms.With regard to data imports from home-based repeated Amsa assessments, raw data and metadata are saved on and retrieved with the device after each 1-week assessment period by the provider. The provider, after checking for technical issues and completeness, transfers results of daily self-ratings and pseudonymized metadata and raw data from Amsa recordings to the study site. Data are provided for QC application as well as kinematic parameters for analysis and archiving.Data from routine care are collected from treating neurologists using structured paper templates.2.6.Approval of the institutional review board (Charité—Universitätsmedizin Berlin) was obtained on 21 October 2021 (EA1/293/21). The study is active with first patient first visit in June 2022.2.7.Based on the study question, the primary hypothesis is to assess the accuracy of detecting disease progression by the repeated short motor assessments at 24 months, compared to progression defined by EDSS at 24 months and confirmed at 27 months.The sample size is justified via the expected precision of the estimate of the area under the receiver operating characteristic curve (AUC) provided in terms of the 95% confidence interval. We hypothesize that the parameters derived from repeated short motor assessment at home can reliably identify disease progression compared to detection of progression according to EDSS.If the AUC is 0.9, and the sample size is 150, from which 10% are diagnosed with a progression according to EDSS at 24 months, then the width of the 95% confidence interval will be 0.103. In case of a lower AUC, e.g., 0.8, the 95% confidence interval would be of width 0.138. These calculations were performed using nQuery version 8.7.0.0, procedure AOC6-1. Given these calculations, the expected precision of the estimated quantity seems sufficient to evaluate the exploratory research hypothesis of this study.Given the baseline definition, the primary endpoint is analyzed as AUC of detection of disease progression according to the repeated short motor assessment at home compared to detection of disease progression according to the EDSS score at 24 months, confirmed at 27 months. The AUC is calculated alongside with the 95% confidence interval. Event of progression at 24 months detected by parameters from repeated short motor assessment at home is defined as observed reliable change in pre-defined direction of worsening in one or more of the parameters derived from this assessment. Threshold for reliable change will be defined based on analysis of baseline data. Secondary endpoint analyses are planned for MSWS-12, HAQUAMS, PGIC, CGI, MSFC, and 6 MW. Respective receiver operating characteristic curves and their AUC will be calculated based on published evidence on minimally important difference for MSFC, 6 MW, MSWS-12, and HAQUAMS while any transition in the direction of worsening will be considered an important change on PGIC and CGI.Subgroup analysis are planned for stratification by age > 55 years vs. younger and EDSS < 3.5 vs. higher. Further exploratory subgroup analysis may be conducted for all endpoints, if there exist relevant subgroups, using standard statistical methods such as parametric or non-parametric location tests and regression methods.3.This study evaluates the concept of remote multipoint assessment of motor performance to improve definitions of disease progression in MS over current definitions of 3 m-CDP. Being among the first and larger studies to evaluate quantitative motor assessments longitudinally , 72–76, Primary analysis will use 3 m-CDP defined by EDSS as the main comparator, which is most commonly used as an endpoint of disability accumulation in MS clinical trials to date. Still, more general concerns have been raised with respect to disability confirmation by EDSS . For exaThe technical approach applied in this study is novel in two aspects: first, assessments of motor function are recorded by patients themselves in their home setting, and second, this approach enables frequent (multi-point) assessment. Both aspects hold potential to overcome the limitations of conventional rater-based assessments in single and infrequent clinical visits. Previous evidence suggests that different features of MS may vary considerably within the same subject, including self-ratings of health status . For fatFor a quantitative assessment of motor functions in MS, this study follows the technical approach of a task-based assessment. Clinical relevance of instrumentally assessed gait quality has been shown in early-stage multiple sclerosis . HoweverShema-Shiratzky et al. found that dual-task walking in the lab better represents walking ability in everyday life, whereas usual walking in the lab is more likely to represent best performance in everyday life .We therefore included additional performance-based and patient-reported outcomes of walking function for contextualization. Another novelty of our study is the integration of data acquired semiannually in the course of routine clinical care by treating neurologists. Analysis will use these, specifically their global ratings of change, as one of the alternative secondary definitions of change. This intends to explore the validity and generalizability of our findings for the setting, in which approved treatments or digital motor applications will ultimately be applied.post hoc quality control using this method of instrumented motion analysis . Reliable remote assessment of disability would seamlessly fit in the landscape of digital health solutions that are highly important in situations where specialized care is scarce or episodically unavailable, such as in recent pandemic conditions. If utility can be shown for this home-based setting, such assessment may serve as a valuable source of information in patient care. An appropriate re-definition of progression events may substantially reduce total observation times and rater involvement in clinical trials that aim to establish clinical stability or clinical progression in MS as their outcome of interest.The study was approved by the Institutional Review Board . Participants are enrolled only after written informed consent. The study was registered at Deutsches Register für Klinische Studien (DRKS00027042). Dissemination includes this submission of the study protocol for peer-reviewed publication and discussion of interim and final results at conferences as well as prospective publication in peer-reviewed journals.E-MD: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing. HR: Conceptualization, Data curation, Software, Writing – review & editing. DZ: Conceptualization, Formal Analysis, Writing – review & editing. LH: Conceptualization, Formal Analysis, Writing – review & editing. FP: Supervision, Writing – review & editing. TS-H: Conceptualization, Data curation, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.


To compare blood pressure (BP) in tonometric radial artery recordings during passive head-up tilt with ambulatory recordings and evaluate possible laboratory cutoff values for hypertension.Laboratory BP and ambulatory BP were recorded in normotensive (n = 69), unmedicated hypertensive (n = 190), and medicated hypertensive (n = 151) subjects.2, ambulatory daytime BP 139/87 mmHg, and 276 were male (65%). As supine-to-upright changes in SBP ranged from −52 to +30 mmHg, and in DBP from -21 to +32 mmHg, the mean values of BP supine and upright measurements were compared with ambulatory BP. The mean(supine+upright) systolic laboratory BP was corresponding to ambulatory level (difference +1 mmHg), while mean(supine+upright) DBP was 4 mmHg lower (P < 0.05) than ambulatory value. Correlograms indicated that laboratory 136/82 mmHg corresponded to ambulatory 135/85 mmHg. When compared with ambulatory 135/85 mmHg, the sensitivity and specificity of laboratory 136/82 mmHg to define hypertension were 71.5% and 77.3% for SBP, and 71.7% and 72.8%, for DBP, respectively. The laboratory cutoff 136/82 mmHg classified 311/410 subjects similarly to ambulatory BP as normotensive or hypertensive, 68 were hypertensive only in ambulatory, while 31 were hypertensive only in laboratory measurements.Mean age was 50.2 years, BMI 27.7 kg/mBP responses to upright posture were variable. When compared with ambulatory BP, mean(supine+upright) laboratory cutoff 136/82 mmHg classified 76% of subjects similarly as normotensive or hypertensive. In the remaining 24% the discordant results may be attributed to white-coat or masked hypertension, or higher physical activity during out-of-office recordings. To diagnose hypertension in clinical practice, the gold standard is ambulatory blood pressure (BP) monitoring where the cutoff point for hypertension in daytime recordings is 135/85 mmHg, in nighttime recordings 120/70 mmHg, and in 24-hour recordings 130/80 mmHg [BP is characterized by high variability, and based on wrist-worn tracker analyses of heart rate , a singlThe study of hemodynamic changes associated with hypertension is usually carried out in the laboratory –12. For As a major proportion of research focusing on the hemodynamics of hypertension has been performed under laboratory conditions, our objective was to compare the results of tonometric laboratory BP recordings versus ambulatory daytime BP measurements and evaluate possible laboratory cutoff values for hypertension. This information mainly serves research purposes but may be helpful in the estimation of the reliability and validity of the laboratory measurements for real-life situations. We also compared supine and upright BP during laboratory measurements with ambulatory daytime BP and evaluated the accuracy of the laboratory measurements to classify patients as normotensive and hypertensive.The study included subjects participating in our study on noninvasive hemodynamics, recruiting patients with primary and secondary hypertension and normotensive subjects  ,27. Writ2. Based on ambulatory daytime recordings [http://links.lww.com/BPMJ/A195.We included those participants of the study who had participated in the recording of ambulatory 24-hour BP and laboratory measurements. We excluded subjects with incomplete ambulatory or laboratory recordings and subjects with chronic renal insufficiency stage 4–5 . The precordings , 69 partAll participants went through ambulatory, office, and laboratory BP recordings, performed with a median of 7 days apart (25th–75th percentiles 0–18 days). Ambulatory BP recording was performed with Microlife WatchBP O3   or MobilIn the laboratory, radial BP from the left wrist was recorded using a tonometric sensor , calibrated approximately every 2.5 min with contralateral brachial BP measurements, coupled with the SphygmoCor PWMx monitoring system . Previously, the Colin tonometric device provided accurate data throughout a wide BP range satisfying the Association for the Advancement of Medical Instrumentation standards for mean SBP and DBP measurements but was found to minimally exceed the allowable SD . The subBlood samples were collected after ~12 h of fasting. Plasma electrolytes, creatinine, C-reactive protein, glucose, and lipid determinations were carried out using Cobas Integra 700/800  or Cobas 6000, module c501 . Standard 12-lead electrocardiograms were registered and the Cornell voltage-duration product was calculated .P < 0.05 was considered statistically significant.The laboratory results and BP values were analyzed using analysis of variance and calculation of Pearson and Spearman correlations, as appropriate. In some subjects, SBP increased and in some decreased in response to the head-up tilt. Subsequently, the subjects were divided into tertiles according to the change in radial SBP in response to the head-up tilt, and results were analyzed using analysis of variance for repeated measurements. To test whether the laboratory measurements classified subjects similarly to ambulatory BP, the participants were divided into four subgroups: (1) normotensive in ambulatory and laboratory recordings, (2) hypertensive in ambulatory but normotensive in laboratory recordings, (3) normotensive in ambulatory but hypertensive in laboratory recordings, and (4) hypertensive in both recordings. The sensitivity and specificity of the laboratory recordings to define hypertension versus ambulatory and office BP measurements were examined using receiver operating characteristic (ROC) curves. The statistics were performed using SPSS version 26.0 , and Bonferroni correction was applied in post-hoc analyses. The results in the tables were presented as means and standard deviations of the mean, in the figures as means and 95% confidence intervals of the mean. In total, 143 (35%) of the subjects were women, and participant ages ranged from 19 to 70 years   Fig. . The meaIndividuals with different BP levels present variations in the white-coat effect . TherefoP < 0.05), whereas upright and mean(supine+upright) SBP was corresponding to ambulatory SBP (Table P < 0.05). Supine and mean(supine+upright) aortic DBP were lower than ambulatory DBP, whereas upright aortic DBP did not differ from ambulatory DBP (Table P < 0.05)  Table .Scatter plots of ambulatory daytime BP versus mean (supine+upright) radial tonometric BP are shown in Fig. With the above cutoffs, 311 (76%) of the participants were classified similarly in ambulatory and laboratory recordings: 76 (19%) subjects were normotensive and 235 (57%) were hypertensive  radial tonometric BP, the laboratory BP 136/82 mmHg corresponded to ambulatory daytime BP 135/85 mmHg. Previously, no reference values for hypertension have been defined for noninvasive laboratory recordings ,18,35. BRadial SBP and pulse pressure are higher than the aortic values due to pulse pressure amplification . Recentlet al. considered the accuracy of tonometric BP values to be moderate in 22 surgical patients [et al. found that mean BP values differed in ~34% of the readings by >10 mmHg from intra-arterial readings among 15 neuro-intensive care patients [et al. reported that tonometry provided accurate and reliable monitoring of BP in 28 patients undergoing orthopedic surgery [Weiss patients , while Spatients . However surgery , while N surgery . In the In the present study, office BP was higher than ambulatory BP in each study group. Higher ambulatory daytime than office heart rate can be explained by out-of-office physical activity. Our laboratory recordings confirmed that body position has a significant effect on the level of BP ,12,18,42We recently examined hemodynamic differences underlying the various BP responses to head-up tilt in 613 participants without the cardiovascular disease . One-thiAn important and reliable method in the diagnosis of hypertension is ambulatory BP monitoring . Also, rOf note, subjects classified as hypertensive in ambulatory recordings only were clearly normotensive in the laboratory and their aortic BP did not differ from the group that was normotensive in both ambulatory and tonometric recordings. Furthermore, subjects classified as hypertensive in the laboratory only had higher aortic BP than subjects who were normotensive in both ambulatory and tonometric recordings, and their diastolic aortic BP did not differ from the group that was hypertensive in both tonometric and ambulatory recordings Table .et al. examined 230 hypertensive patients (mean age of 68 years) and found that an interarm difference in office SBP of ≥10 mmHg was associated with >2-fold hazard ratio for cardiovascular events and >3-fold hazard ratio for mortality during 10 years of follow-up [The ROC curves showed that the laboratory and ambulatory BP values were not entirely corresponding Fig. . Moreoveollow-up . On the ollow-up . Thus, oAs most of the hemodynamic research has been performed in the laboratory, we compared tonometric laboratory BP recordings with ambulatory daytime BP. High individual variation in the BP in response to head-up tilt suggests that upright measurements along with supine or seated measurements should be considered in the evaluation of the BP level. Seated BP measurements are the prevailing standard for BP measurements both in the office and at home . The preThe authors thank research nurses Emmi Hirvelä, Paula Erkkilä, and Reeta Kulmala, for invaluable technical assistance. The authors wish to acknowledge CSC – IT Center for Science, Finland, for computational resources.This work was supported by Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital (grants 9AA062 and 9AB057); Finnish Foundation for Cardiovascular Research; Päivikki and Sakari Sohlberg Foundation, Sigrid Jusélius Foundation, Pirkanmaa Regional Fund of the Finnish Cultural Foundation, Pirkanmaa Regional Society of the Finnish Kidney and Liver Association, and The Finnish Medical Foundation.Data availability statement: Analyses and datasets of the current study are not available publicly as the clinical database contains indirect identifiers and the informed consent does not allow publication of individual patient data. The datasets are available from the corresponding author upon reasonable request.There are no conflicts of interest.


Gender-related differences have been reported in atrial fibrotic remodeling and prognosis of atrial fibrillation (AF) patients after ablation. We assessed in persistent AF the regional distribution of left atrial (LA) bipolar voltage and the extent of low-voltage zones (LVZ) according to gender as well as the results of a voltage-guided substrate ablation.Consecutive patients who underwent a voltage-guided AF ablation were enrolled. LA endocardial voltage maps were obtained using a 3D electro-anatomical mapping system in sinus rhythm. LVZ was defined as <0.5 mV.p < 0.01) and in each atrial region in women compared with men, whereas the LA indexed volume was similar. LVZ were found in 56.1% of women and 16.2% of men (p < 0.01). LVZ were also more extensive in women (p = 0.01), especially in the anterior LA. Atrial voltage alteration occurred earlier in women than in men. In a multivariate analysis, the female sex  and LA indexed volume  were predictive of LVZ. Atrial arrhythmia-free survival was similar in men and women 36 months after a single ablation procedure.A total of 115 patients were enrolled . The LA bipolar voltage amplitude was twice lower in the whole LA (The study reports a strong relationship between the female gender and atrial substrate remodeling. The female gender was significantly associated with higher incidence, earlier occurrence, and greater extent of LVZ compared with men. Despite the female-specific characteristics in atrial remodeling, LVZ-guided ablation may improve the AF ablation outcome in women. HigheRecently, left atrial low-voltage zones (LVZ) assessed by electro-anatomical mapping (EAM) were determined as a surrogate marker of atrial fibrosis  and corrLVZ are a powerful predictor of recurrence after AF catheter ablation (CA) . The assTo fill this knowledge gap, we aimed both in an unmatched and matched cohort of persistent AF patients referred to our institution for CA to assess the LVZ extent and the regional distribution of LA bipolar voltage according to gender. The other goal was to evaluate the outcome 36 months after LA voltage-guided substrate ablation in addition to PVI.2.2.1.This observational study enrolled 281 patients who underwent initial ablation of persistent AF at Strasbourg University Hospital, France, between November 2017 and December 2019.After exclusion of patients without LA voltage maps in sinus rhythm (SR), 166 patients were enrolled. A total of 51 patients with a structural heart disease were also excluded . A strucThe patient demographics and baseline clinical characteristics were recorded.Written informed consent for the ablation and the use of data for research purposes was obtained from all patients before the procedure of AF catheter ablation, and the study protocol was approved by the Institutional Review Board of the University of Strasbourg.2.2.2DS2-VASc* , Hypertension (HT), dyslipidemia, diabetes, obstructive sleep apnea, previous thrombo-embolic events, paroxysmal AF history, and estimated glomerular filtration rate (eGFR). A nearest neighbor algorithm was used to match sex difference in a 1:1 ratio, with a caliper width equal to 0.2 of the standard deviation of the logit of the propensity score. The propensity score-matched cohort included a total of 56 patients with 28 males and 28 females. The patient demographics and baseline clinical characteristics were recorded.To minimize the confounding factors on the occurrence of LVZ, a propensity score (PS) matching was assessed. The propensity score model included the following covariates: AF duration, time to treatment , age, body mass index (BMI), CHA2.3.The CA procedures were performed under general anesthesia using a three-dimensional (3D) electro-anatomical mapping system  and a deflectable decapolar circular mapping catheter . LA endocardial voltage mapping was performed in SR prior to radiofrequency ablation. SR was achieved with electrical cardioversion in patients with AF.An endocardial contact during point acquisition was validated by a stable contact signal for >2 beats. All points recorded in SR were analyzed to exclude mechanically induced premature beats. Any area with abnormal voltage resulting from inadequate contact between the circular catheter and LA tissue was reassessed carefully point by point with a 4-mm irrigated contact-force ablation catheter  to avoid any mistakes. LA was divided into six anatomical regions: posterior, anterior, septal, lateral, left atrial appendage (LAA), and inferior . The rooThe bipolar voltage amplitude was recorded for every point and within each individual region. The median LA  and the bipolar voltage measurements of each specific region were calculated.2.The left atrial intracavitary volume (LAIV) excluding LAA was obtained for each patient after LA anatomic reconstruction and expressed in ml. The left atrial intracavitary volume index (LAIVI) corresponded to LAIV indexed to the body surface and expressed in ml m2) of each atrial region and of LVZ within each region were measured using the software of 3D-EAM.LVZ was defined as sites of >3 adjacent low-voltage points with a bipolar peak-to-peak voltage amplitude of <0.5 mV , 18 and P-wave to the local activation time of the LAA (P-LAA) was measured after LA voltage mapping for each patient in SR.The duration from the onset of 2.4.. At the end of CA, an arrhythmia induction was performed by atrial burst pacing to refractoriness. No additional ablation lesions were performed except for an organized atrial tachycardia (AT).Ablation was performed with a maximal power limit of 35 W  using an irrigated contact-force catheter. The ablation protocol was the same in the two groups. If the LA voltage map was normal, PVI was only performed for Stage I patients, whereas LVZ homogenization or isolation in addition to PVI was done in patients with mild or moderate LVZ. Linear ablation was done when LVZ could be seen as a critical isthmus site for a potential macro-reentrant tachycardia2.5.Antiarrhythmic drugs (AADs) were continued in all patients during a blanking period of 3 months after CA during which arrhythmia recurrences were not judged as ablation failure. The patients were reviewed at 3 months, then every 6 months until the 42nd month by their cardiologist. At each time point, a 12-lead ECG and 24-h Holter ECG were recorded. A recurrence of AAs was deﬁned as any documented AF, atrial flutter, and AT lasting more than 30 s with or without AADs. AADs were gradually discontinued between 3 and 6 months post-ablation in the absence of recurrence at the discretion of the physician.2.6.t-test or Wilcoxon test, depending on data distribution. One-way ANOVA was applied to assess the significant differences between three or more groups. If significant, Tukey's post-hoc test was used to detect the level of significant differences.The Shapiro–Wilk test was used to determine the Gaussian distribution for each quantitative variable. Normally distributed variables were expressed as mean ± SD. The variables with a non-Gaussian distribution were expressed as median (25th–75th interquartile range). The categorical variables were presented as a number and percentage. The statistical differences of the categorical variables between genders were tested using chi-square test or Fischer's exact test. The differences of quantitative variables were evaluated for statistical significance using Student’s p < 0.15 in the univariate analysis. All statistical analyses were performed using SPSS statistical software, version 23.0 (IBM Corp.) for the unmatched cohort. A two-tailed p-value of <0.05 was considered statistically significant.The event-free survival was demonstrated using Kaplan–Meier survival curves for men and women using the log-rank test with Bonferroni correction. Binominal logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) of independent variables associated with LVZ. The variables selected for testing in the multivariate analysis were those with The propensity score model was developed using logistic regression. For the matched cohort, all analyses were performed using R version 3.6.3.3.3.1.p < 0.01] and had a mild altered kidney function than men (p < 0.01). Lower LA intracavitary volume was observed among women without reaching significance (p = 0.06), but no difference regarding indexed values was further observed (p = 0.71). The patient characteristics before and after PS matching of the primary cohort are available in A total of 115 patients, predominantly male (64%) with initial ablation of persistent AF met the inclusion criteria . For the3.2.p = 0.52). The total mapping points per map collected in men and women were, respectively, 944  and 1,144   bipolar voltage amplitudes were lower in women in the unmatched cohort  bipolar voltage amplitudes were lower in women except for the lateral wall at the limit of significance (p = 0.059).The median number of total mapping points collected per map was 944  in the whole unmatched cohort and was similar for both sexes  . The medd cohort . After Pp < 0.0001), the posterior wall (p = 0.004), and the lateral wall (p = 0.03).In the unmatched cohort, LAA bipolar voltage in men was higher compared with other atrial regions . The sepp = 0.001) and anterior (p = 0.004) region.For the unmatched cohort, in women, a homogenous voltage was observed across all regions but LAA . Indeed,n = 25 and women n = 7, aged 30–59 years old), a middle age group , and an older age group . LA voltage was similar in both sexes (p = 0.99) in the younger age group (p = 0.009) and the older age group (p = 0.07) showed lower LA voltage in women.The unmatched population in this study was divided into three groups according to their age: a younger age group (men ge group . The midp = 0.007] without difference between the middle age and the older age group (p = 0.99). In men, LA voltage remained stable across age groups and did not reach statistical significance between extreme age groups (p = 0.37).Among women, LA voltage decreased significantly after 59 years of age  attesting to an anterior remodeling.In the unmatched cohort, LVZ were more frequently evidenced in women ( < 0.01) . Higher p = 0.007) (p = 0.012) and especially anterior localization (p = 0.002) were more frequently observed in women.After PS matching, LVZ were more frequently evidenced in women (= 0.007) . Higher p = 0.007). LVZ increased in men in the older age group compared with the younger age group .There was no difference in LVZ between men and women until 59 years of age , but its3.3.All PVs were successfully isolated during the CA procedure . PVI alop < 0.01) compared with women. There was no difference between the two groups for cavo-tricuspid isthmus (CTI) ablation . The total RF duration (p = 0.02) and the fluoroscopy time (p < 0.01) were higher in women compared with men.PVI alone was more frequently performed in men [55 (74.3%) vs. 16 (39%), 3.4.p = 0.284). In total, 61.8% of women and 60.8% of men remained free of AF/AT after 36 months (After a follow-up period of 37.2 (33.9–40.5) months in this unmatched cohort, AAs recurrence could be observed in 12 out of 115 (10.4%) patients after one single procedure. The Kaplan–Meier survival curves are shown in 6 months . In the p = 0.05).Among patients without AA recurrence at 12 months, AADs were discontinued in 69% (71/103) of the cohort, 56.4% (22/39) in women and 76.5% (49/64) in men (p = 0.875). In total, 61% of women with PVI alone and 63% of women with additional LVZ ablation remained free of AF/AT after 36 months  (p = 0.013) was a predictor of AF recurrence after CA , age (p = 0.002), and LA indexed volume (p = 0.001) were identified as the predictors of LVZ  was identified as a predictor for LVZ in women (p = 0.01) and LA indexed volume (p = 0.007) were predictive of LVZ (Only LA indexed volume (in women . In men,e of LVZ .4.The current report demonstrated a strong relationship between the female gender and atrial substrate remodeling, using electro-anatomical mapping. Both global and regional LA bipolar voltage appeared twice lower in women, even though the LA indexed volumes were similar in both sexes. We found that LVZ occurred earlier in women. Moreover, the female gender was significantly associated with a higher incidence and a greater extent of LVZ, especially in the LA anterior wall, attested by an increased P-LAA duration. The female gender, age, and LA indexed volume were the predictors of LVZ in persistent AF patients. Despite a significant difference in the LA remodeling extent according to gender, LVZ-guided ablation outcome was similar and favorable in both sexes. The PWD was the sole predictor of AAs recurrence in the whole cohort.4.1.Several studies demonstrated lower LA voltage amplitude in AF compared with SR across all LA regions . ConversOur study is among the first reports to highlight that bipolar voltage was twice lower in both LA and each atrial region in women compared with men for a similar LA indexed volume. Kim et al.  also rep4.2.Controversial results remain about gender-related impact to clinical outcomes after AF ablation . A recenWong et al.  demonstrLA remodeling and LVZ in particular could therefore explain such gender differences in AF recurrence rates.Consistent with our findings, LVZ has been reported to be related to both AF recurrence after ablation  and the Consistent with the previous finding , LVZ werThe external structure may also influence the LVZ progression and more specifically the contact between LA and the ascending thoracic aorta causing external stress, which may lead to the progression of the anterior wall remodeling . In the Interestingly, we evidenced that the LVZ presence and the decrease in LA bipolar voltage occurred earlier in women, which could explain gender differences in the time course of fibrosis remodeling. Women usually develop AF after menopause , and hor4.3.Some authors have reported an association between LVZ and age , 17. In 2. Renal dysfunction associated with an activation of pro-inflammatory and pro-fibrotic pathways at the cellular level was found to be a predictor for the presence of LVZ and recurrence after AF ablation (2, and such observation could not be done.Matsuda et al.  reportedablation . In our 4.4.Several studies have shown that women had higher AF recurrence rate after initial and multiple CA procedures , 21.This gender difference in the recurrence rate could be due to increased non-PV triggers and more AF substrate in women. LVZ presence is known to be a powerful predictor of AF recurrence after PVI alone . Tanaka We also found that PWD was the sole predictive factor of AAs recurrence after a single procedure of AF ablation in the whole cohort. A prolonged PWD corresponds to inter- and intra-atrial abnormal conduction delay. It was also correlated with atrial electro-anatomical delay assessed by tissue Doppler echocardiography . A relat4.5.Our study was a single-center retrospective observational study. Therefore, one potential limitation is the cohort size. Including a greater number of patients particularly women would help to validate our findings. Moreover, LA bipolar voltage maps were obtained without multipolar catheter, which would have provided more rapid and extensive maps with higher resolution of LVZ. In addition, discontinuation of AADs is variable and handled by the cardiologist of the patient. It could have influenced the ablation results. Further studies are mandatory to evaluate the long-term follow-up after a voltage-guided AF ablation according to gender.5.This study reports a strong relationship between the female gender and atrial substrate remodeling, using electro-anatomical mapping. The female gender and LA indexed volume were both independent predictors of left atrial LVZ in persistent AF patients. The global and regional LA bipolar voltage was lower in women. We found that the female gender was significantly associated with a higher incidence, earlier occurrence, and greater extent of LVZ compared with men. Despite female-specific characteristics in atrial remodeling, LVZ-guided ablation may improve the AF ablation outcome in women.