BackgroundOral squamous cell carcinoma (OSCC) is the sixth most common cancer worldwide accounting for 90% of all malignant oral lesions with high mortality and a five-year survival rate of about 50%. Various studies have shown mast cells regulate carcinogenesis by immunosuppression, angiogenesis enhancement, and promotion of tumor cell mitosis.AimHence, the present study was aimed to compare mast cell counts in normal oral mucosa with histological grades of oral squamous cell carcinoma by using toluidine blue stain.MethodologySixty formalin-fixed, paraffin-embedded tissue samples included 15 well-differentiated, 15 moderately differentiated, and 15 poorly differentiated OSCC, as well as 15 cases of the normal oral mucosa (control), were sectioned and stained with 1% toluidine blue.ResultsWe observed that the mean mast cell (MMC) count was comparatively more in normal mucosa than in various grades of OSCC. It was higher in low-grade OSCC. However, the differences between grades were not statistically significant.ConclusionIn the present study, according to the results obtained, the MMC count was significantly decreased in OSCC in comparison with normal oral mucosa. Therefore, it can be assumed that mast cells could serve as an indicator of tumor progression. Oral squamous cell carcinoma (OSCC) represents 90% of head and neck malignant tumors. OSCC can be broadly described as a malignant neoplasm of stratified squamous epithelial origin with the highest recurrent invasion. Alcohol consumption and tobacco smoking still remain the primary etiological agents of OSCC, along with predisposing factors such as ultraviolet radiation or human papillomavirus infection. Histologically, SCC of the head and neck region is categorized as a well-differentiated, moderately differentiated, or poorly differentiated type based on the nature of the cell differentiation .Mast cells (MCs) are large connective tissue cells with numerous basophilic cytoplasmic granules rich in histamine and heparin, which originated from hematopoietic bone marrow precursor cells and are frequently found scattered along the capillaries. In 1877, Paul Ehrlich identified the MC and termed it as mastzellan, which denotes “a well-fed cell” with intracellular granules contained phagocytosed material or nutrients that could be food for neighbor cells . HistoloNumerous studies have shown the association of these normal cells with resistance and susceptibility in the tumor advancement process. Because of these unique properties, these cells are ideally poised to aid as 'gatekeepers' of the normal and tumor microvasculature in the oral cavity -5. AngioThe study was conducted on 60 formalin-fixed, paraffin-embedded tissue samples that were retrieved from the archives of the Department of Oral and Maxillofacial Pathology, RajaRajeswari Dental College and Hospital, Bangalore. The study included 15 cases of histologically confirmed, well-differentiated OSCC, 15 cases of moderately differentiated OSCC, 15 cases of poorly differentiated OSCC, and 15 cases of the normal oral mucosa. The paraffin infiltrated tissues embedded in wax blocks were sectioned to a thickness of 5 μm using a soft tissue semi-automatic microtome. One set of the section was subjected to routine H&E staining to re-confirm the histopathological diagnosis. Another set of the section was stained by acidified 1% toluidine blue as per protocol for MCs metachromatic staining technique. All stained sections were examined under a binocular light microscope. Five areas were randomly selected at low power (4x) to identify the area of hot spots and the MCC was evaluated under high power (40x) for each specimen. The areas under one high-power field (HPF) were taken as one microscopic field .Evaluation of mast cells and analysisUnder the light microscope, MCs appearing as pinkish/purple-colored spindle to oval-shaped cells with sky blue-colored nuclei were evaluated. Counting was carried out in five random high-power fields (40x) having a larger number of MCs, with one field depth from the basement membrane of the epithelium and the average per high field (HF) were determined, further the MCC was expressed per square mm within the radius of one field under the high-power objective (40x). All the data were tabulated and a one-way analysis of variance (ANOVA) test was performed to compare and evaluate the number of MCCs in histologically diagnosed OSCC and normal mucosa. This was done to compare and evaluate the MCC in well-differentiated OSCC, moderately differentiated OSCC, and poorly differentiated OSCC using the Statistical Package for Social Sciences (SPSS), version 19.0 .The study comprised 60 samples including 15 cases of well-differentiated OSCC, 15 cases of moderately differentiated OSCC, 15 cases of poorly differentiated OSCC, and 15 cases of normal mucosa. One-way ANOVA performed to compare the mean MCC between the three grades of OSCC  and the control group  showed a p-value of 0.1311. The p-value was not found to be significant at α = 0.05 (p < 0.05), denoting there was no substantial difference in the mean MCC among the study groups Table .Oral cancer is often diagnosed at the later stages of the disease where most individuals present with localized or regional involvement of the tumor cells  . In IndiVarious studies have shown MCs regulate carcinogenesis by immunosuppression, angiogenesis enhancement, and promotion of tumor cell mitosis. Increased accumulation of MCs within tumor environments has been correlated with poor prognosis, increased metastasis, and reduced survival in melanoma, adenocarcinomas, squamous cell carcinoma, Hodgkin lymphoma, and B-cell leukemias -14. Our In the present study, the highest MCC was seen in normal tissue and it was higher in low-grade OSCC in comparison with high-grade. However, the differences between groups were not statistically significant. The same result was seen between high-grade and low-grade OSCC. Therefore, we conclude that the mean MCC was decreased in OSCC in comparison with normal oral mucosa. Hence, it can be assumed that MCs could serve as a possible indicator of tumor progression. However, further studies on the evaluation of various mediators are prerequisites to draw a conclusion on the exact role of MCs in tumor progression.


Web-based assessments of mental health concerns hold great potential for earlier, more cost-effective, and more accurate diagnoses of psychiatric conditions than that achieved with traditional interview-based methods.The aim of this study was to assess the impact of a comprehensive web-based mental health assessment on the mental health and well-being of over 2000 individuals presenting with symptoms of depression.Individuals presenting with depressive symptoms completed a web-based assessment that screened for mood and other psychiatric conditions. After completing the assessment, the study participants received a report containing their assessment results along with personalized psychoeducation. After 6 and 12 months, participants were asked to rate the usefulness of the web-based assessment on different mental health–related outcomes and to self-report on their recent help-seeking behavior, diagnoses, medication, and lifestyle changes. In addition, general mental well-being was assessed at baseline and both follow-ups using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS).Data from all participants who completed either the 6-month or the 12-month follow-up (N=2064) were analyzed. The majority of study participants rated the study as useful for their subjective mental well-being. This included talking more openly  and understanding one’s mental health problems better . Although most participants  found their assessment results useful, only a small proportion  subsequently discussed them with a mental health professional, leading to only a small number of study participants receiving a new diagnosis . Among those who were reviewed, new mood disorder diagnoses were predicted by the digital algorithm with high sensitivity (above 70%), and nearly half of the participants with new diagnoses also had a corresponding change in medication. Furthermore, participants’ subjective well-being significantly improved over 12 months . Significant positive predictors of follow-up subjective well-being included talking more openly, exercising more, and having been reviewed by a psychiatrist.Our results suggest that completing a web-based mental health assessment and receiving personalized psychoeducation are associated with subjective mental health improvements, facilitated by increased self-awareness and subsequent use of self-help interventions. Integrating web-based mental health assessments within primary and/or secondary care services could benefit patients further and expedite earlier diagnosis and effective treatment.RR2-10.2196/18453 Mood disorders are psychiatric conditions in which disturbances in a person’s mood are associated with a diverse range of functional impairments ,2, psychThe high socioeconomic burden of mood disorders is, in part, a consequence of the difficulty in early diagnosis and treatment of these conditions, resulting in chronic and sometimes lifelong illness. A major cause of delayed diagnosis is that many psychiatric patients are affected in silence and never seek help . MoreoveA particularly promising innovation in this area comprises digital diagnostic tools, in the form of web-based or smartphone apps, which offer increased user accessibility, cost efficiency, and data collection capacity . Most ofDespite the potential for fast, cost-effective, and accurate diagnosis, the benefit of web-based psychiatric assessments on users’ mental health remains unclear. First, a clear link between completing a web-based assessment and improved clinical outcomes, such as help seeking, diagnosis, and treatment, has not been established. Although there has been evidence that receiving web-based assessment results can promote help-seeking attitudes and behaviors -22, one This study aimed to address the following primary question: Does completing a web-based assessment have the ability to improve participants’ perceived mental health and well-being? To answer this question, we used data from over 2000 participants in the Delta Study, a single-arm study that aimed to improve the diagnosis of mood disorders through comprehensive screening for mood and comorbid disorders combined with the development of diagnostic algorithms . We analmild depression. Participants who were pregnant or breastfeeding or who self-reported current suicidal thoughts or behavior were excluded. This resulted in 3232 participants completing the baseline mental health assessment. Of these, participants who replied to either the 6- or the 12-month follow-up were included in the analysis . Baseline demographic data  [, Tenth Revision [Upon enrolment in the study, participants completed the baseline web-based assessment. This contained 635 questions organized into 6 sessions focusing on (1) demographic information, mental well-being, and diagnostic history; (2) manic and hypomanic symptoms; (3) depressive symptoms; (4) personality traits; (5) history of medication, treatment, and substance use; and (6) other psychiatric symptoms. Questions in the psychiatric screening sessions  were based on existing questionnaires for mood disorders, drawing from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) ; the IntRevision ; and othRevision ,30-37. PRevision . PersonaRevision . The assFollowing the completion of the baseline assessment, participants were sent a brief nondiagnostic results report through email , 1542 completed the 12-month follow-up , and 1257 completed both .At the end of each follow-up questionnaire, participants were asked whether they wished to answer a further short set of questions. These asked them to rate the usefulness of participating in the Delta Study for different aspects of their mental health: (1) talking more openly, (2) understanding their mental health problems better, (3) being more proactive about help-seeking, (4) getting the right diagnosis, (5) communicating better with mental health professionals, and (6) getting more effective medication. In addition, they were asked to mark which aspects of the Delta Study online assessment , using or Boolean logic , or imputing missing values with values from the previous time point . Details on data coding and preprocessing can be found in All data processing and analysis were performed in R version 3.5.1, and all plots were made using the R package ggplot2 version 3.2.1. Where possible, the 6- and 12-month follow-up responses were combined into one single All participants who responded to the usefulness questionnaire at the end of either follow-up session were included (n=1939). Two types of ratings were assessed: (1) the usefulness of the online assessment for different mental health aspects and (2) the usefulness of different aspects of the Delta Study (middle panel of The following questions were asked: (1) Has the participation in the Delta Study encouraged people to seek professional help? (2) Have participants sought professional help to review their assessment results? To answer the former question, the number and proportion of participants who sought professional help were computed for before and after the baseline assessment, respectively. To answer the latter question, the number and proportion of participants who sought help after the baseline assessment and also discussed their results report with a professional were computed.new BD) and those without a previous mood disorder diagnosis who received an MDD diagnosis (new MDD). Baseline and follow-up diagnoses were self-reported in the respective assessments. The assessment results were computed using a DSM-5-style algorithm that used the clinical symptom profiles to output a diagnostic label. This was presented as a nondiagnostic mood result in the report participants received, to clarify its distinction from a clinical diagnosis. This result was either BD, MDD, or neither. Medication was divided into 3 classes: antidepressants, antipsychotics (including mood stabilizers such as lithium), and anxiolytics. Diagnosis and medication numbers were summarized for the whole population and subpopulations of interest. McNemar tests were used to test whether the proportion of prescriptions from each class was the same before and after baseline; for medication changes in the new BD and new MDD groups, McNemar exact tests were used because of the small sample sizes.The following questions were asked: (1) How many participants received a new mood diagnosis? (2) With what sensitivity were newly received mood diagnoses predicted by the Delta Study diagnostic algorithm ? (3) How appropriate was the medication change for the newly diagnosed participants? Two categories of participants were of primary interest: those who gained a BD diagnosis .WEMWBS total scores were computed by summing up the scores from each of the 14 questions of the scale. Paired The majority of participants reported that the online assessment was useful for talking more openly  and understanding one’s mental health problems better  and after the online assessment . Around half  of all the participants sought help both before and after the baseline assessment, and approximately equal numbers of participants initiated , or discontinued clinical contact after the baseline assessment , respectively. Among all the 1295 participants who sought clinical help after the assessment, only 302 (23.32%) discussed their report with a mental health care professional. The percentage of participants who discussed their report with a professional was higher among participants who first sought clinical support after the assessment  as compared with participants who had sought help before  in the prescription of antipsychotic or mood-stabilizing medication from baseline (n=161) to follow-up (n=219). In contrast, the prescription of antidepressant and anxiolytic medication did not change significantly  received a new diagnosis of either BD (n=45) or MDD (n=55), with the total number of patients diagnosed with BD increasing by 15.7% (24/153) and the total number of patients with MDD decreasing by 7.07% . In total, 46.4% (51/110) of the participants who received a new diagnosis also received new, clinically appropriate medication (23 new antipsychotic prescriptions in the new BD group and 28 new antidepressant prescriptions in the new MDD group).The algorithm predicted new BD diagnoses with 76% sensitivity and new MDD diagnoses with 73% sensitivity  and a further 1.20 points between the 6- and 12-month assessments , followed by 2 behavioral changes  and the 2 highest usefulness ratings . The other 3 significant predictors were discontinuing antidepressant medication (associated with depression remission) and 2 outcomes related to professional contact .At the population level, mental well-being significantly improved on average over the course of the 12 months, by 4.75 WEMWBS points between the baseline and 6-month assessments , and clinical outcomes, which require access to mental health services . The self-reported data clearly showed that taking the assessment had a greater impact on personal outcomes. This was further supported by the well-being regression results, in which 4 of the 7 significant positive predictors of well-being (excluding the baseline score) were related to personal factors. This underlines the benefit of online mental health assessments for promoting mental health, even in the absence of clinical help.Overall, the findings of this study can be broadly grouped into It is important to consider through which mechanisms online mental health assessments can improve mental health. According to the participants in the Delta Study, the results and psychoeducation were the most useful aspects of the assessment. The latter is an established means of increasing awareness, and online psychoeducation has previously been shown to increase help-seeking attitudes . HoweverTwo of the positive significant predictors of well-being were related to help-seeking, suggesting that contact with health care professionals positively contributes to patient well-being. However, restricted access to mental health care services, a reality across the world (including the United Kingdom ), is a mAlthough the impact of the Delta Study on diagnostic outcomes was limited, new mood disorder diagnoses were predicted with more than 70% sensitivity. However, the algorithm employed during the study was preliminary, allowing us to provide a screening result and a brief personalized report to each participant. Since the completion of the Delta Study, we have been able to improve the accuracy of the diagnostic algorithm. Moreover, we developed new machine learning algorithms that were validated against a structured clinical interview. Specifically, highly accurate algorithms have recently been developed for identifying patients with BD who were initially misdiagnosed as MDD  and for Finally, as an online mental health assessment is not a psychological intervention, we did not expect a substantial impact on participants’ well-being. Nonetheless, the well-being improvement of 6 WEMWBS points over 12 months is comparable with the average effect size of different psychological interventions . It is iTo our knowledge, this study is the largest study involving an online mental health assessment of BD to date ,48. TargOn the downside, the recruitment strategy employed also meant that the population might differ from patients recruited within specific health care settings. First, people with suicidal ideation, despite being most in need of a timely assessment, were excluded from the study for ethical reasons, as we had no means to provide crisis support. Second, although the preliminary algorithm used to classify participants had good sensitivity (more than 70%), it tended to overdiagnose both BD and MDD and thus suffered from low specificity (65.33% for new BD and 30.78% for new MDD diagnoses). Third, for assessing the perceived impact, we relied on self-reported usefulness ratings, which are prone to response biases . Fourth,We provide evidence that completing an online mental health assessment and receiving personalized assessment results and psychoeducation are associated with a perceived positive impact on mental health and well-being. More precisely, our results suggest a high perceived impact on personal, self-initiated outcomes, such as awareness and self-help; however, the effect on clinical outcomes such as access to clinical support and treatment is lower. Therefore, we recommend that online mental health assessments should be integrated within existing mental health triage and treatment pathways, such that assessment results are reviewed by clinical professionals, allowing for the initiation of effective interventions.


With the rising importance of aluminum sheets for automotive applications, the influence of microstructure and texture on mechanical properties and on forming behavior has gained re-increased interest in recent years. This paper provides an introduction to the topic and demonstrates the evolution of microstructure and texture in the standard alloys EN AW-5182 and EN AW-6016 for different processing scales. Moreover, strategies for texture and microstructure characterization of automotive Al-sheets are discussed. As the development of alloys or processes usually starts in laboratory facilities, the transferability to the industrial scale of the results thereof is studied. A detailed analysis of the entire processing chain shows good conformity of careful laboratory production with the industrial production concerning microstructure as well as qualitative and quantitative texture evolution for EN AW-5182. While comparable grain sizes can be achieved in final annealed sheets of EN AW-6016, quantitative discrepancies in texture occur between the different production scales for some sample states. The results are discussed in light of the basics of plasticity and recrystallisation including the effect of solutes, primary phases, and secondary phases in the alloys. In order to meet the increasing demands on safety standards and mechanical properties, a deep understanding of the mechanisms underlying the various application-relevant properties is required [In recent decades, the use of aluminum components has increased, particularly in the automotive industry, as the associated weight reduction leads to a reduction in COrequired ,2,3,4. Arequired ,6,7.As far as the orientation distribution of the grains within forming operations is concerned, the texture of a material describes the entirety of the crystallographic orientations. However, textured materials are commonly understood to exhibit intensified orientations that are characteristic of the strain conditions of previous forming operations. The progress in measurement techniques over the last decades provides a variety of possible methods for texture characterization. In general, the most prominent techniques are X-ray diffraction (XRD) and electron backscattered diffraction (EBSD), both having beneficial aspects. X-ray diffraction texture measurements show improved statistics when compared with those of EBSD, because of larger sampled areas. However, with the lack of microstructural information in the X-ray measurements (only macrotexture measurements are possible), EBSD is superior in terms of achieving meaningful results concerning microstructure and texture simultaneously (microtexture). In any case, the usage of these techniques provides reliable information concerning texture analysis and the suitability of XRD or EBSD depends at least on the sample processing conditions and the information sought .Owing to the face-centered cubic crystal structure of Al, typical deformation structures occur in the rolling process. The basic deformation mechanism of dislocation slip, which is also relevant in other crystal structures, occurs on twelve independent {111}<110> slip systems and generally results in structural features of different dimensions, namely, cells or subgrains, deformation bands, and shear bands ,10,11. IThe investigation of the microstructure and texture of Al-sheets first requires a very precise description of the parameters regarding the position within the sheet thickness. The different strain conditions within the sheet result in a variety of microstructural features. The resulting texture components can be completely different, which also affects the final sheet properties. While high-strained near-surface layers often show distinct shear components, the microstructure in the center of a sheet often suffers more typical plane-strain conditions ,13. A stThe complex interactions of all these phenomena can lead to a large diversity of annealed sheet grain structures. As far as EN AW-5182 is concerned, the chemical composition facilitates the formation of shear bands owing to the slightly reduced stacking fault energy and the enhanced solute drag. In addition, Mn-containing dispersoids limit grain growth. For EN AW-6016, the systematic control of second-phase particles is crucial as the age-hardening phases can readily form in earlier stages of the processing route and affect the microstructure of the final sheet. These basic mechanisms form the backbone for understanding microstructure development in such alloys .β-fiber [Intense research in the field of texture and the related properties of Al-sheets lead to a common understanding of the typical mechanisms for rolling- and recrystallization-texture evolution ,17,18,19β-fiber ,21. Thesβ-fiber . Typical recrystallization textures in Al are dominated by the Cube component, which arises from Cube nuclei in the deformation zones ,26,27,28In EN AW-6016, second phase particles show potential to modify occurring textures by various mechanisms. In general, the influence of particles on the final texture can be divided into two main mechanisms. Small, closely spaced particles with sizes below 500 nm are able to increase the Smith–Zener pinning on grain boundaries, and thus delay recrystallization . DependiExemplary textures of annealed EN AW-5182 and EN AW-6016 are shown in As new alloys or process changes are often only implemented in laboratory facilities, the further development of aluminum alloys is very often based on small series production. However, difficulties can arise in the transferability of the results to industrial scale, and the comparability of laboratory and industrial products must always be guaranteed. The first difficulties in the casting process can already be observed in the typical processing of wrought aluminum alloys.In particular, the Al-series AlMg(Mn) (5xxx) and AlMgSi (6xxx) both require precise knowledge of the parameters in casting, as micro- and macro-segregations have to be controlled. As the distribution of the alloying elements as primary phases or dissolved elements can have a significant influence on the subsequent deformation process, controlled cooling conditions upon casting are indispensable . In the In this study, we evaluate the microstructure and texture evolution in the two Al-alloys EN AW-5182 and EN AW-6016 on different processing scales. Particular attention is paid to individual processing steps and the underlying changes in microstructure and texture in laboratory scale. The results will be discussed in the light of well-established theories and will demonstrate the need for careful consideration of the differences between laboratory and industrially produced Al-sheets.The alloys EN AW-5182 and EN AW-6016 were studied. The chemical composition is given in Sample production is based on a conventional production process of 5xxx and 6xxx alloys, as shown schematically in 3, samples of EN AW-6016 were homogenized in an air-circulated furnace for 10 h at 565 °C with subsequent air cooling, while EN AW-5182 remained untreated.Casting: The ingot material for both alloys was provided by AMAG rolling GmbH company, Ranshofen, Austria. Initially, the ingot material was remelted in a resistance-heated furnace , degassed using an impeller with Ar gas, and finally casted into laboratory-scaled molds . After mRolling: For the laboratory scaled rolling process, a small-scale laboratory rolling mill with roll diameter of 250 mm was used. Both alloys were hot- rolled and cold-rolled (HR and CR), including an intermediate soft annealing (IA) heat treatment at 370 °C in between the cold-rolling passes. Maximum reductions per pass were 2 mm for hot-rolling and 1 mm for cold-rolling. From the initial thickness of 40 mm, the EN AW-5182 was hot-rolled to a thickness of about 2.5 mm, and subsequently cold-rolled to 1.5 mm before intermediate annealing. EN AW-6016 was hot-rolled to 7.3 mm, cold-rolled to 3.1 mm, and intermediate annealed. For the IA heat treatment, an air-circulated furnace  was used. Relatively low heating and cooling rates are intended to mimic large scale processing of coils in a batch furnace. The final sheet thickness was specified to be 1.20 mm and 1.25 mm for the 5182 and 6016 alloys, respectively. The dimensions were achievable within a tolerance of 0.03 mm in thickness.Heat treatment: The final heat treatments, meaning soft annealing (SA) for EN AW-5182 and solution annealing  for EN AW-6016, were performed in a salt bath for 5 min at temperatures of 500 °C and 530 °C, respectively, to mimic an industrial continuous heat treatment line. Subsequently, the samples were water quenched.As the aim of this work was to acquire a sound knowledge of texture and microstructure evolution, samples were examined at different stages of the production process. In addition to the information given in s = 0.5, with Equation (1) as metallographic samples in the sheet plane comprising the RD and transverse direction (TD).tD represents the distance from center and t0 represents the initial thickness [The material of the designated processing steps was further processed by means of standard metallographic preparation in two sample orientations: (1) the cross-section spanned between rolling direction (RD) and normal direction (ND); (2) position at hickness .The sample preparation included cutting, embedding, grinding, and polishing, as well as polishing with an oxide polishing suspension  at relatively high contact forces of up to 50 N for at least 18 s. In addition to the OPS-polishing reactant, unperfumed liquid soap was used to improve lubrication during preparation.Measurements of both alloys required further treatment for sufficient surface quality. For EBSD, electropolishing (EP) was performed on a Struers Lectro-Pol 5 electropolishing unit with electrolyte A2 (provided by Struers) for 4–8 s at 36 V and 10 °C.Microstructure and texture were investigated using scanning electron microscope (SEM)  equipped with an EBSD-measurement system . For qualitative analysis, backscattered electron (BSE) images of the prepared sections were also collected. The EBSD-measurements were done using a 70° pre-tilt specimen holder and accelerating voltage of 20 kV. Acquisition and analysis of the diffraction patterns required a large variation in parameters, as deformed and annealed sample states were measured.The post processing and evaluation of EBSD data were done by means of the Matlab based toolbox MTEX 5.2.beta3 .Grain size analysis: The linear intercept length (LIL) is calculated for the data from EBSD measurements. For the grain reconstruction, a tolerance angle of 5° was chosen and larger areas of connected, not-indexed pixels  were excluded from the dataset. The rest of the EBSD data were smoothed by applying a half-quadratic filter .2 of the hot-rolled and at least 1.5 mm2 of the cold-rolled material were analyzed by EBSD with step sizes depending on the amount of stored deformation. Note that XRD measurements of the hot-rolled material did not lead to better results, although a beam of 1 cm2 was applied to measure samples of 23 × 23 mm2.Texture Analysis: The raw data were rotated manually and centered by means of stereographic projections of the discrete orientations. For a sound representation of a materials’ texture, the orientation information of a minimum number of 1000 ,51 to 30To quantify changes in texture and to compare it to the XRD data, orientation distribution functions (ODF) were calculated from the EBSD data in the mtex toolbox. The ODF best represents the entirety of discrete orientations when combining the calculation via a direct kernel density estimation and the kernel density estimation via Fourier series. The semi-automatic half width selection algorithm was applied on discrete orientations as well as on the mean orientation (weighted by area) from “orientation clusters”, which are grains defined by a misorientation threshold of 2°. The half widths for the kernel density estimation were confined between 6° and 10° for the individual orientations  analysis of particles identified the formation of (primary-)Al– constituents and small (secondary-) particles—dispersoids with higher Fe and Mn concentrations compared with the matrix. During processing, the primary phase particles align to the rolling direction and easily fragment owing to the stress conditions during rolling. A more detailed analysis of dispersoids composition is not concerned in this study.More information on the microstructure is given by the grain linear intercept length illustrated in The micrographs in The cold-rolled microstructure in In the solution annealed EN AW-6016, BSE and BC images show good accordance regarding the qualitative microstructure and occurring features. Overall, the microstructure shows polygonal, almost equiaxed grains with only a slight remaining stretch in RD.A comparison of the LIL deduced from large area EBSD mappings for laboratory and industrial products is given in A description of the results regarding the orientation distribution during the process steps in the alloy EN AW-5182 is made based on the illustrations shown in β-fiber formation in both laboratory and industry samples, although the total intensities are not equal. Owing to the elevated temperatures, the entire rolling texture is rather weak, but still shows pronounced Brass and S components. Comparing laboratory and industry samples, the pole figures show good accordance of the orientations occurring. During further processing, cold-rolling leads to intensified β-fiber components, especially in the industrially produced samples. Therefore, the pole figures in Starting with hot-rolled conditions, pole figures The representation of proportions of some specific texture components, given in The components of the recrystallization texture in The results on texture evolution in EN AW-6016 are presented in The pole figures of the solution annealed sample states in The entire texture evolution in The trend of recrystallization texture components for the industrial sample in In the following, the comparability of texture and microstructure development in industrial and laboratory samples will be discussed, including some considerations on general texture evolution in Al-alloys.The microstructure evolution of the EN AW-5182 laboratory-sheets generally confirms the results and theories of previous publications . While tAs far as the influence of particles on the overall microstructure development is concerned, different mechanisms must be considered. As shown in Moreover, regarding texture evolution in EN AW-5182, General minor intensities of the recrystallization texture components, including Cube orientation, suggest randomization of texture to a certain degree . Concerning the strengthening of the Q component during recrystallization, the sometimes-stated origin near to shear bands  could not be verified due to the absence of attendant microstructural features and the rarely emerging Goss component, which can also indicate features of shear during deformation ,11,37,60The comparison of the microstructure development of EN AW-6016 in laboratory and industrial samples shows similarities for individual processing steps. Starting from hot-rolling, fragmented grains with enormous elongation show typical characteristics of the rolling process in the laboratory sheets a,b. AddiThe hot-rolled microstructure shows the alignment of subgrain structures in specific angles to RD, as well as inhomogeneous distribution of deformation structures over the sampled area. These inhomogeneities arise from the different orientations and sizes of the grains, which causes an unbalanced stress propagation over the whole sample . The higInteresting behavior can be seen in the texture evolution of EN AW-6016 samples. Owing to the already discussed problem of giant grains in the hot-rolled condition, the pole figures depicted in Following the pole figures in Solution annealed samples show typical recrystallization components in Another possible explanation for the balanced distribution of recrystallization components in As qualitative conformity in microstructure and texture evolution for the EN AW-6016 is found for the entire process, the comparability of laboratory and industrial processes can be endorsed. However, while the microstructure shows good quantitative agreements in the term of final grain size, the quantitative texture development is not comparable for all processing steps.Texture and microstructure evolution throughout the process shows good conformity for EN AW-5182, both qualitatively and quantitatively. Typical rolling and recrystallization behavior of fcc-metals is found.For EN AW-6016, results from laboratory and industrial scale can be compared qualitatively over the process chain, although quantitative differences do occur. Slight differences in both rolling and recrystallization texture components emphasize the necessity of more detailed analysis of some sample states.Final annealed sheets show highly comparable microstructure and texture in both laboratory and industrially produced sheets for both alloys.Although EN AW-5182 and EN AW-6016 both include alloying elements forming primary and secondary phases, the influences of particle stimulated nucleation or intensified Zener-pinning are not clearly observable in either of these alloys.This work provides a comprehensive overview on microstructure and texture evolution of the Al-alloys EN AW-5182 and EN AW-6016. Moreover, it investigates the influences of different processing scales and highlights the importance of carefully designed laboratory experiments. The following conclusions can be made:In general, careful design of laboratory production of automotive aluminum sheets is necessary to study new alloys or processes. However, at least qualitative comparison to industrially processed sheets should be possible.


National immunisation programmes globally are at risk of suspension due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing COVID-19 pandemic. We aimed to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through visiting routine vaccination service delivery points.Haemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever to approximate the future deaths averted before 5 years of age by routine childhood vaccination during a 6-month COVID-19 risk period without catch-up campaigns. In the low-impact scenario, we approximated the health benefits of sustaining routine childhood immunisation on only the child deaths averted from measles outbreaks during the COVID-19 risk period. We assumed that contact-reducing interventions flattened the outbreak curve during the COVID-19 risk period, that 60% of the population will have been infected by the end of that period, that children can be infected by either vaccinators or during transport, and that upon child infection the whole household will be infected. Country-specific household age structure estimates and age-dependent infection-fatality rates were applied to calculate the number of deaths attributable to the vaccination clinic visits. We present benefit–risk ratios for routine childhood immunisation, with 95% uncertainty intervals (UIs) from a probabilistic sensitivity analysis.We considered a high-impact scenario and a low-impact scenario to approximate the child deaths that could be caused by immunisation coverage reductions during COVID-19 outbreaks. In the high-impact scenario, we used previously reported country-specific child mortality impact estimates of childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, In the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa. The benefit–risk ratio for the vaccinated children is 85 000 (4900–546 000), for their siblings (<20 years) is 75 000 (4400–483 000), for their parents or adult carers (aged 20–60 years) is 769 (148–2700), and for older adults (>60 years) is 96 (14–307). In the low-impact scenario that approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10); if the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000).The deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children. Routine childhood immunisation should be sustained in Africa as much as possible, while considering other factors such as logistical constraints, staff shortages, and reallocation of resources during the COVID-19 pandemic.Gavi, the Vaccine Alliance; Bill & Melinda Gates Foundation. Vaccines have substantially improved health and reduced mortality, particularly among children in low-income countries.10Evidence before this studyNational immunisation programmes globally are at risk of disruption due to the severe health system constraints caused by the ongoing COVID-19 pandemic and the physical distancing measures to mitigate the outbreak. Outbreaks of vaccine-preventable disease have been observed during previous interruptions to routine immunisation services, such as during the 2013–16 Ebola outbreak in west Africa, when most health resources were shifted towards the Ebola response and decreased vaccination coverage led to consequent outbreaks of measles and other vaccine-preventable diseases. WHO has recommended that countries conduct individual benefit–risk assessments to support decision making on sustaining immunisation services during the COVID-19 pandemic based on the local transmission dynamics of severe acute respiratory syndrome coronavirus 2, the epidemiology of vaccine-preventable diseases, and the characteristics of their immunisation and health systems. To the best of our knowledge, this is the first benefit–risk analysis on sustaining routine childhood immunisation in African countries during the COVID-19 pandemic.Added value of this studyHaemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, Neisseria meningitidis serogroup A, rubella, and yellow fever with the excess COVID-19 deaths associated with vaccination clinic visits. The benefit of routine childhood immunisation programmes in all 54 African countries was found to be greater than the COVID-19 risk associated with these vaccination clinic visits.We estimated the benefit–risk ratio by comparing the deaths prevented by sustaining routine childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, Implications of all the available evidenceRoutine childhood immunisation programmes should be safeguarded for continued service delivery and prioritised for the prevention of infectious diseases, as much as is logistically possible, as part of delivering essential health services during the COVID-19 pandemic in Africa. The current immunisation service models will require adaptation, including physical distancing measures, personal protective equipment, and good hygiene practices for infection control at the vaccination clinics.The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in December, 2019, when it caused cases of COVID-19 in Wuhan, China.On March 26, 2020, WHO and the Pan American Health Organization issued guidance on the operation of immunisation programmes during the COVID-19 pandemic.Our aim was to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring SARS-CoV-2 infection through visiting routine vaccination service delivery points. Specifically, we did a benefit–risk analysis of vaccine-preventable deaths averted by sustaining routine childhood immunisation in comparison with excess COVID-19 deaths from SARS-CoV-2 infections acquired by visiting routine vaccination service delivery points.Haemophilus influenzae type b, Streptococcus pneumoniae, and rotavirus ; (2) 9 months for measles (MCV1), rubella (RCV1), Neisseria meningitidis serogroup A, and yellow fever ; and (3) 15–18 months for the second dose of measles . The target age for N meningitidis serogroup A routine immunisation varies by country and is given along with the first or second dose of measles vaccine; it is given at 9 months in Central African Republic, Chad, Côte d'Ivoire, Mali, Niger, and Sudan, at 15 months in Burkina Faso, and at 18 months in Ghana.We assessed the benefit and risk of continued routine childhood immunisation during the COVID-19 pandemic in all 54 African countries. We focused on the delivery of infant immunisation at: (1) 6, 10, and 14 weeks of age for diphtheria, tetanus, and pertussis (DTP), hepatitis B, During the period of SARS-CoV-2 circulation, we assumed that contact-reducing measures were in place and that although those measures did not contain the outbreak, they did substantially flatten the epidemic curve. However, with gradual easing of interventions and in the absence of a vaccine, we assumed that SARS-CoV-2 transmission will infect around 60% of the population. In both alternative scenarios (uncontrolled epidemic or successful containment), sustaining vaccination as far as possible would be the obvious choice because doing so would not substantially affect the risk of SARS-CoV-2 infection.We assumed that the risk from COVID-19, and hence the potential disruption to health services, including routine childhood vaccination, lasts for 6 months. The main analyses consider the impact of continuation of all five immunisation clinic visits in comparison with the risk of COVID-19 disease in the vaccinated child's household as a result of attending the vaccine clinic, tracking the health benefits from immunisation among the vaccinated children until 5 years of age.H influenzae type b, measles, N meningitidis serogroup A, S pneumoniae, rotavirus, rubella, and yellow fever. For the health impact of vaccines against diphtheria, tetanus, and pertussis, we calculated basic estimates for the annual number of deaths averted per 1000 vaccinated children by DTP3 in Africa, on the basis of global annual DTP3 vaccine impact estimates from 1980 to 2013.We used the health impact estimates provided by Li and colleaguesThe child deaths averted by routine vaccination during a 6-month suspension period of immunisation are the product of country-specific and antigen-specific estimates of per-capita deaths averted by vaccination from the time of vaccination until 5 years of age,We considered a high-impact scenario and a low-impact scenario for approximating the effects of sustaining routine childhood immunisation during the COVID-19 pandemic. In the high-impact scenario, we approximated the impact of sustaining routine childhood immunisation with use of the estimates of vaccination impact for a 6-month cohort in 2020. Hence, this scenario assumes that the suspension of immunisation will result in a cohort of unvaccinated children who have the same risk of disease as children in a completely unvaccinated population, and their vulnerability persists until they are 5 years old . Because of herd protection and likely catch-up activities at the end of a potential disruption of immunisation services, this high-impact scenario is likely to overestimate the negative impact of suspending immunisation services for a short period.By contrast, in the low-impact scenario, we attempted to estimate a lower bound for the expected number of deaths due to disruptions to routine childhood immunisation services. We assumed that, in the absence of immunisation, herd immunity would protect children missing vaccination for all diseases with the exception of measles, and that vaccination through catch-up campaigns would close measles immunity gaps immediately following the 6-month COVID-19 disruption period. This scenario was implemented as illustrated by the following example. In a country with 80% routine measles vaccine coverage, the interepidemic period of measles outbreaks is about 4 years.Supplementary immunisation activities for 17 African countries in 2020 are either currently postponed or of unknown status and reflect a higher risk of measles outbreaks in comparison with the low-impact scenario used in this study.We assume that in the coming months African countries will experience SARS-CoV-2 spread similar to that observed in non-African countries affected earlier in the pandemic, which were unable to contain the virus. We assume that the warmer climates in Africa will not notably reduce the transmissibility of SARS-CoV-2.24The risk of COVID-19 depends on exposure probability to SARS-CoV-2 and progression to disease. For this analysis, we consider only the infection-fatality risk for COVID-19 and ignore other potentially severe health outcomes. We model the additional SARS-CoV-2 exposure risk for the vaccinated child, their carer, and household members as a result of contact with the vaccinator and other community members during travel to the vaccine clinic. The simulation parameters for SARS-CoV-2 infection dynamics were based on the Reed-Frost epidemic model .25 The CWe did a probabilistic sensitivity analysis by conducting 4000 simulation runs to account for the uncertainty around the parameters governing the SARS-CoV-2 infection model, as well as the reported uncertainty ranges for the infection fatality rate estimates (modelled using a γ distribution) and the vaccine-preventable mortality estimates , and assessed their impact on our findings. We constructed a tornado diagram using a multivariate Poisson regression model fitted to the estimated posterior distribution of the benefit–risk ratio using our model input parameters as predictors, and treating total deaths averted by childhood immunisation as a single variable.program code and data for the benefit–risk analysis in this study are accessible online. All analyses were done using R 3.6.0.The The funders were involved in study design, data collection, data analysis, data interpretation, writing of the report, and the decision to submit for publication. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.H influenzae type b, S pneumoniae, rotavirus, measles, rubella, N meningitidis serogroup A, and yellow fever) in Africa during a 6-month period in 2020 will prevent around 702 000  deaths in children from the time of vaccination until they are 5 years old  could prevent approximately 471 000 (406 000–548 000) deaths. Immunisation during the EPI-2 visit (first dose of vaccination for measles [MCV1] and rubella [RCV1] and vaccination for N meningitidis serogroup A and yellow fever) is estimated to prevent around 220 000 (205 000–236 000) deaths, and immunisation during the EPI-3 visit (second dose for measles [MCV2]) to prevent 10 300 (9400–11 200) deaths among children until they are 5 years old. A third of the deaths prevented by routine childhood vaccination are predicted to be in Nigeria, Democratic Republic of the Congo, Ethiopia, and Tanzania  and each immunisation visit of EPI-2 and EPI-3 adds 0·8% (0·2–2·7) to the probability of excess SARS-CoV-2 infection in the household. As a result, continuation of routine childhood immunisation in Africa could lead to 8300 (1300–25 000) excess deaths attributable to additional SARS-CoV-2 infections associated with the immunisation visits of children. About eight (0–40) of these are expected to be among the vaccinated children, nine (0–45) among their siblings, 914 (83–2800) among their parents or adult carers, and 7300 (852–22 300) among older adults in the household.For every one excess COVID-19 death attributable to additional household exposure to SARS-CoV-2 infection due to routine childhood immunisation visits in this high-impact scenario, we estimate that the routine childhood immunisation programme would prevent 84 (95% UI 14–267) deaths in children up to 5 years of age in Africa . The benIn the low-impact scenario, which approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10). If the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000). Even with these highly conservative assumptions, the benefit–risk ratio for most countries in Africa is greater than 1, indicating in favour of sustaining the routine childhood immunisation programme during the COVID-19 pandemic . TunisiaWe evaluated the contribution of the uncertainty in the model parameters to the uncertainty in the benefit–risk ratio estimates . The maiOur analysis suggests that the benefit of sustaining routine childhood immunisation in Africa far outweighs the excess risk of COVID-19 deaths due to the additional risk of SARS-CoV-2 infection during the child's vaccination visit, particularly for the vaccinated children. This finding reinforces the guidance issued by WHOWe based our analyses on model-based country-specific and antigen-specific vaccine impact estimates in low-income and middle-income countries for 2020.In the high-impact scenario, we approximated the impact of sustained routine childhood immunisation with the estimates of vaccination impact for a 6-month cohort in 2020. This is a basic estimate of the likely impact, which, in reality, is also governed by herd protection and physical distancing. Although pathogen resurgence will happen gradually due to herd protection from the rest of the population and potentially only once physical distancing is lifted, this could be counterbalanced by unvaccinated children of this and other cohorts continuing to be at risk of disease beyond the 6-month period. In the presence of physical distancing measures, the exposure to non-coronavirus pathogens will also probably be reduced, but those who remain susceptible as a result of immunisation service suspension could get infected once physical distancing measures are relaxed. In the low-impact scenario, we approximated the impact of sustaining vaccination by the number of child deaths as a result of potential measles outbreaks during the COVID-19 risk period, assuming that catch-up campaigns will be delivered at the end of the COVID-19 risk period. We showed that, in both scenarios, continuation of routine childhood immunisation is beneficial and outweighs the excess risk of COVID-19 deaths due to the additional risk for SARS-CoV-2 infections during the immunisation visits, especially for the vaccinated children. Of note, SARS-CoV-2 infections acquired by the vaccinated children or their adult carers and parents at the vaccination clinics pose a risk primarily for the older adults in their households. This finding highlights the importance of shielding older adults to lower their risk of acquiring SARS-CoV-2 infections, while allowing children in their households to benefit from routine vaccination to lower their risk of acquiring vaccine-preventable infectious diseases.Although the young age demographic in Africa might mitigate some of the COVID-19 disease burden, infection fatality rates in Africa could be substantially higher because of the prevalence of likely risk factors, including HIV, tuberculosis, and malnutrition, and poor access to antibiotics to reduce the risk of bacterial co-infections in some parts of Africa. In the event that infection fatality rates in Africa turn out to be higher than elsewhere, then the estimated benefit–risk ratio would be reduced. However, our uncertainty analysis shows that although the uncertainty of the COVID-19 infection fatality rate is a key factor in the overall uncertainty of our estimates, even at the upper mortality bounds, sustaining routine childhood vaccination is beneficial. Furthermore, the effects of a potentially higher COVID-19 case-fatality ratio in Africa might be balanced by a higher case-fatality ratio of measles and the other vaccine-preventable diseases in times when the health-care system is stretched, treatment supplies are disrupted, and access to drugs such as vitamin A and antibiotics is reduced.Our findings were similar across countries with respect to the benefit–risk ratios, indicating in favour of sustaining the childhood immunisation programmes during the COVID-19 pandemic in Africa. Although there will be heterogeneity in the implementation of and compliance with prevention and control measures for COVID-19 in different countries, the benefits of sustaining childhood immunisation far outweigh the risks of excess SARS-CoV-2 infections acquired during the vaccination visits, especially for the vaccinated children.Because of high transmissibility of measles, routine childhood immunisation coverage in many countries is insufficient to prevent outbreaks. To aid routine vaccination coverage, supplementary immunisation activities are conducted regularly, and many were scheduled for 2020, at a time shortly before sufficient accumulation of susceptible children had built up to trigger measles outbreaks.We did a probabilistic sensitivity analysis to assess the impact of parameter uncertainty on the estimated benefit–risk ratios. We found that the biggest contributors to the uncertainty around the benefit of sustaining routine childhood immunisation during the COVID-19 pandemic in Africa were the transmission probability and the number of contacts during a vaccination visit. These factors highlight the need for personal protective equipment for vaccinators, the need to implement physical distancing measures, including the avoidance of crowded waiting rooms for vaccination visits, and the importance of good hygiene practices to reduce the risk of SARS-CoV-2 acquisition and transmission at the vaccination clinics. Although the implementation of some of these infection prevention and control measures in many African countries will be challenging due to resource constraints, the risks can be minimised and the benefits can be enhanced by providing immunisation bundled with other health services, thereby reducing the number of physical touch points with the health system.Our study has limitations and other factors must be considered during strategic decision making on sustaining routine childhood immunisation in African countries during the COVID-19 pandemic. These factors include logistical constraints of vaccine supply and delivery cold-chain problems caused by the COVID-19 pandemic, reallocation of doctors and nurses to other prioritised health services, health-care staff shortages caused by SARS-CoV-2 infections among the staff, staff shortages because of ill-health or underlying health conditions that put staff members at increased risk for severe COVID-19 disease, logistical and resource constraints for implementation of SARS-CoV-2 infection prevention and control measures at the vaccination service delivery points, and decreased demand for vaccination arising from community reluctance to visit vaccination clinics for fear of contracting SARS-CoV-2 infection or broader distrust of vaccines fuelled by COVID-19-related rumours and misinformation. The risk of SARS-CoV-2 infection for the vaccinated children and health-care staff involved in immunisation activities, as well as to their households and onward SARS-CoV-2 transmission into the wider community, should also be considered .Although we have estimated benefit–risk ratios on the basis of deaths averted, this analysis could be extended to estimate benefit–risk ratios on the basis of disability-adjusted life-years averted or quality-adjusted life-years gained. Because the deaths averted by vaccination are primarily among children younger than 5 years and deaths caused by COVID-19 are primarily among older adults, the benefit–risk ratios will be relatively higher using disability-adjusted life-years averted or quality-adjusted life-years, and will be more favourable towards sustaining routine childhood immunisation programmes during the COVID-19 pandemic in Africa.In conclusion, routine childhood immunisation programmes should be safeguarded for continued service delivery and prioritised for the prevention of infectious diseases, as much as is logistically possible, as part of delivering essential health services during the COVID-19 pandemic in Africa.


During the last months and following the implementation of containment measures in the context of coronavirus disease 2019 (COVID-19) pandemic, the number of new human immunodeficiency virus (HIV) diagnoses radically decreased in Liege AIDS Reference Center, Belgium. The number of HIV screening tests has also dramatically dropped down to an unprecedented level. This decline of HIV diagnosis is caused by missed diagnoses of individuals infected before the establishment of such measures and to the reduction of high-risk sexual behaviours during the COVID-19 pandemic. Most countries around the world have implemented a range of community containment strategies to prevent transmission of SARS-CoV-2. Health care systems have been dramatically changed by the crisis with the worthy objectives of facing ingoing flows of infected patients, reducing nosocomial transmission and protecting health care providers. COVID-19 has also become the top differential diagnosis in any person with flu-like symptoms, leading to a rapid isolation of at-risk patients with testing of SARS-CoV-2. Altogether, those practices eventually mitigate the outbreak in several countries in Europe, including Belgium (https://www.sciensano.be/en).The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already affected more than 20 million people in more than 200 countries and territories and resulted in more than 700 000 deaths . Additional measures were imposed from 18 March with penalties for individuals who did not respect the restrictions. Citizens were required to stay at home to avoid contact outside of their family, except for essential travel .The coronavirus pandemic and containment measures dramatically affected the Belgian health care system, including human immunodeficiency virus (HIV) screening. In our centre of Liege University Hospital, Belgium, a mean of 8.4 new diagnoses has been made monthly during the last 15 months . About 1This is likely a multifactorial phenomenon. The rapid decline of HIV diagnoses, which directly followed the beginning of the SARS-CoV-2 pandemic, is most likely caused by missed diagnoses of individuals infected before the establishment of such measures. In addition to well-known barriers to HIV screening , the SARS-CoV-2 pandemic was indeed the cause of additional hurdles to HIV testing at different levels.From an individual perspective, fear of getting COVID-19 at the hospital or in facilities where HIV screening test can be done is one of them. Testing for HIV would also add more stress to an already stressful situation. Moreover, the symptoms related to HIV infection could have been misinterpreted as caused by SARS-CoV-2. High rates of missed opportunities for HIV diagnosis have previously been reported, highlighting the ongoing need for physician education on HIV testing and clinical signs suggestive of HIV infection [From an organisational perspective, the reduction of public transport and the work overload in infectious diseases units as well as virology laboratories could have created other barriers to HIV testing.At the community and societal level, SARS-CoV-2 infection has been in the spotlight, while communication about other diseases including HIV has been poorly perceptible.Finally, a reduction of high-risk sexual behaviours associated with containment measures such as closing of gathering places has possibly contributed to the decrease of new HIV diagnoses.In conclusion, the SARS-CoV-2 pandemic and associated containment measures will result in a transient decrease of HIV incidence. However, it could also favour late diagnosis, an issue that was already described before the dramatic events we are currently dealing with , 2.Given the importance of rapid HIV diagnosis, public health communications should highlight that effective HIV care is readily and safely available despite SARS-CoV-2 pandemic, that early diagnosis of HIV improves health outcomes, and that HIV infection can mimic other infectious diseases including SARS-CoV-2 infection.


Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease, the management of which requires the continuous provision of multidisciplinary therapies. Owing to the novel coronavirus disease (COVID-19) pandemic, regular contact with ALS patients at our center was severely restricted and patient care was at risk by delay of supportive therapies. We established a triage system based on the D50 disease progression model and were thus able to identify a prospective cohort with high disease aggressiveness (D50 < 30). Thirty-seven patients with highly aggressive disease were actively offered follow-up, either via telephone or on-site, depending on their disease-specific needs and abilities. We describe here the procedures, obstacles, and results of these prescient efforts during the restrictions caused by COVID-19 in the period between March and June 2020. In conclusion, four patients with highly aggressive disease were initiated with non-invasive ventilation and two received a gastrostomy. We could show that a comparable amount of advanced care was induced in a retrospective cohort within a similar time period one year prior to the COVID-19 outbreak. Our workflow to identify high-risk patients via D50 model metrics can be easily implemented and integrated within existing centers. It helped to maintain a high quality of advanced care planning for our ALS patients. Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by the predominant loss of motor neuron function. The mean survival time is three years after symptom onset, with most patients succumbing to respiratory insufficiency ,2. HowevThe rapid outbreak of the novel coronavirus disease (COVID-19) pandemic in early 2020 brought restrictions and disruptions to public life and substantially impacted the healthcare system. National and local governments undertook unprecedented measures, including banning elective hospitalization, reallocating resources and staff to intensive care units and limiting public transportation. This caused a severe breakdown of the established care workflow for patients in our ALS center. In particular, planned hospitalizations for the evaluation of the necessity and/or initiation of assisted ventilation and/or gastrostomies were indefinitely postponed. Advanced care planning managed via three monthly appointments was affected owing to social distancing and quarantine requirements, travel restrictions, and patients’ own apprehensions and cancellations. We had to greatly reduce in- and out-patient consultations whilst ensuring timely critical ALS-specific therapies.Thus, a triage system needed to be promptly established. Broadly speaking, there are two extremes of the ALS disease spectrum that need to be differentially catered to. The first encompasses patients with highly aggressive disease whose deterioration occurs within weeks or even days, e.g., the onset of orthopnea or dyspnea. Herein, the disruption of symptomatic treatment could directly lead to the need for emergency hospitalization. In the second scenario, patients suffer from a slowly progressive disease with muscular dysfunction occurring over weeks and months rather than days. Herein, postponing specialized follow-ups is unlikely to lead to immediate dire consequences assuming that the guiding principles of preventative counselling and care planning have been adhered to in prior appointments.To provide a risk-adapted triage for the highly heterogenous cohort of our ALS patients, we used the recently developed D50 disease progression model ,12,13. Dst March 2020  for both cohorts including the following: age, gender, revised ALS Functional Rating Scales (ALSFRS-R), time-point and region of first symptom onset , time of gastrostomy, time of start of ventilatory support (invasive or non-invasive), and time of death.Patient-specific data were extracted from a center specific neuromuscular database developed by J.G. .The D50 model provides unified parameters of patients’ individual disease course, e.g., of overall disease aggressiveness (D50) or individual disease covered (rD50) ,12,13. CBriefly, the D50 model describes the disease course of individual ALS patients as a sigmoidal state transition from full health to functional loss A. The va® software program . Non-normal distribution of all data was established using the Shapiro Wilks test. Therefore, the Mann-Whitney U or the chi-square/Fisher’s exact tests were used to perform between-group comparisons. The longitudinal comparison of patients’ ALSFRS-R scores were conducted with the Wilcoxon signed rank test. p-values were adjusted via Bonferroni-correction to account for multiple testing and a statistical significance level of a p-value below 0.05 was applied.All statistical analyses were performed using the SPSSThe patients were stratified by their individual D50 values, as either having low (D50 < 30 months) or high disease aggressiveness (D50 ≥ 30 months). The cumulative time-dependent probability for reaching a critical event (ventilation or gastrostomy) was estimated using the Kaplan–Meier method and a log-rank test was applied to measure differences between both disease aggressiveness subgroups.st March 2019. Seventy-five patients had highly aggressive ALS (D50 < 30 months) and 20 (26.7%) of them had already died. One hundred and two patients had low disease aggressiveness; within this group, significantly fewer people had died until 1st March 2020 in comparison to the highly aggressive ALS group . An overview of the demographic and clinical data of alive patients is given in We identified 177 patients who had at least one in person contact in our center since 1We additionally identified patients who had only one ALSFRS-R assessment because the D50 model carries the highest uncertainty in this group. There were 11 patients with one ALSFRS-R allocated to the low aggressiveness group, seven of whom decided for an active follow-up at our center. Importantly, only one female patient needed a planned intervention with initiation of non-invasive ventilation (NIV) and a gastrostomy in April and at follow-up was allocated to the high aggressiveness group (D50 = 12.5 months).st March and 31st May 2020 for this group. Seventeen patients were lost to follow-up . One patient died 13 months after bulbar onset with highly aggressive ALS disease (D50 = 7.19 months).During the triage of patients for our center we paid specific attention to the high aggressiveness patients. Here, we report all events that occurred between 1For the remaining 37 patients we balanced their disease specific needs  and their abilities and wishes . The patients were offered pre-chosen options for either on-site or telecommunication-based appointments . The reswww.redmedical.de). The latter was successful in only one contact for a high aggressiveness patient. Typical obstacles were disease-related problems , limited availability of required devices at patients’ home , miscellaneous technical constraints , and patient refusal.The majority of patients favored telephone contact although we offered real-time video-contact via a telemedicine platform . All hospitalized patients were negatively tested for an infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), before any airway-bound diagnostics or use of a ventilator. Two of the 37 patients in this group received sleep studies shortly before March 2020 which did not indicate a need for assisted ventilation, and they were appropriately planned for follow-ups in the sleep laboratory. Five patients refused a proactive sleep study, all of them were fully informed about the nature and purpose of this therapeutic option as well as possible and negative consequences if rejected or delayed. Three of these patients declared their final decision to reject any kind of assisted ventilation. Neither of these patients had any respiratory symptoms at the time of visit and they were informed to contact our center immediately if such symptoms would occur. The remaining 18 patients were already under treatment with assisted ventilation . The proportion of refusal for a gastrostomy was higher for this therapeutic intervention than for assisted ventilation. Fifteen fully informed patients confirmed their will to not have a feeding tube placed at any time during their disease course. For six patients, a feeding tube was considered to be not immediately needed: neither of these patients reported any bulbar symptoms (12 of 12 points in bulbar subscores of the ALSFRS-R) and all had a functional vital capacity above 60% at last measurement. Fourteen patients had already received a gastrostomy prior to March 2020 B.st March and 31st May. The total ALSFRS-R for the 28 patients who received scoring during their follow-up significantly declined from a median of 34  to 28 points .None of the 37 patients required any emergency medical attendance, unplanned hospitalization or initiation of invasive ventilation (tracheostomy) between 1st March–31st May 2019). Here, 79 of these had highly aggressive ALS, and of them, 54 were still alive on the 1st March 2019. Nine patients were lost to follow up and nine patients died within the regarded time-period.We retrospectively identified a cohort of 174 patients who were treated in a comparable time frame before the COVID-19 pandemic  had a longer ventilation-free period with a median of 36 months (95%-CI: 33.61–38.39). The cumulative probability for this group was 0% after three months and 0.89% after both six months and 12 months.Time until first use of assisted ventilation was known for 301 patients. For the subgroup of patients with a D50-value below 30 months, a significantly shorter time until ventilatory support was revealed, with a median of 16 months  within the three-month study period were comparable to a retrospective cohort from a comparable time period.We experienced mostly positive reactions by the patients and/or their relatives and our active follow-up offers were accepted by the majority of patients. We were able to provide and use different mediums to follow up with patients; telephone contact was preferred. This was favored because the transport to our center and related issues could be avoided (our patients travel distances of up to 250 kilometers). Efforts to aid these telephone-visits with a real-time video were only successful on one occasion. Although we are convinced that video-telemedicine is a promising opportunity to provide remote follow-up with patients ,22, it wThe acute necessity of a triage for the ALS patients due to the COVID-19 pandemic has been reported for other tertiary ALS centers before ,25,26. SALS is known to show a high heterogeneity of symptom worsening and patterns of spread throughout the affected regions ,34. ThusGastrostomy is an established palliative therapy that is known to increase quality of life and to prolong survival for ALS patients ,17,18,19Non-invasive ventilation (NIV) is considered a standard palliative therapy that is capable to lower symptom burden and to prolong survival in ALS ,15. HoweThe consideration of high-risk patients under active follow-up at our center was promptly possible due to the availability of an established and specialized database. Regular entries of patient-specific data were long before integrated in daily clinical routines at our center and are based on clinical milestones in the framework of the D50 model in order to enable the management of multidisciplinary therapies. The advantages of organizing patient’s disease-specific information in a database were postulated before, especially in the context of (future) ALS research ,44. HereThe present study is not without its limitations. To begin with, we cannot provide direct evidence, that our approach directly prevented poorer outcomes for our patients. This assessment will become available with long-term clinical milestone data . Naturally, telephone contacts with patients didn’t allow for detailed neurological examinations or diagnostic workups; spirometry and cough flow assessments were not possible, thus important clinical information may have been missed. However, COVID-19-related restrictions began to be lifted from June 2020 onwards, which allowed us to see more patients on-site within the framework of our three-monthly comprehensive follow-ups. Thus far, our clinical data strongly suggest that our approach successfully helped to mitigate the healthcare disruptions caused by the three month “lockdown” period and met the needs of patients with highly aggressive forms of ALS.The data presented here are mono-centric and therefore cannot be generalized for ALS patients, e.g., due to pre-existing referral bias that is typically observed in tertiary centers . Also, eFinally, possibly contributing patient-specific co-factors were incompletely known, e.g., the access to allied health care services, comorbidities or cognitive impairment. The patients of this study were in different stages of the diagnostic workup in the beginning of the pandemic, thus, e.g., standardized neuropsychological testing was not available for all of them. Further multi-center studies incorporating information about patients’ access to allied health care are needed in order to provide implications for possible future lockdown situations.We were able to highlight the ability of the D50 model to identify ALS patients with higher disease aggressiveness. These patients need particular attention and frequent follow-ups, especially during periods of restricted access to health resources like the COVID-19 pandemic. Based on this, we demonstrate how patient triage in combination with anticipatory counselling help to balance their high dependence on the timely initiation of therapies whilst minimizing their risk of infections with the novel coronavirus SARS-CoV-2 .The implementation of the workflow presented in this study and the D50 model itself is feasible and can be recommended for other (tertiary) ALS centers in order to maintain quality standards for advanced care planning.