personnel costs are the most significant component of operating expenses and consist of salaries , benefits , stock-based compensation and sales commissions . sales and marketing . sales and marketing expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for personnel employed in sales , marketing , customer service , medical education and training , as well as investments in surgeon training programs , industry events and other promotional activities . in addition , our sales and marketing expense includes sales commissions and bonuses , generally based on a percentage of sales , to our sales managers , direct sales representatives and independent sales representatives . recruiting , training and retaining productive sales representatives and educating surgeons about the benefits of our products are required to generate and grow revenue . we expect sales and marketing expense to increase as we build up our sales and support personnel and expand our marketing efforts . our sales and marketing expense may fluctuate from period to period due to the seasonality of our revenue and the timing and extent of our expenses . research and development . research and development expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for personnel employed in research and development , regulatory and clinical areas . research and development expense also includes costs associated with product design , product refinement and improvement efforts before and after receipt of regulatory clearance , development of prototypes , testing , clinical study programs and regulatory activities , contractors and consultants , and equipment and software to support our development . as our revenue increases , we will also incur additional expense for revenue share payments to our past and present scientific advisory board members , including one of our past directors . we expect research and development expense to increase in absolute dollars as we develop new products to expand our product pipeline , add research and development personnel and conduct clinical activities . general and administrative . general and administrative expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for our administrative personnel that support our general operations , including executive management , general legal and intellectual property , finance and accounting , information technology and human resources personnel . general and administrative expense also includes outside legal costs associated with intellectual property and general legal matters , financial audit fees , insurance , fees for other consulting services , depreciation expense , long-lived asset impairment charges , freight , facilities expense , allocation of manufacturing training costs , and severance expense . we expect our general and administrative expense will increase in absolute dollars as we increase our headcount and expand our infrastructure to support growth in our business and our operations as a public company . as our revenue increases we also will 66 incur additional expenses for freight . our general and administrative expense may fluctuate from period to period due to the timing and extent of the expenses . total other income ( expenses ) , net total other income ( expenses ) , net consists primarily of interest expense and amortization of debt discount associated with our term loans outstanding during the year , debt extinguishment loss , and gains ( losses ) from foreign currency transactions . the effect of exchange rates on our foreign currency-denominated asset and liability balances are recorded as foreign currency translation adjustments in the consolidated statements of comprehensive loss . income tax provision income tax provision consists primarily of a provision for income taxes in foreign jurisdictions in which we conduct business . we maintain a full valuation allowance for deferred tax assets including net operating loss carryforwards and research and development credits and other tax credits . 67 consolidated results of operations comparison of the years ended december 31 , 2020 and 2019 the following table sets forth our results of operations expressed as dollar amounts , percentage of total revenue and year-over-year change ( in thousands ) : replace_table_token_1_th product revenue . product revenue was $ 58.5 million for the year ended december 31 , 2020 compared to $ 76.6 million for the year ended december 31 , 2019 , a decrease of $ 18.1 million or 24 % . we believe the decline is primarily due to the postponement of elective surgeries as a result of the covid-19 pandemic . the following table sets forth , for the periods indicated , our product revenue by geography expressed as u.s. dollar amounts , percentage of product revenue and year-over-year change ( in thousands ) : replace_table_token_2_th product revenue in the united states was generated through our direct sales force and independent sales representatives . product revenue outside the united states was generated through our direct sales force and distributors . the percentage of product revenue generated in the united states was 87 % for the year ended december 31 , 2020 compared to 88 % for the year ended december 31 , 2019. united states product revenue decreased $ 16.4 million to $ 50.7 million or 24 % year over year . we believe the decline in revenue inside the united states was primarily due to the postponement of elective surgeries due to the covid-19 pandemic . germany product revenue decreased $ 1.1 million to $ 6.5 million , or 14 % year over year 68 on a reported basis and 16 % on a constant currency basis . rest of world product revenue decreased $ 0.6 million to $ 1.3 million , or 33 % year-over-year on a reported basis and 34 % on a constant currency basis , we believe primarily due to restrictions of elective surgeries in the uk related to the covid-19 pandemic . the impact of covid-19 is affecting all geographies . royalty and licensing revenue . story_separator_special_tag at december 31 , 2020 , we had an accumulated deficit of $ 528.4 million . in january 2017 , we filed a shelf registration statement on form s-3 , which was declared effective by the sec on may 9 , 2017 , or the 2017 shelf registration statement . the 2017 shelf registration statement allows us to sell from time to time up to $ 200 million of common stock , preferred stock , debt securities , warrants , or units comprised of any combination of these securities , for our own account in one or more offerings . on may 10 , 2017 , we filed with the sec a prospectus supplement , pursuant to which we could issue and sell up to $ 50 million of our common stock and entered into an equity distribution agreement with canaccord genuity llc ( formerly canaccord genuity inc. ) or canaccord , pursuant to which canaccord agreed to sell shares of our common stock from time to time , as our agent in an “ at-the-market ” , or atm , offering as defined in rule 415 promulgated under the u.s. securities act of 1933 , as amended , or the securities act . we are not obligated to sell any number of shares under the distribution agreement . on august 4 , 2020 , we and canaccord mutually agreed to terminate the distribution agreement , and as of that date , we had sold 2,663,000 shares under the distribution agreement resulting in net proceeds of $ 4.4 million . on march 23 , 2020 , we filed a new shelf registration statement on form s-3 or the new shelf registration statement , which was declared effective by the sec on august 5 , 2020. under the new shelf registration statement , we will be permitted to sell from time to time up to $ 200 million of common stock , preferred stock , debt securities , warrants , or units comprised of any combination of these securities , for its own account in one or more offerings . the new shelf registration statement is intended to provide us flexibility to conduct sales of our registered securities , subject to market conditions and our future capital needs . on august 5 , 2020 , we filed with the sec a prospectus supplement , for the sale and issuance of up to $ 25 million of its common stock and entered into an at-the-market issuance sales agreement , or the sales agreement , with cowen and company , llc , or cowen , pursuant to which we may offer and sell shares of the our common stock to or through cowen , acting as agent and or principal , from time to time in an “ at-the-market ” offering as defined in rule 415 promulgated under the securities act of 1933 , as amended , including without limitation sales made by means of ordinary brokers ' transactions on the nasdaq capital market or otherwise at market prices prevailing at the time of sale , in block transactions , or as otherwise directed by us . cowen will use commercially reasonable efforts to sell the common stock from time to time , based upon instructions from us ( including any price , time or size limits or other customary parameters or conditions we may impose ) . we will pay cowen a commission of up to 3.0 % of the gross sales proceeds of any common stock sold through cowen under the sales agreement , and we also provided cowen with customary indemnification rights . the shares of common stock being offered pursuant to the sales agreement will be offered and sold pursuant to the new shelf registration statement . we are not obligated to make any sales of common stock under the sales agreement . the offering of shares of common stock pursuant to the sales agreement will terminate upon the earlier of ( i ) the sale of all common stock subject to the sales agreement or ( ii ) termination of the sales agreement in accordance with its terms . as of december 31 , 2020 , we had not sold any shares under the sales agreement . on december 17 , 2018 , we entered into a stock purchase agreement , or the `` stock purchase agreement , `` with lincoln park capital , or `` lpc . `` upon entering into the stock purchase agreement , we sold 1,921,968 shares of common stock for $ 1.0 million to lpc , representing a premium of 110 % to the previous day 's closing price . additionally , as consideration for lpc 's commitment to purchase shares of common stock under the lpc agreement , we issued 354,430 shares to lpc . we have the right at our sole discretion to sell to lpc up to $ 20.0 million worth of shares over a 36-month period subject to the terms of the stock purchase agreement . we will control the timing of any sales to lpc and lpc will be obligated to make purchases of our common stock upon receipt of requests from us in accordance with the terms of the stock purchase agreement . there are no upper limits to the price per share lpc may pay to purchase the up to $ 20.0 million worth of common stock subject to the stock purchase agreement , and the purchase price of the shares will be based on the then prevailing market prices of our shares at the time of each sale to lpc as described in the stock purchase agreement , provided that lpc will not be obligated to make purchases of our common stock pursuant to receipt of a request from us on any business day on which the last closing trade price of our common stock on the nasdaq capital market ( or alternative 70 national exchange in accordance with the stock purchase agreement ) is

cash flows the following table sets forth a summary of our cash flows for the periods indicated , as well as the year-over-year change ( in thousands ) : replace_table_token_3_th net cash used in operating activities . net cash used in operating activities was $ 18.3 million for the year ended december 31 , 2020 and $ 2.8 million for the year ended december 31 , 2019 , an increase of $ 15.5 million . these amounts primarily reflect net losses of $ 24.3 million for the year ended december 31 , 2020 and $ 28.5 million for the year ended december 31 , 2019. the increase in net cash used in operating activities for the year ended december 31 , 2020 was affected by a decrease in accounts payable , accrued expenses and other liabilities of $ 4.8 million , a decrease in contract liability of $ 10.0 million and advances for research and development of $ 4.5 73 million under the asset purchase agreement with stryker , a decrease in inventory of $ 2.0 million , and a decrease in prepaid and other assets of $ 2.1 million , partially offset by an increase in royalty and licensing receivable of $ 1.1 million . non-cash reconciling items include an increase in unrealized foreign exchange income/loss of $ 3.8 million , partially offset by a decrease from loss from debt extinguishment of $ 1.1 million . net cash ( used in ) provided by investing activities . net cash used in investing activities was $ 3.2 million for the year ended december 31 , 2020 compared to $ 4.3 million cash provided by investing activities for the year ended december 31 , 2019 , a decrease of $ 7.6 million .


 Write a concise suspicious activity report of the following text delimited by triple backquotes. Return your response as a formal report which covers the key points highlighting the location,dates,entity names and account holder information in chronological order of the text.
     ```cash flows the following table sets forth a summary of our cash flows for the periods indicated , as well as the year-over-year change ( in thousands ) : replace_table_token_3_th net cash used in operating activities . net cash used in operating activities was $ 18.3 million for the year ended december 31 , 2020 and $ 2.8 million for the year ended december 31 , 2019 , an increase of $ 15.5 million . these amounts primarily reflect net losses of $ 24.3 million for the year ended december 31 , 2020 and $ 28.5 million for the year ended december 31 , 2019. the increase in net cash used in operating activities for the year ended december 31 , 2020 was affected by a decrease in accounts payable , accrued expenses and other liabilities of $ 4.8 million , a decrease in contract liability of $ 10.0 million and advances for research and development of $ 4.5 73 million under the asset purchase agreement with stryker , a decrease in inventory of $ 2.0 million , and a decrease in prepaid and other assets of $ 2.1 million , partially offset by an increase in royalty and licensing receivable of $ 1.1 million . non-cash reconciling items include an increase in unrealized foreign exchange income/loss of $ 3.8 million , partially offset by a decrease from loss from debt extinguishment of $ 1.1 million . net cash ( used in ) provided by investing activities . net cash used in investing activities was $ 3.2 million for the year ended december 31 , 2020 compared to $ 4.3 million cash provided by investing activities for the year ended december 31 , 2019 , a decrease of $ 7.6 million .
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 Suspicious Activity Report : personnel costs are the most significant component of operating expenses and consist of salaries , benefits , stock-based compensation and sales commissions . sales and marketing . sales and marketing expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for personnel employed in sales , marketing , customer service , medical education and training , as well as investments in surgeon training programs , industry events and other promotional activities . in addition , our sales and marketing expense includes sales commissions and bonuses , generally based on a percentage of sales , to our sales managers , direct sales representatives and independent sales representatives . recruiting , training and retaining productive sales representatives and educating surgeons about the benefits of our products are required to generate and grow revenue . we expect sales and marketing expense to increase as we build up our sales and support personnel and expand our marketing efforts . our sales and marketing expense may fluctuate from period to period due to the seasonality of our revenue and the timing and extent of our expenses . research and development . research and development expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for personnel employed in research and development , regulatory and clinical areas . research and development expense also includes costs associated with product design , product refinement and improvement efforts before and after receipt of regulatory clearance , development of prototypes , testing , clinical study programs and regulatory activities , contractors and consultants , and equipment and software to support our development . as our revenue increases , we will also incur additional expense for revenue share payments to our past and present scientific advisory board members , including one of our past directors . we expect research and development expense to increase in absolute dollars as we develop new products to expand our product pipeline , add research and development personnel and conduct clinical activities . general and administrative . general and administrative expense consists primarily of personnel costs , including salary , employee benefits and stock-based compensation for our administrative personnel that support our general operations , including executive management , general legal and intellectual property , finance and accounting , information technology and human resources personnel . general and administrative expense also includes outside legal costs associated with intellectual property and general legal matters , financial audit fees , insurance , fees for other consulting services , depreciation expense , long-lived asset impairment charges , freight , facilities expense , allocation of manufacturing training costs , and severance expense . we expect our general and administrative expense will increase in absolute dollars as we increase our headcount and expand our infrastructure to support growth in our business and our operations as a public company . as our revenue increases we also will 66 incur additional expenses for freight . our general and administrative expense may fluctuate from period to period due to the timing and extent of the expenses . total other income ( expenses ) , net total other income ( expenses ) , net consists primarily of interest expense and amortization of debt discount associated with our term loans outstanding during the year , debt extinguishment loss , and gains ( losses ) from foreign currency transactions . the effect of exchange rates on our foreign currency-denominated asset and liability balances are recorded as foreign currency translation adjustments in the consolidated statements of comprehensive loss . income tax provision income tax provision consists primarily of a provision for income taxes in foreign jurisdictions in which we conduct business . we maintain a full valuation allowance for deferred tax assets including net operating loss carryforwards and research and development credits and other tax credits . 67 consolidated results of operations comparison of the years ended december 31 , 2020 and 2019 the following table sets forth our results of operations expressed as dollar amounts , percentage of total revenue and year-over-year change ( in thousands ) : replace_table_token_1_th product revenue . product revenue was $ 58.5 million for the year ended december 31 , 2020 compared to $ 76.6 million for the year ended december 31 , 2019 , a decrease of $ 18.1 million or 24 % . we believe the decline is primarily due to the postponement of elective surgeries as a result of the covid-19 pandemic . the following table sets forth , for the periods indicated , our product revenue by geography expressed as u.s. dollar amounts , percentage of product revenue and year-over-year change ( in thousands ) : replace_table_token_2_th product revenue in the united states was generated through our direct sales force and independent sales representatives . product revenue outside the united states was generated through our direct sales force and distributors . the percentage of product revenue generated in the united states was 87 % for the year ended december 31 , 2020 compared to 88 % for the year ended december 31 , 2019. united states product revenue decreased $ 16.4 million to $ 50.7 million or 24 % year over year . we believe the decline in revenue inside the united states was primarily due to the postponement of elective surgeries due to the covid-19 pandemic . germany product revenue decreased $ 1.1 million to $ 6.5 million , or 14 % year over year 68 on a reported basis and 16 % on a constant currency basis . rest of world product revenue decreased $ 0.6 million to $ 1.3 million , or 33 % year-over-year on a reported basis and 34 % on a constant currency basis , we believe primarily due to restrictions of elective surgeries in the uk related to the covid-19 pandemic . the impact of covid-19 is affecting all geographies . royalty and licensing revenue . story_separator_special_tag at december 31 , 2020 , we had an accumulated deficit of $ 528.4 million . in january 2017 , we filed a shelf registration statement on form s-3 , which was declared effective by the sec on may 9 , 2017 , or the 2017 shelf registration statement . the 2017 shelf registration statement allows us to sell from time to time up to $ 200 million of common stock , preferred stock , debt securities , warrants , or units comprised of any combination of these securities , for our own account in one or more offerings . on may 10 , 2017 , we filed with the sec a prospectus supplement , pursuant to which we could issue and sell up to $ 50 million of our common stock and entered into an equity distribution agreement with canaccord genuity llc ( formerly canaccord genuity inc. ) or canaccord , pursuant to which canaccord agreed to sell shares of our common stock from time to time , as our agent in an “ at-the-market ” , or atm , offering as defined in rule 415 promulgated under the u.s. securities act of 1933 , as amended , or the securities act . we are not obligated to sell any number of shares under the distribution agreement . on august 4 , 2020 , we and canaccord mutually agreed to terminate the distribution agreement , and as of that date , we had sold 2,663,000 shares under the distribution agreement resulting in net proceeds of $ 4.4 million . on march 23 , 2020 , we filed a new shelf registration statement on form s-3 or the new shelf registration statement , which was declared effective by the sec on august 5 , 2020. under the new shelf registration statement , we will be permitted to sell from time to time up to $ 200 million of common stock , preferred stock , debt securities , warrants , or units comprised of any combination of these securities , for its own account in one or more offerings . the new shelf registration statement is intended to provide us flexibility to conduct sales of our registered securities , subject to market conditions and our future capital needs . on august 5 , 2020 , we filed with the sec a prospectus supplement , for the sale and issuance of up to $ 25 million of its common stock and entered into an at-the-market issuance sales agreement , or the sales agreement , with cowen and company , llc , or cowen , pursuant to which we may offer and sell shares of the our common stock to or through cowen , acting as agent and or principal , from time to time in an “ at-the-market ” offering as defined in rule 415 promulgated under the securities act of 1933 , as amended , including without limitation sales made by means of ordinary brokers ' transactions on the nasdaq capital market or otherwise at market prices prevailing at the time of sale , in block transactions , or as otherwise directed by us . cowen will use commercially reasonable efforts to sell the common stock from time to time , based upon instructions from us ( including any price , time or size limits or other customary parameters or conditions we may impose ) . we will pay cowen a commission of up to 3.0 % of the gross sales proceeds of any common stock sold through cowen under the sales agreement , and we also provided cowen with customary indemnification rights . the shares of common stock being offered pursuant to the sales agreement will be offered and sold pursuant to the new shelf registration statement . we are not obligated to make any sales of common stock under the sales agreement . the offering of shares of common stock pursuant to the sales agreement will terminate upon the earlier of ( i ) the sale of all common stock subject to the sales agreement or ( ii ) termination of the sales agreement in accordance with its terms . as of december 31 , 2020 , we had not sold any shares under the sales agreement . on december 17 , 2018 , we entered into a stock purchase agreement , or the `` stock purchase agreement , `` with lincoln park capital , or `` lpc . `` upon entering into the stock purchase agreement , we sold 1,921,968 shares of common stock for $ 1.0 million to lpc , representing a premium of 110 % to the previous day 's closing price . additionally , as consideration for lpc 's commitment to purchase shares of common stock under the lpc agreement , we issued 354,430 shares to lpc . we have the right at our sole discretion to sell to lpc up to $ 20.0 million worth of shares over a 36-month period subject to the terms of the stock purchase agreement . we will control the timing of any sales to lpc and lpc will be obligated to make purchases of our common stock upon receipt of requests from us in accordance with the terms of the stock purchase agreement . there are no upper limits to the price per share lpc may pay to purchase the up to $ 20.0 million worth of common stock subject to the stock purchase agreement , and the purchase price of the shares will be based on the then prevailing market prices of our shares at the time of each sale to lpc as described in the stock purchase agreement , provided that lpc will not be obligated to make purchases of our common stock pursuant to receipt of a request from us on any business day on which the last closing trade price of our common stock on the nasdaq capital market ( or alternative 70 national exchange in accordance with the stock purchase agreement ) is

