Methods. All patients were diagnosed according to the DSM-IV-TR, and the severity of the symptoms was evaluated using the Hamilton Depression Rating Scale (HDRS). Growth factors IL-7, IL-9, IL-17A, VEGF, basic FGF, G-CSF, and GM-CSF were quantified by cytometric bead array using serum samples from 22 adolescents with MDD and 18 healthy volunteers. Results. All patients showed clinical improvement since the fourth week of pharmacological treatment according to the HDRS. Considerably higher levels of IL-7, IL-9, IL-17A, VEGF, basic FGF, G-CSF, and GM-CSF were detected in MDD adolescents as compared to healthy volunteers. A significant but temporal decrease was detected in basic FGF, G-CSF, and GM-CSF at week four of fluoxetine administration. Conclusions. To the best of our knowledge, this is the first report to show alterations in the levels of growth factors, such as IL-7, IL-9, IL-17A, VEGF, basic FGF, G-CSF, and GM-CSF in MDD adolescents during eight weeks of clinical follow-up. These disturbances might be involved in the physiopathology of MDD since such growth factors have been proven to participate in the neural development and correct functioning of the CNS; therefore, subtle alterations in it may contribute to MDD.Major depressive disorder (MDD) has a prevalence of 5% in adolescents. Several studies have described the association between the inflammatory response and MDD, but little is known about the relationship between MDD and growth factors, such as IL-7, IL-9, IL-17A, VEGF, basic FGF, G-CSF, and GM-CSF. It must be appointed that there are scarce reports on growth factors in adolescents with MDD and even fewer with a clinical follow-up. In this work, we evaluated the levels of growth factors  in MDD adolescents and the clinical follow-up during eight weeks of treatment with fluoxetine.  Its onslescents .β, and VEGF in peripheral blood [β, VEGF, and IGF-1, as well as the expression of EGF [Soluble inflammatory mediators are molecules that not only activate and promote an efficient immune response  but alsoal blood . The phan of EGF –16. TogeThe study was performed in the National Institute of Psychiatry “Ramón de la Fuente Muñiz” in Mexico City, Mexico. We recruited 336 adolescents with MDD from January 2006 to December 2008, and 22 of them participated in the study based on the inclusion criteria. The inclusion criteria included men and women aged between 14 and 19 years who met the diagnostic criteria for major depressive disorder (MDD) per the DSM-IV-TR and had a minimum baseline score on the HRSD ≥ 14 and no history of treatment for MDD with SSRIs and whose current episodes were moderate, lasting no more than two years. All the patients who were included agreed to participate in the study (INPRF-2035) and signed informed consent forms. The patients were recruited per the clinical follow-up in the INPRF-2035 research protocol, as approved by the ethics committee of the National Institute of Psychiatry “Ramón de la Fuente Muñiz,” Mexico.Eighteen healthy volunteers (HVs) were recruited from the general population between January 2006 and December 2008. Clinical parameters of the HVs were within normal reference ranges (data not shown). The MINI  confirmed that the HVs did not suffer from any mental disorder and all had been free from any medication use for at least three weeks before blood sampling. The demographic data of patients and healthy volunteers are shown in Psychiatrists diagnosed all the subjects while the clinical status of adolescents with MDD was determined using the validated Spanish version of the 21-item Hamilton Depression Rating Scale (HDRS) . PatientThe dosage of fluoxetine was 20 mg/day. Doses were established for each patient by the psychiatrist and adjusted when necessary. All patients paid for their drugs out of pocket.Peripheral blood (10 mL) was collected by venipuncture from the cubital vein into Vacutainer® SST™ tubes with gel for serum separation . Blood samples were centrifuged immediately (1.125 × g) at 4°C for 15 min to obtain serum. Serum samples were separated into aliquots and stored at –80°C until analysis.The levels of IL-7, IL-9, IL-17A, VEGF, basic FGF, G-CSF, and GM-CSF were measured in serum using a Bio-Plex Pro™ Human Cytokine 27-Plex Assay kit (Lot. #5029511) per the manufacturer's instructions. Analytes were detected using streptavidin phycoerythrin and quantified in a Bio-Plex MAGPIX™ Multiplex Reader . Analyte concentrations were calculated by interpolation using standard curves in Bio-Plex Manager™ . The ranges of detection were as follows (pg/mL): IL-7: 2.9–33,292; IL-9: 0.8–9,281; IL-17A: 2.4–28,099; VEGF: 2.6–29,672; basic FGF: 1.3–14,858; G-CSF: 2.4–28,053; and GM-CSF: 1.5–17,729.P < 0.05.Statistical analysis for HDRS scores and growth factors was performed using GraphPad Prism, version 6.00, for MAC OS X . Homogeneity of variance and normality tests were applied, followed by a one-way ANOVA with Bonferroni's post hoc test. All values were expressed as mean ± standard deviation. Statistical significance was attributed when Demographic data of twenty-two adolescents with MDD and eighteen healthy volunteers are described in Adolescents with MDD had an HDRS score of 19.41 ± 4.72 at the beginning of the study (W0), 9.13 ± 3.5 at week four (W4), and 6.09 ± 2.4 at week eight (W8). HDRS scores at W4 and W8 were significantly lower when compared to W0, as shown in (1) IL-7, IL-9, IL-17A, and VEGF. Serum levels of IL-7, IL-9, IL-17A, and VEGF were significantly higher in adolescents with MDD at W0 compared with those in HVs . Levels were consistently elevated during the eight weeks of treatment (reatment .(2) Basic FGF, G-CSF, and GM-CSF. We observed a significant increase in serum levels of basic FGF, G-CSF, and GM-CSF in adolescents with MDD . Interestingly, basic FGF, G-CSF, and GM-CSF showed a significant decrease after four weeks of treatment with fluoxetine , but they increased again at W8  is involved in important processes as long-term potentiation, neurogenesis, and proliferation of neural progenitor cells , which aThe vascular endothelial growth factor (VEGF) plays an essential role in angiogenesis; therefore, it is considered to be a neurotrophic factor. Numerous studies in adults have shown significantly higher levels of VEGF in MDD patients versus healthy volunteers . Within macrophage theory of depression [G-CSF and GM-CSF are two important hematopoietic factors that have been associated with MDD. These growth factors can promote macrophage migration from the bone marrow, giving rise to the inflammatory process observed in MDD. The link between macrophages and MDD is known as the pression . Our respression . Moreovepression . Finallypression .macrophage theory of depression in MDD onset [Taken together, all these results demonstrate that GM-CSF and G-CSF may play crucial roles in MDD given that they can promote the mobilization of leukocytes from the bone marrow, leading to an increase in macrophages and the release of cytokines in inflammatory processes as depression. These findings reinforce the DD onset  but now Our results showed a significant increase in the circulatory levels of growth factors in adolescents with MDD in comparison with healthy volunteers (HV). This increase was consistent throughout the 8-week pharmacological treatment with fluoxetine [The patient cohort was small, mainly due to the difficulties involved in pickup adolescents in clinical studies, but the numbers of HVs and patients were sufficient for statistical analysis. Also, the clinical follow-up was only 8 weeks long. In all cases, the discrepancies in our values and those by other groups can be explained by differences in samples (serum or plasma), detection techniques, sample size, age of participants, and confounding factors such as alcohol and tobacco consumption and body mass index.


This Q-methodology study revealed four viewpoints: “not donating your organs is a waste”, “it does not go with my religion”, “my family should decide”; and “it’s a good deed, but I’m doubtful”. These viewpoints convey information on potential reasons for the gap between people’s favourable attitudes towards organ donation and the low number of actual registrations, and opportunities for policy makers to address certain target groups more adequately.In many countries, such as the US, Germany, France, and the Netherlands, governments are dealing with a great shortage of organ donors. Even though people generally show positive attitudes towards organ donation, they often do not actually register as organ donors themselves. This study’s objective was to explore prevailing viewpoints among the Dutch population on deceased organ donation and the relation between aspects of the viewpoints potentially influencing the decision to register as an organ donor. Although substantive research about attitudes on organ donation has been conducted, this is the first study investigating people’s viewpoints focusing on the  In many countries, such as the US, Germany, France, and the Netherlands, governments are dealing with a great shortage of organ donors e.g., –4). Even. Even4])In order to develop adequate and effective public policies to promote organ donor registration, it is essential to gain insight in people’s viewpoints on organ donation. Understanding the existing viewpoints on this issue is important to be able to identify target groups for policy, and how to approach them adequately and effectively. Some citizens will have made up their mind about registering as an organ donor, others might still be in doubt, for a variety of reasons. These various groups require different approaches in terms of raising awareness and knowledge, and incentivizing registration. Moreover, it may inform about potential drawbacks of policies for particular subgroups that need consideration. For instance, implementing an opt-out policy might disadvantage people who are against organ donation but for whom information on the registration process and instructions for opting out are less accessible. In this context, several studies have investigated people’s attitudes towards organ donation and their willingness to register as an organ donor e.g., –28). Fur. Fur28])We used Q-methodology to explore the viewpoints about organ donation among the public in the Netherlands. Q-methodology combines qualitative and quantitative methods to discover what constitutes the view of individual respondents about a value-laden topic, identify shared viewpoints among respondents, and the consensus and differences between these viewpoints , 37. In For this study, a set of 43 statements was constructed, containing a large variety of aspects relating to the decision to register for deceased organ donation. In order to enable all respondents to express their view it is important that the statement set is comprehensive and balanced, broadly representative of the issues of debate on this topic in the literature and among the target population For this purpose, we first identified potentially relevant aspects to cover from common theoretical models about health intentions and behaviour like the Health Belief Model  and the It should be stressed that the aim of using these theoretical models was to make sure that the statement set is comprehensive and captures all relevant aspects potentially relevant for people’s viewpoints on organ donation, not to function as a model by which the causal relations of these aspects are explained.Next, 350 statements on organ donation were extracted from academic literature, newspaper articles, radio and television documentaries, discussions on social media, and related information websites. Academic literature published between 2003 and 2017 was searched through Google Scholar and PubMed using the keywords “organ donation”, “viewpoints on organ donation”, “attitudes towards organ donation”, “opinions on organ donation”, “organ donation default positions”, “organ donation opt-in opt-out systems”. A total of 350 statements was retrieved, which were structured according to the components of the theoretical models to ensure these were all covered. Redundant, unclear and irrelevant statements were deleted, leaving an initial set of 47 statements for pilot-testing.In order to check whether the statement set was comprehensive and intelligible, all other research materials were clear, and the whole approach feasible and sufficiently appealing to participants, two pilot studies were conducted. Respondents varying in age, gender, education level, ethnicity and religiosity were presented with the draft research material and asked to critically review the information letter, instructions and statement set. Based on a first pilot study in which five respondents took part, several changes were made to the statement set, including the rephrasing of several statements, deleting three statements that were considered irrelevant by the respondents and combining two statements that were regarded as too similar. Next, another five respondents and two researchers experienced with Q-methodology were asked to review the adjusted study materials. As a result, one more statement was deleted, four statements were rephrased and one statement was added, resulting in a set of 43 statements for the main study. Moreover, because participants in both rounds of the pilot indicated that the sorting grid did not provide sufficient opportunity to rank statements in the least and most agree categories, the number of spaces for placing statements in the two outer columns of the grid was expanded from two to three .In the main study, a total of 30 respondents were interviewed . ProvideAt the start of the interview, respondents received an information letter informing them about the aim of the study, the content of the interview, and the processing and analysis of the data. Next, respondents received an informed consent form and were instructed that they could stop the interview at any time, for any reason. Respondents were required to provide informed consent and to finish the interview to be included in the study.After the consent form was signed, the respondent received the set of 43 statements printed on cards in a random order. In order to ensure a correct understanding of the statements, the researcher would first read each statement out aloud after which the respondent would read the card herself, briefly comment and then place the card on one of three piles, for statements they agreed with, disagreed with, or felt neutral about. After all statements were placed on one of the three piles, respondents were instructed to read the statements they had placed in the ‘agree with’ pile once again and to rank them according to the level of agreement on the right side of the sorting grid . After tAfter completing the ranking exercise, respondents were asked to explain the placement of certain statements on the sorting grid; all respondents elaborated on the statements placed in the two outer columns of the grid, and depending on time, on randomly chosen other statements. The interview ended with a short questionnaire consisting of closed questions about socio-demographic characteristics and whether they had registered their preference for organ donation or intended to do so.The interviews took approximately 45 minutes and were conducted on Erasmus University campus. Respondents received 25 Euros in cash as financial compensation for their time. The study protocol was approved by the Medical Ethics Review Board of the Erasmus Medical Centre (reference number MEC-2017-221).The 30 rankings of statements were analysed using by-person factor analysis  in the dedicated software package PQMethod . These cThe final sample consisted of 30 respondents. I really don’t see why you would choose not to donate your organs. If you cannot use your organs anymore yourself, why wouldn’t you help someone else?” In line with this, no distinction is made between which organs to donate or not : “you no longer need any of them yourself, so as far as I am concerned they can take them all”; or to whom .This can be considered a pro organ donation perspective, as in this viewpoint the perceived benefits of becoming an organ donor clearly outweigh the perceived barriers. People with this view sympathize with the suffering of people waiting for a donor organ , realize they might need an organ someday themselves  and emphasize benefits of organ donation such as diminishing the suffering of other people  and being able to pass on life to others . Distinguishing for this view is the notion that not donating your organs is considered a waste  as they are of no use to yourself after death : “Sure, it takes some time, but you search on google, fill out a short form and there you go”. They discussed the matter with their family , who do not object to them being organ donor . More than in the other views, they agreed that their family members encouraged them to register as an organ donor . Still, they strongly disagreed that family members should have the last say on whether their organs eventually will be donated , even if family members would object to the donation.People with this view see themselves as efficacious. Finding the relevant information is considered as relatively easy  and they feel they have sufficient knowledge about organ donation  and about how to register or unregister as organ donor : “Trust in the healthcare system is widespread within this group. Respondents expected that medical professionals will treat their dead body and its organs with respect , and the possibility that the donated organs end up on the black market is considered negligible . All in all, the choice to register as organ donor was not difficult for them . People with this view either already had registered as organ donor or stated their intention to do so , and do not see the need for incentivizing the decision to register .Based on this description, we labelled this viewpoint “Not donating my organs would be a waste”. Thirteen respondents were statistically significantly associated with this viewpoint.Giving in general is considered a good deed and I think it is very important to give. So, for myself, I would really like to become an organ donor. But my religion forbids me to become an organ donor, because you should consider your body to be a loan from God and return it to Him. This is difficult for me, because I think giving and helping other people is an import part of my religion and of who I am, but I have to respect God’s will, even though I do not understand it”.People with this view strongly agree that organ donation does not match their religious beliefs . This is not because they expect they will need their organs in the afterlife , as they believe body and soul will be separated after death. But the body is borrowed and should be returned, and thus be preserved. At the same time, they strongly agreed with the statement “By donating your organs you do a good deed”  and often even presented a religious reason for this. According to them, people receive the gift of life from God and by organ donation you could pass on this gift to someone else . Moreover, one day you might need an organ yourself , and you should be willing to give if you wish to receive . People holding this view therefore see organ donation as a “paradox” or “personal challenge” that concerns them ; as one of the respondents explained: “Organ donation it is not a common topic of family conversion . Family members are said to hold a similar religious perspective on this topic and would therefore not support them registering as organ donor . However, while they value the opinion of their family highly, the family should not have the last say in the decision to donate their organs ; it is considered to be an individual matter, for which one is personally accountable when faced with God. Notwithstanding, more than those with other views, this group does discuss the topic of organ donation with friends .that you just don’t really think about”.People defining this view say they view would not officially register their preference for becoming organ donor or not  because under the current opt-in system the only reason to register would be to become organ donor; and that’s not what they want, after all. In line with this, they were neutral regarding how difficult it is to register as an organ donor . They have little knowledge and information about the registration procedure for organ donation or the transplantation process , and stated not to know how to register ; the whole procedure is something “Based on this description, we labelled viewpoint two “It does not go with my religion”. Two respondents were statistically significantly associated with this factor.Personally, I find the decision to become an organ donor very difficult. My children are the main reason. I think the moment to say goodbye must be very difficult and terrible for them, especially if you know your mother’s body is missing parts. The medical staff also has to take the body away within 24 hours after death in order for the transplantation to be able to succeed. I think this time constraint is especially difficult for the family of the deceased, not being able to stay with the deceased so soon after she passed away must be very unpleasant.” Since according to this group, the impact of organ donation is on the family of the deceased rather than on the deceased herself, they strongly agreed with the statement that family members should have the final say in deciding whether the organs of the deceased will be donated . As this suggests the decision to donate is made post mortem by their family, not being registered as organ donor should not have consequences for their eligibility to receive a donor organ, if needed .People with this view consider the choice to register as an organ donor as very difficult , which can best be characterized by a dilemma. On the one hand, they see various benefits of organ donation. For instance, they strongly agreed with the statement that organ donation is a good deed  that would prevent further suffering or perhaps even cure people with severe health problems . On the other hand, respondents argue that the potential suffering of family members constitutes a considerable barrier for them to donate their organs, even though they are not sure whether their family members would actually have problems with them becoming an organ donor . People defining this view often emphasized the rapidity of transplantation and expressed a fear of adding extra trauma to family members if their dead body would be taken away so shortly after death. In addition, respondents viewed the incompleteness of the body after the transplantation as difficult for family members, especially in cases when this would be visible . One respondent explained: “People with this view claim to know well how to register or unregister as organ donor , do not think it is too much of an effort  or conflicts with their philosophy of life , and do not see significant problems with donating . However, they are quite doubtful about whether they have sufficient knowledge on organ donation  or sufficient information is available to them .Based on this description, we labelled viewpoint three “My family should decide”. A total of 8 respondents were statistically significantly associated with this factor.organ donation is something that you do for others, not for yourself, to give yourself a good feeling”, these people see donating your organs as a good deed  and they would feel proud of themselves  for doing something that could impact another person’s life positively . In this way, registering as organ donor would give more meaning to their own lives . As one of the respondents defining this view explained: “registering as an organ donor shows that you value life, not only your own but also the life of others”. They argued that by registering as organ donor one would endorse the conviction that life is worth living.Whereas respondents holding the other viewpoints repeatedly stated that “Even though people with this view seem to have a positive attitude towards organ donation, they also put forward various barriers to registering as organ donor that are primarily related to fears and unease about the donation process. Distinguishing for this viewpoint were the fear that donated organs might be sold on the black market , as well as unease with the possible visibility of removed organs for family members  and their naked body being exposed to others during the process of transplantation . Also distinguishing for this viewpoint is the disagreement with the statements saying that if you want to receive a donor organ might you need it, you should be willing to register as donor yourself  and that priority should be given to registered donors in case they need an organ . They also disagreed that those who have not registered as donor should not be eligible for a donor organ themselves . They explained these conditions are too strong; there could be many valid reasons not to become an organ donor, such as the opinion of the family or religious reasons, and severe suffering or even death would be too serious a consequence.People with this viewpoint doubt about the decision to register as organ donor. It is not a subject they avoid , but also not one they talk about with friends  or family . They are generally not very well informed about the organ donation process  or about how to register as organ donor , and not quite so sure what information is available . They think registering would not require much effort  and intend to do it once they’ve made up their mind , but at the same time feel that their family should eventually have the final say .It is a good deed, but I‘m doubtful”. A total of 5 respondents were statistically significantly associated with this factor.Based on this description, we labelled viewpoint four “This aim of this study was to explore the prevailing viewpoints on deceased organ donation among the public in the Netherlands, and their implications for the decision to register as an organ donor. Attitudes about organ donation have been studied extensively before using survey research, but this study contributes by exploring the diversity in relations between the broad range of underlying beliefs and other constituents of people’s views on organ donation. Using Q-methodology, we found four prevailing viewpoints: “not donating your organs is a waste”, “it does not go with my religion”, “my family should decide” and “it’s a good deed, but I‘m doubtful”.as soon as I knew I wanted to become an organ donor, I signed up”. Explanations regarding the placement of statements on the ranking grid collected during the interview revealed that for this group conversations with friends and family and encouragement by the family were important cues to action, and to a lesser extent media attention for organ donation. Answers to follow-up questions revealed that the majority of respondents who defined this viewpoint already had registered as organ donor, and otherwise stated their intention to do so in the near future.The first two viewpoints are most distinct from each other, representing positions in favour and against registering as an organ donor. For people with the first viewpoint (“not donating your organs is a waste”) the potential benefits outweigh the potential barriers. The perception of self-efficacy was also relatively high in this group, with respondents indicating that they had sufficient information and knowledge about organ donation and claiming that “made up their mind”. However, the qualitative materials of the interviews show that these respondents were generally dissatisfied with the type of information one can find in the media. Commercials and other information are considered superficial and understood as promotion material for registering as organ donor rather than an objective overview of different arguments and viewpoints on organ donation. As one respondent stated: “The information I see only tells you to donate your organs because it can help other people. But it doesn’t really tell you anything about the up- and downsides of organ donation. I think the government should show examples that really resonate with all sorts of citizens. They should talk about the procedure of organ donation, but also discuss various spiritual and religious points of view”.In viewpoint two (“it does not go with my religion”), on the other hand, potential barriers clearly outweigh potential benefits, self-efficacy is low and there are few cues to action. Respondents who hold this perspective generally had little knowledge and information about organ donation. Arguably, they do not experience the need to look for such information, considering the fact they had already “I would like to become an organ donor, under the condition that my family does not object”.Viewpoints three and four showed no clear overweight of benefits or barriers. In viewpoint three (“my family should decide”), the perceived barriers were centred on the potential harm for family members rather than for themselves. These respondents often had not registered their preference for organ donation. Not because they are indifferent, too lazy or forgot, but because they do not have a clear preference on this complicated matter. Those who had registered or stated they intended to do so in the near future, still wanted their family to have the last word: “I should do it because it helps other people, but it does make me feel a bit uneasy. I don’t really have a preference because of these pros and cons, so my family should decide. That is less difficult for them than for me, I think, although it still may be aggravating.”Respondents with viewpoint four  were generally positive towards organ donation, but were not well informed and expressed several fears regarding the donation process. For instance, a fear of their organs ending up on the black market and an uneasy feeling about others seeing their naked body when their organs would be removed. Like those with viewpoint three, they see an important role for the family; not because of the potential trauma for family members, as in viewpoint three, but because they are uninformed and undecided. As one respondent defining this view stated: “A striking finding of this study is that people with all views appear to appreciate the benefits of organ donation, and therefore have a positive attitude towards the topic. This is quite obvious for people with the “not donating your organs is a waste” view. Those with the other three views also all consider organ donation as a good deed, but those with the “it does not go with my religion” view will not register because of their philosophy of life, those with the “my family should decide” view hand the decision to their loved ones, whereas those with the “it’s a good deed, but I‘m doubtful” view appear not to be sufficiently involved with the topic to form a preference and come to a decision.didn’t really help, but maybe it starts a conversation every now and then”. Some argued that information in the media only stresses the relief in suffering for others, but does not provide any insight in the transplantation process, the communication with the family, and potential disadvantages of organ donation. Many respondents suggested it would be helpful to have a decision aid, something resembling the quizzes one can take during election times to learn which political party best represents your principles and interests. It should be noted that the interviews were conducted at the time of national elections, probably prompting respondents to make this analogy. In this context, many participants saw the ranking grid from the interview a useful tool to structure one’s thoughts about the topic of organ donation. Several respondents took a picture of their ranking grid, to further discuss the topic with their family and to deliberate themselves on the decision whether to register as organ donor.Another striking finding was the consensus among participants in the study about the neutral ranking of the statement: “information in the media helps me to determine my preference whether to become an organ donor”. Respondents explained that current information campaigns “Based on the present study one could argue that direct questions asking whether people are in favour or against organ donation may have limited information value, especially in relation to understanding decisions to register as organ donor or developing policies to influence them. Attitudes on topics like organ donation are rich and complex that need to be understood before they can be appropriately measured or influenced. As discussed, most respondents appear to have a basic positive attitude to organ donation, but in three of the four viewpoints people holding them experience different barriers that prevent them to translate this positive attitude into action.Some limitations of this study need to be mentioned. First, we used two theoretical models and adjacent literature for identifying the variety of issues relevant for inclusion in the statement set. Although such a structured approach to the development of the statement set should make it easier to capture the full spectrum of issues, we experienced some difficulties with categorizing statements unambiguously according to these issues. In addition, although complemented with additional issues from the literature, such as ‘moral beliefs’, it may be that certain issues were missed.We have paid extra attention to potentially missing issues relevant to respondents during the pilot study and the interviews by asking for this specifically, but no missing issues were identified by these respondents. Secondly, during the interview some respondents stated that, when in doubt about the placement of statements according to agreement, they gave higher rankings to statements that they considered more important in the decision to register as organ donor. Hence, in some cases importance was evaluated in addition to agreement as ranking criterion. Although this was not in accordance with the instructions, it is conceivable that respondents would want to give a higher rank to a statement they find important as compared to one they agree with equally but find less important. Because it concerns the relative ranking of very few statements, perhaps one column to the left or the right on the sorting grid, by a small proportion of the participants, we believe this has not affected our findings. Finally, this study identified four prevailing attitudes to organ donation but does not give information about the distribution of these views within the Netherlands. This may be relevant information if one wishes to choose optimal policies to improve donor registration. Identifying the distribution was not the aim of this study and Q-methodology is not the most appropriate method for that purpose, in particular also considering the purposive sampling of respondents. Survey research that matches respondents to these views in a representative sample of the population would be better fit for that purpose, and also verify whether any important viewpoints have been missed , 56.Our findings have some important implications for public policies aimed at promoting deceased organ donation. First, the results indicate that respondents who hold perspective three and four are in a modifiable phase. This could be understood as an opportunity to address existing fears and educate on the organ donation process. Respondents of all views indicated that current media campaigns played little to no role in their decision to register as organ donor because they are focused on the benefits for recipients and do not provide information about aspects of the process relevant to the donor, which suggests an opportunity to develop more informative media campaigns, conveying information for the various viewpoint holders.Finally, early 2018 a law was passed in the Netherlands that will change donor registration from an opt-in system into an opt-out system effective 2020. All viewpoints show a positive attitude concerning the effects of the opt-out system, indicating that people often forget to register and that the new law will prompt people who do not want to donate their organs to make an active decision to opt out. However, viewpoint two “it does not go with my religion” expresses grave concerns regarding opt-out systems, mainly regarding family members who are not able to access or adequately understand the available information and will stay registered, thereby being considered for organ donation against their religious beliefs. People with the view “my family should decide” will be happy to know that the law provides a voice for the family, although it is not clear how the family will be involved in practice. Finally, it is not immediately clear whether those with the “it’s a good deed, but I‘m doubtful” viewpoint will appreciate the change in default. It may bring forward the fears and unease about the donation process but may also bring relief because the weight of the decision is taken away from them. Given the variety in reactions to this new law that can be expected on the basis of our findings, it seems appropriate to use the two remaining years ahead of the implementation of the law to devise information policies that take away the main concerns of people with reservations towards an opt-out system or organ donation in general, and to promote that people with different views are enabled to enact their preferences under this new system.S1 Table(XLSX)Click here for additional data file.


The mechanisms behind molecular transport from cerebrospinal fluid to dural lymphatic vessels remain unknown. This study utilized magnetic resonance imaging along with cerebrospinal fluid tracer to visualize clearance pathways to human dural lymphatics in vivo. In 18 subjects with suspicion of various types of cerebrospinal fluid disorders, 3D T2-Fluid Attenuated Inversion Recovery, T1-black-blood, and T1 gradient echo acquisitions were obtained prior to intrathecal administration of the contrast agent gadobutrol , serving as a cerebrospinal fluid tracer. Propagation of tracer was followed with T1 sequences at 3, 6, 24 and 48 h after the injection. The tracer escaped from cerebrospinal fluid into parasagittal dura along the superior sagittal sinus at areas nearby entry of cortical cerebral veins. The findings demonstrate that trans-arachnoid molecular passage does occur and suggest that parasagittal dura may serve as a bridging link between human brain and dural lymphatic vessels. Mechanisms behind molecular transport from cerebrospinal fluid to dural lymphatic vessels remain unknown. This study demonstrates that trans-arachnoid molecular passage does occur and suggests that parasagittal dura may serve as a bridging link between human brain and dural lymphatic vessels. Clearance from CSF to blood was for long considered to be dual; one directly to venous blood through arachnoid granulations, and one via lymphatic channels along exiting nerves at the skull base and from the spine2. Lymphatic CSF drainage, and the interplay between the lymphatic- and central nervous system (CNS), gained renewed interest when true lymphatic vessels were shown to reside within the dura mater4. Subsequently, impairment of these meningeal lymphatic pathways has been shown to slow paravascular efflux of amyloid-β from interstitial brain fluid and may possibly represent an aggravating factor in Alzheimer’s disease and age-associated cognitive decline5. Neuromodulators from meningeal lymphatics can even possibly modulate brain tissue by their direct release into CSF6. A recent animal study was, however, unable to reproduce passage of CSF tracer into dural lymphatic vessels7 and was thus in line with previous observations indicating that the arachnoid constitutes an impermeable barrier layer between the CSF and dura mater9.The human subarachnoid space is shown to be continuous with the paravascular compartment of all brain regions10. The substance is therefore suitable for tracing molecular efflux from the cranial compartment along extra-vascular pathways.Our aim was to explore how these diverging findings of CSF tracer efflux from animal studies translate into a human cohort. We carried out multi-phase magnetic resonance imaging (MRI) for up to 48 h in order to follow the movements of the MRI contrast agent gadobutrol, serving as a CSF tracer. Gadobutrol is a non-ionic, highly hydrophilic molecule of relatively small size (604 Da), prevented by the intact brain–blood–barrier from leakage into CNS blood vessels when administered intrathecallyThe study included 18 patients who were under clinical work-up for possible CSF disorders of various etiologies  and at T1-BB (not blood)) was visually identified almost exclusively along the middle to posterior segment of the superior sagittal sinus   lymphatic vessels for CSF molecular uptake and transport due to their closer proximity to the subarachnoid space in areas with a much thinner dural layer7. With concern to clearance rate, another rodent study reported very quick exit of tracer from CSF along perineural routes at the skull base19. In our human cohort, tracer was present in CSF at a far longer time span (even after 2 days), and the tail of the remaining tracer bolus at late scans along parasagittal dura An obvious limitation of this study is the MR image resolution of 1 mm voxel size. The possible interchange between microscopic contents of the parasagittal dura, such as intradural channels and arachnoid granulations, and dural lymphatic vessels, should be further explored in future studies. In the lack of T1-mapping techniques with image resolution even close to 1 mm, we did not have the opportunity to go beyond semi-quantitative measures of tracer enrichment. Ideally, we could also have used an extra-cranial device as reference for normalization of signal units, as the ocular bulbs may be affected by some motion artifacts during scans of several minutes. Moreover, the long duration of molecular clearance from human CSF, and the high demand on patients and resources associated with multi-phase MR imaging over 48 h, has limited the number of scans we were able to perform in single patients through this time span. Therefore, the time point for peak tracer enhancement in human parasagittal dura must be considered to represent a rough estimate.In conclusion, the present study demonstrates in vivo escape of a CSF tracer from the subarachnoid compartment over the arachnoid and into the parasagittal dura along the superior sagittal sinus in humans. The parasagittal dura may thus represent a bridging link for CSF-mediated exchange of molecules between brain tissue and dural lymphatic vessels.The study was approved by The Institutional Review Board (2015/1868), Regional Ethics Committee (2015/96) and the National Medicines Agency (15/04932-7). Patients were included after written and oral informed consent. The study was registered in Oslo University Hospital Research Registry (ePhorte 2015/1868).The study design was prospective and observational: randomization of patients was not relevant; neither was a priori sample size calculation needed.The study included consecutive individuals referred to the Department of neurosurgery, Oslo University Hospital—Rikshospitalet, Oslo, Norway, for various CSF circulation disorders (Supplementary Table Whole-brain 3D T2-Fluid Attenuated Inversion Recovery (FLAIR), repetition time (TR)/echo time (TE)/inversion time (TI) = 4800/311/1650 ms, echo train length = 167, flip angle = 90°, 2 averages, 1 × 1 × 1 mm voxel size (isotropic), acquisition time = 5 min and 41 s.Whole-brain 3D T1-Black-blood (BB) scan with TR/TE = 700/35 ms, echo train length = 55, flip angle = 80°, 2 averages, 1 × 1 × 1 mm voxel size (isotropic) and acquisition time 4 min and 54 s.Whole-brain 3D T1-gradient echo (GRE) with TR = shortest , echo time = shortest , echo train length = 232, flip angle = 8°, 1 average, 1 × 1 × 1 mm voxel size and acquisition time 6 min and 29 s.Scans were obtained in a 3-Tesla MRI unit (Philips Ingenia®) with a 32-channel head coil.We repeated the T1-weighted scans at 3, 6, 24 and 48 h, respectively, after intrathecal injection of 0.5 ml gadobutrol (1 mmol/ml) . Gadobutrol injection was preceded by injection of 3 ml of 270 mg I/ml iodixanol  to ensure correct needle position within the intrathecal compartment. Patients were kept in the supine position with a pillow under their heads until the 6 h scan was completed and were then allowed to move freely.23. T1-BB images are tuned to darken the contents of blood vessels, even when containing a contrast agent24. Thus, in areas with moving protons, such as in arteries and veins, the T1-BB signal is nulled. Around the high brain convexities, there are little motions within the CSF, and therefore the signal is not black (nulled) as in the blood vessels, rendering for a more intermediate CSF-signal.Sagittal T2-fluid FLAIR, as well as T1-BB scans from all time points, were reformatted into coronal and axial 1-mm slices perpendicular and parallel to the plane defined by a line between the anterior and posterior commissures (AC–PC plane), respectively. Identically positioned coronal slices were used to identify parasagittal dura with tissue characteristics remaining unsuppressed  at both T2-FLAIR and T1-BB. T2-FLAIR has the ability to suppress free (unbound) CSF within the ventricular compartment and subarachnoid spaceIn areas of parasagittal dura with these features, regions of interest (ROIs) were placed in identical locations at all time points and well within the outer perimeter of parasagittal dura at T1-BB images for robust measurement of T1 signal change as a sign of tracer enrichment. In addition, a ROI was placed within adjacent subarachnoid space to assess T1 signal change in CSF. The CSF tracer enrichment was measured as change in T1-BB signal units, and was normalized against the reference (i.e. the vitreous body of the ocular bulb) to correct for any baseline shift of image grayscale between time points  illustrating the relations between the brain surface and CSF tracer enhancement. T1-GRE was, however, unsuitable for precise ROI-placement in parasagittal dura, since the border against the enhancing CSF compartment became effaced at late scans . Differences between continuous data were determined using linear mixed models with a random intercept. Correlations were determined by Pearson correlation coefficient. Statistical significance was accepted at the 0.05 level (two-tailed).Further information on research design is available in the Supplementary InformationPeer ReviewReporting SummaryDescription of Additional Supplementary FilesSupplementary Movie 1Supplementary Movie 2Supplementary Movie 3


Listeria monocytogenes (Lm) and Neisseria meningitidis (Nm)) and herpes simplex virus (HSV). CSF concentration of DA, DOPAC, HVA, and 5HIAA were found significantly elevated in all test cohorts. Present study highlights that the analysis of BAs is pivotal for the early diagnosis of bacterial and viral meningitis. In addition, coinfections of varied etiology can also be diagnosed by their quantification. Thus, BAs can serve as potential biomarkers of these CNS infections.Catecholamine and serotonin are biogenic amines (BAs) that serve as neurotransmitters and play an important role in the regulation of cardinal functions that are mainly altered during central nervous system (CNS) infections. A total 92 samples of cerebrospinal fluid (CSF) were classified into 4 groups based on their etiology. In these samples, BAs/neurotransmitters i.e., dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), and 5-hydroxyindoleacetic acid (5HIAA) were detected and quantified by high performance liquid chromatography with electrochemical detection (HPLC-EC) to determine the neurophysiology of the CNS infections by bacteria ( Cerebrospinal fluid (CSF) is a watery liquid that circulates within the ventricles of the brain, and surrounds the brain and spinal column. It contains small molecules, salts, peptides, proteins, and enzymes that play critical roles in many physiological processes of the human host. Changes  in its composition reflect pathological processes in central nervous system (CNS) ,2.An extensive literature survey has revealed that a few studies have been reported in recent past that examined the concentration of amino acids in the CSF during bacterial ,5,6,7,8 Biogenic amines (BAs) refer to the neurotransmitters associated with several neurological and systemic functions governed by autonomic and central nervous system ,10. TheyTherefore, interest in the quantification of BAs is stimulated by an attempt to explore their role in the active state of CNS infection of varied etiology. Consequently, this study will contribute additional evidence to understanding the pathogenesis of these infections. The present study was designed to quantify the concentration of BAs in the CSF samples resulted in the isolation of bacterial and viral etiology.This experiment was delineated to quantify the concentration of BAs in infected CSF samples. Concentrations of biogenic amine (BA) neurotransmitters were quantified in all groups i.e., Nm, Lm, Nm+HSV, and HSV by taking standard mean. Diagnostic analysis of CSF is usually recommended by the doctors of patients with mental ailments which could be infectious or physiological disorders. A healthy individual can never go through the trauma of the procedures of the CSF collection. Therefore, hypothetical composition of the CSF is available but the details of the healthy personnel CSF are scarcely available in the literature. Keeping these facts in mind, intra group comparative analysis was done in the present study. However, the baseline of BAs was determined by the external standards.p < 0.05) in the Lm cohort (72.5 ng/mL of CSF)  was found ( of CSF) A. Howevep < 0.05) . It is worth mentioning here that, in the Lm group the relative quantity of DOPAC (0.181 ng/mL of CSF) was found to be significantly elevated compared to the rest of the cohorts ( < 0.05) B. Althoup < 0.05) in the quantity of HVA in Lm (0.023 ng/mL of CSF) (p < 0.05) revealed that the lowest quantity (0.0136 ng/mL of CSF) of this BA was found in HSV cohort.The downstream degrading product of DOPAC i.e., homovanillic acid (HVA) was detected in all four CSF groups infected with varied etiologies. The relatively highest quantity of this BA degradation pathway intermediate was found to be 0.027 ng/mL of CSF of Nm and Nm+HSV cohorts. Two-way ANOVA showed a significant relative reduction ( of CSF) C. Whereap < 0.05) of 5HIAA (1.365 ng/mL of CSF) was found in Lm group (p < 0.05) revealed that Nm and Nm+HSV groups showed relatively same levels (0.300 ng/mL of CSF) of this BA.In this set of experiment, 5-hydroxyindol acetic acid (5HIAA) levels were quantified in CSF during the active state of infection. It is significant to note that relatively highest quantity  for the diagnosis and treatment of various central nervous system (CNS) infections consists of CSF pressure, measurement, total and differential leukocyte count, glucose and protein quantification, Gram stain, bacterial and viral culture, and polymerase chain reaction (PCR) of different etiological agents. Conversely, we focused on exploring the significance of the quantification of biogenic amines (BAs) in the CSF which may additionally contribute in the existing diagnostic tools of CNS infections.It is worth mentioning herein that analysis for BAs in CSF samples reflected a correlation between varied concentrations of these with infection associated etiology (bacteria/virus). Present study emphasized that infections may disturb the neurotransmitters degradation pathway. In the present study, comparative analysis of the results has indicated complete downstream degradation of dopamine (DA) into its metabolic products i.e., 3,4-Dihydroxyphenylacetic acid (DOPAC) and Homovanillic acid (HVA) in HSV infection whereas, in Lm infection, DA catabolized into DOPAC devoid of further degradation into HVA A–C. Alth+/K+ channels for the generation of action potential. Elimination of extracellular DA from the synaptic cleft is mandatory and it occurs either when DA gets recycled after reuptake by dopaminergic neurons or degraded after uptake by glial cells [Transitionary elevation of DA in response to pain, stress, and fear is a well-documented fact. However, sustained elevation in its concentration is attributed to pathological manifestations in response to any etiological agent. Conventionally, DA is released into the synaptic cleft as a consequence of excitation of presynaptic dopaminergic neurons where it interacts with the DA receptors of postsynaptic neuron and initiates signaling cascades such as Naal cells ,15 by foal cells . InteresThe results of the present study can be further explained by the schematic models A and A1  that indIn a nutshell, our study obviously indicated the variation in the pattern of neurotransmitter degradation in bacterial and viral infections. The increased quantity of DA in Lm the animal cohort  is superUnless otherwise stated, biogenic amine standards were obtained from Sigma, St. Louis, MO, USA. High performance liquid chromatography with an electrochemical detection (HPLC-EC) system was acquired from Merck, Frankfurter, Darmstadt, Germany with Chromeleon v.6.8.0 software.The present study is a sub-analysis of cerebrospinal fluid (CSF) samples collected randomly from patients admitted with neurological ailments in the two major government hospitals of Karachi, Pakistan . DetailsAll procedures performed in this study involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments.Neisseria meningitidis (Nm) and Listeria monocytogenes (Lm) respectively. While group 3 was composed of CSF samples showed bacterial and HSV coinfection (Nm+HSV). Furthermore, group 4 was consisted of CSF samples yielded the presence of HSV strains i.e., (HSV1) and Herpes simplex virus 2 (HSV2) (HSV)  (HSV) .CSF samples those proven the presence of infection either with single etiology or coinfection with varied  etiological agents were selected and used for conducting these experiments. To analyze the presence of biogenic amines, representative CSF samples were taken from each of the four groups . Groups 2PO4, 0.1% octyl sodium sulphate, 0.0035% EDTA, 14% methanol (pH 2.9 adjusted with phosphoric acid). The flow rate of the pump (Dionex Ultimate 3000) was 1 mL/min. The sensitivity of the detector was 1.0 nA and potential of the working electrode was 0.6 V. 25 μL of each CSF sample was injected into the HPLC-EC system. The peak areas generated from the CSF samples were recorded and quantified by comparison with external standards containing 100 ng/mL of dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), and 5-hydroxyindoleacetic acid (5HIAA). All of these experimental procedures were run in triplicate.HPLC-EC system was consisted of a Dionex ED50 electrochemical detector, a glassy carbon working electrode, 5 μm Octadecyl silane (ODS) reverse phase, 250 × 4.6 mm, C-18 column and Chromeleon v.6.8.0 software. The column buffer consisted of 0.1 M NaHp < 0.05) of between group differences was analyzed using the two-way ANOVA tool in SPSS version 15. Statistical data are expressed as mean ± SEMs.The significance (CSF’s DA and/or its downstream conversion products seem to be good biomarkers for identifying the ongoing bacterial and/or viral infection. Therefore, we strongly recommend the detection of biogenic amines for thorough diagnosis of neuro-infections.


Cerebrospinal fluid (CSF) rhinorrhea is most commonly associated with preceding trauma. Spontaneous CSF rhinorrhea has rarely been documented. Clinical, biochemical, and radiological examination are necessary to establish its diagnosis. Detection of beta-2 transferrin in watery nasal discharge is diagnostic for the presence of CSF. Computed tomography (CT) cisternography or magnetic resonance imaging (MRI) cisternogram are confirmatory radiologic modalities for localization of the leakage site. The most frequent cause of cerebrospinal fluid (CSF) rhinorrhea is iatrogenic or traumatic. Spontaneous CSF rhinorrhea has rarely been reported . Here weA 52-year-old otherwise healthy female presented with clear nasal discharge. The nasal discharge reportedly began happening in 2016 and spontaneously resolved. It resumed in April 2018 with no inciting events. The watery nasal discharge worsened with bending over, activity, and coughing. She reported that the nasal discharge was associated with headache as well as a continuous salty taste in her mouth and a feeling of fullness in her ear. The patient denied any trauma. A review of systems was negative except for the headaches and nasal discharge. The patient denied a history of any connective tissue disease, rhinitis, or recurrent sneezing. On physical exam no other abnormalities were noted other than a clear liquid coming from the right side of her nose. Her neurological examination was unremarkable as well.Testing of the fluid for beta-2 transferrin was positive, indicating that the fluid was CSF. An MRI of the brain showed an empty sella, intracranial hypertension, and a right middle fossa encephalocele associated with a possible CSF fistula Figure . A CT ciMost CSF rhinorrhea cases have traumatic or iatrogenic etiologies. However, our case report is a rare presentation of spontaneous CSF rhinorrhea . The etiSpontaneous CSF leak is a rare cause of CSF rhinorrhea. The diagnosis of CSF rhinorrhea is established with the biochemical testing of the fluid for beta-2 transferrin and imaging tests using CT cisternogram. Surgical repair, preferably using an endonasal approach, is indicated to prevent the complication of meningitis.


The purpose of the study was to compare the differences of the subjective satisfaction of the donor site morbidity between the free radial forearm flap (FRFF) and anterolateral thigh flap (ALTF) for tongue reconstruction.One hundred and nineteen patients underwent FRFF or ALTF reconstruction were retrospectively evaluated by a standardized self-established donor site morbidity questionnaire which included 5 domains, sensibility, movement disabilities, cosmetics, social activities and general impacts on the quality of life.P< 0.05). No significant differences were found in the movement disabilities, social activities and general impacts on the quality of life between the two groups (P > 0.05).The Cronbach’s coefficient alpha of the questionnaire was 0.707. The exploratory factor analysis revealed that the 5 items of the questionnaire might load onto two distinct subscales. Patients with ALTF had higher scores in the sensibility, cosmetics and the composite score (ALTF has the advantage of better results of donor site morbidity, such as sensibility and cosmetics, over FRFF. Key words:Quality of life, tongue cancer, free radial forearm flap, anterolateral thigh flap, donor site morbidity. Free radial forearm flap (FRFF) and anterolateral thigh flap (ALTF) have established themselves as the most popular choices for reconstruction of tongue and other intra-oral defects. However which flap is better remains controversial. The most advantage of ALTF over FRFF may be at the donor site. With the ALTF, the defect at the donor site is almost always closed primarily, however harvesting FRFF leaves a large defect requiring skin grafting.Some studies had revealed that patients reconstructed with the ALTF had lower complications, better functional results and aesthetic outcomes at donor site than those with FRFF by objective evaluation -6. Howev Despite the importance of the previous studies on the subjective evaluation of the donor site morbidity ,8, lack -PatientsTwo tertiary stomatological hospitals, Tianjin Stomatological Hospital and Peking University School and Hospital of Stomatology, were included. From January 2011 to January 2016, a total of 250 consecutive patients underwent FRFF or ALTF reconstruction after ablative surgery for untreated, primary tongue squamous cell carcinoma  at the studied hospitals. Patients who received surgery due to a recurrent disease, had been irradiated before surgery, or had inadequate medical records were excluded. Patients who were with malignant tumor in other body regions or with flap loss were also excluded.From October 2016 to December 2017, the patients were asked to answer a donor site morbidity questionnaire by the same trained doctor through a telephone interview. The doctor completed the questionnaire by directly reading the questions to the patients and recording their verbal responses. The local ethics committees approved the retrospective study. Of the 250 patients, 76 (30.4%) died because of cancer or other diseases, 42 (16.8%) lost to contact, 8 (3.2%) refused to answer the questionnaires, 5 (2%) were excluded because of recurrence after reconstruction surgery, and 119 (47.6%) completed the questionnaires.Sociodemographic data , comorbidity , and clinical data  were retrospectively gathered from the medical records. The extent of tongue resection were divided into two categories: hemiglossectomy , and subtotal glossectomy . The modes of tongue reconstruction were divided into FRFF group and ALTF group.-The donor site morbidity questionnaireThe donor site morbidity questionnaire was a self-established scale which comprised 5 items: 4 are disease-specific  and 1 is a general question . Each of-Statistical methodsInternal consistency reliability was measured by Cronbach’s coefficient alpha. If an item fails to correlate well with the other items, the Cronbach’s alpha increases in its absence. The construct validity was evaluated by exploratory factor analysis, grouping individual questions with strong correlation into discrete cluster or constructs. A conventional varimax method of rotation was used.For descriptive purposes, mean and standard deviation (SD), and median and range were used. The independent t tests or Chi-square tests were used to explore any difference in patient’s characteristics between the FRFF group and ALTF group. The Mann-Whitney U-test was used to compare differences of the donor site morbidity between the FRFF group and ALTF group.P < .05.SPSS 17.0 software package  for Windows was used for the statistical analysis. The level of statistical significance was taken as -Patients characteristicsPatients’ characteristics were shown in Of the 119 responders, 90 (75.6%) underwent hemiglossectomy and 29 (24.4%) subtotal glossectomy. FRFF was performed in 64 (53.8%) and ALTF in 55 (46.2%) patients. All patients reconstructed with the FRFF had split-thickness skin graft, while the donor defects of the ALTF were closed directly. There were no significant differences in age, comorbidity, education level and postoperative radiotherapy between the FRFF group and ALTF group (see P = .006). The difference in the proportions of man between the two groups was statistically significant (P = .016). Compared to ALTF group, patients in FRFF group had a significantly lower disease stage (P < .001), received a significantly smaller extent of glossectomy (P < .001) and a significantly smaller flap size (P < .001) (see The mean follow-up time in FRFF group (40.2 months) was longer than that in ALTF group (33.5 months) . The Cronbach’s alpha decreased if an item was deleted, except for the item of movement disabilities. All the inter-item correlations were positive and were shown for each item in figure The principal components factor analysis extracted two principal components  from the 5 items see . The ana-The differences of subjective satisfaction of the donor site morbidityP = .025), cosmetics , and composite score , while patients in ALTF group had more favorable scores. No significant difference was found in the movement disabilities, social activities and general question domains between the two groups, although the ALTF group was inclined to obtain higher scores for social activities  and general question .The scores for the five domains and composite score were demonstrated in The important goal of reconstructive surgery in tongue cancer patients is to maximally recover the oral function. In addition, the donor site morbidity after the flap harvest is another important issue when tailoring a suitable flap. Although the use of objective measures of the donor site morbidity provided important information, the use of a questionnaire to evaluate the subjective complaints from a patient perspective could not be neglected, especially when the inconsistency between the subjective and objective testing existed.In the present study, we designed a standardized questionnaire to measure the subjective satisfaction of the donor site morbidity after harvesting ALTF or FRFF. The psychometric properties, such as reliability and construct validity, were evaluated. Internal consistency reliability was one of most frequently used methods for the evaluation of the instrument reliability. It was recognized that the Cronbach’s coefficient alpha should be at least 0.70 . Our resData obtained in the present study demonstrated that donor site sensibility, cosmetics, and the composite score of the questionnaire were better when ALTF was used. Harvest of FRFF may lead to diminished sensation supplied by antebranchial cutaneous nerve, with the rate of abnormal sensitivity ranging from 26% to 80% ,9,13. AsFor the forearm donor site, a split- or full-thickness skin graft is often necessary, although direct closure can be achieved by an ulnar fasciocutaneous V-Y transposition flap for defects smaller than 6×4 cm . Howeveret al. (et al. (Movement disability of forearm was another serious complication of FRFF. Although some studies described rare or no movement disabilities after harvest of FRFF ,16, otheet al.  who foun (et al.  found th (et al. . In addi (et al. ,10, and et al. (et al. (et al. (In the present study, we found the trend of better social activities in the ALTF group, but no significant difference. Better social function was revealed when the ALTF was used . Ten peret al.  found th (et al.  and Huan (et al.  both theSeveral factors required attention when interpreting the findings of the study. First, the cross-sectional design allowed for rapid evaluation of the differences of donor site morbidity, but the inaccuracy of clinical parameters was an inherent flaw. Second, due to the designed drawback, we did not perform a second assessment in a short time interval, so the test-retest reliability, another important reliability index, could not be calculated. Third, it was not a longitudinal study, and the responsiveness of the questionnaire over time could not be explored, although the present study revealed that the instrument could detect the differences of donor site morbidity between groups sensitively.Data obtained in the present study showed that ALTF has the advantage of better results of donor site morbidity, such as sensibility and cosmetics, over FRFF.


The gap between the kidney transplant recipient list and the number of organs available for transplantation continues to grow. Pediatric donors help fill a small and valuable portion of that gap. Normally these organs are transplanted en-bloc by closing the proximal vascular caps and using the distal aorta and distal inferior vena cava (IVC) for inflow. They are however commonly injured during the donor operation making the standard operation for pediatric en-bloc transplantation not possible. This case report presents two cases in which injured small pediatric kidneys were transplanted successfully in adult patients. We are presenting two examples of common vascular injuries to small pediatric kidneys, one venous and one arterial. In both scenarios, the kidneys were transplanted using a modification to the standard technique. The two kidneys were separated and the technique of implantation was modified to allow safe transplantation. This way we were able to transplant both kidneys successfully and using a reproducible methodology. Both recipients were young adults. There were no surgical complications. There is a large discrepancy between the number of organ donors and the number of patients on the kidney transplant list. As of June 18, 2018, over 95,000 patients are on the waiting list for a kidney transplant in the United States . PatientWe present two cases of successful transplantation of small pediatric kidneys with major vascular injuries. Such injuries occur in 18–36% of all donors. Performing the multi-organ donor operation in donors of such small body size is very challenging—explaining the high rates of injury , 10. We Case 1The patient in this study is a 23-year-old female with ESRD secondary to hypoplastic kidneys. She received an offer from a brain dead, 9-month-old female donor with a terminal creatinine of 0.2 mg% and donor weight of 10 kilograms. The recipient-to-donor weight ratio was roughly six-to-one. After performing the standard multi-organ procurement, it was noted that the donor left renal vein was essentially dismembered from the inferior vena cava (IVC). This prohibited performing the standard en-bloc technique to transplant the kidneys. Normally, the suprarenal IVC is sutured closed, and the infrarenal IVC is spatulated at the iliac bifurcation for anastomosis to the recipient iliac vein. The pediatric kidneys were divided on the back table similar to an adult kidney procedure. The left renal vein was separated completely. The aorta was split down the middle and Carrel patches were made around the renal arteries. The right renal vein was elongated using the donor IVC in the standard fashion, and a venotomy was made on the side of the IVC for the anastomosis. The transplant then proceeded normally by exposing the right iliac vessels. Adequate exposure was achieved. The internal iliac veins were ligated and divided to elevate the external iliac vein and allow for a tension-free anastomosis. The external iliac artery was dissected to its full length, from the takeoff of the internal iliac artery to the inguinal ligament. The two kidneys were transplanted by stacking them on the same side. The left kidney was placed higher to allow the longer vein to cross over the iliac artery. The arterial anastomosis was performed using Carrel patch to the external iliac artery. The iliac veins were reconstructed in the usual fashion to the external iliac veins. Schematic diagram of the techniques is demonstrated in Figure The patient’s initial post-transplant eGFR was 9 ml/min, and had a creatinine of 6.4 mg/dL and eGFR of 10 ml/min on post-operative day one. On post-operative day six, the patient was discharged with a baseline creatinine of 1.3 mg/dL. The eGFR continued to improve to 82 ml/min 30 days post-transplant, reaching a maximum eGFR of 94 ml/min at 30 weeks post-transplant. About a year later the patient had a computed tomography (CT) scan for an unrelated reason and it showed significant growth in the size of the kidneys (Figure Case 2The second patient was a 36-year-old male who had ESRD secondary to adult polycystic kidney disease. He received an offer from a 6-month-old brain dead male donor who weighed seven kilograms. The donor had a terminal creatinine of 0.4 mg%. The recipient-to-donor weight ratio was nearly ten-to-one. After the multi-organ procurement operation was performed, it was noted that the suprarenal aorta was cut too close to the right renal artery Figure . The uppKidneys from small pediatric donors are an option to increase the number of organs available for transplantation. They have shown good outcomes, with function and rejection rates similar to adult kidneys. Injuries to the pediatric en-bloc grafts are very common. Alternative surgical techniques to mitigate such injuries, with at least equivalent success, were attempted in this report. To our knowledge, this is the first time this technical modification has been described to mitigate vascular injuries that occur secondary to the donor operation in small pediatric donors. Shapiro et al. reported a technique of reconstructions using an adult iliac vein for vein injuries . In thatAnother observation noted in these two cases is that the eGFR equalizes rather rapidly, regardless of the recipient-to-donor weight ratio. This observation is being described in a much larger study that is currently under review for publication, but has also been reported by others .This operation uses a simple modification to the standard transplant technique by stacking the kidneys on one side to achieve a safe transplant with no major vascular reconstructions. These cases provide an opportunity to explore transplantation of kidneys from small pediatric donors with vascular injuries. The outcomes were excellent, with no early or medium-term complications related to the technique. Further studies will be required to validate the reproducibility of this method.


Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder affecting upper and lower motor neurons (MNs) that still lacks an efficacious therapy. The failure of recent therapeutic trials in ALS, other than depending on the poor knowledge of pathogenic mechanisms responsible for MNs loss, is largely due to diagnostic delay and the lack of reliable biomarkers for diagnosis, prognosis and response to pharmacologic intervention. Neurofilaments (Nfs) are neuron-specific cytoskeletal proteins, whose levels increased in biological fluids proportionally to the degree of axonal damage, both in normal and in pathologic conditions, representing potential biomarkers in various neurological disorders, such as motor neuron disorder (MND). Growing evidence has shown that phosphorylated neurofilaments heavy chain (p-NfH) and neurofilaments light chain (NfL) are increased in blood and cerebrospinal fluid (CSF) of ALS patients compared to healthy and neurological controls and are found to correlate with disease progression. In this review, we reported the most relevant studies investigating the diagnostic and prognostic role of Nfs in ALS. Given their reliability and reproducibility, we consider Nfs as promising and useful biomarkers in diagnosis of MND, early patient identification for inclusion in clinical trials, prediction of disease progression, and response to pharmacological intervention, and we suggest the validation of their measurement in clinical activity. Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disorder affecting upper and lower motor neurons (MNs) that still lacks an efficacious therapy. In the past decades, several studies have been led to find a molecule able to halt disease progression, but they were unsuccessful. The incomplete knowledge of pathophysiological mechanisms underlying ALS and the lack of available and reliable biomarkers for diagnosis, disease progression, prognosis, and response to pharmacologic intervention has limited the clinical experience about motor neuron disorders (MND) and has probably contributed to the failure of recent therapeutic trials in ALS.An ideal biomarker would have higher levels of expression in patients compared with controls, would maintain steady levels throughout the disease course, being susceptible to treatment effects and disease exacerbations, and would reflect the rate of neurological decline and the disease duration.Evidence showing that neurofilaments (Nfs) are found at elevated concentrations in cerebrospinal fluid (CSF) and blood of patients affected by ALS, has prompted the scientific research to explore their role as diagnostic and prognostic biomarkers in ALS.O-glycosylation are crucial for neurofilaments aggregation, especially in NfM and NfH . ThBeing highly expressed in large caliber myelinated axons, Nfs are released in the extracellular space and their levels increase in blood and CSF proportionally to the degree of axonal damage, both in normal and in pathologic conditions . PhysiolGrowing evidence showed that NfL and phosphorylated-NfH (p-NfH) are non-specific markers of axonal damage and are reported to be increased in CSF and blood of ALS patients, at higher levels compared to other neurodegenerative disorders or disease mimics .In particular, CSF and serum p-NfH concentrations are significantly increased in ALS in comparison with controls and ALS mimics, representing a useful diagnostic biomarker, especially in early symptomatic phases of the disease. NfL elevation in biofluids is the first detectable event accompanying neurodegeneration in ALS, nevertheless they are less specific for MND, being increased also in other neurodegenerative disorders. Conversely, both plasma/serum NfL and p-NfH might be used as prognostic and pharmacodynamic biomarkers, since they are reported to correlate with disease severity and their blood levels remain stable over time.In this review, we reported the most relevant studies investigating the role of Nfs in ALS. Describing the main findings of these works, we highlighted the advantages and the pitfalls of blood and CSF measurements of p-NfH and NfL, and we discuss their role as potential diagnostic and prognostic biomarkers in ALS.Since their reliability and reproducibility, Nfs could represent diagnostic and prognostic biomarkers useful for precocious identification of patients and their inclusion in clinical trials, assessment of individual prognosis and response to experimental drugs.The role of Nfs as diagnostic and prognostic biomarkers in MND has been suggested by several evidence showing that Nfs are found at elevated concentrations in CSF and blood of patients affected by ALS.More than two decades ago, Nfs were discovered at higher levels (5 to 10 folds) in CSF of ALS patients, compared to healthy controls (HC) . Given tThe improvement of new immunoassays able to detect proteins in biological fluids even if when present at low levels, has allowed Nfs measurement also in serum and plasma, providing the possibility to conduct longitudinal studies, useful to evaluate biological response to therapies.Indeed, first- and second-generation Nfs assays, i.e. immunoblot and enzyme-linked immunosorbent assay (ELISA), respectively, were able to detect precisely only high concentrated CSF proteins, having a poor sensitivity in detecting Nfs in blood B. ConverAlmost all the studies investigating both CSF and blood compartments on ALS patients have showed high correlation between CSF and blood Nfs concentrations, with increased Nfs levels than in blood ,11,12,13Several studies have shown that both p-NfH and NfL are found at higher levels in CSF and blood of ALS patients, not only as compared to controls, but also to disease-mimics (DM), suggesting their potential utility in differential diagnosis. Furthermore, it has been investigated their role in distinguishing among different ALS phenotypes.In a recent metanalysis including 15 studies, levels of CSF and blood Nfs in ALS patients were compared to HC, ALS mimic and neurological controls with CNS parenchymal involvement . The maiNfH undergo post-translational phosphorylation, which is relevant for Nfs transport along the axons and regulates axon stability and protein-protein interactions.Compared to NfL, p-NfH are more stable and less susceptible to proteases degradation, representing a steady and reproducible biomarker in consecutive measurements. Nevertheless, the presence of immune response against NfH and the hook effect due to p-NfH aggregation in plasma samples represent an issue in accurate Nfs measurement, since they may accelerate p-NfH clearance or reduce the binding sites available for antibody binding through ELISA techniques .Different studies have investigated the utility of p-NfH in blood and CSF samples of ALS patients .Boylan et al. compared p-NfH levels in plasma, serum and CSF in ALS patients, showing a significant association between higher concentrations and faster disease progression, evaluated as faster decline in ALS Functioning Rating Scale Revised (ALSFRS-R) . AlthougSeveral studies did not find an association between Nfs concentrations and age at onset of ALS, suggesting a stronger relationship with clinical course than with age of the patients . McCombeLu and colleagues lead a prospective study on 74 ALS affected patients, whose blood samples have been collected every three months for a period of three years . AlthougSimilar results were obtained from McCombe 2015 et al., who found a significant difference in blood p-NfH levels at baseline between ALS and HC . DespiteLi and colleagues confirmed the presence of higher p-NfH levels both in plasma and in CSF of ALS patients in comparison to controls and they identified a cut-off level of 685 pg/ml for p-NfH in plasma (sensitivity of 80.39% and specificity of 73.81%), and the optimal cut-off value in CSF of 589 pg/mL, with a sensitivity of 82.35% and a specificity of 73.81% [In the retrospective study by De Schaepdryver et al.  CSF and The most relevant finding of the study lead by Zucchi et al. was that CSF and serum p-NfH can discriminate ALS with predominant UMN signs from other UMN syndromes, like hereditary spastic paraplegia (hSP) and primary lateral sclerosis (PLS); moreover, CSF p-NfH concentration may differentiate UMN syndromes from HC and are the most stronger predictors of survivals .Finally, p-NfH in CSF have shown to be a good prognostic biomarker not only in sporadic ALS, but also in ALS affected patients harboring mutation in the C9Orf72 gene. Gendron and colleagues identified a cut-off value of 176 pg/mL for p-NfH in CSF, able to discriminate with elevated sensitivity and specificity (98.8% and 96.4% respectively) between symptomatic and asymptomatic C9Orf72 mutation carriers . MoreoveIn a large prospective study on patients affected by MND, CSF p-NfH were increased as compared to MND mimics and HC, showing a cut-off level of 560 pg/mL, and were associated with progression and disease duration .In the work of Poesen et al., CSF p-NfH were shown to have a diagnostic role, since they were able to discriminate with high sensitivity and specificity  ALS patients from DM, with a cut-off of 768 pg/mL . TherefoIn the study led by Feneberg et al., CSF p-NfH discriminated patients with early symptoms from other neurological diseases and MND mimics, confirming their potential utility in precocious enrollment of patients in clinical trials. Moreover, they were higher in early versus later presenters .NfL is the lowest molecular weight subunit and the most abundant in axons. Given its high solubility and precocious diffusion from neural cells into CSF, it is rapidly detectable in biofluids after axonal degeneration. Accordingly, it presents high sensitivity in diagnosis of MND, being able to early identify ALS patients from DM. Nevertheless, NfL is an unspecific indicator of axonal damage, so its potential diagnostic role should be complemented with other neurological assessments .Tortelli and colleagues found elevated CSF NfL levels in ALS respect to DC and identified a cut-off value of 1981 pg/mL discriminating between the two groups with a sensitivity of 78.4% and specificity of 72.5% . In ALS Lu et al. measured NfL concentrations in serum, plasma and CSF in two cohorts of patients, and found higher levels in all biofluids in ALS compared to controls, discriminating with high sensitivity and specificity between ALS patients and HC . Blood NCSF NfL concentrations were compared to measures of Diffusion Tensor (DT) techniques on brain Magnetic Resonance Imaging (MRI) by Menke and colleagues . Higher C9Orf72 or SOD1 mutations.Verde et al. identified a cut-off level of 62 pg/mL discriminating between ALS and DC, and between ALS and other neurological diseases, including neurodegenerative diseases, with high sensitivity and a relatively high specificity . ALS patConversely, NfL showed a strongly significant correlation with progression rate and survival and, as demonstrated by other studies, they remained stable over time in longitudinal analysis . In consThis is in agreement with the findings of Benatar and colleagues, who found increased serum and CSF NfL levels not only in ALS patients, but also in pre-symptomatic individuals as far back as 11.6 months before the onset of clinical signs or symptoms of the disease . While lNfs can be considered as markers for the extent of MND, indeed CSF p-NfH and NfL were reported to be increased with number of regions with both UMN and LMN involvement .Confirming this hypothesis, Gaiani et al. correlated CSF NfL with subtypes of MNs disorders, identifying higher NfL levels in patients with atypical ALS, progressive bulbar palsy and UMN-dominant, in comparison with those with progressive muscular atrophy (PMA) and flail arm or leg syndrome . Since MSerum NfL were confirmed to correlate with UMN degeneration by Gille and collegues, and were reported to be independent predictors of survival in ALS patients . Their lIn the prospective study of Steinacker et al. CSF NfL showed a high positive predictive value (PPV) in discriminating MND from other diseases, with a cut-off of 2200 pg/mL; besides they correlated with disease duration and progression [CSF and serum NfL were found to be increased in patients with early symptoms from other neurological diseases and MND mimics; nevertheless, no difference in CSF and serum NfL concentrations have been found between early and later symptomatic phase, neither between fast and slow progressors .Similarly to p-NfH, CSF and also blood NfL were reported to be massively elevated in symptomatic mutation carriers, while their levels are low and comparable in controls and asymptomatic carriers . MoreoveIn the study of Rossi and colleagues, CSF pNF-H and NfL levels were found to be increased in ALS with respect to patients with non-inflammatory neurological diseases and with acute/subacute inflammatory diseases and tumors, reaching the level of statistical significance only in the first group . These fGrowing evidence have confirmed the potential utility of p-NfH and NfL as biomarkers in ALS, both in assessing diagnosis and predicting prognosis, and in monitoring treatment efficacy.Considering its high sensitivity and its precocious elevation in biological fluids, NfL are promising diagnostic biomarkers in neurodegenerative disorders. They are able to discriminate accurately not only between ALS and HC, but also between ALS and DM; nevertheless, they lack specificity for MNs damage, since their levels showed relevant increase also in other neurodegenerative disorders. Therefore, serum and CSF NfL represent useful tools in diagnosis, especially in patients with high clinical suspicion for MND and when associated with other complementary assessments .Conversely, the diagnostic utility of p-NfH has been extensively supported by the results of the above-mentioned studies. In particular, CSF p-NfH showed the higher diagnostic accuracy in discriminating ALS from both DM and DC in observational and retrospective studies ,18,19,20A common matter in MND diagnosis is that a huge number of patients will not reach the requested criteria for definitive diagnosis in life or will reach them only in the ending stage of the disease: this issue could be overcome by adding some biological biomarkers to El Escorial Revised diagnostic criteria , and NfsMoreover, it must be taken into considerations the neuroanatomical correlate of Nfs elevation in biofluids: both p-NfH and NfL correlate with the extent of UMN and LMN involvement, although the first is primarily associated with LMN damage , while tThe vast majority of these works also assessed the prognostic value of blood Nfs in ALS.Serum and plasma p-NfH concentrations were reported to peak in the early phase of the disease, especially in patients with shorted diagnostic delay and faster disease progression, probably reflecting the neurodegenerative process and the trend of neurological decline, and to fall in the later stages of the disease, when the pool of MNs has been already depleted. The trend of plasma p-NfH identified by Lu et al. and McCombe et al. ,17 may rAdditionally, from a therapeutic perspective, the use of a non-invasive and relatively stable biomarker may be of paramount importance in potential clinical trials based on neuroprotective drugs. While in other diseases, like multiple sclerosis, CSF and blood Nfs have been tested in evaluating the effects of disease-modifying therapies, so far there are no studies investigating the use of Nfs as indicators of treatment response in ALS. This application would be very important in the current epoch, as new molecular therapies (i.e. antisense oligonucleotides in SOD1 and C9Orf72 mutated ALS) are coming to light in the therapeutic scenario of MND.In conclusion, the diagnostic clinical relevance of Nfs dosage in biofluids, along with the positive correlation with disease progression and the easy accessibility of this biomarkers, points towards the standardization and validation of Nfs measurements in clinical activity. Nonetheless, they could be employed for improving early diagnosis and monitoring treatment efficacy, thus representing promising biomarkers in observational and interventional clinical trials.