GDAP1 gene have been associated with a severe form of CMT, prompting us to investigate the effect of readthrough and NMD inhibitor molecules. Although not clearly defined, GDAP1 could be involved in mitochondrial functions, such as mitophagy. We focused on the homozygous c.581C>G (p.Ser194*) mutation inducing CMT2H using patient human induced pluripotent stem cell (hiPSC)-derived neuronal cells. Treatment during 20 h with 100 µM of amlexanox on this cell model stabilized GDAP1 mRNAs carrying UGA-PTC and induced a restoration of the mitochondrial morphology. These results highlight the potential of readthrough molecules associated to NMD inhibitors for the treatment of genetic alterations in CMT, opening the way for future investigations and a potential therapy.Nonsense mutations are involved in multiple peripheral neuropathies. These mutations induce the presence of a premature termination codon (PTC) at the mRNA level. As a result, a dysfunctional or truncated protein is synthesized, or even absent linked to nonsense-mediated mRNA degradation (NMD) system activation. Readthrough molecules or NMD inhibitors could be innovative therapies in these hereditary neuropathies, particularly molecules harboring the dual activity as amlexanox. Charcot–Marie–Tooth (CMT) is the most common inherited pathology of the peripheral nervous system, affecting 1 in 2500 people worldwide. Nonsense mutations in the  Nonsense mutations cause 11% of genetic diseases .Recent therapeutic strategies, based on pharmacological approaches, can be applied to limit or inhibit nonsense mutations consequences. The first approach consists in using readthrough (RT) molecules, that are able to bypass the PTC. These molecules allow, by the incorporation of a near cognate amino acid at the PTC position, to restore the full protein expression, sometimes potentially modified ,4. The sBoth types of molecules have been previously identified and characterized, and, it has been shown that, sometimes, they even combine both mechanical approaches. The first class, the RT molecules, is organized in aminoglycosides and non-aminoglycosides compounds . Aminoglpes cavus, and sometimes sensory loss and balance issues [PMP22 gene  remains the main genetic cause of this pathology, PTCs have been detected in numerous CMT genes and we estimated that they represent around 10% of the detected mutations . Among the genes involved in CMT disease, GDAP1 (ganglioside-induced differentiation associated protein 1) appears to be one of the top 10 [In neurodegenerative disorders, the readthrough strategy has been displayed only twice in the literature, both times regarding the central nervous system ,15. For e issues . Electroe top 10 . GDAP1 gene, located on chromosome 8 (8q13-q21) of the human genome, encodes a 358 aa protein [ protein , which i protein . GSTs ar protein . A part This protein is highly expressed in the outer mitochondrial membrane of neuronal cells ,22 such Although mitochondria are known as the powerhouse of ATP production, they are also responsible for metabolism, apoptosis and cell signaling . They arCorrect architectural structure of cristae reflects a crucial mitochondria functioning . It is wGDAP1 have been described as related to CMT [GDAP1 mutations can present an autosomal recessive (AR-GDAP1) or an autosomal dominant (AD-GDAP1) mode of inheritance, and they can be involved in axonal forms (CMT2K), or demyelinating forms (CMT4A), which makes their classification complicated. The clinical characteristics of patients with AR-GDAP1 mutations are more severe than patients with AD-GDAP1 and they develop first symptoms at a very early age in childhood [More than 100 mutations in d to CMT  includinhildhood ,37,38. IGDAP1 [GDAP1 mRNA is mainly expressed in neuronal cells (PNs and MNs) compared to other cell types . In the motor neurons of the patient, this level of GDAP1 mRNA is drastically reduced, probably degraded by the NMD system [Therefore, in view of the lack of efficient therapeutic approaches, assessing readthrough molecules for patients displaying nonsense mutation in this gene represents a major challenge. However, these therapeutic developments are often limited by the lack of pertinent in vitro models. Our team developed few years ago a human induced pluripotent stem cell (hiPSC) in vitro model from CMT2H patient fibroblasts carrying the nonsense mutation c.581C>G in GDAP1 ,39. whicD system . MorpholD system .GDAP1 gene. In an original way, this study propose to assess the effect of amlexanox as readthrough molecule combined to NMD inhibitors activity, on neuronal progenitors derived from CMT patients’ hiPSCs, harboring the homozygous c.581C>G nonsense mutation in GDAP1 (p.Ser194*). We demonstrated the rescue effects of this cellular treatment at molecular and protein levels, but also investigating their impact on mitochondrial morphology.To our knowledge, no curative and efficient treatment has ever been proposed for CMT caused by nonsense mutations in GDAP1 nonsense mutation  from a CMT patient, and the other used as control, free from any mutations in this same gene. To generate neuronal progenitors, we used a protocol adapted from Hörner et al. [Two human induced pluripotent stem cell (hiPSC) clones, previously reprogrammed by our team , were usr et al. . NPs werGDAP1 represented only 10 to 20% of mRNA levels in the control, suggesting that PTC-containing GDAP1 mRNA could be degraded by NMD [GDAP1 mRNA to 3.35 fold compared to untreated NPs. As expected, G418 also allowed a significant increase in GDAP1 mRNA, but it cannot be used as a treatment for patients because of its toxicity. Our data supported that this mRNA carrying PTC is a substrate of the NMD system.We have previously observed, by RT-qPCR, in neuronal cells (NPs and MNs) that patient mRNA levels of d by NMD . To inved by NMD ,42, or 1To determine whether amlexanox allows GDAP1 full-length protein re-expression, immunofluorescence staining was performed. NPs were incubated for 20 h with amlexanox (100 µM), or G418 (1 mg/mL). In the presence of amlexanox that display readthrough and NMD inhibitor activities, the protein expression was restored , such asAccording to previous results on mitochondrial morphology alteration observed in patient MNs , we inveAt mitochondrial level, no structural modifications emerged in control cells, in un-treated and treated conditions D–F. In cGDAP1 gene.Cellular models allow screening a high number of molecules simultaneously. Unfortunately, a pertinent cellular model suitable for the evaluation of specific nonsense mutation is not always available. Cells of interest could be isolated from tissues of patients with genetic diseases, but, sometimes, the cell purification is difficult or impossible (such as neurons), leading to use the induced pluripotent stem cell (iPSC) strategy. Indeed, iPSCs, obtained from adult somatic cells (often fibroblasts), can be differentiated into all cell types including neurons. In our lab, we previously created hiPSCs from CMT patient fibroblasts carrying the nonsense mutation c.581C>G to characterize cells injuries and mechanisms involved in the pathogenicity . In thisGDAP1, amlexanox  exhibited a promising beneficial effect, without any apparent cytotoxicity [GDAP1 and to restore the synthesis of the GDAP1 protein. This molecule also induced a morphological improvement in mitochondria inner organization, evaluated by electron microscopy. These encouraging results indicate that amlexanox is able to display efficient readthrough inside neuronal cells, suggesting that it could be used as a strategy to treat neurological diseases induced by PTCs. This dual property has also been observed for the aminoglycoside G418 used as a positive control in our study. Unfortunately, this molecule exhibits toxic side effects that forced it to be withdrawn from clinical use in this indication. In order to reduce this toxicity, several G418 derivatives have been developed, such as ELX02 [Our analysis has shown that, in NPs carrying the nonsense mutations in as ELX02  which unIn NPs, we demonstrated that both G418 and amlexanox offer the double property to stabilize mRNA, countering the involvement of the NMD system, and to induce readthrough activity. Previous studies are consistent with our results ,44. On tGDAP1 gene. Further investigations with adapted models, potentially created by the CRISPR-Cas9 technology, will be necessary to determine whether amlexanox displays the ability to bypass all three PTC on NPs. Indeed, amlexanox, was first characterized as an NMDI and its ability to correct the three forms of PTC has been highlighted on three different cellular models  [Our results show that amlexanox and G418 have an activity to bypass the UGA-PTC on the cancers) . Moreovecancers) ,46. Indecancers) . In our cancers) . Among tGDAP1, offering a restored, or a less severe, phenotype. However, it will be important to conduct further analysis to investigate the activity of amlexanox in other genes carrying PTC and mediated CMT disease.In conclusion, these results underlined the proof of concept that this strategy combining NMD inhibitor and readthrough activities could be applied to CMT patients exhibited nonsense mutations in GDAP1. He presented a severe axonal peripheral neuropathy and a polyvisceral disorder, which led to his death at the age of three. The control was a healthy 24-year-old male donor. Previous investigations allowed us to determine that the healthy individual did not show any signs of peripheral neuropathy, and did not carry any mutations in GDAP1 hiPSCs clones of both subjects were obtained as previously described [2. The culture medium was changed daily. Passages were carried out every 5 to 8 days using StemMACS Passaging solution XF .The human induced pluripotent stem cells (hiPSCs) were obtained from dermal fibroblasts of a CMT patient and a control subject. The patient was a male child carrying the homozygous c.581C>G (p.Ser194*) mutation in escribed . hiPSCs The differentiation protocol was adapted from Hörner et al. . BrieflyAmlexanox was purchased from Sigma-Aldrich (ref: SML0517), and dissolved at 25 mM in DMSO. G418 was purchased from Life technologies, Waltham, MA, USA (ref: 11811031), and dissolved at 100 mg/mL in water.At day 10, NPs were seeded at a density of 500,000 cells in a 12-well plate, previously coated with Geltrex. Culture medium completed with small molecules (previously described in GDAP1 gene and exons 7 and 8 of the TATA box binding protein (TBP) gene, chosen as the reference gene. All primers used are reported in TBP as endogenous control gene.RNAs were extracted from patient and control NPs following the instructions of the RNeasy Plus Mini Kit . Reverse transcription of 1 μg of total RNA into cDNA was performed using the QuantiTect Reverse Transcription kit (QIAGEN) and following the manufacturer’s protocol. The analysis of gene expression was carried out by real-time quantitative PCR (qPCR). Primers were designed spanning the exon/exon boundaries, of exons 5 and 6 of the TM 488 or Alexa FluorTM 594; Molecular Probes, Thermo-Fisher SCIENTIFIC, 1:2000 dilution), for 1 h at room temperature. Nuclei were stained with 2 µg/mL 4′,6′-diamidino-2-phénylindole dihydrochloride (DAPI) . Images captures were acquired using a fluorescence microscope . All antibodies’ dilutions and references are reported in Expression of GDAP1 protein has been assessed by immunofluorescence (IF). NPs were seeded on glass slides coated with diluted Geltrex. On day 4, cells were treated with DMSO, or molecules, using preset concentrations according to literature. After 20 h of treatment, cells were fixed for 10 min with 4% paraformaldehyde (PFA) , and then permeabilized with 0.1% Triton X-100  for one hour. Cells were incubated overnight at 4 °C with the primary antibody, prepared in 3% BSA /DPBS (Thermo Fisher SCIENTIFIC), then the next day with the secondary antibody , at room temperature. NPs, were than rinsed with distilled water. Dehydration was performed by a series of ethanol dilutions: 30%, 50%, 70%, 95%, and 100%., cells were embedded in Epon 812. Selected thick blocks were stained with uranyl acetate and lead citrate, and finally analyzed by Jeol 1011 electron microscope. Experiments for electron microscopy, were conducted in Neurology and Anatomic Pathology departments at University Hospital of Limoges.p < 0.05 was considered significant).Statistical analyses were performed using the GraphPad Prism 8 software . Data were presented as the mean ± SEM (Standard Error of the Mean). Data were compared using the nonparametric Mann–Whitney test (GDAP1 gene, mimicking the condition of patients with CMT. These results underline that combining readthrough and NMD inhibitors activities could be used in these genetic alterations involved in CMT, opening the way for future investigations and a potential therapy in patients without efficient treatment.In conclusion, this study demonstrates for the first time the efficiency of amlexanox to restore the synthesis of GDAP1 protein and mitochondrial morphology in a NP model exhibiting an UGA-PTC mutation in the


At 12 months postoperatively, the average ECD was 1376 ± 509 cells/mm2 with a mean decrease of 56.8 ± 19.1% from the preoperative donor count. At 12 months, four out of six eyes had significantly improved and reached a BCVA of ≥20/25 . The mean CCT significantly decreased from 788 ± 138 μm before surgery to 576 ± 30 μm at 12 months postoperatively (p < 0.01). Conclusions: Hemi-UT-DSAEK grafts using pediatric donor corneas are surgically feasible and can provide similar clinical outcomes compared to conventional UT-DSAEK. Transplanting pediatric donor tissues with high ECD into two patients could potentially increase the donor tissue pool to treat endothelial disease.Objective: We sought to evaluate the clinical outcomes of hemi-UT-DSAEK grafts from the pediatric donor corneas of patients affected by Fuchs Endothelial Corneal Dystrophy (FECD). Methods: A prospective, interventional case series was conducted at the Ophthalmology Department of Venice Civil Hospital and the Veneto Eye Bank Foundation . Six eyes of six patients affected by FECD received large-diameter, semicircular hemi-UT-DSAEK grafts obtained from three pediatric donor corneas using the standard pull-through method. Endothelial cell density (ECD), central corneal thickness (CCT), best-corrected visual acuity (BCVA) and intraoperative and postoperative complications were recorded at different time intervals up to 12 months. Results: The average donor age was 64.6 ± 8.6 years, and the pre-operative ECD was 3266 ± 225 cells/mm Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) is the most frequently performed subtype of endothelial keratoplasty for the treatment of Fuchs Endothelial Corneal Dystrophy (FECD) . In receSix eyes of six patients affected by stage II FECD were involved in this prospective, interventional case series. The present study was conducted according to the Declaration of Helsinki and was approved by the local ethics committee. All patients provided written informed consent before surgery.One cornea from a 3-year-old donor and two corneas from a 10-year-old donor were used. The donor consent was obtained from the parents. Graft tissues were prepared at the Veneto Eye Bank Foundation  using the microkeratome-assisted double-pass technique, as previously described by Busin et al. . BrieflyAll surgical procedures were performed by a single expert surgeon (P.L.) at the Ophthalmology Department of Venice Civil Hospital  between April 2021 and July 2021. The peripheral cornea was clear in all cases, and the central area affected by guttae was greater than 5 mm in diameter; hence, the patients were not suitable for descemetorhexis without endothelial keratoplasty (DWEK) procedure. Two eyes were pseudophakic, and out of the remaining four phakic eyes, three underwent combined phacoemulsification, intraocular lens implantation and endothelial keratoplasty. A complete descemetorhexis was performed in all the eyes.In the operating room, the pre-cut corneoscleral buttons were divided into two equal halves with a surgical diamond knife and implanted, following a standard pull-through technique, with a modified Busin glide. While the anterior chamber was maintained with fluid, each graft was carefully oriented with the widest diameter along the horizontal meridian. An air bubble was then injected into the anterior chamber underneath the graft to keep it pressed against the recipient stroma. The anterior chamber was completely filled with air for up to 120 min, and the patients were instructed to lie in the supine position. All the patients were examined two hours after surgery using the slit-lamp examination, and some air was removed, leaving the eye at 50% minimal residual air. Postoperative management included antibiotic (netilmicin 0.3%) and steroid (dexamethasone 0.1%) eye drops six times a day for three months with a slow tapering off over a period of six months, and the treatment was stopped after six months. Patients underwent a follow-up ophthalmic examination at 1 day, 1 week and 1, 3, 6, 9 and 12 months postoperatively. Each follow-up included a slit-lamp examination, best-corrected visual acuity assessment (BCVA), endothelial biomicroscopy , anterior-segment optical coherence tomography (AS-OCT) and pachymetry . The postoperative ECD was calculated centrally in the recipient patient’s cornea from the equivalent paracentral area of the hemi-UT-DSAEK graft. The later time points were compared with the pre-surgical/donor values using Friedman’s repeated-measure non-parametric test with Dunn’s post hoc test  to obtain statistical significance.n = 1) and 9.00 mm (n = 2). The peripheral cornea was clear in all the cases, as we included only grade II FECD patients. The preoperative mean ECD of the peripheral cornea was 1853 ± 452 cells/mm2. The postoperative ECD was calculated centrally in the recipient patient’s cornea from the equivalent paracentral area of the hemi-UT-DSAEK graft.The donor graft thickness, after preparing the UT-DSAEK graft, was found to be in the range of 87–130 μm with a diameter of 8.75 mm . After surgery, all the grafts were well-centered and completely attached A. One eyp < 0.01) (2 (range 3000–3500 cells/mm2) preoperatively to 1538 ± 565 cells/mm2 at 6 months (p < 0.05) and 1376 ± 510 cells/mm2 at 12 months (p < 0.001) after surgery (p < 0.05) and 577 ± 31 μm at 12 months postoperatively (p < 0.01) . One of the two remaining eyes underwent a rebubbling procedure for graft detachment and experienced an improvement in BCVA from 20/200 to 20/32 , while the other eye remained stable  due to pre-existing glaucoma. Overall, BCVA significantly improved from 1.1 ± 0.6 logMAR  to 0.32 ± 0.5 logMAR at 6 months (<0.05) and 0.27 ± 0.5 logMAR at 12 months ( < 0.01) B. The do surgery C. The me < 0.01) D (Table  < 0.01)  (Supplem < 0.01) .The concept of hemi-DMEK was introduced in 2014 by Lam et al. , when thp < 0.01) and 577 μm at 12 months postoperatively (p < 0.001), showing similar results to hemi-DMEK. The results following DMEK are expected to be homogeneous due to the uniform thickness of the graft; however, we did not find any difference in the outcome measures following the UT-DSAEK transplants even when the graft thickness ranged from 87 to 138 µm  to 533 um at 1 year postoperatively , whereaso 138 µm . The deno 138 µm .2 (range 3000–3500 cells/mm2), whereas the general healthy adult ECD ranges are between 2000 and 3000 cells/mm2 [Although corneal grafts from younger donors are more difficult to handle, hemi-UT-DSAEK with grafts obtained from pediatric donors are technically feasible and provide higher ECD than grafts from adult corneas. However, it is recommended to maintain consistent pressure in the artificial anterior chamber during UT-DSAEK preparation to avoid any perforations. In the present study, the preoperative mean graft ECD was 3266 ± 225 cells/mmells/mm2 . The graells/mm2 .The use of hemi-DMEK grafts with larger diameters has been reported previously . Romano 2) than pediatric corneas, have been reported previously. In our case series, the initial decrease in ECD within the first month was sharper than that of standard UT-DSAEK, but it may be compensated by the higher ECD of younger donor corneas [A 12 postoperative months, the ECD showed a mean decrease of 56.8% from the preoperative donor count, most of which (35.3%) occurred in the first month. Lam et al. showed a similar decrease after hemi-DMEK (31–49%) in the initial months ,25, wher corneas . Lam et In terms of visual outcomes, Birbal et al. described a BCVA of ≥20/40 in 86% of patients following hemi-DMEK, which remained stable for 2 years and improved thereafter . Lam et The visual outcome after UT-DSAEK indicates that the use of thin grafts allows a higher number of eyes to achieve early visual rehabilitation. However, the percentage of eyes recovering 20/20 vision after UT-DSAEK is lower ,21,32,33Graft survival probability following UT-DSAEK grafts has been shown to be roughly 98% and 96% at 12 and 24 months . Price en = 1), secondary graft failure (n = 1) at 2.5 years and suspected allograft reaction after 1.5 years (n = 1) postoperatively [n = 1) and ocular hypertension (n = 1) one week after surgery, which were successfully treated.Following hemi-DMEK, Birbal et al. reported a rebubbling rate of 40% with complications such as persistent graft detachment (ratively , whereasratively . AlthougDespite the limited sample size of our case series, the clinical outcomes of hemi-UT-DSAEK using pediatric donor corneas are encouraging, especially as they are comparable with standard UT-DSAEK. Transplanting a hemi-UT-DSAEK graft is surgically feasible and could potentially increase the availability of donor tissues for endothelial keratoplasty. Experienced surgeons may accept grafts from younger donors with confidence and consider performing hemi-UT-DSAEK. In fact, these grafts can also be prepared by eye banks and shipped as preloaded tissues to further enhance their quality and validation , in addi


In view of the importance of neck strength training and the lack of adequate training equipment, this study designed a new oscillating hydraulic trainer (OHT) of neck based on oscillating hydraulic damper. We used surface electromyography (sEMG) and subjective ratings to evaluate the neck OHT and compared the results with a simple hat trainer (HATT) and traditional weight trainer (TWT) to verify the feasibility and validity of the OHT. Under similar exercise conditions, 12 subjects performed a set of neck flexion and extension exercise with these 3 trainers. The sEMG signals of targeted muscles were collected in real time, and subjects were asked to complete subjective evaluations of product usability after exercise. The results showed that the root mean square (RMS%) of sEMG indicated that the OHT could provide two-way resistance and train the flexors and extensors simultaneously. The overall degree of muscle activation with OHT was higher than that with the other two trainers in one movement cycle. In terms of resistance characteristics exhibited by the sEMG waveform, duration (D) with OHT was significantly longer than HATT and TWT when exercising at a high speed, while Peak Timing (PT) was later. The ratings of product usability and performing usability of OHT were remarkably higher than that of HATT and TWT. Based on the above results, the OHT was proved to be more suitable for strength training, such as neck muscles, which were getting more attention gradually, but lacked mature and special training equipment. The incidence and burden of neck injury has gradually attracted people’s attention. Individual and social costs of severe head and neck injury could be very high . The incIt is generally believed that neck strengthening may result in fewer neck injuries ,11. In rSince neck muscle strength training can reduce the risk of injury, applying the principle of traditional gravity trainer into the design of neck muscle training equipment was currently a way that could be seen  of muscle activities. By comparing the activation degree and mode of relevant muscles in the neck exercise process, the influence of different trainers on the resistance traits of neck muscles was explored. Subjective ratings of the product usability were evaluated by referring to the satisfaction assessment model of Ren . The proOscillating hydraulic trainer (OHT) is mainly divided into five parts: the oscillatory hydraulic damping device, adjustment mechanism, swing arm, electric height adjustment support post, and support base. This is shown in ω is the swing angular velocity, c is the throttle over current coefficient, ρ is the fluid density, α is the throttle area, p is the fluid pressure, p0 is the return pressure, A is the blade area, and dR is the oscillation cylinder equivalent radius [The core component of the trainer is the oscillatory hydraulic damping device; as shown in t radius . From Eqt radius . The nect radius . Thus, iAccording to the human morphological data of Chinese adults , we desiA total of 12 healthy men were recruited as subjects to participate in the experiment. The basic information was as follows: age 23.8 ± 1.7 years, height 176.7 ± 5.2 cm, weight 69.3 ± 4.3 kg, no neck and shoulder musculoskeletal injuries. In order to ensure the validity of the experiment, subjects were required not to participate in any heavy physical activities within 24 h before the experiment to avoid muscle fatigue producing deviation in the experimental results. Before the experiment, all participants understood the purpose and process of the experiment, signed the informed consents, and registered their personal information.The simple hat trainer (HATT) could perform neck flexion and extension exercise with the steel wire rope, pulley, and barbell pieces. The resistance load was changed by adjusting the number of barbell pieces. It was purchased online.The overall structure of the TWT was consistent with the aforementioned OHT. The training resistance was achieved by gravity pulling.Subjects adjusted the resistance load by turning the knob on the hydraulic cylinder. The load range was from 1 to 12 gears, which could meet the needs of light, medium, and heavy resistance.A mobile phone  was used to play the animation videos to guide the subjects’ neck flexion and extension speed.A multichannel physiological signal acquisition system  was used in the experiment to collect sEMG signal data for targeted muscles. Disposable Ag/AgCl electrodes were used, and the gel-based electrodes had a diameter of 30 mm and a distance of 2 cm between detecting electrodes. The sampling frequency of sEMG data acquisition was set to 1024 Hz.A 2-factor (3 trainers × 2 speeds) within subject experimental design was used in this study. Trainer types were the HATT, TWT, and OHT, and angular speeds of neck movement were 60°/s and 120°/s.There were 4 muscles that could be used for sEMG detection in the neck joint, namely, semispinalis capitis, splenius capitis, sternocleidomastoid muscle (SCM), and upper trapezius (UT). However, according to the study of Queisser et al., sEMG signal detection of semispinalis capitis was greatly limited . In ordeAfter skin was lightly abraded and swabbed with alcohol, the electrode was placed on the corresponding site of the target muscles. The sternocleidomastoid electrodes were placed adjacent to a point 30% of the distance from the sternal notch to the mastoid process and over the muscle belly of the sternal head. The upper trapezius electrodes were placed in the middle between the C6 spinous process and the lateral acromion . Each paSubjects sat on the trainer and wore the HATT attached to a steel wire rope. The steel wire rope was connected ahead to the force sensor horizontally by a pulley, and the other end of the sensor was fixed to the ground. After the subject’s warming up moderately, the maximum isometric flexion and extension at the neck position of 0° were performed. The sEMG signals were recorded during experimental for the amplitude standardization of relevant muscles . The MVCThirty percent of the average of the three times of MVC for each subject was used as the resistance load for the HATT and TWT . Then, tAfter the end of all MVC tests, 20 min of rest was provided. Then, the subjects performed 5 neck flexion and extension training at 60°/s and 120°/s with 3 trainers . The speed was guided by the animation video. That is, each subject needed to complete 6 sets of neck flexion and extension exercise (3 trainers × 2 angular speeds), and the action angular range was −45~45°. The experimental process is shown in 1), including the aesthetically pleasing (A11), the sense of coordination (A12), and texture (A13); (2) performing usability (A2), including controllability of the product (A21), ease to adjust (A22), fault tolerance (A23), efficiency (A24), and man–machine (A25); (3) perceived usability (A3): product satisfaction (A31), reliability (A32), and comfortability (A33). Rating was on a 5-point scale: 1—very dissatisfied, 5—very satisfied. The indicators and weights are shown in After completing the 6 sets of exercises, subjects were also required to complete a subjective survey for the ratings of product usability referring to Ren’s research. The survey asked each subject to rate from the following three categories for product usability (A): (1) appearance usability  was used to represent the degree of muscle activation. The activation duration (D) and the peak timing (PT) of the sEMG signal waveform were used to characterize the muscle activation pattern.t represents the sample start time of the signal data, and t + T is the sample end time. In order to reduce the differences between individuals, the sEMG amplitude index was usually normalized (or standardized) based on signals under MVC for analysis and comparison. The normalization process calculation formula was as follows:The RMS value of the sEMG signal was used to express muscle activation intensity . In the In statistical analysis, the RMS% of left and right eponymous muscles were averaged to represent the neck flexor or extensor muscles.When analyzing and comparing the total amount of muscle activation in a single flexion and extension cycle with different trainers, the RMS% of neck flexor and extensor muscles were averaged to represent it.The sEMG original signals were full-wave rectified, 4th-order Butterworth filtered, and 7 Hz cutoff. The length of muscle activity between onset and offset was defined as duration (D) . The onset and offset thresholds were determined as 20% of the peak amplitude of the sEMG signal. The detailed process referred to the research of Hull et al. . The schPT was expressed as a percentage with the following formula:Total, D and PT were calculated by the average value of left and right muscles with five-time exertions. They were used to indicate the activation characteristics of the relevant muscles during neck flexion and extension.In the same manner as RMS%The subjective evaluations of the three trainers were carried out by product usability survey, which was calculated by taking the weights of apparent usability, performing usability, and perceived usability into account. The indicators and weights are shown in SPSS 26.0 was used for statistical analysis of all processed data.p < 0.001. However, during the neck flexion, the RMS% of SCM muscle with the OHT was significantly higher than the HATT and TWT, p < 0.001. The results are shown in As shown in p < 0.001). The effect of three trainers on RMS% was also significant. The RMS% with the OHT was significantly greater than the other 2 trainers (p < 0.001). There was no significant difference of RMS% between HATT and TWT . The interaction effect of speed and trainer on RMS% was very significant (p = 0.001).In order to observe the overall muscle activation when subjects performed neck flexion and extension with the three trainers at different speeds, the RMS% of the agonist muscles and antagonist muscles of neck flexion and extension were averaged for observation. The results are shown in Hull used the waveform after sEMG signal rectification and filtering to reflect the activation state of leg muscles when the cyclist was paddling a bike. In this study, subjects were asked to perform neck flexion and extension exercise. Since the HATT and TWT only can give one-way gravity load ahead in this experiment, the resistance was only applied in the direction of neck extension during exercising. Therefore, the sEMG signal of the upper trapezius was processed during neck extension. Then, the duration (D) and peak timing (PT) were compared among the three trainers.p < 0.001). Further comparison of D among three trainers was used at different speeds. The D of sEMG waveform with the OHT was significantly shorter than that with the other 2 trainers at low speed , but was longer than the other 2 trainers at high speed .The D and PT of the sEMG waveform with the three trainers at two speeds are shown in p = 0.004 and p < 0.001) on the PT during neck extension. The interaction of speed and trainer was not significant (p = 0.753). The PT of sEMG waveform was earlier at a faster neck extension than a slower extension in all trainers. Regardless of the speed of neck extension, the PT of sEMG waveform with the OHT was significantly later than that with the HATT and TWT.There were significant speed and trainer effects (p = 0.047). Apparent usability and perceived usability did not differ obviously among trainers . The performing usability of OHT was the highest among the 3 trainers (p = 0.014).The subjective evaluation results of the three trainers are shown in There was research comparing the effectiveness of the pin-load neck exercise machine and elastic resistance bands; no significant difference was found . In thisSome of the roles and functions of the neck musculature may be not identical to those of the limbs or trunk, and thus the strength and conditioning needs of the neck might be different ,35. The RMS was an indicator that characterizes the magnitude of the amplitude of the sEMG signal, reflecting the degree of activation or exertion of local muscles ,37. It wThe sEMG waveform after rectification and filtering could reflect the exertion characteristics of muscles. The duration (D) between sEMG onset and offset represented the length of time the muscle contracting. In this experiment, the HATT and TWT provided one-way gravitational resistance, thus the continuous contraction time of the neck extensor group was remarkably long during slow movement, and it was relatively shortened during rapid movement. Since the OHT provided passive hydraulic resistance, D of extension with OHT appeared shorter than that with the HATT and TWT when performed at a low speed. However, in the case of fast motion, gravitational trainers could provide greater resistance in the early stage, but might be a lack of sufficient resistance in the later stage due to mass inertia caused by high speed. The D of sEMG waveform in OHT under fast motion was significantly longer than that in the HATT and TWT. It showed that OHT can provide more adequate resistance stimulus for speed endurance training. This characteristic was especially suitable for strength training of athletes who overcome fluid resistance, such as swimming and aquatic sports. In these kinds of sports, athletes need to overcome the water resistance as consistently as possible in their range of motion , which wPeak timing (PT) of muscle contraction has been investigated in previous studies. Wirianski A. described changes in EMG using duration, time from EMG onset to peak EMG, and peak time relative to the onset . To somep < 0.05. The results showed that users were satisfied with the OHT on the whole. The advantage of the OHT may be mainly reflected in performing usability (4.18 ± 0.47), which was higher than the HATT (3.24 ± 1.09) and TWT (3.58 ± 0.51), p < 0.05. The reason may be that the OHT only needs to rotate the damper’s throttle valve knob to achieve stepless adjustment of damping resistance. People will not give a high score for the evaluation of simple apparatus in accordance with human nature [Product usability was defined as “for users, the product can be effective, efficient and satisfactory to the level of specific goals” . Though n nature . For theIn this paper, a new neck oscillating hydraulic trainer was designed based on the oscillating hydraulic damper, and compared with the simple hat trainer and traditional gravitational trainer by objective test and subjective evaluation. Using the OHT can carry on two-way resistance training, thus the exercise volumes were almost twice as much as that using one-way gravitational trainers. The compliance of hydraulic resistance was safer and more suitable for neck strength training in multiple populations. The new neck OHT had high scores on performing usability and product usability evaluation, which reflected high user satisfaction and was more appreciated by users. Therefore, the OHT could provide a more efficient, safer, and better experience option for neck strength training.The limitation with this study was that only healthy men were tested, while women and people with neck injury were not included in the experiment. Different groups using these trainers might have different sensations and effects; therefore the objective and subjective data in the experiment should be narrowly interpreted. The task carried out in the experiment was dynamic flexion and extension exercises in the sagittal plane, which was likely to limit the generalizability of the results to some extent. Therefore, in future studies, we would consider carrying out the test of various groups including women and patients with neck injury, and test of the neck lateral flexion  trainers with the same damping principle to verify the feasibility and validity of the new neck strength trainers.


Conversion from intravenous (IV) antibiotics to an oral (PO) in eligible patients is an important antimicrobial stewardship strategy. Recently, King Abdul-Aziz University Hospital (KAUH) in updated its IV to PO conversion policy. This policy describes eligibility criteria for patients to be switched to oral therapy from IV and it suggests PO alternative to IV medications. The aim of this prospective observational study is to observe IV to PO conversion practices on selected antimicrobials in selected ward after updating and implementing this policy.Adult patients admitted to the medical, surgical, and hematology/oncology wards who received either metronidazole, ciprofloxacin or clindamycin IV were evaluated for antibiotic need and for eligibility for IV to PO conversion according to the policy. Evaluation period spanned from November 2021 – December 2022.194 patients were evaluated. Of them, 154 (80%) had a clear indication for the antibiotic of which 98 (63%) required IV administration for the following reasons: impaired oral route (59%), impaired gastrointestinal absorption (15.3%), acute treatment phase of the infection (15.3%), and other reasons such as surgical prophylaxis (3%) and severe sepsis/septic shock (2%). The remaining 56 (36.7%) met the policy’s eligibility criteria for IV to PO conversion.We found that most patients received antibiotics appropriately in the appropriate route for an existing indication. However, there are plenty of opportunities for improvement in discontinuing unnecessary antibiotics and de-escalating from IV to PO. Ideally, this discussion should be had while rounding on the patient for collective decision making at the point of care.Nour Baghdady, PharmD, BCPS, MPH, BCIDP, CSL Seqirus: Advisor/Consultant|CSL Seqirus: Stocks/Bonds


The primary aim of this study is to evaluate heterogeneity in the current management of testicular torsion (TT). A secondary aim is to investigate incidences of recurrent torsion and the methods used for primary fixation. An online multiple-choice questionnaire comprising 10 questions was distributed to paediatric surgeons and urologists. There were a total of 99 questionnaires distributed to representatives from 39 paediatric surgery and urology departments in Poland. The majority of participants agreed on fixation of the torsed testicle (98%). Use of sutures was reported by 95% of surgeons: absorbable by 48%, non-absorbable by 42%, and 4% using both. There was no consensus on the number of sutures. The contralateral testicle was always fixed by 69%, with 28% fixing it only in case of necrosis and amputation of the torsed testicle, and the remaining 2% never fixing the contralateral side. In case of negative scrotal exploration, 18% of surgeons would still fix the testis. The recurrence of torsion after prior fixation was identified by eight of the participants. The most commonly reported primarily used technique was absorbable sutures. There is a general consensus on the fixation of torsed testicles; however, other aspects remain controversial. Based on the survey and the literature review, the use of non-absorbable sutures rather than absorbable sutures would be advisable. Testicular torsion (TT) nowadays is known as an emergency condition requiring prompt diagnosis and surgical intervention. However, it was only in 1895 when Hutchinson suggested that this condition should be referred to a surgeon rather than a psychiatrist ,3,4. TheIt is widely accepted that suspected TT requires urgent surgical intervention. The severity of consequences resulting from torsion depends on two key factors: the degree of torsion, which can range from 180 to 1080 degrees, and the time taken to untwist the testicle. According to Zvizdic’s research on the duration of symptoms, the latter factor is particularly crucial in determining the extent of damage. Time is a critical aspect, as irreversible changes may occur within just 4 h of symptom onset . Delays The primary aim of this study is to evaluate the heterogeneity in the current management of TT in Poland. A secondary aim is to investigate incidences of recurrent torsion and the methods used for primary fixation.A recruitment email was sent to paediatric surgeons and paediatric urologists practising in Poland, with a link to an online survey. The questionnaire was distributed to all departments of Paediatric Surgery in Poland via the National Consultant of Paediatric Surgery, the Polish Paediatric Surgeons’ Association, and e-mail requests. The survey was taken online, open (non-anonymous), and voluntary. All participants were informed of the purpose of the study. The respondents were asked to answer questions according to their practice. The survey included 10 questions concerning methods of operation, fixation preferences, management of the contralateral testis, removal of an appendix of testis, and recurrence rates of scrotal explorations. Questions were multiple choice and some of them contained an additional comment section to allow participants to add supplementary information. Only respondents that completed the survey were included in the study. The questionnaire is included in A total of 99 questionnaires were issued. Participants represented 39 out of 60 departments of paediatric surgery in Poland. The complete respondent demographic is displayed in The majority of respondents (98%) fix the testicle after torsion. However, only three (3%) participants rely entirely on sutureless fixation of the testis. As a result, 94 (95%) respondents used sutures to fixate the torsed testicle. However, there was no consensus on the type of sutures used. Absorbable sutures were used by 48 (48%) surgeons, while non-absorbable sutures were used by 42 (42%), and 4 (4%) surgeons used both types. Similarly, the respondents also disagree on the number of sutures used, with the most common response being two sutures for fixation (57%).A total of 69 participants always fixate the contralateral testicle, with the remaining 28 fixating it only in the case of necrosis and amputation of the torsed testicle, and 2 respondents never fixate the contralateral testis. There is also a discrepancy in timing of the fixation. The majority prefer to perform a one-step procedure, while the others opt for scheduling an elective surgery within a few weeks of the main event. As a result, according to our survey, 30% of surgeons perform contralateral orchidopexy as a subsequent procedure. There are three approaches described by participants to gain access to the torsed testicle: via individual incisions on both sides (80%), through the septum (17%), or through a midline incision (1%).Only four (4%) respondents would not remove the Morgagni appendix during exploration, while the remaining surgeons routinely excise it. If the diagnosis during the operation reveals a condition other than torsion, 18% of the surveyed surgeons would still opt for testicular fixation. Additionally, some participants (5%) stressed the importance of fixation when an anatomical anomaly is detected. Three surgeons reported an inconsistent approach to managing normal testicles without torsion during operation.The need for re-exploration of the testicle after previous surgery for TT was reported by fifteen surgeons. Recurrences of torsion after prior fixation were identified by twelve of the participants. The techniques used in previous cases were as follows: absorbable sutures were used in six cases, including two participants from the same centre; non-absorbable sutures were used in four cases, including two participants from the same centre; sutureless fixation was used in one case; and there was no data available on the fixation method used in one case. Two surgeons reported the need for re-operation due to bleeding or haematoma, while another two had observed abscess formation. In three cases there was testicle atresia observed and amputation was carried out.In light of the fact that there are no national recommendations to follow, the care of patients with suspected TT is highly dependable on the decision-making surgeon. Although the EAU’s ESPU Guidelines exist, they are not universally followed, and the management of TT can vary between healthcare facilities. While the development of TT and the best treatment algorithms are still debated, new data continue to surface in the literature.It is well known that prolonged ischemia time will cause irreversible injury and atrophy of the gonad involved . In a reIt is generally agreed that emergency surgical exploration is mandatory if a diagnosis of TT cannot be ruled out. To prevent re-torsion, fixation is advised. This statement is in agreement with our survey results 98%). However, there is no consensus on how the fixation should be achieved. In the literature, a variety of descriptions of methods used to fixate the torsed testicle are present. In our survey, most of the participants (95%) use suture fixation. The efficacy of fixation techniques was assessed in several animal studies 8%. Howev,11. MorsAnother controversial aspect is the number of sutures used to fix the testicle. According to the results of our survey, the most frequent response was two-point fixation, which was chosen by 57% of the participants. To our knowledge, there are no data showing a comparison of the advantages and risks of using a certain number of sutures. However, the existing reference literature recommends three-point fixation using non-absorbable sutures ,15,16,17The majority of participants in the study (70%), shared a view of the need for routine contralateral exploration and fixation of the testis. The necessity of the contralateral fixation is usually explained by a high incidence of bilateral bell clapper deformity and therefore, the risk of anorchia ,16. The There are also reports of bilateral synchronous torsion identified in newborns with minimal clinical manifestation . HoweverHowever, this management was called into question by Arnbjornsson et al. It was presented in the study that during the observation period (mean: 7 years), no contralateral torsion was reported. Some have argued that in cases where the risk of contralateral torsion is low, the potential harm caused by contralateral fixation outweighs its benefits . Djahangirian et al. reinforces that testis fixation may lead to complications, as he reported in the study that 18% of patients had postoperative complications, such as recurrent hydrocele, wound infection, or urinary tract infection. In addition, six patients developed ipsilateral testicular atrophy .One of the predisposing factors for TT described in the literature is a bell clapper deformity . In thisCaesar et al. presented in his autopsy series that the incidence of the bell clapper deformity was 12%, suggesting that other factors must be involved in addition to the anatomic anomaly .Notably, a higher percentage (68%) of our respondents favoured contralateral exploration upon initial exploration. Some respondents delayed the timing of contralateral fixation surgery, arguing that prolonged torsion can cause excessive inflammatory reactions in the scrotum, and therefore the surgery should be performed at a later stage. However, this approach requires an additional hospital stay and procedure under general anaesthesia, which carry relative risks. Furthermore, a recent study by Hampl et al.  reportedThe recent study by Koh et al. reported a low incidence of postoperative complications in exploration of the other side due to testicular appendage torsion. The study also noted that selecting a midline raphe incision may allow for simultaneous bilateral exploration . HoweverA vast majority (96%) of surgeons in our survey routinely excise the appendix testis in order to pre-empt torsion of the appendix in the future. Similar results were achieved in a survey on operative management of TT in the UK and Ireland, by Bolln et al. . There are no guidelines regarding the management of the testis in negative exploration, where the testis is found to be non-torsed. In our survey, 18% of respondents would proceed with fixation, while another 8% would consider it under special circumstances, such as the presence of an anatomical anomaly. In the literature, there is no consistency regarding management ,26. Naumann et al. describe orchidopexy during negative exploration as an unnecessary procedure, which is performed due to the lack of guidelines and proper training. In this study, 57% of patients without a diagnosis of TT underwent ipsilateral orchidopexy, and 14% underwent contralateral orchidopexy. Orchidopexy was more often performed by general surgeons than by urologists .There are reported complications after exploration and fixation of the torsed testis, including haematoma, abscess formation, and atrophy of the testis. In our survey, six surgeons reported re-operations due to complications. In some studies, it is shown that up to 54% of patients develop testicular atrophy after TT ,28,29. PIt is important to note that orchidopexy might not guarantee the prevention of potential future torsion, and thus might give doctors and patients a false feeling of safety. There are numerous reports of re-torsion in the literature. Those studies demonstrate a correlation between the recurrence of torsion and the use of absorbable sutures ,25,29.Various studies on animals have suggested that unilateral TT may cause damage to the contralateral testicle ,31. FurtThe primary reasons for follow-up in patients after TT are potential fertility and hormonal disturbances, although the exact consequences remain inconsistent in published data, as noted by the EAU guidelines . AlmekatOur study has some limitations which must be acknowledged. First, the ability to gain access to the wide scope of surgeons from all hospitals and regions practising in Poland was limited. Taking that into account, the people who responded to these survey questions may not be a truly random sample. Second, our population was restricted only to paediatric surgeons and paediatric urologists, and thus there is a potential for sampling bias. It is important to note that general surgeons or urologists, who were not included in this study, may have different approaches to treatment. The study is also limited to surgeons from Poland; therefore, it would be beneficial to compare the data with professionals in other countries.Our data validity, as with any self-reported survey, may potentially be threatened by response biases, where the format of the question or the nature of the previous questions may have had an unwanted impact on how a person responded to the survey.Despite these limitations, we believe that our findings are meaningful.First, to our knowledge, there is no prior study exploring the heterogeneity in the clinical management of TT in Poland. Second, the variety of responses and collected literature data reveal that there is a need for further studies regarding the proper management of TT, in order to preserve reproductive capabilities.In conclusion, this survey demonstrates a wide variation in practices of TT management amongst paediatric surgeons in Poland. The emergency procedure for TT is highly dependent on the decision of the caring surgeon. The most controversial aspect is the method used for the fixation and management of the contralateral testis. There is also a lack of consensus in the literature regarding evidence-based practice. There is an indispensable need for future studies on multi-centre and long-term outcomes of the effects on the testicles after an incident of torsion. To provide the best patient care, all of the benefits and risks must be weighed with proper counselling of patients and their parents in order to facilitate a better understanding. Therefore, there is a need to establish national guidelines in order to provide homogenous management of TT.


Perivascular spaces (PVS) are fluid-filled compartments that dilate in response to many different conditions. A high burden of enlarged PVS (EPVS) in the centrum semiovale (CSO) has been linked to neurodegeneration. Moreover, an increase in cerebrospinal fluid (CSF) levels of aquaporin-4 (AQP4), a water channel expressed on PVS-bounding astrocytes, has been described in patients with neurodegenerative dementia. Our aim was to investigate the relationship between neurodegenerative diseases and two putative glymphatic system biomarkers: AQP4 and EPVS.We included 70 individuals, 54 patients with neurodegenerative diseases and 16 subjects with non-degenerative conditions. EPVS were visually quantified on MRI-scans applying Paradise’s scale. All subjects underwent lumbar puncture for the measurement of AQP4 levels in the cerebrospinal fluid (CSF). CSF levels of amyloid-β-1-42, phosphorylated and total tau (tTau) were also measured. Linear regression analyses were adjusted for age, sex, education and disease duration, after excluding outliers.p = 0.001), basal ganglia  and centrum semiovale EPVS . tTau levels predicted CSO-EPVS . Moreover, increased levels of AQP4 were strongly associated with higher levels of tTau in the CSF .Cerebrospinal fluid (CSF)-AQP4 levels were independent predictors of total (β = 0.28, standard error [SE] = 0.08, We provide evidence that CSO-EPVS and CSF-AQP4 might be clinically meaningful biomarkers of glymphatic dysfunction and associated neurodegeneration. Perivascular spaces (PVS) are fluid-filled compartments that run parallel to penetrating arterioles in the brain and lie between endothelial cells and astrocytes . PVS havRecently, we found increased levels of AQP4 in the CSF of patients affected by neurodegenerative dementia, which closely mirrored CSF tau levels .The main purpose of this pilot study was to retrospectively investigate the association between two putative GS biomarkers−AQP4 and EPVS−and established CSF biomarkers of neurodegeneration in a population of people with suspected dementia.For this study, we retrospectively recruited 70 subjects who underwent neurological workup at the Neurodegenerative Diseases Unit of the Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico in Milan  in suspicion of dementia.n = 6), psychiatric diseases (n = 5) or subjective memory complaints (n = 5). Patients with a diagnosis of vascular dementia were excluded. The number of cardiovascular risk factors  was rated in every included subject.Of them, 54 were finally diagnosed with neurodegenerative diseases−of which 39 with Alzheimer’s disease (AD), 9 with fronto-temporal dementia (FTD), 3 with Lewy-body dementia (LBD), 3 with other neurodegenerative diseases −according to the diagnostic criteria of each syndrome. The remaining subjects had negative CSF AD biomarkers and were diagnosed with stable mild cognitive impairment (1–42 (Aβ42), phosphorylated-tau at threonine 181 (pTau), total tau (tTau) and AQP4 levels in the CSF was performed in all subjects.All patients underwent a brain MRI using a 3T unit . Multiple MRI protocols were used, but all included three-dimensional T1-weighted images  and three-dimensional fluid-attenuated inversion recovery (FLAIR) scan . Moreover, a lumbar puncture for the determination of AβEnlarged perivascular spaces (EPVS) were visually rated by AA, a neurologist expert in neuroimaging and trained in EPVS counting, applying Standards for Reporting Vascular Changes on Neuroimaging (STRIVE) criteria  . Accordig for 10 min at 4°C. The supernatants were aliquoted in polypropylene tubes and stored at –80°C until use. Before freezing them, the samples were analyzed and CSF cell count, glucose, and total protein levels were calculated. CSF levels of Aβ42, tTau, and pTau were assessed using either a ChemiLuminescence Enzyme ImmunoAssay (CLEIA) by a Lumipulse G600II platform  or an ELISA method. Subjects for whom only older ELISA-based measurements were available were not included in subsequent analyses involving Aβ42 and tau proteins. AQP4 concentration in the CSF was determined with a specific ELISA kit from Cusabio for the whole population under study. The sensitivity of this assay or lower limit of detection of human AQP4 is typically less than 39 pg/ml, as reported by the manufacturer.1Lumbar puncture was performed in the L3/L4 or L4/L5 interspace between 8 and 10 am after a night of fasting. The samples were later centrifuged at 1,500 × 10(x)-transformed] on EPVS number [log10(x + 1)-transformed], adjusting for demographic and clinical characteristics . Moreover, the confounding role of different MRI protocols and cardiovascular risk factors was controlled for. Results with a p-value of < 0.05 were considered statistically significant.Data were analyzed using the statistical spreadsheets Jamovi 1.6.23 and RStudio 2022.07.2. At visual inspection, the distribution of EPVS and all CSF biomarkers was positively skewed; hence, data were log-transformed for correlation and regression analyses. After transformation, distributions of EPVS numbers were inspected and outliers (defined as being more than 3 SDs from the mean) were excluded. Pearson’s correlation test was used, after checking for normality with Shapiro–Wilk test. Multivariate linear regression analysis was used to determine the independent effect of different CSF biomarkers [logn = 3; 2 AD, 1 MCI) based on CSO-EPVS number, 67 subjects were included. Of them, 51 subjects had CLEIA-based measurements of Aβ42 and tau proteins available and were considered for analyses concerning AD biomarkers. Main demographic and clinical characteristics of the population under study are summarized in After excluding outliers . No other significant associations between CSF biomarkers and clinic-demographic data were found.Aquaporin-4 (AQP4) levels were negatively associated with mini mental state examination scores at the time of lumbar puncture , and CSO-EPVS were positively correlated with tTau . AQP4 and tTau were also positively correlated between each other   . Neitherp = 0.003) and tTau  levels in the CSF were significantly and independently associated with the presence of CSO-EPVS. In addition, AQP4 was an independent predictor of greater BG-EPVS  and total EPVS  burden and of higher tTau levels in the CSF  .Multivariate linear regression analyses revealed that higher AQP4  . AQP4 anIn this pilot study, we demonstrated that EPVS, particularly in the CSO, were strongly correlated with AQP4 levels in the CSF in a population of patients undergoing neurological work-up in suspicion of dementia. Moreover, we found that both CSO-EPVS counts and CSF-AQP4 levels were associated with levels of CSF-tTau, an established biomarker of neurodegeneration.Given the close spatial and functional link between PVS and AQP4 according to the GS model , the hypSeveral studies have described an association between MRI-visible PVS and neurodegenerative diseases, particularly in CSO white matter . MoreoveRegression analyses showed that higher levels of tTau in the CSF were predictive of a greater number of CSO-EPVS and were also associated with increased levels of CSF-AQP4.Some previous works explored the association between EPVS and tau pathology, with conflicting results. In a study by Our data show a strong association between tTau and CSO-EPVS but not BG-EPVS. This finding seems biologically conceivable, since GS dysfunction may limit effective waste removal from the brain, including tau , which cRegarding the relationship between tau and AQP4, our group already described a positive correlation between the CSF levels of tTau and AQP4 . Since pAlthough our research is rather preliminary and needs replication, our findings provide evidence that MRI-visible CSO-EPVS and AQP4 might be clinically meaningful biomarkers of glymphatic dysfunction and associated neurodegeneration. In fact, though the exact pathophysiology of PVS enlargement is still poorly understood, our data may suggest that a failure to eliminate waste products and abnormal proteins through the glymphatic pathway may lead to PVS dilation on one hand and hasten neurodegeneration on the other.Limitations of this study include the small sample size and its cross-sectional design, which prevents conclusions on the temporal and causal sequence of the events observed. In addition, different protocols were used for MRI acquisition, as a direct consequence of the retrospective nature of the study and its clinical setting. However, the confounding effect of different protocols was controlled for in regression models. A third limitation is that, although several PVS rating methods have been described, we used a visual rating scale applied by a single rater and restricted the quantification of PVS to two brain regions, BG and CSO. Though automated quantitative techniques for EPVS quantification exist  and haveOur study has several strengths as well: it is one of the first exploring the correlation between putative biomarkers of the newly described GS; it focuses on easily accessible biomarkers since both MRI and lumbar puncture are already widely used in the diagnostic workup of people with suspected dementia; data were highly homogeneous since all CSF analyses were performed in the same laboratory and all MRI images were acquired with standardized protocols in a single MRI scanner.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Comitato Etico Area 2 Milano, approval N 859_2021, date 14.09.2021. The patients/participants provided their written informed consent to participate in this study.LS and AA designed the study, analyzed, and interpreted the data. LS drafted the manuscript. TC, MP, GF, and AP contributed to the analysis and interpretation of the data. MA, CF, MS, FS, and CV performed CSF analyses. GC and VC helped in the analysis of MRI data. FT acquired MRI data. ES and DG drafted and revised the manuscript for intellectual content. All authors read and approved the final manuscript.


In cerebrospinal fluid, beta‐synuclein performed better than protein 14‐3‐3 (AUC 0.95 vs. 0.89) and, to a lesser extent, than total tau (AUC 0.92). Further, the diagnostic value of plasma beta‐synuclein (AUC 0.91) outperformed that of plasma tau (AUC 0.79) and neurofilament light chain protein (AUC 0.65) and was comparable to that of cerebrospinal fluid biomarkers. Beta‐synuclein might represent the first highly accurate blood biomarker for the diagnosis of sporadic Creutzfeldt–Jakob disease.Beta‐synuclein is a promising cerebrospinal fluid and blood biomarker of synaptic damage. Here we analysed its accuracy in the discrimination between sporadic Creutzfeldt–Jakob disease ( The use of cerebrospinal fluid (CSF) biomarkers of neurodegeneration and prion pathology as well as brain magnetic resonance imaging (MRI) have significantly improved the diagnostic assessment of sporadic Creutzfeldt–Jakob disease (sCJD).In this context, developing a highly accurate blood biomarker might present considerable advantages in terms of minimal invasiveness, wide applicability for early diagnosis, and tracking of disease progression. However, available markers, such as blood neurofilament light chain protein (NfL) and tau protein, although showing a good prognostic value,Recently, we have reported elevated levels of the presynaptic protein beta‐synuclein (beta‐syn) in CSF and blood of patients with prion disease as a surrogate marker of synaptic damage.We analysed retrospectively CSF and plasma samples from patients with RPD submitted to the neuropathology laboratory at the Institute of Neurological Sciences of Bologna between 2004 and 2022. Detailed inclusion criteria are reported in supplementary methods. We included 150 patients with sCJD and 106 participants representative of the most common etiologies of non‐prion RPD.Survival was defined as the time (in months) from LP or blood collection to (i) death or (ii) akinetic mutism if life‐extending treatments  were performed.The study was conducted according to the revised Declaration of Helsinki and Good Clinical Practice guidelines and approved by the ethics committee “Area Vasta Emilia Centro” . Written informed consent was given by study participants or the next of kin.in‐house established classic and digital ELISAs, respectively (supplementary methods).CSF and EDTA plasma samples were collected, aliquoted, and stored at −80°C according to standard procedures. We measured CSF t‐tau, CSF 14‐3‐3 gamma isoform, plasma tau, and plasma NfL as reported.p‐values were considered statistically significant at <0.05. Further details are reported in supplementary methods.We used the Mann–Whitney U or Kruskal–Wallis test (followed by Dunn‐Bonferroni post hoc test) to compare continuous variables. Spearman's correlations and linear regression analyses were used to test the possible associations between variables. Each marker's diagnostic accuracy was calculated using receiver operating characteristic (ROC) analyses. The DeLong test was used to compare the different areas under the curve (AUCs). Univariate and multivariate Cox regression analyses tested the associations between survival and CSF or plasma beta‐syn, and/or known prognostic factors in sCJD.Demographic features and biomarker results in the diagnostic groups are shown in Table p < 0.001 for both) . In plasma, instead, the marker reached the highest values in sCJD MM(V)1 (p < 0.001 vs. both VV2 and MV2K) with no significant differences between the VV2 and MV2K groups. All findings mentioned above remained significant after the exclusion of probable cases (supplementary results). The profiles of classic CSF and blood surrogate biomarkers in sCJD subtypes and non‐prion RPD groups are reported in Table sCJD patients showed higher CSF and plasma beta‐syn levels compared to non‐prion RPD subjects (th) Fig. . Moreoveth) Fig. . Both sCThe ROC curve data of all CSF and blood biomarkers in the differential diagnosis between sCJD and non‐prion RPD are reported in Table At cut‐off values favouring sensitivity (99%) over specificity, as in the context of a screening test Table , CSF andThe ROC curves for the distinction between sCJD and major non‐prion RPD etiologies are shown in Table PRNP codon 129 genotype , and pe Table . Howeverpe Table .Beta‐syn is emerging as a promising CSF and blood biomarker for synaptic damage in several neurodegenerative diseases.As reported for tau protein,Most interestingly, CSF beta‐syn performed better than CSF 14‐3‐3 and, to a lesser extent, than CSF t‐tau, and, if adopted as a screening test, correctly excluded a higher number of non‐prion RPDs than all other biomarkers. Thus, while the CSF RT‐QuIC still represents the most sensitive and specific biofluid marker for sCJD, CSF beta‐syn might represent a highly performant first‐level test in patients with suspected sCJD for those laboratories performing the prion seeding assay as a confirmative test when other tests are suggestive of prion disease.noninvasively the degree of synaptic/neuronal damage with relatively low cost and a potential application for screening and monitoring to a broad population.Nevertheless, the significant added value of beta‐syn mainly relies on the maintenance of a high diagnostic performance in the blood. Blood NfL and tau showed poor discriminative performance in the clinical setting of RPDs.PRNP codon 129 genotype, etc.). Here, the lack of associations between the biomarker values and survival in the molecular subtypes might partially rely on the small sample size of each subgroup. Moreover, another potential limitation of the study is the lack of clinical measurements of functional status and progression rate, which previously correlated with biomarker values.In the context of prognostication, CSF and plasma beta‐syn concentrations, like other CSF and blood markers,in vivo. Further, the marker might contribute to patient stratification and prognostication.In conclusion, by providing evidence that the diagnostic value of plasma beta‐syn is comparable to that of classic CSF surrogate markers , the present results suggest that beta‐syn might represent the first accurate blood marker for the diagnostic screening of patients with suspected sporadic Creutzfeldt–Jakob disease Conception and design of the study: Samir Abu‐Rumeileh, Markus Otto, and Piero Parchi; acquisition and analysis of data: Samir Abu‐Rumeileh, Steffen Halbgebauer, Giuseppe Mario Bentivenga, Lorenzo Barba, Simone Baiardi, Andrea Mastrangelo, Patrick Oeckl, Petra Steinacker, Angela Mammana, Sabina Capellari, Markus Otto, and Piero Parchi; drafting of the manuscript: Samir Abu‐Rumeileh, Markus Otto, and Piero Parchi.M.O. gave scientific advice to Axon, Biogen Idec, Fujirebio and Roche, all unrelated to the work presented in this paper. The foundation of the state Baden–Wuerttemberg handed in a patent for the measurement of β‐synuclein in neurological diseases. Relevant authors are M.O., S.H., and P.O. The other authors report no conflicts of interest.Data S1 Supporting Information.Click here for additional data file.


Intestinal donor criteria are classically kept strict, thereby limiting donor supply. Indications for intestinal transplantation (ITx) are rare, but improved outcome and new emerging indications lead to increased demand and relaxing donor criteria should be considered. We sought to compare the donor criteria of intestines transplanted at our center with predefined (per protocol) criteria, and to determine how relaxing donor criteria could impact the potential donor pool. Donor criteria used in 22 consecutive ITx at our center between 2000 and 2020 were compared with predefined criteria. Next, multiorgan donors effectively offered by our Donor Network to Eurotransplant between 2014 and 2020 were retrospectively screened, according to predefined and effectively used intestinal donation criteria. Finally, utilization rate of offered intestines was calculated. In our ITx series, the effectively used donor criteria were less strict than those initially predefined. With these relaxed criteria, a favorable 5-year graft/patient survival of 75% and 95%, respectively was reached. Applying these relaxed criteria would lead to a 127% increase in intestinal offers. Paradoxically, 70% of offered intestines were not used. In conclusion, a significant increase in intestinal donation could be obtained by relaxing donor criteria, while still achieving excellent outcome. Offered intestines are underutilized.  Intestinal transplantation (ITx) is indicated in patients with intestinal failure and life-threatening complications of parenteral nutrition , 2. So fn = 30/113) has been observed, and 3% of the patients (n = 3/113) were delisted because deemed unfit for ITx . “Extended” donor criteria are now accepted for the majority of solid organs   . BecauseAt the start of our program, we predefined strict donor criteria and we now wanted to determine whether these criteria had actually been respected in our ITx series. Secondly, we determined, in our own donor pool, how slightly relaxing donor criteria would increase the number of intestinal grafts. Lastly, we studied the utilization rate of offered intestines.Belgium has opt-out legislation for organ donation since 1986 and no separate informed consent is needed for intestinal donation. Each of the seven Belgian transplant centers has its own procurement organization, consisting of the respective transplant university hospitals and their own network of cooperating “donor” hospitals. The UZ Leuven Donor Network for organ procurement includes The University Hospitals Leuven and its 37 cooperating hospitals across Flanders, Belgium (LSGO). Belgium is part of ET, and solid organs procured in the LSGO are allocated by ET. Allocation of intestinal grafts to ET waitlisted patients occurs in a patient-driven manner, over three active ITx centers in three countries in 2022. In the time period of the study, 2014–2020, there were seven active ITx centers in four countries.2. Blood group matching is identical or compatible. Exclusion criteria included smoking, alcohol, drug abuse, and diabetes. Liver and kidney function tests must be normal. Recent cardiac arrest, cardiopulmonary resuscitation (CPR), or hypotensive episodes are excluded. The donor should be hemodynamically stable, with minimal transfusions and inotropic support (<2 drugs at low dosage). ICU stay should be less than 5 days. As a result, intestinal donors are often multi-organ donors .At the start of our ITx program in 2000, intestinal organ donor criteria were predefined and are summarized in n = 22) were analyzed. Data analyzed were: donor type, age, weight, length, BMI, donor/recipient weight ratio, ABO blood group compatibility, smoking/alcohol/drug abuse, diabetes, latest lab results (Aspartate Transaminase (AST), Alanine Transaminase (ALT), total bilirubin, International Normalized Ratio (INR), amylase, lipase, creatinine, [Na+], CPR time, cardiac arrest time, hypotensive episodes, inotropic use and dosage, number of transfused packed cells, ICU stay, and other organs offered .A retrospective analysis of our prospectively collected ITx database (October 2000—September 2020) was performed. One living donor ITx was excluded and only deceased ITx recipients , CPR time, cardiac arrest time, hypotensive episodes, inotropic use (number and dosage), transfused packed cells, ICU stay, organs offered and transplanted , and reasons for not offering or for refusing the intestine.Data of donors offered by LSGO to ET during a 6-year period (1st January 2014—31st December 2019), and prospectively collected in an This donor cohort was screened, first according to the aforementioned predefined intestinal donor criteria, and second according to the criteria effectively applied in our ITx program and defined in the first part of the study.p-value < 0.05 was considered statistically significant.Data were collected using Excel (Microsoft Office 2019). Results are reported as median (range). Subgroup analysis was performed by non-parametric Mann-Whitney Test in GraphPad Prism version 9.0.0 for Windows . All ITx patients gave consent for database recording of transplant-related data and their use for research purposes. This study was approved by the ethics committee of University Hospitals Leuven, Belgium (S63306) and was conducted according to the revised version of the Declaration of Helsinki .Between 19 October 2000 and 01 September 2020, 22 deceased ITx were performed. Ten were isolated ITx, five multivisceral transplants, and seven combined liver-ITx. Two were retransplants. Eight donors (36%) were from our local network (LSGO) and the remaining 14 (64%) from ET. Pre-, peri-, and post-transplant surgical and medical management have been described extensively elsewhere . One- an2 (11–26). BMI was higher than the predefined maximum of 25 kg/m2 in one donor. Donor/recipient weight ratio was 0.9 (0.5–1.5). Blood group was compatible in 5 and identical in 17. Smoking and alcohol abuse were present in 2 and 1 donors, respectively. Drug abuse and diabetes were not reported. The latest lab results were acceptable for liver transplantation and kidney transplantation, and last [Na+] was 148 mmol/L (130–157). The predefined maximum [Na+] was overruled in one donor with a [Na+] of 157 mmol/L. In three donors, CPR had been performed for 20 min (10–30) and cardiac arrest time in these donors was 25 min (5–45). Hypotensive episodes of 10 min were noted in two donors (5–15). Norepinephrine was used at a dosage of 0.1 μg/kg/min (γ) (0.0155–0.68) as single inotropic in 13 donors and in combination in 2 others. In eight donors, norepinephrine dosage exceeded the predefined maximum of 0.1γ. Dobutamine was used in two donors, in one as single inotropic, at a dosage of 2γ (1–3). In one donor, epinephrine was used, as second inotropic, at a dosage of 0.14γ. Packed cells transfusion was given in eight donors with a median of 2 units of packed cells (1–5). Median ICU stay was 2 days (1–9) and exceeded the predefined maximum in two donors, with 5 and 9 days, respectively. All abdominal organs were offered in all donors. Heart and lungs were not offered in three donors due to thoracic trauma, atrial fibrillation, and for unknown reason (All donors used for ITx were DBD with a median age of 16 years (1–37). Median weight was 50 kg (12–75). BMI was 19.6 kg/mn reason .n = 12/22) of these effective intestinal donors, the strict predefined criteria had been overruled for BMI, CPR, inotropic use, and ICU stay.In 55%  were DCD and 476 (72%) were DBD donors.n = 326/476) were excluded for age ≥ 50 years  matched the predefined theoretical anthropomorphic criteria for ITx. Thirty-three intestines from these donors  were offered to ET. Ten were effectively transplanted within ET, of which 6 in our own center. Out of the 33 offered intestines, only 10 were transplanted and 23 could not be allocated, representing a utilization rate of 30.3% (n = 10/33).Of the 476 DBD donors, 68% , ICU stay of > 5 days  and high inotropic need . In the 15 remaining donors, the most important reasons for not offering the intestine were low cardiac ejection fraction on ultrasound in 3 (5%) and malignancy in 2 (3%) .In 64 out of 97 donors (66%), the intestine was not offered, for which the reasons are listed in In 55 of these non-offered donors (86%), only one exclusion criterium for not offering the intestine (CPR) was present. In 7 (11%), two criteria  were present. In 2 (3%), 3 exclusion criteria were present .In 33 donors, the intestine was offered despite the presence of one exclusion criteria in 20 (61%) and two exclusion criteria in 4 (12%). Overruled criteria were mainly: CPR time, hypotension, ICU stay, and/or inotropic need. Other reasons for overruling criteria were noted in four donors but were not specific to intestinal donation: bacterial meningitis in two, meningioma in one, and a thyroid tumor in another .In 5 out of the 10 transplanted intestines (50%), one predefined criterium was overruled  and in one donor (10%) two criteria were overruled (prolonged ICU stay and high inotropic need) .Of the 23 refused donor intestines, 7 (30.4%) had directly been offered to our own center but could not be used for organizational reasons. They were then offered to ET but could not be transplanted either. Fifteen intestines directly offered to ET (65%) could not be used, potentially due to absence of suitable recipients within ET or for organizational reasons . Finally. not transplanted intestines , and ICU < 10 days.The predefined criteria were extended with the following effectively applied criteria: BMI ≤ 26 kg/mn = 326/476) were excluded for age ≥ 50 years. Of the remaining 150 donors, 28 were excluded due to a BMI > 26 kg/m2 and an additional 16 donors were excluded for weight > 80 kg. Hence, 22% of DBD donors (n = 106/476) met the effective anthropomorphic criteria. Seventy-five donors (71%) met all of the effectively applied criteria and could have been potential intestinal donors  and another 23% had an ICU stay ≥ 10 days (n = 7/31). Drug abuse would still lead to the exclusion of 16% (n = 5/31) and low cardiac ejection fraction to 10% (n = 3/31). Other reasons are mentioned in Only 31 non-offered donors would then remain. Twenty-three percent had a CPR ≥ 45 min  is an incentive to propose ITx earlier in the course of intestinal failure [At first sight, the need for extension of the intestinal donor pool appears less urgent than for other solid organs. Indeed, ITx remains a rare procedure representing less than 0.5% of the overall solid organ transplant activity. That is because the incidence of intestinal failure is much lower compared to failure of other organs and, in case of “uncomplicated” intestinal failure, parenteral nutrition is still the first treatment option . Obstacl failure . Finally failure . For all2. Liver and kidney function are to be normal, and only limited resuscitation time is accepted. An ICU stay of less than a week and cold ischemia time of max 9 h are other standard cut offs . Our overall 5-year patient survival of 95% compares favorably to the international registry, suggesting that having slightly relaxed the donor criteria had no impact on outcome in our program [By retrospectively analyzing the characteristics of the intestinal grafts we actually procured and transplanted, we observed that we had overruled our own center-predefined strict criteria in 55%. The most frequently overruled criteria were BMI, CPR, inotropic dosage, and ICU stay. Of note, overruling was more frequent in more recent years which suggests a learning and experience effect (data not shown). When comparing the outcome of our “strict” vs program .Historically, hemodynamically unstable donors were deemed unfit for intestinal donation, as the intestine is extremely sensitive to ischemia –20. Howeper se limit intestinal organ donation if other criteria are acceptable.Another discriminatory factor in our predefined criteria is ICU stay < 5 days. In literature, mostly 1 week is used as upper limit . HoweverAnother option to increase the intestinal donor pool is to accept older donors. The arbitrary upper age limit has usually been fixed at 50 years , 16, 23.2 , ICU stay up to 10 days, limited inotropic usage, previous episodes of hypotension, short period of cardiac arrest and CPR, and limited packed cells transfusions should -separately- not be seen as absolute contraindication for intestinal donation, particularly for patients already more than 1 year on the waiting list or who need a suitable organ more urgently [Based on our findings and the data published by others, we recommend a slight extension of the intestinal donation criteria. Donor age up to 60 years, BMI up to 28 kg/murgently ..We showed that the pool of suitable bowels could be substantially enlarged by using these slightly relaxed donor criteria. Indeed, applying these extended criteria to our whole potential donor pool resulted in a 127% increase in intestinal donorsOf note, a multivisceral graft has been recently procured in a DCD donor after normothermic regional reperfusion (NRP) and the transplant was successful . This stStrikingly, we noticed that 70% of the intestines offered by our network, were ultimately not used for transplantation. These organs did not differ with regard to anthropometric data and ICU stay, from those grafts that were effectively used. We see two reasons for this underutilization. First, a substantial number of intestinal offers were declined for organizational reasons. Indeed, ITx and procurement require full mobilization of experienced transplant surgeons, transplant anesthesiologists, and gastroenterologists and these are not necessarily permanently standby. On the other, several heart and lung procurement/transplant teams fear inferior outcomes of their graft, if an intestinal graft is concomitantly procured and if special donor preprocurement therapies were initiated. However, the study by Farinelli et al. showed that these intestinal donor preprocurement therapies might even be beneficial for other transplanted organs, without impacting allocation, quality or long-term outcome . ITx maySecond, one intestinal offer at a given time may not necessarily fit all recipients. It is likely that perfectly transplantable intestines were turned down for size-, age-, CMV-mismatch, or other surgical or medical reasons. Size-mismatch is very common in ITx. Most recipients have had previous abdominal surgery and multiple intestinal resections, leaving them with little abdominal domain. Concerning the abdominal domain, there is an important difference whether the transplant graft is liver-containing  versus isolated small bowel. This limitation can be overcome -to a certain extent-by techniques such as fascia or even full thickness abdominal wall transplantation, graft reduction, etc. . HoweverOffering these unused intestines outside ET should be considered to increase organ utilization and optimize donor-recipient matching, thereby reducing waiting time and associated mortality. Such cross-program exchange structures already exist for other organs between allocation organizations such as NHSBT (United Kingdom) and Scandiatransplant. Rushton et al. already suggested the possibility to implement a formalized European-wide intestinal donor organ sharing program . A prereA limitation of our study is that -in all surveyed donors-, a specific reason for not offering the intestine was sought in retrospect. We cannot exclude that in several cases, one simply “forgot” to offer the intestine. That is because ITx is a relatively poorly known activity. We cannot quantify this, but we suspect this has been a relatively frequent reason for not offering the intestine. This could be overcome by mandatory reporting of the intestinal graft if a donor fits the intestinal donation criteria. Another option could be with a UK-like system where all DBD are potential intestinal donors and are allocated through the system to potential recipients. Thereby reducing the subjectivity of the initial offering process . In geneIn conclusion, this study makes three points. First, the strict intestinal donor criteria that we had predefined are not routinely followed in our actual practice and -despite that-excellent outcomes are obtained. Second, slightly relaxing intestinal donor criteria and in particular accepting donors with prolonged ICU stay, limited CPR time, and mild inotropic usage can substantially increase the nu mber of offered intestines. Third, the pool of offered intestines is paradoxically underutilized, which is multifactorial in origin. A European intestinal donor organ sharing program should be considered to facilitate donor-recipient matching.


Recently, magnetic resonance imaging (MRI) has been developed as a widely available and noninvasive method for detecting and evaluating hepatic iron overload. This case report presents a successful living donor liver transplantation (LDLT) in which the donor was suspected to have hepatic iron deposition by MRI evaluation. A preoperative donor liver biopsy and genetic examination were performed to exclude hereditary hemochromatosis and other chronic liver diseases. A liver biopsy showed an almost normal liver specimen with a slight deposition of iron in 2-3% of hepatocytes, and a genetic examination of hereditary hemochromatosis revealed no typical mutations in HFE, TFR2, HJV, HAMP, or SLC40A1. Despite the traumatic hemothorax complication caused by the liver biopsy, the liver transplant eligibility was confirmed. Two months after the hemothorax complication, an LDLT donor operation was performed. The donor was discharged from the hospital on postoperative day (POD) #17 with favorable liver function. The recipient's posttransplant clinical course was generally favorable except for acute cellular rejection and biliary complications, and the recipient was discharged from the hospital on POD #87 with excellent graft function. A one-year follow-up liver biopsy of the recipient demonstrated almost normal liver with iron deposition in less than 1% of the hepatocytes, and no iron deposition was identified in the liver graft by MRI examination. Liver biopsy and genetic examination are effective methods to evaluate the eligibility of liver transplant donors with suspected hepatic iron deposition. The living donor with slight hepatic iron deposition, if hereditary hemochromatosis was ruled out, can donate partial liver safely. Iron is an essential mineral in the body and plays an important role in cellular and organismal processes such as heme synthesis, DNA synthesis, and oxidative phosphorylation. While iron deficiency induces anemia, excess iron produces free oxygen radicals that can be toxic to DNA, proteins, and lipids , 2. As tIt has been shown that the liver is the major storage site for iron and plays a vital role in iron homeostasis. Several genes related to hepatic iron regulation have been identified, including HFE, HJV, and HAMP –3. If thMagnetic resonance imaging- (MRI-) based liver susceptibility measurement techniques have recently been developed as widely available and noninvasive methods for detecting and evaluating iron overload in the liver –9. In thA 31-year-old Japanese man, who was diagnosed with primary sclerosing cholangitis and ulcerative colitis at the age of 17, was referred to our transplant center. The patient presented with severe jaundice and was suffering from a recurrent episode of bacterial cholangitis. Contrast-enhanced computed tomography revealed an enlarged liver with an irregular surface, splenomegaly, massive ascites, esophageal varices, and splenorenal shunt. His Child-Pugh score was 10 (grade C), and the model for end-stage liver disease score was 20. Although preparation of living donor as well as cadaveric liver transplantation was initiated, preparation of living donor liver transplantation was accelerated because of consideration of the waiting time of deceased donor liver transplantation in our country.μg/dL, 202 mg/dL, and 273 μg/dL, respectively), we found mild elevation of ferritin level . In magnetic resonance cholangiopancreatography for biliary tree evaluation, radiologists pointed out mild hepatic iron deposition due to lower signal intensity of the liver compared to the signal of paraspinal musculature on T2-weighted images , which is the principal regulator of iron absorption and may be high in ferroportin disease, was slightly elevated, but it could be considered normal range under the elevated level of serum ferritin . FerropoHe donated the right lobe graft weighing 874 g, and the remnant liver was estimated at approximately 30.2%. The liver function test recovery was relatively slow probably due to a smaller remnant liver volume. The donor was discharged from the hospital on POD #17 with favorable liver function. The recipient's posttransplant clinical course and graft function were generally favorable including iron homeostasis, although the recipient required treatment for acute cellular rejection and biliary complications. The recipient was discharged from the hospital on POD #87 .The recipient's percutaneous liver biopsy one year after LDLT showed an almost normal liver with iron deposition in less than 1% of the hepatocytes Figures . There wAs the living donor liver transplantation, any kinds of concerns must be cleared. During the living donor assessment process in this case, we noticed a slight difference in MRI findings. To answer this question, liver biopsy and genetic examination were added to check his iron metabolism.Iron is an essential element in human cell function, particularly for hemoglobin and myoglobin production. Because it is difficult to excrete excessive iron from the human body, iron homeostasis is tightly controlled to avoid the toxicity of free oxygen radicals that are generated by systemic iron overload –3. HepciIn the present case, the donor was suspected to have a hepatic iron overload on our routine evaluation. MRI is a widely accepted method for detecting and quantifying hepatic iron overload –9; howevThe donor developed traumatic hemothorax after the liver biopsy and required thoracic drainage. Previous reports have shown that LDLT donor screening liver biopsy was useful with a low complication rate and provided valuable information to increase donor safety while maximizing the donor pool –14. CertIn this case report, we present a successful living donor liver transplantation case after the confirmation of eligibility by liver biopsy and genetic examination in the donor candidate of possible hepatic iron deposition suspected by MRI examination. Liver biopsy and genetic examination are effective methods to evaluate the eligibility of liver transplant donors with suspected hepatic iron deposition. These evaluation steps must be done to avoid donor risks from their underlying iron-related disease and recipient risks related to their poor qualities of iron deposition graft. After these evaluations, the living donor with slight hepatic iron deposition can donate partial liver safely.