Severe traumatic brain injury (sTBI) is an intracranial damage triggered by external force, most commonly due to falls and traffic accidents. The initial brain injury can progress into a secondary injury involving numerous pathophysiological processes. The resulting sTBI dynamics makes the treatment challenging and prompts the improved understanding of underlying intracranial processes. Here, we analysed how extracellular microRNAs (miRNAs) are affected by sTBI. We collected thirty-five cerebrospinal fluids (CSF) from five sTBI patients during twelve days (d) after the injury and combined them into d1–2, d3–4, d5–6 and d7–12 CSF pools. After miRNA isolation and cDNA synthesis with added quantification spike-ins, we applied a real-time PCR-array targeting 87 miRNAs. We detected all of the targeted miRNAs, with totals ranging from several nanograms to less than a femtogram, with the highest levels found at d1–2 followed by decreasing levels in later CSF pools. The most abundant miRNAs were miR-451a, miR-16-5p, miR-144-3p, miR-20a-5p, let-7b-5p, miR-15a-5p, and miR-21-5p. After separating CSF by size-exclusion chromatography, most miRNAs were associated with free proteins, while miR-142-3p, miR-204-5p, and miR-223-3p were identified as the cargo of CD81-enriched extracellular vesicles, as characterised by immunodetection and tunable resistive pulse sensing. Our results indicate that miRNAs might be informative about both brain tissue damage and recovery after sTBI. Traumatic brain injury (TBI) is a disruption of brain anatomy and function due to the action of an external force . This maIn terms of pathogenesis, TBI involves a complex process that starts as a primary injury at the moment of physical impact to the head, and continues as a secondary injury during hours, days or even weeks after the primary injury . The secIn clinical settings, TBI is classified as mild, moderate or severe. The initial assessment is based on the international Glasgow Coma Scale (GCS), with predefined points for eye, verbal and motor response. The scale ranges from 3 to 15 points, where 3 points are assigned to a comatose patient with no response, and 15 are assigned to a fully alert and cooperative patient. Taken together, GCS subranges of 3–8, 9–12 and 13–15 define the severe, moderate and mild TBI, respectively . Even whDespite the significant progress in the field of TBI, both in terms of pathophysiology as well as diagnostic and treatment procedures, several intrinsic TBI features are still associated with challenges in clinical settings and require a deeper understanding of processes in the brain after the injury. Not only can the clinical presentation of TBI be very different, but it can also change rapidly due to the dynamic nature of the secondary injury. On top of that, continuous monitoring of brain morphological changes via neuroradiological imaging is not applicable for both practical and safety issues. Therefore, additional diagnostic and prognostic tools for evaluating the brain function after TBI are greatly needed. Recent studies identified circulating biomarkers in body fluids such as cerebrospinal fluid (CSF) and blood with growing interest in microRNAs (miRNAs) ,10.miRNAs are small (19–28 nucleotides), non-coding RNAs involved in posttranscriptional gene regulation. This is especially noticeable in CNS, since approximately 70% of known miRNAs are estimated to be expressed in nervous tissue, both in physiological and pathophysiological conditions . SimilarAn additional feature of extracellular miRNAs, which might affect isolation and characterisation, is that miRNAs can circulate either bound to proteins or as the cargo of extracellular vesicles (EVs) . EVs areTo provide a more systematic approach, we decided to monitor a set of miRNAs in several time points after sTBI. We collected CSF samples during the 12 days (d) after sTBI and combined them into d1–2, d3–4, d5–6 and d7–12 CSF pools. We quantified 87 miRNAs by real-time PCR in all CSF pools, as well as in EV- and free protein (FP)-fractions obtained after size exclusion chromatography (SEC). We found that the majority of targeted miRNAs showed the highest levels in d1–2 and d3–4, which were also compromised by haemolysis. Furthermore, most miRNAs were associated with FPs. Although the main limitation of the study is the low number of patients and CSF samples, our data show a high range of miRNA concentrations and identify miRNA candidates indicative for ongoing processes in the brain.Severe traumatic brain injury (sTBI) changes the molecular composition of cerebrospinal fluid (CSF) due to the very nature of intracranial tissue damage ,29. To eA total of thirty-five individual CSF samples were collected daily for up to twelve days after the injury until EVD was in place, a decision which was at the discretion of the supervising physician . To faciSeveral studies have shown that diverse microRNAs (miRNAs) can be detected in human CSF after sTBI, but no comprehensive comparison of miRNA types and levels during patient recovery have been described. To provide a more systematic analysis of miRNA, we decided to simultaneously quantify a set of 87 miRNAs in the consecutive CSF pools spanning the twelve days after the injury. We applied a commercially available PCR-array containing primers for CSF-associated miRNAs and enabling absolute miRNA quantification based on spike-in miRNAs A.We isolated miRNAs from four CSF pools and determined RNA concentrations by spectrophotometer. We detected the lowest RNA concentration of 9.2 ± 0.3 ng/µL in d1–2 CSF pool followed by increasing RNA concentrations of 11.1 ± 0.3 ng/µL, 12.9 ± 0.3 ng/µL and 14.6 ± 0.5 ng/µL in d3–4, d5–6 and d7–12, respectively B. The inTo better characterise plasma-derived content in CSF pools and their potential association with detected miRNAs, we performed a western blot analysis for albumin and some apolipoproteins (Apo). We detected similar profiles for albumin and ApoAI, with the highest protein levels in d1–2 followed by moderate but comparable levels in d3–4 and d5–6 and low levels in d7–12 D. We notAfter the initial characterisation of total miRNA in CSF pools together with proteins of plasma and cellular origin, we then set out to identify and quantify miRNAs present in CSF after sTBI. To enable the quantification of miRNAs, we utilised spike-in miRNAs , which were available at a 100-fold concentration difference and were included for detection in the PCR-array to be applied. We added spike-ins in the cDNA synthesis step, thereby preserving their initial concentrations. After performing a real-time PCR we used the resulting Ct values to create standard curves A. We werWe detected and quantified all 87 targeted miRNAs, but their levels differed by more than a million-fold across the four CSF pools . Almost We noticed that the following 10 miRNAs are the most abundant across all four CSF pools: miR-451a, miR-16-5p, miR-144-3p, miR-20a-5p, let-7b-5p, miR-15a-5p, miR-21-5p, miR-223-3p, miR-106a-5p and miR-15b-5p B. AlthouThe trend of a decreasing amount of miRNA was also visible when we calculated the total mass of the targeted miRNA across all CSF pools C. The hiTo identify relative changes in individual miRNA levels across all CSF pools, we normalised miRNA levels against d5–6 levels, since the haemolysis at that time point was low in comparison to d1–2 and d3–4 D. The reTo test whether some of the 87 targeted miRNAs were EV-cargo in CSF after sTBI, we first characterised the EV populations present in CSF pools A. By appAfter characterising EV populations, our next goal was to separate the CSF pools into EV- and free protein (FP)-enriched fractions and use them for miRNA isolation and quantification B. For CS9 particles/mL, which was significantly higher in comparison to later days where we found concentrations of (0.52 ± 0.15) × 109, (1.32 ± 0.19) × 109 and (0.93 ± 0.19) × 109 nanoparticles/mL in d3–4, d5–6 and d7–12, respectively. Interestingly, EV sizes were comparable in d1–2, d3–4, and d5–6, with a median diameter of 162 nm (IQR 137–202 nm), 160 nm (IQR 137–202 nm) and 160 nm (IQR 135–197 nm), respectively, but EVs at d7–12 measured 175 nm (IQR 151–218 nm) in diameter, which was significantly higher in comparison to EVs from earlier pools  offers a unique opportunity to investigate complex pathophysiological processes unfolding in the brain early after the injury. One of the measures in sTBI treatment includes the placement of an external ventricular drain (EVD), which provides access to the intracranial cerebrospinal fluid (CSF). Moreover, the intracranial CSF obtained by EVD might also contain signals required for the recovery and/or normal functioning of the brain. We hypothesized that microRNAs (miRNAs) released either passively from damaged tissue or actively from living cells could be such signals. Our results describe CSF dynamics in the context of miRNA types and quantities during the early days after the injury.The study included five sTBI patients with a different number of consecutive CSF samples collected after the injury . The reaWe combined consecutive CSFs to enable PCR-array based screens—including CSF before and after separation by size-exclusion chromatography (SEC)—from different time points after sTBI. The combining of the CSFs samples into pools resulted in the dilution of the originating samples. While the d1–2, d3–4, and d5–6 CSF pools provide average miRNA amounts for the two days (d) included, the d7–12 CSF pool provides average miRNA amounts for the six days included. Therefore, it is very likely that at least some miRNAs at different time points were detected at low levels or not at all due to their dilution in CSF pools, posing an additional limitation of the study.CSF after sTBI has a specific composition due to the cell damage and impaired blood-brain barrier as part of the TBI pathophysiology. This also reflects the miRNA content in the CSF after sTBI, with many miRNAs most likely originating from the blood, as our and other groups have shown . We founAlthough all miRNAs showed a general trend of decreasing amounts towards later CSF pools with the consistent decrease of haemolysis, we noted that highly abundant miRNA levels tend to decline at different rates B. This wOur miRNA quantification suggests that other miRNAs, not necessarily of blood-origin, could be present in CSF. We found that the total amount of targeted miRNAs has made up only a small portion of miRNAs applied in cDNA synthesis. This particularly applies to the d5–6 and d7–12 CSF pools in which haemolysis was not pronounced so much as in earlier CSF pools C. To seeBefore isolating EVs, we analysed common EV-protein markers in CSF and found high levels of Flotilin-1 and -2, TSG101, CD81 and CD9 at d1–2, followed by decreasing amounts in later days A. This iWe did not detect all targeted miRNAs after SEC, and we noticed much lower amounts in comparison to CSF pools . This isTaken together, we here described the quantitative changes of miRNAs in CSF of patients recovering from sTBI. We showed the high impact of haemolysis on 87 targeted miRNAs in the first four days. However, the CSF from later days contained enlarged EVs carrying RNA, which is yet to be characterised. Our results emphasise the dynamic nature of sTBI and the need to further analyse CSF at later days when neuro-recovery signals, such as miRNAs, might be present.Research included five patients with severe traumatic brain injury (sTBI) treated at the Anaesthesiology, Intensive Medicine and Pain Treatment Clinic at the Clinical Hospital Centre Rijeka and at the Clinic for Anaesthesia, Reanimation, Intensive Care Medicine and Pain Treatment at Pula General Hospital, Croatia. Clinical requirements for sTBI were Glasgow Coma Scale (GCS) ≤ 8, neurological physical examination, and neuroradiological imaging of the brain . The study was approved by the Institutional Review Board of both hospitals, and informed consent was signed by the family member or a legal representative due to the patient being unconsciousness and under critical care management. Treatment included placement of an external ventricular drain (EVD) at the indication of an attending neurosurgeon for the purpose of intracranial pressure (ICP) monitoring and management. The exclusion criteria were patient age under 18 years, since it was a study conducted on adults, and patient age over 80 years, due to inevitable physiological changes in the brain. Patients with susceptible immune, malignant and infectious conditions due to potential interaction at the level of pathophysiological signalling pathways were also excluded from the study. No specific clinical parameters were considered or monitored for the purposes of this study. The control group was not included for two reasons. Firstly, applying EVD in healthy subjects, which would provide cerebrospinal fluid (CSF) from the same anatomic position as in sTBI patients, is not possible due to ethical reasons. Secondly, CSF obtained by lumbar punction includes a risk of different CSF composition due to the changed anatomical location. Additionally, lumbar-CSF has a further risk of potential contamination with other cellular content in comparison with EVD-derived CSF. Patient treatment outcomes were monitored after three months using the international Glasgow Outcome Score (GOS).CSF was sampled from the EVD and its drainage chamber daily, starting from 24 h after its placement. Samples were collected during twelve days after the sTBI in low-protein binding tubes . The indication for stopping the sampling was the removal of the EVD indicated by the attending neurosurgeon or the fatal outcome of the patient. After sampling, CSF was stored at −80 °C. Samples were pooled in equal volumes to obtain four consecutive CSF pools .v/v), 10% SDS (w/v), 0.05% bromophenol blue (w/v), 2-mercaptoethanol) and boiled at 95 °C for 10 min. Pooled CSF together with a protein standard  were loaded onto 12% polyacrylamide gel and electrophoresed  in 1x running buffer  on 90 V to 150 V. Separated proteins were transferred to 0.2 µm nitrocellulose membrane  at a constant voltage of 70 V for an hour and a half in a 1x transfer buffer . Following the protein transfer, membranes were stained with Ponceau S (0.1% Ponceau S in 5% acetic acid), blocked with 5% milk in Tris-buffer saline  for 15 min, and incubated with rabbit monoclonal antibodies against albumin (#4929), apolipoprotein E (#13366), CD9 (#13403), CD81 (#52892), Flotilin-1 (#18634), Flotilin-2 (#3436) and TSG101 (#72312) and mouse monoclonal antibody against apolipoprotein AI (#3350), and diluted 1:1000 in 5% bovine serum albumin /TBS-T (TBS supplemented with 0.1% Tween 20) over-night at 4 °C. Membranes were washed three times for 5 min in TBS-T and incubated with horseradish peroxidase-linked anti-rabbit (#7074) or anti-mouse (#7076) secondary antibodies at room temperature for 30 min . After additional washing in TBS-T, the signal was visualised using SignalFire Plus ECL Reagent or SignalFire Elite ECL Reagent  and imaged with an ImageQuant LAS 500 CCD imager .Generated CSF pools were mixed with 5× Laemmli buffer  was performed on CSF pools as previously described . BrieflyCollected SEC fractions were mixed with a 5x Laemmli buffer without glycerol and boiled at 95 °C for 10 min. Nitrocellulose membrane  was soaked in distilled water and placed in slot blot apparatus , connected to a vacuum pump. SEC fractions in volume of 300 µL were applied to the slot blot, pulled through a membrane by a vacuum pump, and rinsed three times with 1 mL of PBS . The membrane was then removed from the slot blot apparatus, stained with Ponceau S, blocked in 5% milk, and blotted for CD81, as described above. The signal was visualised using SignalFire Elite ECL Reagent  on an ImageQuant LAS 500 .Tunable resistive pulse sensing (TRPS) analysis of the size distribution and concentration of nanoparticles in the CD81+ pool of SEC fractions was conducted on a qNano Gold platform . The nanopore was wetted, coated and equilibrated with an Izon reagent kit as per the manufacturer’s instructions. The calibration was performed with 200nm carboxylated polystyrene beads , diluted 500-fold in filtered electrolyte solution, and stretch was adjusted until the blockade magnitude for calibration particles averaged between 0.25 and 0.3 nA. Measurements were conducted at a constant 46.00 mm stretch and a baseline current at approximately 125 nA. Samples were diluted twofold in filtered electrolyte solution and vortexed for 30 s prior to TRPS measurements. Each sample was measured at two pressure steps of 5 and 2.5 mbar, in triplicate. At least 500 particles were recorded for each measurement. Before each measurement, the nanopore was washed with the electrolyte solution at a pressure of 20 mbar to avoid cross-contamination between samples. Data processing and analysis were performed in Izon Control Suite v3.4 software . A concentration fraction from 110 to 420 nm was applied for all measurements prior to any data analysis.® P330, Implen GmbH, München, Germany) in triplicates for every sample.Isolation of RNA from total CSF-, EV-, FP- pools was performed using Norgen’s Urine microRNA Purification Kit , as it was previously shown to be efficient in miRNA isolation from CSF . AccordiAn amount of 20 ng of miRNA isolated from each CSF-, EV- and albumin pool was reverse transcribed in 20 µL reactions using miRCURY Locked Nucleic Acid (LNA) RT Kit  with a thermal cycler . A known amount of 5 different RNA spike-ins  was added to each reaction prior to the cDNA synthesis step for quality control and quantification purposes. RNA quality and reverse transcription were assessed by PCR-based QC array  before proceeding with miRNA analysis. miRNA profiling was undertaken using a PCR-based array on a 96-well plate  and a real-time PCR machine .This study describes quantities of 87 miRNAs in the cerebrospinal fluid (CSF) of patients with severe traumatic brain injury (sTBI). Absolute quantification was performed at four time points over twelve days after the injury, providing an insight into the dynamics of miRNAs of putative CSF origin.We showed that CSF contains miRNAs throughout the twelve days after sTBI. The targeted 87 miRNAs were detected at very different levels in CSF, with their combined amounts making only a small portion of total miRNA present in the CSF. Furthermore, our results indicated that the targeted miRNAs most likely originate from lysed erythrocytes and potentially other damaged cells. We also demonstrated that the majority of targeted miRNAs were associated with free proteins, while only some miRNAs were enriched in extracellular vesicles (EVs). However, EVs were found in all analysed CSF pools, and their content included miRNAs.Several major limitations of the study should be emphasized. First of all, the number of subjects was low and the analysed cohort of patients was heterogenous with regard to the underlying intracranial pathology, including the type of haemorrhage, site of intraparenchymal damage, and whether diffuse axonal injury was detected. This is especially critical since blood-derived content in CSF after sTBI largely influenced the amount and type of miRNAs detected in the study. Furthermore, no clinical parameters were included in the study, and therefore their potential correlation with the study findings is missing. Taken together, this is a preliminary miRNA study which further corroborates the complex dynamics of sTBI in the acute phase.Future studies should identify other miRNAs present in CSF after sTBI, including the CSF-EVs. Moreover, in contrast to the current study based on pooled CSF samples d1–2, d3–4, d5–6 and d7–12, novel research should involve more frequent time points and the investigation of unpooled samples. This might enable the detection of novel miRNAs in CSF and could improve the understanding of intracranial processes after sTBI.


Obesity is the basis of numerous metabolic diseases and has become a major public health issue due to its rapidly increasing prevalence. Nevertheless, current obesity therapeutic strategies are not sufficiently effective, so there is an urgent need to develop novel anti-obesity agents. Naturally occurring saponins with outstanding bio-activities have been considered promising drug leads and templates for human diseases. Cyclosiversioside F (CSF) is a paramount multi-functional saponin separated from the roots of the food-medicinal herb Astragali Radix, which possesses a broad spectrum of bioactivities, including lowering blood lipid and glucose, alleviating insulin resistance, relieving adipocytes inflammation, and anti-apoptosis. Recently, the therapeutic potential of CSF in obesity and relevant disorders has been gradually explored and has become a hot research topic. This review highlights the role of CSF in treating obesity and obesity-induced complications, such as diabetes mellitus, diabetic nephropathy, cardiovascular and cerebrovascular diseases, and non-alcoholic fatty liver disease. Remarkably, the underlying molecular mechanisms associated with CSF in disease therapy have been partially elucidated, especially PI3K/Akt, NF-κB, MAPK, apoptotic pathway, TGF-β, NLRP3, Nrf-2, and AMPK, with the aim of promoting the development of CSF as a functional food and providing references for its clinical application in obesity-related disorders therapy. Obesity is a metabolic syndrome caused by a complex interaction between environmental and genetic factors, which mainly include, but are not limited to, imbalanced diet, endocrine dyscrasia, genetic and epigenetic regulation, sociodemographic influences, as well as intrauterine condition ,2. The iIt is well-established that obesity underlies various debilitating disorders covering diabetes mellitus, cardiovascular diseases, hypertension, hyperlipidemia, and non-alcoholic fatty liver disease ,12. ActuAstragalus mongholicus Bunge, a perennial belonging to the family Fabaceae, is native to Siberia to the Russian Far East as well as Western and Northern China and widely distributed in temperate Asia ), despite the fact that a few other Astragalus species have been demonstrated to induce serious toxicity in livestock due to chemical components like indolizine alkaloids Astragaluammation , cardiovammation ,35,36, dammation ,38, and ammation , NF-κB pammation , MAPK paammation , TGF-β pammation , NLRP3 [ammation , Nrf-2 pammation , AMPK paammation , Wnt patammation , and intammation , and othAstragalus mongholicus and possesses favorable bioactivities, can it be developed as a functional food to fight obesity and related complications? In this systematic review, the publications over the past decades collected from PubMed, Google Scholar, and Web of Science databases were summarized. The keywords used for the search were CSF, obesity, obesity-related diseases, and mechanisms of action. In this paper, the mechanism of CSF discovered through in vitro and in animal models are presented, which are important for undertaking further research that assesses the usefulness of CSF in the prevention and/or treatment of obesity and other disorders arising on its basis.Since CSF is derived from the edible plant Interfering with PI3K/Akt-centered signaling pathways could be one of the primary mechanisms of CSF in alleviating physiological damages triggered by obesity, hypertension, and other complications. CSF was shown to improve leptin resistance by down-regulating leptin level and the expression of p-PI3K, suppressor of cytokine signaling 3 (SOCS3), and protein-tyrosine phosphatase 1B (PTP1B) while up-regulating the expression of p-STAT3, leptin receptor, and pro-opiomelanocortin in high-fat diet (HFD)-induced hypertension rats . Further2+ influx, suggesting that CSF protected MCs from HG-induced damage by suppressing NADPH oxidase/ROS/Akt pathway [Additionally, CSF also displayed promising therapeutic effects on diabetic nephropathy (DN) via an Akt-signal mediated axis. Treatment of CSF caused a significant inhibitory effect on cell growth and ROS generation in HG-induced MCs, which markedly reduces NADPH oxidase activity and the protein expression level of Nox4. In addition, CSF application significantly down-regulated HG-induced Akt phosphorylation in the MCs and enhanced Ca pathway . Further pathway , which s pathway , which sThrough modulating the PI3K/Akt signaling pathway, CSF might be potentially useful in alleviating diabetic vascular complications, diabetic retinopathy, diabetic peripheral neuropathy (DPN), diabetic cardiomyopathy, as well as gestational diabetes. CSF intervention mitigated apoptosis in ox-LDL-treated HUVECs via up-regulating the expression of miR-140-3p and down-regulating the expression of p-PI3K and p-Akt. Intriguingly, inhibition of miR-140-3p expression or overexpression of KLF4, a valid target of miR-140-3p, countervailed these effects of CSF , which idb/db mice by blocking the activation of CX3CL1-RAF/MEK/ERK pathways, which down-regulated the expression of vimentin, α-SMA, IL-1β, p-c-Raf/c-Raf, and IL18, while up-regulated the expression of E-cadherin. Notably, CX3CL1-siRNA exhibited similar effects as CSF, whereas pReceiver-M90-CX3CL1 countervailed the protective effect of CSF on EMT [db/db and STZ-induced diabetic mice by down-regulating Podocin, Nephrin, ATF6/PERK downstream signal CHOP, IRE1α downstream signals p-JNK as well as cleaved caspase-12 levels, and rescued SERCA activity. Furthermore, the expression of Bcl-2, SERCA2, and GPR78 was enhanced in the renal cortex of db/db mice after CSF intervention, while that of Bax, cytochrome c, APAF1, and AIF was down-regulated. Moreover, CSF application suppressed ER stress and restored basal cytosolic Ca2+ levels by inhibiting PTP proteins [It was found that CSF might exert kidney-protective properties under hyperglycemic conditions by modulating the MAPK signaling pathway. CSF intervention inhibited HG-induced apoptosis of renal tubular epithelial cells, down-regulated the expression of TGF-β1 and p-p38, while up-regulated the levels of hepatocyte growth factor (HGF) . In addiF on EMT , revealiF on EMT . Similarproteins ,66. Inteproteins . In briedb/db mice with DR via blocking ERK1/2 phosphorylation and NF-κB pathway activation, which also suppressed AR activity, reduced the numbers of apoptosis of retinal RGCs, and down-regulated IL-1, IL-6, VEGF, VCAM-1, TNF-α, as well as MMPs expression [Moreover, a recent study found that targeting the JNK/Nrf-2 pathway might be one of the crucial mechanisms of CSF in treating diabetic ketoacidosis. CSF administration alleviated oxidative stress in STZ and alloxan-induced DKA mice via promoting p-JNK, Nrf-2 activity, as well as related antioxidant enzymes SOD, CAT, and GSH-Px expression, and down-regulating MDA levels. Furthermore, the JNK pathway activator (Anisomycin) exhibited the equivalent effect as CSF, while the JNK pathway inhibitor (SP600125) inhibited the antioxidant effect of CSF , suggestpression . Taken t−/− mice by suppressing the lipid deposition and inflammation via inactivating MAPK/NF-κB signaling pathway, which reduced the levels of IL-1β, IL-6, TNF-α, iNOS, and VCAM-1, and down-regulated the expression of p65, JNK, ERK1/2, and p38. Further, CSF exerted a protective effect in the liver and aortic sinus, as evidenced by the increase in collagen deposition and the expression of α-SMA, the decrease in caspase 3, TG, and total cholesterol (TC) expressions, and the reduction in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels [Interfering with NF-κB and relevant cross-talks might be another pivotal mechanism of CSF in ameliorating atherosclerosis, hepatic steatosis, hypertension, DM, and its complications. CSF alleviated the atherosclerosis and hepatic steatosis in HFD-induced LDLR) levels . Moreove) levels . In addi) levels . Further) levels . 2+ influx in the MCs [Further, CSF was found to mitigate DN by targeting NF-κB-mediated inflammation, which ameliorated podocyte foot process effacement and albuminuria, alleviated the injury of glomerular and tubular, as well as extracellular matrix accumulation in STZ-induced diabetic rats through decreasing the expression of NF-κB, p65, a1-chain type IV collagen, MCP-1, ICAM-1, and TNF-α ,74. Like the MCs . Further the MCs , which rdb/db mice with DR. The protective effect of CSF on RGC dysfunction in DR mice was found to be implicated in the blockade of ERK1/2 phosphorylation and NF-κB pathway activation. CSF treatment suppressed AR activity, reduced the numbers of apoptosis of retinal RGCs, and down-regulated IL-1, IL-6, VEGF, VCAM-1, TNF-α, as well as MMPs expression [CSF administration obviously relieved the increased blood glucose levels and the body weight loss, improved the structure of the aortic endothelium wall, and down-regulated FPG and HbAlc in HFD, HG, and STZ-induced diabetic rats. In addition, CSF improved endothelial dysfunction via enhancing the release of NO and eNOS and blocking the activation of MCP-1, TNF-α, and p65 . Furtherpression , which spression . CSF allpression . Taken t2+, and suppressing the nuclear translocation of NFAT2, but TRPC6 siRNA partly inhibited these effects of CSF [2+ levels by inhibiting PTP proteins [2+ homeostasis in podocytes. Moreover, Chen et al. demonstrated that CSF could effectively alleviate palmitic acid (PA)-induced HK-2 cell injury, which protected renal tubular epithelial cells from apoptosis by restraining ROS production, up-regulating Bcl-2, and down-regulating Bax, Cleaved Caspase-9 as well as Cleaved-caspase3 expression [CSF might be a therapeutic agent for DN via inhibiting the ER-stress-induced cell apoptosis. CSF treatment ameliorated epithelial cells exfoliation, dilation of tubular, basement membrane of renal tubules thickening, collagen deposition, and the apoptosis of renal tubular epithelial cells in diabetic rats and apoptosis ratio in HG-treated podocyte through down-regulating the expressions of Bax, caspase-12, cytochrome c, BIP, APAF1, AIF, caspase-9, and caspase-3, while up-regulating Bcl-2, and suppressed the ER-stress by diminishing the expressions of GRP78, p-eIF2α, p-PERK, TRB3, ATF4, ATF6, p-IRE1α, XBP1, and CHOP, while up-regulating SERCA2b ,80,81,82s of CSF . Intriguproteins . Taken tpression ,84. Addipression . Furtherpression . CollectCSF was reported to improve intervertebral disc degeneration induced by DM via an apoptosis-mediated pathway, which ameliorated the morphology and viability of HG-treated nucleus pulposus cells (NPCs), attenuated senescence and apoptosis through improving the telomere length and activation of telomerase, as evidence by the down-regulated expressions of cleaved-caspase 3, Bax, FITC, and p-16 and up-regulation of TERT and Bcl-2 . In addiTargeting the TGF-β signaling pathway was illustrated to be a promising mechanism of CSF in attenuating the deterioration of DN. CSF intervention significantly diminished HG-induced EMT and arrested HG-induced NRK-52E cell viability and apoptosis via blocking the activation of TGF-β1 and Smad pathways, as reflected by the down-regulation of TGF-β1, α-SMA, HG, p-Smad2, N-cadherin, and vimentin, and up-regulation of E-cadherin and ocludin. In addition, the protective effect of CSF on EMT was suppressed by the TGF-β1 activator SRI-011381 hydrochloride . FurtherAdditionally, CSF could promote diabetic wound healing via elevating cell proliferation, re-epithelialization, and angiogenesis via the TGF-β/Smad pathway. Gao et al. demonstrated that CSF accelerated wound healing via up-regulating TGF-β1, p-Samad2, and p-Samad3 and down-regulating Samd7 in HG-induced HaCaT cells. In addition, CSF relieved oxidative stress and inflammatory responses through increasing SOD, IL-10, and TGF-β1 while down-regulating ROS, MDA, IL-6, as well as IL-8 . Furtherdb/db mice. Furthermore, CSF partly reversed reductions of podocin and synaptopodin, improved NLRP3 inflammasome-mediated inflammation by down-regulating NLRP3, pro-caspase-1, caspase-1, as well as IL-1β in the renal cortex and serum of db/db mice, and restored the viability of podocytes induced by HG [CSF treatment significantly decreased TG urinary albumin, the total protein of urinary, albumin-to-creatinine ratio, creatinine clearance rate, mean glomerular volume, and fibrotic area in the glomeruli in ed by HG . Furthered by HG . Therefoed by HG . AltogetCSF was shown to relieve β cell damage induced by DM via targeting cross-talk between Nrf-2 and Akt signals. Lin et al. found that CSF application reversed the decrease in Nrf-2 and p-Akt in STA-treated INS-1 cells, which was accompanied by the down-regulation of Bax, caspase-3, and MDA as well as elevation of Bcl-2, SOD, and GSH-Px . In addiModulating the AMPK signaling pathway was regarded as a promising mechanism of CSF in alleviating NAFLD and DM. Wang et al. demonstrated that CSF might function as an AMPK activator that prevented lipid accumulation in IR HepG2 cells. Specifically, CSF intervention suppressed the intracellular accumulation of glucose, down-regulated the expression of TG and FFA, curbed the nuclear transcription of SREBP-1c by activating AMPK, down-regulated the levels of SREBP-1c and its downstream factors FAS as well as SCD, up-regulated the activity of AMPKα1, AMPKα2, as well as IRS-2, and restored the levels of ACC1 and SREBP-2c, accompanied by the restoration of lipid metabolism. Notably, the APMK inhibitor compound C can eliminate the effects of CSF . LikewisAdditionally, CSF administration obviously relieved the metabolic dysfunctions, enhanced the mRNA expression of AMPK and SIRT1, and up-regulated the protein expression of p-AMPK and SIRT1 in T2DM mice. Notably, similar results could be observed in IR HepG2 cells , which sCSF treatment reduced renal tubular epithelial cell vacuolization, decreased the levels of Scr and blood urea nitrogen (BUN) in DN rats and improved the viability of HG-induced HK-2 cells by increasing SOD and down-regulating ROS, MDA, IL-1, IL-4, as well as IL-6. Moreover, CSF postponed EMT advancement via blocking the activation of the Wnt/β-catenin pathway, as evidenced by the elevation of APC, Axin, GSK-3β, and E-cadherin and the diminution of N-cadherin, α-SMA, Wnt1, β-catenin, Vimentin, FN, as well as Col-IV . In addiCSF pre-treatment significantly decelerated the excretion of proteinuria in STZ-induced DN rats in a dose-dependent manner. Simultaneously, thylakoid expansion, glomerulosclerosis, and interstitial fibrosis were alleviated in STZ-induced DN rats after CSF intervention. Further, CSF prevented the shedding of podocyte foot process and reduced podocyte density in DN rats by up-regulating integrin α3 and integrin β1 expression, down-regulating β1-ILK expression, and reducing the number of WT-1 positive cells . AdditioCSF repaired vasoconstriction damage, enhanced NO bioavailability, elevated p1177eNOS content, and modified endothelial dysfunction in STZ-induced diabetic mice. In addition, the oxidative stress is alleviated after CSF intervention, accompanied by the decrease in NADPH-related oxidase, down-regulated expressions of SOD, MDA, p22phox, p47phox, p67phox, NOX2, NOX4, as well as Rac-1, and up-regulated levels of SOD . FurtherConsiderable evidence elucidated that scavenging free radicals might be a crucial mechanism of CSF in ameliorating NAFLD, DN, DR, and diabetic hepatopathy. CSF intervention significantly rescued weight and liver weight gains in HFD-induced NAFLD mice, which restored liver damage through downregulating 5-LO, LTA4H, as well as LTB4. CSF administration was reported to alleviate oxidative stress in PA-induced LO2 cells, accompanied by the reduction in lipid accumulation, increased expression of GSH-Px, and decreased expression of TG, TC, ROS, and MDA . CSF attCoordinating the activation of the HIF-1α/VEGF signaling pathway might be responsible for the molecular basis of CSF in promoting diabetic wound healing. CSF intervention accelerated the closure of the wounds in diabetic mice by elevating the number of alternative activated macrophages F4/80+CD206+ cells, up-regulating the expression of fibronectin, collagen IIIa, VEGF, vWF, arginase-1, Ym1, as well as IL-13, and down-regulating the activities of SOD, CAT, and TNF-α. Further, topical application of CSF improved the formation of thick granulation tissue with more new blood vessels, stimulated re-epithelialization, and promoted collagen synthesis and deposition in diabetic wounds . In addiExploring the side effects or risks associated with CSF is of great significance for the development of CSF as a dietary supplement. So far, potential maternal toxicity and fetal toxicity of CSF have been investigated in rats and rabbits . CSF wasAt present, remarkable progress has been made in the investigation of the pathophysiological mechanisms underlying the occurrence and development of obesity. Growing studies reported that obesity appears to be the consequence of disturbed brain circuits and impaired feedback of neuroendocrine, which is connected to pathological overeating as well as lack of exercise . More imAstragalus mongholicus Bunge, has been demonstrated to possess a variety of bioactivities, such as attenuating adipose tissue inflammation, relieving oxidative stress, reducing blood glucose, regulating lipid metabolism, protecting β cell damage, and improving insulin resistance, etc. Based on these outstanding bioactivities, CSF displays promising therapeutic effects on obesity and relevant diseases. So far, considerable studies have been devoted to elucidating the potential mechanisms of CSF in the prevention or treatment of these diseases, which, although not comprehensive, could advance the development of CSF as an anti-obesity drug candidate. From these studies, it could be inferred that interfering with PI3K/Akt-centered signaling cascades, MAPK, NF-κB, and apoptotic pathways might be the most critical mechanism of CSF in treating obesity, hypertension, NAFLD, DM, obesity-induced cardiovascular and cerebrovascular diseases, retinopathy, neuropathy, as well as gestational diabetes. In addition, CSF also modulated signals, including TGF-β, NLRP3, Nrf-2, AMPK, Wnt, integrin/ILK, eNOS/NO, and free radicals to exert its protective effects against obesity-derived diseases. Interestingly, there existed several cross-talks between these signaling pathways, like MAPK-NF-κB and ERK1/2-NF-κB, which might explain, in part, the therapeutic effects of CSF in different metabolic diseases at similar dosages. The primary underlying mechanisms of CSF in alleviating obesity and related disorders have been portrayed in CSF, derived from the root of the edible herb


Promotoras de Donación e-learning module was developed to train Latinx lay health educators  to discuss deceased organ donation and promote donor designation within their communities.Latinx populations are severely underrepresented among organ donors compared with the non-Hispanic White population. The This paper described the results of 2 studies designed to assess the direct and indirect effects of the module on promotoras’ and mature Latinas’ organ donation and donor designation knowledge, attitudes, and behaviors.Promotoras de Donación e-learning module, with participating promotoras and mature Latinas serving as their own controls. Brief surveys were administered to participating promotoras before and after module completion to assess changes in organ donation knowledge and support and communication confidence (study 1). Promotoras participating in the first study were asked to hold at least 2 group conversations about organ donation and donor designation with mature Latinas (study 2); paper-pencil surveys were completed by all participants before and after the group conversations. Descriptive statistics, means and SDs, and counts and percentages were used as appropriate to categorize the samples. Paired sample 2-tailed t test was used to assess changes in knowledge of and support for organ donation and confidence in discussing donation and promoting donor designation from pre- to posttest.In partnership with 4 community-based promotoras organizations, we designed 2 nonrandomized, quasiexperimental pragmatic studies to evaluate the P=.01). The module was well received, with most participants deeming it well organized, presenting new information, and providing realistic and helpful portrayals of donation conversations. A total of 52 group discussions with 375 attendees were led by 25 promotoras (study 2). The trained promotora-led group discussions about organ donation resulted in increased support for organ donation in promotoras and mature Latinas from pre- to posttest. Knowledge of the steps to become an organ donor and belief that the process is easy to perform increased in mature Latinas from pre- to posttest by 30.7% and 15.2%, respectively. In total, 5.6% (21/375) of attendees submitted completed organ donation registration forms.Overall, 40 promotoras completed this module (study 1). Increases in organ donation knowledge  and support  were observed from pre- to posttest; however, these changes did not reach statistical significance. A statistically significant increase in communication confidence was found (mean 692.1, SD 232.4 to mean 852.3, SD 139.7; This evaluation provides preliminary support for the module’s direct and indirect effects on organ donation knowledge, attitudes, and behaviors. The need for additional modifications to and future evaluations of the module are discussed. The demand for organs continues to supersede the supply, making interventions to increase the number of Americans enrolled in state organ donor registries, with signed organ donor cards, or with “organ donor” indicated on their driver’s license  timely and meritorious pursuits. Despite the increased availability of organs for transplantation owing to the national opioid crisis , >106,00The revised Uniform Anatomical Gift Act, which made donor designation legally binding, allows people to register as a posthumous organ donor on a driver’s license, organ donor card, or on a web-based registry . This rePromotoras de Donación, targeting the existing network of Latinx lay health educators or Promotores de Salud [Numerous barriers to donor designation have been identified among Latinxs. Mistrust of the medical establishment and the organ distribution system and lack of knowledge of organ donation have been cited as barriers by most racial and ethnic minority groups, including Latinxs ,13. Rumode Salud .Promotores de Salud  are trusted sources of health information in Latinx communities. As lay health educators or community health workers, promotores typically work or volunteer for health and community-based organizations; some large academic institutions also maintain community health workers’ programs. Promotores are trained members of local and regional health and public health workforces created to provide culturally and linguistically appropriate health information and improve access to and use of health care services among low-income Latinx communities. Promotores have proven to be an effective means of increasing knowledge of numerous health topics and health-promoting behaviors and improving chronic disease management [Promotores de Salud are considered a potentially fruitful approach to mitigating inequities in health and health care outcomes for Latinx communities [nagement -26. Largmunities . HoweverPromotores de Salud programs to increase donor designation rates in Latinx communities. The web-based e-learning module, Promotoras de Donación, was developed to address gaps in knowledge and correct misinformation about organ donation identified in focus group interviews with promotoras and mature Latinas [promotores to promotoras reflects the focus on Latinx women for these studies.) Specifically, the culturally targeted e-learning module was designed to provide basic information about organ donation and donor designation and to train promotoras in the communication skills needed to effectively initiate and maintain conversations about organ donation and promote the act of donor designation among family, friends, and community members.Our overall objective was to leverage existing  Latinas ,22. . Trained promotoras were then asked to hold at least 2 group conversations about organ donation and donor designation with mature Latinas (women aged ≥50 years) in their communities (study 2). Perceptions of the conversations and attitudes toward organ donation and donor designation were collected via a survey before and after each group discussion to assess the indirect effects of the module. The findings from these studies provide a better understanding of the utility of promotoras in disseminating information about organ donation and promoting donor designation in Latinx communities. The findings can also help guide future modifications and use of the newly developed This study was conducted in partnership with 4 community-based promotores organizations: Esperanza Health (Philadelphia), Enlace Chicago and Centro San Bonifacio (Chicago), and the Bexar County Community Health Collaborative (San Antonio). At the study’s outset in 2016, these cities had donor designation rates of 47%, 45%, and 60%, respectively. Each state supported donor designation on the web, enrollment at the local Department of Motor Vehicles offices, and a signed organ donor card. Organizational staff met with the Temple University–based investigative team quarterly to provide ongoing input and feedback on study-related processes and procedures, including developing and piloting the module.From January to March 2019, partnering organizations assisted with recruitment of promotoras by posting study flyers in high traffic areas, sending email announcements of the opportunity to participate, and via word of mouth. Eligible promotoras were English- or Spanish-speaking, aged >18 years, and had completed all requirements to work or volunteer as a promotora with their respective organizations. Individuals expressing interest in participating were referred to the research team for screening and enrollment. Once enrolled, participating promotoras were sent emails containing links to the training along with credentials for logging into the web-based system. Participants were instructed to complete the training and web-based surveys in a single sitting, if possible.Promotoras de Donación e-learning module was designed as a highly engaging and interactive web-based learning experience. The web-based format was chosen over in-person training to allow participants  flexibility in completing the training and, if effective, to extend the reach of the training and integrate the module into existing web-based promotores training. The curriculum for the 74-minute training consisted of 2 components, a didactic educational component and a skills-based communication component. The theoretical underpinnings, development, curriculum, and final format of the module have been described in detail elsewhere [plática with mature Latinas. The module is in Spanish with English subtitles and was informed by focus groups with promotoras and mature Latinas [The lsewhere . Briefly Latinas . The GifStudy 1 was designed to test the direct effects of a newly developed, web-based training. We hypothesized that, compared with the baseline, participating promotoras would report higher levels of organ donation knowledge and support and communication confidence after completing the training.Promotoras de Donación e-learning module. The 48-item pre- and posttests were created in Qualtrics and embedded in the e-learning module for easy access. The following validated measures were included:Brief web-based surveys were administered before and after participating promotoras completed the Knowledge of organ donation: Knowledge was assessed using a series of 10 factual statements previously developed and used to assess knowledge of organ donation in a Latinx community sample . RespondSupport for organ donation: Support for organ donation was assessed using a single categorical item  -30.Communication confidence: A series of 10 items assessed participants’ confidence in handling various aspects of organ donation–related conversations. Respondents reported confidence with each aspect along a continuous scale  developed by Bandura et al .Participants’ sociodemographic information  was collected at pretest. The posttest included 10 additional items assessing the acceptability of the module. Specifically, 8 items queried participants on the length, organization, and realism of the module using 4-point Likert-type scales of agreement . The quality of the module was assessed using a single categorical item , and 2 open-ended questions prompted respondents to describe their most and least liked aspects of the module.a priori power analysis, computed to detect a difference within subjects measured on 2 occasions, assuming α=.05 and a medium effect size (Cohen d=0.25) determined that a sample of 40 promotoras would yield a power of 0.91.An All promotoras enrolled in the study completed the training and served as their own controls. There was no separate control group and thus no assignment to groups.This study had a single condition  of which all participants and staff were aware.t test was used to assess changes in promotoras’ knowledge of and support for organ donation and confidence discussing donation and promoting donor designation from pre- to posttest. Before the analysis, knowledge items were recoded to indicate whether the response was correct or incorrect, with unsure responses coded as incorrect. Correctly answered items were summed to create a composite knowledge score. Confidence items were summed to create a global confidence score, which exhibited high internal consistency reliability (Cronbach α=.92). A P value of .05 was used to determine statistical significance. SPSS  was used for all analyses.All study variables were fully summarized using univariate statistics, including means and SDs for continuous variables and frequency counts and percentages for categorical variables. The paired sample 2-tailed Promotoras de Donación training in study 1 were asked to hold at least 2 group conversations  about organ donation and donor designation with mature Latinas in their communities. Before leading any pláticas, participating promotoras received in-person training in research basics, human participants research ethics, and the study protocol. To facilitate data collection, packets containing paper-pencil surveys and clear instructions on the steps to follow in recruiting plática attendees and planning and leading the discussions were sent to each partnering organization for distribution. Participating promotoras returned packets with completed surveys to their organization for shipment to the Philadelphia-based research team. Promotoras were provided with a US $50 Visa debit card for each plática to defray costs of refreshments for the attendees.From July 2019 to January 2020, promotoras who had completed the Mature Latinas were recruited through participating promotoras’ personal and professional networks, as well as through community announcements, flyers, and listserves.Promotoras de Donación e-learning module. Specifically, we sought to understand whether the training prepared promotoras to lead discussions on organ donation and donor designation. We also hypothesized that plática attendees would demonstrate increases in organ donation knowledge, attitudes, and behaviors after participating in a group discussion.Study 2 was conducted to assess the indirect effects of the pláticas. The 23-item presurvey included the following items:Brief self-administered, paper-pencil surveys were completed by promotoras before and after leading the Support for organ donation: A single 5-point categorical item assessed support for organ donation .Attitudes toward organ donation: Attitudes toward organ donation and donor designation were assessed using separate sets of 7 Likert-type items .Organ donation behaviors: 4 dichotomous items  assessed promotoras’ organ donation behaviors, including family conversations about organ donation, family knowledge of donation wishes, and donor designation status (registered as an organ donor or not registered). Respondents who indicated that they had not yet registered were asked if they intended to register as a posthumous organ donor.Preparation to hold conversations about organ donation and donor designation: The last 4 questions gauged promotoras’ perceptions of preparation for and confidence in holding small group discussions about organ donation.pláticas.The 7-item postsurvey included 4 single items that asked promotoras to rate the group discussions held about organ donation , support for organ donation , and preparation for and confidence in communicating about organ donation . Furthermore, 3 open-ended questions asked what would have helped improve the discussions, and what would improve feelings of preparation and confidence for future Plática attendees also completed self-administered, paper-pencil surveys before the conversations began and at the end of the discussions. Presurveys included the following:Support for organ donation: A single categorical item assessed support for organ donation .Attitudes toward organ donation: A series of 7, 4-point Likert-type items captured attitudes toward organ donation . A similar series of 6 four-point Likert-type items assessed attitudes toward donor designation.Organ donation behaviors: 3 dichotomous items  gauged family conversations about organ donation, donation intentions, and donor designation. The postsurvey included 8, four-point Likert-type items assessing the conversation about organ donation .pláticas as they would in their work as promotoras.A power analysis was not conducted for study 2. Rather, participating promotoras were asked to recruit individuals for the plática). There was no separate control group and thus no assignment to groups.Study 2 was designed as a single arm study  was used for all analyses.The protocols for both studies were approved by the ethics board of Temple University . This study has been registered with ClinicalTrials.gov (NCT04007419). The Transparent Reporting of Evaluations with Nonrandomized Designs checklist was used to guide the reporting of both studies .Participating promotoras (N=40) were all Latina, with an average age of 45 (SD 11.1) years and self-reported Christian faith . Participants were experienced promotoras with an average tenure of 3.7 (SD 4.6) years .P=.9). However, notable increases in knowledge were observed in questions regarding the equitable distribution of organs, the existence of a national organ matching system, and whether registration includes agreement to the donation of organs, tissues, and eyes.Composite knowledge of organ donation was modest at pretest, with respondents correctly answering an average of 6 of 10 questions . P=.3).Overall support for organ donation increased slightly from 3.4 (SD 0.9) to 3.6 (SD 0.9) from pre- to posttest. However, this difference was not statistically significant  to posttest . Individual items assessing confidence answering questions about donation, providing information about the organ shortage, encouraging and instructing people to become donors, and ending a discussion about organ donation also demonstrated statistically significant increases.Overall, 83% (33/40) participating promotoras completed an evaluation of the module. Most “agreed” or “strongly agreed” that the module presented new information , that it was well organized , and that there was interest in the material covered . Participants also “agreed” or “strongly agreed” that the conversation portrayed was realistic , and that it was helpful to see an example of a conversation about organ donation . In addition, 60% (18/30) of respondents felt the module tried to cover too much information and 30% (9/30) of respondents felt the module was too long. However, most participants  rated the module quality as good (n=2), very good (n=11), or excellent (n=19).No adverse events or unintended effects were reported.pláticas about organ donation and donor registration (range: 1-4 pláticas per promotora). Participant demographics are presented in Of the 40 promotoras participating in study 1, 25 (62%) led 52 plática attendees, 229 (61.1%) self-identified as only Hispanic or Latina; the remainder  identified as Hispanic or Latina and another racial or ethnic group . Most of those reporting a religious affiliation  were of Protestant or Christian  or Catholic  faith. Most participants  reported having received <12 years of schooling.Of the 375 plática.Most participating promotoras indicated supporting organ donation “totally”  or “quite a bit” . Most promotoras also reported being much more supportive  or somewhat more supportive  of organ donation after leading a Attitudes toward organ donation were generally positive . All parplática, with all also indicating high levels of confidence to do so , and a slight majority felt more or somewhat more confident  after holding the group discussions.All participating promotoras indicated feeling “somewhat” or “very” prepared to lead a to do so . Respondpláticas at donor registration sites, such as regional Organ Procurement Organizations.When asked how the discussions could be improved, promotoras noted a need for more techniques to engage with older adults holding strong beliefs in common organ donation myths, more personal stories and testimonials, more written information with visuals, and bolder graphics to help focus on the discussion and for later reference. More training and practice, active listening, real-life examples, researching opinions of their communities, more participant incentives, and use of a PowerPoint presentation were cited as strategies to increase their comfort and preparation for future discussions. One participant suggested holding plática attendees expressed some level of support for organ donation at baseline. Specifically, a plurality of the attendees  reported full support for organ donation, with another 54.1% (203/375) reporting “quite a bit,” “a fair amount,” or “a little bit” of support. Only 7.7% (29/375) of the attendees reported no support for organ donation when initially asked  ly asked .Plática attendees expressed mixed support for and attitudes toward organ donation and donor designation, as assessed before starting each discussion. Although most of the respondents agreed or strongly agreed that organ donation saves lives  and just more than half  reported family support for organ donation, more than a quarter of the sample  agreed that their religion did not support organ donation, with 18.4% (69/375) agreeing that organ transplantation was against God’s will  reported having discussed organ donation with their family before the plática. However, 53.3% (200/375) of the plática attendees stated that their family did not know their donation wishes, and 39.2% (147/375) of the attendees reported having registered as posthumous organ donors. Most plática attendees understood that signing up to become an organ donor would help other Latinxs waiting for transplants  of attendees submitted a completed organ donation registration form.The post-g module . Most ofNo adverse events or unintended effects were reported.Promotoras de Donación e-learning module was developed in partnership with 4 community-based organizations, with organizational leadership and active promotoras informing all aspects of the module’s design, development, and implementation. This evaluation assessed both the direct effects of the module on participating promotoras’ knowledge of and support for organ donation and donor designation and confidence in communicating about organ donation and encouraging donor registration as well as indirect effects on attendees of the trained promotora-led small group discussions with mature Latinas. Although modifications to the module were clearly identified, the results suggest that it increased promotoras’ preparation for and confidence leading pláticas, ultimately leading to more positive organ donation sentiment among plática attendees. However, this resulted in only 21 completed donor registration forms.The plática by 30.7% and 15.2%, respectively.Specifically, we found small, nonsignificant changes in overall knowledge of and support for organ donation and a large and statistically significant increase in communication confidence among participating promotoras. It is unknown why we found small and nonsignificant increases in knowledge of organ donation. The knowledge items chosen reflect the information contained within the module, information deemed critical to understanding the shortage of organs for transplantation, and the need for donors in the Latinx community. Knowledge increases were observed in items assessing the existence of the national organ matching system, the disproportional prevalence of Latinx organ transplants, the equitable and ethical distribution of organ matching, and that registration include agreement to the donation of organs, tissues, and eyes. Thus, the module aided in demystifying organ donation, especially in relation to misinformation regarding discrimination in the organ transplant system. However, knowledge decreased in items querying about the need for a license for donor designation, prevalence of mortality owing to lack of organs, cost associated with donor designation, Latinxs’ disproportional wait times for organ transplantation, and criteria for becoming a donor. Participant evaluations offered some insights into these findings. In particular, a considerable proportion of respondents felt that the module was too long and tried to cover too much. Therefore, the observed results may simply be a byproduct of information overload and not a true reflection of knowledge of organ donation, or may reflect how certain topics resonate more clearly than others in this specific participant group. Notably, knowledge of the steps to become an organ donor and belief that the process of registering is easy to perform increased in mature Latinas from pre- to post-A statistically significant increase was found in promotoras’ composite communication confidence scores from pre- to posttests, as did scores for each individual item. Most notably, items assessing confidence in answering questions about donation, providing information about organ shortages, encouraging and instructing people to become donors, and ending a discussion about organ donation demonstrated statistically significant increases. Although all communication skills exhibited increases in confidence from pre- to posttest, we note that arguably the most important communicative skills—to start the discussion, to discuss the need for Hispanic donors, and to provide instructions on how to register as an organ donor—did not exhibit the largest gains in confidence. Future iterations of the module should bolster education and demonstration of these specific skills.Promotoras de Donación included clear indication of specific skills needed to effectively communicate the need for organ donors in the Latinx community and to encourage and instruct others to register as posthumous organ donors. We suspect that the narrative format, in combination with the skills demonstration, produced the results observed in participants’ communication confidence. However, further investigation is needed to determine the specific aspects of the intervention that are most effective.The second half of the module portrays a promotora engaging in discussions about organ donation and donor registration with a group of mature Latinas. Such narrative storytelling is a valuable educational tool defined by individuals who share their experiences through autobiographical narratives related to a specific theme ,34. Storplática attendees, the discussions led to increased comfort with organ donation and greater willingness to register as posthumous organ donors.To assess the indirect effects of the e-learning module, promotoras from the first study were asked to facilitate small group discussions on organ donation with mature Latinas in their communities. Most participating promotoras continued to express positive attitudes toward organ donation months after completing the e-learning module, believed it was important for their communities, and did not report common barriers such as family disapproval and medical mistrust. Upon postassessment, most promotoras viewed their small group discussions as a success, and more than half reported a greater support for organ donation after the facilitation. Even though a small minority of promotoras did not feel more prepared or more confident after leading the discussion, for most plática attendees completed an organ donation registration form despite it being available in English and Spanish. Although women tend to serve as the main source for health-related knowledge in Latinx families [Subjective willingness did not translate into behavioral action; only 21 families , the cenfamilies . Despitefamilies , may be plática attendees who may have been undocumented. We did not collect data on citizenship owing to the national sentiment toward immigrants during the study period. However, future research should assess citizenship to elucidate its role in donor designation. We recommend the use of proxy measures, such as qualification for federal stimulus payments, rather than directly asking about citizenship as many individuals may be hesitant to share their status.Another related key concern that some Latinxs have is the fear that their families can legally overturn their decision to become a donor , which mplática attendees reported plans to sign up to be an organ donor in the next month. Future research should include partnerships with regional Organ Procurement Organizations so that an accurate, objective assessment of participants’ donor designation status may be ascertained.These findings suggest that participation in the group conversations with trained promotoras changed attendees’ perceptions of organ donation. For instance, most attendees reported that the discussion helped them understand the need for donors, convinced them that organ donation saves lives, and inspired them to want to hold family discussions about organ donation. Furthermore, more than half of the This multisite study recruited promotoras from organizations located in regions with Latinx populations with differing nativity, reflecting the diversity of the Latinx community and increasing the generalizability of the study. The module was created in partnership with 4 promotora organizations that were engaged throughout the developmental process—from the formative research needed to inform the module’s content to the design and implementation of the evaluation—to ensure that the module provided culturally and linguistically appropriate education about organ donation and donor designation. However, our findings must be considered in the context of this study’s limitations. Although randomized controlled trials are considered the gold standard in evaluations of behavioral interventions owing to their ability to control for potentially confounding factors and bias , the compláticas, an estimated 600 mature Latinas would have been reached. Moreover, the preliminary data from this test of the Promotoras de Donación e-learning module supports its future modification and expansion. However, our findings also suggest that the module may need revision before implementing a larger, more definitive evaluation. Specifically, the didactic component requires shortening and reorganization to create a more user-centered, less burdensome learning experience. Participating promotoras also requested additional training and specific training in how to effectively dispel strongly held myths and misinformation about organ donation. As the module was designed as a web-based learning experience, it can be made accessible to lay health educators and community health workers through a mobile device or internet; this capability is crucial as observed throughout the COVID-19 pandemic.Findings from these 2 studies suggest that trained promotoras may be feasibly leveraged to help educate Latinx communities about organ donation and promote donor designation. The 25 trained promotoras participating in study 2 reached an average of 15 mature Latinas. If all 40 promotoras participating in study 1 held Future research should focus on understanding the ways in which promotoras use the skills advanced in the module in conversations about donation. Future studies should also seek to understand the module’s effects on more distal outcomes, that is, the impact trained promotoras have on knowledge of and attitudes toward organ donation and on rates of donor designation in their communities. Once its effectiveness is established, the module could be incorporated into routine promotoras training programs across the nation with minimal difficulty, including the web-based training offered and maintained by the United States Department of Health and Human Services’ Office of Minority Health .The results of this study highlight the benefits of partnerships with community-based organizations. Regional Organ Procurement Organizations should consider establishing and maintaining strong partnerships to educate the public about organ donation, engender positive attitudes toward donor designation, and encourage donor designation. In this study, 25 trained promotoras engaged 375 community members. Coordinating training to coincide with national organ donation campaigns, such as the Donate Life campaign implemented annually in April, has the potential to reach thousands of people and inspire local and regional conversations that may lead to both increase in donor designation and the number of lives saved through increased organ availability and access to transplantation.


Anti-NMDA receptor (NMDAR) encephalitis is an autoimmune disease characterized by complex neuropsychiatric syndrome and cerebrospinal fluid (CSF) NMDAR antibodies. Triggering receptor expressed on myeloid cells 2 (TREM2) has been reported to be associated with inflammation of the central nervous system (CNS). Matrix metalloproteinase-9 (MMP9) and cluster of differentiation (CD44) were measured to evaluate blood‒brain barrier (BBB) permeability in anti-NMDAR encephalitis. The roles of microglial activation and BBB disruption in anti-NMDAR encephalitis are not well known.r = 0.702, p < 0.0001) and serum MMP9 levels . In addition, CSF sTREM2 levels were related to clinical parameters .In this work, we detected increased expression levels of CSF sTREM2, CSF and serum CD44, and serum MMP9 in anti-NMDAR encephalitis patients compared with controls. CSF sTREM2 levels were positively related to both CSF CD44 levels (Increased sTREM2 levels in CSF as well as increased CD44 and MMP9 in serum and CSF reflected activation of microglia and disruption of the BBB in anti-NMDAR encephalitis, expanding the understanding of neuroinflammation in this disease. The factors mentioned above may have potential as novel targets for intervention or novel diagnostic biomarkers. N-methyl-d-aspartate (NMDA) receptor (NMDAR) encephalitis is an autoimmune-mediated disease characterized by a complex neuropsychiatric syndrome, including rapidly progressive psychiatric symptoms or cognitive impairment, seizures, abnormal movements, or coma of unknown cause [Anti-wn cause –3. The dwn cause , 5. Bothwn cause . These pwn cause . The onlwn cause . Other dwn cause . Some inwn cause . Solublewn cause . Thus, twn cause .Recent brain biopsy and autopsy research and clinical evidence have shown that anti-NMDAR encephalitis patients at the acute stage (approximately 3 months or longer) have infiltration of immune cells, while neuroinflammation and the role of microglial activation have not yet been explored . In addiThe triggering receptor expressed on myeloid cells 2 (TREM2) is an immune receptor that is expressed abundantly by microglia in the central nervous system (CNS) and is involved in key immune-related functions of microglia activation –14. SoluCluster of differentiation (CD) 44 is a type 1 transmembrane receptor, and its standard form is widely expressed in the majority of immune cells . As a mu2+-dependent endopeptidase that can cleave type IV collagen in the extracellular matrix of the BBB, is induced by inflammatory cytokines, leading to disruption of the blood‒brain barrier (BBB) [Matrix metalloprotease (MMP) 9, a Zner (BBB) , 21. AltIn this study, we measured the concentrations of the above biomarkers in the CSF and serum of anti-NMDAR encephalitis patients to explore the relationship between microglial activation, BBB disruption, and anti-NMDAR encephalitis, providing insights into potential diagnostic markers and pathogenesis.n = 7), peripheral neuropathy (n = 2), diabetic retinopathy (n = 1), intracranial hypotension headache (n = 1), anxiety disorders (n = 3), and hypertension (n = 1).In this study, 29 anti-NMDAR encephalitis and 15 control patients from the Neuroinfection and Neuroimmunology Center, Department of Neurology, Beijing Tiantan Hospital were enrolled between Jan. 2017 and Sep. 2021. The anti-NMDAR encephalitis patients were diagnosed according to the revised anti-NMDAR encephalitis diagnosis criteria of 2016 based on the clinical manifestations and identification of CSF antibodies against the GluN1 subunit of NMDAR by cell-based analysis . The cong for 10 min and stored in the supernatant at − 80 °C until detection by ELISA.All samples were collected before treatment when anti-NMDAR encephalitis patients were in an acute phase. The CSF and serum samples were immediately centrifuged at 1000×The clinical parameters in this study included demographic information , adapted modified Rankin Scale (mRS), Glasgow Coma Scale (GCS), and Qalb. The patients’ evolution or functional outcome was evaluated using the GCS and mRS, and data were obtained from digital medical records.The adapted modified Rankin Scale is an ordinal 7-point scale ranging from no symptoms (0) to severely disabled (5) or death (6) Table . The mRSThe Glasgow Coma Scale is an essential and well-validated coma scale in critical care for rapidly determining the neurological status of patients and for estimating their long-term prognosis . The sca−3. We calculated the Qalb (AlbCSF/Albserum) in all patients, and an elevated Qalb  was defined as disruption of the BBB [The cerebrospinal fluid (CSF)/plasma albumin ratio  is believed to reflect the integrity of the blood‒brain barrier (BBB) . As Qalb the BBB .Experiments were carried out following the ethical principles established in the Declaration of Helsinki. Patients (or their representatives) were informed about this study and gave written informed consent. The study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (No. KY2015-031-02). All participants provided written informed consent before proceeding with the study.Enzyme-linked immunosorbent assay (ELISA) kits were applied to measure the concentration of sTREM2 , CD44 , and MMP9  in humoral fluids. All detections and measurements were performed following the manufacturer’s instructions, and every standard and sample was assayed in duplicate.t test. The Mann‒Whitney U test was applied when comparing the differences in age, CSF white blood cell (WBC) counts, CSF CD44 levels, CSF sTREM2, and serum MMP9 levels between the anti-NMDAR encephalitis and control groups. Differences in both CSF sTREM2 and CSF CD44 levels between the good clinical outcome group and the poor clinical outcome group in anti-NMDAR encephalitis were assessed by the Mann‒Whitney U test. Statistical analysis of CSF sTREM2, serum sTREM2, serum MMP9, serum CD44, and CSF CD44 levels was performed after adjusting the confounding factors, age, and sex in the multivariate linear regression analyses. The differences in sex between the control group and anti-NMDAR encephalitis were performed with Chi-squared analysis with Yates’ continuity correction. Correlation coefficients between sTREM2, CD44, MMP9, mRS scale, GCS scores, and Qalb were calculated using Spearman’s two-tailed correlation test when one of the variables did not satisfy a normal distribution. A p value < 0.05 was considered statistically significant.All statistical analyses were conducted using SPSS version 24.0  and Prism (GraphPad software 8.0 version). Data are presented as the mean ± SD or the median with an interquartile range based on the normality test. The differences in CSF total protein concentrations and serum CD44 levels between the anti-NMADR encephalitis and control groups were assessed with an independent two-sample n = 29, 15 male and 14 female) and OND controls  are presented in Table p = 0.006, Table p < 0.001, Table p = 0.048, Table The clinical data and the concentrations of the biomarkers from patients with anti-NMADR encephalitis (p = 0.001), and the serum sTREM2 levels showed an increase in the anti-NMDAR encephalitis patients .The median levels of CSF sTREM2 were 49.15 (37.48–97.54) ng/mL in the anti-NMDAR encephalitis group and 24.75 (14.45–32.88) ng/mL in the OND control group. The median levels of serum sTREM2 were 25.64 (17.50–42.92) ng/mL in the anti-NMDAR encephalitis group and 24.55 (13.32–34.73) ng/mL in the control group. The level of CSF sTREM2 was increased significantly in the anti-NMDAR encephalitis patients compared with the control group .The median levels of serum MMP9 were 306.09 (209.68–527.40) ng/mL in the anti-NMDAR encephalitis group and 210.63 (179.56–268.60) ng/mL in the control group. The serum MMP9 levels increased markedly in the anti-NMDAR encephalitis group compared with the control group  were observed between the anti-NMDR encephalitis group and the control group, while the CD44 levels in serum showed no marked differences .In addition, the median levels of CSF CD44 were 42.55 31.33–69.47) ng/mL in the anti-NMDAR encephalitis group and 15.95 (12.09–72.15) ng/mL in the control group. The median levels of serum CD44 were 13.2 (10.92–17.33) ng/mL in the anti-NMDAR encephalitis group and 7.72 (4.26–12.17) ng/mL in the control group. Significantly elevated CD44 levels in CSF .CSF sTREM2 is related to anti-NMDAR encephalitis inflammatory factors. As shown in Fig. r = 0.509, p = 0.005, Fig. r = − 0.382, p = 0.041, Fig. r = 0.467, p = 0.011, Fig. r = 0.493, p = 0.007, Fig. Other inflammatory factors (CD44 and MMP9) are related to clinical parameters, including mRS, GCS, and Qalb. For the CSF CD44 expression level, a positive correlation was shown between the CSF CD44 expression level and the mRS scale , serum CD44 (p = 0.940), and serum MMP9 (p = 0.295) showed no differences in patients with a good outcome compared with patients with a poor outcome in anti-NMDAR encephalitis. These results showed that CSF sTREM2 levels and CSF CD44 levels had different distributions in the prognosis of anti-NMDAR encephalitis.We defined the clinical outcome according to mRS scores . In the anti-NMDAR encephalitis patients, the CSF sTREM2 levels in patients with good outcomes were lower than those in patients with poor outcomes (p = 0.0109), and the AUC for CSF CD44 was 0.794  analysis. We found that both CSF sTREM2 levels and CSF CD44 levels showed predictive value in the clinical outcome of anti-NMDAR encephalitis. The area under the curve (AUC) for CSF sTREM2 in anti-NMDAR encephalitis patients to distinguish from poor clinical outcome was 0.800 (N = 29) well from the control group (N = 15), with an AUC of CSF sTREM2 levels of 0.864 (p < 0.0001). The AUC for CSF CD44 levels was 0.729 (p = 0.018), for serum CD44 levels was 0.837 (p = 0.0003), and for serum MMP9 levels was 0.687 (p = 0.0436), while the serum sTREM2 level showed a poor diagnostic value with an AUC of 0.568 (p = 0.4651).In addition, we also applied ROC analyses to show the diagnostic value of sTREM2, CD44, and MMP9 in CSF or serum for anti-NMDAR encephalitis  the increased concentrations of sTREM2, CD44, and MMP9 in the CSF and serum of the anti-NMDAR encephalitis group compared with the control groups; (2) the above biomarkers are related to clinical parameters ; (3) CSF sTREM2 and CSF CD44 have predictive value in distinguishing the severity of clinical outcome; and (4) the activation of microglia and disruption of the BBB play a role in the pathogenesis of anti-NMDAR encephalitis.. However, very few studies have detected sTREM2 levels in the CSF and serum of patients with anti-NMDAR encephalitis. Based on the correlation between sTREM2 and inflammation, our study aims to explore the possibility of sTREM2 as a biomarker of anti-NMADR encephalitis, and our results also confirm the hypothesis.The soluble form of TREM2 (sTREM2) is reported to be increased in the cerebrospinal fluid of patients with Alzheimer’s disease, multiple sclerosis, and neurosyphilis as a marker of microglial activation during neuroinflammation –33. ZhonActivation of microglia promotes the production of cytokines, chemokines, and matrix metalloproteinases , which dPrevious studies have shown that a damaged BBB is related to a poor prognosis in anti-NMDAR encephalitis . To furtAbove all, from the perspective of neuroinflammation, our study emphasized the evidence of microglial activation and disruption in anti-NMDAR encephalitis. The results showed that microglia play a role in pathogenesis and that the damaged BBB is involved in pathology, which provides a new perspective on potential targets for treatment and biomarkers for diagnosis.


The objectives of this article are to present an original surgical procedure for the temporary or definitive resolution of hydrocephalus, in the case of repeated failure of standard treatment techniques, and to present a case that was resolved using this surgical technique. Materials and methods: We present the case of a 20-year-old male patient with congenital hydrocephalus who underwent a number of 39 shunt revisions, given the repetitive dysfunctions of various techniques . The patient was evaluated with the ventricular catheter externalized at the distal end and it was necessary to find an emergency surgical solution, considering the imminent risk of meningitis. The patient was also associated with the diagnosis of acute lithiasic cholecystitis. Results and discussions: The final chosen solution, right ventriculo-venous drainage using the cephalic vein, was a temporary surgical solution, but there are signs that this procedure can provide long-term ventricular drainage. Conclusions: Transcephalic ventriculo-subclavian drainage represents an alternative technical option, which can be used when established options become ineffective. Identifying the etiology of hydrocephalus, and the medical or surgical treatment of its cause, represent objectives that can only be achieved in a small number of cases ,2. The sThe technical variants adopted for the evacuation of excess CSF from the ventricular cavities are very numerous and have appeared as a necessity, given the imperfections of the reported methods ,6. ImproThe Imagined surgical techniques for the evacuation of excess CSF are diverse . In general, these techniques are well tolerated and solve these patients’ problems for long periods ,15,16,17The choice of the type of drainage takes into account a number of parameters: age, type of hydrocephalus, the severity of the condition, associated disorders, operative risks, possible inconveniences and complications, temporary or definitive nature of the chosen surgical solution, etc. ,19.Unfortunately, there are situations in which the chosen surgical procedure cannot ensure the long-term drainage of excess CSF, either due to malfunctions of the materials used , due to the onset of complications in the structures that receive the excess CSF, or of complications at the level of cerebral structures  ,26,27,28Currently, the gold standard for the surgical solution of hydrocephalus is the ventriculo-peritoneal shunt. An efficient and well-tolerated procedure, the drainage of the peritoneal cavity of the CSF has spread widely and represents, in many cases, the first therapeutic option. Unfortunately, the range of complications specific to this technique is quite extensive: the obstruction or disconnection of the distal catheter, septic complications in the peritoneum or intraperitoneal organs, CSF pseudocyst, CSF ascites, bowel obstruction, inguinal hernia and hydrocele, visceral perforations, peritoneal metastases from central nervous system tumors, etc. ,34,35,36Ventriculo-atrial shunts are frequently associated with septic or immunologically mediated complications (shunt nephritis), gas embolism, venous thrombosis, rhythm disorders, valvular lesions, interventricular perforation, intracranial hypotension, etc. ,49,50,51The existence of such repetitive complications requires shunt revisions or choosing another surgical technique, with a progressive reduction of the chances of achieving long-term functionality. A series of technical variants already tried have proven limited efficiency, associated with severe complications, and used only in certain particular cases . ,56,57,58We present the case of a 20-year-old male patient diagnosed with congenital hydrocephalus treated by a surgical procedure for the first time six months after birth . During the next four years, the functionality of the drainage was good but, later, a CSF pseudocyst occurred. This complication led to surgical evacuation of the pseudocyst and repositioning of the distal catheter. Such episodes arrived at various time intervals, constraining the surgical team to change the type of placement to a biventriculo-atrial shunt with a low-pressure valve at the age of 17. Unfortunately, 13 months later, the patient presented with headache, vomiting and unsystematized static and dynamic balance disorders. The cerebral CT scan performed at admission revealed enlarged cerebral ventricles. Due to this situation, a new surgery followed in order to convert the drainage to a unishunt biventriculo-peritoneal system.In the next three years, new surgical procedures were interspersed in 12 situations externalizing the shunt for several days, the time needed to rest the peritoneum, performing investigations on the quality of the CSF and establishing the therapeutic strategy to follow (subsequently). Thus, about 38 ventriculo-peritoneal shunt revisions and a ventriculo-cardiac shunt took place in a relatively short interval.The recurrence of the intracranial hypertension symptoms after this long succession of surgeries brought the patient, once again, to the emergency department. Upon hospital admission, the imaging exams showed the occurrence of a new CSF pseudocyst A–D and aThe surgical evaluation confirmed the existence of the two pathological entities that required surgical resolution. Although the rate of success after the evacuation of the pseudocyst and repositioning of the intraperitoneal catheter was relatively low, this was attempted considering the laparoscopic approach required to solve the acute lithiasic cholecystitis. On this occasion, we observed an intense process of bowel adhesions (predominantly in the inframesocolic space) and we performed adhesiolysis, retrograde laparoscopic cholecystectomy, pseudocyst evacuation and the repositioning of the distal tip of the catheter in the lower abdomen, after reconnection to the drainage system. The subhepatic drainage tube was removed 24 h postoperatively.The immediate postoperative evolution was favorable, both surgically and neurologically for approximately 14 days, until the intracranial hypertension phenomena reappeared, the patient presenting headache, vomiting, fever, altered state of consciousness, drowsiness and divergent strabismus. A cerebral CT scan and Magnetic Resonance Imaging (MRI) showed active hydrocephalus , which aFaced with this therapeutic impasse, we found the solution of catheterizing the right cephalic vein, a tributary of the superior cava system, as the equivalent of the ventriculo-cardiac shunt. The vein was identified in the right deltopectoral space and catheterized with the distal end of the ventricular tubing A,B, withThe evacuation of excess CSF from the ventricular system represents an objective that can be solved by medical or surgical means, to avoid severe intracranial hypertension, with consequences on the cerebral noble substance. Due to the low efficiency of the medication, it is used solely in mild forms and as a preoperative preparation .−endoscopic internal drainage .The surgical treatment uses three leading solutions:The main beneficiaries of these procedures are patients with obstructive hydrocephalus by posterior cerebral fossa tumors, those with CSF circulation disorders  and skull base malformations. The multiple advantages of these surgical procedures are overshadowed by: the limitation of applicability to the aforementioned pathologic conditions, bleeding from the cervical plexus, risk of injury to the basal artery branches, closure of the surgically created communication or subdural hematoma ,66,67,68−external drainage of the CSF and its collection in an external reservoir is acceptable as a temporary solution in the case of association with meningitis or intraventricular bleeding ,70,71.−extracranial drainage of the CSF is the most extensive method and it is applied to all patients, with the choice of the technical solution depending on several criteria: age, generating cause, associated disorders, operating risks, temporary or definitive nature of the procedure, etc. ,18,72,73The efficiency of drainage in the cephalic vein  with results and possible complications similar to ventriculo-cardiac drainage, but using another approach, confirms the validity of the procedure and gives hope for the alternative surgical treatment of hydrocephalus in case of the appearance of complications related to established surgical procedures.In the period elapsed from the moment our surgical team applied this imagined therapeutic solution, no complications related to the neurological condition and the operative act were found.Although physiological considerations suggest that the drainage of excess CSF from active hydrocephalus should drain into a venous segment, the well-established surgical method is represented by the ventriculo-peritoneal shunt. The peritoneum provides a generous resorption surface, which tolerated the CSF well. The resorptive function of the peritoneum can be canceled or reversed by certain factors, which are partially known: immunological, septic, mechanical, allergic factors, etc. Under these conditions, the ventriculo-peritoneal shunt becomes non-functional due to the appearance of an intraperitoneal complication: CSF pseudocyst, CSF ascites, plastic peritonitis, etc. Thus, a ventriculo-peritoneal shunt, well tolerated for long periods of time, can become quite suddenly ineffective. Reinterventions that propose shunt revision, with the possible solving of intraperitoneal surgical complications, represent the solution, but with the diminished possibility of finding a long-term resolution using the same surgical procedure ,76,77,78This problem determines the quest for another surgical solution . The alternative methods mentioned above resolve the situation, but they are also burdened by certain complications as previously noted. Thus, a therapeutic impasse that can endanger the neurological condition and even the patient’s life can appear in many cases. Finding alternative solutions has been a permanent concern, but unfortunately no superior treatment options have been identified.Analyzing the particular situation of our patient, considering that the iterative repositioning of the catheter is doomed to failure, that the indication of intraperitoneal drainage was not an option and that the transjugular path (ventriculo-cardiac shunt) was exhausted, we identified the solution of placing the ventricular catheter in the right cephalic vein, thus accessing the superior cava system, with the possibility of progression up to the level of the right side of the heart.The reasons considered In choosing this surgical approach were: the sufficient pressure gradient between the cerebral ventricular system  and central venous pressure, the convenience of access , reduced surgical risks, physiological considerations , the ease of re-accessing the valve and the venous approach (if necessary), the excellent tolerance of CSF in the venous system, etc.The pressure gradient ensures adequate drainage . It is assumed that the drainage of excess CSF by the transcephalic/transsubclavian pathway reactivates or worsens a previously observed pathological condition .In the event of a dysfunction of this type of shunt, the revision takes little effort to perform, the access being convenient, on the ventricular catheter, valve, or distal segment of the drainage tubing.In the literature, the ventriculo-subclavian shunt was described by a series of authors. Matsuoka et al., in 1993, published two case reports of a 64-year-old male and of a 65-year-old male, respectively, both of whom had their subclavian vein punctured through the infraclavicular approach, with positive results . AnotherUsing the right cephalic vein as the anatomic area of insertion of the ventricular shunt into the venous system is the innovative step of our procedure. The proposed surgical procedure did not raise any particular technical problems, and the intervention was carried out without complications. We did not study the flow of the cephalic vein preoperatively , but the lack of other therapeutic options led us to use the cephalic vein as an access path to reach the subclavian vein whose venous flow we considered sufficient to absorb the excess CSF; the favorable clinical and imagistic evolution of the patient showed that this assumption was correct.The test of time will prove whether the proposed method will be imposed as a therapeutic alternative to the well-established techniques, in the event of a therapeutic impasse, or as a first-option solution.The ventriculo-subclavian shunt is an easy surgical procedure.It is a solution for cases where the variants of standard surgical treatment have been exhausted.It is a drainage solution of excess CSF in the superior vena cava system .It uses an access path that does not have anatomical/functional disadvantages.Depending on the patency of the method and possible late complications, it can become a variant of a first-option treatment.