The sensitivity of the FLCκ-IF was 98% in the DC and 97% in the VC with a corresponding NPV of 99%. The use of the FLCκ-IF as a first line analysis would have reduced the Ig and OCB analysis by 62% in the DC and 74% in the VC. The absence of a FLCκ-IF predicts the absence of a humoral intrathecal immune response with a very high NPV of 99%. Thus, integration of our proposed algorithm into routine CSF laboratory analysis could help to reduce analytical efforts.We performed this cohort study to test whether further analysis of intrathecal inflammation can be omitted if the free light chain kappa (FLCκ) quotient is within the reference range in the corresponding quotient diagram. FLCκ concentrations were measured in serum and cerebrospinal fluid (CSF) samples. The intrathecal fraction (IF) of FLCκ was calculated in relation to the hyperbolic reference range. 679 patient samples were used as a discovery cohort (DC). The sensitivity and negative predictive value (NPV) of the FLCκ-IF for the detection of an intrathecal humoral immune response (CSF-specific OCB and/or IF IgG/A/M > 0%) was determined. Based on these data, a diagnostic algorithm was developed and prospectively validated in an independent validation cohort (VC,  The detection of an intrathecal humoral immune response is an important diagnostic aspect in many neurological diseases of the central nervous system (CNS). One method to represent this is the quantitative protein analysis of immunoglobulins. It is usually performed using quotient diagrams in which the cerebrospinal fluid (CSF) and serum quotient of immunoglobulins  is related to the CSF and serum albumin quotient. These calculations are necessary to distinguish the fractions of proteins that enter the CSF from blood by passive diffusion from those produced intrathecally . AnotherDespite a broad variety of publications about the use of FLCκ in CSF in the diagnostics of MS and other neurological diseases, integration into the diagnostic routine in CSF laboratories has not yet been undertaken. We hypothesized that in the absence of intrathecal FLCκ synthesis, a qualitative or quantitative Ig synthesis  should also not be detectable. Therefore, the main objective of this work was to evaluate a laboratory workflow that integrates the presence of intrathecal FLCκ synthesis as a highly sensitive marker with a strong negative predictive value for an intrathecal humoral immune response. This has the potential to minimize the qualitative and quantitative determination of Ig in laboratory routine CSF diagnostics.The retrospective part of the study was based on the votum of the local ethics research committee . For the prospective part of the study, consecutive CSF and serum samples were collected between 3 January 2019 and 28 May 2019, based on the votum of the local ethics research committee . Written informed consent was obtained from all participants. n = 679) was established to determine sensitivity and negative predictive value of the FLCκ-IF to predict an intrathecal humoral immune response. Based on these data, a laboratory workflow integrating the FLCκ as a first line analysis for detection of an intrathecal humoral immune response was created. The discovery cohort consisted of patient samples which had been acquired prospectively between 2015 and 2017, as well as samples collected between 2008 and 2016, which were stored at −80 °C. This novel workflow was then prospectively evaluated with an independent validation cohort (n = 278), which has been acquired consecutively between 3 January 2019 and 28 May 2019. All samples were acquired from patients of the Department of Neurology, University Medicine Greifswald . For this cohort study, a two-step study design was used: First, a discovery cohort  > 500/µL and QIgM > Qlim (IgM) and if present QIgA > Qlim (IgA) and QIgG > Qlim (IgG) but IF IgM > IF IgA > IF IgG . The resCharacteristics of the discovery and validation cohort including CSF results are presented in Laboratory analyses were performed in the interdisciplinary CSF laboratory of the University Medicine Greifswald as described previously .As a qualitative method to detect intrathecal IgG synthesis, the analysis of OCB was done by isoelectric focusing with a semiautomatic agarose electrophoresis system . FLCκ in sera and CSF were measured by nephelometry with the N Latex FLC kappa kit , using monoclonal antibodies on the BN Prospec analyzer. CSF pre-dilution was set to 1:2, and serum pre-dilution was set to 1:100. The lower limit of quantification of the assay was 0.034 mg/L. One major concept in CSF diagnostics is to distinguish the serum fraction of proteins from intrathecally synthesized proteins . Therefore, the interpretation of Ig and FLCκ quotients in quotient diagrams is a well-established method ,10. In tThe hyperbolic reference range, as well as the intrathecal fraction of Ig and FLCκ was calculated according to the formulas described by Reiber et al. ,2,3: Q_lThe upper line (Qlim) of the reference range discriminates between the blood derived- and intratecally synthesized- Ig and FLCκ fraction.Data from the discovery cohort were used to establish an evaluation algorithm by estimating the sensitivity and the negative-predictive value of the presence of an intrathecal fraction of FLCκ for the prediction of an intrathecal humoral immune response as defined above. RStudio (R version 3.5.1 2 July 2018) was used for statistical and graphical processing of the data.A total of 679 patient samples were identified to form the discovery cohort . Signs oThe use of the IF FLCκ as a primary selection marker in this cohort would have resulted in a sensitivity of 98%, a specificity of 86%, a negative predictive value of 98% and a positive predictive value of 81% see . The results from the discovery cohort analyses suggest that there is a high probability of an absent intrathecal humoral immune response in the absence of FLCκ synthesis. Therefore, we established a new laboratory workflow  using thThe validation cohort comprised 278 patient samples . Of thesAll together, these results yielded an excellent sensitivity of 97% and a negative predictive value of 99.5% to identify an intrathecal humoral immune response by using the FLCκ-IF as first line parameter , Table 2If the FLCκ-IF would have been used in this cohort according to the suggested workflow, the Ig and OCB analyses would have been reduced by 208 patient samples . Using the suggested workflow also increases the pre-test probability of a positive OCB result and thus increases the percentage of positive test results.While a large body of work has been reported to establish the FLCκ in CSF as a diagnostic biomarker, the final translating step from research into clinical routine is still missing. This is at least partially caused by insufficient agreement on the best method of interpretation and cut-off values . As someBased on previous studies, we hypothesized that in the absence of intrathecal FLCκ synthesis, a humoral intrathecal immune response as defined above should also not be detectable ,13,17,18Considering the results of our discovery cohort, the intrathecal fraction of FLCκ seemed suitable as first line analysis for the presence of an intrathecal humoral immune response, as only a small proportion of false negative samples were found . Of these, 66% were explicable by elevated serum FLCκ levels above the serum reference range. This is in line with the concept of quotient diagrams that excessive serum concentrations of any protein of interest reduces the sensitivity to detect intrathecal synthesis of this protein see . TherefoOnly one patient sample in the discovery cohort showed an intrathecal IgM synthesis in the quotient diagram which could not be explained by an artificial blood contamination, while lacking an intrathecal fraction of FLCκ. We suspect that inacurracies in measurement of IgM due to its low concentration in CSF and its high serum gradient , may be Appling the newly developed workflow to the prospective validation cohort resulted in an excellent sensitivity of 98% with a negative predictive value of 99.5%, confirming the findings of the discovery cohort. One patient in the validation cohort showed CSF specific borderline OCB results but no intrathecal FLCκ synthesis. Some authors suggest that two CSF bands do not reliably indicate an intrathecal IgG-synthesis . Diagnostic laboratory workflows especially for the diagnosis of MS with a sequential determination of FLCκ and OCB have already been suggested ,21,22. SOur data demonstrate the benefits of including the intrathecal fraction of FLCκ as a key parameter into the laboratory workflow: In our cohorts, 62% of the Ig and OCB analysis in the discovery cohort and 74% in the validation cohort would not have been required. Thus, the implementation of this workflow would have a considerable cost-, resources- and personnel-saving effect. In addition, using the suggested workflow with a high positive predictive value for positive OCB results will avoid unnecessary OCB analysis. Certainly, if clinical findings, other laboratory parameters such as conspicuous CSF cytology, or imaging suggest an intrathecal inflammation despite a lack of intrathecal FLCκ synthesis, it will be reasonable to perform Ig quotient diagrams and OCB. Nevertheless, the use of this workflow can simplify the diagnostic pathway to exclude intrathecal humoral immune responses due to the high negative predictive value. The monocentric study design is a limitation of our study. On the other hand, we used a large cohort to establish the workflow. If a general diagnostic pathway is recommended, it is important that it also yields robust results for different assays. Especially OCB  and FLCκ determination on different platforms warrant further investigation. Noteworthy is also that the discovery cohort does not reflect the general neurological patient population due to the selectivity of the previous studies that were utilized in this cohort.The presence of an intrathecal fraction of FLCκ shows an excellent sensitivity to identify an intrathecal Ig synthesis. The integration of the FLCκ-IF as a screening parameter into the routine procedures of CSF laboratories can simplify CSF laboratory evaluation and analytical effort. In addition, this will increase the pre-test probability of a positive OCB result and thus increase the percentage of positive test results.


MYD88L265P mutation was detected in the CSF of 12 VRL patients, with a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 63.2%, 100%, 100%, and 46.2%, respectively. No meaningful lymphoma related mutations were found in CSF samples from uveitis controls with typical intraocular lesions. Meanwhile, CSF IL-10 levels were elevated in 95.7% of the VRL patients, with a sensitivity, specificity, PPV, and NPV of 95.7%, 100%, 100% and 88.9%, respectively. Key somatic mutations like MYD88L265P and CD79B detected from CSF cfDNA and elevated CSF IL-10 levels can be promising adjuncts for primary vitreoretinal lymphoma diagnosis.Primary vitreoretinal lymphoma (PVRL) is a rare variant of primary central nervous system lymphoma (PCNSL) that presents diagnostic challenges. Here, we focused on circulating cell-free DNA (cfDNA) and interleukin-10 (IL-10) isolated from cerebrospinal fluid. Twenty-three VRL patients  and 8 uveitis patients were included in this study. CSF samples from 19 vitreoretinal lymphoma patients had sufficient cfDNA for next-generation sequencing. Of these patients, 73.7% (14/19) had at least one meaningful non-Hodgkin lymphoma-related mutation. The characteristic  Primary vitreoretinal lymphoma (PVRL) is a rare extranodal non-Hodgkin lymphoma of the retina, vitreous, and optic nerve. Most PVRL patients are of the B-cell lineage; approximately 80% develop intracranial progression eventually, while 15%–20% of patients with primary central nervous system lymphoma (PCNSL) have intraocular involvement at diagnosis . Thus, PMYD88L265P and CD79B, and immunoglobulin gene rearrangement  diagnosis. The detection of PVRL characteristic gene mutations, including angement , 12–21 fangement . Our preangement , 24. SinCirculating cell-free DNA (cfDNA), double-strand DNA fragments  released from cells into surrounding blood or other body fluids by cellular breakdown or active secretion –28, has Vitreous fluid is the key sample to PVRL diagnosis. However, the number of diagnostic tests is limited by the small sample size, while sample dilution adds to false-negative results. Considering the anatomic relationship between vitreoretinal and cerebrospinal fluid, and the role of CSF in PCNSL diagnosis, we conducted this study to evaluate the potential of baseline CSF cfDNA mutation profiles and IL-10 levels for VRL diagnosis and establish the foundation of serial CSF monitoring for early detection of intracranial progression in VRL patients.Seventeen patients with PVRL, two patients with primary central nervous system lymphoma and intraocular involvement (PCNSL/O), and four patients with relapsed vitreoretinal lymphoma (RVRL) were included in this study as experimental group. All the patients were diagnosed in our center, from 10/2018 to 12/2021 and treated. The PVRL patients were enrolled from our two prospective single-center open-label phase II trials (NCT03746223 and NCT04899453), with the same diagnostic criteria as previously described  and buccal mucosa were obtained from each patient prior to treatment for sequencing. Data on clinical characteristics were collected from electronic health records.Germline DNA was extracted from buccal mucosa using the DNeasy Tissue Kit  according to the manufacturer’s guidelines. CSF was collected and processed within 4 h. CSF-derived circulating cell-free DNA (cfDNA) was extracted with the QIAamp Circulating Nucleic Acid Kit (Qiagen). Then, the fragment length and quantity of cfDNA were assessed with the Qubit Fluorometer, Qubit dsDNA BR Assay Kit , and Labchip GX Touch system . All libraries were hybridized to custom-designed biotinylated oligonucleotide probes  covering 413 genes. DNA sequencing was performed using the GeneSeq-2000  with a read length of PE100 and depth of 500–1,000× , and 90 Terminal adaptor sequences and low-quality reads were removed separately from raw data of paired samples using NCrealSeq  and NCfilter . The Burrows–Wheeler Aligner  tool was used to align clean reads to the reference human genome (GRCh37). Duplicate reads of cancer sample derived from PCR amplification were marked using realSeq, which was designed to retain reads containing rare events by treating Unique Molecular Indexes, and the normal sample was marked using Picard tools (version 2.6.0).Single nucleotide variants (SNVs) and Indels were detected by comparing tumor-normal pairs using TNscope (version 201808) and realDcaller , a software developed to review hotspot variants. The results of these analyses were merged using NChot  and then annotated to multiple public databases using NCanno . For somatic copy-number alteration, CNVKIT (version 0.9.2)  was perfg at 18°C); then, the supernatants were collected, and the IL-10 levels were measured with an electrochemiluminescence immunoassay (ECLIA) analyzer following the manufacturer’s instructions (Siemens Immulite 1000 and IL-10 detection kits). The levels of detected CSF IL-10 range from 5 to 1,000 pg/ml.One milliliter of fresh CSF samples was used to detect the levels of inflammation factor IL-10 as previously described , 24. In RStudio was used to present the results of sequencing. As for validity measurement, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated .We collected CSF samples from 23 patients with B-cell vitreoretinal lymphoma, with or without CNS involvement and lymphoma history  in one (CONTROL-5).cfDNA was extracted from CSF; then, targeted deep sequencing of NHL-related genes was performed to identify somatic mutations (Ig gene rearrangement (78.3%). Notably, in the 14 cases that exhibited cfDNA mutation, 12 were with MYD88L265P mutation , and 6 were with MYD88L265P and CD79B co-mutation. Although in some cases lymphoma cells were not detected by cytology , the characteristic MYD88L265P mutation was detected in the CSF cfDNA  with patients’ clinical outcome–progression-free survival time in the five patients treated with R2 , as shown in Ig rearrangement test) and flow cytology, the remaining vitreous samples could not provide enough DNA for NGS. Hence, we wondered whether CSF could be a substitute marker for PVRL diagnosis, since PVRL is a special subset of PCNSL and previous studies have demonstrated the diagnostic role of CSF cfDNA and elevated IL-10 levels , droplet digital PCR, or sequencing  detected from CSF samples can be a promising additional approach for the accurate diagnosis of VRL. Notably, mutations without specific clinical meanings might be detected in non-lymphoma patients, like low frequency DNMT3A splicing mutation.gnancies . Severalquencing –19. The quencing . We wondMYD88L265P or CD79B variant allele frequencies are promising. This study confirmed the presence of PVRL characteristic mutations in CSF, also established the foundation of assessing CSF samples to monitor disease progression. Furthermore, routine lumbar puncture for cerebrospinal fluid reduces the possible intraocular complications from aqueous puncture or vitreous aspiration.With CSF samples, we were able to overcome the difficulty of insufficient vitreous biopsy samples and picture the genomic features of vitreoretinal lymphomas. This can be a promising adjunct to vitreous fluid samples genomic analyses . AlthougMYD88L265P and CSF IL-10 levels showed a sensitivity of 98.4% and specificity of 100%. Furthermore, we have been detecting the IL-10 levels in serial CSF samples after treatment to assess whether IL-10 can be a potential disease monitoring biomarker.IL-6 and IL-10 are the most extensively studied cytokines in vitreoretinal lymphomas; studies have demonstrated that elevated aqueous humor or vitreous fluid IL-10 and IL-10/IL-6 ratio can help distinguish vitreoretinal lymphomas from uveitis. However, there are also lymphoma cases with low IL-10 levels or non-lymphoma cases with elevated IL-10 levels , 57–59. MYD88L265P mutation and CSF IL-10 can be complementary approaches to the current diagnostic standard of PVRL. NGS of the CSF cfDNA also provides targets for precision therapy, including MYD88, CD79B, and CDKN2A. In the meantime, we have been collecting CSF samples of PVRL patients during therapy to investigate whether the mentioned biomarkers can monitor treatment response or indicate disease progression.A significant limit of our study is the small cohort size. Future studies with larger cohorts are needed. Furthermore, cfDNA extraction procedure still needs optimization to eliminate the effect of cfDNA degradation and increase the quantity of extracted cfDNA for sequencing. Nevertheless, we demonstrate that meaningful molecular data can be obtained from CSF cfDNA in PVRL patients. CSF MYD88L265P or CD79B mutation detected from CSF circulating cell-free DNA aids in primary vitreoretinal lymphoma diagnosis. Patient-specific genomic alterations are also pictured, which provide therapeutic targets for personalized medicine. Furthermore, IL-10 levels are also elevated in the CSF of VRL patients, with higher specificity than vitreous fluid IL-10.Our study provides mutation landscape of vitreoretinal lymphomas with next-generation sequencing. https://ngdc.cncb.ac.cn/gsa-human/browse; Accession - HRA002732/HRA002732.The original contributions presented in the study are publicly available. This data can be found here: Link - The studies involving human participants were reviewed and approved by the Institutional Ethics Committee of Peking Union Medical College Hospital. The patients/participants provided their written informed consent to participate in this study.ZZ, YZ, XZ, MFZ, and WZ designed the experiment. YZ, XZ, MFZ, and WZ enrolled participants and treated the enrolled patients. ZZ and DMZ collected patient samples and data. ZZ, DMZ, and LZ conducted the experiments. CWJ double checked all the histology samples. ZZ wrote the first draft manuscript. All authors edited and approved the manuscript.This study was funded by the CAMS Innovation Fund of Medical Sciences (CIFMS) 2019-I2M-2-009, the CAMS Innovation Fund for Medical Sciences (CIFMS) [2021-I2M-C&T-B-005], and Natural Science Foundation of Beijing Municipality 7202154.We thank all the patients for their consent in participating in the study and sharing their medical records. We thank the medical staff and physicians who participated in this study. We are also grateful to Dr. Nanzhao for her help in statistical analysis.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


R2 = 0.0625, p = 0.032) and showed comparable predictive value for 6-month mortality . The optimal troponin I cutoff to effectively diagnose NSTEMI with type 1 MI in patients with sepsis was 300 ng/L.The diagnostic value and optimal cutoff level of cardiac troponin I in patients with sepsis have not been studied. In this single hospital retrospective study, we assessed the optimal cutoff value of troponin I for diagnosing non-ST-segment elevation myocardial infarction (NSTEMI) with type 1 myocardial infarction (MI) in patients with sepsis who had undergone a percutaneous coronary intervention from 2009 to 2019. In total, 5,341 patients (excluding patients with chronic kidney disease) were included, of whom 277 had sepsis or septic shock. Of the 123 patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and sepsis, 77 (62.6%) were diagnosed with NSTEMI with type 1 MI. The receiver-operating characteristic curve showed an area under the curve (AUC) of 0.705 for diagnosis of NSTEMI with type 1 MI with a troponin I cutoff of >300 ng/L . Multiple linear regression showed no significant predictors of NSTEMI with type 1 MI. Troponin level and the Global Registry of Acute Coronary Events (GRACE) scores were correlated ( Acute myocardial infarction (AMI), defined by evidence of myocardial injury with a clinical condition consistent with acute myocardial ischemia and elevation in the level of at least one cardiac troponin above the 99th percentile upper reference limit (URL) , 2, is aThere are five types of myocardial infarction (MI). Type 1 MI is defined as atherothrombotic myocardial injury, caused by either an ulceration or a plaque rupture. Most type 1 MIs occur in patients with STEMI, but some occur in patients with NSTEMI. Type 2 MI is characterized by myocardial necrosis caused by inequality of myocardial oxygen supply and demand due to factor other than coronary plaque instability. Type 3 MI is defined as an MI that caused death in the absence of cardiac biomarkers. Type 4 and 5 MIs are intervention-related MIs [Elevated troponin I may complicate cardiac catheterization in patients with sepsis. Many patients with a primary diagnosis of sepsis receive troponin testing  and haveElevation of cardiac troponin is a diagnostic cornerstone for AMI diagnosis. However, many non-AMI conditions, including renal dysfunction and sepsis, may also cause elevated cardiac troponin . A newer2 for ≥3 months [We performed an observational and retrospective study in the Division of Cardiology at a secondary hospital in Taichung, Taiwan, between 2009 and 2019. The participant selection process is summarized in 3 months ; and diaA paramagnetic particle, chemiluminescent immunoassay  was used to measure cardiac troponin I. A cardiac troponin I level > 40 ng/L (99th percentile) was considered abnormal . The lowThe Global Registry of Acute Coronary Events (GRACE) score is used to predict in hospital deaths and 6-month mortality after discharge in patients with acute coronary syndrome. The GRACE scores (range 2–372) were calculated based on the patients' age, heart rate, systolic blood pressure, creatinine level, cardiac arrest at admission, ST-segment deviation on ECG, abnormal cardiac enzymes, and Killip class at admission before the PCI .We collected laboratory, clinical, and radiological data from the patients' medical records. Demographic data, vital signs, and medical history were also recorded. Blood samples were collected from all included patients within three days before the PCI. WBC counts, total bilirubin, and creatinine levels were measured. The date of death was also documented, and those <6 months were included for the analysis of prognosis.9/L) or leukopenia (WBC < 4 × 109/L), hypothermia (<36.0°C) or fever (>38.0°C), and tachypnea (>20 breaths/min) or tachycardia (>90 beats/min) [Sepsis in our patients was defined according to the criteria for systemic inflammatory response syndrome, i.e., the occurrence of more than two of the following: leukocytosis  . Patientats/min) . FurtherPatients with confounding factors that may impact the troponin level including chronic kidney disease (CKD), chronic heart failure, pulmonary embolism, or pulmonary hypertension  were excNSTE-ACS is defined as the occurrence of acute chest discomfort or symptoms of cardiac ischemia  combined with significant ST-T wave changes  , 2. PatiNSTEMI with type 1 MI was defined as patients referred for a PCI with imaging findings of embolization or decreased blood flow in a coronary artery caused by an intracoronary atherosclerotic lesion, such as ulceration, plaque rupture, erosion, or a fissure with thrombus .p value < 0.5 were considered significant in the univariate analysis and were included in a subsequent multivariate analysis. The results are reported as the p value and 95% confidence intervals (CI). All statistical analyses were conducted using the MedCalc Statistical Software version 20 .The Shapiro-Wilk test was used to assess the normality of distribution of continuous variables. Chi-squared tests were used to compare categorical variables. Continuous variables were reported as the median and interquartile range, or the mean ± standard deviation, depending on their distribution. Receiver-operating characteristic (ROC) curve analysis was used to determine the area under the curve (AUC) to evaluate the diagnostic ability of troponin I. The optimal cutoff value of troponin I for the NSTEMI with type 1 MI group was calculated with the Youden index (specificity − 1 + sensitivity) derived from the ROC analysis. ROC curves were compared to evaluate the predictive value of troponin I level and GRACE scores in 6-month mortality. Variables with a A total of 5,341 patients were included in the study . In totaA total of 123 patients with NSTE-ACS and sepsis/septic shock received a PCI . Their mp < 0.001). With a troponin I level cutoff of >300 ng/L, we could predict NSTEMI with type 1 MI with a sensitivity of 68.4% and specificity of 70.2%, and the Youden index was 0.386. The ROC curves for different combinations of predictors are shown in Figure The ROC curve  was usedp value < 0.5 was defined as significantly different for the univariable linear regression. Hypertension, male sex, and age were significant factors and were included in the multiple linear regression model to predict troponin I. Multiple linear regression analysis (significance at p < 0.05) revealed no significant factors for troponin I in the NSTEMI with type 1 MI group   . Both trR2 = 0.0625, p = 0.032).Our study showed that the troponin I level directly correlated with the severity of myocardial injury. Moreover, troponin and GRACE scores could predict the 6-month outcome with similar predictive values. As expected, our findings revealed that troponin I levels correlated with GRACE scores. This correlation was validated by examining the troponin I levels and GRACE scores. R2 = 0.0625, p = 0.032). Our study is the first to report the optimal cutoff value of troponin I for NSTEMI with type 1 MI diagnosis in patients with sepsis and without CKD.In total, 5,341 patients were included initially, and 123 patients with NSTE-ACS and sepsis or septic shock were included for analysis. Of these, 77 patients were diagnosed with NSTEMI with type 1 MI and 46 patients were not. Our study showed that a cutoff value of >300 ng/L for troponin I could predict NSTEMI with type 1 MI in patients with sepsis. The ROC curve had an AUC of 0.705 with a sensitivity of 68.4% and specificity of 70.2%. Factors such as age or creatinine level were not associated with troponin levels. Furthermore, both troponin levels and GRACE scores could predict 6-month mortality, and troponin levels were correlated with GRACE scores (The ROC curves showed an AUC of 0.705. This may prove the utility of the troponin I level (>300 ng/L) for predicting NSTEMI with type 1 MI in patients with sepsis or septic shock. The specificity of our study is not high (70.2%). In clinical practice, clinicians may have performed a PCI in all the patients regardless of troponin I levels; however, NSTEMI with type 1 MI was diagnosed in only 62.60% 77/123) of the patients in our study. Thus, our approach—using a cutoff value of >300 ng/L—may increase diagnostic accuracy by approximately 8%. In addition, our study also had a high diagnostic rate compared to that in a previous study. In a retrospective study, Kim et al.  studied  of the pOur study was similar to the aforementioned study. Since troponin is a specific biomarker for cardiac injury, other factors such as age, hypertension, DM, and male sex were not associated with it. Moreover, since we excluded patients with renal dysfunction, it is reasonable to assume that the creatinine levels were not related to troponin values in our study. The GRACE score is a well-known predictor of mortality in patients with AMI. It is a rapid method used worldwide to calculate cardiovascular risk in clinical assessment and guide patient triage and management . In addiThe troponin complex is composed of troponin I, C, and T and is essential for cardiac muscle and skeletal contraction . CardiacBecause of the high mortality rate (35.8%) among patients with sepsis with AMI , even a The current study had several limitations. First, all patients were recruited before 2019. Therefore, our study is based on cardiac troponin I rather than hs-cTn, which is a newer method. Newer algorithms  were not used for diagnosing NSTEMI with type 1 MI in our patients . HoweverThe datasets generated during and/or analyzed during the current study are not publicly available due to patient privacy and confidentiality, but are available from the corresponding author on reasonable request.


Furthermore, patients with both high CRP and high troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p < 0.01. These patients also had the highest all-cause mortality rates after a median follow-up of 4.5 years compared to the rest of the cohort; 42.9% vs. 12.7%, p < 0.01. In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CTT as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-interleukin-1ß agents.Elevated concentrations of C-reactive protein (CRP) early during an acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST-segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI by using a combined CRP and troponin test (CTT) and determine their short- and long-term outcome. We retrospectively examined 1186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 h of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing , and cut-offs should be used to predict mortality. Patients with high CRP concentrations  had higher 30 day and all-cause mortality rates compared to the rest of the cohort, regardless of their troponin test status ; 14.4% vs. 2.7%,  Cardiac troponin is a sensitive and specific marker for myocardial injury, and its prognostic value in acute coronary syndrome (ACS) is well established . ElevateSystemic vascular inflammation plays a pivotal role in the progression of CAD, and several anti-inflammatory therapies have been examined in recent trials, including methotrexate , anti-inHere, we sought to identify individuals who are prone to an elevated inflammatory response following STEMI using serial simultaneous measurements of both CRP and cardiac troponin-I during the first 48 h of admission. We characterized patients based on their CRP-Troponin-Test (CTT) results and determined their short- and long-term outcome.We performed a retrospective, single-center observational study at the Tel-Aviv Sourasky Medical Center. We included consecutive patients admitted between January 2008 and January 2020 to the Cardiac Intensive Care Unit (CICU) with the diagnosis of acute STEMI, who had at least two successive measurements of both CRP and cardiac troponin levels within the first 48 h of admission ,8. The CThe diagnosis of STEMI was based on a typical history of chest pain, diagnostic electrocardiographic changes, and serial elevation of serum cardiac biomarkers . PrimaryCAD was defined if a ≥50% narrowing in an epicardial coronary artery was present, or a history of coronary intervention (stent or angioplasty) to an epicardial coronary artery, or bypass surgery. CAD severity was divided into 4 categories according to the number of diseased vessels  as previously described ,14. FollThe MDClone platform was used to automatically extract multiple demographic and clinical variables from Electronic Health Records as well as determine 30-day and all-cause mortality rates . MissingComplete blood count parameters were measured with a Coulter STKS electronic counter. Blood samples for CRP and cardiac troponin assessments were drawn in all patients upon admission to the emergency department or at the catheterization laboratory prior to primary PCI. A second sample was drawn following primary PCI, and within 48 h from CICU admission.® TnI-Ultra® assay .The white blood count (WBC) was determined by the Coulter STKS  electronic cell analyzer. Wide range C-reactive protein (CRP) levels were determined by the Bayer wr-CRP assay  . High-set-test for normally distributed variables and by the Mann–Whitney U test for non-normally distributed ones. To assess associations among categorical variables, we used a Chi-square test. We assessed normal distributions using Kolmogorov–Smirnov’s test and Q-Q plots. The correlations between continuous variables were assessed by Pearson’s r for normally distributed variables and Spearmen’s r for variables with abnormal distribution.All continuous variables are displayed as means (±standard deviation (SD)) for normally distributed variables or median (interquartile range (IQR)) for variables with abnormal distribution. Categorical variables are displayed as numbers (%) of subjects within each group. Continuous variables were compared by a student’s To determine which CRP and troponin measurements , and corresponding cut-offs should be used to predict 30-day mortality, we used Chi-square automatic interaction detection (CHAID) . CHAID aTo adjust for possible confounding variables, we used a binary logistic regression to predict 30-day mortality status. We adjusted our model for the combined second CTT test status, age, sex, and conventional risk factors including history of heart failure, prior myocardial infarction (MI), diabetes, hypertension, and hyperlipidemia. Adjusted odds ratios (OR) with 95% confidence intervals (CI) were reported.p < 0.05 was considered statistically significant. All analyses were performed with the SPSS  and GraphPad Prism version 9.00 .A two-tailed Patient characteristics are displayed in p < 0.01 for both. Notably, the correlation between the first troponin and the second CRP was stronger  and might reflect the slower rate of CRP increase compared to cardiac troponin following myocardial infarction [The median first and second CRP levels were 4.3 [IQR 1.5–11.1] and 5 [IQR 1.6–11.8] mg/L, respectively. The corresponding median first and second troponin levels were 430.5 [64.7–4967.5] and 9995.5  ng/L. The correlation between CRP and cardiac troponin was r = 0.28 for the first measurement, and r = 0.22 for the second measurement, farction .A total of 46 patients (3.9%) died within 30 days of admission (mean age = 80.3 ± 10 years). We used CHAID tree analysis to determine which CTT measurement and cutoffs should be used to predict 30-day mortality. A second CRP level > 33 mg/ L (90th percentile of the cohort) was associated with the highest 30-day mortality rate. Accordingly, patients were divided into four groups based on their combined CTT results, i.e., CRP/troponin levels above or below the 90th percentile .Patients with both high CRP (>33 mg/L) and high troponin  levels were older and had a higher prevalence of diabetes mellitus and prior heart failure compared to the rest of the cohort . Individp < 0.01  had higher 30-day and all-cause mortality rates regardless of their troponin test status ; 14.4% vs. 2.7%, p < 0.01 . Howeverp < 0.01 . We alsop < 0.01 . Patientp < 0.01 .p = 0.02 for patients with both high CRP and high troponin on their second measurement (above 90th percentile). Age and a history of heart failure were also significant predictors in the model  were at increased risk for 30-day and all-cause mortality during a median follow-up of 4.5 years. We propose here the use of the combined CTT as an early and simple marker for inflammatory-prone patients with worse outcomes following ACS.Our results portray the wide spectrum of the human inflammatory response to MI by considering cardiac troponin as the “antigen” in this relatively sterile inflammatory process. We show that some individuals demonstrate low systemic inflammation (evidenced by low CRP levels) even in the presence of extremely high myocardial necrosis  . On the Recent studies have suggested that serial CRP measurements can help reclassify stable and unstable CAD patients undergoing coronary interventions by assessing their “residual inflammatory risk” in terms of long-term outcomes ,21,30,31n = 14) limits the statistical power of additional analyses aimed to detect residual confounding. Future studies should evaluate these cutoffs in other non-Caucasian populations and also explore the possibility of sex-specific thresholds [Our study has several limitations. First, the retrospective nature of this study and the non-standardized timing of both CRP and troponin measurements poses a risk of residual confounding. Furthermore, the maximum time interval between the first and second CTTs was arbitrarily set at 48 h from admission. Future standardized, large-scale efforts are needed to determine the optimal time intervals between serial measurements. Finally, the cutoffs for both CRP and troponin levels used here were optimized for this specific study sample and may not present the same diagnostic yield in other populations. Moreover, the relatively small group of patients with both high CRP and troponin (resholds . FurtherIn summary, we suggest further investigation of the novel CTT as an early clinical assessment tool for identifying patients at increased risk for worse outcome following STEMI. Future clinical trials should investigate the usefulness of the CTT in improving optimal patient selection to receive novel anti-inflammatory agents in the setting of ACS.


Identifying the factors that can influence the prognosis and final outcomes of pediatric heart transplantation is important and makes it possible to prevent complications and improve outcomes. Coordination of donor characteristics with the recipient in terms of sex, weight, body mass index (BMI), and body surface area (BSA) is an important factor that can influence the outcome of the transplantation. There is still no consensus regarding the role of discrepancy in anthropometrics between donors and recipients. The aim of this study was to investigate the relationship between donor and recipient weight mismatch on the early outcomes of pediatric heart transplantation. In this historical cohort study, 80 children who had underwent heart transplantation for the first time between 2014 and 2019 in Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, were enrolled and divided into three groups according to donor-to-recipient weight ratio . The early outcomes of transplantation, during the first post-transplant month, including right heart failure, renal failure, graft rejection, inotrope dependency, duration of intubation, length of ICU stay, death and requiring extracorporeal membrane oxygenation, were recorded through reviewing patient records.P = 0.038), while no significant association was found between donor-to-recipient weight ratio and vasoactive–inotropic score (P = 0.07). No significant relationship was found between other outcomes and donor-to-recipient weight ratio or donor-to-recipient BSA ratio.Median donor-to-recipient BSA ratio was directly associated with higher vasoactive–inotropic score (Patients who require heart transplantation may also benefit from mismatch donors, especially in those with significant cardiomegaly. In recent years, the number of annually performed pediatric heart transplants has been increasing . HoweverHeart transplantation is the latest treatment in patients with severe heart failure who remain symptomatic despite standard medical therapy and are estimated to survive less than 1 year . PediatrIdentifying the factors that can influence the prognosis and final outcomes of pediatric heart transplantation is important and makes it possible to prevent complications and improve outcomes , 13. TheThis observational study was conducted as a historical cohort. Census method was used to calculate the sample size, and 80 patients under 16 years old who had undergone a first-time heart transplantation between 2014 and 2019 in Shahid Rajaie Cardiovascular Medical and Research Center (RCMRC), a tertiary care hospital for cardiovascular patients in Tehran, Iran, were enrolled. The study protocol was approved in the review board and ethics committee of RCMRC. Patients' files were reviewed, and age, gender, type of heart disease leading to transplantation, familial history, weight, and body surface area (BSA) were recorded. Donor-to-recipient weight and BSA ratio was also calculated. Patients were divided based on donor-to-recipient weight ratio (D/RW) into three groups . Donated hearts with a donor-to-recipient weight ratio of less than 0.8 were not used for transplantation in any of patients due to reports of poorer outcomes. Pre-transplant severe infection or sepsis, end organ damage, long-term intubation, and requiring extracorporeal membrane oxygenation (ECMO) were also considered as the exclusion criteria.Early outcomes of transplantation during the first post-transplant month including the presence and severity of right heart failure, renal failure, graft rejection, inotrope dependency, duration of intubation (based on hours), length of intensive care unit (ICU) stay (by day), requiring ECMO and death were recorded after reviewing the patients' records.Renal failure was considered as urine volume less than 0.5 cc/kg/hour or glomerular filtration rate less than normal range based on age. Graft rejection was detected based on echocardiographic data  and/or laboratory data (increased troponin). In heart transplantation, some degree of right ventricular dysfunction is expected because of preexisting elevated pulmonary vascular resistance of the recipient. This right ventricular dysfunction is usually less than moderate and does not last for more than several days.In the current study, moderate-to-severe right ventricular dysfunction was defined based on echocardiographic findings  > two standard deviations lower than expected for age and right ventricular Sa < 7 cm/s) at daily intervals until the 7th day after transplantation. Inotropic dependency was also defined based on vasoactive–inotropic score [VIS = dopamine dose (µg/kg/min) + dobutamine dose (µg/kg/min) + milrinone dose (µg/kg/min) × 10 + epinephrine dose (µg/kg/min) × 100 + norepinephrine dose (µg/kg/min) × 100 + vasopressin dose (U/kg/min) × 10000]. Whereas most heart transplant receivers need some inotropic support in early post-op, VIS > 13 is defined as inotrope dependency.P values less than 0.05 were considered statistically significant.Normality of the interval variables was assessed using one-sample Kolmogorov–Smirnov test. Data were presented as median (inter-quartile range) for skewed interval and frequency (percentage) for categorical variables. Categorical variables were compared between D/R mismatch groups using chi-square for trend test. Skewed quantitative variables were compared between the study groups via Kruskal–Wallis test. For the statistical analysis, IBM SPSS Statistics 22 for Windows  was used. 2 (IQR 0.76–1.26 m2). Cause of heart failure was dilated cardiomyopathy in 66 patients (83%), restrictive cardiomyopathy in 3 patients (3.8%), congenital heart disease in 7 patients (9%), and other disease in 4 patients (5%). One patient had concomitant dilated cardiomyopathy and congenital heart disease.Of these patients, 46 (57.5%) were male and 34 (42.5%) were female. The median age of patients at the time of transplantation was 133.50 months (inter-quartile range [IQR] 84–156 months). The median weight of the patients was 29.50 kg (IQR 17.25–38.75 kg). The median BSA ratio was 1.07 mThe median time of intubation was 8 6–15] hours. The median length of the ICU stay was also 7 (6 to 11.57) days. Familial history of cardiomyopathies of any types was present in 17 patients (21.3%). Median donor-to-recipient weight ratio was 1.75 and median donor-to-recipient BSA ratio was 1.42 (Table 5 hours. Right ventricular dysfunction was mild in 39 patients (48.8%), moderate in 27 patients (33.8%), and severe in 14 patients (17.5%). Twenty-six patients (32.5%) had renal failure. Thirty patients (37.5%) were inotrope dependent with vasoactive–inotropic score (VIS) of more than 13. In addition, 23 patients (28.8%) experienced graft rejection. Five patients (6.3%) died during the follow-up period, and 11 patients (13.8%) required ECMO.P = 0.009). This means that at a younger age, the weight disproportion between the donor and the recipient is greater. Similar association was revealed between donor-to-recipient weight ratio and BSA (P < 0.001). Thus, the younger the age, the higher the D/R BSA (P < 0.001).There was a moderate relationship between age and D/R weight, so that the higher the D/R W, the younger the patient (P = 0.001 for both), which means that the lower the patient's weight or BSA, the greater the mismatch between the D/R weight and D/R BSA. This suggests that at a lower age, the number of suitable donors for heart transplantation is limited. In terms of other characteristics, no significant relationship was found between gender and the two ratios (P = 0.64).There was also a significant relationship between the weight and BSA of the transplant recipients and the D/R W (P = 0.038), while no significant association was found between D/R weight and VIS of more than 13 (P = 0.05).There was a significant relationship between inotrope dependency (vasoactive–inotropic score of more than 13) and D/R BSA , none of the outcomes were significantly different between these three groups. These results are in line with other studies that have been conducted on this field. As shown by Jayarajan et al., the use of low donor-to-recipient weight ratio did not influence median survival, but in female donor-to-male recipient group, lower donor-to-recipient weight ratio was associated with decreased median survival . Tang etThere was no difference in survival of patients with donor-to-recipient weight ratio 0.6–0.79 and donor-to-recipient weight ratio 0.8–2.0, and thus they suggested that donor-to-recipient weight ratio between 0.6 and 0.8 has no adverse outcome on the survival of pediatric heart transplantation . A similOn the other hand, in the current study if the donor-to-recipient weight ratio was less than 0.8, the donated tissue was not used for heart transplantation. This policy is due to the fact that in previous studies, the donor-to-recipient weight ratio of less than 0.8 is one of the risk factors for transplant rejection and donor heart failure. Tamisier et al. indicated that donor-to-recipient weight ratio less than 1 is a risk factor for donor heart failure and early mortality. In this study, from 1987 to 1994, 73 patients who underwent heart transplantation were retrospectively evaluated. Pulmonary hypertension before the transplantation, major inotropic support of the donor, and the donor-to-recipient weight ratio were risk factors for donor heart failure. Donor heart failure was seen in 50% of patients whom donor-to-recipient weight ratio was less than 1, 33% of patients with donor-to-recipient weight ratio between 1 and 1.6, and 7% of patients with donor-to-recipient weight ratio more than 1.6. They also concluded that patients, particularly with pulmonary hypertension, may benefit from the use of grafts with greater donor-to-recipient weight ratio .In another study by Conway et al., a lower donor-to-recipient ratio was a risk factor for transplant rejection , whereasWhereas matching donated tissue with the recipient is a complex process, race, age, and size of the donor are important determinants in this area. Our study showed that in patients who are candidates for heart transplantation, allografts which are not matched with the recipient in terms of weight can be used, especially allografts which are larger in size. Since most cases of brain death occur in adults who have a larger heart in size, this size mismatch has limited the number of heart transplantations. The results of this study will reduce this limitation; however, this study examined only early outcomes, and more studies are needed to evaluate the late consequences of using a larger allograft.According to this study, higher donor-to-recipient weight ratios had no adverse effect on early outcomes. Therefore, donor pools can be expanded using non-baby donors with weights not commensurate with weight of the recipient baby; thereby, mortality of many children who are waiting to receive a heart transplant will be reduced.


Although basal cell carcinoma (BCC) can, in the majority of cases, be diagnosed based on clinical and dermoscopic assessment, a potential overlap with benign adnexal skin tumours seems to exist, including trichoblastic tumours (TT). The aim of this study was to analyse clinical and dermoscopic features of benign TT and BCC to develop a diagnostic algorithm with a potential utility in clinical practice. Despite differences in frequency of clinical and dermoscopic features between BCC and TT in the studied group, differential diagnosis based on these variables is not reliable. Histopathological examination remains a diagnostic gold standard in differentiation of BCC and TT.Background: Although basal cell carcinoma (BCC) can, in the majority of cases, be diagnosed based on clinical and dermoscopic assessment, a potential overlap with benign adnexal skin tumours seems to exist, including trichoblastic tumours (TT). Methods: Retrospective analysis of clinical and dermoscopic features of benign TT and BCC cases was performed to develop a diagnostic algorithm with a potential utility in clinical practice. Results: In the study, 502 histopathologically confirmed BCC cases were compared with 61 TT (including 44 TB (72.13%), 10 TE (16.39%) and 7 DTE (11.48%]). Patients in the BCC group were statistically older . BCC presented generally as larger tumours  and was more frequently associated with clinically visible ulceration . Comparison of lesion morphology, clinically visible pigmentation, and anatomical location did not show significant differences between the analysed groups. Dermoscopically visible ulceration was significantly more common in the BCC group compared to the TT group . Pigmented structures, specifically brown dots and brown globules, were significantly more prevalent in the TT group . Similarly, TT more commonly than BCC showed the presence of cloudy/starry milia-like cysts  and yellow globules . Conclusions: Despite differences in frequency of clinical and dermoscopic features between BCC and TT in the studied group, differential diagnosis based on these variables is not reliable. Histopathological examination remains a diagnostic gold standard in differentiation of BCC and TT. Dermoscopic criteria for diagnosis of basal cell carcinoma (BCC) have been systematically evaluated and updated in recent years ,2. AlthoCurrently, the gold standard in differential diagnosis of the above-mentioned tumours and BCC is histopathological  assessment. Differential diagnosis is important, as benign trichoblastic tumours differ in terms of growth character, planned surgical excision margin, and the risk of recurrence.The aims of the study were to conduct detailed clinical and dermoscopic analysis of patients diagnosed with benign trichoblastic tumours, comparing them with a large cohort of patients with histopathologically confirmed BCC.Medical records from a tertiary clinical centre from northern Poland  including completely excised and histopathologically examined skin tumours between May 2016 and August 2021 were retrospectively analysed to identify all cases of BCC and benign TT . Sample biopsies, recurrent BCC, giant tumours (diameter > 50 mm), purely superficial BCC, as well as collision lesions were excluded from analysis. Additionally excluded was TB associated with Brook–Spiegler syndrome/multiple familial trichoepitheliomas and TB arising over sebaceous nevus. After quality assessment of clinical and dermoscopic pictures, 502 BCC cases and 61 TT were finally included in further analysis. All cases were retrieved from one image database, performed by the same videodermoscope  with the same methodology  by dermoscopists working in a skin cancer unit, using dermoscopy in daily practice. All histopathological cases were assessed by two histopathologists experienced in dermatopathology . Clinical and dermoscopic pictures were independently analysed by predefined criteria by two investigators (M.Sł and M.So) blinded for histopathological diagnosis. In case of any discrepancy, a third investigator was consulted, and a decision was reached by consensus (M. Si). In addition to dermoscopic criteria, clinical data including age, gender, tumour location, tumour size, clinically visible pigmentation and ulceration, and lesion morphology (flat/elevated) were evaluated. As all pictures were performed using non-polarised mode, the structures visible only on polarised dermoscopy were not analysed.https://cran.r-project.org/), and κ statistic and percentage of positive concordance were calculated for interobserver agreement analysis of dermoscopic features. A p < 0.05 was considered statistically significant. Statistical tests used according to the analysed variables are mentioned in the t-test was used to analyse the differences of variables with normal distribution. If the distribution significantly differed from normal, Mann–Whitney U test was used instead.Data analysis was carried out using statistical software R  and the control group, a binary classification algorithm was developed.All patients with TT  were grouped together as benign changes. No data imputation was used; patients with missing data were excluded from the further analysis. The analysed cohort was split randomly into four subgroups while preserving the proportion of benign changes to BCC. Three of these groups were used to develop the algorithm. The fourth group was excluded from the process and was used only as the independent test set to evaluate the performance of the final model. To avoid information leak between the training set and the independent test set, results from the statistical analysis of the whole cohort of patients were not used in the development of the algorithm.Three-fold cross-validation was used during the training. A classification algorithm was constructed using the XGBoost library . Three iThe summary of the analysed clinical and dermoscopic variables is presented in p = 0.0152; age range 9–94 years for TT, and 12–95 years for BCC). In the BCC group female predominance was observed, in contrast to the latter, however, with no statistical significance . BCC presented generally as larger tumours  and more frequently associated with clinically visible ulceration . Comparison of lesion morphology (flat vs. elevated) did not show significant differences between the analysed groups. Similarly, no differences were found in the presence of clinically visible pigmentation and anatomical location.In the study, 502 cases of histopathologically confirmed BCC were compared with 61 TT (including 44 TB (72.13%), 10 TE (16.39%) and 7 DTE (11.48%)). Patients in the BCC group were statistically older, compared to those diagnosed with TT . Pigmented structures, precisely brown dots and brown globules, were significantly more prevalent in the TT group . Similarly, TT more commonly than BCC showed the presence of cloudy/starry milia-like cysts  and yellow globules .Dermoscopically visible ulceration was significantly more common in the BCC group, compared to the TT group  on the randomly selected independent test set. The detailed ROC curve is presented in Epidemiological data regarding trichoblastic tumours remain incoherent. While some studies indicated that TB occurred in younger patients, in others there were no statistically significant differences in the patients’ age . In a stIn contrast, we did not observe differences in clinically observable pigmentation in either of the analysed groups.Data concerning dermoscopic presentation of TT are scarce and limited to case reports and small case series ,6,7. GhiCostello et al. , in a rePitarch et al.  describeIn our study, in both groups, polymorphic vessels were observed in almost half of the analysed cases, with branched (arborizing) vessels and superficial fine telangiectasia most commonly observed. We did not find circular white structures in any of the analysed trichoblastic tumours. Similarly, we did not observe shiny white structures/white striae/chrysalis, as no polarised dermoscopy pictures were available for analysis.Additionally, we found yellow cloudy/starry milia-like cysts (MLCs) and yellow globules to be more prevalent in the TT group. Previously, Belluci et al. , in a stNavarrete-Dechent et al.  analysedStudy limitations include its retrospective and single-centre character as well as lack of analysis of dermoscopic features visible on polarised dermoscopy. The patients studied represented I-III Fitzpatrick phototype. Thus, the results cannot be easily extrapolated to populations with darker skin phototypes.Additionally, we did not examine the diagnostic significance of alternative imaging modalities in differential diagnosis of BCC and TT. Previous studies suggested possible utility of in vivo reflectance confocal microscopy (RCM), optical coherence tomography, as well as high-frequency ultrasound examination ,28,29,30Despite differences in frequency of clinical and dermoscopic features between BCC and TT in the studied group, differential diagnosis based on these variables is not reliable based on the developed algorithm, as the overlap of the analysed features was observed in both tumour types. Histopathological examination remains a diagnostic gold standard in differentiation of BCC and TT.


The optimal treatment protocol of intraabdominal testis is still a matter of debate and until now there are a lot of areas of controversy as regards this challenging subtype. The aim of this report is to document current practice patterns among surgeons from different continents through an online Redcap survey supervised the World Federation of the Association of Pediatric Surgeons (WOFAPS).via RedCap. The WOFAPS headquarters sent an email to all members inviting voluntary survey participation. Data were entered using Microsoft EXCEL spreadsheet and analyzed. Descriptive statistics were performed for each survey item.A 16-question-survey related to the management of intraabdominal testis was created and administered There were 436 WOFAPS members who participated in this study with a response rate of 29%, and the vast majority were pediatric surgeons. Only 13% tried to use hormone therapy aiming to induce testicular descent or to improve future fertility. The choices of various surgical techniques were noted. During laparoscopy, if vessels and cord structure were seen entering the ipsilateral internal inguinal ring, most respondents chose to explore the groin. On the other hand, should there was an absent or atrophic testis, the respondents were split on whether to perform a contralateral orchiopexy.This survey describes the current practices of a sample of pediatric surgeons and urologists in the management of intraabdominal testis. The use of hormonal treatment, timing of fixation and management in case of passing through vas and vessels through DIR were undisputable. However, management of low-lying and peeing testis together with the management of contralateral testis were still debatable. Cryptorchidism or undescended testis is the most common genitourinary anomaly affecting boys with an overall incidence of around 3% in full term neonates, reaching up to 30% in pre-mature boys . During While the management of boys with palpable undescended testis is more or less standardized, the optimal treatment protocol of intraabdominal testis is still a matter of debate and until now there are a lot of areas of controversy as regards this challenging subtype . Among tvia RedCap, a web application for building and managing online surveys and databases. The first four demographic questions were required, but all other questions were answered at participant discretion. The survey was developed and screened through the WOFAPS Outcomes and Evidence Based Practice Committee prior to dissemination. The headquarters of WOFAPS sent an email on 4th of April 2021 to all WOFAPS members inviting voluntary survey participation. Collective survey answers were tabulated and reported as frequencies and percentages. Data were entered using Microsoft EXCEL spreadsheet and analyzed using IBM SPSS software package version 20.0. . Descriptive statistics were performed for each survey item.A 16-question-survey regarding respondent demographics and practices related to the management of intraabdominal testis was created and administered A total of 436 of 1,503 WOFAPS members (29%) who received the survey responded with the majority being from Latin America and Asia (both contribute to around one-third). This was followed by Africa and Europe with minimal contribution by North America and Australia. Around 92% were pediatric surgeon, 7% pediatric urologist, and 1% general surgeons. Approximately two-fifth of the respondents had 21–30 years of experience.The results of the response to the survey is summarized in This survey describes the current practices of a sample of pediatric surgeons and urologists in the management of intraabdominal testis. Points of interest were the use of hormonal therapy, timing of surgery, and surgical options in different scenarios during diagnostic laparoscopy.The majority of the respondents chose not to use hormonal therapy by any means during management of an intraabdominal testis, where only 13% use hormonal therapy to induce testicular descent and 7% to improve future fertility. The hormonal treatment of cryptorchidism is based on the hormonal reliance of testicular descent. Human chorionic gonadotropin (hCG), gonadotropin releasing hormone  or a combination of both are the most used hormonal therapies .The main reason for not recommending hormonal treatment of the undescended testis is the low success rate of this treatment (up to 20%),  which afOn the other hand, proponents of the role of hormonal therapy demonstrated that cryptorchidism is a serious andrological problem even if it is a unilateral one. This is supported by the fact that even after successful surgery, azoospermia is 25 times more common in unilateral and 80 times more common in bilateral cryptorchidism in comparison with the control population . Thus, iThe optimal timing for intervention was not a subject of controversy in the survey as 82% reported to perform orchiopexy from 6 to 12 months , whilst only one-fifth prefer at 12–18 months.Because of the high incidence of spontaneous descent during the first few months of life, surgery for undescended testes diagnosed at birth should not be performed before 6 months of age . Wenzler et al.  performeThis distance is measured from the lowest point in which the testis can reach the DIR without tension using a piece of suture material and then measured externally on a scale. Two techniques, the two-stage Fowler-Stephens (FS) and the lap assisted single stage vessel sparing orchiopexy, were almost equally preferred by around 70% of the respondents in management of low-lying testis. These are followed by Shehata technique in 18% and one-stage FS in a tenth of the surgeons.For the low-lying abdominal testis (<3 cm from DIR), one-stage orchiopexy is a suitable option. The key steps are mobilization of the peritoneum, dividing the gubernaculum and redirecting the spermatic cord medial to the inguinal canal (Prentiss maneuver). Excellent results are reported in low-lying abdominal testis, for instance, Baker et al. reported success in 173/175 cases (97.2%) and Radmayr et al. in 28/28 cases (100%) , 23.in situ without any treatment after ligating the spermatic vessels, followed by staged surgery. As regards the outcome, Esposito et al. , some surgeons believe that lap-assisted orchiopexy for such high inguinal testes is an attractive alternative approach. The most preferred lap-assisted technique in our survey was the lap assisted one stage orchiopexy (40% of the respondents), followed by lap assisted FS and lap assisted Shehata techniques.The potential advantages of laparoscopy in such situations are a better magnification, and a wide range of testicular dissection with facilitation of the Prentiss maneuver to allow satisfactory orchiopexy without significant vascular compromise. In a study performed by Elderwy et al.  open andWhen cord structures found entering the DIR, some surgeons prefer not to explore the inguinal canal regardless the patency of the DIR claiming that even there was a testicular nubbin, excision is not necessary as it lacks viable germ cells . Nonethevia the open surgery to patients with a closed DIR. In a more recent study, laparoscopic inguinal exploration was feasible in cases of impalpable UDTs, irrespective of the status of the DIR or the appearance of the testicular vessels; however, this study was limited by the small number of included cases . The rationale of fixation is to prevent the disastrous event of torsion of the solitary testis, where, in our survey, around quarter of the respondents reported seeing torsion of a single testis. On the other hand, those who argue that contralateral fixation is not necessary claim that prevalence of contralateral bell clapper anomaly is exceedingly small, substantiating an insufficient risk of subsequent torsion to justify routine fixation of the solitary testis. In a research conducted by Martin and Rushton , 50 chilTo sum up, this survey describes the current practices of a sample of pediatric surgeons and urologists in the management of intraabdominal testis. The use of hormonal treatment, timing of fixation and management in case of passing through vas and vessels through DIR were generally agreeable. However, management of low-lying and peeing testis together with the management of contralateral testis were still areas of debate in this survey.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.SS: protocol development and critical revision. FH: critical revision. DK and MK: data collection and manuscript writing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Alkaline phosphatase (ALP) enzymes are widely used as signal amplifiers in immunoenzymatic methods. Conditions that cause ALP elevations, such as bone or liver diseases, can cause interference in immunoenzymatic methods. We aimed to examine ALP's effect on immunoenzymatic assay by adding isolated pure ALP to the prepared serum pool.We prepared a serum pool and divided it into 4 groups. By adding isolated pure ALP at different concentrations to each group, we obtained sample groups containing ALP enzyme at concentrations of 85 U/L, 340 U/L, 870 U/L, and 1570 U/L. 20-repetition of bhCG, ferritin, FT4, TSH, troponin I, and Vit B12 tests were performed in each group. The coefficient of variation, bias, and total error was calculated. All groups were compared by using the Friedman test for paired samples.After ALP addition, the calculated total error values of FT4, bhCG and troponin I tests were above the acceptable error limits. There were statistically significant differences in bhCG, FT4, troponin I, and Vit B12 tests compared to the baseline ALP level (P<0.0125).Isolated ALP elevations can be a source of interference for immunoenzymatic methods. Alkaline phosphatases  EC 3.1.3.1) are homodimeric and glycoprotein enzymes in the hydrolase group with a molecular weight of 86 kilodaltons. These groups of enzymes are commonly found in nature in both eukaryotes and most prokaryotes. Each monomer is encoded by multiple genes to contain five cysteine residues, two zinc atoms and one magnesium atom, which are vitally important for its catalytic function.ALP enables the detachment of phosphate groups from a variety of molecules, including nucleotides, proteins and alkaloids, in alkaline pH environments ALP mainly functions as bound by hydrophobic glucosyl-phosphatidylinositol to the cell membrane Serum ALP measurement plays a vital role in the diagnosis of hepatobiliary and bone diseases associated with an increased osteoblastic activity. Intrahepatic and extrahepatic cholestasis, spaceoccupying lesions in the liver, metastasis and infiltrative liver diseases cause an increase in serum ALP levels ALP is used to provide signal amplification by conjugating it with antibodies in immunoenzymatic methods In our laboratory, we use UniCelDxl 800 and Access II  auto analyzers that measure by immunoenzymatic method and use ALP conjugates as signal amplifiers. Our purpose is to evaluate the interference caused by the ALP elevation on these systems through beta human chorionic gonadotropin (βhCG), ferritin, free thyroxine (FT4), thyroid-stimulating hormone (TSH), troponin I and Cobalamin (Vit B12) tests.We created a serum pool with 20 patients' sera who have previously consulted our laboratory in January 2020 and whose ALP, βhCG, ferritin, FT4, TSH, troponin I, and Vit B12 tests were found to be within the reference range.The prepared serum pool was divided into four groups. Commercially prepared isolated ALP , with an activity of 30,000,000 U/L, was added at different doses to the groups. Commercial ALP enzyme is in transparent liquid form, has grade 2 activity  and contains Adenosine deaminase and Phosphodiesterase. First of all, due to the enormous enzyme activity, isolated ALP was diluted to a working stock by adding 2 μL of commercial ALP to 998 μL of distilled water. We prepared a stock solution immediately before the assay. We added 5 μL, 10 μL and 20 μL of this stock solution, respectively, to the serum pools of 8 mL each. We obtained four groups, one being our reference group without ALP addition and the others containing ALP at concentrations of 340 U/L, 870 U/L and 1590 U/L after adding isolated ALP.The ALP was measured spectrophotometrically with a Beckman Coulter AU 5800  auto-analyzer. Ferritin, FT4, TSH and Vit B12 tests were measured immunoenzymatically with an UniCelDxl 800  autoanalyzer and βhCG and troponin I test with an Access II  auto-analyzer. All assays are two-site sandwich immunoassay using enzyme-conjugated antibodies with direct chemiluminometric technology. In all groups, each test was performed with 20 repetitions. All measurements were completed on the same day and within-run.In the evaluation of the effect of the ALP enzyme on the immunoenzymatic tests, Total error (TE), Bias and coefficient of variations (CV) were calculated by 20 repetitions of each group.TE was calculated by the following formula:TE = total errorCV = coefficient of variation.Bias was calculated as follows 1 = mean value of reference group and C2 =mean value of groups added with ALPCWe applied the Friedman test to show the difference between groups using Med Calc  software. We used Bonferroni correction to determine the adjusted significance level as p<0.0125.CV, Bias, and TE values of each analyte are reported as separate groups in After adding ALP, in βhCG, calculated TE values at ALP concentrations of 340 U/L and 1590 U/L were found to be above the acceptable error limits. In the FT4 test, the calculated TE value at ALP concentrations of 340 U/L was found to be above the acceptable error limits. Calculated TE values were found to be above the acceptable error limits in all groups for the troponin I test. We observed that the calculated CV values for the βhCG test increased with increasing ALP concentrations. In the troponin I test, calculated CV's at ALP concentrations of 340 U/L and 1590 U/L were found to be higher than the group without ALP added.In our study, ALP interference was observed in immunoenzymatic assays for bhCG, FT4, troponin I and Vit B12 tests. We observed that TE and CV values increased after ALP addition, especially in troponin I and βhCG tests. Likewise, Sofronescu et al. We observed that ALP addition could cause interference on βhCG, FT4, troponin I and Vit B12 tests. While Herman et al. In a way similar to our study, Dasguptaet et al. Similar to our study, Marinheiro et al. While preparing the study plan, we had to determine the final ALP concentration that we would reach. The linearity upper limit of the system that we used (Beckman AU5800) was set at 1500 U/L for the ALP test. Nargis et al. The interference effect of the presence of heterophilic antibodies on the test for immunoenzymatic methods is reported as a generally erroneous test result Other studies investigating ALP interference areoften presented as case reports and are not statistically strong. They tried to understand and show the interference through a patient. Our study design was structured very well, and we compared our results to the reported guideline.Based on the findings obtained from our study, we determined that elevated ALP caused interference on βhCG, FT4, troponin I and Vit B12 tests, but it did not cause a significant interference on Ferritin and TSH tests. Especially in terms of misdiagnosing myocardial infarction, it should be considered that troponin I could be affected by high ALP levels. It would be beneficial to repeat the βhCG and troponin I tests with DXI-800. There is a need for repeating the study with samples free of any heterophilic antibodies and with samples containing higher rates of ALP.All the authors declare that they have no conflictof interest in this work.ALP, Alkaline phosphatase;
βhCG, betahuman chorionic gonadotropin;
FT4, Free thyroxine;
TSH, thyroid-stimulating hormone;
Vit B12, Cobalamin;
TE, Total Error;
CV, coefficient of variations;
MEIA, microparticle immunoassay;
FIA, fluorometric immunoassay


Research on organ-specific autoimmune disease generally covers both systemic and local regulations. In contrast, studies on the testis are focused mainly on local mechanisms. This is because of the general belief that haploid germ cell-specific antigens (Ag) are sequestered within the seminiferous tubule (SFT) by the blood–testis barrier (BTB) and do not communicate with the immune system and that the late ontogeny of haploid germ cell Ag precludes neonatal tolerance induction. However, these arguments are not evidence-based, and recent findings indicate they are not valid.Harakal et al., Ag sequestration applies only to some sperm Ag. Other haploid sperm Ag continuously egress the normal SFT. The physiological sperm Ag lactate dehydrogenase 3 (LDH3) enters the residual body (RB), egresses into the testis interstitial space, and forms immune complexes with circulating antibodies (Ab). LDH3 first egresses at postnatal week 5 when RB formation begins. Ag-specific systemic tolerance to LDH3 is documented in male wild-type (WT) mice, but not in male LDH3 -/- mice or Treg-depleted male WT mice. When Tregs are depleted from adult mice expressing the transgenic Foxp3-diphtheria toxin receptor, they spontaneously develop LDH3 Ab and severe autoimmune orchitis (AO), and both are preventable with Treg from WT male donors. Therefore, the egress of the sperm Ag from the SFT beyond the neonatal period is protected by Treg-dependent systemic tolerance. A similar mechanism applies to autoantigens in mouse stomachs, ovaries, prostates, and lacrimal glands . Although systemic tolerance for ZAN is undetected in normal mice, when ZAN is exposed by unilateral vasectomy, it induces Ag-specific Treg-dependent tolerance in 7 days. Thus, when unilaterally vasectomized mice are immunized with the brain Ag or testis Ag, they develop an autoimmune disease in the brain but not in the testis. When unilaterally vasectomized mice are 60% Treg-depleted, they develop ZAN Ab and severe bilateral AO.The rapid Treg response to the exposed sequestered sperm Ag resembles the response against microbial Ag, which may reduce collateral tissue damage and enhance infection chronicity . The newLustig et al. reviewed the overall functional anatomy of the testis and described the cells located in the testis interstitial space. They also describe in detail local mechanisms that operate in rat experimental AO (EAO). First, indoleamine 2,3-dioxygenase (IDO) produced by Sertoli cells and other cell types. The essential amino acid trytophan is deprived by IDO, and it leads to the production of kynurenine. Second, the cytokines IL6 and TNFα disrupt the BTB integrity and expose sperm Ag. Third, the dendritic cells (DC) present testis Ag to T cells and include Treg in draining the lymph node (LN). (de (LN). . Fourth,Bhushan et al. details the macrophages in two unique locations. Those in close contact with Leydig cells are yolk sac-derived and they self-renew. They are essential for Leydig cell function, including steroidogenesis that maintains BTB integrity, the hypothalamic–pituitary–gonadal axis, and spermatogenesis. Moreover, the macrophages co-localized with the spermatogonia are BM-derived and renewed from blood, and they support pre-meiotic germ cell development. The peri-tubular macrophages may also process and present endogenous and exogenous Ag to Ag-specific T cells locally and in the regional LN. The M2 macrophages in a normal testis express high levels of CD163 and IL10 and minimal levels of nitric acid and TNFα. They stimulate a Treg response and maintain local and systemic tolerance for testis Ag. However, when the testis is inflamed from AO, infections, or LPS exposure, the macrophages switch from M2 to M1. M1 macrophages are major histocompatibility complex class II+ (MHC Class II+), and they produce proinflammatory cytokines (TNFα and IL6) and chemokines. A new in vitro study by Fan et al. on the small Ca2+ binding protein S100A9 documented its effect on the immunosuppressive property of M2 macrophages. The process requires the activation of the P13kt pathway; and S100A9 and/or P13K inhibitors prevent the activation of M2 macrophages in vitro.The study from Pleuger et al. and Zhao et al. Importantly, the proximal caput epididymis is structurally and functionally distinct from the distal cauda epididymis. The caput has a complex epithelial lining with intraepithelial lymphocytes surrounded by a network of dendritic cells and F4/80+ and CD11c+ macrophages. The latter projects cytoplasmic processes into the lumen to contact intraluminal cell contents (The immunology of the epididymis is quite different from the immunology of the testis, as described by contents . Interescontents . Mice deThe findings in this review suggest future directions for exploration that may better clarify the nature of human gonadal diseases. Said findings include how an autoimmune disease develops as well as what and how testis autoantigens are selected based on different mechanisms of autoimmunity, including those driven by infection. Future studies will benefit from active collaboration between research on local and systemic mechanisms.KT drafted the editorial, and DH and Y-GD contributed to the final submitted version. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study aimed to investigate the associations between ApoE4 with CSF Aβ42, total tau (t-tau), phospho-tau181 (p-tau), and with the progression of decline in a large cohort of MCI subjects, both progressors to AD and other dementias, as well as non-progressors. We analyzed associations of CSF Aβ42, p-tau and t-tau with ApoE4 allele frequency cross-sectionally and longitudinally over 3 years of follow-up in 195 individuals with a diagnosis of MCI-stable, MCI-AD converters and MCI progressing to other dementias from the German Dementia Competence Network. In the total sample, ApoE4 carriers had lower concentrations of CSF Aβ42, and increased concentrations of t-tau and p-tau compared to non-carriers in a gene dose-dependent manner. Comparisons of these associations stratified by MCI-progression groups showed a significant influence of ApoE4 carriership and diagnostic group on all CSF biomarker levels. The effect of ApoE4 was present in MCI-stable individuals but not in the other groups, with ApoE4 + carriers having decreased CSF Aβ 42 levels, and increased concentration of t-tau and p-tau. Longitudinally, individuals with abnormal t-tau and Aβ42 had a more rapid progression of cognitive and clinical decline, independently of ApoE4 genotype. Overall, our results contribute to an emerging framework in which ApoE4 involves mechanisms associated with both CSF amyloid-β burden and tau aggregation at specific time points in AD pathogenesis. Alzheimer’s disease (AD), the most frequent neurodegenerative disease, is characterized by an accumulation of extracellular beta-amyloid (Aβ) plaques and intracellular tau tangles in the brain. Its pathobiology is multifactorial with both genetic and environmental risk factors  biomarkers, such as different species of amyloid-β (Aβ), total tau (t-tau) and phosphorylated tau (p-tau), have been proven to be of great diagnostic value in the early diagnosis of AD , : amyloid-beta1-40 , Aβ42, total tau (t-tau), and phosphorylated tau181 . The analyses were performed in a certified laboratory and under a routine quality control regime  . The apolipoprotein ε4 genotype was determined as previously described . Besides the single variables, we also assessed the interaction effect (CSF ~ ApoE4 * group). The ANOVA model was also stratified for age and gender. To assess the effects of ApoE4 and the level of CSF markers on cognitive decline, the CSF markers were dichotomized based on the median value: 356 for total-τ, 52 for phospho-τ and 681 for Aβ-42. Cognitive decline was quantified by calculating the slopes of a linear model of CDR or MMSE over time for each patient individually. ANOVA analysis was performed to assess the effects of ApoE4 and CSF markers on cognitive decline (Cog. Decline ~ ApoE4 * CSF group). The ANOVA model was also stratified for age and gender. All statistical analyses were performed with R version 3.5.1  years old and had an average of 9.57 (1.91) years of education, with 61.03% of them being female. Clinical follow-up data were available with an average follow-up length of 25.7 month. Table (+ /–), and thirteen (6.6%) were homozygous ApoE4 carriers (ε4 + / +). The baseline levels of CSF Aβ-42, t-tau and p-tau differed significantly between the groups  had one ApoE4 allele (ε4ps Table . The MCIp < 0.001). Likewise, t-tau and p-tau were increased in ApoE4 carriers than in non-carriers in a gene dose-dependent manner (p < 0.01). Comparisons are shown in Fig. In the total cohort, CSF Aβ-42 concentrations were lower in ApoE4 carriers than in non-carriers in a gene dose-dependent manner .N = 147). In amyloid-positive subjects (Aβ42 < 500), there was no significant relation between APOE epsilon4 and CSF tau visible .In amyloid-negative individuals (Aβ42 ≥ 500), we found a significant association between APOE epsilon4 and CSF tau  and increased levels of t-tau (p < 0.01) and p-tau (p < 0.05). In MCI-AD progressors and MCI-Other, no differences regarding ApoE4 carriership were found. ANOVA Models (adjusted for age and gender) show a significant influence of ApoE4 carriership and diagnosis on Aβ42, t-tau and p-tau concentrations . In addition, we also analyzed a potential combinatorial effect of ApoE4 and diagnosis. However, we found that the influence of ApoE4 was similar across all diagnosis .Comparisons by ApoE4 carriership status and MCI groups’ diagnoses of CSF concentrations are shown in Table p ≤ 0.001; Aβ42 p ≤ 0.01) and for clinical progression CDR-sb  while a non-significant trend was seen for p-tau for MMSE (p = 0.09). ApoE4 status did not have a significant effect on rate of cognitive decline. We found no significant interaction of CSF * ApoE4 influence on the progression rate of cognitive decline. In ApoE4+ individuals, normal levels of Aβ42 seem to decline clinically similarly (CDR-sb) to those individuals with Aβ42 abnormal levels; however, this interaction did not reach significance (Interaction Aβ42* ApoE4 p = 0.42)  cross-sectionally and on progression of decline in a cohort of MCI subjects from the Dementia Competence Network, stratified into 3 groups: MCI-stable individuals, MCI-AD progressors and MCI subjects progressing to other forms of dementia. Our results confirm a clear impact of ApoE4 on all CSF AD core biomarkers: (1) In our total sample, ApoE4 carriers had lower concentration of CSF Aβ42, and increased concentration of t-tau and p-tau than non-carriers in a gene-dose-dependent manner. (2) Comparisons of the associations stratified by MCI-progression groups show a quantitatively differential influence of ApoE4 carriership on CSF biomarkers dependent on diagnostic group. (3) In the largest group from our sample, i.e., MCI-stable individuals, CSF biomarker levels were close to normal, in line with clinical outcome, and most strongly affected by ApoE4 carrier status, i.e., decreased CSF Aβ42 levels and increased concentration of t-tau and p-tau. (4) When assessing the influence of ApoE4 and CSF biomarkers on cognitive and clinical decline over time, those individuals with abnormal t-tau and Aβ42 had a more rapid cognitive and clinical decline.Our results add to the body of findings, showing that ApoE4 exerts a pathological influence on both Aβ42 and tau levels. However, the data also demonstrated that in clinical AD at the stage of MCI, the impact of ApoE4 is diminished by neurodegeneration. Our findings are in line with previous studies, showing an effect of ApoE4 on CSF Aβ42 and CSF tau in cognitively unimpaired subjects and early MCI, but not in AD dementia, supporting the idea that other mechanisms of neurodegeneration may override the effect of ApoE4 later in the course of AD , regardless of ApoE4 status. In line with previous studies, showed the association between CSF t-tau levels and lower cognitive performance and increase rate of decline as well , our results add to the growing body of recent findings, suggesting the involvement of ApoE4 on tau accumulation as well. In the case of tau pathology, ApoE4 is associated with higher levels of CSF tau  Our findings may be affected by a sample size bias, as we chose to include only participants with complete data in the longitudinal analysis, the sample used was rather small for some of the diagnostic groups. This may also reflect that ApoE4 effects were most pronounced in the largest group, and least clear in the smallest group. Alternatively, the findings support the hypothesis that ApoE4 role is more visible in the early stages of AD rather than in more advanced stages. (2) All diagnoses in our sample were made clinically at follow-up, but not confirmed histopathologically nor confirmed by biomarker results. This may cause some diagnostic inaccuracy, and thus disease-specific mechanisms of ApoE4 remain speculative. Still, the lack of a significant interaction of ApoE4 carriership with diagnosis on CSF biomarker levels does not suggest any AD-specific mechanisms of ApoE4 on biomarkers. (3) The DCN sample is not a population-based cohort, rather it is more representative of real clinical setting of specialized memory clinic patients, what may be a strength of the study when considering clinical diagnostic practice. (4) Although AD core CSF biomarkers of amyloid, phospho-tau and total tau are currently well validated measures of AD pathology, this study should be replicated using modern neuroimaging techniques such as in vivo amyloid and Tau PET 5) Lastly, due to practical reasons, , we applied a relatively short follow-up period with a mean of 2.5 years, implying that a certain proportion of patients who were classified as stable are likely to progress to dementia later on. We strongly encourage that the confirmation of these finding in larger sample, with longer follow-up time, or with higher conversion rate to AD, should be carried out.In summary, we confirmed the powerful ApoE4 dosage-dependent effect on CSF Aβ42 levels reported previously, add data on a positive association between ApoE4 allele number and both, CSF t-tau and p-tau levels, with an effect independent of  CSF Aβ42 in amyloid-negative subjects, and show that ApoE genotype affects speed of clinical progression in AD. The data also may indicate that in clinical AD at the stage of MCI, the impact of ApoE4 is modified by other mechanisms of neurodegeneration, with implications for diagnostic utility. Thus, our results contribute to an emerging framework in which ApoE4 involves general mechanisms associated with both CSF amyloid-β burden and tau aggregation at specific time points in AD pathogenesis.