Clostridioides difficile infection and is being investigated as a potential therapy for dozens of microbiota-mediated indications. Stool banks centralize FMT donor screening and FMT material preparation with the goal of expanding access to FMT material while simultaneously improving its safety, quality, and convenience. Although there are published consensuses on donor screening guidelines, there are few reports about the implementation of those guidelines in functioning stool banks.Fecal microbiota transplantation (FMT) is a recommended therapy for recurrent To help inform consensus standards with data gathered from real-world settings and, in turn, to improve patient care, here we describe the general methodology used in 2018 by OpenBiome, a large stool bank, and its outputs in that year.In 2018, the stool bank received 7,536 stool donations from 210 donors, a daily average of 20.6 donations, and processed 4,271 of those donations into FMT preparations. The median time a screened and enrolled stool donor actively donated stool was 5.8 months. The median time between the manufacture of an FMT preparation and its shipment to a hospital or physician was 8.9 months. Half of the stool bank’s partner hospitals and physicians ordered an average of 0.75 or fewer FMT preparations per month.Further knowledge sharing should help inform refinements of stool banking guidelines and best practices. Clostridioides difficile infection , the transfer of minimally manipulated stool and its associated microbiota from a healthy donor into the gastrointestinal tract of the patient , is a renfection . C. diff in 2017 . FMT’s ry 80-90% , has insy 80-90% .patient-selected donors and stool banking  FMT, which comes with significant risk to patient safety , a large stool bank, to fulfill clinicians’ requests for FMT material to treat recurrent scretion . Since iThe stool bank follows phase-appropriate current good manufacturing practices (cGMP) , which iC. difficile infection under enforcement discretion as well as requests for material for research purposes. Some procedures differ between enforcement discretion and research. For clarity, only the enforcement discretion procedures are described here.In 2018, the bank used the six-part methodology described above and outlined previously: donor recruitment, donor evaluation, manufacturing, health monitoring and release, fulfillment, and patient safety . This mea priori exclusion . Important categories used for preliminary screening include logistics , infectious risk   , and comhistory) . CandidaTo protect the security and quality of stool donation programs, the bank does not publicize the precise inclusion and exclusion criteria for donors nor the precise methodology for donor recruitment or evaluation, described below. This policy is intended to ensure that donors or donor candidates provide truthful information to the bank, rather than answering questions in a way that ensures that they are permitted to donate stool.During on-site evaluation, candidates provide informed consent and sign an affidavit attesting that the health information they provide is true and complete . Next, cCandidates who pass the in-person clinical assessment undergo a three-part laboratory screening: blood, stool, and nasal swab. Samples are sent to external laboratories for testing Table 1,Donors provide donations by visiting the stool bank’s collection facility, where they are given a stool collection kit. After passing the stool on site, donors close the container’s lid and place it in a resealable plastic bag for secondary containment. A staff member labels the donation with a donor identification number and the time of passage. The donor’s health status is re-assessed at each donation as described below. Donors are remunerated for the time and travel required to provide each processed donation.The donation is transferred to a dedicated biosafety cabinet that is cleaned with a sporicidal agent and ethanol. A trained technician opens the container and evaluates the stool for any visible pathology . Donations with poor consistency  or visual pathology are destroyed, and clinical staff are notified of the abnormality. Donations that do not meet a minimum weight of 55 grams are not cost-effective to process and are destroyed. After visual inspection and weighing, the stool is transferred to a sterile 330 μm filter bag, diluted in a sterile, US Pharmacopeia-grade glycerol-saline solution (12.5% glycerol in 0.90% w/v NaCl in water), and fully homogenized while still in the filter bag using a paddle blender for at least 180 seconds. Fibrous material remains on one side of the filter while bacteria, small molecules, and water are pressed to the other side of the filter.The filtrate is diluted and aliquoted depending on the final FMT preparation. Each FMT preparation is derived from a single donor; filtrates from different donors are never mixed. All donations are processed within six hours of the donor’s initial passage, and material that cannot be processed in time is destroyed .The bank produces two liquid preparations Figure 1The capsule formulation is designed to be swallowed and resist degradation from stomach acid until reaching the small intestine . Each caTo support traceability, each FMT preparation and aliquot is labeled with a barcode that links it to the donation. All steps in the manufacturing process are monitored and logged according to cGMP standards. Completed FMT preparations are kept in quarantine until they are determined to be free of specific risk factors, as described below.A donor’s health and eligibility for continued donation are continually assessed by five mechanisms.First, donors must report travel or change in health status while actively part of the program, including fever, cough, congestion, change in bowel habit, nausea, vomiting, seasonal allergies, medical or dental procedures, bodily injury, and use of oral or topical over-the-counter medications. If an illness or travel event is reported, the donor is further evaluated by a member of the clinical staff, who determines if the donor should be temporarily deferred or permanently excluded from the stool donation program. For example, travel to certain countries entails a high risk for acquiring antibiotic-resistant bacteria and may lead to temporary deferral or permanent exclusion. Any donor who is temporarily deferred undergoes a partial or complete re-screening before being re-admitted to the program.Second, at each stool donation, donors complete a short heath questionnaire. If the donor reports a change in health status or a clinical staff member’s direct observation of the donor leads them to suspect a change in the donor’s health status, a clinician interviews the donor to gather additional information. Clinical staff may determine that the donation should be destroyed, and the donor may be temporarily deferred or permanently excluded. If a donor is temporarily deferred because of a transient illness, the donor must pass a partial or complete re-screening before being re-admitted to the program.Third, if a manufacturing technician observes a suspected stool pathology in the donation as described above, the technician takes a photograph of that donation, destroys the donation, and shares the photograph with the clinical staff. Clinical staff review the photograph and follow up with the donor to determine if the abnormal stool pathology is related to a risk of infection or an underlying disease.Fourth, donors must agree to undergo random health checks. A clinician examines the donor’s vital signs and assesses the donor’s health status, with a focus on bowel habits, infectious risk factors, and new behaviors that may impact the microbiota. If the clinician detects any clinical concerns, the donor may be temporarily deferred or permanently excluded. Any donor who is temporarily deferred undergoes a partial or complete re-screening before being re-admitted to the program.Finally, every donor repeats the complete set of clinical and laboratory assessments, the same set that they passed when first enrolling as a donor, approximately every 60 days. These re-assessments “bookend” 60-day collection periods. FMT preparations produced from stool donations during a collection period are released from quarantine only after the donor passes the second full assessment at the end of the collection period. It is not the case that every donation is screened. Instead, the assessments of a donor’s health at the beginning and end of a 60-day period and a review of all clinical data collected during the collection window are taken as sufficient evidence that the intervening donations are fit for use as FMT preparations .Individuals exposed to HIV or other pathogens may not test positive until some days after their initial infection . To accoMaterial is released from quarantine only after a full review of all clinical and laboratory data in each collection period and requires approval from two clinicians and one quality assurance staff member. All material releases are performed in accordance with cGMP standards.C. difficile as well as chronic infections like hepatitis B and HIV, are permanently excluded from the donor program and all material collected since the donor’s last screening is destroyed. In other cases, such as rotavirus, infections are transient, and donors are temporarily deferred. As stated above, temporarily deferred donors must undergo a partial or complete re-screening before being re-admitted to the program.If a donor newly tests positive for any infectious pathogens or other clinically significant abnormalities indicating there may be a potential underlying exclusionary medical condition, all FMT preparations produced from the corresponding collection period are destroyed. Donors who newly test positive for certain pathogens, including C. difficile infection not responsive to standard therapies  to the stool bank within 24 hours of the event.Registered physicians or healthcare facilities who received stool bank material submit three kinds of information back to the stool bank. First, they must complete a log confirming that each FMT preparation was frozen upon arrival and report whether it remains in inventory, was used in treatment, or destroyed due to expiration or other reasons. Second, they are asked to complete a clinical follow-up form for each patient within 8 weeks of the FMT procedure, indicating the severity and subtype of When a clinician reports a serious adverse event to the bank, the bank begins an investigation. Safety staff appraise the event with respect to seriousness, severity, expectedness, and relatedness. Safety staff engage subject matter experts, including the stool bank’s clinical advisory board, which is an independent group of gastroenterologists, infectious diseases specialists, and other subject matter experts.Barcoding, tracking, and quality assurance systems allow the bank to identify the donation and donor associated with an adverse event. If the adverse event presents a risk to other individuals who would receive material from the same donor, existing material from that donor is immediately placed in quarantine and no more is shipped until safety and quality staff have determined that it is safe to do so. If the event involves an infectious pathogen, safety and quality staff can retrieve the safety aliquot taken from that donation and test it for the presence of the pathogen. If the adverse event is linked to the FMT material, quarantined material from the donor is destroyed, material from the donor that was already shipped may be recalled, and the donor may be permanently excluded from the donation program. If the adverse event is found to be unrelated to FMT, the quarantined material will be released.Findings from the investigation are entered into a safety database with MedDRA terminology. . Data are analyzed through an analysis of similar events to detect safety signals which may indicate a trend or safety risk. Serious adverse events considered related to the FMT are reported to the appropriate regulatory authorities through the Council for International Organizations of Medical Sciences or the MedWatch  system. C. difficile infection patients, advancing research, and receiving the per-donation compensation  of the liquid FMT preparations manufactured in 2018 had been destroyed before leaving quarantine. The most frequent reasons for destruction were a failed bookend laboratory screening , a change in donor’s clinical status, such as the onset of an illness , a donor not completing a re-screen within the required window , and deviations during the manufacturing process . By 1 July 2020, the bank had shipped 62%  of the FMT preparations produced in 2018 to physicians and hospitals for clinical use to treat recurrent To quantify how different hospitals and physicians used different amounts of the bank’s material, we measured the number of FMT preparations shipped to each recipient in 2018, regardless of when those preparations were manufactured. In 2018, 12,453 preparations were shipped to 968 recipients Figure 5C. difficile infection in a specific regulatory environment  Jessica R. Allegretti, Kanchana Amaratunga, Daniel Blackler, Michael Bougas, Shrish Budree, Laura Burns, Jessica W. Crothers, Michael Dickens, Jacob Dixon, Nancy DuBois, Carolyn Edelstein, Michael Edmond, Ryan J. Elliott, Monika Fischer, Dinara Gabdrakhmanova, Richard Hunt, Stacy Kahn, Daelyn Kauffman, Deberly Kauffman, Colleen Kelly, Ciaran Kelly, Clara Kerwin, Kelly Ling, Daniel Martin, Gina Mendolia, Rodrigo Munoz, Kelsey O’Brien, Majdi Osman, Allison Perrotta, Sonny Qazi, Alexandra Scheeler, Monica Seng, Madeline Sovie, Neil Stollman, Zac Stoltzner, Elaine Vo, Kurt Warren, Karl Yoder, Charles Young.The original contributions presented in the study are included in the article/JC and SO conceived the project and performed the analysis. JC, AZ, BR, and SO wrote the original draft. All authors contributed to the article and approved the submitted version.® trademark is registered by IFPMA on behalf of ICH.BR is a former employee of Finch Therapeutics. MedDRAThe remaining 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.


In this review we will describe the testicular vessels anatomy and the implications of these vessels in surgical treatment of high undescended testis.We performed a narrative review of the literature about the role of the testicular arteries anatomy in the treatment of high undescended testis. We also studied two human testes to illustrate the testicular vascularization.Each testis is irrigated by three arteries: testicular artery , a branch of the right aorta; deferential artery , a branch of the inferior vesicle artery that originates from the anterior trunk of internal iliac artery and cremasteric artery , a branch of the inferior epigastric artery. There are important communications among the three arteries with visible anastomotic channels between the testicular and deferential arteries.Laparoscopic transection of the testicular vessels by dividing the spermatic vessels (Fowler-Stephens surgery) is safe in patients with high abdominal testis due to the great collateral vascular supply between testicular, vasal and cremasteric arteries; also, two-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach. Cryptorchidism is the consequence of lack or insufficiency of the process of testicular descent taking place during fetal life . UndesceStudies show that, in Europe, the percentage of individuals with cryptorchidism ranges from 2% to 8%, 6% in the United Kingdom . AccordiApproximately 20% of the cryptorchid testes are non-palpable , 8. A suIn this review we will describe the testicular vessels anatomy and the implications of these vessels in surgical treatment of high undescended testis.In this study we carried out a review about the role of the testicular arteries anatomy in the treatment of high undescended testis. We analyzed papers published in the past 60 years on Pubmed, Embase and Scielo databases searching by key the following expressions: “Undescended testis”, “Cryptorchidism”, “Fowler-Stephens Surgery”, “High undescended testis”, “Testicular artery”, “Cremasteric artery” and “vasal artery”. In this review we found several papers, but we included only papers published in English and excluded case reports, editorials, and opinions of specialists.We also studied two human fetuses (one with 20 weeks post conception and the second with 32 weeks post conception) to illustrate the testicular vascularization. The fetuses were well preserved and have been demised due to spontaneous or induced abortion. The gestational age of the fetuses was determined in weeks post conception (WPC) according to the foot-length criterion, which is currently considered the most acceptable parameter to estimate the fetal gestational age –12.After measuring the fetuses, microvascular silicone rubber resin (red or white) was injected through the thoracic aorta to fill the arterial tree. The testes were identified and the vessels were dissected under low magnification using a surgical microscope. In 2014, the American Urologic Association (AUA) guidelines for evaluation and treatment of cryptorchidism were published and recommended that: 1) at initial evaluation a complete gestational history of all boys suspected of cryptorchidism must be obtained; 2) the testicles should be palpated at each recommended well-child visit for appropriate quality and position; 3) all infants who are found to have cryptorchidism at birth and who do not have spontaneous descent by age of 6 months  must be referred to a surgeon for appropriate evaluation; 4) all boys with a possible new diagnosis of acquired cryptorchidism after 6 months of corrected gestational age be referred for possible surgical correction; 5) any phenotypic male newborns with bilateral non-palpable testes be referred for evaluation of possible disorder of sexual development (DSD); 6) ultrasound and other imaging studies (which are rarely sensitive diagnostic tools) not be ordered prior to referral to a surgical specialist; 7) severe proximal hypospadias and cryptorchidism alert the provider to assess for DSD; 8) a boy who is found to have bilateral non-palpable testes and who does not have congenital adrenal hyperplasia, Müllerian inhibiting substance, or other additional hormones be tested to evaluate for anorchia; and 9) at least annual physical exams be used to assess for secondary ascent in boys found to have retractile testicles , a branch of the right aorta; deferential artery , a branch of the inferior vesicle artery that originates from the anterior trunk of internal iliac and cremasteric arteries , a branch of the inferior epigastric artery . These tModifications in the position and anatomy of the testicular arteries during the process of testicular migration needs to be related. The testicular migration has two phases: the abdominal and the inguinoscrotal stages –22. DuriIn an interesting anatomical study in cadavers and undescended testis, using the injection-corrosion casting technique, it was demonstrated for all testes studied, including the undescended ones, had testicular, they presented deferential and cremasteric arteries . This stIn an experimental study with 32 human fetuses (64 testis), the authors studied the testicular vascularization in fetuses with the testis in abdominal position . The autKnowledge about the anatomy of the veins that drain the testes is clinically important. The testes are drained by the pampiniform venous plexus, which in the region of the deep inguinal ring originates the testicular veins. The left testicular vein opens into the left renal vein and the right testicular vein opens directly into the inferior cava vein .Today, the laparoscopic approach to the inguinal and intra-abdominal non-palpable testicles is the first choice of most surgeons , it alloOrchidodopexy in patients with intra-abdominal testicles is applied using one out of three surgical techniques: conventional orchiopexy, laparoscopic orchiopexy, Fowler-Stephens orchiopexy at one stage, and Fowler-Stephens orchiopexy in two stages. In the three types of techniques, the surgery consists of locating the testis, dissectising it near the spermatic cord, obtaining free tension, and then repositioning it near the scrotum. When performed open, a medial inguinal incision is made from the anterosuperior iliac spine to the external oblique fascia allowing exploration of the peritoneal cavity. The advantages of performing these techniques by laparoscopy include improved visualization, extensive vascular dissection capacity at vessel origin, lower morbidity, and ability to create a medial inner ring for the lower epigastric vessels, also performing a direct course to the scrotum .Fowler and Stephens in 1959 show the vascular supply of the testes applied in the surgical treatment of high undescended testis and showed an important collateral circulation through the deferential artery and the cremasteric artery . In thisFowler-Stephens orchiopexy, both in one and two stages, is adopted when the testis is located high and the testicular vessels are too short to be fixed in the scrotum. The vessels are ligated and the blood supply to the testis preserved via collateral circulation and proceeding with the repositioning and fixation of the testis . In the According to Igarashi , in a stGeuvbashian et al.  reportedIn an interesting study with patients undergoing a second-stage FS procedure the authors photographed prior to pexy of the testis in the Dartos pouch. The photographs were evaluated for the extent of vascular collateralization between gubernacular, deferential and the ligated spermatic artery, and concluded that exists an important collateral communication between the cremasteric and deferential vessels at second-stage FS procedure .Braga et al.  showed tOrchiectomy is adopted in cases of unilateral cryptorchidism in which the affected testis is atrophic, there is atresia or small length of the vas deferens, the testicular veins are located in the retropertium because they are too short or in the presence of intra-abdominal testis in the postoperative pubescent patients, associated with the contralateral testis without anatomical and morphological alterations . HoweverPreservation of an adequate arterial supply for the testis is crucial for successful orchiopexy to ensure normal testicular size and texture so the anatomy of testicular arteries is very important to success of the surgical procedures. Laparoscopic transection of the testicular vessels by dividing the spermatic vessels (Fowler-Stephens surgery) is safe in patients with high abdominal testes because the great collateral vascular supply between testicular, vasal and cremasteric arteries, and two-stage Fowler-Stephens orchiopexy appears to carry a higher rate of success than the single stage approach.


Enterococcus faecalis  meningitis is a rare disease, and most of its occurrences are of post-operative origin. Its rapid diagnosis is critical for effective clinical management. Currently, the diagnosis is focused on cerebrospinal fluid (CSF) culture, but this is quite limited. By comparison, metagenomic next-generation sequencing (mNGS) can overcome the deficiencies of conventional diagnostic approaches. To our knowledge, mNGS analysis of the CSF in the diagnosis of E. faecalis meningitis has been not reported.E. faecalis meningitis in a 70-year-old female patient without a preceding history of head injury or surgery, but with an occult sphenoid sinus bone defect. Enterococcus faecalis meningitis was diagnosed using mNGS of CSF, and she recovered satisfactorily following treatment with appropriate antibiotics and surgical repair of the skull bone defect.We report the case of E. faecalis meningitis can occur in the presence of occult defects in the cranium, and mNGS technology could be helpful in diagnosis in the absence of a positive CSF culture.Non-post-traumatic or post-surgical  Enterococcus faecalis is a common species of enterococcus, belonging to Gram-positive cocci [E. faecalis meningitis are rarely reported, with an incidence of 0.3–4% of bacterial meningitis [ve cocci . Cases oningitis . HoweverE. faecalis meningitis cases unrelated to trauma or surgery are rare.In addition, congenital defects can contribute to the development of meningitis . CerebroE. faecalis meningitis diagnosed using mNGS analysis.And, while, conventional diagnostic methods such as culture still have a place in the evaluation of clinical specimens, mNGS, as an emerging detection technology, can improve diagnostic accuracy in the presence of negative traditional culture methods. It has a higher positive rate than traditional culture methods, and it can identify novel or rare pathogens within 1–2 days . Here, w9/L , with 85.6% neutrophils, and an elevated C-reactive protein of 32.87 mg/L . Together with clinical presentation and physical examination, a clinical diagnosis of meningitis was made and a lumbar puncture done, and CSF samples sent for ‘routine analysis’ and mNGS. The sample for the latter was sent to IngeniGen XunMinKang Biotechnology Inc. A blood culture was also done.The patient, a 70-year-old woman was referred to our hospital in June 2020 because of sudden headache, fever and unconsciousness for 7 h. She had no history of treatment or nose picking before admission. She was a farmer who raised poultry and had a history of renal calculi but was without clinical attacks. Physical examination showed signs of meningeal irritation. On the day of admission, cranial CT showed no abnormality. Routine blood testing showed increased white blood cell count of 14.28 × 10Analysis of the CSF Table  confirmeOn the second day following admission, magnetic resonance imaging of the head revealed extensive enhancement of the meninges and sphenoid sinus effusion Fig. A–C. The E. faecalis (Fig. On the third day following admission, repeated CSF examination Table  showed plis Fig. . No otheFive days after the onset of the disease, when she was now fully conscious, she gave a history of persistent rhinorrhea of four months before admission, and a 3-dimensional cranial CT imaging Fig. D confirmOn the 8 day after admission, the patient was transferred to the Neurosurgery Ward and underwent repair of sphenoidal bone defect.Another lumbar puncture on the 13th day following admission revealed that the CSF indicators were significantly improved (Table We followed up the patient for 6 months, but she refused to come back for further review as her physical condition was good without meningitis symptoms and CSF rhinorrhoea.Enterococcus faecalis was not previously considered pathogenic, but it has rapidly become the most prevalent nosocomial pathogen in recent years [E. faecalis infections are endogenous, but CNS infections are relatively rare being only generally observed in adults secondary to neurosurgery, and in children with congenital malformations of the central nervous system [nt years . Most E.s system .E. faecalis meningitis are similar to those of other bacterial meningitis [E. faecalis in CSF. This case started with manifestations of CNS infection, but a detailed inquiry revealed that the patient had a history of CSF rhinorrhoea. The cause of CSF rhinorrhoea was confirmed as sphenoid sinus bone defect through surgical exploration. The route of infection with E. faecalis in the patient may be endogenous through the CSF rhinorrhea. However, such a CSF leak may not always be overt or clinical, and radiological examinations may even fail to demonstrate a leak [The symptoms of ningitis . The pate a leak . We alsoE. fecalis, but could be applicable generally to the isolation by culture of any bacterial pathogen [E. faecalis in CSF by next-generation sequencing has not been published previously, but it has comparative advantages. In addition, mNGS is appropriate for various specimen types, including peripheral blood, CSF, tissue, sputum, and bronchoalveolar lavage [In the diagnosis of meningitis, the traditional microbiological tests may yield negative results because of prior antibiotic treatment or the low number of bacteria in the CSF. However, these factors are not specific to the isolation of pathogen . To imprpathogen . The detr lavage . Many rer lavage –16 show E. faecalis meningitis can occur in the absence of trauma or surgery in patients with preexisting anatomic cranial bone defects.In conclusion, this case highlights the place of next-generation sequencing in identification of the etiologic agent of meningitis.


We compared the prognostic performances of serum neuron-specific enolase (sNSE), cerebrospinal fluid (CSF) NSE (cNSE), and CSF S100 calcium-binding protein B (cS100B) in out-of-hospital cardiac arrest (OHCA) survivors. This prospective observational study enrolled 45 patients. All samples were obtained immediately and at 24 h intervals until 72 h after the return of spontaneous circulation. The inter- and intragroup differences in biomarker levels, categorized by 3 month neurological outcome, were analyzed. The prognostic performances were evaluated with receiver operating characteristic curves. Twenty-two patients (48.9%) showed poor outcome. At all-time points, sNSE, cNSE, and cS100B were significantly higher in the poor outcome group than in the good outcome group. cNSE and cS100B significantly increased over time  in the poor outcome group than in the good outcome group. sNSE at 24, 48, and 72 h showed significantly lower sensitivity than cNSE or cS100B. The sensitivities associated with 0 false-positive rate (FPR) for cNSE and cS100B were 66.6% vs. 45.5% at baseline, 80.0% vs. 80.0% at 24 h, 84.2% vs. 94.7% at 48 h, and 88.2%  vs. 94.1% at 72 h. High cNSE and cS100B are strong predictors of poor neurological outcome in OHCA survivors. Multicenter prospective studies may determine the generalizability of these results. Despite numerous medical studies and clinical efforts to improve the prognosis of cardiac arrest (CA) survivors with successful return of spontaneous circulation (ROSC), achieving competent mortality and neurological outcomes in this patient population remains challenging . In a prFor these reasons, many studies have attempted to develop accurate and efficient neurological prognostication in CA survivors. In particular, various biomarkers have been investigated because of their advantages over other tools, such as the ability to obtain quantitative results and the likely independence from the effects of sedatives . A numbeS100B, which shows biochemically different characteristics from NSE, such as a lower molecular weight (10.7–21 vs. 78 kDa) and shorter half-life (2.0 vs. 24 h), has also been reported to be a useful additional biomarker for neurological prognostication in OHCA survivors ,12. HoweThe present study was performed prospectively on adult comatose OHCA survivors treated with TTM at Chungnam National University Hospital (CNUH) in Daejeon between February 2019 and August 2020. This study was approved by the CNUH Institutional Review Board (CNUH-2017-10-027), and informed consent was obtained from the patients’ designated decision-makers prior to enrolment. Patients were subsequently excluded if the patient’s next of kin declined provision of further treatment after CA or if the patients (1) were younger than 18 years, (2) had experienced CA due to trauma, (3) failed to maintain a temperature of 33 °C for TTM due to unstable hemodynamics, (4) were ineligible for lumbar catheter placement , (6) had a medical history of cerebral disease .® and Energy Transfer Pads™ . A target temperature of 33 °C was maintained for 24 h and monitored with a bladder probe. Upon completion of the TTM-maintenance phase, the patients were rewarmed at a rate of 0.25 °C per hour to 37 °C. Midazolam  and cisatracurium  were administered for sedation and to control shivering. All patients received standard intensive care according to our institutional intensive care unit protocol.Patients were managed according to our previously published TTM protocol . In thisi,24,48,72, cNSEi,24,48,72, and cS100Bi,24,48,72) after ROSC via venipuncture and lumbar catheter drainage, respectively. The procedure for lumbar catheterization was performed with the patient lying in the lateral decubitus position, with the neck, hips, and knees flexed. The lumbar catheter was inserted using a Hermetic TM lumbar accessory kit  under aseptically guided sonography by an expert physician. All samples were analyzed at one laboratory, namely Green Cross Laboratory . NSE and S100B concentrations were determined using an electrochemiluminescence immunoassay (ECLIA) with Elecsys NSE®  and Elecsys S100® , respectively. The measurement ranges of NSE and S100B were 0.1–300 ng/mL and 0.005–30 μg/L, respectively. GC Labs was compliant with the relevant national and international guidelines.All serum and CSF samples were repeatedly obtained, immediately and at 24 h intervals until 72 h  scale, either through face-to-face interviews or structured telephone interviews . The intThe following baseline demographics and characteristics of the enrolled patients were recorded: age, sex, presence of a witness on collapse, bystander cardiopulmonary resuscitation (CPR), first monitored cardiac rhythm, etiology of CA, no- and low-flow time from CA, Glasgow coma score (GCS) immediately after ROSC, and time from ROSC to lumbar puncture.The categorical variables are presented as frequencies and percentages. They were compared using Fisher’s exact tests. Continuous variables were presented as means with standard deviations or medians with the interquartile range (IQR) depending on the normality of the data. Differences in the concentrations of biomarkers obtained from the serum or CSF between good and poor neurological outcomes were assessed using Student’s t-test or Mann–Whitney U-test. Repeated-measures ANOVA or Friedman test with Wilcoxon signed rank-sum test after Bonferroni correction was used to evaluate the changes in serum and CSF NSE and S100B values over time in each neurological outcome group.y-axis and (1-sensitivity) on the x-axis, and it measures the overall accuracy of a test. The most important summary index of the ROC curve is the area under the ROC curve (AUROC). As high specificity is the most critical metric for use in CA, in which false-positive predictions may lead to the death of the patient, we set the cutoff values to at least 95% specificity based on the Touden index. The DeLong method was used to perform a pairwise comparison of the AUROC curves of NSE and S100B  concentrations at each time point [To assess the predictive accuracy for a 3 month poor neurological outcome, receiver operating characteristic (ROC) curves were constructed for the prognostic values of NSE and S100B. The ROC curve plots the sensitivity of a measure on the me point .p < 0.05.Statistical analyses were performed using IBM SPSS Statistics version 25.0  and MedCalc version 15.2.2 . The results were considered significant at A total of 60 comatose OHCA patients were treated with TTM during the study period. Among them, 15 patients were excluded for the following reasons: 10 were ineligible for lumbar catheter placement, the kin of one patient did not provide consent for the study, and 4 had a known medical history of cerebral disease. Thus, 45 patients were included in this study, of which 22 (48.9%) showed poor neurological outcome, corresponding to a primary outcome defined by a CPC score of 3 to 5 . The basROSC, return of spontaneous circulation; GCS, Glasgow coma score; TTM, targeted temperature management; ECMO, extracorporeal membrane oxygenation; PCI, percutaneous coronary intervention.All the serum and CSF NSE values and CSF S100B values obtained in the poor neurological outcome group were significantly higher than the values obtained at the same time points in the good neurological outcome group i, serum NSE24 and NSE48 were significantly higher in the poor neurological outcome group  for poor neurological outcome, were analogously observed at 48 h after ROSC in this study. The predominance of AUROC values between NSE and S100B fluctuated over time from ROSC until 72 h. Although the differences in AUROC values between NSE and S100B measurements at all four time points did not achieve statistical significance, S100B showed relatively higher AUROC values and sensitivities than NSE for poor neurological outcome immediately and at 48 and 72 h, and at 48 and 72 h from ROSC, respectively. These findings may indicate that CSF NSE and S100B concentrations are independently increased by their own specific pathophysiologic mechanisms according to the treatment course during TTM in OHCA survivors.n = 20) [Since the CSF sample has the advantage that the biomarker need not be transported across the blood–brain barrier (BBB) for detection, thus greatly reducing contamination, the CSF sample for biomarkers derived from damaged cells in the central nervous system was suggested . In the n = 20) . Recentln = 20) . ThroughIn this study, the CSF S100B concentration measured immediately after ROSC showed a relatively higher AUROC value than the CSF NSE concentration at the same time point . This result is consistent with the findings of previous studies . BottigeDirect sampling of NSE and S100B from the CSF can eliminate interferences related to half-life and molecular weight, both of which influence the detection and clearance time in serum and the ability to penetrate the BBB, and was performed in this study. However, interestingly, the results of this study were similar to those of previous studies in which the initial serum S100B concentration showed a relatively higher prognostic performance than the serum NSE concentration. These findings suggest that, while molecular characteristics such as molecular weight and half-life, are important, they could not fully explain the variations in the values of NSE and S100B obtained from the serum or CSF. Therefore, we suggest some possible explanations below.S100B is dominantly expressed in astrocytes and glial cells of the grey matter ,20, whicIn the good neurological outcome group, the repeated paired statistical comparisons of CSF NSE and S100B concentrations between immediately and 24 h after ROSC showed ascending and parallel patterns. Considering the discrepancy in half-lives between NSE and S100B, the trends in these biomarkers between immediately and 24 h after ROSC may be interpreted as continuous excretion into the CSF space resulting from ongoing cerebral damage in OHCA survivors with good neurological outcomes. However, in two other previous studies using serum analysis, NSE and S100B concentrations showed parallel and descending patterns between baseline and at 24 h from ROSC in the good neurological outcome group ,27, in cThese findings have several limitations with regard to generalization. First, this study involved an insufficient number of patients. A total of 15 patients who underwent TTM were excluded due to their ineligibility for lumbar catheter placement and a known medical history of cerebral disease. This could have caused selection bias and limited the generalizability of these results. However, in six patients, the values of biomarkers derived from the brain were modified by a known medical history of cerebral disease and severe brain edema . FurtherHigh CSF NSE and S100B concentrations are strong predictive markers of poor neurological outcome in OHCA survivors, even immediately after ROSC. In particular, CSF S100B concentration showed higher sensitivities with 0% FPR at 48 and 72 h after ROSC than with CSF NSE. Further multicenter studies with large sample sizes are required to generalize our results.


ObjectiveIn this study, we aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF rhinorrhea and otorrhea in particular and to identify the main topic clusters in these areas.MethodsWe identified all relevant documents, using the medical subject heading (MeSH) term “Cerebrospinal Fluid Leak”, that are indexed in the MEDLINE database between 1945 and 2018. We performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research.ResultsFrom 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type , while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were “Postoperative Complications,” “Tomography, X-Ray Computed,” and “Magnetic Resonance Imaging.” The terms “Adults,” “Young Adult,” and “Middle-Aged” were most common in CSF rhinorrhea research; and the terms “Infant,” “Child, Preschool,” “Child,” and “Adolescent” were more common in CSF otorrhea.ConclusionsBased on our findings, articles and case reports related to “Surgery” and “Postoperative Complications” associated with the diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field. Cerebrospinal fluid (CSF) leak is the discharge of CSF through a hole in the skull bone, most commonly involving drainage from the nose (CSF rhinorrhea) or from the ear (CSF otorrhea), occurring either through the external auditory meatus or through the eustachian tube into the nasopharynx . Common The past decades have witnessed a significant increase in research publications in the field of otorhinolaryngology . BibliomOne of the areas that have seen significant development within bibliometrics is the generation of visual representations, networks, and maps of scientific activity. These have great analytic potential, helping to characterize the structures, groupings, and interconnections between the elements under analysis, including the descriptors assigned to the documents, such as in the present study. Although bibliometric indicators have been used to approach the study of numerous diseases ,16, thisThe aim of this study is to describe the research production on CSF leak through bibliometric indicators, using the documents indexed in the MEDLINE database between 1945 and 2018. We analyze the evolution in the number of publications, the publication types, the document categories of clinical interest, the journals of publication, the geographical distribution of the research, and the topics addressed according to the different types of CSF leak (CSF rhinorrhea and CSF otorrhea) by means of co-word maps.Identification of documents on “Cerebrospinal Fluid Leak”The first step in this study was to identify the documents about the CSF leak in the MEDLINE database, the main database of reference for researchers and professionals in the health sciences. It is an open-access resource that permits, through the use of the medical subject headings (MeSH) thesaurus, the precise identification of documents that address the concepts under analysis as well as the contents of those documents. The CSF leak descriptor was included in 2005 in the database. This term encompasses the specific terms “Cerebrospinal Fluid Rhinorrhea” and “Cerebrospinal Fluid Otorrhea,” both included in 1966. The search of indexed documents with any of these three descriptors was carried out on the Clarivate Analytics Web of Science (WOS) platform, which includes the MEDLINE database, on January 21, 2019.The Clarivate Analytics WOS platform provides information on the institutional affiliation of all authors. Using this strategy, 4,155 documents were retrieved, but we excluded 25 editorials, leaving 4,130 documents to be analyzed. The analysis of the scientific production by country was limited to the 3,019 documents (73.1%) included in the WOS database.Standardization of bibliographic informationUsing the bibliographic information from the retrieved documents, we created a relational database to standardize the bibliographic data and calculate the study variables as follows:Publication Type [Field: Publication Type (PT)]Based on the information collected from this field, we classified the records according to the document types  as well as the clinical approach .Institutional Affiliation of Papers Included in WOS [Field: Author Address (C1)]This field includes information relating to the institutional affiliation of the authors signing the documents. Although all institutional affiliations have been available for papers published in MEDLINE since 2014, we aimed to study and present the information using a standardized approach, and hence we limited the analysis to the papers included in the WOS.Descriptors [Fields: MeSH Terms (MH) and MeSH Subheadings  (SH)]We differentiated the MeSH terms from the subheadings or topic qualifiers (82 auxiliary descriptors that specify the aspect being addressed in relation to the MeSH terms) and identified the descriptors assigned with respect to CSF leak, CSF rhinorrhea, and CSF otorrhea.Calculation of indicatorsTo analyze the scientific activity of the area, we determined the number of documents published each year, the journal of publication, the document types, the clinical approach to the study, and the countries of the authors signing the documents. This information generates a picture of the scientific activity, the media used , and the weight of countries leading the research in general and according to the different types of CSF (rhinorrhea or otorrhea).To characterize the research in the area at a topic level, we determined the frequency with which the descriptors assigned to the documents appeared for each group: the generic CSF leak group and the specific document groups on CSF rhinorrhea and CSF otorrhea. We constructed topic maps to analyze the relationship between the descriptors and the research groups around them, that is, the existing research clusters, approaches, and specializations. This process involved the following steps:Determination of the Co-occurrence of the Descriptors Assigned to the Documents and Generation of a Matrix of Absolute ValuesThe joint assignment of two descriptors in a single document implies a thematic affinity, as both aspects are addressed simultaneously in the same paperElimination of Generic DescriptorsWe eliminated some excessively generic descriptors that did not describe relevant information on the content or that presented a high density of relationships with the rest of the descriptors.Visual Representation of the NetworkTo establish the existing topic clusters in the area and represent them visually, we used a clustering algorithm in the VOSViewer program, which helps to detect the communities (clusters) within a network, made up of groups of homogeneous items that are strongly related to each other .Statistical analysisWe compared the MeSH terms in CSF rhinorrhea- and CSF otorrhea-related documents using the Chi-squared test. P-values of less than 0.05 were considered statistically significant. We used SPSS Statistics version 22.0  for statistical analysis.Ethical considerationsDue to the nature of the study and dataset, it was not necessary to obtain informed consent or approval from an institutional ethics committee.Evolution of productionFrom 1945 to 2018, 4,130 articles were published involving CSF leak terms. The term CSF rhinorrhea was found in 2,821 documents (68.1%) and CSF otorrhea in 1,040 (25.8%). Both terms were present in 316 documents, while 269 documents used only the generic CSF leak descriptor. Figure Publication type distributionThe main publication type was journal article, which comprised 86.8%  of the documents; followed at a considerable distance by reviews, which made up 9.4% (n=390); and letters at 3.8% (n=156). With regard to the type of clinical research, 37.4%  of the documents were case reports; 1.7% (n=74) were clinical trials; 0.6% (n=48) were evaluation studies; and 0.5% (n=19) were meta-analyses. The rest of the study types were negligible in number .Journal distribution and thematic categoriesThe documents were published in 735 different journals. The main journals were World Neurosurgery/Surgical Neurology n=178), Laryngoscope (n=176), Journal of Neurosurgery (n=134), Otology & Neurotology/American Journal of Otology (n=124), and Otolaryngology-Head and Neck Surgery (n=101). These five journals published 16.8% of the documents. Moreover, there were 371 journals with just one document, which cumulatively represented 9.0% of the total documents. Table 78, LarynGeographical distributionOf the 3,019 articles included in WOS, 2,578 had information on the country of the institution producing the manuscript. Table MeSH distributionThe three principal MeSH terms in the field were “Postoperative Complications,” “Tomography, X-Ray Computed,” and “Magnetic Resonance Imaging.” MeSH terms that were significantly more common in documents relating to CSF rhinorrhea compared to CSF otorrhea were “Magnetic Resonance Imaging,” “Treatment Outcome,” “Endoscopy,” “Dura Mater,” “Neurosurgical, Procedures,” “Pituitary Neoplasms,” and “ Sphenoid Sinus.” The terms “Meningitis,” “Recurrence,” “Ear, Inner,” “Neuroma, Acoustic,” “Mastoid,” and “Otitis Media” appeared more frequently in relation to CSF otorrhea Table .QualifiersThe most common qualifiers were “Surgery” and “Etiology.” The qualifiers “Surgery” and “Methods” were significantly more common in CSF rhinorrhea, whereas the qualifier “Abnormalities” was significantly more common in CSF otorrhea Table .Generic MeSH termsTable Visual representation of the network of MeSH termsFigure The number of articles published on CSF leak steadily increased throughout the study period, which is normal, as most bibliometric analyses on other diseases also reveal an upward trend in the number of publications -20. The At a journal level, this study shows the important multidisciplinary approach in the area, as the three most prominent publications were journals of otorhinolaryngology, surgery, and clinical neurology. The multidisciplinary approach in science is a tradition that has been associated with greater advances in knowledge, translation of results, and impact of research ,22.USA was the predominant country in research production, followed by various European countries  and Japan. This fact also applies specifically to the otolaryngology field ,7, neuroWith regard to the MeSH terms, CSF rhinorrhea was the main branch, while surgery and postoperative complications were the most important sub-topics. Relevant topics related to managing patients with CSF were otorhinolaryngology and clinical neurology . ResearcThere is a difference in the patient profile of research between CSF rhinorrhea and CSF otorrhea, with the former area concentrating on older patients (“Adult” or “Middle-Aged”). Spontaneous CSF rhinorrhea is associated with increased intracranial pressure and is considered a manifestation of idiopathic intracranial hypertension in middle-aged people, whereas secondary CSF rhinorrhea is associated with trauma in the same age group ,24. On tThe main limitation of this study was that we did not analyze the citations, with a focus on the journals with the highest impact and dissemination at an international level; this perspective would be necessary to reach a truly comprehensive view of research in the field. Likewise, other aspects could also be considered, such as co-authorship networks or gender disparities in scholarly productivity .The present study on CSF leak-related scientific production has revealed some features that differ notably from bibliometric analyses on other clinical pathologies: the predominant interest in surgery and the weightage of clinical case reports, which emerge as the primary channel for generating and disseminating knowledge in the field. Postoperative complications, diagnostic aspects related to CT and MRI, treatment outcomes, and surgical procedures such as endoscopy were also topics of interest. The USA leads the research production in CSF leak, while European countries and emerging countries such as China have contributed less when compared to other research areas.


Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy, with mass-forming growth pattern being the most common. The typical imaging appearance of mass-forming ICC (mICC) consists of irregular ring enhancement in the arterial phase followed by the progressive central enhancement on portal venous and delayed phases. However, atypical imaging presentation in the form of hypervascular mICC might also be seen, which can be attributed to distinct pathological characteristics. Ancillary imaging features such as lobular shape, capsular retraction, segmental biliary dilatation, and vascular encasement favor the diagnosis of mICC. Nevertheless, these radiological findings may also be present in certain benign conditions such as focal confluent fibrosis, sclerosing hemangioma, organizing hepatic abscess, or the pseudosolid form of hydatid disease. In addition, a few malignant lesions including primary liver lymphoma, hemangioendothelioma, solitary hypovascular liver metastases, and atypical forms of hepatocellular carcinoma (HCC), such as scirrhous HCC, infiltrative HCC, and poorly differentiated HCC, may also pose a diagnostic dilemma by simulating mICC in imaging studies. Diffusion-weighted imaging and the use of hepatobiliary contrast agents might be helpful for differential diagnosis in certain cases. The aim of this manuscript is to provide a comprehensive overview of mICC imaging features and to describe useful tips for differential diagnosis with its potential mimickers. Intrahepatic cholangiocarcinoma (ICC) is the second most common primary malignant liver tumor after hepatocellular carcinoma (HCC) . These tAccording to the growth pattern, ICC can be classified into mass-forming, periductal-infiltrating, or intraductal growth types . Among tTaking into account the variability of mICC presentation, the precise preoperative diagnosis may sometimes represent a real diagnostic challenge even for experienced radiologists. Additionally, atypical appearance of different benign and some malignant lesions may resemble mICC on imaging. Therefore, the aim of this study is to provide a comprehensive overview of typical and atypical imaging features of mICC, as well as to describe the wide spectrum of benign and malignant lesions that can simulate its appearance on magnetic resonance imaging (MRI). Moreover, useful tips for the differentiation of mICC from its potential mimickers are highlighted.The imaging appearance of mICC depends on its pathohistological composition and is determined by the amount of fibrous stroma, viable tumor cells, intralesional mucin, and necrosis .Mass-forming ICC typically presents as a large, lobulated, irregularly shaped lesion with well-defined borders . On MRI,However, in highly fibrotic lesions or in lesions with internal necrosis, central parts may remain non-opacified even on delayed images  14]..14].b-value diffusion weighted imaging (DWI), could be considered to be a pathognomonic finding in mICC . Ot. Ot55]. Another potential diagnostic pitfall is related to the presence of extensive intralesional necrosis in mICC, which may simulate hepatic abscesses . AlthougHydatid liver disease results from incidental infection with Echinococcus granulosus, which causes cystic echinococcosis, or Echinococcus multilocularis, which causes alveolar echinococcosis (AE) . If charWhile the diagnosis of a typical hepatic hydatid cyst is in most cases straightforward, the alveolar form of hydatid disease frequently represents a diagnostic challenge ,64. AccoSolitary hypovascular liver metastases (SHLM) are the most common mimickers of mICC . AlthougThe most common postcontrast enhancement seen in SHLM is ring enhancement in the arterial phase with minimal central enhancement in the delayed phases . This vaScirrhous HCC is a rare variant of HCC characterized by rich intralesional fibrotic stroma with incidence of 4.6% among all HCC cases . ScirrhoThe absence of a typical HCC vascular enhancement pattern may be observed in poorly differentiated, large, and sarcomatous HCC . Namely,Infiltrative HCC is a rare type of HCC presenting as an ill-defined tumor that occupies multiple liver segments, an entire lobe, or the entire liver . It is aTaking into account the absence of typical vascular behavior and permeative ill-defined hypovascular appearance in images, infiltrative HCC may sometimes pose a diagnostic dilemma with mICC ,91. In tCombined hepatocellular-cholangiocarcinoma (cHCC-CC) is a rare primary liver tumor exhibiting unequivocal characteristics of both HCC and mICC . AlthougThe majority of studies indicate that cHCC-CC has intermediate clinical and radiological features between HCC and mICC with poorer prognosis compared to HCC and similar to ICC . ImagingHepatic epitheloid hemangioendotelioma (HEH) is an uncommon type of low-grade malignant hepatic neoplasm that originates from endothelial cells, occurring more commonly in females ,101. CliHEH may be of three different pathological types: single nodular, multifocal nodular, and diffuse type. The most common presentation is in the form of multiple, subcapsular nodes located in lesions that coalesce during the course of the disease . AlthougPrimary hepatic lymphoma (PHL) is defined as a lymphatic malignancy limited to the liver without the involvement of other lymphatic tissues and organs for at least 6 months after appearance . It is cAmong the three morphological types, including single lesion, multiple lesions, and diffuse involvement of the liver, the single lesion is most commonly seen (55–60%), while the diffuse type is extremely rare . Due to In conclusion, we have described the key imaging features of mICC with an emphasis on the association between imaging presentation and clinicopathological features. In addition, we have provided a comprehensive overview of the benign and malignant lesions that may mimic mICC. Thorough interpretation of MRI examination data, including lesion appearance in T2-weighted images, DWI, and hepatobiliary phase in addition to the relative enhancement pattern, is mandatory for accurate lesion characterization. Moreover, ancillary features such as the shape of the lesion, the presence of biliary dilatation, and the relationship to liver capsules and vascular structures are very helpful in establishing a correct diagnosis. Considering the different treatment strategies for mICC and lesions simulating its appearance in images, it is of great clinical importance to differentiate mICC from its mimickers in order to avoid unnecessary surgery or delayed treatment of mICC with dismal prognosis.


Microtus duodecimcostatus, in the area around the city of Granada in Southern Spain, and found that individuals living in wastelands reproduce seasonally whereas those living in close poplar plantations (just 8 km apart) reproduce throughout the year, as did voles captured in wastelands and kept in captivity. These animals represent thus a paradigm of an opportunistic breeder as particular individuals stop breeding or not, depending on the environmental conditions they face at any moment. Sexually inactive male voles undergo complete testis inactivation and their sperm production is halted. The immune system in active testes is depressed, a phenomenon known as “immune privilege” that protect germ cells from autoimmune attack. We studied gene activity in active and inactive testes and our results indicate that such an immune privilege is lost in inactive testes, suggesting an important role for this process during testis regression.In temperate zones of the Earth, some mammalian species reproduce seasonally whereas others do it continuously. Other species are summer breeders in the north and winter breeders in the south. Thus, the reproductive pattern seems not to be a species-specific but a population-specific trait. We investigated the reproduction pattern of the Mediterranean pine vole, Microtus duodecimcostatus, in the Southeastern Iberian Peninsula. Morphological, hormonal, functional, molecular and transcriptomic analyses were performed. As reported for populations of other species from the same geographic area, male voles captured in wastelands underwent seasonal testis regression in summer whereas, surprisingly, those living either in close poplar plantations or in our animal house reproduced throughout the year, showing that it is the microenvironment of a particular vole subpopulation what determines its reproductive status and that these animals are pure opportunistic, photoperiod-independent breeders. In addition, we show that several molecular pathways, including MAPK, are deregulated and that the testicular “immune privilege” is lost in the inactive testes, providing novel mechanisms linking seasonal testosterone reduction and testis regression.Most mammalian species of the temperate zones of the Earth reproduce seasonally, existing a non-breeding period in which the gonads of both sexes undergo functional regression. It is widely accepted that photoperiod is the principal environmental cue controlling these seasonal changes, although several exceptions have been described in other mammalian species in which breeding depends on cues such as food or water availability. We studied the circannual reproductive cycle in males of the Mediterranean pine vole,  The existence of climatic seasons force species of the temperate zones of the Earth to follow a circannual biological cycle in which reproduction and other functions concentrate in those periods with more favorable conditions. Since individuals do not need their gametes during the non-breeding season, both males and females undergo significant changes in their reproductive systems in this period . In manyTalpa occidentalis [Chaetophractus villosus [Hemiechinus auritus [The mechanisms of testis regression have been studied in many species of vertebrates, including reptiles, amphibians, birds and mammals. Apoptosis is the main testis-regression effector in birds, reptiles and amphibians ,5,6,7,8.dentalis ,10, in wvillosus ,12, and  auritus .Peromyscus californicus, in which reproduction depends on water availability [Ovis aries, where male fertility depends on food availability and social factors [Suncus murinus, a species in which females completely lose sexual receptivity when nutrition is insufficient [Crocidura russula, in the Iberian peninsula, where northern populations stop breeding in winter whereas southern ones do it in summer [It has long been known that reproduction is controlled by the hypothalamic–pituitary–gonadal (HPG) axis, where kisspeptin neuropeptides, gonadotrophin-releasing hormone (GnRH), pituitary gonadotrophins (luteinizing hormone (LH) and follicle-stimulating hormone (FSH)) and gonadal steroid hormones are the most important activating elements . There alability , the Mer factors  and the fficient . The sean summer ,21. Thisn summer .Microtus duodecimcostatus, is distributed across most of the Iberian Peninsula, except in the north-western region, and in Southern France [The Mediterranean pine vole, n France . It is cn France . In the M. duodecimcostatus living at different habitats throughout the circannual cycle of reproduction in Southeastern Iberian Peninsula. Histological and immunohistological studies, including morphometry, blood–testis barrier (BTB) permeability tests, serum testosterone level determinations, apoptotic cell detection techniques and transcriptomic analyses were performed. Our results show that the analyzed voles are pure opportunistic breeders and suggest that in regressed testes several molecular pathways involved the control of spermatogenesis and BTB dynamics are deregulated and the intensity of the immune response is altered.The reproduction timing of this species in this geographic area has not been studied to date and this is the aim of this work. We report here the results of a comprehensive study of the testes in different populations of n = 19; spring, n = 9; summer, n = 6; autumn, n = 12; Pitymys duodecimcostatus (the former name of the Mediterranean pine vole) we maintained during the entire year of 1990 for a different study. We analyzed testes from 13 males euthanised in July to show that these animals do not stop breeding during the summer in our animal house conditions ), temperature around 20–25 degrees and natural day light.Forty six Mediterranean pine vole adult males were initially captured alive in isolated small wastelands populations near the localities of Las Gabias and La Malaha  throughout two consecutive years. Four study groups were established according to the season of capture , and stained with hematoxylin and eosin according to standard methodology. For immunohistochemistry, testis sections were deparaffinized and mounted on slides that were processed using the ABC Kit , according to the manufacturer’s instructions. For single and double immunofluorescence, testis sections were incubated with primary antibodies overnight, washed, incubated with suitable conjugated secondary antibodies at room temperature for 1 h and counter-stained with 4′,6-diamino-2-phenylindol (DAPI). We used a Nikon Eclipse Ti microscope equipped with a Nikon DS-Fi1c digital camera  to take photomicrographs. In negative controls, the primary antibody was omitted. Animals were transported to our laboratory and euthanised by COApoptotic cells were detected in testis histological sections by using the TUNEL  technique with the fluorescent in situ cell death detection kit , according to the manufacturer’s guidelines. The enzyme solution was omitted to prepare negative controls.Blood samples were obtained from male voles by heart puncture, stored at 4 °C overnight and centrifuged at 6000 rpm for 20 min at 4 °C. The supernatant was isolated and stored at −80 °C until used. Testosterone concentrations were determined by radioimmunoassay (RIA) with the DRG testosterone RIA (CT) kit , according to standard procedures. The analytical sensitivity of the kit was 0.05 ng/mL, the intra-assay coefficient of variation was 3.3% and the interassay coefficient of variation was 4.8%. Duplicate measurements were made for all animals. The specificity (percentage of cross-reaction estimated by comparing the concentration yielding a 50% inhibition) was 0.28% for androstenedione and 0.31% for dihydrotestosterone.M. duodecimcostatus (two of each) were anaesthetized with 0.125% avertin , their testes were exposed and a total of 50 μL of 10 mg/mL of EZ-Link Sulfo-NHS-LC-Biotin  diluted in PBS containing 1 mM of CaCl2 were injected beneath the tunica albuginea of the left testis by several punctures. As a control, the right testis was injected in a similar way with PBS containing 1 mM of CaCl2. The testes were placed again inside the body, and the voles were euthanised after 30 min. The testes were immediately collected, fixed overnight in 4% paraformaldehyde and paraffin-embedded following standard methods. Sections (7 μm thick) were deparaffinized, rehydrated and incubated for 30 min with an Alexa Fluor 568-conjugated streptavidin solution (included in the tracer kit) at 25 °C and counterstained with DAPI.To check the permeability of the BTB, both sexually active and inactive males of http://www.bioinformatics.bbsrc.ac.uk/projects/fastqc/). A detailed protocol of the bioinformatic tools used to analyze transcriptomic data is provided in Total RNA was isolated from both testes of three males captured in the wastelands during the summer (reproductively inactive) and three males captured during the winter (reproductively active) using the Qiagen RNeasy Midi kit following the manufacturer’s instructions. After successfully passing quality check, the RNAs samples were paired-end sequenced separately in an Illumina HiSeq 2000 platform at the Max Planck Institute for Molecular Genetics facilities in Berlin and the quality of the resulting sequencing reads was assessed using FastQC /body mass (mg) × 100) together with the matrix of p values corresponding to the statistical Student’s t-tests are summarized in p = 0.48; p values corresponding to the statistical Student’s t-tests of voles captured in the wastelands during summer and winter, and males from both the poplar groves and laboratory animal facilities during the summer. Body mass of males captured in the wastelands were around 20% smaller than those from either the poplar groves or the animal house facilities, as expected if we consider the harder environmental conditions of this habitat , and found that it was 10 times higher than that of males from the wastelands at the same season (inactive)  revealed a strong expression in Leydig cells, with no apparent difference in the signal intensity between active and regressed testes A,B. The ic cells D,E and d−5), male gamete differentiation  and sperm motility , among others. These categories were enriched in Act-up-DEG , angiogenesis , smooth muscle contraction , regulation of phagocytosis  and negative regulation of androgen receptor signaling pathway . All these categories were also found in the GO analysis of Inact-up-DEG but not in that of Act-up-DEG (−3) [−5; Zhang et al., 2014), phosphatidylinositol 3-kinase signaling  [−4) [−5) [−10) [−2), which shared many genes with the other signaling pathways  , ERK1 an × 10−2)  and regu−4) [−5)  and cell5) [−10) . Gene-copathways d. Altoge−3), positive regulation of inflammatory response  and regulation of lymphocyte proliferation , among others. We also found terms related to pathways involved in the genetic control of the immune system such as regulation of tumor necrosis factor production  and regulation of cytokine secretion . As before, all these terms were found in the GO analysis of Inact-up-DEG but not in that of Act-up-DEG , testis regression occurs (facultatively in the later species) during the non-reproductive period, which takes place in summer. Three of these species are rodents  and M. duodecimcostatus (family Cricetidae)) whereas the other two are Eulipotyphlans  and C. russula (family Soricidae)). Thus, phylogeny seems not to be associated with the existence or not of seasonal testis regression. Additionally, even populations of the same species may show latitudinal differences in their seasonal reproductive patterns (summer breeding in the north and winter breeding in the south), showing that seasonal breeding is not a species-specific but rather a population-specific feature [T. occidentalis and A. sylvaticus, meiosis initiation is not halted, so that early spermatocytes are present even in fully regressed testes. However, meiotic cells do not progress beyond the zygotene-pachytene stage because they are eliminated by apoptosis [M. duodecimcostatus, and regressed seminiferous tubules are composed only of Sertoli and spermatogonial cells. Accordingly, no apoptosis is needed in these testes as there are no spermatocytes to be depleted.We studied the seasonal changes occurring in the testes of five species of micromammals living in the area around the city of Granada, in the Southeastern Iberian Peninsula. In two of these sympatric species, the Algerian mouse,  spretus  and the  russula , males ddentalis ,10,53, tlvaticus , and the feature . The lac feature ,55, two  feature . Howeverpoptosis ,10,52. IM. duodecimcostatus, as it also happens in the inactive testes of the Iberian mole, T. occidentalis, where it is upregulated as well [All these species-specific differences make it very difficult to establish a general mechanism to explain testicular regression in mammalian species. In this context, the study of the differences at the gene expression level between active and inactive testes in different species will help to explain which mechanisms and gene pathways are conserved, and which ones are species-specific. Here we report the first comprehensive study of the transcriptomes of active and inactive testes in a mammalian species, and have identified several biological processes and signaling pathways that are altered during testis regression. As expected, we found that genes involved in promoting spermatogenesis are preferentially upregulated in the active testes . Many of as well . Since t as well , this trM. duodecimcostatus. All these pathways operate in Sertoli cells and are involved in the regulation of spermatogenesis and the dynamics of tight and adherens junctions present in the BTB [M. duodecimcostatus affects the regulation by Sertoli cells of several interconnected molecular pathways that lead to (1) alterations of the spermatogenic cycle, (2) deregulation of cell–cell adhesion molecules and (3) disruption of the BTB dynamics. Concluding, our results suggest that the MAPK/ERK signaling pathway plays a central role as a mediator between testosterone signaling and Sertoli cell function.We found that the MAPK/ERK1/2, WNT, TGF-β, Cytosolic Ca2+ and PI3K signaling pathways are deregulated in the inactive testis of  the BTB ,64,65,66 the BTB ,62,66, p the BTB , and in  the BTB ,68. In a the BTB . AltogetM. duodecimcostatus  testosterone induced a reduction of proinflammatory cytokines in macrophages (including TNF-α) [M. duodecimcostatus  that activate the macrophages and diminish the Tregs population. In a similar study performed in European beavers, the authors also reported altered inflammatory processes in the testes of non-breeding males [The testis is subjected to a special immunological environment known as “immune privilege” that protect germ cells from autoimmune attack. This “immune privilege” is based on (a) the formation of the BTB in the seminiferous epithelium, (b) the diminished capability of the testicular macrophage population to mount an inflammatory response and (c) the constitutive expression of anti-inflammatory cytokines by immune and other somatic cells ,71,72. Ucostatus . In addicostatus . Thus, ig TNF-α) , (3) gencostatus , (4) TNFng males . These fng males ,72. Our M. duodecimcostatus, represents a paradigmatic example of opportunistic breeding mammal as only males living in the wastelands undergo testis regression during the summer, whereas those living either in close poplar plantations of the same region or in our animal house keep breeding throughout the year. Unlike other mammals, in the regressed testes of these voles spermatogenesis was halted at the spermatogonial stage, existing no cells completing the initial stages of the meiotic prophase. During testis regression, the BTB becomes permeable, serum testosterone levels were reduced but testicular was is not increased. Finally, our transcriptome analysis indicate that both the suppression of the testis “immune privilege” and the deregulation of the MAPK/ERK signaling pathway probably play important roles in mammalian seasonal testis regression.The Mediterranean pine vole,


Since the first statement of the German Society of Oto-Rhino-Laryngology, hypoglossal nerve stimulation (HNS) is meanwhile an established treatment option for obstructive sleep apnea (OSA). There are three HNS systems available in Germany which differ in their technical details of the underlying comparable basic principle. For the unilateral HNS with respiratory sensing, several comparative studies, high-volume register analysis and long-term reports exist. The continuous HNS without respiratory sensing does not require a sleep endoscopy for indication. For the bilateral continuous HNS as the single partially implantable device, a feasibility study exists. For indication, the assessment of positive airway pressure failure by sleep medicine is crucial, and the decision for HNS should be made in discussion of other treatment options for at least moderate OSA. The implantation center holds primarily responsibility among the interdisciplinary sleep team and is primary contact for the patient in problems. This depicts why structural processes are required to secure outcome quality and minimize the complications. The aftercare of HNS patients can be provided interdisciplinary and by different medical institutions, whereat, minimal reporting standards to document outcome and usage are recommended. Since the first position paper of the sleep medicine work group of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery (DGHNO) , hypogloWarrant a high quality of interdisciplinary patient care regardless of residence in Germany and socio-economic status,Provide a structural, procedural, and outcome-based interdisciplinary care pathway in the provision of hypoglossal nerve stimulation,Implement evidence-based decision making,Minimize therapy risks and adverse effects,Avoid OSA-associated complications and co-morbidities as well as to improve quality of life among patients with non-adherence to positive airway pressure therapy (PAP).This positional paper aims tohere, the system provided by Nyxoah, Inc.—added information by the authors) reveals no novel theoretical–academic concept” . Currently, a randomized controlled study with therapy withdrawal of 89 patients regardless of treatment responsiveness is under review (“EFFECT”). This study assessed the recurrence of daytime sleepiness and OSA events under subtherapeutic voltage . There aFor the continuous HNS ImThera system, there are first studies for safety and effectiveness which reveal an improvement in OSA , 36. In So far, Nyxoah’s Genio system was assessed in two smaller case series during device development. There is a publication on 27 patients with a 6-month follow-up published in 2019, which demonstrated the benefit of this system In Germany, there are more than 35 implanting centers for HNS with specialized infrastructure and certification by the manufacturer. HNS is considered in patients using the following criteria:Structural requirements for the treatmentHypoglossal nerve stimulation therapy should be allocated in centers with sleep medicine expertise and specialized infrastructure. The treatment pathway and responsibilities should be defined when the center is established and need regular review.b.Follow-up of patients with hypoglossal nerve stimulationThe following structural requirements need to be fulfilled in implanting centers. This assures a smoother process, better outcome quality and helps to minimize complications Table .b.FollowIt is very important to provide long-term follow-up resources for patients with HNS. The patient care and follow-up can be carried out in the implanting center or by external physicians with sleep medicine qualification. The implanting centers need to provide timely availability for potential medical and technical complications. Special consultation hours help to provide appropriate service for HNS candidates and patients. If the follow-up is provided by external sleep physicians, the implanting center should be updated about the patients' treatment course for quality management (see chapter 6).For assurance of therapy quality, implanting centers should document therapy effects properly and do regular evaluations Table . IndustrIn recent years, OSA treatment with HNS is well-described as a second line therapy in PAP failure and positioned in national guidelines. All three available HNS systems differ in technical details of the common underlying therapy principle, indication and, most of all, evidence. The implanting centers obtains the main responsibility within the interdisciplinary treatment concept. Quality management is essential for the entire treatment pathway, especially for the long-term follow-up.


Increased tibial tubercle-trochlear groove distance (TT-TG) was proposed as one of the main risk factors for patellofemoral instability (PFI). The increased TT-TG distance indicated externalization of the tibial tubercle with the reference of the trochlear groove. However, in the case of severe trochlear dysplasia, the reference point on the trochlear groove was indistinct, and the accuracy of TT-TG was controversial. The purpose of this study was to evaluate the accuracy of TT-TG and TT-PCL in consideration of the mild and severe trochlear dysplasia.From 2015 to 2020, MRI findings of consecutive knee joints with PFI symptoms diagnosed in our hospital were retrospectively analyzed. All knees with trochlear dysplasia were diagnosed by longitudinal MRI scan and lateral radiograph. The knees were classified according to the four-type classification system described by Dejour et al. Twenty cases of type A (mild trochlear dysplasia); 20 cases of type B, C, and D (severe trochlear dysplasia); and 20 cases of normal type were selected and divided into normal group , mild group (type A), and severe group . Tibial tubercle-trochlear groove distance (TT-TG), tibial tubercle-posterior cruciate ligament distance (TT-PCL), and the Dejour classification of trochlear dysplasia were assessed by 2 experienced orthopedics. The reliability of TT-TG distance and TT-PCL distance was tested by intraclass correlation coefficients (ICCs).P > 0.05; mild, 17.30 ± 4.81 mm vs. 20.09 ± 5.05 mm, P < 0.05; severe, 10.79 ± 4.24 mm vs. 12.31 ± 5.43 mm, P > 0.05). The Pearson correlation coefficient of TT-TG and TT-PCL measurements of trochlear dysplasia were r = 0.480  and r = 0.585 . The intra-observer ICCs of TT-TG were r = 0.814 (mild group) and r = 0.739 (severe group). The inter-observer ICCs of TT-TG were r = 0.810 (mild group) and r = 0.713 (severe group). In the normal knee, the Pearson correlation coefficient of TT-TG and TT-PCL was r = 0.787(P < 0.001), the intra-observer ICC of TT-TG was r = 0.989, and the inter-observer ICC of TT-TG was r = 0.978.Comparing the differences between TT-TG and TT-PCL in the normal, mild, and severe groups, the TT-TG and TT-PCL in the mild and severe groups show different meanings . In the present study, the determination of TT-TG and TT-PCL distance are of great significance for patients with low-grade trochlear dysplasia. And TT-PCL, without referring to the abnormal trochlear groove, is an effective indicator to measure the lateralization of tibial tuberosity in patients with severe dysplastic trochlea. High tibial tubercle-trochlear groove distance (TT-TG) is considered to be one of the main risk factors for patellofemoral dislocation . In the The protocol of the study was approved by the Academic Ethics Committee of the Third Hospital of Hebei Medical University. Informed written consent was acquired from all individuals prior to participating in the study. Sixty consecutive MRI scans were retrospectively analyzed, including 40 patients with patellofemoral dislocation and 20 patients without patellofemoral dislocation. Prior to MRI, no patients in the patellofemoral dislocation group underwent distal reduction or osteotomy. The PFI manifestations of 40 patients with trochlear dysplasia of the knee were evaluated by longitudinal MRI scan and true lateral radiograph. Magnetic resonance imaging (MRI) with the patient in a supine position with 1.5 T units  was performed. During the MRI scan, the knee was fully extended. The scans were performed in a fat-saturated proton density-weighted fast spin-echo imaging sequence under standardized conditions. To assess trochlear dysplasia, an axial MRI scan was performed at the distal femoral transition where the full width of the trochlear cartilage was visible. Measurements were made using GE Central PACS-IW . The software allows measurement accuracy to one decimal place. The knees are distributed according to the four-type classification system described by Dejour , 19. FirIn the TT-PCL measurement, the common sources of tibial nodules were the same as those described above. For the posterior cruciate ligament (PCL) measurement, an axial MRI was performed at the farthest end of the tibia with a clear image of PCL origin, and then the posterior condyle line of the bone tibia was mapped on the axial MRI, just distal to the articular surface. The vertical line originates from this line through the innermost PCL Fig. . TT-PCL Using axial and sagittal MRI in patients with each block form of identification and classification of Dejour, the following was found: the normal femoral trochlear , superficial femoral trochlear  are used to calculate the Kappa statistics of the statistical analysis measures for continuous measures and the discrete measures (such as Dejour classification). The simple linear regression model was used to evaluate the correlation. Between TT-PCL and TT-TG, all patients were grouped by trochlear morphology. The mean values of TT-TG and TTPCL were used to evaluate the severity of trochlear dysplasia by linear trend analysis. The differences in TT-TG and TT-PCL indexes between the PF group and the normal group were compared by an independent sample t test. All analyses and P values were calculated using SPSS version 22.0 . P values below 0.05 were considered statistically significant.P = 0.051; severe vs. mild, P < 0.001; normal vs. mild, P < 0.001). Observer 2 calculated the TT-PCL mean ± the standard deviation values, 8.44 ± 4.57 mm for normal group, 20.09 ± 5.05 mm for the mild group, and 12.31 ± 5.43 mm for the severe group . Table P > 0.05; mild, 17.30 ± 4.81 mm vs. 20.09 ± 5.05 mm, P < 0.05; severe, 10.79 ± 4.24 mm vs. 12.31 ± 5.43 mm, P > 0.05). Figure P = 0.032) and r = 0.585 . The intra-observer ICCs of TT-TG were r = 0.814(mild group) and r = 0.739(severe group). The inter-observer ICCs of TT-TG were r = 0.810(mild group) and r = 0.713(severe group). In the normal knee, the Pearson correlation coefficient of TT-TG and TT-PCL was r = 0.787(P < 0.001), the intra-observer ICC of TT-TG was r = 0.989, and the inter-observer ICC of TT-TG was r = 0.978.There were 14 male and 6 female patients in the normal group, aged between 26 and 11 years (17.15 ± 4.21). The A type group included 6 male and 14 female patients, with an age range of 41 and 12 years 20.35 ± 6.84). The B, C, and D type group included 5 male and 15 female patients, with an age range of 31 and 13 years (19.10 ± 5.04). According to the Dejour classification system, the distribution of 60 knee joints is as follows: normal = 20, A type = 20, and B, C, and D type = 20. Observer 1 calculated the TT-TG mean ± the standard deviation values, 8.83 ± 3.62 mm for normal group, 17.30 ± 4.81 mm for the mild group, and 10.79 ± 4.24 mm for the severe group , “mild” (A), and “severe”  will increase the significance. However, this paper has no evidence to prove the advantages and disadvantages of the relationship between TT-TG and TT-PCL. It is also a pity that we did not come up with a better solution. We just found out in our clinical work that in the coronal assessment of patellofemoral instability, tibial tubercle-trochlear groove distance (TT-TG) and tibial tubercle-posterior cruciate ligament distance (TT-PCL) show different meanings when the femoral trochlea is stunted.In conclusion, TT-TG is of great significance for mild trochlear dysplasia, but it has become increasingly inaccurate in the measurement of severe trochlear dysplasia, especially preoperatively. In severe trochlear dysplasia, TT-PCL can more accurately measure the position of tibial nodules because it is not affected by trochlear dysplasia. TT-TG was not statistically significant in severe trochlear dysplasia, while TT-PCL was statistically significant in severe trochlear dysplasia. In patients with severe trochlear dysplasia, TT-PCL has more clinical significance in the decision-making of tibial nodular osteotomy. Therefore, TT-PCL may challenge the use of TT-TG in some situations, especially in the case of severe femoral trochlear dysplasia. Further research is needed to confirm whether TT-TG is less sensitive and specific than TT-PCL for severe trochlear dysplasia.