There were no significant differences between the compliant and non-compliant groups in terms of their corneal topographic measurements, refractive results, RGPCL parameters, or corneal cross-linking surgery history . In contrast, KC patients’ subjective experience with RGPCL wear—including visual acuity (p = 0.006), overall satisfaction (p < 0.001), quality of life (p < 0.001), and good adaptation during the short-term (p < 0.001)—had a significant effect on the long-term compliance with RGPCL wear. In conclusion, patients’ subjective experiences, rather than their ocular biometrics, significantly influence their long-term compliance with RGPCL wear.The purpose of the study was to investigate the factors affecting long-term compliance with rigid gas-permeable contact lens (RGPCL) wear in patients with keratoconus (KC). A total of 189 patients with KC (374 eyes) were included in the study, and were divided into two groups: the compliant group and the non-compliant group. Corneal topographic measurements, refractive results, and RGPCL parameters were compared between the two groups. A vision-related quality of life questionnaire was completed by all of the patients. The results demonstrated that patients diagnosed with bilateral KC were more compliant with RGPCL wear than patients diagnosed with unilateral KC ( Keratoconus (KC) is a bilateral, noninflammatory corneal ectasia characterised by progressive corneal thinning and protrusion, leading to increasing myopia, irregular astigmatism, and an eventual scarring of the cornea, with poor-quality vision ,2. The pDepending on the severity of the disease, different options for KC management are available. Irregular astigmatism in the early stages of KC can be corrected with spectacles; as the disease progresses, spectacles can no longer meet the needs of visual rehabilitation. Rigid gas-permeable contact lenses (RGPCLs) are most commonly used for the non-surgical management of patients with KC. RGPCLs provide better visual acuity and quality of life than spectacles ,5. MoreoRGPCLs create a thin lacrimal lens between the irregular corneal surface and the smooth posterior regular surface of the contact lens, which can neutralise most of the corneal astigmatism error . In addiSurgical management options are available for KC, including corneal collagen cross-linking (CXL), intra-corneal ring segments, and corneal grafting . CXL surAlthough RGPCLs can improve corrected distance visual acuity (CDVA), patients may stop wearing RGPCLs due to discomfort, inconvenience, and intolerance. A recent study found that CXL could increase RGPCL tolerance due to decreased corneal sensitivity and corneal flattening after CXL .There are studies discussing the effect of long-term RGPCL wear on KC progression  and visiThis study aimed to determine the factors affecting long-term compliance with RGPCL wear in patients with KC, and to provide clinical recommendations for better KC management. The factors were mainly recorded from clinical data and patients’ answers to the questionnaire, and were categorized into objective and subjective factors for further analysis and discussion. Objective factors included the patients’ clinical data, such as corneal topographic measurements, refractive results, RGPCL parameters, and CXL surgery history. Subjective factors included the patients’ experience with RGPCL wear, such as visual acuity, overall satisfaction, quality of life, and good adaptation in the short-term.A total of 374 eyes of 189 patients with KC, who were fitted with an RGPCL at the Eye & ENT Hospital, Fudan University, between February 2009 and June 2019, were included and divided into two groups: the compliant group (patients with KC who were still wearing RGPCLs) and the non-compliant group (patients with KC who stopped wearing RGPCLs). The inclusion criteria of clinical KC were as follows: an asymmetric bowtie pattern with or without skewed axes revealed by corneal topography, and at least one KC clinical sign detected by slit-lamp examination . Unilateral KC was considered to be present if a patient had KC in one eye but did not meet the diagnostic criteria in the contralateral eye. This study was approved by the Ethics Committee of Eye & ENT Hospital, Fudan University, and adhered to the tenets of the Declaration of Helsinki.The data included CDVA with RGPCL wear and the final specifications of the best fit . In addition, in order to compare the visual acuity between RGPCLs and spectacles, CDVA with spectacles was measured. The spherical equivalent and cylinder with spectacles were also recorded. CDVA was converted to the logarithm of the minimum angle resolution, and was used for further analysis.A Pentacam HR imaging system , which uses the Scheimpflug imaging technique, was used to perform the corneal topographic examinations. The rotating camera was set to capture 25 Scheimpflug slit images in approximately 2 s. All of the procedures were performed by experienced operators, and all of the patients were instructed to blink once before the image acquisition. In order to avoid miscalculations of poor imaging quality, the measurement quality was displayed in a specific Quality Specification (QS) window. Only results with ‘OK’ in the QS window, indicating good image quality, were included in the statistical analysis. Each eye was examined three times to obtain the mean value.The following parameters were evaluated in this study: the thinnest corneal thickness (TCT), flat keratometry (K1), steep keratometry (K2), and maximum keratometry (Kmax).The fitting procedure of the RGPCLs was performed based on the standard ‘three-point touch’ method. The lens fit was assessed using a slit-lamp biomicroscope. The fit was deemed good if there was good centration, adequate movement, and a ‘three-point touch’ fluorescein pattern. Rose-K or aspheric RGPCL designs were used .2, delivering a surface dose of 7.2 J/cm2. This treatment step lasted for 5 min and 20 s. Subsequently, a bandage contact lens was applied. Antibiotic drops were applied for 1 week, and topical steroids were administered for 16 days . The bandage contact lens was removed on postoperative days 1–5, according to epithelialisation. RGPCLs were prescribed 1 month after CXL.The patients were placed in a supine position, and anaesthetic eye drops were applied preoperatively, after which a lid speculum was used. The corneal epithelium remained intact. Paracel  in corneal epithelial trephine  was used to completely cover the cornea for 4 min. VibeX Xtra  was then used to rinse and cover the cornea with corneal epithelial trephine for 6 min. A KXL System (Avedro) was used to conduct ultraviolet treatment with pulsed illumination for 1 s at 45 mW/cmThe indications for CXL surgery were as follows: diagnosis with progressive KC with a thinnest corneal thickness (TCT) greater than or equal to 400 μm, or patients younger than 40 years. KC progression was confirmed by an increase in maximum keratometry (Kmax) of at least 1.00 diopter (D) in the past year.Patients wearing RGPCLs discontinued their use for at least two weeks before surgery.The demographic and vision-related quality of life questionnaire was prepared in English and then translated into Chinese. All of the subjects were required to complete the questionnaire in Chinese. The questionnaire comprised scale questions, multiple-choice questions and close-ended questions. Age, occupation, educational level, residence, number of eyes diagnosed with KC, year of first-time RGPCL wear, family history of KC, and corneal CXL surgery history were collected from the demographic questionnaire. The vision-related quality of life questionnaire comprised questions about comfort, visual acuity, overall satisfaction, quality of life, and adaptation to the RGPCL wear.In order to clarify the validity of the questionnaire, Cronbach's alpha and Kaiser-Meyer-Olkin (KMO) tests were used. The results were 0.78 and 0.87, respectively, which indicated the acceptable reliability and good validity of the questionnaire.The details of the questionnaire survey are available online at A logistic-transformed generalised estimating equation (GEE) regression was used to measure the effect of factors on the long-term compliance with RGPCL wear.The inappropriate analysis of data for one eye or both eyes of the same subjects without accounting for inter-eye correlation could lead to a biased or inefficient estimation of the difference between the two groups. In order to adjust for potential correlations between the two eyes of the same subject, the GEE model was used. The GEE model examines whether independent variables could predict the odds of a particular dichotomous outcome, either for the compliant or non-compliant group. The odds ratios (ORs) and their 95% confidence intervals (CIs) were computed using the available data from each patient. Both single-factor and multiple-factor analyses were performed using GEE.Demographics and baseline characteristics—such as age, sex, K1, K2, CDVA, and answers to the questionnaire—were summarised by the compliant and non-compliant groups. Differences in characteristics between the groups were tested using the chi-squared, corrected chi-squared, and Fisher’s exact tests for the categorical variables, and one-way analysis of variance for the normally distributed continuous variable.p < 0.05 were considered statistically significant. All of the statistical analyses were performed using R software (version 4.0.5).Two-sided values of A total of 208 patients (416 eyes) were reviewed, of which 42 eyes were excluded due to incomplete information on the answer sheet. Finally, 189 patients with KC (374 eyes) were included in the analysis.p = 0.236). Respondents diagnosed with bilateral KC had better compliance with RGPCL wear than those diagnosed with unilateral KC (p = 0.0167).p > 0.05).p > 0.05). The K1 and Kmax of the patients who received CXL surgery were significantly higher than those of the patients who did not undergo CXL surgery .p = 0.006), overall satisfaction (p < 0.001), quality of life (p < 0.001), and adaptation to RGPCL wear (p < 0.001)—significantly influenced their long-term lens-wear compliance. The patients with KC who gained better visual acuity and quality of life with RGPCL wear were more likely to insist on wearing RGPCLs. Similarly, patients with KC who became used to the RGPCL wear in the short term and felt satisfied with lens wear would be more compliant with RGPCL wear. In contrast, patients with KC who were compliant with RGPCL wear were barely affected by the cost (p = 0.002) or the short-term discomfort with RGPCLs (p < 0.001)  .p = 0.798) (There were no significant differences between the compliant and non-compliant groups in CXL surgery (= 0.798) .A total of 283 eyes of 154 patients with KC with comprehensive clinical data were analysed using GEE.p > 0.05).p = 0.03) were more likely to insist on wearing RGPCLs than those who only attempted to improve visual acuity. Patients with KC who agreed  or strongly agreed  with the statement that “I am satisfied with RGPCL wear overall” had better compliance with RGPCL wear than those who disagreed. Patients with KC who agreed  or strongly agreed  with the statement “My quality of life has improved due to the improvement of visual acuity with RGPCL wear” were more likely to insist on wearing RGPCLs than those who were not sure about it.The reason for wearing RGPCLs, overall satisfaction, and quality of life with RGPCL wear had a significant effect on the long-term compliance with RGPCL wear. Patients with KC who attempted both to control the progression of KC and improve visual acuity with RGPCL wear  for ‘agree’ and 14.12  for ‘strongly agree’ compared with ‘not sure’.In the multiple-factor analysis, the quality of life with RGPCL wear had a positive effect on compliance with RGPCL wear. The ORs were 6.5  and the non-compliant group (308 eyes) was significantly different, which may have led to bias in the results. Second, the classification of bilateral versus unilateral KC was based on the topographic findings before RGPCL wear and on the answers provided by patients per se. Some of the originally ‘unilateral’ patients might have progressed to ‘bilateral’ at the time of the survey, thereby confounding the comparison between the two groups.The current study revealed that patients with bilateral KC are more compliant with RGPCL wear than those with unilateral KC in the long-term. Ocular biometrics—including corneal topographic measurements, refractive results, and RGPCL parameters—did not affect the long-term compliance with RGPCL wear. Patients with KC who attempt to control KC progression with RGPCLs, who gain better visual acuity and quality of life with RGPCL wear, who become used to the RGPCLs in the short term, and who feel more satisfied with lens wear are more likely to insist on wearing RGPCLs. Improved visual acuity with RGPCLs compared with spectacles and CXL surgery history did not have a positive effect on compliance with long-term RGPCL wear. Short-term discomfort with RGPCL wear, a long distance from resident locations to the hospital, and the high cost of RGPCLs have no negative effect on long-term compliance with lens wear.


Cother/(Cother + Cliver)) corresponding to male frogs were significantly greater than those of females, suggesting that male frogs could have higher metabolic potentials for PFRs and plasticizers. No obvious correlations between OLR and log KOW were found, indicating that the other factors  besides lipophicity could influence the deposition of PFRs and plasticizers in frog livers. Different parental transfer patterns for PFRs and plasticizers were observed in frogs when using different tissues as parental tissues. Moreover, the liver tissues had similar parental transfer mechanism with muscle tissues.Five types of tissues, including the liver, kidney, intestine, lung, and heart, were collected from black-spotted frogs and bullfrogs to study the tissue-specific accumulation of organophosphorus flame retardants (PFRs) and plasticizers. Thirteen PFRs and nine plasticizers were detected, with average total concentrations of 1.4–13 ng/g ww and 858–5503 ng/g ww in black-spotted frogs, 3.6–46 ng/g ww and 355–3504 ng/g ww in bullfrogs. Significant differences in pollutant concentrations among different tissues in the two frog species were found, indicating the specific selectivity distribution of PFRs and plasticizers. Overall, liver tissues exhibited significantly higher pollutant concentrations. The pollutant concentration ratios of other tissue to the sum of liver tissue and other tissues (OLR,  Organophosphorus flame retardants (PFRs), known as a suitable replacement of the banned brominated flame retardants, have been extensively applied to a wide variety of consumer and industrial products in the last decade, acting as flame retardants and plasticizers, as well as antifoaming agents ,2. PlastChemical pollution has been considered as a crucial cause for the decrease in global numbers and the increase in morphological abnormalities of amphibians ,28,29. FIn the last few years, some laboratory studies have reported the tissue-specific bioconcentration and distribution of PFRs in vertebrate fish ,30,31. ARana nigromaculata, 11 females and 14 males) and 10 bullfrogs  were collected at an e-waste contaminated site in Longtang Town, Qingyuan County, Guangdong, South China. Detailed information about these two frog species, such as body weight and length, has been shown in our previous study [In April 2019, 25 black spotted frogs  after spiking with surrogate standards. Clean-up was achieved by solid-phase extraction using a Florisil® ENVI cartridge , which was conditioned with acetone (ACE), ethyl acetate (EtAC), and hexane. After loading the extract, the cartridge was washed with 12 mL of dichloromethane/hexane , and then eluted with 10 mL of EtAC and 8 mL of ACE. Finally, the eluate was evaporated to dryness and replaced with methanol, and spiked with triamyl phosphate for LC-MS/MS analysis. In addition, 20 µL of this final mixture was transferred and mixed with 80 µL of EtAC for GC-MS analysis. Detail information about the target analytes and surrogate standards and instrument analyses were presented in The PFR and plasticizer analysis procedures were performed as previously reported ,34. In bThe recoveries of native standards in triplicates of spiking samples were ranged from 66% to 126%. The relative standard deviations of the analytes in three replicates were all less than 15%. One procedural blank sample was tested in parallel for every fifteen samples in the process of samples treatment. The averages of blank contamination were 0.025–1.8 ng/g ww for PFRs, and 0.19–121 ng/g ww for plasticizers. The blank values were subtracted from the detected results. Limits of quantitation (LOQs) of PFRs and plasticizers were 0.032–2.5 ng/g ww, and 0.29–266 ng/g ww, respectively. In addition, the recoveries of ISs in the analyzed samples were 70–111%. Detailed data on procedural blank levels and LOQs of each targeted chemical, as well as recoveries of each IS in the analyzed samples are listed in KOW values. Significance were considered as p < 0.05.Statistical analyses were performed using IMB SPSS Statics 19.0 and Origin 8.5 software. Independent samples t-tests were used to compare concentrations and compositions between two groups. One-way analysis of variance (ANOVA) was used to compare the contaminant patterns among different tissues. Pearson’s correlation analyses were conducted to explore the relationships on pollutant concentrations among different tissues, between pollutant concentrations and physiological parameters of bullfrogs, and parental transfer potential and log Detailed concentrations of PFR and plasticizer analytes in the five investigated tissues of black-spotted frogs and bullfrogs are presented in p < 0.05), indicating the specific selectivity distribution of these pollutants in frog tissues. Overall, the liver tissue with blood-rich perfusion and active metabolism showed significantly higher pollutant concentrations in these two frog species, whether for females or males. Relatively high concentrations of PFRs were also observed in the livers of some wild freshwater fish species  and marine fish [The total concentrations and compositional profiles of PFRs and plasticizers in each tissue of black-spotted frogs and bullfrogs are presented in ine fish ,21,26,32ine fish  and Kim ine fish  found thine fish ,30. Noteine fish .n-butyl-phthalate (DnBP) (3.0–75%), followed by di-iso-butyl-phthalate (DiBP) (1.0–34%) in tissue samples of these two frog species.As for the composition patterns of these pollutants, PFRs were dominated by tris(2-chloroethyl) phosphate (TCEP) (12–42%) and tris(chloro-2-propyl) phosphate (TCIPP) (13–47%) in most of black-spotted frog tissues. The exceptions were for the female tissues of kidney, heart, and intestine, tris(2-butoxyethyl) phosphate (TBOEP) (26%) and triphenyl phosphate (TPHP) (24%) were dominant in the kidney, and TCEP  and TPHP (20% and 18%) were dominant in the heart and intestine. In all bullfrog tissues, TCEP (23–72%) was the predominant PFR pollutants. As for plasticizers, it was commonly dominated by di-2-ethylhexyl-phthalate (DEHP) (7.0–78%) and di-Cother/(Cother + Cliver)) were calculated. When OLR was significantly deviated from 0.5, it indicated the significant difference in distribution of PFRs and plasticizers between other tissues and the liver [To further examine the distribution of PFRs and plasticizers among these seven different tissues in frogs, the ratios of pollutant concentrations in other tissues to sum (livers + other tissues) , suggesting that the high exposure of PFRs and plasticizers could tend to shrink the livers of these frogs [The hepatosomatic index (HSI) calculated as the ratio of liver weight to body weight, has been conveniently used for estimating the energy status  and contse frogs . Du et ase frogs  also fouse frogs  and Zarose frogs  pointed se frogs . p = 0.009). Additionally, significantly positive correlations were found between HSI and SVL, and between HSI and body weight in male bullfrogs (p = 0.039 and 0.008). These findings could indicate that the high exposure to PFRs and plasticizers may reduce the energy storage in frog livers, and further reduce the survival rate of frogs during hibernation [Since the body weight and snout-vent lengths (SVL) are often used to represent the physical condition of creature, the relationships between body weight (or SVL) and contaminant concentrations in frog livers, and between body weight (or SVL) and HSI were further investigated. Significantly negative correlation was observed between the total PFR concentrations and SVL in female bullfrogs  besides lipophicity could influence the deposition of PFRs and plasticizers in frog livers. The high exposure to PFRs and plasticizers may reduce the energy storage in frog liver, and further reduce the survival rate of frogs during hibernation. Additionally, different parental transfer patterns for PFRs and plasticizers assessed by using different tissues as parental tissues were found. Moreover, the liver exhibited similar mechanisms with the muscle in frogs. Due to the high metabolic potential of PFRs and plasticizers, more investigations on the metabolites are recommended to comprehensively understand the mechanism and kinetics of the tissue-specific accumulation of PFRs and plasticizers in amphibians.In this study, the internal exposure of PFRs and plasticizers in wild amphibian frog tissues were investigated. Overall, livers exhibited significantly higher contaminant concentrations among different tissues in black-spotted frogs and bullfrogs, as evidenced by the fact that most OLR values were significantly less than 0.5. The OLR values corresponding to the paired tissues in male frogs were significantly greater than those in females, indicating that male frogs could have higher metabolic capacities of PFRs and plasticizers. The lack of significance between OLR ratios and log


Mean age of donors was 45.22 years, mean BMI was 28.82, sex ratio was 48:52 F:M and mean time in ICU was 3.07 days. There was no significant difference between local and non-local for these characteristics. The mean CIT resulting in islet transplantation was 297.1 ± 91.5 min and longest CIT resulting in transplantation was 676 min. There was no significant difference in islet isolation outcomes between local and non-local donors for characteristics other than CIT. There was also no significant effect of distance from the isolation facility on positive islet transplant outcomes (C-peptide > 0.2 at 1 month post-transplant). Conclusions: Distance from the isolation centre did not impact on isolation or transplant outcomes supporting the ongoing nationwide use of shipping pancreata for islet isolation and transplantation.Cold ischemia and hence travel time can adversely affect outcomes of islet isolation. The aim of this study was to compare the isolation and transplant outcomes of donor pancreata according to the distance from islet isolation facility. Principally, those within a 50 km radius of the centre were compared with those from regional areas within the state and those from interstate donors within Australia. Organ donors were categorised according to distance from National Pancreas Transplant Unit Westmead (NPTU). Donor characteristics were analysed statistically against islet isolation outcomes. These were age, BMI, cause and mechanism of death, days in ICU, gender, inotrope and steroid use, cold ischemia time (CIT) and retrieval surgical team. Between March 2007 and December 2020, 297 islet isolations were performed at our centre. A total of 149 donor pancreata were local area, and 148 non-local regions. Mean distance from the isolation facility was 780.05 km. Mean pancreas CIT was 401.07 ± 137.71 min and was significantly different between local and non-local groups (297.2 vs. 487.5 min,  Pancreatic islet cell transplantation has become a successful modality of treatment for a select group of patients with type 1 diabetes. ,3,4. In p =< 0.01) (p < 0.01).Between March 2007 and December 2021, 297 islet isolations were performed and analysed for this study. Donor pancreata came from multiorgan donors that were accessed from multiple hospitals across Australia . The mean distance from isolation centre was 780.05 km (range 0 to 3278.7 km) for all donors. The distance from the isolation facility provided significant impact on the islet isolation outcome the closer local donors provided a positive outcome at 11.34 km ± 10.22 vs. 883.04 km ± 625.45 for a positive outcome from non-local donors, =< 0.01) A. The chp = 0.011). As one moves out from zone 2 to zone 6, there was a progressive increase in cold ischemia times. (The mean CIT for each zone is shown on p = 0.12). However, regardless of the region, there was a negative association between CIT and chances of a positive isolation outcome (p = 0.55). Although isolations with a positive outcome tended to have a shorter CIT compared to those with a negative outcome (297.1 ± 91.5 min vs. 297.6 ± 105.5 min) (p = 0.73) . CIT correlated closely with distance from isolation facility B. From l5.5 min) C this wa = 0.73) C.p = 0.554) and there were no differences in the gender balance between local and non-local donors . There was no difference in age between donors accepted from local versus those from non-local regions . The mean age of all donors was 45.22 years (range 10 to 71), and there was no difference in age of the donor between those with a positive isolation outcome and those that did not (44.34 (range 23 to 69) vs. 45.49 (range 14 to 71), p = 0.46, 2 (range 19.80 to 57.46) and the mean BMI was greater in isolations with a positive isolation outcome with those that did not (31.01 (range 20.09 to 51.05) vs. 28.12 (range 17.90 to 57.46), p = 0.0004, p = 0.927). The mean time spent in ICU for all donors was 3.07 days (range 1 to 13) and no impact on isolation outcome,   , whereas= 0.042) .The clinical outcome of those isolations that were transplanted were assessed and evaluated for their effect of donor-related factor on outcome using the non-parametric Spearman’s rank correlation. Donor distance, CIT, days in ICU, donor BMI had no effect on C-peptide levels achieved .Availability of suitable donor pancreata is a major limiting factor for islet transplant activity. Hence, the ability to access pancreata that are retrieved at a distance from the isolation centre is essential if more patients are to be transplanted. However, it is essential to ascertain whether pancreata retrieved from more distant centres provide equivalent outcomes to those retrieved locally. This study evaluated the differences in donor characteristics between locally retrieved local donor organs with those retrieved from non-local regions. Because of the distances between major cities and states within Australia there was a large variation in distances between the donor hospital and the isolation centre. Because of the logistics of transport, there were substantial differences in CIT between local and non-local donors. This did impact on the chances of achieving a positive isolation resulting in reaching release criteria. However, provided the release criteria were met there were no differences in transplant outcomes between local and non-local donors. The one caveat to this conclusion was that no successful isolation was achieved if the CIT was greater than 676 min.The contributing factors that affect the logistics of the transport of the organ included- time from organ retrieval to shipping. These included the time to separate the pancreas from the liver after removal en-bloc during organ retrieval and the availability of a commercial flight to Sydney. These variables tended to have a substantial impact on CIT. These logistical issues had a major impact on organs retrieved from regions 3 to 5 where flight times range from 44 min to 2 h. Pancreata transported from zone 6 had flight times ranging from 3 to 6 h. By contrast those retrieved within the local region were transported to the isolation facility by car which meant that it tended to travel with the retrieval team and did not suffer from delays caused by transfer to couriers and delays with airport transfers. In most instances though the careful planning of organ donor retrieval surgical times around flight times and urgency to meet assigned flights made significant differences to flight times as seen between zone 6 and those undertaken in zone 4 where similar urgency to make flight times was not as critical or there were significant distances driven from a distant regional hospital to make the flight interstate.Other studies have looked at the impact of distance on isolation outcome including an initial report of 3 patients with a follow up of 11 patients, transplanted with islets isolated from pancreata obtained in Houston that were transported by air to the isolation centre in Miami, before being transported back to be implanted into patients in Houston ,8,9. HowThe study reported by the GRAGIL study is a relatively small number of isolations performed and the consequent small number of preparations suitable for transplantation. Whilst we did not identify an impact of CIT and days in ICU on isolation outcome, these have been identified as important variables in other studies. In this setting, CIT is a good surrogate for distance travelled but only when taken in the right context and in relation to the exceptionally long distances travelled across Australia that can only occur by air travel. CIT has been shown to have an adverse outcome on islet isolation in both single-centre and registry studies ,9.A unique feature of this study was the distance travelled between the donor hospital and the islet isolation facility. Donor pancreata were transported up to 3290 km from the city of Perth situated on the west coast to Sydney on the east coast of Australia for islet isolation. Whilst these large distances did impact on the chances of a successful outcome, we show that it is possible to achieve release criteria and good outcomes from those organs that come from distant regions.The BMI of a donor was also significant in determining a positive isolation outcome meeting release criteria and thus we must continue to consider this when deciding whether we should perform a donor pancreas isolation. The BMI of a donor has been found to correlate with the size of their pancreas and bigger pancreata often result in greater islet numbers . This reAll other factors were not significantly different between all comparison groups. The data we used for this analysis were retrospective and donor selection criteria were based on the Edmonton Score . If possIn conclusion, excellent islet transplant outcomes can be achieved from pancreata retrieved at distant centres, despite substantial logistical issues involved. The nationally funded program provides a fair and equitable use for donor organs regardless of the state they are retrieved in and will provide outcomes for patients equivalent to the best units in the world despite major logistical hurdles compared to other units. Whilst pancreata retrieved from distant sites are less likely to achieve release criteria, those that do achieve release criteria have comparable outcomes to locally retrieved outcomes. Distant pancreas retrieval does pose challenges and careful selection of appropriate donors and minimisation of CIT by improved logistics is essential to ensure success.All multiorgan heart-beating brain dead donors were accepted for donation based upon their suitability as described previously ,17. OrgaIslets were separated as described previously using a variation of the closed-loop method described by Ricordi et al. ,18. Panc2 at 37 °C for up to 24 h with quality assurance, including beta cell viability index, oxygen consumption rate, endotoxin and Gram stain, being repeated prior to release of the islets for transplant. Islets were deemed suitable for transplantation if they reached the appropriate release criteria defined as greater than 5000 IEQ per kg of recipient body weight, a negative Gram stain, less than 5 EU/kg endotoxin and the total tissue volume less than 10 mL as based on CIT release criteria published previously [Purified islets were counted and islet number and mass were expressed in terms of islet equivalents (IEQ) . Islet peviously .The patient selection criteria and outcomes of the trial have been published previously. Eligible patients had type 1 diabetes mellitus for more than 5 years and were aged between 18 and 65 years. Additionally, they had recurrent severe hypoglycaemia unawareness that required constant monitoring or regular intervention by a third party with a hyposcore as assessed by the Edmonton criteria of greater than 1000 . All patFor the purposes of this evaluation, all islets were isolated, and all patients were transplanted at Westmead Hospital. The islets were resuspended in 120 mL of medium 199  containing 5000 U heparin and 20% human albumin. Patients received a general anaesthetic, and a mini-laparotomy was performed to access a mesenteric vein. An arterial angiographic catheter was inserted and threaded into the main portal vein with the assistance of image intensification and the islets infused under gravity.Donor information was collected at the time of retrieval on national organ donor data sheets supplied with the organ by the organ donor agency. Additional information was also requested from the relevant organ donor agency if this was missing. Distance from islet isolation facility was calculated as-the-crow-flies and then grouped into six zones: 1 =< 50 km, 2 = 50 to 150 km, 3 = 151 to 400 km, 4 = 401 to 800 km, 5 = 801 to 1200 km and 6 = 1201 to 4000 km . The disFor CIT, age and days in ICU, absolute values were used for analysis. For gender, females were assigned to group 1 and males to group 2. Retrieval team was split into group 1—our local team and group 2—all other retrieval teams.13 by agreement between two members of our team (Surgeon and Islet Operations Manager). Inotrope use was classified into 4 groups: 1 = none, 2 = normal/low (4–6 mg/100 mls at <6 mls/h), 3 = moderate (4–6 mg/100 mls at 6–10 mls/h) and 4 = high (4–6 mg/100 mls at >10 mls/h). Steroid use was assigned a 0 for none and 1 for some and C-peptide in recipients 0 for a negative isolation (<0.2 at one month) and 1 for a positive isolation (>0.2 at one month).Cause and mechanism of death were classified into CITR structured groupsA positive isolation outcome was defined as ‘preparation of transplant quality islets meeting all release criteria allowing for transplantation of the islets’. A positive transplant outcome was defined as ‘recipient C-peptide >0.2 at 1 month post-transplant’.p-value of less than 0.05 was considered significant.The statistical software package S-PLUS v8 was used to analyse the data. Ranges , means and standard deviations (SD) were calculated for all data. For non-continuous data, a value was assigned to each group for analysis , and Chi


Pythium, soil-borne plant pathogens, are in the class Oomycetes. They are not true fungi, but are related to diatom and algae. There are two human pathogens including P. insidiosum and P. aphanidermatum. To date, only one case of pythiosis caused by P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia.P. aphanidermatum with 100% identity. Final diagnosis is vascular pythiosis. Unfortunately, the patient eventually expired after treatment with itraconazole, terbinafine, azithromycin, and doxycycline.A 47-year-old Thai woman, living in North Thailand, with ß thalassemia/hemoglobin E presented with acute recurrent arterial insufficiency of both legs. Emergent embolectomy with clot removal was performed. The pathology of the clot exhibited noncaseous granulomatous inflammation with many fungal hyphal elements. PCR identified P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia.To date, only one case of pythiosis caused by  Pythium are soil-borne plant pathogens in swampy areas in Thailand and many tropical and subtropical countries [Pythium have two forms including perpendicular branching hyphae and biflagellate zoospore [ountries . Based oountries . Pythiosountries –5. Pythizoospore . The zoozoospore , 7. To dzoospore . Most ofzoospore , 5.P. insidiosum and P. aphanidermatum. To date, only one case of pythiosis caused by P. aphanidermatum has been reported [P. aphanidermatum in Asia.There are two human pathogens including reported . We presP. insidiosum was1:800 , and serum ß-d-glucan was 523 pg/mL. Unfortunately, the organism could not be isolated from the clinical specimens. The definite identification of the organism from the clot, by amplifying the internal transcribed spacer (ITS) of ribosomal DNA using the polymerase chain reaction (PCR) technique with sequencing of the amplicon and GenBankBLAST searching as previously described [P. aphanidermatum (100% identity). Unfortunately, the patient eventually expired due to uncontrolled sepsis 2 weeks after treatment with itraconazole, terbinafine, azithromycin, and doxycycline as well as an iron chelator, deferoxamine.A 47-year-old Thai woman, living at Maesot, Tak, North Thailand, with ß thalassemia/hemoglobin E, was referred from a provincial hospital for further investigations regarding acute arterial insufficiency of both legs. Two months prior to admission (PTA), she noted a self-limited blackish painful nodule at left labia minor. Few weeks later, she developed a low-grade fever with bilateral groin pain. One month PTA, she had severe pain at left foot, and a diagnosis of acute arterial insufficiency was made a doctor at provincial hospital. Emergent embolectomy with clot removal at left common iliac artery was performed. Few days after hospitalization, there was a recurrent limb ischemia, and embolectomy was performed again. One week after hospitalization, the pathology of the clot exhibited noncaseous granulomatous inflammation with many fungal hyphal elements Fig. A, and heescribed , was P. P. aphanidermatum infection was described by Calvano and colleagues in the year 2011. The patient was a 21-year-old Hispanic male soldier who had extensive wound infection affecting both legs, right arm, and buttock in an explosive device blast injury in Afghanistan [Mucor circinelloides, Aspergillus flavus, and P. aphanidermatum. In the authors’ opinion, it was not clear whether the infection caused by P. aphanidermatum was a coinfection or not. Our case had vascular pythiosis without known history of trauma, similar to those caused by P. insidiosum in most studies.The first case of pythiosis caused by hanistan . The patPythium and Lagenedium [Lagenedium giganteum was reported to cause keratitis mimicking ocular pythiosis caused by P. insidiosum [Pythium, there have been two species of human pathogens including P. insidiosum and P. aphanidermatum. P. aphanidermatum is also a plant pathogen [P. insidiosum. In addition, the morphology from the pathology of clinical specimens could not be distinguished between the two species. Both of them are irregularly branching, pauciseptate hyphae present within the arterial walls [P. insidiosum. Surprisingly, it turned out to be P. aphanidermatum. We believe that vascular pythiosis can be caused by either P. insidiosum or P. aphanidermatum, and the latter may be underestimated due to similar clinical manifestations, morphology, and false-positive serum antibody using P. insidiosum enzyme-linked immunosorbent assay, as in our case.To date, there have been two genera of the class Oomycetes causing human diseases including genedium , 10. Lagpathogen . The bioal walls . Hence, Of the most reported cases of vascular pythiosis, the skin at the foot is the most entry site of infection , 5. AftePythium, the surgery is the main choice of treatment of vascular pythiosis, usually amputation of the involved limb with organism-free surgical margin by microscopic demonstration [Due to no effective antimicrobials against stration , 5. In ostration .P. aphanidermatum has been reported. We present herein the first case of P. aphanidermatum vascular pythiosis in Asia. There are no differences between pythiosis caused by P. aphanidermatum and P. insidiosum regarding the clinical manifestations, the predisposing conditions, and cross-reaction of serum antibody with our in-house enzyme-linked immunosorbent assay against P. insidiosum.To date, only one case of pythiosis caused by


CSF dynamics variables showed an association with the severity of LSS symptoms, independent of structural stenosis. PC-MRI can help to further our understanding of the pathophysiology of neurogenic claudication and support the diagnosis of LSS.Neurogenic claudication is a typical manifestation of lumbar spinal stenosis (LSS). However, its pathophysiology is still unclear. The severity of clinical symptoms has been shown not to correlate with the degree of structural stenosis. Altered cerebrospinal fluid (CSF) flow has been suggested as one of the causative factors of LSS. The objectives of this study were to compare CSF dynamics at the lumbosacral level between patients with LSS and healthy controls and to investigate whether CSF dynamics parameters explain symptom severity in LSS. Phase-contrast magnetic resonance imaging (PC-MRI) was conducted to measure CSF dynamics in 18 healthy controls and 9 patients with LSS. Cephalic peak, caudal peak, and peak-to-peak CSF velocities were evaluated at the lumbosacral level in the patients and controls. The power of CSF dynamics parameters to predict symptom severity was determined using a linear regression analysis adjusted for demographic and structural variables. Significantly attenuated CSF flow velocity was observed in the patients compared with the controls. The cephalic peak, caudal peak, and peak-to-peak velocities at the lumbar level were greater in the controls than in the patients (p<0.001). The predictive power increased most when the peak-to-peak velocity was added (adjusted R Lumbar spinal stenosis (LSS) is a common degenerative disease characterized by a narrowed spinal canal in imaging and neurogenic claudication as a phenotype , 2. NeurCerebrospinal fluid (CSF) dynamics have been proposed to be associated with neurogenic claudication . AlteredThe aim of this study was to examine the hypothesis that CSF dynamics independently contribute to the development of neurogenic claudication in LSS. For that purpose, we quantitatively measured CSF dynamics at the lumbosacral level using phase-contrast magnetic resonance imaging (PC-MRI) in patients with LSS and healthy controls and compared their hydrodynamic parameters. Furthermore, the predictive power of CSF dynamic variables for LSS symptom severity was evaluated in addition to epidemiologic and structural variables.This level-3 investigational, observational study compared the CSF dynamics of patients with LSS and healthy controls. The study was approved by the institutional ethics committee of Seoul National University Hospital , and written informed consent was obtained from each subject (IRB number: H-1203-088-402). Patients with LSS were recruited from the outpatient clinic of a tertiary hospital and met the following criteria: (a) symptoms were experienced for more than 3 months; (b) claudication was provoked after less than 30 minutes of walking; and (c) spinal canal stenosis with a minimal anterior-posterior (AP) diameter less than 10 mm was confirmed by lateral plain radiology. The exclusion criteria were as follows: (a) systemic peripheral neuropathy, peripheral vascular disease with vascular claudication, or a history of lumbar or brain surgery based on the patient’s medical history; (b) segmental instability, which was defined as a > 4-mm translation of the sagittal plane or > 10° angular motion  based onDemographic variables were obtained, including age, sex, and body mass index (BMI), which was calculated based on height and weight. A subjective assessment of symptom severity was conducted by recording the patient history and performing a physical examination. Patient history included information on the duration, characteristics, and distribution of symptoms and aggravating or relieving factors. Physical examination included the straight leg raise test, prone instability test, and neurological examinations, such as the manual muscle strength test, sensory examination, and deep tendon reflex. The ankle brachial index was assessed using a cuff manometer to exclude vascular claudication.To evaluate symptom severity, all subjects completed the Oswestry disability index (scores range from 0 to 100 points) . In this3, slice thickness = 5 mm, 25% oversampling of the AP phase-encoding direction, bandwidth = 195 Hz/pixel, foothead single-direction velocity encoding, and generalized autocalibrating partially parallel acquisition with an acceleration factor of 2). T2-weighted images were acquired in the sagittal plane to determine structural stenosis.The MRI examinations were performed using a 3.0 Tesla MR system . The same PC-MRI protocol was used for all subjects  and the first sacral vertebra (S1) using axial plane PC-MRI , and a negative velocity indicates the CSF flow downward along the axis . Three variables with simple but large descriptive power were calculated to represent CSF hydrodynamics: the maximum positive and minimum negative velocities were defined by the cephalic peak velocity and caudal peak velocity, respectively, and the peak-to-peak velocity was defined as the difference between the cephalic and caudal peak velocities.The AP diameters of the canal were measured from the L1/2 to the L5/S1 mid-disc level using the mid-sagittal T2-weighted image. To indicate the severity of structural stenosis, the smallest AP diameter was designated as the minimum AP diameter (min AP). Region of interest (ROI) segmentation of the spinal canal was manually performed to measure CSF dynamics within the ventral part of the dural sac. An ROI was placed within the ventral part of the dural sac, showing an evident change in CSF flow on the axial phase images. Next, the location of the ROI was adjusted by excluding the dura mater or rootlets. The size of the rectangular ROI placed on the axial images was 0.3×0.3 cmAll statistical analyses were conducted with SPSS 25.0 . First, all the data were tested for normality using the Shapiro-Wilk test.U-test) were used to compare the categorical or discrete variables  between the patients with LSS and the controls. The categorical variables, sex and claudication distance score, were examined using a chi-square test. A repeated-measures ANOVA was conducted to assess the variability in velocity at the sacral level during one cardiac cycle.Parametric tests (t-test) were used to compare the normally distributed variables , and nonparametric tests (Mann-Whitney 2) value was calculated to evaluate the predictive power of each model. Statistical significance was set to a p-value of less than 0.05; a Bonferroni correction (p < 0.017 (0.05/3)) was applied to adjust for multiple pairwise comparisons between 3 groups.Associations of epidemiological, structural, and CSF dynamics variables with symptom severity were explored by performing a univariate linear regression analysis using the claudication distance score as the dependent variable. A multivariate linear regression analysis was performed by adding or deleting epidemiological, structural, and hydrodynamic variables in multivariate models to determine whether the CSF hydrodynamic parameter contributed to symptom severity. Model 1 included the epidemiological variables, and structural variables were added to Model 1 to produce Model 2. Model 3 substituted CSF dynamics variables for the structural variables in Model 2. Model 4 included all the epidemiologic, structural, and CSF dynamics variables. The variables in the multivariate models were those with a p-value <0.10 in the univariate analysis and were evaluated for the collinearity effect using the variance inflation factor. The adjusted R-square . When the structural variables in Model 2 were replaced with the CSF hydrodynamics , the descriptive power was found to increase markedly (adjusted R2 = 0.393). Model 4, which included age, BMI, min AP, and peak-to-peak velocity, showed the highest goodness-of-fit and had peak-to-peak velocity as the only significant variable (adjusted R2 = 0.410).Multivariate linear regression analyses were performed to determine whether CSF dynamics parameters independently contributed to symptom severity . All the2 = 0.623; model 4 , adjusted R2 = 0.609). Age, which showed no significance in the model for all subjects, was significantly correlated with the claudication distance score in the model for aged subjects. Nevertheless, the predictive power of all the models showed improvements compared to the models analyzed in the all-subjects group .Further linear regression analysis was conducted with closer age matching by excluding the younger healthy controls from all subjects : 61.7 (49–76) years; This study was conducted to test whether CSF dynamics explained the severity of neurogenic claudication in LSS using PC-MRI. In the comparison of patients with LSS and healthy controls, greater CSF flow velocities were found in the healthy controls and the difference was particularly significant at the lumbar level. CSF dynamics parameters predicted the severity of LSS symptoms independent of epidemiological or structural parameters; the predictive power was improved by the addition of a CSF dynamics parameter.2, p = 0.008). However, none of the CSF dynamics variables were correlated with the CSA , CSF dynamics variables, i.e., cephalic peak velocity and peak-to-peak velocity, had no correlation with the severity of stenosis . Further the CSA .Another possible confounder that may entail the correlation between attenuated CSF dynamics and symptom severity is age. The age distribution in this study was uneven and could lead to biased results. To compensate for the uneven distribution of age, the healthy controls were divided into younger and older groups, and the CSF dynamics variables were compared between the subgroups (younger controls vs. older controls/younger controls vs. LSS patients/older controls vs. LSS patients). The CSF velocities measured at the lumbar level in the older control group tended to be lower than those in the younger control group, without statistical significance; however, those variables were remarkably decreased in the LSS patient group compared to both the younger and older controls . The redCSF dynamics in the spine are determined both by pulse generation from the neurovasculature of the brain and by flow resistance in the spinal canal. The attenuation of CSF pulsation might have resulted from reduced compliance of the central nervous system rather than from structural stenosis of the spine based on the Monro-Kellie doctrine . A previSeveral previous studies have explained how changes in CSF dynamics affect neurogenic symptoms in patients with LSS. In terms of the kinetics of CSF, the theory of stagnant anoxia suggests that an increase in CSF pressure may block radicular venous drainage, resulting in relative hypoxia or a reduction in metabolic exchange , 25; howAlthough spinal imaging is considered the most informative examination for the diagnosis of LSS, its diagnostic value remains uncertain. In practical studies, there is a high prevalence of asymptomatic stenosis; approximately 20% of the elderly population exhibits asymptomatic spinal stenosis on spinal images , 28. NonIn this study, postprocessing of the ROI segmentation has limitations in assessing the CSF flow at the lumbosacral level. The ROI was obtained manually from the small area placed within the ventral part of the dural sac. The CSF flow within the ROI could be different from the total CSF flow in the spinal canal. However, as the spinal cord ends and divides into rootlets in the lumbosacral spine, it is difficult to delineate the CSF space. Moreover, the CSF flow at the lumbosacral level is much attenuated compared with that at the cervical level; it is hard to determine the adequate threshold of the dural sac. A previous study proposed a method for semiautomated ROI segmentation at the C2-C3 level by creating a parametric image with subsequent application of a visually selected threshold . Future Several limitations of this study should be noted. First, kinetic parameters, such as CSF pressure, could not be analyzed using PC-MRI. The CSF pressure may more directly affect neurological impairments in LSS than CSF kinematics. Second, MRI-based tests cannot be used to evaluate CSF dynamics in an active state, which would have revealed pathophysiology more directly. Third, the patient group did not represent LSS patients in general because the current study included only patients with central stenosis without instability or lateral  stenosis to test the effect of CSF dynamics within the canal on LSS symptoms under more homogenous conditions. Fourth, due to the technical constraints of PC-MRI, the detailed parameters of fluid dynamics  were not considered. Future studies that employ computational fluid dynamics could model the kinetic parameters using PC-MRI. CSF flow in the brain or at the cervical level should be assessed, which would allow pulse generation to be directly measured. Furthermore, four-dimensional PC-MRI, which can be used to quantify velocities in the horizontal plane, will provide detailed insights into fluid dynamics. The main limitation of this study is the small cohort size, which may limit its statistical power for obtaining a convincing conclusion. A sufficient sample size could not be calculated, mainly due to the lack of relevant literature. Future research should test the present study’s findings with larger sample sizes.To conclude, attenuation of CSF flow at lumbar spine level is associated with development of neurogenic claudication in LSS, better than severity of structural stenosis. Evaluation of CSF dynamics using PC-MRI may help diagnose LSS in the clinic.S1 Video(MP4)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file. 12 Feb 2021PONE-D-21-01349Cerebrospinal fluid dynamics correlate with neurogenic claudication in lumbar spinal stenosisPLOS ONEDear Dr. Kim,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please adress the suggestions for improvement from the Reviewers and amend your manuscript accordingly.plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.Please submit your revised manuscript by Mar 29 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). 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Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Partly**********2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: I Don't Know**********3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: NoReviewer #2: No**********4. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The work presented is original and well presented, it could help clinicians working in this field.Nevertheless some methodological points should be clarify before publication to improve the value of this paper.Introduction : Authors should introduce previous pioneers works done on the CSF velocities in the spinal canal and discuss itOrigin of subarachnoid cerebrospinal fluid pulsations: a phase-contrast MR analysis. Magn Reson Imaging. 2000 May;18(4):387-95.Henry-Feugeas MC et al“Region of interest (ROI) segmentation of the spinal canal was manually performed to measure CSF dynamics within the ventral part of the dural sac. An ROI was placed within the ventral part of the dural sac, showing an evident change in CSF flow on the axial phase images. Next, the location of the ROI was adjusted by excluding the dura mater or rootlets. “This is a crucial point of the paper; it should be interesting to see clearly the CSF ROIs obtained for the 3 cases presented in figure 1. We can see the CSF flow curves in the graph but we can’t see the Phase contrast images of the CSF flows around the spine!Do the ROIs include all the CSF around the spine present in the slice?Why a background of interest was not applied to avoid eddy current effects ?It should also be important to know how many pixels were in the ROIs, what was the area of the ROIs ?Discussion about MRI acquisition and the post processing steps is important to highlight that the measurements of the small CSF flows obtain in all the spinal canal should be interpreted with caution.Figure 1,2,4 present CSF flow velocity. Is it the mean flow?Please indicate on the graphs that positive values represent cephalic and negative caudal directions.If these curves represent mean velocities of the entire CSF ROIs that mean that CSF have a net flow during the cardiac cycle. In S1 mainly in the cephalic direction whereas in S2 it is mainly in the caudal direction ! IMPOSSIBLEIf authors make the hypothesis that no net flow exist at this level and their ROIs include all the CSF around the spine, May be it should be an idea to automatically move all their CSF flow velocity curves on the Yaxis to correct the error of measurement and obtain a zero net flow. Then the results could be interpreted in a physiological way.In the tables : simplify the numbers : example 0.7 cm/sec rather than 0.719 cm/sec unfortunately accuracy of the measurement is not so good !Reviewer #2: This study provides an interesting look at spinal stenosis from the viewpoint of CSF dynamics that implements a PC-MRI technique to generate a more sensitive marker of neurologic claudication. The study compared CSF dynamics at the lumbosacral level between patients with LSS and healthy controls and investigated whether CSF dynamics parameters explain symptom severity in LSS. 18 healthy controls and 9 patients with LSS MRI examinations were performed.However, the limited sample size and age distribution of cohorts that were compared severely limit the scope of analysis. In addition, the use of ANOVA and linear modeling may not be appropriate given the age distribution of the healthy group. These and other issues should be addressed to better validate use of PC-MRI in LSS.Mayor concerns:(1) The authors showed that there are non-negligible changes in PC-MRI measurements as a function of age; yet the LSS group is older than the control group and the control group is not normally distributed (with both young and old components). The linear models should be repeated with closer age matching, as univariate and multivariate linear models may be biased by bimodal distributions of variables.(2) Line 141-142: The venc was selected as 4 cm/s because the CSF flow was between -2 and 2 cm/s. A reference is needed for this. Also, should different velocities be thought about in each group, if CSF dynamics are significantly altered in the LSS group?(3) Table 2 – These velocities are measured in cross sections, so since the cross-sectional areas of the dural sac in each subject are not provided, it is not clear if this could be driving the differences seen in the velocity profiles.(4) Line 316-317 – It can’t be said that CSF flow at the lumbar level explains the development of neurogenic claudication, but it is simply correlated with it. To explain it there has to be a definite physiological link, which, while hypothesized, has not been proven.(5) It is stated in line 279-280 that increased CSF pressure leads to decreased metabolic exchange. Wouldn’t an increased CSF pressure be associated with higher peak amplitudes, the opposite of what is seen in this study?(6) Table 4 – A log likelihood ratio test (LRT) would be more informative about the relative performance of each model in comparison.(7) Should an ROC analysis be used for different models?Other minor points:(1) Line 43 – Define neurogenic claudication(2) Line 45 – “Mechanical nerve root compression have been” should be “Mechanical nerve root compression has been”(3) In Methods the authors stated that Bonferroni corrected p-values were accepted at p < 0.017, but in Tables 3 and 4 p-values were shown to be significant above this threshold. Were these p-values not subject to Bonferroni correction; explain why.(4) Line 50 – Sentence doesn’t make sense grammatically(5) Can you show an example of an ROI placed in the dural sac?(6) Line 256-257 – This sentence doesn’t make sense(7) Line 307 – Should be turbulent flow(8) Fig 3 is intended to show that none of the CSF velocity profiles correlated with the severity of stenosis. There is no y labels for some plots.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  31 Mar 2021The authors are grateful for the reviewers’ critical comments and the editor’s decision regarding the manuscript. We recognize the importance of the advice, and we have significantly revised the manuscript to the best of our ability.The two reviewers shared concerns regarding the ROI segmentation of the spinal canal. Given the importance of these comments, we answer the overlapping comment first and then address the questions that were more specific. Furthermore, we also employed a professional academic editing service to correct any remaining grammar or syntax problems. We consider the revised manuscript to represent a significant improvement over the previously submitted version.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 13 Apr 2021Cerebrospinal fluid dynamics correlate with neurogenic claudication in lumbar spinal stenosisPONE-D-21-01349R1Dear Dr. Kim,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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For more information, please contact Kind regards,Michael C Burger, M.D.Academic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #1: All comments have been addressedReviewer #2: All comments have been addressed**********2. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: Yes**********3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: Yes**********4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: Yes**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Authors have done an important work to respond to the reviewers commentsthe paper have largely improve and present now coherent results.finally the authors should increase the quality of the images presented because actually the quality doesn't allow to see clearly the rois and understand where the CSF was segmented.Reviewer #2: All my previous comments have been properly addressed. I have no other critiques and I think the article could be an interesting contribution to the field**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article (If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? 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Clostridium perfringens is a potent producer of a variety of toxins. Well studied from these are five toxins , epsilon, iota and CPE) that are produced by seven toxinotype strains (A–G) of C. perfringens. Besides these toxins, C. perfringens produces also another toxin that causes necrotizing enterocolitis in piglets. This toxin termed consensus Beta2 toxin (cCPB2) has a molecular mass of 27,620 Da and shows only little homology to CPB and no one to the other toxins of C. perfringens. Its primary action on cells remained unknown to date. cCPB2 was heterogeneously expressed as fusion protein with GST in Escherichia coli and purified to homogeneity. Although cCPB2 does not exhibit the typical structure of beta-stranded pore-forming proteins and contains no indication for the presence of amphipathic alpha-helices we could demonstrate that cCPB2 is a pore-forming component with an extremely high activity in lipid bilayers. The channels have a single-channel conductance of about 700 pS in 1 M KCl and are highly cation-selective as judged from selectivity measurements in the presence of salt gradients. The high cation selectivity is caused by the presence of net negative charges in or near the channel that allowed an estimate of the channel size being about 1.4 nm wide. Our measurements suggest that the primary effect of cCPB2 is the formation of cation-selective channels followed by necrotic enteritis in humans and animals. We searched in databases for homologs of cCPB2 and constructed a cladogram representing the phylogenetic relationship to the next relatives of cCPB2. Clostridium perfringens consensus Beta2 toxin (cCPB2) has been first identified as the unique virulence factor of a C. perfringens strain isolated from a piglet neonatal necrotic enteritis  which is characteristic of C. perfringens types B and C and which is responsible for necrotic enteritis notably in young animals (Songer C. perfringens harboring cCPB2 gene (ccpb2), CPB gene (cpb) alone, or both cpb + ccpb2 were associated with necrotic enteritis in piglets, and strains containing ccpb2 were also isolated from horses with typhlocolitis , are harbored by non-porcine isolates  based on the combination of 6 toxins , iota, enterotoxin (CPE), and NetB)   Popoff . cCPB2 w) Popoff .C. perfringens enterotoxin (CPE)  containing ampicillin (100 mg/mL) at 37 °C with shaking to an optical density at 600 nm of 0.7. The culture was induced with 1 mM isopropyl b-D thiogalactoside (IPTG) and incubated with shaking at 18 °C overnight. All media for cell growth were obtained from Gibco (ThermoFisher Scientific). After centrifugation, the pellet was suspended in phosphate-buffered saline (PBS) containing protease inhibitors  and sonicated. The cell debris was separated from the soluble fraction by centrifugation . The soluble fraction was applied onto a Glutathione Sepharose 4B column  equilibrated with PBS. The column was extensively washed with PBS and eluted with reduced glutathione 15 mg/mL in 50 mM TRIS–HCl pH 8. The fractions containing GST-cCPB2 were pooled, dialyzed against 50 mM TRIS–HCl, NaCl 150 mM, pH 7.5. Protein content was assayed with Coomassie brilliant blue G-250 (Bio-Rad protein assay). Cleavage by thrombin was performed with the Novagen thrombin kit  according to the manufacturer's recommendations.E data were processed using ProteinLynx Global SERVER version 2.3 (Waters MS-Technologies). Protein identifications and partial amino acid sequence assignments were obtained by searching against all entries of a UniProt/Swiss-Prot (UniProt release 2021_01) database to which the sequence information of GST-cCPB2 was manually added , we subjected the GST-cCPB2 protein to mass spectrometry. The Coomassie-stained 1D-SDS gel band with GST-cCPB2 was worked up to generate tryptic peptides according to published protocols  were used unbuffered and had a pH around 6, because of the dissolved CO2 and the carbonic acid–bicarbonate equilibrium. Other pH-values are indicated. Recombinant GST-cCPB2 and cCPB2 cleaved with thrombin was added from concentrated stock solutions to the aqueous phase bathing membranes in the black state. The temperature was kept at 20 °C throughout. The conductance experiments were performed using a pair of Ag/AgCl electrodes with salt bridges switched in series with a voltage source and a highly sensitive current amplifier . The amplified signal was monitored with a storage oscilloscope and the reconstitution of cCPB2 channels in the black lipid membrane was recorded with a strip chart recorder. Zero-current membrane potential measurements were obtained by establishing fivefold salt gradients across membranes containing about 100 cCPB2 channels as described elsewhere  and ε (= 80) are the absolute dielectric constant of vacuum and the relative constant of water, respectively, and lD is the so called Debye length, which controls the decay of the potential (and of the accumulated positively charged ions) in the aqueous phase , and F the Faraday constant (RT/F = 25.2 mV at 20 °C). The concentration of the monovalent cations near the point charge increases because of the negative potential. Their concentration, The single-channel conductance of the cCPB2 channels was not a linear function of the bulk aqueous conductance see “” section2 incubator. For cytotoxicity and propidium iodide (PI) (Roche) assays, cells were grown to confluency in 96-well plates. The monolayers were washed once in DMEM and incubated in PBS containing 5 mM glucose, 0.1% BSA (Gibco) and serial dilutions of CPE in DMEM .Vero, MDCK, HUVEC cells were grown in Dulbecco's modified Eagle medium (DMEM) + Glutamax™  supplemented with 10% fetal calf serum (Gibco) and containing 100 units/mL penicillin G sodium and 100 μg/mL streptomycin sulfate  at 37 °C in a 5% COFor assay of (propidium iodide) PI entry, HUVEC cells were grown on 96-well plates until confluency. PI (Roche) (5 μg/mL) was added in the culture medium together with toxins. The plates were read with a spectrofluorimeter (Fluoroskan II) (excitation 540 nm and emission 620 nm) at 1, 2, 4, and 22 h. The results were expressed as the percentage of fluorescence obtained by treatment with Triton X-100 (0.2%) for 30 min at 37 °C.E. coli was found to be present as minor contamination in the band (data not shown). The mass spectrometry results verified that we were indeed working with GST-cCPB2 and upon thrombin cleavage with cCPB2, respectively, as the only pore-forming compounds in the protein extracts.Purified recombinant GST-cCPB2 and cCPB2 as obtained by thrombin cleavage of GST-cCPB2 were essentially free of contaminant proteins as shown in Fig. –7 S/cm2) to 10–4 S/cm2 within about half an hour as shown in Fig. In a first set of experimental conditions, we studied the pore-forming ability of the recombinant GST-cCPB2 fusion product in lipid bilayer membranes made of DiPhPC/n-decane. Surprisingly, the addition of this construct in a concentration of about 3 µg/mL to black lipid bilayer membranes resulted in a strong increase of the membrane conductance within about 25 min  of the membranes containing cCPB2 channels. These results indicated again preferential movement of cations for all three salts. The analysis of the zero-current membrane potentials using the Goldman–Hodgkin–Katz equation  were tested for cytotoxicity in human umbilical endothelial cells (HUVEC) by monitoring the entry of propidium iodide (PI) as already used for other C. perfringens pore-forming toxins such as C. perfringens enterotoxin (CPE) or C. perfringens epsilon toxin . The alignment demonstrates the high homology between both toxins. There exists only little doubt that also atypical Beta2 is a channel-forming component because of its high homology to cCPB2.Several versions of CPB2 are known. We performed here experiments with the plasmid-encoded cCPB2 . These programs suggested an only very small fraction of α-helical stretches of amino acids for both Beta2 toxins (cCPB2 and aCPB2) that are not sufficient to cross a membrane. This means presumably that they are not channel-forming proteins that have an α-helical backbone. The content of stretches with β-depleted sheets was much higher. Nevertheless, the search for transmembrane β-strands in both primary sequences with PRED-TMBB (http://bioinformatics.biol.uoa.gr/PRED-TMBB/input.jsp) did not classify both proteins as transmembrane proteins in terms of bacterial outer membrane proteins. This means presumably that only a small part of cCPB2, for instance one or two β-hairpins are involved in the channel similar as for other toxins, including CPB  for proteins that are related to cCPB2. We obtained four proteins that are in sequence and length related to cCPB2, which means presumably that they act also as toxins. The highest homology to cCPB2 has a hypothetical protein from Streptococcus equi (WP_059215460), where the mature protein is identical to the mature cCPB2. The next relative is a hypothetical protein FILTAT 026  from the Firmicute bacterium Filibacter sp. TB-66, which is with a similarity of only 20.77% already distantly related to cCPB2. An even smaller similarity to cCPB2 has a hypothetical protein  from the Firmicute Paenibacillus sp. FSL H7-0357, which has only a similarity of 18.3%. For these proteins, cCPB2, aCPB2 and CPB, we constructed a phylogenetic tree of the CPB2-like proteins from Firmicutes using the program MEGA7 . Figure s Popoff . Pore fo


Modern high-security cryptography and optical communication call for covert bit sequences with high coding capacity and efficient authentication. Stimuli-responsive lasing emissions with easily distinguishable readout are promising in the coding field as a novel cryptographic primitive, while the application is frequently restricted by the limited number of emission states. Here, we report a strategy of achieving multiple competitive lasing signals in responsive organic microspheres where a donor–acceptor pair was introduced. The competitive lasing from the donor and acceptor was reversibly switched by modulating the competition between the radiative rate of the donor and the rate of energy transfer, and the generated multiple lasing signals enabled a quaternary coding for recognizable cryptographic implementation. Data encryption and extraction were demonstrated using a 4 × 4 microlaser array, showing vast prospects in avoiding the disclosure of security information. The results offer a comprehensive understanding of excited-state dynamics in organic composite materials, which may play a major role in high-security optical recording and information encryption. As photonic information technology rapidly develops, confidential tags with high density and security are urgently required and have attracted tremendous interest ,2. An efOrganic materials with multiple upper-level structures and excited-state processes have been proven to possess tunable emission . The lasHerein, we propose a strategy to achieve multiple lasing states for high-security optical encryption by modulating the competition between the radiative rate of the donor and the rate of energy transfer in FRET microlasers. The competitive lasing signals from the donor–acceptor pair were reversibly switched, resulting in multiple distinguishable lasing states. The controlled lasing output enabled a quaternary coding and a proof-of-concept cryptographic implementation was demonstrated using a 4 × 4 microcavity array, which holds vast prospects in avoiding the disclosure of security information. The results not only offer a comprehensive understanding in excited-state dynamics in organic composite materials, but also open up a new way to construct flexible photonic components toward high-security optical recording.rK and the other is energy transfer to the acceptor molecules non-radiatively at the rate of ETK. The radiative rate rK is highly dependent on the population of the first singlet excited state of the donor, which could be effectively controlled by the pump fluence, while the ETK remains approximately unchanged in a certain system. Thus, the competition between rK and ETK can be finely manipulated to enable different excitonic emissions [The smart responsive microlasers with multiple emission states were designed based on the FRET process, which has been utilized to finely modulate excitonic emission . Figure missions ,29. SuchHere, 1,4-bis(α-cyano-4-diphenylaminostyryl)-2,5-diphenylbenzene  aqueous solution. Under vigorous stirring, an oil-in-water emulsion was formed . Driven by isotropic interfacial tension, PS molecules with low crystallinity prefer to aggregate into spherical structures after complete evaporation of CH2Cl2 solvent. The hydrophobic OPV–BODIPY molecules prefer to be embedded into the nonpolar PS spherical structures. The obtained microsphere composites have perfect circular boundaries and ultra-smooth surfaces , which are favorable for whispering-gallery-mode (WGM) resonance  and might trigger a low-threshold lasing. Under 420- to 480-nm light excitation corresponding to the OPV absorption band, the composite microspheres emit strong red fluorescence from the BODIPY  is dominated by the broad spontaneous emission of the BODIPY. The absence of OPV emission (550–580 nm) should be attributed to the highly efficient energy transfer from the donor to the acceptor. With the increase in pump energy, several mode peaks located within the BODIPY emission band were selectively and strongly amplified, manifesting in the occurrence of lasing from the BODIPY . The FRET microlaser exhibits high photostability under laser operation, which may be attributed to the robust microcavity and efficient FRET process in the microspheres . Under a high photoexcitation fluence (435.8 nJ cm−2), surprisingly, the lasing signal from the BODIPY disappeared. Instead, a series of new lasing peaks appeared in the emission band of the OPV molecules. Moreover, dual-wavelength lasing emission was achieved when a moderate pump fluence of ∼314.5 nJ cm−2 was employed. As shown in the corresponding real-color images  system . A typical dye-doped microsphere was excited locally with a focused pulsed laser beam Fig. − is domin−2 for the acceptor and donor, respectively), superlinear increases in PL intensity are observed, which are assigned to the occurrence of stimulated emissions from the donor–acceptor pair. With further increase of pump fluence to >310 nJ cm−2, a gain saturation phenomenon is observed for the donor (yellow line) accompanied by the gradual decrease in the lasing intensity of the acceptor (red line), announcing that the lasing from the donor dominates the deexcitation processes of the donor–acceptor pair. At even higher pump fluences, the lasing signals from the acceptor totally disappear, while the lasing peaks from the donor continue to grow in intensity, revealing the suppression of the FRET process by the direct radiation of the donor.Figure rK and ETK , the PL emission follows a single-exponential decay with an average lifetime τD of 1.62 ns, corresponding to the spontaneous decay process (see Supplementary Table 1). Once the excitation fluence has increased above the lasing threshold, the PL signal turns to decaying biexponentially. Besides the initial slow component (∼1.6 ns), a new rapid component (<80 ps) emerges, which corresponds to the stimulated emission-induced excited-state-population depletion [The competitive lasing signals arise from the competition between stimulated emission from the donor and energy transfer from the donor to the acceptor, which is associated with the relative magnitude of KET Fig. a. The Krrgy Fig. b. When tepletion . The decrK (= 1/τD) increased from 6.2 × 108 to 2.2 × 1010 s−1 with the rising pump fluence  was located within the scope of the rK changes. Therefore, the balance between rK and ETK synchronously changed with the pump fluence, which led to the generation of multiple lasing signals. The underlying mechanism behind the multiple lasing states is schemed in Fig. ETK is larger than the rK, FRET dominates the deexcitation processes, leading to spontaneous emission from the acceptor. When the pump fluence exceeds the first lasing threshold (137.9 nJ cm−2), the majority of the excitation energy captured by donor transfers to the acceptor and lasing from the BODIPY occurs when population inversion is created. Further increasing of the pump fluence would induce simultaneous lasing emissions from the donor and acceptor as a result of the approaching of rK to ETK. At an even higher pump fluence, the rK outpaces the ETK and radiative decay from the donor begins to dominate the deexcitation processes, resulting in lasing from the donor when the corresponding population inversion is built up. Consequently, energy transfer to the acceptor is suppressed and lasing emission from the acceptor disappears due to the inefficient gain. Therefore, dynamic lasing action was well controlled through tailoring the balance between the radiative rate of the donor and the rate of energy transfer.Correspondingly, the rK, ETK is also very important in the manipulation of lasing signals. Considering that ETK is highly dependent on the donor-to-acceptor ratio [ETK-dependent lasing in microspheres with varied molar ratios , which are presented in Supplementary Fig. 11. It is shown that lasing emissions from both the donor and the acceptor were obtained from the microspheres with a low doping ratio of the BODIPY (fBODIPY = 0.125 or 0.250), implying that the ETK is comparable with the rK in both cases. The ETK increases gradually with an increasing doping ratio. For microspheres with a higher doping ratio such as 0.375 or 0.500, high-density excitation only induces the BODIPY lasing as a result of a larger ETK than rK. Therefore, the microspheres with different doping ratios exhibit diverse emission states under a fixed pump fluence . Thus, the quaternary coding greatly enlarges the encoding capacity in comparison with the conventional binary counterpart. For example, an 8-bit quaternary code provides a theoretical capacity of 48 (6.55 × 104), which is 256 times higher than the magnitude of an 8-bit binary one (2.56 × 102). More importantly, the quaternary coding could significantly enhance the security level of the cryptographic keys without increasing the physical size of the bit array .As mentioned above, multiple lasing states have been achieved in dye-doped microspheres through modulating either the pump intensity or doping the ratio of donor-to-acceptor molecules. Such multiple lasing states can potentially carry more information, providing a good platform for developing a quaternary coding resulting from the four possibilities of lasing states. The number of possible combinations in binary bits is 2The application of the smart responsive microlasers with multiple emission states in optical recording and identification is demonstrated in Fig. The coded information is decrypted through collecting the emissions from each microsphere of the whole array using a reading beam Fig. b. As menIn conclusion, we have demonstrated a smart responsive microlaser with multiple emission states for high-security cryptographic implementation. The responsive microlasers, fabricated by incorporating a donor–acceptor pair into an identical microscale resonator, enable unique laser switching among multiple emission states of the donor–acceptor pair, which originates from the competition between the radiative decay of the donor and the energy transfer from the donor to the acceptor. On this basis, we realized a novel quaternary coding platform and a proof-of-concept demonstration of cryptographic application was exhibited with an inkjet-printed microlaser array. The results not only offer a comprehensive understanding of the function-oriented construction of organic composite materials, but also open up a new way for the fabrication of flexible photonic components that can be used for optical recording and information encryption.NSR online.The detailed preparation and characteristic methods of materials are available as Supplementary data at nwaa162_Supplement_FileClick here for additional data file.


Objective: Spontaneous intracranial hypotension (SIH) is typically caused by CSF leakage from a spinal dural tear, a meningeal diverticulum, or a CSF venous fistula. However, some patients present with classic orthostatic symptoms and typical intracranial imaging findings without evidence of CSF leakage despite repeated diagnostic work-up. This article aims to elaborate a hypothesis that would explain a pathologically increased orthostatic shift of CSF from the cranial to the spinal compartment in the absence of a CSF leak.Medical Hypothesis: The symptoms of SIH are caused by a decrease in intracranial CSF volume, intracranial hypotension, and downward displacement of intracranial structures. A combination of pathologically increased spinal compliance, decreased intracranial CSF volume, low CSF outflow resistance, and decreased venous pressure might result in a pathological orthostatic cranial-to-spinal CSF shift. Thus, in rare cases, intracranial hypotension may occur in the absence of CSF leakage from the dural sac.Conclusion: We propose a pathophysiological concept for the subgroup of SIH patients with typical cranial imaging findings and no evidence of CSF leakage. In these patients, reducing the compliance or the volume of the spinal compartment seems to be the appropriate therapeutic strategy. Orthostatic headache is the hallmark of headache attributed to spontaneous intracranial hypotension (SIH) as defined by the third edition of the international classification of headache disorders (ICHD-3) category 7.2.3 . The effOrthostatic headache without CSF leakage due to a pathologically increased spinal compliance was first discussed by Hunderfund and Mokri . However4 are displaying the physiological and pathophysiological concepts of CSF dynamics relevant for SIH that are going to be elaborated in detail in the following.In a person in a recumbent position, the CSF pressure is equal along the craniospinal axis. Thus, the opening pressure during lumbar puncture in a recumbent position corresponds to the ICP. When moving to an upright position, the pressure redistributes along the hydrostatic column from negative values in the cranial compartment to positive values in the spinal compartment . The zerC) is a measure of distensibility. It describes the ratio between changes in volume and pressure Craniospinal compliance  ml . Roughly2O in an upright position  or most often normal but not negative pressure. Thus, in the recumbent position, the intracranial pressure is positive, even in patients with CSF loss, which prevents brain sagging and explains the immediate relief experienced when the patient is lying down.Due to the equal distribution of pressure and fluid when in a horizontal position, the reduced CSF volume and the increased compliance have only a minor effect on ICP in the recumbent position. Measurements of opening lumbar pressure of SIH patients in the recumbent position demonstrate lower  a large number of meningeal diverticula , (2) durIn the case of an overall reduction in CSF volume, the state of the craniospinal compartment shifts to the left on the pressure-volume curve, leading to increased compliance . This mihigher intracranial CSF volume the proportion of CSF shifted is lower and more CSF remains in the intracranial space , CSF outflow resistance (Rout), and sagittal sinus pressure (Pss), as defined in Davson's equation: Clear benefit from unspecific epidural blood patch (EBP), upon repeated applications.These criteria do not provide direct proof and thus allow only the suspicion of internal SIH. Several problems need to be considered when trying to establish this diagnosis: First, because of the limited sensitivity of MR-myelography, CT-myelography, dynamic CT-myelography, and digital subtraction myelography, it is not possible to exclude an existing, but undetected small dural leak or CSF venous fistula. Thus, repeated and targeted work-up is required before considering the diagnosis of internal SIH.out, shows considerable variations and time-dependent behavior , seizures (4.5%), and infections (1.6%) . Hence, out by lumbar infusion testing, and CSF volumetry of cranial and spinal spaces in the diagnostic work-up of these patients.From a pathophysiological point of view, we also advocate measurement of ROf all the contributing factors described above, addressing the pathologically increased spinal compliance and thus the spinal volume reservoir is most feasible. A simple and well-tolerated method to achieve this is EBP , 38. TheAnother therapeutic option to reduce compliance of the spinal compartment is reduction of prominent meningeal diverticula or dural reduction surgery. The principle of the surgery is to reduce the volume capacity of the spinal CSF reservoir and thus to decrease the compliance of the spinal compartment. Consequently, a smaller volume of CSF is shifted from the cranial to the spinal compartment when assuming an upright position. Schievink et al. demonstrated a positive effect of lumbar dural reduction surgery in a patient with intractable SIH but no evidence for CSF leakage . This isWe propose a pathophysiological concept for the subgroup of SIH patients with typical cranial imaging findings and no evidence of CSF leakage after repeated and meticulous work-up. Pathologically increased spinal compliance as the main factor, in combination with predisposing factors such as decreased total and intracranial CSF volume, low CSF outflow resistance, and decreased venous pressure might cause a pathological orthostatic CSF shift resulting in intracranial hypotension and brain sagging even in the absence of CSF leakage. The compliance of the spinal compartment seems to be the most attractive therapeutic target.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author/s.JGo, LH, JB, and AR: design and conceptualized study and drafted manuscript. CJ, IZ, EP, JGr, and TD: revised manuscript for intellectual content. 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.