Background: Immune evaluation of biomaterials for tissue regeneration is a critical preclinical evaluation. The current evaluation criterion (ISO 10993-1 or GB/T 16886) uses rodents to perform the immune evaluation. However, the immune system of rodents is different from humans, the obtained results may not be reliable, which could lead directly to the failure of clinical trials. Granulocyte-macrophage colony-stimulating factor (GM-CSF) shows a great potential application in tissue regeneration by regulating local immune responses. The presented work combines the advantages of GM-CSF (immunoregulation) and hierarchically 3D nanofiber scaffolds (tissue regeneration).Methods: Firstly, we fabricated GM-CSF loaded 3D radially aligned nanofiber scaffolds, and then subcutaneous implantation was performed in humanized mice. The whole scaffold and surrounding tissue were harvested at each indicated time point. Finally, the cell infiltration and local immune responses were detected by histological observations, including H&E and Masson staining and immunochemistry.Results: We found significant cell migration and extracellular matrix deposition within the 3D radially aligned nanofiber scaffold after subcutaneous implantation. The locally released GM-CSF could accelerate the expression of human dendritic cells (CD11c) only 3 days after subcutaneous implantation. Moreover, higher expression of human cytotoxic T cells (CD3+/CD8+), M1 macrophages (CD68/CCR7) was detected within GM-CSF loaded radially aligned nanofiber scaffolds and their surrounding tissues.Conclusions: The 3D radially aligned scaffold can accelerate cell migration from surrounding tissues to regenerate the wound area. And the locally released GM-CSF enhances dendritic cell recruitment and activation of cytotoxic T cells and M1 macrophages. Taken together, the GM-CSF loaded 3D radially aligned nanofiber scaffolds have a promising potential for achieving tissue regeneration. It is mainly divided into helper T cells (CD3+/CD4+) and cytotoxic T cells (CD3+/CD8+). The ratio of helper T cells/cytotoxic T cells is able to determine the status of local immune responses (+/CD8+) is dominant, the local immune responses will be towards anti-infection and removing necrotic tissue (2 fluid expansion technique.Granulocyte-macrophage colony stimulating factor (GM-CSF) is a glycoprotein-based growth factor . It can esponses . When thc tissue . Thus, tc tissue . It showc tissue . It can c tissue . Among oc tissue . In this+ hematopoietic stem cells .We found the locally released GM-CSF could accelerate the expression of human dendritic cells (CD11c) only 3 days after subcutaneous implantation. Moreover, higher expression of human cytotoxic T cells (CD3+/CD8+), M1 macrophages (CD68/CCR7) was detected within GM-CSF loaded radially aligned nanofiber scaffolds and their surrounding tissues. Suggesting the GM-CSF loaded 3D radially aligned nanofiber scaffolds have a promising potential for immune regulation during tissue regeneration.PCL (Mw = 80 kDa) was purchased from Sigma-Aldrich . Dichloromethane (DCM) and N, N-dimethylformamide (DMF) were purchased from BDH Chemicals . DAPI was obtained from Santa Cruz Biotechnology, Inc. . Antibodies, including human CD8 (1:250), human CD4 (1:500), human CD3 (1:500), human CD11c (1:300) were ordered from Abcam . GM-CSF recombinant human protein and GM-CSF human ELISA kit were purchased from Invitrogen .The GM-CSF was dissolved in a 10% pluronic F-127 aqueous solution. Then, the GM-CSF containing pluronic F-127 solution and 10% PCL solution were fed to the inner (0.06 mL/h) and outer nozzles (0.6 mL/h) of co-axial spinnerets during co-axial electrospinning. A rotating drum was used to collect the core-sheath nanofibers. A 1 mm-thick aligned GM-CSF loaded PCL nanofiber mat was collected .2 fluid, we quickly loosened the cap and removed the expanded nanofiber scaffold from the tube. This procedure was repeated until the desired expansion was reached. The expanded, radially aligned PCL nanofiber scaffolds with and without GM-CSF loading were sterilized with ethylene oxide gas before subcutaneous implantation . Next, ∼1 g of dry ice and one piece of nanofiber mat was put into a 30 mL Oak Ridge centrifuge tube, and the tube was sealed. After the dry ice transformed into COantation .After expansion, Pt sputter coating was performed on the surface of GM-CSF loaded radially aligned nanofiber scaffolds. Then the morphology of GM-CSF loaded radially aligned nanofiber scaffolds was characterized by SEM .One GM-CSF loaded expanded radially aligned nanofiber scaffold was immersed in 2 mL distilled water at 37°C. The supernatant was collected at each indicated time-point, and subsequently, 2 mL of fresh filtered water was added. The concentration of released GM-CSF at each time point was measured using an ELISA kit.2 on the back of each animal was shaved, and the povidone-iodine solution was applied three times on the exposed skin. Subcutaneous pockets were made (1 cm incisions) on both sides of the dorsum. The GM-CSF encapsulated expanded radially aligned nanofiber scaffold was directly inserted into a subcutaneous pocket with tweezers, and the skin incisions were closed with a stapler. Each mouse received two scaffolds. Two mice were considered the treatment group to investigate four implants for each group. Mice were euthanized with CO2 at 3, 7, 10, and 14 days post-implantation. Each explant with the surrounding tissue was gently dissected out of its subcutaneous pocket and then immersed in formalin for at least 3 days before histology analysis.The humanized mice used in this study were created as in our previous study . The humFixed samples were dehydrated in a graded series of ethanol (70%–100%), embedded in paraffin, and then sectioned (5 μm thick). Samples were stained with either hematoxylin, eosin (H&E), or Masson’s trichrome stain.+/CD4+, and CD3+/CD8+ positive cells in each 200 μm2 area, and five randomly selected areas were used to determine the average positive cells per mm2.For immunohistochemical staining, slides were deparaffinized and rehydrated, followed by antigen retrieval in heated citrate buffer for 5 min . Non-specific antibody binding was prevented with a 5% BSA solution. The sections were incubated with primary antibodies overnight at 4°C. Then the corresponding secondary antibodies were added and incubated for 1 h at room temperature, followed by staining with DAPI for 5 min. We counted all CD11c, CD3post hoc tests. The values of p < 0.05 were considered statistically significant. The values of p < 0.01 were considered statistically highly significant.Data are presented as the mean ± S.D., and statistical analysis was performed using SPSS 13.0 software . Differences among groups were assessed using one-way ANOVA followed by in vivo evaluations of these studies were performed in rodents model, which provided a limited understanding of interactions between the human immune system and these therapies, resulting in the failure of a clinical trial, even inducing some unexpected side effects in patients. To address this limitation, humanized mice have been widely used for long-term in vivo studies in transplant rejection, cancer immunology, and infectious diseases because of their unique human immune system , 7 (p < 0.01), 10 (p < 0.01), and 14 (p < 0.01) days. These results indicate the locally released GM-CSF from implanted radially aligned nanofiber scaffold could enhance the expression of dendritic cells.Here, we first examined the effects of GM-CSF on the recruitment of dendritic cells, which highly expressed CD11c. As shown in +/CD4+) (A) and human cytotoxic T cells (CD3+/CD8+). As shown in +/CD4+) between the expanded radially aligned PCL nanofiber scaffolds with or without GM-CSF loading after subcutaneous implantation for 3 and 7 days. While the expression of human helper T cells (CD3+/CD4+) within expanded radially aligned PCL nanofiber scaffolds with GM-CSF loading was dramatically increased compared to that within expanded radially aligned PCL nanofiber scaffolds after 10 (p < 0.01) and 14 (p < 0.01) days of subcutaneous implantation. As shown in +/CD8+) within expanded radially aligned PCL nanofiber scaffolds with GM-CSF loading was significantly increased compared to that within expanded radially aligned PCL nanofiber scaffolds after 3(p < 0.01), 7 (p < 0.01), 10 (p < 0.01) and 14 (p < 0.01) days of subcutaneous implantation. In other’s studies, the earliest detection point for dendritic cells and cytotoxic T cells is 5, 7, and 9 days after surgery, respectively  and human M1 macrophages (CD68/CCR7). As shown in in vivo , helper T cells (CD3+/CD4+), and cytotoxic T cells (CD3+/CD8+) was found to be significantly higher in the expanded radially aligned PCL nanofiber scaffold loaded with GM-CSF than it in the radially aligned nanofiber scaffold unloaded with GM-CSF. It has been shown that CD11c+ has a synergistic stimulatory effect on immune cells and is an essential regulator of CD4+ T cells and CD8+ T cells proliferation and function  will also be encapsulated into the 3D radially aligned scaffolds along with the GM-CSF. The maturation of dendritic cells will be further explored . For ano


Discoidin Domain Receptor (DDR)-1 is activated by collagen. Nilotinib is a tyrosine kinase inhibitor that is FDA-approved for leukemia and potently inhibits DDR-1. Individuals diagnosed with mild–moderate Alzheimer’s disease (AD) treated with nilotinib (versus placebo) for 12 months showed reduction of amyloid plaque and cerebrospinal fluid (CSF) amyloid, and attenuation of hippocampal volume loss. However, the mechanisms are unclear. Here, we explored unbiased next generation whole genome miRNA sequencing from AD patients CSF and miRNAs were matched with their corresponding mRNAs using gene ontology. Changes in CSF miRNAs were confirmed via measurement of CSF DDR1 activity and plasma levels of AD biomarkers. Approximately 1050 miRNAs are detected in the CSF but only 17 miRNAs are specifically altered between baseline and 12-month treatment with nilotinib versus placebo. Treatment with nilotinib significantly reduces collagen and DDR1 gene expression (upregulated in AD brain), in association with inhibition of CSF DDR1. Pro-inflammatory cytokines, including interleukins and chemokines are reduced along with caspase-3 gene expression. Specific genes that indicate vascular fibrosis, e.g., collagen, Transforming Growth Factors (TGFs) and Tissue Inhibitors of Metalloproteases (TIMPs) are altered by DDR1 inhibition with nilotinib. Specific changes in vesicular transport, including the neurotransmitters dopamine and acetylcholine, and autophagy genes, including ATGs, indicate facilitation of autophagic flux and cellular trafficking. Inhibition of DDR1 with nilotinib may be a safe and effective adjunct treatment strategy involving an oral drug that enters the CNS and adequately engages its target. DDR1 inhibition with nilotinib exhibits multi-modal effects not only on amyloid and tau clearance but also on anti-inflammatory markers that may reduce cerebrovascular fibrosis.The online version contains supplementary material available at 10.1186/s12974-023-02802-0. Vascular contributions to cognitive impairment are increasingly recognized –6. SmallDiscoidin Domain Receptor (DDR)-1 is a non-receptor tyrosine kinase (TK) that is implicated in several fibrotic disorders. DDR1 inhibition reduces accumulation of macrophages, attenuates the inflammatory response and suppresses fibrosis in models of atherosclerosis , 14, andTo address the question of DDR1 effects on blood vessels and inflammation in dementia, we performed longitudinal epigenomic studies via unbiased next generation whole miRNA genome sequencing of CSF obtained from mild–moderate AD patients who were treated with nilotinib (versus placebo), which significantly reduced CSF Aβ levels and CNS amyloid burden as measured with Positron Emission Tomography (PET) .n = 20) or nilotinib, 150 mg for 6 months followed by nilotinib, 300 mg, for another 6 months (n = 17). All enrollees (N = 37) met inclusion/exclusion criteria and the study excluded cardiovascular disease, mini mental status exams (MMSE) score out of range, or a diagnosis of AD not supported by biomarker evidence. Concomitant drugs known to prolong the QTc interval and history of any cardiovascular disease, including myocardial infraction or cardiac failure, angina, arrhythmia were not permitted. Any cardiovascular or cerebrovascular event , congestive heart failure, second- or third-degree atrioventricular block, sick sinus syndrome, or other serious cardiac rhythm disturbances were excluded. Significant pathological findings on brain MRI , including cerebral microhemorrhages, cerebral macro-hemorrhages, or superficial siderosis with vasogenic edema were excluded. Other excluded MRI findings included more than 4 micro hemorrhages (defined as 10 mm or less at the greatest diameter); a single macro hemorrhage greater than 10 mm at greatest diameter; evidence of cerebral contusion, encephalomalacia, aneurysms, vascular malformations, or infective lesions; evidence of multiple lacunar infarcts or stroke involving a major vascular territory, severe small vessel, or white matter disease; space occupying lesions; or brain tumors. There was two diabetic patients in this study. Mean (SD) age of the participants was 70.7 years (6.48) and the sample included 10 men (27%) and 27 women (73%). The mean (SD) MMSE was 19.2 (3.1) in the placebo group and 19.8 (2.5) in the nilotinib group. The apolipoprotein-E (APOE) genotype in the placebo group was E4/E4 5 (25%), E3/E4 5 (25%), E2/E4, 4 (20%), E2/E2 1 (5%), and 5 (25%) inconclusive genotypes. In the nilotinib group, APOE was E4/E4 7 (41.2%), E3/E4 1 (5.9%), E2/E4 3 (17.6%), E3/E3 1 (5.9%), E2/E2 1 (5.9%), and 4 (23.5%) inconclusive genotypes. Participants and study partners were recruited, and this study was conducted in accordance with Good Clinical Practice guidelines and approved by the Institutional Review Board (IRB #2016–0351) at GUMC as well as GHUCCTS scientific review board. The study was conducted under FDA Investigational New Drug (IND) #130732 and registered in ClinicalTrials.gov (NCT02947893) [The primary research objective of this study was to assess longitudinal alterations in CSF microRNAs from samples previously collected in mild–moderate AD patients . As prev2947893) . All samCSF was collected via lumbar puncture (LPs), which was performed on all patients between 1 and 4 h at baseline and 12 months (end of treatment) with placebo or nilotinib. Cell-free total RNA was isolated from 200 µl of CSF using the Qiagen miRNAeasy extraction kit  and CSF microRNA sequencing was performed as we previously explained . Samplesp values obtained are then adjusted for multiple testing using the Benjamini and Hochberg method. Gene ontology (GO) pathway and functional enrichment analyses were performed on the gene targets of the significant DEMs using PANTHER Classification System. Only enriched pathways and GO terms that met Benjamini–Hochberg p < 0.05 were reported.Data analysis was performed using Partek Flow software to identify differentially expressed microRNAs. An optimized workflow was used to perform quality assessment, alignment, quantification, normalization, and different analysis. Quality assessment of data in fastq format was performed in Partek flow and reads containing the adapters or low-quality bases (Qscore ≤5) were removed. The trimmed reads were then aligned to the hg38 reference genome using the Bowtie method. The aligned reads were then quantified to the miRBase reference to obtain the total miRNA read count for each sample. DESeq2 method was used for normalization of the miRNA read counts, followed by DESeq2 implementation of the likelihood ratio test (LRT) to test for multiple terms at once and interaction between the variables. The LRT for count data is conceptually similar to an analysis of variance (ANOVA) calculation, except that in the case of the Negative Binomial GLM, an analysis of deviance (ANODEV) is used, where the deviance captures the difference in likelihood between a full and a reduced model . The p vm) that is y = mx + c using linear regression analysis as a convenient mathematical expression. Slower slope suggests less active DDR1 (less pDDR1), and faster slope is more active DDR1 (more pDDR1) over time.To estimate spectrophotometrically the levels of active or phosphorylated DDR1 (pDDR1) in CSF, we measured the level of pan-tyrosine pDDR1 via ELSA using PathScan phosphorylated DDR1 panTyrosine  and determined the absorbance (AU) change during the assay. To perform longitudinal measurement of CSF pDDR1 over time within the same patient, absorbance measurement of CSF pDDR1 collected at baseline was subtracted from absorbance (AU) at the next CSF collection and estimated the change of linear absorbance versus time of assay mixture measured at wavelength 450 nm. We plotted the linear graph with absorbance change versus time that is the absorbance change per time of the reaction (ΔA/time) and found the slope  Platform  that uses UMI magnetic reagents  and Aβ40, Aβ42, total tau, and p-tau 181 and p-tau217 IMR reagent .The data supporting the current study are available from the corresponding author on request.n = 11) and nilotinib groups (n = 12). A total of 17 microRNAs (1.6%) were significantly different between the placebo and nilotinib groups, accounting for both treatment and time. Ingenuity Pathway Analysis (IPA) microRNA Target filter tool matched associated mRNAs or targets that are experimentally validated from TarBase, miRecords, as well as highly predicted miRNA–mRNA interactions from TargetScan and revealed that these microRNAs are associated with genes that primarily control molecular pathways of autophagy, inflammation, collagen expression, and dopamine metabolism.Unbiased next generation whole genome sequencing of CSF miRNA showed expression profiles of a total of 1050 miRNA . However, treatment of AD patients with the DDR1 inhibitor nilotinib . We previously demonstrated that DDR1 inhibition with nilotinib lowers CSF Aβ levels and reduces CNS amyloid burden by PET in the same cohort of AD patients [To verify the effects of nilotinib on DDR1 activity, we show that the level of CSF pDDR1 in placebo-treated AD patients Fig. A was signib Fig. B showed patients . Here, wpatients . A speciWe observed changes in specific miRNAs that control interleukins (ILs) and chemokines that are collectively indicative of reduced inflammation with nilotinib treatment Fig. . Specifitg/tg/DDR−/−) and showed that vascular collagen IV  were increased in the nilotinib group Fig. , indicatIn addition, specific miRNAs that target autophagy-associated genes (ATGs) were altered to promote autophagy flux in the nilotinib group when compared to the placebo group Fig. . These mWe also observed upregulation of the nuclear transcription factor CREB , that binds to cAMP response element (CRE) to regulate neuronal processes, including metabolism and survival and expression of different transcription factors and growth factors. Platelet derived growth factor (PDGF)B (hsa-miR-150-5p) is upregulated in the nilotinib group. There is also a significant decrease in insulin growth factor (IGF), (hsa-miR-206) and Insulin Receptor Signaling (IRS1), (hsa-miR-96-5p) that control main pathways of insulin signaling, such as the phosphatidylinositol 3-kinase (PI3K) (hsa-miR-124-3p), Akt (hsa-miR-150-5p), Akt substrates, Ras and mitogen-activated protein (MAP)  kinase. Hypoxia-Inducible Factor (HIF1A) (hsa-miR-199b-5p), and the Forkhead/winged helix box gene (FOXO) (hsa-miR-96-5p) are involved in energy metabolism, oxidative stress, proteostatis, apoptosis, immunity, and inflammation, and are downregulated, whereas, expression of the immediate early gene, Fos (hsa-miR-155-5p), that is critical to learning and memory in increased with nilotinib.We previously demonstrated that AD patients treated with nilotinib exhibit a decrease in dopamine metabolism following 12 months of treatment with nilotinib versus placebo . Here, w50 > 20 nM) [50 = 1 nM) [max: 3.46 nM and 1099 nM, respectively) and the 300 mg daily dosage , suggesting a linearly proportional increase to dose in the brain [50 1 nM). Here, we show that treatment with nilotinib significantly increases CSF miRNAs that inversely regulate DDR1 mRNA expression to decrease active CSF pDDR1, indicating a pharmacokinetic and pharmacodynamic relationship. Nilotinib penetrates the CNS (> 1 nM) and directly inhibits DDR1 and alters AD biomarkers, including Aβ as measured by PET, CSF Aβ42 and Aβ40, and the plasma ratio of Aβ42 to p-Tau217. Clinically, nilotinib (Tasigna) 150 mg and 300 mg, resulted in stabilization of cognitive and motor decline in PD–MCI over 27 months [The current study is a continuation of our previous phase 2 investigation in mild–moderate AD patients treated with the DDR1 inhibitor, nilotinib, which significantly lowered CSF Aβ levels and amyloid burden as measured by PET . Nilotin> 20 nM)  and is F = 1 nM) . Pharmache brain  that wou7 months . In AD, 7 months . Importa7 months , 26, 30.7 months .COL25A1 increases AD risk in a Swedish population [COL4A1 gene, in association with COL4A3, are necessary for maturation of type IV collagen, and COL4A1 mutations cause cerebral small vessel disease, i.e., intracerebral hemorrhage and shortened life-span [DDR1 plays a direct role in angiogenesis  and regupulation . COL25A1pulation . The COLife-span , 47. COLife-span  and DDR1ife-span ; we obseife-span  in the nife-span , as wellife-span  and chemife-span . COL6 geife-span .Dopamine plays an important role in executive functions via dopaminergic neurons in the mesolimbic system and this role may be particularly relevant to AD , 56, as Demonstration of miRNA changes that control genes which regulate molecular pathways involved in autophagy are indicative of autophagosome maturation, membrane trafficking and cellular transport  and are The current miRNA analysis has several limitations due to underpowered study design that would consider more adequate inclusion and stratification of other co-morbidities of AD, such as diabetes, cerebrovascular disease, and other factors, such as sex differences and ApoE genotypes. Furthermore, evaluating extracellular vesicles in CSF following nilotinib delivery is highly desirable in future studies.In conclusion, the tyrosine kinase inhibitor nilotinib enters the CNS, inhibits DDR1, and is associated with diverse tissue changes Fig.  not onlyAdditional file 1. Additional methods and results.Additional file 2: Fig. S1. Collagen 4and amyloid-betastaining in the cortex of 5-month-old male and female A–D APPtg/tgDDR−/−mice and E–H age matched APPtg/tg DDR+/+littermate controls, and quantification of I vessel wall thickness and J vessel diameter. A–C and E–G blood vessels were imaged longitudinally, D and H blood vessels were imaged cross-sectionally. N=4 mice per group, **=0.0048, ***=0.0002, unpaired two-tailed students t test.


Split-thickness skin grafts (STSG) are commonly used to treat soft-tissue defects. Harvesting a STSG creates an additional partial thickness wound at the donor site which must be managed. Many dressings are commercially available for the management of STSG donor sites; however, there is no evidence-based consensus on optimal dressing for site management. Urinary bladder matrix (UBM) is an extracellular matrix that acts as a structural support for tissue remodeling and provides molecular components for repair. Common clinical applications of UBM include coverage of deep wounds, burns, and irradiated skin. Skin grafting from the lower extremities poses a challenge due to the increased dermal tension. UBM-based reconstruction is an alternative method of managing lower extremity skin graft donor sites. This case study demonstrates the use of UBM in the reconstruction of a STSG donor site of the anterolateral thigh, which resulted in satisfactory healing, no pain, and excellent cosmetic and functional outcomes.  Large soft-tissue defects are traditionally treated with immediate full- or partial-thickness skin grafts . Split-tA 35-year-old male diagnosed with necrotizing fasciitis of the right lower extremity was transferred to our facility from a rural hospital to undergo irrigation and debridement with intraoperative placement of a subcutaneous wound VAC. Plastic surgery was consulted for skin grafting after serial debridements were complete. The wound, which measured 4.4 × 14.1 cm and extended to the level of the soleus muscle, was closed 3 days later with a 0.014-inch STSG harvested from the anterolateral left thigh in one continuous piece. Epinephrine-soaked gauzed was applied to the donor site to aid with hemostasis and then the graft was anchored to the wound edges circumferentially with interrupted 4-0 gut sutures. The graft was covered with a layer of nonadhering dressing, and a wound VAC was placed.The left anterolateral thigh donor site  was coveThe donor site dressing was removed 1 week postoperatively, revealing a well-healing wound with no infectious signs or symptoms . The patSTSG involves excising the epidermis and part of the dermis to form a graft used for the coverage of a tissue defect caused by trauma, burns, surgical resection, and acute and chronic wounds. The dermis that remains facilitates healing of the donor site and reepithelialization typically occurs within 7–14 days . Proper Extracellular matrices (ECM) are naturally derived products with clinical applications, including tissue reconstruction and wound management. ECM is derived from many biologic tissues, including heart valves, blood vessels, skin, nerves, skeletal muscle, tendons, ligaments, small intestine, liver, and urinary bladder . UBM actCommon clinical applications of UBM include coverage of deep wounds, burns, and irradiated skin. Porcine UBM has been shown to be an effective alternative to flap coverage in patients with orthopedic wounds that have exposed tendon and bone . In trauAlthough current literature supports UBM as an alternative to the traditional grafting of fasciocutaneous free flap donor sites , there iThis case study demonstrates that the use of UBM in the management of a STSG donor site results in excellent cosmetic and functional outcomes.


Cryptococcus neoformans primarily affects immunocompromised individuals and the central nervous system (CNS) is the most common site of dissemination. Entrapped temporal horn syndrome (ETH) remains a rare CNS manifestation and has not previously been described in solid organ transplant recipients. Here, we present a case of ETH in a 55-year-old woman with history of renal transplant and prior treated Cryptococcal meningitis. Cryptococcus neoformans (C. neoformans) is an encapsulated yeast pathogenic to both humans and animals [C. neoformans has been found in soil worldwide and in the avian environment in particular [C. neoformans primarily affects those who are immunocompromised due to conditions such as acquired immunodeficiency syndrome, organ transplantation on immunosuppressive agents, or malignancy on anti-cancer drugs [ animals ,2. C. neer drugs ,3. Specier drugs ,5.Cryptococcus survives within pulmonary macrophages [C. neoformans can migrate from the lungs to the bloodstream or meninges if not contained by the patient’s immune system [Infection occurs primarily through inhalation of the fungus. Due to a thick polysaccharide capsule, rophages . C. neofe system . The cene system ,6.C. neoformans CNS infection.Complications of CNS infection include meningoencephalitis, cranial neuropathies, brain abscess, vasculitis, ischemic or hemorrhagic stroke, and communicating or non-communicating hydrocephalus. Temporal horn entrapment represents a rare form of isolated non-communicating hydrocephalus and has not previously been described in association with cryptococcosis in solid organ transplant patients. Here, we report a case of an immunocompromised kidney transplant recipient who developed temporal horn entrapment following treatment of This case describes a 55-year-old woman with a history of recurrent kidney stones, which led to kidney failure. She was maintained on hemodialysis for 6 years prior to kidney transplantation. She received thymoglobulin induction therapy at the time of transplantation. She was maintained on tacrolimus 1.5 mg once every morning and 1 mg once every evening, mycophenolate mofetil 750 mg twice daily, and prednisone 5 mg daily. Post-transplant course initially presented with delayed graft function, but she eventually was able to discontinue dialysis and currently has good allograft function, with a baseline creatinine of 1.0 mg/dL. She had no history of rejection.2O, elevated cerebrospinal fluid (CSF), elevated white blood cells (115 per mm3), minimally elevated CSF red blood cells (10 per mm3), low CSF glucose (4 mg/dL), elevated CSF protein (164 mg/dL), positive Cryptococcal CSF antigen, and a yeast which, on blood and chocolate agar, was identified as C. neoformans using Matrix-Assisted Laser Desorption/Ionization (MALDI). She received induction therapy with liposomal amphotericin B 5 mg/kg IV daily and flucytosine 1500 mg PO QID. After 2 weeks of treatment, opening pressure normalized, CSF white blood cells dropped to 53 per mm3, CSF glucose rose to 18 mg/dL, and protein dropped to 132 mg/dL; Cryptococcal CSF antigen was negative, and repeat CSF cultures were negative. Following 2 weeks of induction therapy, she was transitioned to fluconazole 600 mg PO daily for 3 months, followed by fluconazole 200 mg PO daily thereafter, based on her renal function. She reported excellent adherence.Her cryptococcal history was pertinent for headaches beginning 5 months after renal transplantation. She was evaluated in the emergency department multiple times and was initially diagnosed with migraine headaches. At 11 months post-transplant, her headaches worsened, and she developed nausea and vomiting, prompting a lumbar puncture to be performed, which showed an opening pressure of 24 cm HComputed tomography (CT) head without contrast revealed a 4.9 × 4.3 × 4.8 cm circumscribed cystic structure/lesion effacing the right temporal lobe with surrounding vasogenic edema and midline shift (3), elevated red blood cell count (23 per mm3), mildly elevated protein (47 mg/dL), high glucose (73 mg/dL), negative meningoencephalitis panel , negative bacterial/fungal cultures, and negative CSF cryptococcal antigen testing. Following the return of CSF results, liposomal amphotericin B was discontinued and home medications of mycophenolate mofetil, fluconazole, and prednisone were restarted. Her presentation of a new trapped right temporal horn was thought to be a complication of her prior episode with C. neoformans meningitis due to intraventricular scarring. Her course was complicated by occipital neuralgia related to the VP shunt and was managed with gabapentin. She completed a total of 26 months of total therapy, after which fluconazole was stopped. At 9 months after the cessation of therapy, she is doing clinically well without a return of prior cryptococcal meningitis.At 21 months post-transplant , she developed worsening headaches, nausea, and vomiting. ne shift a. Magnetne shift b. She waEntrapped temporal horn syndrome (ETH) is a form of focal hydrocephalus in which the obstruction of one lateral ventricle in the region of the trigone isolates the temporal horn. Due to the continued secretion of cerebrospinal fluid within the temporal horn, the pressure increases with a surrounding mass effect, mimicking a mass lesion. Following focal ventriculitis within the temporal horn and the accompanying elevated CSF protein concentration, meningeal inflammation and the increased CSF viscosity may cause obstruction of the foramen of Monro. This obstruction impairs normal CSF flow from the lateral ventricles to the third ventricle .Infectious causes of a trapped temporal horn, such as meningitis, ventriculitis, and hydatid cysts, as well as intraventricular neurocysticercosis and the development of fibrosis, are thought to be predisposing factors ,9,10. MePreviously, there have been reports in the literature involving mass lesions caused by choroid plexus involvement due to cryptococcal infection. One case in an immunocompetent patient demonstrated that choroid inflammation from cryptococcal meningitis can lead to the formation of intraventricular synechiae, loculation, and temporal horn entrapment ,13. FindCryptococcus spp. Zhuang et al. previously described a case of presumed bacterial meningitis complicated by an entrapped temporal horn two months after successful antimicrobial treatment [Because the choroid plexus is the interface between the CSF and systemic circulation, it is the portal of entry for many pathogens, including cytomegalovirus, tuberculosis, and other infectious agents, in addition to reatment . Anotherreatment .The treatment of entrapment syndrome consists of surgical intervention to alleviate the obstruction, and this can be performed endoscopically. Given that this complication may occur in the absence of ongoing presence of pathogens, fluid analysis and cultures for the assessment of disease quiescence is important to guide ongoing therapy. Surgical treatment is paramount and includes re-establishing communication of the trapped ventricle with the rest of the ventricular system, or providing a shunt system, as in our patient .In summary, ETH should be suspected when patients develop symptoms of an expanding temporal lobe mass following a condition involving the trigone of the lateral ventricle. The diagnosis should also be considered in patients who have a history of cryptococcal meningitis with imaging findings of a large cystic structure centered within the temporal lobe.


Background: Traditionally, there is a widely held belief that drug dispersion after intrathecal (IT) delivery is confined locally near the injection site. We posit that high-volume infusions can overcome this perceived limitation of IT administration.Methods: To test our hypothesis, subject-specific deformable phantom models of the human central nervous system were manufactured so that tracer infusion could be realistically replicated in vitro over the entire physiological range of pulsating cerebrospinal fluid (CSF) amplitudes and frequencies. The distribution of IT injected tracers was studied systematically with high-speed optical methods to determine its dependence on injection parameters  and natural CSF oscillations in a deformable model of the central nervous system (CNS).Results: Optical imaging analysis of high-volume infusion experiments showed that tracers spread quickly throughout the spinal subarachnoid space, reaching the cervical region in less than 10 min. The experimentally observed biodispersion is much slower than suggested by the Taylor–Aris dispersion theory. Our experiments indicate that micro-mixing patterns induced by oscillatory CSF flow around microanatomical features such as nerve roots significantly accelerate solute transport. Strong micro-mixing effects due to anatomical features in the spinal subarachnoid space were found to be active in intrathecal drug administration but were not considered in prior dispersion theories. Their omission explains why prior models developed in the engineering community are poor predictors for IT delivery.Conclusion: Our experiments support the feasibility of targeting large sections of the neuroaxis or brain utilizing high-volume IT injection protocols. The experimental tracer dispersion profiles acquired with an anatomically accurate, deformable, and closed in vitro human CNS analog informed a new predictive model of tracer dispersion as a function of physiological CSF pulsations and adjustable infusion parameters. The ability to predict spatiotemporal dispersion patterns is an essential prerequisite for exploring new indications of IT drug delivery that targets specific regions in the CNS or the brain. Tracking tracer dispersion in vivo with multimodal PET/MRI , are a complement and a logical alternative to authentic, but often inaccurate, in vivo infusion trials with limited temporal and spatial resolution. Several labs have also employed in vitro tests  and achievable drug distributions. A key requirement for realistic infusion bench tests is the availability of an anatomically accurate model of the spinal microanatomy with a deformable, closed, fluid-filled spinal compartment with controllable pulsatile CSF flow.Previous studies on intrathecal (IT) administration in pigs using very slow infusion rates  contribu PET/MRI  or compu PET/MRI . In part PET/MRI . Hence, ro tests  and CFD ro tests  for studdispersion speed) as a function of infusion settings  and natural physiological properties . We further compare the experimental data with prior theories (Taylor) of solute transport in oscillatory pipe flow.In this paper, we will present parametric studies of IT infusion experiments in a subject-specific, anatomically accurate, deformable, and transparent replica of the human spinal SASs with natural CSF pulsations within the physiological range of spinal fluid amplitude and frequency inside the closed spinal compartment reproduced in a unique 3D printed, deformable, and transparent CNS analog. High-speed video recording enabled accurate observation of spatiotemporal tracer distribution patterns following high-volume IT injection as a function of natural CSF oscillations. The results characterize the speed of the tracer front  and systemic blood pump settings  enabled the implementation of a comprehensive spectrum of infusion scenarios (bolus and chronic drug pump) occurring in the physiological range of CSF oscillations. More than 50 tracer infusion experiments of trypan blue (Sigma-Aldrich) released with a programmable syringe pump (Harvard Instruments) were performed to precisely investigate the correlation between dye dispersion, CSF pulsations, and infusion parameters. Trypan blue was chosen for its intense blue color needed in optical front tracking. In a clinical setting, acute high-volume injection via a catheter is administered in a lying down  position for safety. Thus, the horizontal patient position was chosen for our experiments.To reproduce conditions of Snapshots were obtained from the experimental videos showing the dispersion of the tracer at different times. RGB triplet values for pixels along the neuraxis were recorded in each frame used for analysis . The RGB color values were aggregated with a grayscale formula and intensities inferred from white-offset . White-offset and area under the curve (AUC) scaling enabled quantitative dye concentration neuraxis .Materials and methods. There was no tracer absorption into the dura and parenchymal walls that would have affected lighting properties. Trypan blue did not stain our system, and no loss of material was observed after months of use.A custom image analysis code was used to determine the speed and spatial position of the visible dye front. method of moments (MoM) was used to determine the apparent tracer dispersion velocity from video data because it minimizes the sensitivity of optically acquired concentration profiles to uneven lighting conditions, scattering effects, and uncertainty in concentration inference from intensity data , cervical stroke volume, rms, correlates a clinical MR quantity to parameters used in our formal flow analysis. Thus, two stroke volume settings of 0.5 mL/beat to 1 mL/beat in the frequency range of 0–120 beat/min enabled us to cover a wide range of CSF flow velocity averages covering the entire physiological range (0.09–0.93 cm/s).The average CSF flow velocity, U0 is the initial volume of CSF in cm3 in the system and f is the frequency in beats per minute, with period T in seconds.The mean CSF flow velocity, p-value of 0.05 was considered statistically significant.Initially, the experiments were repeated three times with the same settings. The repeats essentially gave the same moments, thus confirming the reproducibility and robustness of data acquisition. The results of the Shapiro–Wilk test indicated that all datasets had a normal distribution. The ANOVA test was used in the regression analyses using IBM SPSS v26 to confirm that regression models described the dependent variables. Confidence intervals were calculated for all regression results. The Durbin–Watson statistic for all regression results was 0.716; therefore, the datasets have autocorrelation. Furthermore, calculated tolerances indicated the multicollinearity effect in the datasets. A 2/min) confirms the reproducibility and acceptably low experimental variability of the experimental setting. The first moment gives information about the caudocranial velocity, and the second moment determines the dispersion coefficient of the tracer as shown in Eq. dispersion width of the tracer at time t, DD(t). The next section shows the systematic analysis of infusion and physiological parameters on the speed of tracer dispersion.10, was measured from the point of the needle tip to the tip of the dye front in the caudal and cranial directions. The duration of 10 min was chosen because this initial time window is critically important for assessing acute risks associated with high-volume IT injection. High local toxicity has been implicated with granuloma formation (We studied the effect of catheter diameter on the speed and size of the dispersion front. Infusion experiments are performed using three different catheters with inner diameters of 0.2 mm (needle N1), 1.0 mm (N2), and 3.2 mm (the widest needle N3). Infusion lasted 1 min over the course of 54 experiments. The dispersion width after 10 min, DDormation . We also1. For identical infusion flow rate , the large caliber needle (N3) generated the shortest dispersion width. 2 value of 0.7916. and IVF , where The realization of a fixed infusion rate with thinner catheters requires higher infusion pressure resulting in higher exit velocities  were conducted to systematically characterize tracer targeting toward the cranial compartment as a function of infusion parameters  and frequencies in a series of dynamic tracer infusion experiments. Two stroke volume settings of 0.5–1 mL/beat in the frequency range of 0–120 beat/min enabled us to induce a wide range of CSF flow velocity averages covering a wide physiological range (Urms = 0.09–0.93 cm/s). The root-mean-square velocity of the CSF, exp, summarized in exp = 1.50–2.94 cm2/min for a 0.5 mL/beat stroke volume, and Dexp = 2.57–4.70 cm2/min for the 1 mL/beat stroke volume as shown in Table E2 and E3, respectively, of Once infusion stops (t > 1 min), further tracer spread is no longer propelled by injection impulse, but by natural oscillations of the CSF. In our closed, deformable model, induced CSF flow in the spinal SAS is also oscillatory with zero net flux. This is also approximately the situation exp, as a function of natural CSF oscillations in terms of amplitude, log (Urms), had a constant slope of f-dependent offset, with 2 = 0.9273.To derive functional correlations, 0, as a function of the dimensionless Peclet number, We also cast all experimental results into a dimensionless form for comparison to prior transport theories. We depart from the commonly known Taylor theory  and Aris2/sec is the kinematic viscosity. All values are listed in 2 = 0.9278.The best-fit parameter set , and the molecular diffusion of the tracer used was D0 = 0.0024 cm2/min. The range of the determined dispersion coefficients was D = 0.6356–1.7735 cm2/min, which is much smaller than that found in our experiment by a factor of over 2.5. The Stockman data are also plotted in We also compared our experimental values to theoretical dispersion coefficient estimates by in vitro data.In summary, We previously observed that annular phantoms without microanatomical features underestimate the actual dispersion after IT . To testExperimental data for tracer infusion experiments served as the input for a reduced-order pharmacokinetic model of IT administration. The full description of this mechanistic drug administration model is beyond the scope of this manuscript but can be found elsewhere . In brieTracer concentration profiles along the neuraxis as a function of time were predicted with mechanistic pharmacokinetic simulations. Pharmacokinetic tracer profile simulations with CNS dimensions and infusion settings used in the experiments took less than one CPU minute to converge, generating asymmetrical profiles with peak concentration decreases with time . The comlearance .IT infusion studies under physiological conditions require deformability of the CSF spaces to accommodate realistic pulse pressure propagation and fluid motion inside a closed spinal SAS. Deformable fluid-filled spaces in the present bench test analog of the human CNS is fully enclosed between the soft dura/parenchyma surfaces and a distensible vascular interface  without fluid exchange across the open system boundaries. The proposed configuration approximates the anatomy and fluid–structure interaction dynamics of the spinal SAS, so we have confidence that it reproduces the complex geometry-induced CSF mixing patterns that were reported in the previous work using the direct numerical simulation of spinal CSF flow . The CNSMoreover, transparent borders of the see-through human CNS replica enabled dynamic optical tracking of tracer concentration profiles during and after IT solute administration. Our experiments characterized in detail two stages occurring during high-volume IT infusion. The initial phase during which the drug is injected lasts only a few minutes in clinical settings. The duration of 10 min was chosen because it is suitable for assessing acute risks associated with high-volume IT administration .10, the distribution length after 10 min of injection, as a function of injection volume/flow rate and catheter diameter. The formula in Eq. The axial dispersion during the injection phase (phase-1) correlated with infusion volume, IVF, and catheter diameters. Thinner catheters (inner diameter d = 0.2 mm) generate wider and fast initial solute dispersion as is attainable with high-caliber catheters (di = 3.2 mm inner diameter). Based on our series of experiments, a simple formula in Eq. Drug pumps are often deployed for the local treatment of chronic pain or spasticity but are less suitable for targeting the brain, which was one of the main objectives of the current study. Drug pumps operate under much lower flow rate settings than possible with acute administration. Accordingly, the effect of the injection impulse may be negligible. Chronic IT administration with drug pumps are, thus, predominately governed by conditions of natural oscillation (phase-2) for its entire time course as discussed as follows. For more recent developments for effective infusion protocols from drug pumps, we refer to the work by After the injection ceases, the tracer spreads due to natural CSF pulsations. Oscillatory fluid flow around microanatomical features create a geometry-induced mixing pattern, which breaks the laminar flow field by introducing eddies and vortices around nerve roots. Localized and interspersed eddies were observed in the flow directly upstream and downstream of the cylindrical peripheral nerve root bundles suspended in the flow. Moreover, trabeculae can substantially enhance this effect as reported in Eq. . We offer two explanations for the experimentally observed caudocranial transport.In all infusion experiments, slow but steady caudocranial advancement of the tracer front from the lumbar injection site toward the cranium was observedFirst, lumbar injection divides the space available for the solute to disperse into a smaller distal volume containing the sacral compartment and a larger cranially facing domain stretching from the catheter tip to the thoracic, the cervical, and the cranial SAS. We observed that tracers initially spread equally in both sections, which is consistent with a diffusive process. Subsequently, the advancing dye fronts fill the closed sacral domain faster due to its smaller size. Once the closed sacral region is occupied, the tracer profile center of gravity begins shifting toward the head. The asymmetric caudocranial tracer profile develops due to a boundary effect that was confirmed with a mechanistic diffusive transport model. Systematic experiments with varying CSF conditions (amplitude and frequency) enabled the determination of a formula for the velocity of the caudocranial shift as a function of CSF pulsations and frequency as shown in Eq. rms, become larger toward the cervical region compared to the lumbar region where the pulse amplitude is almost zero. Thus, effective dispersion tends to become faster in the caudocranial direction. These two effects cannot be studied in rigid, open systems.The graded biomechanical deformation profile of the spinal SAS responsible for CSF pulse attenuation is a secondary factor. The CSF pulse amplitude was shown to diminish gradually from the cervical toward the sacral region . The CSFnot necessary for caudocranial drug dispersion to occur. Rather, experiments suggest that caudocranial transport of infused solutes can simply result from the asymmetry of the CSF spaces and graded CSF pulse amplitudes.The infusion experiments were conducted in a closed deformable CNS model with no net CSF generation or removal. This supports the notion that bulk CSF flow or absorption is Recently, an interesting analytical solution for drug dispersion in the SAS was developed by Tracer dispersion after high-volume injection was very rapid, reaching the cervical region in less than 10 minutes, and it spread quickly throughout the spinal SAS. The apparent dispersion coefficient was robustly determined experimentally as a function of CSF amplitudes and frequencies. An empirical correlation Eq.  between 10.We provide a simple guideline for estimating the volume of distribution of the drug during the injection phase as a function of catheter caliber and injection volume based on the experimental data and model in Eq. Pe number is in the same range as for trypan blue with a diffusion coefficient of D0 = 1.938 × 10−6 cm2/min.For tracer dispersion in the oscillatory CSF flow (phase-2), Eq. 0 in the denominator of Pe) may not be an ideal dimensionless scaling characteristic.The analytical Taylor–Aris approach was shown to grossly overestimate the bio dispersion process. All versions of the TAD models showed that the spread of the tracer in human spine does not follow the trend proposed by Taylor dispersion. Effective dispersion by geometry-induced mixing seems to follow a different trend than that described by TAD. Moreover, TAD does not consider the effect of injection volume, catheter geometry, and placement as discussed during phase-1 of the infusion experiments. Also, TAD assumes a constant flow velocity throughout the channel. Finally, poor predictions by TAD theories for IT tracer dispersion and the very large Peclet number ranges seem to suggest that the molecular diffusivity  in the subarachnoid villi. These additional features could be incorporated in a more refined head model, which was not needed in our study focusing on spinal dynamics. The current model was able to induce cervical CSF displacements (stroke volume 0–1 mL/beat) within the physiological range but was not designed to faithfully reproduce the biomechanical compliance of the spinal compartment. Accordingly, we also did not attempt to measure the absolute pressure changes and gradients that occur during infusion. We plan to study the rise in the line pressure or the increase in pressure in the CSF of the spinal SAS as a function of injection parameters in future work.Another related limitation pertains to the practice of fluid removal before high-volume injection . There was no attempt made to interrogate the CNS model regarding the biomechanical response of the CSF spaces subjected to tapping.in vitro quantification of the spatiotemporal tracer dispersion patterns and their dependence on significant infusion parameters and pulsatile CSF conditions. This study reports a unique set of experimental data on the combined effect of infusion and natural oscillations in a deformable CNS replica that have not been reported previously. Our bench experiments suggest the feasibility of targeting large sections of the neuroaxis to the brain with the help of high-volume injection protocols. Infusion studies using human CNS models may serve as an inexpensive surrogate for testing and optimizing infusion protocols for the safe distribution of IT-administered solutes along the neuraxis to inform clinical trials in humans.We conducted an extensive parametric study of tracer distribution in a subject-specific deformable bench model of the human CNS with anatomical and functional reproduction of CSF dynamics from the spine to the cranium. A systematic variation of parameters in numerous infusion experiments enabled the


This work is mainly intended to investigate the flysch landslide reinforcement measures used in the Smokovac-Mateševo section of the North-South Expressway project in Montenegro. Bentley’s Plaxis software is used for a numerical analysis of sliding surface parameters of flysch strata in the limit equilibrium state. This study analyzes the slope safety factor for rreinforcement measures such as rock bolts, retaining walls, anti-sliding piles, slope unloading and bolt anchoring and obtains an optimal combination of reinforcement application for the flysch landslide. The effects of seismic action on complex stress and the discontinuous stress boundary conditions arising from various reinforcement measures on landslide stability are also examined. The measures applied in this paper can be used as a reference for flysch landslide reinforcement or other similar slope engineering measures. Flysch, a sedimentary structure primarily composed of sandstone, shale, mudstone, and other rock masses, is predominantly found in semi-deep and deep-sea environments . This tyOur study focuses on the complex topography of the Smokovac-Mateševo section of the North-South Expressway construction project in Montenegro, where the flysch stratum is a dominant feature. Comprising of inter-bedded sandstone and thin layers of sandy marl and shale, the flysch formation is especially vulnerable to brittleness, weathering, and softening when exposed to water and air. The area is characterized by a high content of weak rock mass, particularly argillaceous rock along the highway, rendering the flysch formation relatively susceptible to degradation, failure, and in-situ landslides. The details on the region’s geological survey data, including the bulk weight, angle of internal friction, and cohesion, are presented in Despite significant advances in geotechnical slope research, flysch slopes and their corresponding protection technologies remain inadequately studied. Some scholars have examined the effect of geological slope evolution and sliding mechanisms in large flysch formations –23, whilThe construction of roads in flysch regions presents landslide risks when the naturally occurring slopes are disrupted, necessitating comprehensive research into the treatment and protection of unstable flysch formations. The disruption of naturally occurring slopes poses landslide risks for the construction of roads in flysch regions, thus entailing comprehensive research into the treatment and protection of unstable flysch formations. Arbanas et al.  discusseIn response, this paper employs numerical simulation to investigate the stability of flysch slopes and the effect of various landslide reinforcement measures  on the slope safety factor. We used PLAXIS, a widely accepted numerical simulation software, to analyse the stress superposition and discontinuous boundary conditions brought about by seismic events and reinforcement support structures, as well as the subsequent changes in slope safety factors and their impact on slope stability. Given the limited research on the combined effects of flysch landslide reinforcement technologies, this study aspires to offer valuable data on the efficacy of slope protection measures for similar rock formations, in an attempt to provide a reference for future works.The structural analysis in this paper was carried out using Plaxis software. Here, the calculation models comprised the following four types of elements: continuum elements, beam elements, geogrid elements and anchors, numerical simulation network model established is shown in The model design and the calculation process is according to the following five steps: defining the soil materials, creating the geometry, applying the boundary conditions, generating the mesh and performing the analysis.σv = γ·h and σh = K0·σv respectively , with ϕ being the friction angle of the soil).Defining the soil (supporting structures) materials: the parameters for the rock strata and supporting structures are defined using values shown in Tables Creating the geometry: The slope’s dimensions, layers, and any other relevant features, such as retaining walls or anchors are defined and modeled.Applying the boundary conditions: Since the flysch and anti-sliding pile have different stiffness values, it is essential to consider the boundary conditions between rock-soil mass and anti-sliding pile elements. For "Discontinuous boundary conditions," the element stress value at the contact point between the flysch boundary plane and anti-sliding pile should be equal so as to satisfy boundary conditions.Generating the mesh: Automatic mesh generation tool is used to create a customized mesh to ensure that the mesh is fine enough to accurately capture the slope’s behaviour.Performing the analysis: Construction stages are defined for the model, and the analysis is run.The seismicity of the system is considered in the "Inconsistent Boundary Conditions and Seismicity" section. The applied seismic loads correspond to the historic maximum of the project area. In all numerical simulations presented in this paper, slope instability is assumed to be reached when the Factor of Safety (FOS) approaches 1.ϕ = 32.5°, which are the cohesion parameter and internal friction angle of the slope sliding surface, respectively. In the limit equilibrium state, numerical simulation method is used to analyse the relationship between reinforcement measures such as retaining walls, anti-sliding piles, anchor bolts and the safety factor of the slope. Sliding plane strength parameters determined in this step were used for all calculations in the following steps.Since slope failure is determined by the strength of the potentially sliding plane, rather than the strength of the rock mass, we use back analysis to gradually reduce the applied sliding plane strength parameters to reach a Factor of Safety (FOS) near 1.0 , and to As the first measure of treatment, fixing of gravity retaining wall is introduced. The wall is fixed with prestressed anchors, anchored in RC frame cast on the surface and bonded to the rock category E, and partially to the rock behind the fault line. The model shows an increase in global stability. The slope FOS is shown in After applying prestressed anchors on the retaining wall, two rows anti-sliding piles, 1.50 m in diameter, are constructed at the bottom of the slope. The model’s global stability is checked, as well as the contribution of the anti-sliding piles. As shown in Unloading refers to the removal of the upper sliding body on top of the slope. This step involves dividing the upper portion into four parts, showing the changes on global FOS. For calculation, the effect of the anchors with steel mesh was neglected, the mesh structure was adopted for local protection of the slope above the retaining wall, and further, the mesh structure has no effect on global stability. The models and simulation results from the first to the fourth unloading of sliding body upper part are shown in Figs The additional prestressed anchors with bonding part extending through the sliding body were introduced. Global FOS and sliding surface did not change from previous steps as shown in H  and FV , acting on the ground mass are introduced. W is the weight of the sliding mass . The seismic wave is bound to decay when propagating through the heterogeneous flysch layers, but the maximum distance of the flysch layers is relatively small (<50m). The attenuation and reduction of seismic waves is, therefore, not considered in the numerical simulation. Calculation shows that seismicity exhibits a local effect after the introduction of the seismic loads. However, global FOS still stands at a high level of 2.038, as shown in Seismic loading was then introduced based on the previous step for the permanent structure design. The design seismic forces FAccording to the assumption of the above theoretical slope model, the displacement and deformation between the reinforcement structure and the rock and soil mass are discontinuous. The anti-sliding piles are the most effective protection measure. There is a discontinuous boundary of displacement and deformation between the reinforcement and surrounding materials. In this step, the numerical simulation analysis will consider the effect of discontinuous boundary conditions between the anti-sliding pile and the rock and soil mass on the safety factor of the slope. This analysis follows the step where the new anchor bolts are applied.In the numerical analysis, discontinuous boundary conditions are modelled by setting a discontinuous interface between the anti-sliding pile and the rock-soil mass in front of the pile. The stress states of the contacting surfaces of the anti-sliding pile and the rock-soil mass are equal on this discontinuous surface. The safety factor of the slope model is calculated, as shown in The introduction of the described changes in the model reduced the global FOS from 2.262 to 2.081, but the critical sliding surface did not show any change because it is more affected by the local properties. Fu  used theThe stiffness equation of the rock mass is “condensed” on to the stiffness equation of the pile, and the resulting displacement of the rock mass is smaller than when the discontinuous boundary is considered. Moreover, the numerical analysis of this step considers the discontinuous boundary conditions of displacement and deformation between the rock-soil mass and the anti-sliding pile. The calculation shows the displacement is large, which caused a decline in slope stability and the slope’s FOS.H and FV) is consistent with the "result of slope seismic stability" mentioned earlier. Here, the complex stress changes and discontinuous stress boundary conditions are investigated for slope reinforcement. As shown in In this step, seismicity is introduced on top of the previous step for permanent structure design case. The magnitude of earthquake inertia force . Slopes generally slide during the construction of anti-sliding piles at the lower part of the slope and the compression of the pile finally comes into effect to stop further sliding. If anti-sliding piles are adopted first, the unstable slope will not have the support of anti-sliding piles’ anchoring force. The disturbance from construction at the lower part of the slope will then cause serious landslide of the slope. The order of reinforcement measures in this paper can be used as reference in similar projects in the future.


Advance in Diagnostics for Central Nervous System Infection” aims to collect studies that focus on recent advances and discoveries in the diagnosis of neuroinfectious diseases. There is an urgent need to optimize the diagnostic assessment of these disorders due to the high disease burden, the elevated incidence of long-term sequelae, and the importance of rapid therapeutical decisions in terms of prognosis. To date, most conventional diagnostic methods are suboptimal in terms of sensitivity and specificity, probably due to the complex interplay between the central nervous system and pathogens. Nevertheless, the introduction of new microbiological tests, such as novel PCR techniques and proteomic approaches, has shown promising results. In this context, the recent COVID-19 pandemic has prompted worldwide healthcare systems to reconsider the management of infectious diseases as a priority  pathogens, in cerebrospinal fluid (CSF) samples obtained from 139 patients with suspected central nervous system infection. The new technique showed promising results, especially in the detection of poly-infections, and good consistency (89.5%) with respect to conventional testing for the diagnosis of Mycobacterium tuberculosis. However, in 40% of cases, the pathogens were correctly diagnosed by conventional testing only, suggesting the need for further validation studies for the new method in larger cohorts. Nevertheless, it might represent a new potential tool, besides conventional testing and clinical assessment, for the early diagnosis of neuroinfectious diseases.The study by Beaver et al. focused their study on CSF shunt infection, the diagnosis of which is still hampered by the low accuracy of bacterial cultures and CSF indices. The authors performed a proteomic study in serial CSF samples obtained from an animal model with a central nervous system (CNS) catheter infection and from another with a sterile catheter placement. The aim was to assess possible shared and distinct CSF proteomic changes during S. epidermidis, C. acnes, and P. aeruginosa shunt infection over time. Although the number of differentially expressed proteins was variable across the three bacterial species, the authors found a shared proteome across diverse pathogens, especially at early points, which was also unique compared with the sterile injury response. If future studies confirm these findings, the identification of shared candidate CSF biomarkers across distinct bacterial infections species may represent a step forward for the early diagnosis and management of these diseases.Similarly, Wen et al. investigated a cohort of patients with cryptococcal meningitis and reported a misdiagnosis at the initial visit in 37 out of 98 included cases (37.8%). The authors suggested that this could be related to the high proportion of non-HIV underlying conditions , in which cultures and antigen tests might perform worse due to the relatively lower cryptococcus load. Furthermore, the authors assessed the short-term and long-term outcomes (more than 1 year) of ventriculoperitoneal shunt placement (VPS) in the same cohort. All patients received standard antifungal therapy and 15 underwent additional VPS. The study showed that critically ill patients treated with VPS showed better overall survival, even if the long-term Barthel Index did not differ between the subgroups receiving surgical or conservative treatment.Cryptococcal antigen testing has shown a very high performance in diagnosing cryptococcal disease, especially in HIV patients . MoreoveIL-1β) seem to play a role in the pathogenesis of febrile seizures (FS), a disease that may clinically overlap with AESD. Most interestingly, Asian patients with febrile seizures (FS) showed a significant excess in the TT genotype of the IL-1β rs16944 polymorphism, which is usually associated with increased IL-1β expression. To investigate these findings in AESD, Shibata et al. performed a genetic association study of rs16944 in 283 AESD patients and found a significantly lower proportion of the TT genotype compared with a control group , suggesting that AESD and FS did not share the same genetic background.Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a severe neurological complication of infantile febrile infectious diseases  and has a high incidence in Japan. Proinflammatory pathways including interleukin 1 beta (In conclusion, all the articles included in the Research Topic, although heterogeneous in their approach, provided novel insights into the diagnosis of neuroinfectious diseases and showed the potential to ameliorate their management by accelerating the diagnostic assessment and therapeutic intervention in different clinical settings.SA-R wrote the manuscript. YL reviewed the manuscript and approved the final version. All authors contributed to the article and approved the submitted version.


Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group . No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons. In the late 1980s, an extended TSA was adopted and has shown the potential to gain access to the suprasellar and/or parasellar area2. More recently, a pure endoscopic technique has expanded the applications of this surgical approach3. However, this approach has several limitations, including a narrow surgical view and/or postoperative cerebrospinal fluid (CSF) leakage4. Despite recent technical advancements in endoscopic skull base surgery, CSF leakage remains one of the most challenging concerns, especially for less-experienced surgeons. The overall CSF leakage rate in the literature varied widely according to tumor characteristics, location, surgical techniques, and surgeons’ expertise7.The transsphenoidal approach (TSA) has been used for the removal of tumors located within the sellar region11. Among these materials, injectable hydroxyapatite (HXA) has shown promising results for the surgical repair of CSF leakage14. HXA is a suitable reconstruction material for repairing bony defects owing to its properties, such as easy incorporation into the bone defect due to its injectable consistency, volumetric stability over time, biocompatibility, mechanical strength, and minimal inflammatory response15. Recently, several studies have shown favorable clinical outcomes using injectable HXA to prevent CSF leakage17. However, to date, little has been reported on the possibility of applying the HXA-based reconstruction technique by surgeons in the middle of learning curve to minimize the CSF leakage rate. This study aimed to assess the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons at the two institutions.Multilayered skull base reconstruction is now a standard technique for repairing skull base defects. The goal of skull base reconstruction for CSF leakage is to achieve watertight closure until the scar formation seals the defect. To date, a variety of reconstruction techniques combined with various materials, including fat, fascia, or vascularized mucosal flaps, has been devised18. Patients with grade 0 to 2 intraoperative CSF leakage who underwent reconstruction without NSF were excluded.This multicenter retrospective study was conducted by two neurosurgeons (Y.S. and K.H.K.) at each independent tertiary institution. Both neurosurgeons performed all endoscopic procedures, from the nasal phase to the reconstructive phase by themselves. At the time of data collection, they had similar clinical experiences of 4–5 years as independent surgeons without supervisors and were on a steep learning curve. The study inclusion criteria were patients who underwent multilayer skull base reconstruction, including a nasoseptal flap (NSF) for high-flow grade 3 CSF leakage following endoscopic endonasal surgeryPatient data, including demographic, clinical, and surgical information, were consecutively collected between March 2018 and November 2022. Since 2021, the recent period of the study, most of the patients underwent skull base reconstruction using an injectable HXA  with NSF (HXA group). Dynamic magnetic resonance (MR) images with gadolinium contrast on a 3 T scanner and computed tomography (CT) scans and angiography with 1 mm slices were obtained from all patients preoperatively to verify the details of the nasal cavity, tumor, and vascular anatomy. Preoperative basal hormone tests and ophthalmological examinations were routinely performed in all patients.The primary outcome was postoperative CSF leakage requiring neurosurgical interventions based on the findings of the endoscopic nasal examination. In addition, the extent of resection, total operative time, surgical complications, nasal complications, and postoperative central nervous system infections were investigated. This study was approved by the local institutional review board of Chungnam National University Hospital (IRB no. CNUH-2023-03-067). The study is in accordance with the Declaration of Helsinki and informed consent was waived.19. All surgeries were performed using a direct 4-mm 0° endoscope and 30° or 45° angled endoscope  under the guidance of a neuronavigation system . In the nasal phase, a vascularized NSF was raised at the beginning of the surgery and prepared for skull base reconstruction. A modified transseptal TSA was used to allow binostril surgery and to reduce sinonasal morbidity by preserving the nasal mucosa20. The anterior septal mucosa, which was dissected in a submucoperichondrial and submucoperiosteal fashion toward the rostrum sphenoidale on the contralateral side of the NSF harvesting side, was tagged to the nostril (left side in most cases). When unexpected high-flow CSF leakage developed during surgery, the NSF was raised from the rescue flap after tumor removal.Endoscopic endonasal surgery was performed as usual, and detailed procedures have been described in the literatureAfter tumor resection, meticulous hemostasis, and complete skeletonization around the skull defect, multilayer skull base reconstruction was performed Fig. . First, Drying the bony surface before using an injectable HXA is mandatory. Therefore, the sphenoid sinus and nasal cavity should be packed with 1:10,000 epinephrine-soaked gauzes and cottonoid patties for a sufficient time. Injection of HXA started from the margins of the skull base defect and construct, and semi-solid HXA had to be in contact with the bony surface. After covering all the margins, it was injected over the central side. This order of injection was helpful for completely covering the target without HXA defects Fig. . During 21. The reconstructions were then covered by an NSF and secured with a fibrin sealant. In contrast to HXA-based reconstruction, tight compression against the NSF by various materials was essential. In addition, postoperative LD was placed when undergoing posterior fossa surgery and when the third ventricle was opened during surgery. Prophylactic antibiotics, including 3rd generation cephalosporin and quinolone, were administered for a duration of 3 to 5 days.In the cases of conventional multilayer reconstruction (control group), autologous fat and/or fascia were commonly used instead of synthetic materials. The most frequently used method was the bilayer button technique using a sutured fascial construct, followed by the gasket seal technique with an autologous septal bone graftPostoperative CT was performed immediately after surgery to determine the state of reconstruction and surgical complications. MR images, including sagittal and coronal sections of T1 contrast enhancement and T2-weighted turbo spin echo sequences, were acquired within 24–48 h after surgery to evaluate the viability of NSF and CSF leakage. Postoperatively, head elevation over 30 degrees was rigorously maintained and ambulation was encouraged to lower intracranial pressure as well as to prevent deep vein thrombosis and lung complications. The nasal cavity was examined endoscopically 2 and 5 days after surgery to assess NSF viability and CSF leakage. The packing materials were removed at five days after surgery. Patients without fever or uncontrolled electrolyte imbalance were discharged 6–7 days after surgery. Outpatient nasal cavity examinations were performed at 1 to 2–week intervals thereafter until the mucosa completely healed without complications. If CSF leakage was evident, neurosurgical interventions including CSF diversion and re-operation was immediately performed.t test and the Mann–Whitney U-test were used in comparing continuous variables. Logistic regression analysis was used for univariate and multivariate analyses for CSF leakage. All statistical analyses were performed using R software , and statistical significance was set at p < 0.05.Categorical variables are presented as number of patients with percentage. The Fisher’s exact test was used in comparing categorical variables. Parametric and nonparametric continuous variables presented as the mean values with standard deviation and the median values with range, respectively. The independent samples This study investigated 41 patients who underwent multilayer skull base reconstruction with or without HXA for grade 3 CSF leakage following endoscopic endonasal surgery. The institutions enrolled 22 (53.7%) and 19 (46.3%) patients, respectively. The median age was 55 years , and 15 patients (36.6%) were female. The most common pathology was craniopharyngioma , followed by pituitary adenoma , meningioma , chordoma , and others . Among the 13 pituitary adenomas, seven were giant macroadenomas with a suprasellar extension to the third ventricle, and six were residual or recurrent lesions requiring re-operation. Prior transnasal surgery was performed in six patients (four microscopic and two endoscopic TSAs for pituitary adenoma). Regarding tumor location, 34 lesions (82.9%) were in the suprasellar region, and five (12.2%) were in the anterior skull base, and two (4.9%) were located in the clivus. In 36 patients (87.8%), gross or near-total resection was achieved and five patients (12.2%) had sub-total resection. The median follow-up time was 23.8 months .According to the HXA use in multilayer skull base reconstruction, there were 22 patients (53.7%) in the HXA group and 19 patients (46.3%) in the control group. Both groups were balanced in age, sex, BMI, maximal diameter, and tumor location (Table Regarding the surgical outcomes, the extent of resection, operation time and hematoma in resection cavity were similar in the both groups Table . HoweverThis retrospective multicenter study revealed the efficacy and safety of HXA-based skull base reconstruction. Neurosurgeons with limited experience achieved promising results with this new approach to prevent CSF leakage. According to this study, CSF leakage may no longer be an obstacle to the learning curve of endoscopic skull base surgery.22. A recent meta-analysis showed that the overall rate of CSF leakage did not change over time13. Several authors have emphasized the learning curve of the surgeon and the importance of adherence to the basic techniques in skull base reconstruction24. In most centers, there is a decrease in postoperative CSF leakage as well as an increase in the rate of the extent of resection after the first 50 to 200 cases, after which the results tend to plateau26. Moreover, initial results from institutions currently at the expert level showed CSF leakage rates in the range of 23–60%27. However, it should be noted that these early results encompass cases performed prior to the establishment of reconstruction techniques. Of course, it takes time to master the skills, but the complications of CSF leakage pose serious risks to the patient28. Although both neurosurgeons in the study had fellowship in their brain tumor subspecialty and had performed nearly 100 endoscopic TSA without supervisors, the early surgical result of the extended endoscopic surgery was miserable. Even for surgeons less experienced in endoscopic skull base surgery, it is important to find a safe and reliable method to reduce the learning curves.In this study, the HXA-based multilayer reconstruction technique effectively prevented CSF leakage without the incorporation of autologous tissue grafts or postoperative LD. Despite the remarkable progress over the past decades, the overall CSF leakage rate was 11.5% in the systematic review12. Kitano et al. used the multilayering method of injectable HXA to repair bone defects with successful results in 98% of patients12. Recently, several studies have reproduced successful outcomes, including the present study, using HXA-based reconstruction17. In this study, successful reconstruction could be predicted immediately after creating a rigid HXA layer, which was evaluated using the Valsalva maneuver. In addition to providing immediate mechanical strength for the reconstruction, HXA promotes bone ingrowth and provides biocompatibility, as the artificial HXA eventually converts to the major component of human skeletal bone29. Nevertheless, the potential risks of acute and chronic inflammation reaction associated with foreign materials are inherent. Several studies have reported favorable outcomes in terms of HXA-related complications30. However, Kim et al. reported that 13.5% of patients who underwent the HXA on-lay reconstruction technique had postoperative meningitis without definite microorganisms. They used a fibrin sealant patch alone on the dural defect as a temporary barrier to the CSF and then covered the bone defect and dura with an HXA layer. It is thought that multilayered isolation of the intradural space minimized contact between the HXA and CSF and played a role in reducing potential intracranial inflammatory reactions. Moreover, naked HXA exposure to the side of the nasal cavity accompanied by failure of mucosalization on the nasal side of the HXA is also a potential risk factor for intracranial inflammation. Jung et al. reported delayed mucosal coverage of a bare HXA implant with an average time of 14 weeks30. Complete NSF coverage over the HXA layer is essential to promote mucosalization of reconstructions and to reduce contact between the nasal cavity and HXA.Since the introduction of injectable HXA, it can be applied in TSA because of the deep-located cranial defect within a narrow surgical corridor32. However, multi-layer reconstruction with NSF does not completely block CSF leakage. Additionally, mechanical supports over the NSF by the proper buttresses, including fat graft, packing materials, or balloon catheter, were required to secure the time for NSF adhering to the defect site18. Moreover, CSF diversion through LD was frequently utilized despite its disadvantages, including patient immobilization, risk of infection, and CSF overdrainage33. Although a recent randomized study found that placement of postoperative LD was effective, the authors recommended LD only for patients with large anterior or posterior fossa intradural defects and not for small defects in the suprasellar region34. Conger et al. described that “LD may provide a ‘false sense of security’ to the surgical team and perhaps even make them more complacent in performing a meticulous repair”5. In this study, HXA-based reconstruction resulted in 0% CSF leakage without the aid of postoperative LD or buttresses for NSF. Permanent and/or temporary mechanical buttresses are recommended, especially in the reconstruction against high-grade CSF leakage34. The HXA layer acts as a rigid permanent buttress beneath the NSF, similar to harvested bone grafts and synthetic buttresses, while completely sealing the bony defect without CSF spillage. Therefore, the need to compress and stabilize the NSF is reduced, and the role of the NSF is primarily focused on covering the HXA for mucosalization.Since the introduction of vascularized NSF, the most important milestone in the evolution of skull base reconstruction, CSF leakage rates were apparently reduced using NSF16. Despite such limitations, this study successfully demonstrated that two independent neurosurgeons with limited experience yielded 0% CSF leakage quickly using an HXA-based reconstruction. Although this new technique also requires experience, it significantly shortens the traditional learning curve for skull base reconstruction. However, this study focused only on the outcomes of skull base reconstruction for high-flow CSF leakage. Successful reconstruction is not the only concern in endoscopic skull base surgery, and our results should be carefully interpreted. Nevertheless, based on recent successful results in the literature, including those of the present study, the risk of CSF leakage might be no longer a major hurdle in endoscopic skull base surgery.This two-institutional study had the inherent limitations of a retrospective study and a small sample size. In addition, there were no cases of large posterior fossa defects in this study population, which is considered the most challenging areaThe results of this study showed that the HXA-based skull base reconstruction provides a rigid buttress and minimizes the risk of postoperative CSF leakage. In addition, this technique is reproducible for less-experienced surgeons and can shorten the learning curve. This allows less-experienced surgeons to perform complex procedures with greater confidence and reduced risk, leading to improved patient outcomes and reduced morbidity. Supplementary Video 1.