Cerebrospinal fluid (CSF) is an ultra-filtrated colorless brain fluid that circulates within brain spaces like the ventricular cavities, subarachnoid space, and the spine. Its continuous flow serves many primary functions, including nourishment, brain protection, and waste removal.The abnormal accumulation of CSF in brain cavities triggers severe hydrocephalus. Accumulating evidence had indicated that synchronized beats of motile cilia  provide forceful pressure to generate and restrain CSF flow and maintain overall CSF circulation within brain spaces. In humans, the disorders caused by defective primary and/or motile cilia are generally referred to as ciliopathies. The key role of CSF circulation in brain development and its functioning has not been fully elucidated.In this review, we briefly discuss the underlying role of motile cilia in CSF circulation and hydrocephalus. We have reviewed cilia and ciliated cells in the brain and the existing evidence for the regulatory role of functional cilia in CSF circulation in the brain. We further discuss the findings obtained for defective cilia and their potential involvement in hydrocephalus. Furthermore, this review will reinforce the idea of motile cilia as master regulators of CSF movements, brain development, and neuronal diseases. Cerebrospinal fluid (CSF), a colorless liquid, is essential for brain homeostasis and functioning. Growing evidence has revealed the various crucial roles of CSF throughout the lifespan of vertebrates. During the early development of vertebrates, the central nervous system (CNS) develops from the neural tube (a hollow pipe-like structure), which is filled with embryonic CSF (eCSF). Studies have documented that eCSF contains several types of diffusible neurotrophic agents, growth factors, and other cytokines, which directly regulate neural differentiation, proliferation, and development, and other neural functions –4. SinceThe healthy brain contains three integrated components that collectively regulate CSF dynamics (or the CSF cycle): the amount of CSF produced, the amount of CSF in circulation, and the amount of CSF available for absorption. These three components typically remain in equilibrium. Disruption in any of these components, e.g., by overproduction or defective circulation, causes excessive accumulation of CSF in the brain and reduces the amount of CSF available for reabsorption, resulting in ventriculomegaly. Ventriculomegaly is one of earliest signs of hydrocephalus and other severe brain pathologies. Impairments in the functioning of motile cilia accentuate the hydrocephalus pathologies attributable to abnormal CSF circulation –14. OverCerebrospinal fluid (CSF), the colorless liquid circulating within spaces surrounded by the brain and the spinal cord, has a long history of discovery that has been well outlined by Hajdu [choroid plexus (CP), a complex vascular structure of epithelial and endothelial cells within the ventricular system of the vertebrate brain, is known to be a significant source of CSF secretion [by Hajdu . The choecretion –18. The ecretion . These oecretion .The starting ventricular system CSF enters the subarachnoid space at the base of the brain laterally at the foramen of Lushka and medially at the foramen of Magendie . The CSFThe continuous circulation of CSF assists in the exchange of essential biomolecules, providing fresh nutrients as well as removing waste products generated by the brain . The comThe CSF is essential for brain functioning in adult animals, and a number of studies in the past decades have strongly supported the crucial role of CSF in early developmental processes, including those involving the brain and body axis. The earliest form of CSF, known as eCSF, is found in the neural tube during the embryonic and fetal development of vertebrates . GeneralDuring the early development of the human brain, neural progenitors  undergo differentiation, proliferation, and migration to form a mature complex neural network , 43. TheThe cilia are highly conserved and widely dispersed throughout the eukaryotic kingdom. Over the last few decades, cilia have emerged as essential organelles involved in various physiological and developmental processes . Typicalfox and rfx families have been identified in vertebrates to play essential roles in ciliogenesis  [mcidas, myb, and foxj1 genes encoding transcription factors (TFs) and acts as a master regulator for early MCC differentiation and motile ciliogenesis [p73 and foxj1, and to drive the multiciliogenic process in vertebrates [foxj1 transcriptional activation in Xenopus [The process of cilia formation and maturation is known as ciliogenesis. It is based on two types of mechanisms, i.e., compartmentalized and cytosolic ciliogenesis . Severalet. al.) . Howeverogenesis –73. GemCtebrates , 72. Add Xenopus . However Xenopus , 73–75.The flow of the CSF is essential to supply fundamental nutrients and other biomolecules for normal brain function, which is maintained by continuous distribution of several growth/signaling factors, balancing of ion concentrations by passive diffusion to support brain homeostasis, and the removal of several metabolic byproducts produced by the brain . The univangl2, frizzled, dsh, intu, and fuz, markedly control ciliogenesis and other cellular functions, and deletions or mutations of PCP target genes severely affect the molecular mechanisms underlying ciliary development and generate different types of ciliary phenotypes (as classified above) [Celsr) 1‒3 genes play multiple vital functions in the CNS, with Celsr1 being mainly involved in PCP, neural differentiation, maturation, and neural tube closure; Celsr1-deficient mice show defective ciliary coordination despite presenting with normal ciliogenesis [Celsr2 and Celsr3 are involved in the functional and developmental organization of cilia [stumpy knockdown mouse, where conditional loss of stumpy resulted in the absence or impairment of cilia in the brain, thereby interrupting CSF circulation and causing hydrocephalus and polycystic kidney disease [Mice provide an excellent platform for studying the novel molecular mechanisms underlying gradational ciliogenesis and their use permits genetic manipulations that can improve our understanding of these mechanisms. The knockdown/mutation of different groups of genes, including those involved in signal transduction, structure, and ciliary elongation/maturation, and the modification or deletion of these genes has been shown to cause several ciliopathies that have been previously reviewed . The plad above) –80. The ogenesis , 82. Morof cilia , 83 and of cilia . A simil disease .Snx27, which was previously known to play an essential role in normal brain function by suppression of y-secretase-dependent amyloid precursor protein, as well in Notch cleavage, triggers the hyperactivation of Notch and produces a disorganized ependymal cell lining of the ventricles, which may result in defective ependymal differentiation. The delicate balancing of the Notch gradient and modification of Notch signaling through Snx27 in a spatiotemporal manner appears to be critical for ependymal cell differentiation and ciliogenesis [Ulk4) triggers a similar phenotype, in which the number of ciliary bundles is dramatically reduced and disorganized, although ciliary length is not substantially affected. This ablation of ciliary organization and coordination inhibits directional beating and impairs CSF flow [Xenopus and zebrafish have emerged as suitable animal models to study several human genetic diseases, including ciliopathies [Xenopus [Xenopus foxj1 was previously shown to play a significant role in MCC differentiation as well as ciliogenesis. Knockdown of foxj1 using antisense morpholino oligonucleotides produces abnormal cilia and massively reduces CSF flow through the brain ventricles. The defective cilia cause blockage of CSF flow and hydrocephalus, which strengthens the idea that ciliary motility regulates CSF circulation [Xenopus. Similar to foxj1, multicilin  is also essential for and sufficient to trigger MCC differentiation, and inhibition of multicilin causes severe defects in the MCC differentiation process [Cfap43 is a highly conserved gene in vertebrates that is abundantly expressed in MCC containing tissues including CP, and its functional protein is involved in the maturation of axoneme of motile cilia. Cfap43 mutant mice demonstrate dysfunctional motile cilia and hydrocephalus, whereas in Xenopus, cfap43 is a necessary for skin MCC and brain development [Similarly, the deletion of ogenesis . ConsistCSF flow . Over thopathies –91. Thesopathies –90. A re[Xenopus , 93 and [Xenopus , 95 indi[Xenopus , 95, 96.culation . Several process . Cfap43 elopment . Taken tL1CAM  are common in CH, generally referred to as L1 syndrome  or X-linked hydrocephalus [Hydrocephalus is a brain disorder caused by blockage in CSF circulation, which causes accumulation of CSF in the brain ventricles and consequent ventriculomegaly. Typically, hydrocephalus can be divided into two groups. First, primary hydrocephalus (at birth), which is principally caused by genetic factors and developmental defects, frequently known as congenital hydrocephalus (CH) . Second,cephalus –102. Reccephalus , 104. Nocephalus  and its cephalus . NPH is cephalus . NPH hascephalus . Additiocephalus . The caucephalus . In moticephalus . Ventriccephalus . Althougcephalus , 111.CCDC39 disturb the axonemal organization as well as ciliary beating [CCDC39 expression is precise and limited to CPs and ECs lining the forebrain of the embryonic mouse. The progressive hydrocephalus (prh) mutation in CCDC39 (CCDC39prh/prh) causes severely impaired ciliary beating, which affects CSF movement and leads to the development of neonatal hydrocephalus in mice [Dishevelled genes (Dvls). In mice, combined knockdown of Dvls results in normal EC differentiation but disrupted intercellular rotational alignment of ECs, which collectively result in hydrocephalus [−/− knockout mice show disordered ciliary rotational beating, postnatal ventriculomegaly, severe sinusitis, and severe hydrocephalus [Many neuropathological conditions can promote hydrocephalus in vertebrates. However, CH is thought to be the result of defects in cilia formation, improper CSF flow, and accumulation of CSF in the ventricular system during early brain development. Consistent with our theme, we have briefly reviewed the recent studies outlining the genetic causes of dysfunctional motile cilia and the development of life-threatening hydrocephalus. The axonemal protein of motile cilia, CCDC39, is also essential for the dynein motor protein regulatory complex, and loss-of-function mutations in  beating . CCDC39  in mice . In contcephalus . In addicephalus . A commocephalus . FinallyDNAH17 (β-heavy chain of ODA) have been reported to be associated with poor sperm motility and male infertility, with no observed effects in respiratory cilia [CEP290  displayed in diverse syndromic ciliopathies [gt/gt (produces a truncated protein) developed severe cystic kidneys and hydrocephalus. In contrast, Cep290ko/ko (produces no protein) mice showed early vision loss and hydrocephalus [The early development of the brain in vertebrates is characterized by many preprogrammed and decisive stages of differentiation, cell migration, and proliferation. Neurogenesis is initiated during gastrulation and proceeds until after birth. The gray and white matter volume begin to increase right after birth and the earliest form of CSF, known as eCSF, is found in the neural tube during neural tube growth –3, 117. ry cilia . This inopathies . Indeed,opathies ). Additicephalus . These f


Measurements of cerebrospinal fluid (CSF) lactate can aid in detecting infections of the central nervous system and surrounding structures. Neurosurgical patients with temporary lumbar or ventricular CSF drainage harbor an increased risk for developing infections of the central nervous system, which require immediate therapeutic responses. Since blood gas analyzers enable rapid blood-lactate measurements, we were interested in finding out if we can reliably measure CSF-lactate by this point-of-care technique.Neurosurgical patients on our intensive care unit (ICU) with either lumbar or external ventricular drainage due to a variety of reasons were included in this prospective observational study. Standard of care included measurements of leucocyte counts, total protein and lactate measurements in CSF by the neurochemical laboratory of our University Medical Center twice a week. With respect to this study, we additionally performed nearly daily measurements of cerebrospinal fluid by blood gas analyzers to determine the reliability of CSF-lactate measured by blood gas analyzers as compared to the standard measurements with a certified device.62 patients were included in this study. We performed 514 CSF-lactate measurements with blood gas analyzers and compared 180 of these to the in-house standard CSF-lactate measurements. Both techniques correlated highly significantly (Pearson correlation index 0.94) even though lacking full concordance in a Bland–Altman plotting. Of particular importance, regular measurements enabled immediate detection of central infection in three patients who had developed meningitis during the course of their treatment.Blood gas analyzers measure CSF-lactate with sufficient reliability and can help in the timely detection of a developing meningitis. In addition to and triggering established CSF diagnostics, CSF-lactate measurements by blood gas analyzers may improve surveillance of patients with CSF drainage.This study was retrospectively registered on April 20th 2020 in the German trial register. The trial registration number is DRKS00021466.The online version contains supplementary material available at 10.1186/s40635-021-00385-9. Lactate is an end-product of anaerobic glycolysis. Elevated blood values of lactate often indicate excessive anaerobic cell metabolism, but can also be related to increased glycolysis of neoplastic tissue (Warburg effect), non-neoplastic hyperglycolysis or liver disease. The tight endothelial barrier between blood and cerebrospinal fluid (CSF) largely restricts transfer of blood-lactate into CSF . AccordiThis study was approved by the ethics committee of the University of Göttingen, and conforms to the Declaration of Helsinki. All patients or their legal guardians gave their informed consent to participation in the study.I = (S * metabolite) + IZ with I being the measured current, S standing for the sensitivity and IZ for the reference current, data both of which can be derived from preanalytic settings, therefore allows calculation of the metabolite concentration .This study was designed as longitudinal observational study. Any patient ≥ 18 years of age with a temporary non-coated lumbar or ventricular catheter and a corresponding drainage  based on an acute neurosurgical indication and being treated on the anesthesiological and surgical intensive care unit of the University Medical Center Göttingen was eligible for inclusion. Inclusion and data collection took place between July 2019 and October 2020. We defined no specific exclusion criteria for this study. The study-related diagnostic measure consisted of nearly daily additional analyses of CSF taken out of the ventricular or lumbar drainage. These regularly began within 24 h after drainage placement. We carefully obtained 400–500 µl of CSF with an uncoated 2-ml plastic syringe under aseptic conditions at the patient-nearest outlet of the drainage. This sample was immediately  analyzed by a blood gas analyzer . In the majority of cases, we repeated the analysis with another blood gas analyzer of the same specification for control purposes immediately after the first analysis. Additionally, and as part of the routine patient care, an arterial blood sample was analyzed using a blood gas analyzer mostly within one hour of analyzing CSF. Independent from that and according to the internal standard operating procedure for CSF analysis in patients with continuous external CSF drainage, we sent a probe of CSF to the neurochemical laboratory of the hospital twice a week. Therefore, for these days we were able to compare CSF analyzed by the internal reference device for CSF diagnostics  with that from the blood gas analyzer. If CSF-lactate as determined by blood gas analyzer and on days without regularly planned CSF measurement by the standard method deviated significantly from the reference range or previous measurements, additional CSF was collected and sent for confirmation of the results to our reference laboratory. However, we immediately put pathological CSF results as determined by blood gas analyzer into clinical context and modified treatment if indicated based on all the available data. Likewise, we determined CSF glucose by blood gas analyzers for this study, but did not compare these values to a certified standard method. The given blood gas analyzers measure lactate and glucose amperometrically. An enzymatic reaction of oxygen with metabolites of lactate and glucose, respectively, drives the oxidation of a platinum electrode inducing a current, which thus is proportional to the metabolite concentration. The equation To determine the correlations of measured values, we calculated Pearson’s correlation index and compared CSF-lactate as determined by blood gas analysis to CSF-lactate as measured by the internal standard method. Additionally, we compared CSF-lactate and blood-lactate as well as CSF-glucose and blood-glucose each measured by blood gas analyzers in this manner. With respect to determining the accuracy of the measurements, we applied the method of Bland–Altman . For datp = 0.001)  . Regarding our main analysis, i.e., comparison between CSF-lactate measured either by the blood gas analyzer or the reference method, we calculated a Pearson correlation index of 0.94 (highly significant correlation on a two-sided significance testing (p < 0.001))  with either lumbar or extraventricular drainage in our study  and l-lactate (eukaryotic) in CSF have shown [Importantly, CSF lactate is an unspecific metabolite and may be elevated in a range of diseases including bacterial and fungal meningitis as well as meningeosis neoplastica , 12. Theve shown  and the ve shown . Still, ve shown . On the ve shown , 8. A reve shown . Indeed,ve shown  it influve shown . Still, ve shown . In geneAs measurements of blood-glucose by blood gas analyzers is part of the routine for nearly any ICU patient, a pair of CSF- and blood-glucose is easily generated. This is important, since CSF-glucose on its own has a rather poor while a low ratio of CSF-to-blood-glucose of < 0.4 has a well-established predictive value for detecting a non-viral meningitis . ImportaCSF-lactate measurements by a blood gas analyzer may accelerate detection of potential CSF inflammation in patients with temporary external CSF drainage.Additional file 1: Fig. S1. Pearson correlation plot demonstrating the correlation between 512 measurements of glucose in CSF and serum in mmol/l.


Retinol, one of the most powerful cosmetic materials for anti-aging supported by a solid scientific background, exhibits a wide range of type and severity of irritation while showing limited user compliance. The lack of understanding of the mechanism of retinol-induced irritation has been the main hurdle in the development of anti-irritation strategies. Here, we identified 30 genetic markers related to the susceptibility to retinol-induced irritation in the Korean population. Based on the genetic analysis, a novel formula against retinol-induced irritation was developed, which mitigated the molecular pathogenesis—as indicated by the genetic markers—of the retinol-induced irritation. In human tests, this formula effectively decreased retinol-induced irritation. Furthermore, a polygenic risk score model for irritation was constructed and validated. Our comprehensive approach for the analysis of retinol-induced irritation will not only aid the development of anti-irritation strategies to ensure higher user compliance but also contribute to improving the current knowledge about the biological effects of retinoids. Retinoids, a family of compounds derived from vitamin A that includes both synthetic and natural compounds, have been intensively studied and utilized in diverse biomedical applications such as cancer treatment (acute myeloid leukemia), cervical neoplasia, and skin disorders in the past few decades. The wide application of retinoids, especially retinoic acid, is based on the scientific premise that retinoic acid is involved in numerous biological pathways in nature by triggering interactions between nuclear receptors that control gene expression ,2,3,4,5.One of the most striking applications of retinoids is the dermatologic approach, along with pharmaceutical drugs and cosmetic products. Since retinoids were first used for the treatment of acne in the 1940s, its therapeutic efficacy against skin disorders such as actinic keratosis, psoriasis, and ichthyosis is reported . As manyHowever, retinoids cause irritation and some side effects characterized by erythema, scaling, burning, and itching, which are also termed retinoid dermatitis . Some stA genetic approach can be another solution for establishing an anti-irritation strategy against retinol. Genetic variations were extensively studied to discover genes associated with drug efficacy and side effects . Nelson MCP-1, TNF-a, interferons, and interleukins) [RARG) [TRPV1) [GPCR (MRGPRX2) [Retinol treatment induces changes in the expression of transcription factors related to cellular growth  and struleukins) , retinoi) [RARG) , pain-se [TRPV1) , and masMRGPRX2) . HoweverEGFR, IL-18, IL-4R, COL6A2, and RARB, to be associated with retinol-induced irritation. We investigated which materials can modulate or alleviate retinol-induced molecular pathogenesis in vitro . Furthermore, we developed and evaluated a polygenic risk prediction model for retinol-induced irritation in the Korean population. This novel genetics-based approach for the determination of anti-irritation strategies against retinol will contribute to a deeper understanding of retinoids—which is currently lacking—and enable the retinol-based cosmetic product to be more accessible to individuals susceptible to retinol-induced irritation.Here, we report a genetically guided anti-irritation strategy using an anti-irritant formula based on the genetic analysis of the Korean population. The results of the genetic analysis undertaken to reveal the genetic factors that govern retinol-induced irritation identified 30 genetic variants of 10 genes including those encoding n = 7) and large-scale clinical evaluation  were performed to verify the anti-irritant efficacy of the newly developed formula.This study was designed as shown in This study was approved by the Ethics Committee of the LG H&H Institutional Review Board . Prior to participation in the study, human test subjects were informed of possible side effects and consented to participate in the study.In the 1st clinical evaluation, we investigated the irritant property of retinol in 173 Korean individuals by applying increasing concentrations of retinol for 3 days with a resting period of 4 days a week for 3 weeks.Using provided retinol cream;Providing information through a questionnaire after the experiment;Collecting saliva for DNA testing.Retinol cream was prepared at three different concentrations , 0.075%; level 2, 3300 IU, 0.01%; level 3, 5000 IU, 0.015%). A corresponding amount of retinol was added to the typical O/W-type cream previously developed in our research institution. The cream formulation is composed of the following components: cetyl stearyl alcohol, glyceryl stearate, PEG-40 stearate, ceteareth-20, beeswax, C14-22 alcohols, C12-20 alkyl glucoside, lecithin, tocopherol, caprylic/capric triglyceride, squalene, cyclopentasiloxane, cyclohexasiloxane, dimethicone/vinyl dimethicone crosspolymer, isocetyl myristate, dipropylene glycol, glycerin, betaine, 1,2-hexanediol, EDTA-3Na, xanthan gum, carbomer, tromethamine, and distilled water. All types of cream used in this study were produced in the LG H&H R&D center by own protocol. The typical cream without retinol was considered as a “non-irritant,” according to patch tests. All participants were informed of the ingredients of the cream prior to the experiment, and the participants who had experienced skin irritation to any of the ingredients in the cream, except for retinol, were excluded from the experiment. The detailed procedure is described in the Genomic DNA was extracted from saliva samples using the QIAmp Mini Prep Kit . Genotyping was carried out using the Global Screening assay version 2 chip according to the Illumina Infinium High-Throughput Screening (HTS) assay protocol . Bead intensity was obtained using the iScan® instrument and subsequently used to yield genotype data using GenomeStudio® software .p-value < 1 × 10−6), and those having more than two alleles were excluded. Among the 173 genotyped individuals, 159 passed the QC criteria and were selected for further analysis.Quality control of the genotype data was preferentially performed under the following conditions: Among the genotyped samples, individuals with a genotype call rate lower than 98% were excluded. For genotyped variants, SNPs with call rates lower than 98%, minor allele frequencies lower than 1%, deviation from Hardy–Weinberg equilibrium , respectively. To measure the pain pressure threshold (PPT), an algometer with a probe diameter of 1 mm combined with a cylinder was manufactured and used. Before the measurement, the faces of the subjects were cleaned and acclimated for 20 min in an air-conditioned room .The two types of creams, namely the control cream with 5000 IU retinol, and the anti-irritant formula (AF)-based cream with 5000 IU retinol, were administered to seven individuals (three men and four women) in the pilot study. The individuals applied the creams on their face before bedtime in the following manner: one cream on one half of the face and another on the other half of the face. The test subjects were blinded to the cream containing the anti-irritant formula (single-blinded). After three days of application, the subjects were asked to cease the application for 4 days. Skin redness and transepidermal water loss (TEWL) were measured using a chromameter  and TewameterConsidering that retinoid-induced irritation triggers an extremely wide range of irritation types and severity, it appears that traditional irritation-measuring guidelines mainly focusing on erythema proposed by Frosh and CTFA guidelines  do not eDetailed information regarding cell preparation and in vitro experimental procedures is provided in the Statistical analysis was performed using SNP and Variation Suit (SVS) v8.9.0 , and PLINK 1.90  . For canIn the analysis of the occurrence rate of irritation based on the dichotomous question (whether retinol cream is irritant: Y/N), the chi-squared test was performed to investigate the statistical significance.We investigated the irritant properties of retinol and its relationship with skin sensitivity in 173 Korean individuals. They applied retinol for 3 days, which was followed by a rest of 4 days a week for 3 weeks, with each concentration of retinol gradually increasing every week . Then, we analyzed the questionnaire received after the experiment to investigate the factors related to retinol-induced irritation.A higher proportion of participants in the sensitive skin group reported that they experienced irritation compared to the non-sensitive skin group a. It wasThe type of irritation induced by retinol usage varies greatly among individuals. However, stinging was most common, which comprised about three-fourths of the irritations and was followed by burning, itching, and erythema e.To discover genetic variants associated with skin sensitivity to retinol, we chose 14 candidate genes that are well-known for their functions in retinoid metabolism and skin sensitivity . We refep < 0.05; RARB, three in EGFR, three in CD44, two in IL18, two in IL4R, and four in BCL2. The other four genes, CD86, RXRB, MMP10, and COL6A2, included single SNPs. The discovered SNPs belonged to 10 genes, two of which were retinol-related genes, and the remaining eight were related to general skin sensitivity according to earlier studies. Among the 10 genes, we selected the most important three genes in terms of skin irritation: COL6A2, EGFR, and IL-4R.A total of 319 SNPs located within the candidate genes were selected and used for the association analysis using the additive model. Thirty SNPs were significantly associated with retinol-induced irritation, none of which have been previously reported  and its receptor, IL-4R, have been extensively investigated. As a key regulator in the humoral and adaptive immune system, IL-4, which is primarily secreted from mast cells and Th2 cells, induces the differentiation of Th2 cells and stimulates B cells. Although its role is not clearly understood, many studies have pointed out that IL-4 may drive extensive pro- and inflammation processes, while its defect was shown to drive allergic disease, Alzheimer’s disease, and tumors . Along tBased on the selected genes, we screened for anti-irritants that could modulate molecular pathogenesis, such as controlling the expression of the target genes.FLG), loricrin, and CLDN1, and upregulation of CLDN2, CLDN4, and a significantly different expression of serpin family member genes were observed in an earlier study, which is thought to be the main cause of retinoid-induced irritation [Earlier reports revealed that retinoids induce physiological and morphological changes in the skin barrier ,42,43. Iritation ,11. COL6A2 and EGFR tend to be susceptible to the weakening of skin barrier function by retinol, which leads to retinol-induced irritation  through the EGFR/ERK pathway in human keratinocytes [AQP3 expression by approximately two-fold in fibroblasts (AQP3 overexpression by niacinamide (nicotinamide) is similar to that found in an earlier study. Among the various substances, trehalose and eupatilin attenuated retinol-induced AQP3 overexpression. Eupatilin , a type of flavonoid found in Artemisa asiatica, was reported to enhance the skin barrier function under pathological conditions in vivo [In the case of EGFR, we carefully considered previous research indicating that retinoic acid induces the overexpression of aquaporin 3  and allergic airway disease [IL-4 in the CNP (carbon nanoparticle)-induced lung inflammation in an in vivo model, supporting our experimental results [Then, we tried to identify anti-irritants related to inflammatory genes. Based on our results of genetic analysis, it has been shown that individuals who are prone to retinol-induced irritation tend to have SNP markers for  of IL-4 , it was  disease ,49. More results .IL-4R in mast cells, with a decrease of 37.03%, 41.97%, and 82.59%, respectively. Ectoine , a natural compound found in several halophilic bacteria, was shown to modulate many cytokines and chemokines under inflammatory conditions, although the role of ectoine in ameliorating the expression of IL-4R has not yet been elucidated. Our observations offer novel insights into the function of ectoine. Previous study by our group showed that ectoin at an optimum concentration of 100 ppm showed the highest anti-inflammatory effect against the effects of retinoids and negligible cytotoxicity in the cell-based in vitro experiment (data not shown).Crocin, glucosamine, and ectoine alleviated the retinol-provoked overexpression of We also measured the β-hexosaminidase release rate of mast cells, which is an indicator of mast cell degranulation  appeared in some analysis models with low to moderate statistical significance. An earlier study of the Korean population showed that the “sensitive” skin phenotype appears to be related to adiponectin deficiency, which consequently contributes to the upregulation of TRPV1 [he skin. ,52,53,54of TRPV1 .TRPV1-overexpressing HEK293 cells were treated with retinol, and the activation of TRPV1 was confirmed by imaging calcium influx. We observed that retinol could activate TRPV1 in a dose-dependent manner  against retinol-induced irritation, which consisted of glucosamine 0.1%, trehalose 2%, ectoine 2%, sucralfate 0.1%, omega-9 1%, and 4-t-butylcyclohexanol 0.7% with retinol. (standardized as an active concentration)First, we performed a pilot study with seven individuals to quantitatively verify the effectiveness of the AF. When the irritation score of each type of irritation for the individual was summed during the test period, it was shown that compared to the control retinol cream, AF effectively decreased retinol-induced irritation, especially desquamation (66.67% decrease), burning (68.42%), and stinging (68.97%), and this amelioration of symptoms was statistically significant a. IntereNext, the overall score of irritation over time was investigated b. As mayMCP-1 and IL-8 from fibroblasts. It is noteworthy that as shown in the previous section, retinol activates macrophages (overexpression of IL-4R), which is the prime driver of cutaneous vasodilation [At the 7th day, we measured the TEWL and redness d. AF reddilation .In the TEWL analysis, the retinol cream based on AF increased TEWL by 19.07% for test subjects individually, while the control retinol cream increased TEWL by 42.54%. This clinical observation is similar to that of a previous report indicating that retinoids temporarily induce an increase in TEWL in vivo in mice and humans . AlthougTRPV1. Earlier studies have shown that neurogenic inflammation is highly related to the mechanical sensitization of cutaneous nociceptors [TRPV1 display attenuated mechanical hyperalgesia to noxious mechanical stimuli [TRPV1 antagonist (V116517) significantly increased the PPT of the skin under various conditions [We also measured the pressure–pain threshold using an algometer with a tip with a radius of 1 mm . The seniceptors , and mic stimuli . One humnditions .To verify the anti-irritant effect of AF in the independent group, we grouped together all the human subjects, which consisted of 44 males and 47 females with ages ranging from 27 to 50 years. The test subjects were asked a dichotomous question, whether “retinol-based cream is irritant or not”, based on their own subjective criteria. This response ratio was compared to that of the first large-scale clinical evaluation of 173 individuals who had used a normal retinol cream in order to derive the anti-irritant effect of AF.The occurrence rate of retinol-induced irritation was calculated and compared e. A 64.42 values between SNPs. Then, the risk scores of all 159 samples were visualized.As anti-irritants in AF were screened from the associated genes, we constructed a polygenic risk prediction model to evaluate the cumulative genetic effect of multiple loci on retinol-induced irritation. A polygenic risk prediction model was constructed using 26 significant SNPs selected after LD analysis based on |D’| and rThe test subjects of the second large-scale clinical test were arbitrarily categorized into three groups: high , middle , and low risk score  . As charAs shown in The total score during the test period was calculated as 6.370 and 10.161 for the low-, middle-, and high-risk score groups, respectively b.The efficacy of AF, according to the polygenic risk score model, was investigated. The results demonstrated that AF alleviated retinol-induced irritation, and the efficacy could be predicted using the polygenic risk score model c.Consequently, these experimental results and observations not only demonstrate the anti-irritation effect of AF but also imply that proposing an appropriate dosage of retinol by estimating the susceptibility to retinol-induced irritation based on individual genetic information is applicable, which can finally offer genetically the most-optimized usage protocol to patients with higher compliance.As mentioned before, allergy-like reactions, which including rapid burning and stinging sensation, itchiness, and rapid diffusive edema and rash were observed in retinol-sensitive individuals. These reactions, which occurred within a few minutes, sometimes even a few seconds, cannot be clearly explained by previous retinoid-mechanistic studies that have mainly focused on cytokine production by keratinocytes or fibroblasts , or the In the first clinical evaluation, it was observed that about 5% of the test subjects experienced violent and severe above-mentioned reactions and were dropped from the test. However, detailed investigations have not been performed regarding the intolerance of retinoid depending on race, sex, or age, and it has been reported that the Asian population is more prone to these reactions, which urges the necessity for the consideration of rapid-provoked irritation for the further development of retinoid-based products. Our human test results suggest that neurogenic inflammation, or a similar prompt mechanism, is also involved in retinol-induced irritation. The burning sensation and stinging were dominantly observed at each retinol treatment within a few minutes in all three groups and repressed over time.Here, these are some points that deserve consideration.RAR or RXR binding is involved.As reported earlier, retinol may be converted into retinaldehyde  and retinoic acid to possess the bioavailability at which However, the homeostasis of retinoids in the skin is very tightly controlled , and parIL-1 or IL-6 through the interaction between RAR and retinoic acid, to which the retinol should be converted.Under retinol treatment, fibroblasts or keratinocytes activate the circumjacent cutaneous immune system as quickly as within a few minutes by producing Based on these considerations, it seems more reasonable that acute irritation within a few minutes may be driven by the histamine–mast cell system or neurogenic inflammation promptly, which subsequently triggers extensive and pervasive inflammation, leading to long-term irritation.COL6A2, EGFR, and IL-4R. Our developed formula against retinol-induced irritation decreased skin redness and TEWL in the objective analysis, and it also decreased the individuals’ degree of irritation on a subjective analysis in both small-scale pilot studies and large-scale human tests. An anti-irritant strategy was developed, and a polygenic risk score model for the prediction of individual irritation was developed.Although retinol is regarded as one of the most effective and attractive cosmetic materials based on its strong scientific background, its characteristic irritation has remained a major hurdle for the ubiquitous anti-aging strategy, since only a handful of individuals are allowed to utilize it. Some efforts to reveal the mechanism of retinoid-induced irritation were attempted, although the in-depth mechanism remains unclear. The lack of understanding of retinol-induced irritation regarding why the types and degree of irritation vary according to ethnicity, sex, or even one person to the next has delayed the development of anti-irritation strategies. Here, we identified genetic markers related to retinol-induced irritation in the Korean population and developed a novel formula for anti-irritation against retinol. As a genetically guided top–down approach, the series of in vitro experiments revealed that glucosamine, sucralfate, trehalose, ectoine, 4-t-butylcyclohexanol, and omega-9 fatty acid could mitigate the irritation-associated molecular pathogenesis for Here, our strategies against retinol-induced irritation include (1) disclosing and screening genetic markers related to retinol-induced irritation, (2) a formula for reducing irritation based on in vitro verification of whether this formula can modulate molecular pathogenesis suspected by genetic markers, and (3) a polygenic risk score model for the prediction of irritation. Our approach will improve the compliance of patients who require retinol for various purposes in the future, while suggesting significant scientific clues to basic retinoid science, which remains to be elucidated.


Multiple sclerosis (MS) pathophysiology comprises both inflammatory and neurodegenerative characteristics. Cerebrospinal fluid (CSF) analysis allows for assessment of inflammation while neurofilament light chain can indicate neuroaxonal damage. Retinal thinning is a robust prognostic biomarker for neurodegeneration in MS. To date, an association between CSF parameters upon MS diagnosis and retinal thinning has not been investigated.We aimed to determine whether CSF parameters are associated with the evolution of retinal layer thinning in people with MS (pwMS).CSFTP], CSF/serum albumin ratio [Qalb], intrathecal synthesis of immunoglobulins, neurofilament light chain [NfL] in both CSF and serum [CSFNfL/sNfL]) as independent variables adjusted for age, sex, and disease duration.For this longitudinal observational study, we investigated pwMS from the Vienna MS database (VMSD), who had undergone (1) a diagnostic lumbar puncture (LP) between 2015 and 2020, and (2) simultaneous optical coherence tomography (OCT) and/or (3) a follow-up OCT scan. Linear stepwise regression models were calculated with OCT parameters  as a dependent variable, and CSF parameters . We did not find any association between other CSF parameters, including CSFNfL, sNfL, and aLpRNFL.We analyzed 61 pwMS . Increased WBC count as an indicator of acute inflammation and blood-brain-barrier breakdown seems to be associated with the amount of retinal thickness already lost at the time of LP. However, neither routine CSF parameters nor a singular NfL measurement allows the prediction of future retinal thinning. Multiple sclerosis (MS) is an inflammatory demyelinating disease of the central nervous system (CNS) that represents the most common neurological disease in young adults . The curTo date, no studies have been published concerning the prognostic impact of the described CSF parameters on retinal layer thinning. With this study, we investigated whether conventional CSF parameters and NfL are associated with pRNFL at baseline and follow-up in a cohort of newly diagnosed pwMS.For this longitudinal observational study, we extracted serum and CSF from patients in the Vienna MS database (VMSD) diagnosed with relapsing-remitting MS (RRMS) according to the 2017 McDonald criteria, aged between 18 and 65 years, who had a diagnostic lumbar puncture (LP) between January 1, 2015 and December 31, 2019, and (1) OCT at LP, and/or (2) follow-up OCT.We documented age and disease duration at baseline as well as the duration of the follow-up period, defined by an interval between the diagnostic LP and the last OCT scan. A relapse was defined as patient-reported symptoms and objectively confirmed neurological signs typical of an acute CNS inflammatory demyelinating event with a duration of at least 24 h in the absence of fever or infection and separated from the last relapse by at least 30 days . The ExpThe patients' disease-modifying treatment (DMT) status was classified as follows: (1) “no DMT” defined as patients receiving no DMT between diagnostic LP and the last OCT scan; (2) “moderately effective DMT (M-DMT)” defined as patients receiving either interferon-beta preparations, glatiramer acetate, dimethyl fumarate or teriflunomide; or (3) “highly effective DMT (H-DMT)” defined as patients receiving either natalizumab, fingolimod, alemtuzumab, cladribine, ocrelizumab, or rituximab. We also defined “escalation (ESC-DMT)” as patients switching from no DMT to moderately effective DMT or from moderately effective DMT to highly effective DMT between the diagnostic LP and the last OCT scan.CSFTP), CSF/serum albumin ratio , intrathecal synthesis of IgA, IgM, and IgG including oligoclonal-IgG-bands (OCB).In all patients, routine LP was performed at baseline as part of the routine diagnostic work-up following written informed consent. The routine CSF parameters included: WBC count, total protein  imaging was performed by experienced neuro-ophthalmologists at the Department of Ophthalmology and Optometry of the same institution using the same spectral-domain OCT  without pupil dilatation in a dark room on both eyes of each patient. For pRNFL measurement, a custom 3.4 mm ring scan (12°) centered on the optic nerve head was used  , Image pEyes suffering ON during the observation period were excluded from the longitudinal part of the study and only the values of eyes without ON during the observation period were used for the calculation of retinal thinning in the analyses . To idenCSFNFL were measured on the SR-X analyzer  using commercially available Simoa NF-light kits and following the manufacturer's instructions. The investigators performing the CSFNfL and sNfL testing were blinded to the clinical and OCT parameters, and vice versa. The samples were analyzed as duplicates. Only samples yielding a coefficient of variance (CV) of <0.2 were included in this study. Sensitivity analyses for missing NfL values were performed as a separate analysis of parameters for subjects with available and subjects with missing NfL values.Serum and CSF samples were extracted from our neurological biobank where aliquots are stored at −70°C in accordance with international consensus guidelines , 25. ConThe study was approved by the ethics committee of the Medical University of Vienna, Austria (EK1446/2021).t-test as appropriate.Statistical analysis was performed using SPSS 26.0 . Categorical variables were expressed in frequencies and percentages, continuous variables as mean and SD or median and interquartile range (IQR) as appropriate. Continuous variables were tested for normal distribution by the Kolmogorov–Smirnov test with Lilliefors correction. Univariate comparisons were done by a chi-square test, Mann-Whitney U-test, or independent CSFTP, Qalb, intrathecal synthesis of IgA, IgM and IgG, OCB) and OCT parameters . Linear stepwise regression models were fitted with the OCT parameters  as the dependent variable and the CSF parameters as independent variables adjusted for age, sex, and disease duration. Second, the CSFNfL, sNfL, and OCT parameters were univariately analyzed by Pearson or Spearman correlation analyses. Linear stepwise regression models were fitted with the OCT parameters as the dependent variable, and the CSF parameters, CSFNfL, and sNfL as independent variables (in separate models to avoid collinearity) adjusted for age, sex, and disease duration. As covariates, the number of relapses and disability progression during follow-up as well as the DMT group was included. A value of p < 0.05 was considered statistically significant. All multiple analyses were corrected using the Bonferroni method.First, we performed a univariate analysis with Pearson and Spearman correlation analyses on the CSF parameters  patients, and baseline serum samples for sNfL measurements were available in 31 (50.8%) patients. Sensitivity analyses regarding missing NfL values did not show a significant effect of missing values on the reported results. The demographics and clinical characteristics of the study cohort are given in We included 61 pwMS in the analysis . In totap = 0.008) but not with any of the other CSF parameters (The mean pRNFL thickness at baseline was 97.0 μm ([SD] = 10.9). In total, 11 (20.8%) patients had a pRNFL thickness ≤ 88 μm at baseline. We detected no differences in the CSF parameters between these two groups. In the multivariable analyses, pRNFL thickness at baseline was associated with the WBC count . In total, 7 (18.4%) patients had a pRNFL thickness ≤ 88 μm at follow-up. We detected no differences in CSF parameters between these two groups, and there was no association between pRNFL thickness and CSF parameters.rs = 0.629, p = 0.016) and IgA index  but not with other CSF parameters (The median follow-up period was 1.9 (IQR 1.1–3.5) years. The mean aLpRNFL was −0.6 (SD 1.5) μm/year with 6 (24.0%) patients showing an aLpRNFL ≥1.5 μm/year. In our sample, the aLpRNFL correlated with both the IgA ratio ; however, no correlation with pRNFL or aLpRNFL was found. Patients with evidence of neuroaxonal loss (characterized by an aLpRNFL ≥1.5 μm/year) had higher concentrations of CSFNfL (830.7 vs. 497.3 pg/ml) and sNfL (6.9 vs. 8.0 pg/ml) compared to patients with aLpRNFL <1.5 μm/year, but these differences were not statistically significant   for CSF and 10.6 pg/ml (IQR 7.1–20.2) for serum. As expected, ctively) . We alsoctively) .In this longitudinal observational study of 61 pwMS, we aimed to determine an association between conventional and novel CSF parameters at the time of diagnosis and OCT parameters at baseline and follow-up (median 1.9 years). This is important, as retinal layer thinning on OCT is a relevant biomarker for MS-associated neurodegenerative changes, such as neuroaxonal loss, physical and cognitive disability, and brain atrophy , 26–28.Out of all classical CSF parameters investigated, WBC count emerged as the sole statistically significant predictor of pRNFL thickness at baseline. That being said, the effect size was moderate at best and only explained about 13% of the pRNFL thickness variation.Importantly, the CSF cell count was not associated with pRNFL thickness at follow-up or thinning of pRNFL during follow-up. The observation that WBC count is associated with pRNFL thickness at the time of LP but not with further pRNFL thinning suggests that WBC count is reflective of short-term inflammatory activity rather than long-term disease progression, i.e., neuroaxonal damage. This is aligned with evidence indicating that increased WBC is associated with faster conversion from clinically isolated syndrome (CIS) to clinically definite MS but only very weakly with EDSS worsening , 30.This was the first published study to investigate the associations between NfL in CSF and retinal layer thinning. We did not find any significant association, even though we observed a trend toward increased CSF NfL levels and both lower pRNFL thickness at baseline, as well as increased aLpRNFL. Previous studies have shown an association between NfL levels in serum and both pRNFL thickness and aLpRNFL . As seruOur results are limited with respect to the small sample size. Data on aLpRNFL was only available for 25 patients with only 6 of them showing signs of progression. We did not include GCIPL thickness which is reported to be even a more sensitive biomarker of disease progression in MS , 33. AlsIn conclusion, we showed some evidence that from all CSF parameters obtained at diagnosis, the WBC count remained the only parameter to determine decreased retinal thickness. In our model, NfL concentrations in both serum and CSF upon diagnosis were not robust enough to predict subsequent retinal thinning.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of the Medical University of Vienna, Austria (EK1446/2021). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.NK: acquisition of data, data management, statistical analysis and interpretation of data, and drafting of the manuscript. PA: acquisition of data, data management, interpretation of data, and drafting of the manuscript. KR, CM, PR, FL, TB, and BP: acquisition of data and critical revision of the manuscript for intellectual content. GB: study concept and design, acquisition of data, interpretation of data, study supervision, and critical revision of the manuscript for intellectual content. All authors contributed to the article and approved the submitted version.This research was funded by the Medical University of Vienna.NK has participated in meetings sponsored by, received speaker honoraria or travel funding from Roche, Novartis, and Merck, and holds a grant for a Multiple Sclerosis Clinical Training Fellowship Programme from the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). PA has participated in meetings sponsored by, received speaker honoraria or travel funding from Biogen, Merck, Roche, Sanofi-Genzyme, and Teva, and received honoraria for consulting from Biogen. He received a research grant from Quanterix International and was awarded a combined sponsorship from Biogen, Merck, Sanofi-Genzyme, Roche, and Teva for a clinical study. CM has received honoraria for consultancy/speaking (incl. funds for e-learning modules) from Bayer, Novartis, and Takeda. PR has received honoraria for consultancy/speaking from AbbVie, Allmiral, Alexion, Biogen, Merck, Novartis, Roche, Sandoz, Sanofi Genzyme, has received research grants from Amicus, Biogen, Merck, Roche. FL received honoraria  from pharmaceutical companies marketing treatments for MS: Alexion, Almirall, Bayer, Biogen, Celgene, MedDay, Merck, Novartis, Octapharma, Roche, Sanofi-Genzyme, Teva. TB has participated in meetings sponsored by and received honoraria  from pharmaceutical companies marketing treatments for MS: Almirall, Biogen, Bionorica, Celgene/BMS, GSK, Janssen-Cilag, MedDay, Merck, Novartis, Roche, Sandoz, Sanofi-Genzyme, Teva. His institution has received financial support in the past 12 months by unrestricted research grants Biogen, Celgene/BMS, Merck, Novartis, Sanofi Aventis, Teva and for participation in clinical trials in multiple sclerosis sponsored by Alexion, Biogen, Merck, Novartis, Octapharma, Roche, Sanofi-Genzyme, Teva. BP has received honoraria for consulting from Novartis. GB has participated in meetings sponsored by, received speaker honoraria or travel funding from Biogen, Celgene, Lilly, Merck, Novartis, Sanofi-Genzyme, and Teva, and received honoraria for consulting Biogen, Celgene, Novartis, Sanofi-Genzyme, Roche, and Teva. The remaining author declares 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.


Corynebacterium striatum is a gram-positive facultative anaerobe found in the environment and human flora that has historically been considered a contaminant. More recently, Corynebacterium striatum has been implicated in human infections, including respiratory infections, endocarditis, and bone and joint infections, particularly those involving hardware or implanted devices.Staphylococcus haemolyticus, Staphylococcus epidermidis and Corynebacterium striatum. Given concern for daptomycin resistance and the reliability of vancomycin susceptibility, daptomycin was discontinued and vancomycin initiated following a graded challenge. Within a few days, the patient developed a diffuse, blanching, erythematous, maculopapular rash and daptomycin was restarted. Over the next 72 h, his rash progressed and he met criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Daptomycin was stopped and oral linezolid initiated; rash improved. C. striatum returned with susceptibility to gentamicin, linezolid, vancomycin and daptomycin. Due to concern for adverse effects on long-term linezolid, daptomycin was restarted and was tolerated for 20 days, at which point purulent drainage from incision increased. The patient underwent another arthroplasty revision and washout. Operative cultures from this surgery were again positive for C. striatum. Repeat C. striatum susceptibilities revealed resistance to daptomycin but retained susceptibility to linezolid. Daptomycin was again changed to linezolid. He completed six weeks of linezolid followed by linezolid 600 mg daily for suppression and ultimately opted for disarticulation.A 65-year-old man presented for washout of his left total knee arthroplasty following a revision 20 days prior. The patient underwent debridement of his left total knee and revision of the left total femur arthroplasty. Daptomycin was initiated empirically due to a previous rash from vancomycin. Operative tissue cultures grew C. striatum has historically been regarded as a contaminant, particularly when grown in tissue culture in the setting of prosthetic joint infection. Based on the available literature and susceptibility patterns, the most appropriate first-line therapy is vancomycin or linezolid. Treatment with daptomycin should be avoided, even when isolates appear susceptible, due to the risk of development of high-level resistance (MIC > 256 µg/mL) and clinical failure. C. striatum is a gram-positive facultative anaerobe found in the environment and in human nasopharynx and skin. Non-diphtheriae Corynebacterium species have historically been considered a contaminant. More recently, C. striatum has been increasingly implicated in a number of infections, including respiratory infections, endocarditis, and bone and joint infections, particularly those involving hardware or implanted devices [C. striatum has been noted to form biofilms on prosthetic material and has been implicated in nosocomial outbreaks. Adherence to a variety of prosthetic surfaces, including both hydrophobic and hydrophilic surfaces has been noted via binding of fibrinogen to the surface of the organism [C. striatum has not been clinically validated on the Vitek MS (bioMérieux) or the Bruker Biotyper, the organism is available in the current Knowledge Base. MALDI-TOF MS has been reported to more accurately identify Corynebacterium species compared to conventional biochemical methods [C. striatum isolates were identified with 100% agreement, however, 4 isolates were misclassified by the RapID CB Plus (ThermoFisher) phenotypic identification system [ devices . While torganism , 3. Incr methods –6. In a n system .C. striatum in bone and joint infections, including those with prosthetic material, remains puzzling. A recent review of Corynebacterium species causing orthopedic infections included 13 cases of C. striatum. The study concluded that Corynebacterium species are most often a contaminant, as defined by Infectious Disease Society of America Prosthetic Joint Infection guidelines as being detected in only 1 of at least 2 samples cultured [C. striatum reported that when isolated from hardware, the organism was considered pathogenic in 87% of cases, as determined by the treating infectious disease physician. These patients were treated with a significantly longer duration of intravenous (IV) antibiotics compared to patients with hardware infections caused by coagulase-negative staphylococci [The presence of cultured , 9. Howeylococci .staphylococci and Pseudomonas aeruginosa, treated with daptomycin and ciprofloxacin, followed by suppression with ciprofloxacin and trimethoprim-sulfamethoxazole. His labs were only notable for mild normocytic anemia.A 65-year-old man presented for repeat washout of his left total knee arthroplasty due to ongoing drainage following revision 20 days prior. The patient’s past medical history was significant for anxiety treated with sertraline. He had undergone multiple previous revisions of his knee arthroplasty and left femoral replacement, initially placed in the 1980s  [On day 4 of vancomycin, the patient developed a diffuse, blanching, erythematous, maculopapular rash and daptomycin was restarted. Over the next 72 h, his rash progressed, he became febrile to 38.9 SI m-45)  and resiEnterobacter cloacae complex, and five of six operative tissue cultures were again positive for rare C. striatum. Antibiotics were changed to linezolid and cefepime. Cefepime was selected due to concern for AmpC induction with the use of third generation cephalosporins over long courses of antibiotic therapy in Enterobacter cloacae. Due to the risk of serotonin syndrome when sertraline is combined with linezolid and the patient reporting little benefit from sertraline therapy, a taper was initiated. Repeat C. striatum susceptibilities revealed resistance to daptomycin (reported as MIC > 1 µg/mL), via E-test but retained susceptibility to linezolid (MIC 0.5 µg/mL). He completed six weeks of linezolid and cefepime followed by linezolid 600 mg daily for suppression, due to the presence of retained hardware. The linezolid suppression was continued for just under a year and a half (522 days) until the patient ultimately opted for disarticulation. At that time the patient noted symptoms consistent with optic neuritis and peripheral neuropathy, so linezolid was discontinued. The patient was treated post-operatively for 6 weeks with oral doxycycline as repeat cultures grew C. striatum susceptible to doxycycline and has not re-presented with infection after 12 months.The patient tolerated daptomycin for 20 days but then noted increasing purulent drainage from his incision. He underwent another arthroplasty revision, washout and gastrocnemius rotational flap. One operative tissue culture from this surgery was positive for C. striatum exhibits limited susceptibility compared to other Corynebacterium species. Resistance to penicillins, cephalosporins, (including variable MICs reported for ceftaroline), carbapenems, clindamycin, and fluoroquinolones is common. Vancomycin, linezolid, and daptomycin often test susceptible [Staphylococcus aureus and Enterococcus spp, E-tests result in variability of susceptibility results depending on the calcium concentration of the Mueller–Hinton agar used [C. striatum bone and joint infections reports treating 8 of those patients with an amoxicillin-rifampin combination. Amoxicillin MICs for 9 organisms in this series ranged from 0.38 to 3 mg/L  and rifampin MICs ranged from < 0.002 to ≥ 32 mg/L (2 resistant organisms). Treatment with this combination resulted in clinical cure in 4 of 8 patients, although the majority of patients received glycopeptide therapy of unclear duration before receiving the amoxicillin-rifampin combination [C. striatum difficult. A recent systematic review of antimicrobial therapy for C. striatum infections reported 100% susceptibility for included isolates to vancomycin, linezolid, piperacillin/tazobactam, amoxicillin/clavulanate, and cefuroxime. However, the review included a total of 85 individual cases from the literature and reported susceptibilities for only 8 organisms for piperacillin/tazobactam, 3 organisms for amoxicillin/clavulanate, and 2 organisms for cefuroxime [C. striatum not included in this review indicate that resistance to these agents may be higher, such as in the above study by Noussair and colleagues [ceptible . Currentceptible . Howevergar used , althouggar used . A recenbination . Applicafuroxime . Reportslleagues  that repS. aureus [C. striatum PJI has not been established. Development of high level daptomycin resistance while on therapy has been reported in patients receiving doses ranging from 6 to 8 mg/kg [C. striatum endocarditis with daptomycin are available in the current literature, one that used 10 mg/kg of daptomycin and the other used daptomycin 6 mg/kg plus oral rifampin 300 mg twice daily [C. striatum is unique compared to other gram-positive organisms. In S. aureus, resistance to daptomycin develops via a variety of mechanisms attributed to a number of single nucleotide polymorphisms (SNPs). Acquisition of multiple SNPs results in resistance via membrane depolarization, cell wall thickening, and reduced affinity for daptomycin binding [C. striatum differs in that a single mutation results in loss of function at phosphatidylglycerol synthase (pgsA2). Daptomycin activity is dependent on the bacterial cell membrane phosphatidylglycerol (PG) concentration. The pgsA2 mutation in C. striatum allows removal of PG from the cell membrane, altering membrane composition to maintain viability of the bacterial cell while conferring resistance to daptomycin [S. aureus, which often reverts once selective pressure is removed [C. striatum should not be recommended given the significant risk of development of high-level resistance on therapy.The development of daptomycin resistance while on therapy is a significant concern, as illustrated in our case. Development of high level daptomycin resistance (MIC > 256 µg/mL) has been reported in vitro in isolates exposed to daptomycin for 24 h . This ha. aureus , the ide 8 mg/kg –16, 20. ce daily , 22. Whi binding . The mec removed . In geneC. striatum isolated from operative cultures at our institution. We identified an additional 11 cases between July 1, 2015 and July 19, 2019 with a median follow-up of 1.4 years (range 0.4–4.4 years) following C. striatum isolation  with C. striatum susceptibilities were performed in seven (63.6%) patients, with all isolates susceptible to vancomycin. Susceptibilities at our institution are performed at an outside laboratory, and include ceftriaxone, clindamycin, doxycycline, erythromycin, gentamicin, levofloxacin, linezolid, meropenem, penicillin, and trimethoprim-sulfamethoxazole. Vancomycin and daptomycin susceptibilities are performed via E-test, if requested. However, only one patient had additional susceptibilities requested for their C. striatum isolate, which was susceptible to daptomycin, linezolid and resistant to fluoroquinolones. Ten (90.9%) patients were treated with vancomycin and one with daptomycin for a median of 42 days (range 17–105 days). Six (54.5%) required additional surgeries of the involved joint, including two amputations or disarticulations, a median of 44 days (range 5–614 days) following their isolation of C. striatum. Only one had C. striatum isolated from subsequent procedures, however this patient (#3) was initially treated with daptomycin, and was changed to vancomycin therapy following repeat C. striatum isolation. Daptomycin susceptibilities were not performed on either isolate from this patient. These cases highlight the appearance of C. striatum in complicated patients with PJI, although they likely under-represent the total cases at our institution, as the practice of identifying C. striatum to the species level is relatively new in our clinical microbiology laboratory.C. striatum has historically been regarded as a contaminant, particularly when grown in tissue culture in the setting of PJIs, which are frequently polymicrobial. This case highlights the need to consider C. striatum a pathogen in certain clinical contexts. The most appropriate antimicrobial therapy for C. striatum PJI includes vancomycin or linezolid, but β-lactams may be considered if susceptible. Treatment of these infections with daptomycin should be avoided even when isolate appears susceptible due to the risk of developing high-level resistance leading to clinical failure.


This study aimed to compare the clinical features and outcomes of neonatal bacterial meningitis (NBM) between patients with positive and negative cerebrospinal fluid (CSF) cultures and determine the risk factors for CSF culture-positive NBM.We retrospectively reviewed the medical records of all patients with NBM. Perinatal clinical data, laboratory results, and cranial radiographs were obtained.Among the 186 neonates who met the inclusion criteria. The risk factors for positive CSF culture results were analysed using multiple logistic regression. The multivariable logistic regression analysis showed that the possible risk factors of NBM with positive CSF culture in this study were: Length of fever , Neurologic symptoms , Cerebrospinal fluid protein . Cases of NBM with a longer duration of fever, more neurologic symptoms, and higher levels of CSF protein were more likely to demonstrate positive results on CSF culture.Bacterial meningitis is clinically defined as a serious inflammation of meningitis, usually caused by a variety of bacterial infections that may leave sequelae and long-term complications and high mortality rates. Early diagnosis is often difficult, particularly when the patient has been treated with antimicrobials.Cases of NBM with CSF culture-positive results were more likely to have severe clinical manifestations and develop more serious neurologic damage. Patients with NBM who have longer durations of fever, more neurologic symptoms, and higher levels of CSF protein were more likely to have CSF culture-positive results, who should be followed up more closely. Bacterial meningitis is clinically defined as a serious inflammation of the meninges, usually caused by a variety of bacterial infections, and which may leave sequelae and, long-term complications and high mortality rates . A cerebNBM is an acute bacterial infection of the central nervous system. Early diagnosis plays an important role in guiding definitive antimicrobial management . The diaIn our study, we analysed the perinatal clinical data, laboratory results, and central nervous system (CNS) imaging studies of patients with NBM and determined whether there was a significant difference between patients with positive and negative CSF culture results. We also examined whether any independent factors increase the likelihood of a positive CSF culture result.This study was a retrospective review of medical records of neonates with NBM. A total of 221 neonates, who were treated for bacterial meningitis in the neonatal intensive care unit (NICU) of Children’s Hospital of Soochow University between January 2015 and May 2019, 35 were abandoned based on exclusion criteria,186 cases were included in our study. Each neonate was treated as per the medical decision made by the assigned attending. We reviewed the demographic features and clinical and laboratory records of each patient. Demographic data included the age at diagnosis, sex, birth weight, gestational age, and maternal conditions such as premature rupture of membrane (PROM), intrapartum fever, chorioamnionitis, and meconium-stained fluids. Clinical characteristics included the presence of any neonatal neurologic symptoms . Laboratory findings that were collected included complete blood cell count (CBC), blood culture, CSF analysis, C-reactive protein (CRP) as well as hepatic chemistry panel (HCP), glycemic status, and electrolytes.3, protein level >170 mg/dL, and glucose level <34 mg/dl [3, protein level >150 mg/dL, and the glucose level <24 mg/dL.NBM was diagnosed if the clinical signs comply with central nerve system (CNS) infection such as seizures, hypertonia/hypotonia, fatigue, limb jitter, and staring, while fulfil a positive CSF culture or a positive CSF analysis. The positive CSF analysis in term neonates was defined as the leukocyte count >32/mmNeonates who were older than 28 days of age upon diagnosis, evidence of congenital infections, genetic disorders, or chromosomal abnormalities, and neonates who had contaminated CSF samples, the neonates who had been pre-treated with antibiotics before admission, were excluded. The neonates were subsequently grouped based on whether their CSF cultures were positive or negative .All the parents or legal guardians of the participants in this study signed informed consent forms. This study was approved by the Ethics Committee of the Children's Hospital of Soochow University.χ2 test. Comparisons of continuous variables were analysed using the Mann-Whitney U test or t-test. Factors were tested through a univariate analysis, and factors with a p < .05, were tested in a logistic regression analysis (Forward: LR), adjusting for potential confounding factors . All tests were two-tailed, and statistical significance was set at p < .05. Analyses were performed using SPSS version 22.0 .Continuous variables are presented as mean ± standard deviation or median ± interquartile range. Differences in categorical variables among the groups were examined using the Escherichia coli was detected in 28 cases (39%); Group B streptococcus was detected in 21 cases (28%); Staphylococcus was detected in 15 cases (20.8%); Enterococcus faeces was detected in 3 cases (4%); and Listeria monocytogenes, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, and coagulase-negative staphylococci were each detected in 1 case (1.4% each).Among the 186 neonates included in our study, 99 were male and 87 were female. The mean birth weight was 2,977.39 ± 850.61 g. The mean age at onset was 14.97 ± 9.95 days. Seventy-two (39%) cases demonstrated positive CSF cultures, whereas 44 (24%) cases demonstrated positive CSF and blood cultures. Among the positive CSF cultures, p < .05, There were no statistically significant differences in sex, gestational age, and birth weight between the two groups. The CSF culture-positive group demonstrated older ages at onset, higher fever peaks, longer durations of fever, and hospital stay. Meanwhile, the CSF culture-positive group had more frequent neonatal CNS neurologic symptoms , and more frequent imaging abnormalities  than the CSF culture-negative group p < .05, .p < .05). There were statistically higher levels of protein, adenosine deaminase, cells, and lower glucose, lactate dehydrogenase of CSF in the CSF culture-positive group than the CSF culture-negative group (In terms of laboratory parameters, the CSF culture-positive group had higher levels of CRP than the CSF culture-negative group (ve group .We also investigated the independent factors that may influence CSF culture positivity among patients with NBM . LogistiNBM is relevant with substantial morbidity and mortality in neonates and requires early diagnosis and therapy . HoweverIn our study, we found that CSF culture-positive NBM had higher levels of CSF protein than CSF culture-negative NBM. In their study, Tan et al.  reportedNeonatal neurological symptoms, such as seizure, hypertonia/hypotonia, fatigue, limb jitter, and stare, were more likely to be observed in the CSF culture-positive group. Lee et al.  used theIn our study, we found that CSF culture-positive neonates had a longer hospital stay and more imaging abnormalities, so we think the CSF culture-positive neonates would have more short-term complications. We tried to find the risks for CSF culture positive, which also would be regarded as the risks for neurologic damage in NBM. So the patients who had those risk factors could achieve early aggressive therapy.CSF culture-positive neonates also demonstrated significantly high levels of CSF protein, which reflects an ongoing inflammatory response. During the acute phase of NBM, increased interstitial vascular permeability allows pathogens to cross the blood-brain barrier. These pathogens release inflammatory mediators, such as teichoic acid and endotoxins, which, in turn, incite an immune response. The increase in inflammatory mediators, such as polymorphonuclear leukocytes, interleukins, and cytokines, in the CSF presents an increased CSF protein count on CSF analysis. However, the same immune response also results in the formation of reactive oxygen species. These free radicals are highly unstable and may produce harmful proteins, lipids, and nucleic acids. High lipid levels in the setting of low cerebral antioxidant levels are harmful to the central nervous system ,20. As sEscherichia coli was the most prevalent pathogen in NBM at our centre. This was similar to the results reported in many other developing countries [Group B streptococcus. Identifying the most common causative agents may help us better understand the epidemiology of NBM, as well as allow us to make more appropriate empirical decisions.Our study also found that ountries . AnotherA significant problem, particularly in China, relates to the high utilisation rate of antimicrobial drugs. Patients have often been prescribed antibiotics at the outpatient level, which increases the likelihood that CSF cultures produce false-negative results . Some reOur analysis also has other limitations. First, our study was a retrospective study and may have suffered from selection bias. Second, all our data were collected from a single centre, resulting in a relatively small sample size. Examining NBM cases across multiple centres and with a larger sample size may provide more generalisable results.Patients with NBM with CSF culture-positive results are more likely to present with severe clinical manifestations, as well as develop serious neurologic damage. Patients with NBM who present with neurologic symptoms or have higher levels of CSF protein should be followed-up more closely.


Cerebral amyloid angiopathy (CAA) is associated with symptomatic intracerebral haemorrhage. Biomarkers of clinically silent bleeding events, such as cerebrospinal fluid (CSF) ferritin and iron, might provide novel measures of disease presence and severity.We performed an exploratory study comparing CSF iron, ferritin, and other metal levels in patients with CAA, control subjects (CS) and patients with Alzheimer’s disease (AD). Ferritin was measured using a latex fixation test; metal analyses were performed using inductively coupled plasma mass spectrometry.n = 10) had higher levels of CSF iron than the AD (n = 20) and CS (n = 10) groups ; the difference between CAA and AD groups was significant in unadjusted and age-adjusted analyses. We observed a difference in CSF ferritin ; the difference between the CAA and AD groups was significant in unadjusted, but not age-adjusted, analyses. We also observed differences between the CAA and AD groups in CSF nickel and cobalt .CAA patients (In this exploratory study, we provide preliminary evidence for a distinct CSF metallomic profile in patients with CAA. Replication and validation of these results in larger cohorts is needed.The online version contains supplementary material available at 10.1007/s00415-021-10711-6. Cerebral amyloid angiopathy (CAA) is a cerebral small vessel disease characterised by amyloid-beta (Aβ) deposition in cortical and leptomeningeal blood vessels . CAA is We performed a pilot study investigating CSF iron and ferritin levels in patients with CAA, control subjects (CS) and patients with Alzheimer’s disease (AD), and how these correlated with other neurodegenerative CSF biomarkers . We hypothesised that CSF ferritin and iron would be highest in the CAA group. In exploratory analyses, we measured concentrations of other CSF metals .We included samples from the cross-sectional prospective observational BOCAA  study , and samMethods for CSF processing, including measurement of Aβ-40, Aβ-42, total tau, phospho-tau and neurofilament light, have been described previously .Ferritin was measured using  a latex fixation test according to manufacturer’s instructions (described previously) . All samCSF metal analyses were performed by inductively coupled plasma mass spectrometry (ICP-MS) with an octopole reaction system operated in the helium collision mode . All samples were diluted 10 times with a basic diluent containing 1-butanol (2%w/v), ethylenediaminetetraacetic acid (EDTA) (0.05%w/v), Triton X-100 (0.05%w/v), and ammonium hydroxide (1%w/v) and were analysed in a single batch after calibration performed in the dilution medium. Germanium was used as internal standard for all elements. One quality control sample was analysed in the beginning and end of the batch ; all element concentrations were within the stated acceptable limits.p < 0.05), Dunn’s test was used for post hoc comparisons, and a Bonferroni correction  applied.Statistical analysis was performed using Stata (Version 15.1). Group characteristics were compared using either one-way ANOVA , Chi-squared  or Kruskal–Wallis  tests. For biomarkers, if a significant difference was identified  and calculated predicted medians. We then performed post hoc pairwise comparisons of the age-adjusted medians; statistical significance was defined as Bonferroni-corrected ρ) above 0.3 or below − 0.3 were regarded as correlations of potential interest.Spearman correlation was used to look for correlations between CSF ferritin and iron and other neurodegenerative CSF markers. Associations with a Spearman’s rho value . Patients with CAA also had significantly higher CSF iron levels than the AD group ; the difference in medians between the CAA and CS group was of a similar magnitude (median 23.42 µg/L vs 17.71 µg/L), but did not reach statistical significance (p = 0.09). There were no significant differences in CSF ferritin or iron when comparing the AD and CS groups.In univariable comparisons Table , Fig. 1,In age-adjusted quantile regression (Supplementary Table 1), there was a significant difference in CSF iron between the CAA and AD groups (median difference − 7.11 μg/L), but no significant difference in CSF ferritin.ρ − 0.5057, p = 0.0009); there was a modest correlation between CSF ferritin and Aβ-40 , although this did not quite reach statistical significance by our definition. There was evidence of a modest correlation between CSF Aβ-42 and CSF iron .We then looked for correlations between CSF ferritin and iron and other CSF biomarkers observed in neurodegenerative disease . When considering all groups together, there was a significant correlation between CSF Aβ-42 and CSF ferritin (Spearman’s p = 0.03), cobalt ; and manganese (median 1.19 μg/L vs 0.84 μg/L), although the latter was not quite of statistical significance (p = 0.05). In age-adjusted analyses, only the difference in CSF nickel remained of statistical significance (median difference − 0.25 μg/L).We performed further exploratory analyses for other CSF metals, the results of which are provided in the Online Supplementary Material . Briefly, there were differences between the CAA and AD groups in CSF nickel , and Aβ-42 ; together these measures might reflect the degree of underlying Aβ pathology , and a combination might provide useful diagnostic information in differentiating AD and CAA. In further exploratory analyses, we found differences of potential interest between the AD and CAA groups in CSF nickel, cobalt and manganese. CSF metallomic profile might therefore provide a novel means to differentiate between disease secondary to parenchymal versus vascular Aβ.We hypothesise that the elevation in CSF iron observed in CAA is due to small asymptomatic bleeding events into the subarachnoid space, which later evolve on MRI into haemorrhagic features such as cortical superficial siderosis and superficially located lobar cerebral microbleeds. In aneurysmal subarachnoid haemorrhage, iron is released into the CSF following the haemolysis of extravasated erythrocytes and subsequent degradation of haemoglobin . In thisData from patients with AD have suggested that iron might have a role in accelerating disease progression. CSF ferritin has been associated with brain hypometabolism , and morIn our exploratory analyses for other CSF metals, we identified potential differences of interest between the CAA and AD groups in CSF nickel, manganese, and cobalt. Although there are some data for these and other CSF metals in AD, to our knowledge similar findings have not been described in CAA. This might suggest that CAA results in a more widespread disruption in metal homeostasis, but the clinical and mechanistic relevance of these results are unclear; again, replication and further study in larger cohorts is needed.We acknowledge that our exploratory study is small and therefore potentially underpowered; however, our aim was to provide hypothesis-generating data for novel biomarkers of CAA. Our preliminary data suggest that CAA might result in a distinct CSF metallomic profile; replication and validation of these results in larger cohorts is needed.Supplementary file1 (TIFF 3421 KB)Supplementary file2 (TIFF 3421 KB)Supplementary file3 (DOCX 28 KB)Below is the link to the electronic supplementary material.


To describe the association between daily activity  and serum TT levels in a representative sample of US adults aged 18 years or older.A retrospective cohort study was carried out utilizing the NHANES  2003–2004 cycle. Physical activity was measured with a waist-worn uniaxial accelerometer  for up to 7 days using a standardized protocol. Using linear and multivariable logistic regression controlling for relevant social, demographic, lifestyle, and comorbidity characteristics, we assessed the association between daily step counts and TT.A total of 279 subjects with a median age 46 (IQR: 33–56) were included in the analysis. 23.3% of the cohort had a low serum TT level (TT < 350 ng/dl). Compared to men who took <4000 steps per day, men who took >4000 or >8000 steps/day had a lower odd of being hypogonadal . While a threshold effect was noted on average, TT increased 7 ng/dL for each additional 1000 steps taken daily .Patients with the lowest daily step counts had higher odds of being hypogonadal. The current work supports a possible association between daily steps, total testosterone, and hypogonadism for men in the US. Testosterone is necessary for normal male development and function. Abnormal testosterone levels have been associated with changes in male body muscle mass and fat distribution as well as bone metabolism and energy levels . Male hyGiven the association between serum testosterone and health, it is reasonable to assume that physical activity (PA) is also associated with TT . PA is ahttps://wwwn.cdc.gov/nchs/nhanes/2003-2004/PAXRAW_C.htm). NHANES consists of a noninstitutionalized US civilians sample, using a multistage probability sampling design that considers geographical area and minority representation via a cross-sectional survey conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention . Sample weights are generated to create nationally representative estimates for the US population and subgroups defined by age, sex, and race/ethnicity [Data from the NHANES cycle 2003–2004 were analyzed , health behaviors  and concomitant comorbidities were also collected. The main inclusion criteria were participants who were at least 18 years or older with available serum samples in the repository and also wore an ActiGraph model 7164 accelerometer on the hip during waking hours for a 7-day period with at least 1 day of valid wear .https://wwwn.cdc.gov/nchs/nhanes/2003-2004/SSCHL_C.htm. fT and Bioavailable T were then separately calculated given the serum values of sex-hormone binding globulin and albumin levels in accordance with the formula described by Vermeulen et al. [http://www.issam.ch/freetesto.htm.Following an overnight fast, men serum samples were firstly dawned between 8.30 and 11.30 a.m. and then testosterone concentrations were determined using a competitive electrochemiluminescence immunoassay on the 2010 Elecsys autoanalyzer  with the lowest detection limit of the assay being 0.02 ng/mL. All sex steroid hormones from the present NHANES cycle were assayed at Boston Children’s Hospital  by laboratory technicians blinded to participant characteristics. The details for the NHANES laboratory methodology for testosterone determination are available from: n et al. , availabMen were excluded from the analysis if they were diagnosed with medical history of PCa (as they may be treated with hormone ablation therapy), reported limitations to engaging in PA , or were missing information on testosterone/accelerometer data or on covariates of interest. Of 2922 men aged at least 18 years old at the time of the survey, 2052 had valid accelerometer data. A total of 386 of the 2052 with accelerometer data also presented with available serum TT information. Out of these, 107 (27.7%) were excluded due to missing data reaching a final sample size of 279 subjects enrolled into analysis.PA was measured with a waist-worn uniaxial accelerometer  for up to 7 days using a standardized protocol  within tPAXINTEN” variable, which correspond to the sequential observation number in minutes as recorded by the monitor device intensity value (available from: https://wwwn.cdc.gov/nchs/nhanes/2003-2004/PAXRAW_C.htm). Each day of wear produces 1440 individual minute records up to the last minute of day 7. Pax intensity values were classified into weighted quartiles and modeled upon TT serum levels and the available covariates information. The 25th percentile (~<155078.6 CPD) was used as the reference [The physical activity monitors used in NHANES collected objective information on the intensity and duration of common locomotion activities such as walking, and jogging defined by the “eference .Although activity count data from the 2003–2004 NHANES cycle has been publicly available, step count data from this cycle were not released because of missing data. Several research teams previously addressed this issue by utilizing a semi-parametric multiple imputation method, whereby bootstrapping and ordinary least squares regression provided accurate values for missing data , 16. Thit test and chi-squared statistic were used to assess differences among means and proportions between continuous variables and subgroups, respectively. To explore the relationship concerning step CPD or pax intensity CPD, we examined the odds of impaired TT levels , fT (<6.5 ng/dl), and bioavailable T (<110 ng/dl) in jointly classified categories with low step counts (<4000 steps/day) and low pax intensity (lower quartile) as reference group. Linear regression was used to estimate and compare variation of serum TT concentrations across cumulative recorded steps and pax intensity measures. One-way ANOVA on ranks  was used to test the differences concerning continuous TT levels between groups categories (steps categories and pax intensity quartiles). Multivariable logistic regression was used to estimate the odds of low TT, fT, and Bioavailable T for varying step and pax intensity levels. Sensitivity analyses were performed using different TT thresholds and associations with step counts. The TT threshold was chosen from established values where men are recommended to consider hormone replacement therapy by several International American/European Andrological and/or Endocrinological Societies and similar to prior analyses [p values < 0.05 considered statistically significant.Following the recommended guidelines from the NCHS (Centers for Disease Control and Prevention 2012a), all the analyses were performed with appropriate weights for the complex survey sampling method of NHANES data. Student’s able T <1 ng/dl inp = 0.045) and had a lower mean BMI (p = 0.006) compared to men with lower TT levels. No significant nor clinically relevant differences were identified with regard to other socio-demographic, or comorbidities distribution  and pax intensity quartiles   men had normal TT levels and 65 men had low TT levels. Men presenting with normal TT levels  were significantly younger  . On multivariable logistic regression, we confirmed a lower odd of hypogonadism, fT, and Bioavailable T with increasing pax intensity levels. LOWESS function showed analogous trajectory revealing the reduced probability of hypogonadism as well as fT and Bioavailable T with cumulative increase of pax intensity values per day  secretion and ultimately testosterone production [Furthermore, studies from human professional sports have historically shown how physical effort directly damage muscle fibers leading to a subsequent increase in concentration of anabolic hormones such as insulin-growth factor-1 (IGF-I) or growth hormone (GH) . Moreoveoduction . This caoduction , 28. In oduction  found thCertain limitations warrant mention. First, only a limited number of NHANES respondents had available data for analysis. Nevertheless, we did identify a significant association between daily step count and TT. Importantly, the NHANES data reported in the present study must be considered observational and no causal inferences may be deemed. Moreover, the information concerning the total steps count were extrapolated through multiple imputation inference strategy given that original information was not released due to missing data in this specific 2003/04 cycle. However, the same techniques have previously been reported by Saint-Maurice et al. in their analysis of daily steps count and overall mortality within NHANES . In addiOur present analysis is the first study assessing PA volume using objective measures of PA. We found that a higher physical expenditure quantified by the daily step count (or pax intensity) taken by each individual was associated with a lower odds of hypogonadal ranges total, free, and bioavailable T levels. While there were differences in baseline BMI and age among men with and without hypogonadism, the current work supports an association between daily steps, serum testosterone levels, and the risk of hypogonadism.Supplementary Figures 1