Evaluation of the potential kidney donor is a complex activity that differs substantially from other types of preoperative assessments. The well being of the donor, who derives no medical benefit from this surgery, must be assured in both the short term and long term, and the potential adverse consequences to the recipient must be determined as well. The criteria that must be met for a person to donate a kidney are rigorous and include medical, social, psychosocial, ethical, and legal issues. Donor evaluation can be divided into assessments to protect the health and safety of the donor and assessments to protect the health and safety of the recipient. This article provides an approach to evaluating a donor, focusing on the complex issues that an evaluator is faced with. A careful assessment of risks and benefits to both the donor and recipient can lead to favorable outcomes. A living kidney donor can improve the quality of life and offer a survival advantage to the recipient. Since 1998, as per Organ Procurement and Transplantation Network data, there have been approximately 309,319 kidney transplantations and of these approximately 108,150 are from living kidney donors  to 125 mg/dL [6.9 mmol/L], or a 2h-OGTT value of 140 mg/dL [7.8 mmol/L] to 199 mg/dL [11.0 mmol/L] . In addiDonors with a history of obesity, gestational diabetes, or a strong family history of diabetes mellitus should undergo testing with fasting glucose, 2-hr OGTT [Hypertension has a well-known association with the development of kidney disease. This needs to be carefully addressed in potential kidney donors as loss of renal mass in a hypertensive patient may increase the risk of parenchymal renal disease developing, or may accelerate the decline of kidney function in those patients in whom other types of kidney disease develop.The Joint National Committee Seventh Report introduced a classification for hypertension which included the term prehypertension. They defined prehypertension as blood pressure ranging from 120–139 mmHg systolic and/or 80–89 mmHg diastolic. The classification in hypertensives is divided into stage 1 hypertension (systolic blood pressure (SBP) 140–159 mmHg and/or diastolic blood pressure (DBP) 90–99 mmHg) and stage 2 hypertension . With this classification system, individuals with prehypertension could be easily identified and counseled due to their increase risk of developing hypertension and cardiovascular disease [For donors, at least two blood pressure readings on two separate occasions should be performed . A donorA donor with a history of hypertension should undergo further evaluation and questioning. If that donor is on two or more medications, he is generally excluded . If thatRacial variations in the development of hypertension and chronic kidney disease in African Americans and Hispanics have been described postdonation . BecauseIt is uncertain what to do with donors who are labeled as prehypertensive. These donors are counseled in detail about lifestyle modification and their increased risk of developing hypertension and cardiovascular disease. Of these who opt to donate, postnephrectomy followup by their primary care provider should be suggested.Individuals with a family history of hypertension are again counseled, as there is a genetic predisposition to developing hypertension. Both paternal and maternal hypertension are strongly associated with the development of hypertension during adult life . CarefulFifty nine percent of centers in the U.S. have no upper age limit. Approximately thirty percent of the centers are using donors over the age of 65 . BiopsieThe majority of centers exclude donors younger than 18 years , 11. YouPregnant patients should not be evaluated. It is not certain when a donor should be allowed to donate post pregnancy . In addiAlthough there is no clear evidence as to the timing of pregnancy postdonation, it is suggested that women should delay pregnancy until at least two months to a year postdonation to allow and assess for the degree of renal compensation and to assess baseline blood pressures, GFR, and microalbuminuria , 17. A hWhile removal of a kidney in a person with two normal functioning kidneys should not result in progressive kidney failure, a large reduction in nephron mass in a person who already has a decreased baseline glomerular filtration rate (GFR) can have adverse consequences.3 [The most common approach to estimating GFR is with a 24-hour urine for creatinine clearance. Approximately ninety percent of U.S. transplant centers use this method . Inadequ3 , 11.The majority of programs assess proteinuria with a 24-hour urine collection , 11. OthAll programs should perform a urinalysis looking for microscopic hematuria. Obtaining any past urinalysis as well as repeating another one would be helpful to determine if the hematuria is transient or persistent. Hematuria is considered significant by one-third transplant centers if there are more than 3 red blood cells/high powered field (RBC/HPF) .If microscopic hematuria is found, an etiology should be determined. Renal ultrasound which is the normal part of the donor workup should be able to reveal most structural causes of hematuria at the level of the kidney. Family history of renal disease including polycystic kidney disease, thin basement membrane disease, or Alport's syndrome or the presence of concomitant proteinuria can suggest an underlying glomerular cause of hematuria in the donor. In such cases, renal biopsy should likely be performed. Dysuria, urinary frequency, and the presence of pyuria can suggest a urinary tract infection. A donor with a family history of renal cell carcinoma or with a strong smoking history should be evaluated for malignancy with a urologic evaluation, urine cytology, and cystoscopy. In men, prostate issues should be ruled out. In women, making sure the urine specimen was not taken at the time of their menstruation is important. African American patients should be screened for sickle cell disease or trait. Asymptomatic nephrolithiasis should be ruled out as well. Almost half of transplant centers will accept donors with >10RBC/HPF if renal and urologic evaluations are negative .A kidney biopsy can identify unexpected pathology and can assist in evaluating the donor. Correlations between a time zero biopsy and donor characteristics have been made leading to the following correlations: interstitial fibrosis and age, tubular atrophy and diastolic blood pressure and proteinuria, arteriolar hyalinosis and serum creatinine and estimated glomerular filtration rate, mesangial increase, and body mass index . Long-teNephrolithiasis with development of obstruction of a single kidney can have catastrophic consequences yet a history of nephrolithiasis need not preclude donation as long as certain conditions are met. The number of stones the potential donor has formed in the past needs to be determined. For example, if a donor has a history of nephrolithiasis but the disease has been quiescent for years and there are no abnormalities in metabolic or radiologic testing, then donating can be acceptable . This doThe other end of the spectrum includes those who do not give a history of nephrolithiasis but are found to be asymptomatic stone formers. Stones may be noted incidentally while doing screening renal ultrasounds as part of the donor evaluation. In addition, some donors may have a strong family history of nephrolithiasis. These donors can likely be accepted but must be cautioned about their increased risk of developing another kidney stone in their solitary kidney during their lifetime.Potential donors who are either overweight or obese pose a number of issues. Some of these relate to the perioperative period where the risk of complications during this time is increased. However, there are special long-term considerations as well and donation of a kidney in someone who is obese may enhance their risk of eventually developing kidney disease. It should also be noted that the increasing prevalence of obesity may prove to be a substantial limiting factor to rates of kidney donation.2 and 29.9 kg/m2 are considered overweight and those with BMI greater than 30 kg/m2 are considered obese. Obesity is further subclassified into class I (BMI of 30.0 to 34.9 kg/m2), class II (BMI 35.0–39.9 kg/m2), and class III (BMI greater than 40 kg/m2). Higher baseline BMI has been shown to be an independent risk factor for end-stage renal disease [All donors should have their height and weight checked during their initial visit. Body mass index (BMI) is then calculated which is defined as weight in kilograms divided by height in meters squared. Those with BMI between 25 kg/m disease .2 [2 but less than 35 kg/m2 should be counseled on lifestyle modifications especially weight loss. In addition, they should be made aware of the long-term associations of obesity with the development of hypertension, diabetes mellitus, metabolic syndrome, and kidney disease, including end-stage renal disease.The majority of transplant centers exclude potential donors with a BMI over 35 kg/mSmoking is an area of concern for a number of reasons but is currently not a contraindication to donate. While the postoperative risks of poor wound healing and pulmonary infections in smokers are known , the lonDonors should have behavioral screening in addition to infectious disease testing. Sexual history and drug history should be examined in detail. They should be interviewed in a confidential manner and should be asked direct questions. Issues of concern are promiscuity; men who have had sex with other men in the previous five years; anyone exposed to or who has had sexual relations with someone at risk for, or with HIV, HCV, or HBV in the preceding year; donors with a history of hemophilia; donors with history of blood transfusions or any human-derived clotting factor concentrates; intravenous, intramuscular, or subcutaneous drug use in the preceding five years; men or women who have had sex in exchange for money or drugs in the previous five years; incarceration . A substDepending on the situation, donors can be excluded if their risk to the recipient is very high. If they are currently engaging in any high-risk behavior, they should be advised of their obligation to avoid the high-risk behavior. If they cannot avoid it, they should be given the choice to opt out of donating with a medical excuse. Due to the high risk, the recipient advocate and recipient should be made aware of the potential increased risk to the recipient for infectious diseases . InformeIt is controversial at this point whether to repeat serology or perform NAT for HBV, HCV, and HIV in high-risk donors two to four weeks prior to transplant. The purpose of NAT would be to detect the disease at the time period between infection and detectability of antibodies. The downside of NAT is that it costly, takes longer to perform and may result in false positives .A thorough psychosocial evaluation adds to the comprehensive evaluation of the donor. Ideally, this evaluation should be done by a social worker and/or psychiatrist who has experience in evaluating donors. The goal of this evaluation is to evaluate the psychological, social, and emotional stability of the potential donor . In addiAn in-depth evaluation of the donor's current mental condition should be done. Any donor with a history of any psychiatric disorder, including major depressive disorder, bipolar disorder, generalized anxiety disorder, mood disorder, or any personality disorder should be assessed for any signs or symptoms of instability. A donor should be asked about any childhood or adolescent problems that suggest mental health issues, suicidality, homocidality, inpatient psychiatric hospitalizations, or outpatient psychiatric evaluations. A thorough assessment of any medications that they were taking or currently taking should be done, keeping in mind any medications that could potentially be nephrotoxic. For example, if a donor has been stable on lithium carbonate and cannot be taken off of it due to fear of relapse, that donor should likely not donate . In addiDonors should not have any evidence of active drug or alcohol abuse. Generally, a period of at least six months of abstinence is acceptable for a donor . Again,  The relationship between the donor and the recipient should be established, as well as what is motivating the donor to donate. Any suggestion of coercion or guilt should be further evaluated, making sure that the donor is not threatened in any way and that there is no gain—either financial or personal. In other words, the donor should be making decisions out of his free will. Other donor and family relationships should be addressed, looking for any signs of marital problems, or any hardships that the donor or evaluator can foresee as a result of donation. Evaluation of the donor's social support system must be made .Any potential economic loss should be evaluated. If time off from work during the postdonation period could cause the donor to lose his job or lose major income, the donor should reconsider. Any out-of-pocket expenses for travel, lodging, or miscellaneous expenses related to transplant or inability to obtain sick leave should be discussed with the donor , 28. EduDonors must demonstrate competence and understanding regarding the donation process and recipient health. He must also receive all the accurate information to make a decision. The donor should demonstrate understanding of the recipient's illness and should understand the other options for the recipient, including deceased donor transplantation or dialysis. He should be able to describe to the best of his knowledge why the recipient needs a transplant. The donor should be able to demonstrate understanding of the nephrectomy including the risks and benefits to the recipient, the risks and benefits to the donor, the postoperative course, the short- and long term-outcomes associated with nephrectomy, the possibility of rejection, and the possibility that the donor may need the sacrificed organ in the future. All preoperative workup, expenses, and postoperative surgical complications and expected outcomes should be fully disclosed to the donor .The donor should demonstrate that he is free of coercion or any outside influence and that his decision to donate is voluntary , 13. TheKidney donation entails the risk of transmission of an infectious disease to a recipient who will be subjected to significant immunosuppression. Hence, the presence of any such infection must be tested for.All donors must be screened for active and past communicable infections. This testing should include human immunodeficiency virus 1 and 2 (HIV-1 and HIV-2), human T lymphotropic virus type-1 (HTLV-I) and type-2 (HTLV-II), hepatitis A, hepatitis B, hepatitis C, and syphilis. In addition, donors are further tested for cytomegalovirus (CMV), epstein-barr virus (EBV), toxoplasmosis, herpes simplex virus (HSV), and varicella zoster virus (VZV).Screening for HIV should include serum enzyme-linked-immunosorbent assay (ELISA) for HIV-1 and HIV-2 using U.S. Food and Drug Administration licensed screening tests. Combination HIV-1/HIV-2 tests are available. Screening for Hepatitis B should include qualitative detection of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis B core antigen  and to HBsAg (Anti-HBs). Screening for hepatitis C can be with antibody testing to hepatitis C virus (Anti-HCV). Whether nucleic acid testing (NAT) should be done in addition to or in place of the above is unknown and case-dependent. Per Centers for Disease Control and Prevention (CDC) recommendations, all recipients should be counseled that negative tests for HBV, HCV, and HIV do not confer absence of disease, as the donor could have donated after infection but before serocoversion . SyphiliHaving any of the above active infections would be a contraindication to donate. Having positive testing for HIV, HCV, HBsAg, or anti-HBc, IgM positivity would be a contraindication to donate. Hepatitis B Core Antibody IgG positivity in an HbsAg-negative donor carries a small risk of transmission and such donors should be excluded . Being AStrongyloides, Trypanosoma Cruzi, West Nile Virus, Tuberculosis with purified protein derivative testing or the interferon gamma release assay should be done on donors from endemic areas if these diseases are suspected.Screening for Kidney donation entails a potential risk of transmission of malignancy to the immunosuppressed recipient. With careful evaluation of donors, unintentional transmission of cancer should be avoidable. The evaluation of potential malignancy in the donor should begin with age appropriate health maintenance screening. Recommendations per the U.S. Preventative Task Force are as follows: all women who are sexually active and have a cervix or those above 18 years of age should have pap smears. Biennial screening mammography for women beginning at age 50 should be performed. Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, should generally be done beginning at age 50 years . In malein situ cervical cancer, in situ vocal cord carcinoma, and certain thyroid cancers [ According to the Disease Transmission Advisory Committee (DTAC) Malignancy Subcommittee, donors can be categorized into risk categories including no significant risk, minimal, low, intermediate, high, or unknown risk . Each of cancers . These d cancers , 34. It is advised that every precautionary measure be taken. During organ retrieval, if a suspicious mass or nodule is found, biopsy should be performed and prompt frozen section examination should be done .The final decision for transplantation should respect the donor's autonomy and decision to donate, the recipient's right to accept, and the respective transplant teams' medical decision making to proceed for living donor transplantation . All par


Lumbar puncture (LP) essentially is a painful and stressful procedure, however indicated for diagnosis and therapeutic purposes. One way to reduce the anxiety is to administer an oral premedication. The aim of this study is to compare clinical effects of oral midazolam and oral promethazine in LP.This prospective randomized controlled clinical trial study was performed on 80 children aged 2-7 years that were candidate for LP. They were divided into two randomized equal groups. First group received oral midazolam syrup 0.5 mg/kg and the other group received oral promethazine syrup 1mg/kg. Level of sedation, hemodynamic changes and any other complications were monitored every 5 minutes from 30 minutes before the start of the procedure.Midazolam group and promethazine group were similar in age, gender and weight. Midazolam had significantly shorter onset of sedation and also shorter duration to maximal sedation. The two groups were similar with respect to sedative effect at all time. The only complication that was significantly more in midazolam group was nausea and vomiting. Midazolam syrup and promethazine syrup have same sedative effect in children. Both of these medications are easy to use in preschool children and none of them appeared to be superior to another.  Lumbar puncture (LP) is indicated for both diagnostic and therapeutic purposes. It is used to obtain a sample of cerebrospinal fluid (CSF). Analysis of CSF is useful in the diagnosis of infectious processes and neurologic diseases. Therapeutically, LP can be used for subarachnoid injection of chemotherapeutic agents, anesthetic drugs, and antibiotics .LPs are essentially painful and in some children can cause severe anxiety and distress -4 that cThe three main modalities reported for decreasing the preoperative anxiety in children are behavioral preparation programs of various kinds, parental presence during induction of anesthesia (PPIA), and sedative premedication ,7.Due to some limitations on behavioral preparation programs  and someAnxiolysis and sedation with oral midazolam are common practice in both adult and pediatric anesthesia because of its onset time of 10-20 min, short duration of action (30 min), and no complications at low doses (less than 0.5 mg/kg) .Promethazine as an anti histamine (H1) agent has some sedative and antiemetic properties . This meAs a routine in Iran, the drugs most commonly prescribed by physicians for premedication are promethazine and midazolam. In the present study we aimed to assay the benefits of these two drugs to help the children and their parents and to provide them more satisfactory condition.This is a prospective randomized controlled clinical trial conducted in Emergency Department of Mofid Hospital in Tehran. The study group consisted of 80 children older than 2 years old, presenting for LP. Study design was approved by Ethics Committee of Mofid Children Hospital. All patients’ parents gave their written informed consent before being included in the study.Patients were randomly separated in two groups. Patients of the first group received oral midazolam syrup 0.5 mg/kg, 50 minutes before LP  and in tPatients who had a hypersensitivity reaction or known idiosyncrasy to the study medications or having a history of psychiatric disease, or aged less than 2 years were excluded. Gutstein et al.’s five-point sedation scale (1992) was used in both groups to evaluate the children’s sedation levels ,13, 30, This scale included the following items:1. Barely arousable 2. Asleep (eyes closed but arouses to a soft voice or light)3. Sleepy 4. Awake5. AgitatedThe last evaluation was at the time of the LP. At the same time patient’s heart rate, respiratory rate, blood pressure, and oxygen saturation percentage were recorded. An expert nurse was responsible for recording of any side effects in patients in each group.After data collection, statistical analysis was performed with SPSS version18 using independent t-test to compare the groups. A p-value of<0.05 interpreted as statistically significant.The mean age in the midazolam group was 4.2+2.1 years (range 2.1-6.7) and it was 4.6+1.8 years (range 2.3-6.5) in promethazine group, (p<0.831). The mean weight was 17.2+4.7 kg (range 10.8-31.2 kg) in midazolam group and 17.0+5.2 kg (range 10.1-30.0 kg) in promethazine group (p<0.144). There were 25 girls and 15 boys in midazolam group and 23 girls and 18 boys in promethazine group. There was no statistically significant difference with respect to gender between the two groups (p<0.071). Two groups were similar with respect to age, gender and weight.Onset of sedation was 25.5+12.2 (12-50) min in midazolam group and 60.55+15.5 (40-90) min in promethazine group (p<0.001). Peak sedative effect was observed at 34.3+11.2 min for midazolam and at 79.5+16.4 for promethazine (p<0.022). These differences were both statistically significant.There was no significant difference in sedation score between two groups . No significant occurrences of hemodynamic changes occurred in either group .The only side effect that was more with midazolam than with promethazine included nausea and vomiting (p<0.014). The other complications of the drugs were not significantly different between the groups .Lumbar puncture has a critical role in diagnosis and therapy of some disease, so in many cases this practice is inevitable . ConsidePharmacologic advantages of midazolam which we found included a rapid onset of action and a shorter duration to maximal sedation that can accelerate patients’ recovery.This finding is similar to that of Mathai et al. (2011) that compared nasal midazolam and oral promethazine on 100 preschool children in the preoperative period . Also inAs in Mathai et al.’s study, we found no difference between the levels of sedation induced by oral midazolam and oral promethazine .On the contrary, in some other studies, the results were different ,16. SingOn the other hand, some other studies were in contrast with them. Parkinson et al. and Crean et al. showed that a combination of promethazine and chloral hydrate is better than midazolam for children’s sedation in PICU ,18.Similar to Mathai et al. and Naziri et al. findings, we did not find any significant differences in hemodynamic changes between our two groups ,16. AlsoWe did not detect any severe adverse events among children. Except nausea and vomiting, there was not any significant difference between complications which followed introduction of two drugs. Promethazine is one of the most frequent drugs used for treatment of nausea and vomiting in the world , and thiThe main advantage of our study in the comparison with other studies was that our population were not candidate for surgeries and they did not need induction of general anesthesia. Therefore, we could assess actual amount of sedative medications without the interference effect of anesthetic drugs.However, there were several limitations to our study. Our sample size was small. In addition, we only studied children older than 2 years old, because promethazine is contraindicated in children younger than 2 years old. So, our findings cannot be applied to children younger than 2 years of age.Although, both midazolam and promethazine have same sedative effects in children, each of them have an advantage over another. Shorter onset of sedation and short duration to peak sedation can be considered in the outpatient setting when we want to use midazolam as a sedative drug. But on the other hand, a better recovery with less nausea and vomiting is the advantage of antiemetic promethazine prescription. Both drugs are easy to use  for preschool children and we conclude that either of them can be used for reduction of the anxiety before and during the LP. However, the writer recommends that multicentre studies should be done on a greater population with more varieties of sedative drugs.


Compartment modeling (CM) of brain data acquired in vivo using magnetic resonance imaging techniques with clinically available contrast agents can be performed to quantitatively assess brain perfusion. Transport of 1H spins in water molecules across physiological compartmental brain barriers in three different pools was mathematically modeled and theoretically evaluated in this paper and the corresponding theoretical compartment modeling of dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) data was analyzed. The pools considered were blood, tissue, and cerebrospinal fluid (CSF). The blood and CSF data were mathematically modeled assuming continuous flow of the 1H spins in these pools. Tissue data was modeled using three CMs. Results in this paper show that transport across physiological brain barriers such as the blood to brain barrier, the extracellular space to the intracellular space barrier, or the blood to CSF barrier can be evaluated quantitatively. Statistical evaluations of this quantitative information may be performed to assess tissue perfusion, barriers' integrity, and CSF flow in vivo in the normal or disease-affected brain or to assess response to therapy.Neurological disorders represent major causes of lost years of healthy life and mortality worldwide. Development of their quantitative interdisciplinary  Neurological disorders are diseases of the central and peripheral nervous system affecting approximately one billion people worldwide irrespective of age, sex, education, or income. The most frequent neurological disorders at present are migraines, followed by neurological problems caused by cerebrovascular disease, epilepsy, Alzheimer's disease, and so forth . HydroceImpact of neurological disorders is expected to increase, for example, the number of people affected by Alzheimer's disease and other dementia conditions is expected to double every twenty years. Almost seven million people die every year as a result of neurological disorders, the most affected being people in the lower middle income category. Investigation of neurological disorders increaseas in importance due to prolonged ageing also .Neuroscientifically relevant observations were recorded since 4000 BC and they contributed to the development of neurosciences . During in vivo, using exogenous or endogenous magnetic resonance imaging (MRI) techniques and compartment modeling (CM) of the MRI data [Kinetics of an agent through physiological barriers, including physiological brain barriers, can be quantitatively evaluated MRI data –6. TheorMRI data –6. The sMathematical modeling of data acquired using exogenous perfusion MRI techniques with intracellular contrast agents (the ssCE techniques) which might become mathematically very complex since there will be more mechanisms of relaxation time modifications in each compartment of a voxel  to be considered. This will lead to more complex equations to be solved and would introduce more parameters to be estimated when fitting the MRI data to the mathematical model developed.in vivo using exogenous perfusion MRI techniques with extracellular contrast agents is easier since the signal-to-noise ratio of the MRI data is the highest and the contrast agent does not penetrate in the extracellular space (EES) through the intact blood-to-brain barrier (BBB). Increase in the signal-to-noise ratio of the DCE-MRI has recently been obtained using a slow infusion technique of Gd-based extracellular clinically available contrast agents [Mathematical modeling of the brain data acquired t agents . This int agents  used a s1H spins in water molecules through the CSF spaces.The mathematical modeling of the perfusion MRI data in general and DCE-MRI data in particular, based on the physiological compartmentalization of voxels, gives more complex and realistic information on the kinetics of agents through barriers between physiological compartments. For brain and brain conditions, this might allow quantitative assessment of the BBB, blood-to-CSF barrier (B-CSF-B), or that of the output to input flow (IOF) imbalance of 1H spins in water molecules present in two different phases  in the three pools assumed  was quantitatively evaluated in this study. The relative volumes of the physiological compartments of voxels situated in the tissue and CSF regions can also be estimated using this physiological CM of the DCE-MRI brain data.Theoretical description of the physiological compartmentalization of tissue and CSF voxels and the mathematical modeling of the blood, tissue, and CSF data acquired using DCE-MRI and a slow infusion technique of Gd-based contrast agents is presented in this paper. Kinetics of in vivo using DCE-MRI techniques. Integrity of physiological barriers in the brain, IOF imbalances in CSF spaces, and relative volumes of physiological compartments can be assessed using this quantitative information.Results in this study show that quantitative information can be extracted from brain data acquired in vivo quantitative monitoring of neurological disorders, therapies, or normal brain function can also be assessed.Future possible statistical experimental studies using these CMs might provide quantitative information on the BBB and B-CSF-B integrity and/or shrinkage of the brain tissue in the diseased brain, for example. Potential of these CMs for the 1H nuclei relevant for DCE-MRI images in the blood, tissue, and CSF pools exist in two different phases: one with unaffected longitudinal relaxation time 1T and one with1 T shortened. The relaxation time1 T is shortened due to the spin-lattice interactions between the 1H nuclei in water molecules with the paramagnetic Gd ions in the exogenous clinically available contrast agents for MRI. Transport of the 1H nuclei in these two aqueous phases across the barriers between the compartments of the pools evaluated was mathematically modeled.The 1H spins in the two phases flow continuously in this pool [CIN and leave the pool at a rate kOUT, their kinetics being described by the following arterial input function, AIF:Infusion of the agent in the blood pool is continuous and, therefore, the his pool –11 at a 1H spins in water molecules in the mixed phases in the blood, CBLOOD, depends on the hematocrit, Hct, level and is given by the arterial input function multiplied by the (1-Hct) factor.Concentration of the 1H spins in water molecules), extracellular space (EES—accessible to 1H spins in water molecules), intracellular space (IES—accessible to 1H spins in water molecules), and a space not accessible to water (NOW—not accessible to 1H spins in water molecules). The bidirectional transport of the 1H spins across the blood to EES and the EES to IES barriers are represented with arrows. Rates of 1H spins with unaffected 1T can be neglected (~0) compared to that of 1H spins with short 1T. The fast and slow exchange of the 1H spins in water molecules between these compartments is bidirectional. These exchanges together with accumulation of the 1H spins in the two phases over time in a compartment produce dynamic changes of the amplitude of the corresponding nuclear magnetic resonance (NMR) signals.Each voxel corresponding to white or gray matter regions was compartmentalized as shown in 1H nuclei in water molecules (NOW). The relative volumes of these compartments: vBLOOD, vEES, vIES, and vNOW fulfill the condition:1H spins in water molecules across barriers is bidirectional. Its mechanisms are similar to action potential transport across cellular membranes due to the concentration gradient of the 1H spins in a phase in a compartment.The four tissue compartments in 1H spins producing changes of the NMR signal in a tissue, CTISSUE, depends on the concentration of the 1H nuclei producing changes of the NMR signals in each of these compartments: CBLOOD, CEES and CIES1H spins in the two phases across the blood to EES and the EES to IES barriers also contributes to the NMR signal intensity changes over time.The concentration of the 1H spins producing changes of the MRI signal intensity in a voxel due to its transport from the blood into the EES compartment can be determined by solving the Kety-Schmidt equation  are zero.Equation  is a lin1H spins with unaffected 1T to the signal intensity change can again be neglected on the assumption made in the previous subsection. The rate of the concentration variation of the 1H spins in water molecules in the IES space, dCIES/dt, increases due to the transport of the 1H nuclei with shortened 1T from the EES into the IES compartment at a rate kPI and decreases due to these spins reentering the EES compartment at a rate kIP:Extracellular contrast agents do not enter the IES compartment and contribution of CEES(t) obtained by solving , similar to the AIF. The spins enter a CSF space at a rate kIN′ and leave the space at a rate kOUT′1H nuclei in water molecules in a CSF space. The mean input/output rates of 1H nuclei in water molecules flowing in a CSF space are calculated for each disease stage . Normalization of each mean input/output rate in a CSF space at a disease stage is performed against the corresponding control  input/output mean rate in that CSF space:The disturbance of the input and output flow mechanisms through the B-CSF-B barrier together with the predominance of the disturbance of a mechanism can be quantitatively assessed by the output to input flow, IOF. The output to input flow, IOF, represents the mean relative normalized rate of Similar blood concentration curves and AIFs were obtained for the mouse  and rat kTRANS values were produced only by the 1H nuclei in water molecules in the blood compartment in the tissue pool evaluated.The zero values of these rates also show that resolution and signal-to-noise ratio of the DCE-MRI technique evaluated need to be increased to detect transport rate values as small as 0.0001 1/min. All kTRANS values calculated showed that, as opposed to normal pressure hydrocephalus [Transport rates between the blood compartment and the EES compartment in the tissue pool ranging between 0 and 0.0005 1/min were calculated using this compartment modeling applied to DCE-MRI images of normal and hydrocephalic rat brains . The chacephalus , the BBBFor fractional volumes of the EES compartment of 20%, the fractional volumes calculated for the blood compartment in the tissue pool  ranged between 0.05 and 7.98%, while the fractional volumes of the IES compartment ranged between 72 and 77% .The IOF values calculated for the CSF pool clearly showed that these are the most sensitive indicators of the mechanisms of the dynamic disturbances in C-HC. The flow disturbances were more pronounced in the aqueduct (IOF = 2.49) and in the IVth ventricle (IOF = 1.96) in the mild stage of the C-HC. The IOF values calculated (IOF > 1) in the lateral ventricle (mild and severe stages of C-HC), aqueduct (mild and severe C-HC stages) and the IVth ventricle (mild C-HC stage) were larger than the corresponding IOF values calculated (IOF = 1) in the normal brain. The most pronounced increases of the IOF values were detected for the mild C-HC stages in all CSF spaces analyzed. In the IVth ventricle, the IOF value increased (IOF = 1.96) for the mild stage of C-HC and decreased below the corresponding IOF (1/IOF = 1.7) for the severe stage of C-HC. The IOF values calculated in the lateral ventricle and aqueduct increased relatively to the corresponding IOF values of the normal brain, and although they decreased in the severe C-HC stage relative to the mild stage, they remained larger than the corresponding IOF values calculated for the normal brain.1H spins with decreased 1T will accumulate at the level of a CSF space compared to the normal brain (control stage), producing volume dilatations of these spaces compared to the corresponding spaces of the normal brain. These dilatations reduced in the lateral ventricle and aqueduct, IOF decreased with disease severity from 1.87 to 1.55 and from 2.49 to 1.4. In the IVth ventricle, IOF increased in the mild C-HC stage (IOF = 1.96) and decreased in the severe stage (1/IOF = 1.7). More 1H spins with decreased1 T will accumulate in the CSF spaces evaluated in the mild C-HC stage  and in the severe C-HC stage  compared to the normal brain (control stage). Many more 1H spins with decreased1 T will evacuate the IVth ventricle in the severe stage of C-HC compared to the normal brain (control stage). This massive evacuation at the level of the IVth ventricle in the severe C-HC stage indicates the disruption of the B-CSF-B at this level of the CSF space in the severe C-HC stage. The calculated IOF value at the level of the IVth ventricle in the severe C-HC stage indicates the disruption of the normal evacuation mechanisms of the 1H spins with decreased 1T at this level of the CSF and for this C-HC stage. The evacuation, in this situation, is made as if no B-CSF-B exists anymore.The increases of the IOF values can be correlated with decreases of the overall output rates relative to the corresponding input rates in a CSF space at a disease stage. More All IOF values calculated in the C-HC brains can physiologically be correlated with the disruption of the B-CSF-B in C-HC at the level of the aqueduct and the lateral and the IVth ventricles. These calculated IOF values indicate the predominance of the disturbed CSF flow mechanism. The disturbance of the input mechanism is predominant if IOF > 1, while that of the output mechanism is predominant if IOF < 1.Increases in the fractional blood volumes in the rat brain cortex of up to 160 times relative to the control values were detected using this CM of the DCE-MRI rat brain data. These changes might be physiologically correlated to the shrinkage of the brain tissue in the C-HC.In the CSF pool, values of the relative volume of the CSF compartment less than 100% were estimated . The bloCompartment modeling of the DCE-MRI data provides quantitative information on the permeability of the BBB and B-CSF-B. Transfer rates as small as 0.0001 1/min were estimated by mathematically modeling the DCE-MRI data in the rat brain tissue pool . The tra1H nuclei in water molecules in different phases through different tissue and CSF compartments of the normal and disease-affected brain can be quantitatively evaluated in vivo using CM of the DCE-MRI data [Tissue perfusion and kinetics of MRI data .Statistical experimental analyses of these CMs for refined stages of disease severity are required for accurate description of the normal and/or of brain disease mechanisms in general and in C-HC in particular.Even without any statistical analysis, the calculated IOF values for each CSF space analyzed clearly show that this is the most sensitive indicator of the CSF flow disturbances through the CSF spaces in C-HC. The predominance of the input or output flow disturbance in a CSF space at a disease stage can also be established based on the IOF values calculated.CM of the DCE-MRI data may represent an important clinical imaging analysis method. It can provide quantitative information that can be used to assess physiology of the normal brain, mechanisms of brain diseases, including hydrocephalus, or responses to therapies.


ABCD1 gene. The most severe course of ALD progression is the cerebral inflammatory and demyelinating form of the disease, cALD. To date there is very little information on the cytokine mediators in the cerebral spinal fluid (CSF) of these boys.X-linked adrenoleukodystrophy (ALD) is a metabolic, peroxisomal disease that results from a mutation in the Measurement of 23 different cytokines was performed on CSF and serum of boys with cerebral ALD and patients without ALD. Significant elevations in CSF IL-8 , IL-1ra , MCP-1 , and MIP-1b  were found in boys with cALD versus the control group. The only serum cytokine showing an elevation in the ALD group was SDF-1 . The CSF cytokines of IL-8 and MCP-1b correlated with the Loes MRI severity score (p = 0.04 and p = 0.008 respectively), as well as the serum SDF-1 level (p = 0.002). Finally, CSF total protein was also significantly elevated in boys with cALD and correlated with both IL-8, MCP-1b (p = 0.0001 for both), as well as Loes MRI severity score (p = 0.0007).IL-8, IL-1ra, MCP-1, MIP-1b and CSF total protein were significantly elevated in patients with cALD; IL-8, MCP-1b, and CSF total protein levels correlated with disease severity determined by MRI. This is the largest report of CSF cytokine levels in cALD to date, and identification of these key cytokines will provide further insight into disease progression and perhaps lead to improved targeted therapies. ABCD1 gene in humans with a disease prevalence of approximately 1 in 20,000 ABCD1 gene is located on the X-chromosome and it encodes the peroxisomal protein ATP-binding cassette-transporter D1 responsible for the trafficking of very-long-chain fatty acids (VLCFA), and over 460 different mutations have been reported Adrenoleukodystrophy (ALD) is a peroxisomal disease affecting the nervous system, adrenal cortex, and testis resulting from a mutation in the Current treatments for cALD are sparse. Although a low-fat diet to reduce VLCFA intake coupled with a lipid supplement known as Lorenzo's Oil has shown to normalize VLCFA concentrations in the blood and perhaps delay the onset of cALD, these treatments have not demonstrated an effect on the progression of cerebral inflammation once it has started more similar to expression levels in control white matter Although cALD is thought to be driven by an infiltrative neuroinflammatory process, there has not been a comprehensive analysis of potential inflammatory mediators involved with cALD We have collected a large number of serum and cerebral spinal fluid (CSF) samples from boys with cALD prior to undergoing hematopoietic stem cell transplant and performed a comprehensive analysis of multiple of cytokines using a Luminex-based inflammatory cytokine panel. Identification of the key mediators will help us better understand the neuroinflammatory process and perhaps give clues to new targeted therapies.CSF and serum samples were evaluated using the 22-plex, human panel A,  measured with the Luminex system  analyzed by Bioplex software . This panel is summarized in To determine which inflammatory cytokines were elevated in the CSF and plasma of boys with cALD. To determine if inflammatory cytokine elevation correlated with disease severity shown by MRI.n = 36, median age 8.3 years) had CSF sampling done 2 to 6 months prior to hematopoietic stem cell transplant at the University of Minnesota. Control patients  were those undergoing intrathecal methotrexate chemotherapy for a prior diagnosis of acute lymphoblastic leukemia and were at least 3 months into maintenance therapy and without CSF leukemia. The CSF was withdrawn prior to administration of methotrexate. Unavailability of “healthy” controls and risk of attaining CSF from healthy children established these patients as the most appropriate control group available and has been previously published Patients with cALD .We performed a comprehensive evaluation of inflammatory cytokine levels in the CSF and serum of boys with cALD summarized in Further cytokine analyses performed on the CSF revealed higher levels in cALD samples compared to controls for IL-8 , IL-1ra , MCP-1 , and MIP-1b  as shown in We have recently shown that another marker, chitotriosidase is elevated in both the serum and the blood in boys with cALD The Loes Score is an MRI-based quantification of the amount of cerebral involvement based on a point system derived from location, extent of disease, and the presence of focal and/or global atrophy that is present in boys with cALD 2 = 0.30). These data suggest that the total protein level by itself can correlate with disease severity/inflammation, which although intuitive, has not been shown quantitatively.In a prior report, our institution characterized the CSF total protein in 25 boys with cALD et al and Philips et al as they also found no difference in TNF-alpha protein levels in the CSF or serum from patients with cALD, although McGuiness did find there was increased TNF-alpha bioactivity in patients with cALD In this study, we determined that there were significant elevations in inflammatory cytokine levels in the serum (SDF-1) and CSF . The serum SDF-1and CSF IL-8 and MCP-1 correlated significantly with the pretransplant MRI Loes score severity and the CSF MCP-1 levels correlated significantly with chitotriosidase activity. Inflammation contributes to neuronal death in many inflammatory neurodegenerative disease such as Alzheimer's disease, multiple sclerosis, Parkinson's disease, and amyotrophic lateral sclerosis This is the first report of the elevation of SDF-1 in the serum of patients with cALD. While SDF1 is typically thought of a homing factor for many cell types MIP-1b (CCL4), IL-8 (CXCL8), and MCP-1 (CCL2) have all been identified as pro-inflammatory chemokines and can induce the migration of leukocytes to a desired site and have also been implicated in other inflammatory diseases such as multiple sclerosis, Alzheimer's disease, and HIV Our finding that MCP-1 levels correlate with chitotriosidase activity is intriguing as chitotriosidase is a chitolytic enzyme produced by activated monocytes/macrophages and has been used as a biomarker in other storage diseases An antagonist of the biologic activity of IL-1, IL-1ra is elevated in many other conditions such inflammatory arthritis  as they were having routine spinal taps every 3 months. The main concern was possibly selecting children as control patients with suppressed CSF cytokines thereby skewing the data, but studies measuring cytokine levels in CSF of healthy children yielded very comparable results to our data, supporting that the cytokine levels in our control patients in this study are congruent with accepted values in the literature


A novel cyclovirus, CyCV-VN, was recently identified in cerebrospinal fluid (CSF) from patients with central nervous system (CNS) infections in central and southern Vietnam. To explore the geographic distribution of this novel virus, more than 600 CSF specimens from patients with suspected CNS infections in northern Vietnam, Cambodia, Nepal and The Netherlands were screened for the presence of CyCV-VN but all were negative. Sequence comparison and phylogenetic analysis between CyCV-VN and another novel cyclovirus recently identified in CSF from Malawian patients indicated that these represent distinct cycloviral species, albeit phylogenetically closely related. The data suggest that CyCV-VN has a limited geographic distribution within southern and central Vietnam. Further research is needed to determine the global distribution and diversity of cycloviruses and importantly their possible association with human disease. Circoviridae family and have recently been found in different sample types from different hosts, including mammals and insects1234Cycloviruses (CyCVs) belong to the To explore whether CyCV-VN is circulating beyond central and southern Vietnam, we screened a total of 615 CSF specimens from patients with acute CNS infections from northern Vietnam (n = 233), Cambodia (n = 123), Nepal (n = 80) and The Netherlands (n = 179) for the presence of CyCV-VN DNA .CyCV-VN DNA, however, was absent from all 615 CSF specimens tested, suggesting a confined geographical distribution of this virus.To determine whether CyCV-VN represents a cycloviral species distinct from CyCV-VS5700009, the novel cyclovirus recently detected in CSF from Malawian patientsIn a previous study we showed that the newly discovered CyCV-VN was widely distributed in central and southern Vietnamese provincesWe previously reported a prevalence of 4% 28/644) among children and adults with confirmed or suspected CNS infections in overlapping time periods with the current study44 among In summary, our new data from clinical case detections suggest that circulation of CyCV-VN is restricted to southern and central Vietnam. Further research utilizing degenerate PCR primers is needed to examine to what extent diverse cycloviruses can be detected in CSF of patients with CNS infections worldwide. In addition, further investigations of cyclovirus prevalence in healthy subjects, clinical cases, and non-human species will be required to assess the epidemiological significance of these findings.CSF specimens analyzed in this study were derived from three prospective clinical studies designed to establish the etiology of CNS infections in northern Vietnam (n = 233), Cambodia (n = 123) and Nepal (n = 80), The Dutch CSF specimens (n = 179) represented a random sample of anonymized specimens from Dutch patients with suspected CNS infections submitted to the Netherlands Reference Laboratory for Bacterial Meningitis in Amsterdam.As part of standard operating procedures applied in our laboratory, CSF samples were spiked with an optimal amount of phocid herpesvirus and equine arteritis virus as (reverse transcription) PCR internal controls82 (provided with the polymerase), 1 × PCR buffer (provided with the polymerase), and 3 μl of extracted NAs. PCR reaction was performed on a LightCycler 480 Instrument II  with an initial polymerase-activation step at 95°C for 14 min 30 sec followed by 45 cycles of 95°C for 30 sec, 55°C for 30 sec and 72°C for 30 sec. A positive control and several negative controls (including extraction controls and water controls) were included in every PCR run. All the PCR experiments were performed in molecular diagnostic facilities that consist of three physically separated laboratories for reagent preparation, extraction and amplification, and these were used a unidirectional workflow.PCR screening of CyCV-VN was performed on extracted nucleic acid samples that had been tested by PCRs for CNS pathogens and had expected crossing point values of internal controls between 33 and 35, and was carried out as previously describedPairwise comparisons and phylogenetic analyses were done using AlignX , USA) and neighbor-joining in MEGA version 4All clinical studies from which the CSF samples were chosen for PCR screening in the present study were reviewed and approved by the Institutional Review Boards of collaborating hospitals and the Oxford Tropical Research Ethics Committee (OxTREC), University of Oxford, United Kingdom. Informed consent was obtained from patients or a parent or guardian of each enrolled patients.H.D.T.N., N.V.V.C., N.V.K., W.T., H.F.L.W., A.v.d.E., A.G., S.S. and T.T.H. collected CSF specimens. M.C., N.V.T., N.H.U., M.C., J.B. and N.T.T.C.B. conducted laboratory experiments. L.V.T. did sequence analyses. L.V.T., H.R.v.D., J.F., L.v.d.H., J.B. and M.D.d.J. designed the study. L.V.T., H.R.v.D. and M.D.d.J. drafted the manuscript. All authors were involved in subsequent reviewing and editing the manuscript.


We also compared aSyn with several other CSF constituents of either central or peripheral sources (or both) including albumin, neuron-specific enolase, β-trace protein and total protein content. Finally, we examined whether aSyn is present within the structures of the choroid plexus (CP). We observed that QaSyn did not rise or fall with Qalbumin values, a relative measure of blood–CSF barrier integrity. In our CSF gradient analyses, aSyn levels decreased slightly from rostral to caudal fractions, in parallel to the recorded changes for neuron-specific enolase; the opposite trend was recorded for total protein, albumin and β-trace protein. The latter showed higher concentrations in caudal CSF fractions due to the diffusion-mediated transfer of proteins from blood and leptomeninges into CSF in the lower regions of the spine. In postmortem sections of human brain, we detected highly variable aSyn reactivity within the epithelial cell layer of CP in patients diagnosed with a range of neurological diseases; however, in sections of mice that express only human SNCA alleles (and in those without any Snca gene expression), we detected no aSyn signal in the epithelial cells of the CP. We conclude from these complementary results that despite its higher levels in peripheral blood products, neurons of the brain and spinal cord represent the principal source of aSyn in human CSF.The source of Parkinson disease-linked α-synuclein (aSyn) in human cerebrospinal fluid (CSF) remains unknown. We decided to measure the concentration of aSyn and its gradient in human CSF specimens and compared it with serum to explore its origin. We correlated aSyn concentrations in CSF versus serum (Q SNCA) dosage with a more severe phenotype observed in the cases of locus multiplication  include progressive cell loss of selective nuclei in the nervous system and the formation of intracellular aggregates that contain insoluble, wild-type α-synuclein (aSyn)  reflects an indirect measure of blood–CSF barrier function in vivo.The production and hydrodynamics of human CSF are complex and vary considerably depending on the level within the neuroaxis. The three main sources for CSF constituents comprise: one, the metabolism of neural cells in the central nervous system (CNS); two, diffusion of constituents from circulating blood into CSF [even in the absence of any trauma  with Qalbumin in 42 patients with various neurological diseases. Next, we quantified aSyn levels in patients with normal blood–CSF barrier function and compared them to specific brain-derived , blood-derived , and leptomeninges-derived  proteins in serially collected CSF samples, to examine their rostro-caudal concentration gradients. Furthermore, we also probed whether CP tissue contained aSyn reactivity.This study was designed to investigate whether CSF aSyn is mainly brain or blood derived. To this end, we compared aSyn concentrations in CSF versus serum (Qn = 31); to exclude chronic inflammatory diseases (n = 3); to determine carcinomatosis of the leptomeninges in the case of a known primary tumor (n = 4), and to carry out CSF volume reduction in patients with normal pressure hydrocephalus . All study participants were enrolled at the Department of Neurology at Goettingen University, Germany. Samples were collected and processed as published  for routine diagnostic purposes Table  to deterIn a second set of study participants we collected CSF from five patients at the Paracelsus-Elena-Klinik, Kassel, Germany. All patients suffered from NPH as determined by magnetic resonance imaging and according to the established clinical criteria  and Snca-null mice without any endogenous Snca and no transgene expression [engineered as described .albumin) were analyzed according to Pearson. Results for aSyn, NSE, β-trace, albumin and total protein values in CSF are demonstrated in Table Possible correlations between the concentrations of CSF/serum aSyn to CSF/serum albumin  (range 1.8–37.2 × 10−3). CSF aSyn levels ranged from 1.29 to 2.97 pg/μl . Serum aSyn levels ranged from 14.33 to 67.47 pg/μl (mean 29.54 ± 10.79), and the mean CSF/serum aSyn (QaSyn) was calculated as 0.08 ± 0.032. The coefficients of variation (CV) for aSyn values measured 19.6% in CSF, 36.5% in serum, and the CV for QaSyn was 40%. Importantly, when examining QaSyn together with Qalbumin values, we recorded no significant correlation , which represented a trend without statistical significance . The levels of exclusively neuron-derived NSE remained stable throughout  and total protein  decrease significantly in the rostral fractions . Figure CSF aSyn levels across all fractions examined ranged from 1.17 to 2.64 pg/μl (mean 1.70 ± 0.36) in specimens from five NPH patients that were analyzed. Qpostmortem human brain sections by routine immunohistochemistry (IHC). We unexpectedly detected highly variable aSyn reactivity within the epithelial cell layer of human CP   to discern the effect of aSyn distribution under pathological blood–CSF barrier conditions.In examining the influence of the blood–brain barrier on CSF and serum aSyn levels from neurological controls, we found no correlation between the concentration of CSF aSyn and QDue to the protective role of the barrier function on CNS integrity, we also calculated the coefficients of variation (CV) as a reflection of biological variability. The CV value for aSyn in CSF was smaller than that for serum aSyn. The latter observation provided independent  support for our conclusion that under normal conditions the majority of aSyn species detected in CSF was unlikely to be blood borne; if it would have been predominantly derived from blood, the CV of CSF aSyn values would have been expected to be at least equal—if not larger—than those of serum aSyn. Another possible explanation for the different CV values is that our assay could have captured CSF aSyn more readily than serum aSyn , but this scenario seems unlikely given the significantly larger amounts of aSyn recorded by our assay in all serum samples than in CSF  associated with nervous system structure and function under physiological conditions, and is less likely to be blood borne. Our results do not exclude the possibility that this distribution is markedly altered in diseases associated with significant neuronal lysis   sections could indicate a relevant site for aSyn uptake Understanding the sources of aSyn, delineating the molecular events underlying its presumed exocytosis by cells into the interstitial, ventricular and subarachnoid spaces of the CNS, and cataloging its modified variants represent pivotal tasks for our field in the future. They are important in the identification of the unknown function of aSyn in CSF, its main degradation pathways in intra- and extracellular compartments (including in CSF), and its possible uptake by neural, ependymal and epithelial cells from circulating CSF. These related topics have major implications for the pathogenesis, the diagnosis and possibly, the progression of several, currently incurable synucleinopathy disorders of the brain including PD, MSA and DLB (Desplats et al.


P = 0.01) and those with elevated CSF protein concentrations . We also observed a correlation between the neopterin and high plasma creatinine value , low blood thrombocyte count , and markedly disturbed refractory properties of an eye . Length of hospitalisation correlated with the neopterin . Patients with signs of tissue oedema and increased permeability also had high neopterin concentrations. These results reinforce the view that PUUV-HFRS is a general infection that affects the central nervous system and the blood-brain barrier.Nephropathia epidemica (NE) caused by Puumala hantavirus (PUUV) is the most common hemorrhagic fever with renal syndrome (HFRS) in Europe. The infection activates immunological mechanisms that contribute to the pathogenesis and characteristics of the illness. In this study we measured cerebrospinal fluid (CSF) neopterin concentration from 23 acute-phase NE patients. We collected data on kidney function, markers of tissue permeability, haemodynamic properties, blood cell count, length of hospitalisation, inflammatory parameters, and ophthalmological properties. The neopterin levels were elevated (>5.8 nmol/L) in 22 (96%) NE-patients (mean 45.8 nmol/L); these were especially high in patients with intrathecal PUUV-IgM production (mean 58.2 nmol/L,  Myodes glareolus) (PUUV) [Nephropathia epidemica (NE) is an emerging infectious disease caused by Puumala hantavirus carried and spread by bank voles  (PUUV) . This he) (PUUV) . Despiteα) the serum levels of which have been correlated with the severity of the infection [Endothelial cells and monocytes are thought to be the primary targets of hantaviruses. The infection may lead to activation of monocyte/macrophage lineage and expression of interleukin-6 (IL-6), interleukin-10 (IL-10), and tumour necrosis factor-alpha .The laboratory diagnosis of NE was based on PUUV serology that was initially analysed using a commercial enzyme-linked immunosorbent assay of IgM antibodies . In selected cases, the samples were also analysed with an indirect immunofluorescence test for PUUV-IgG which displayed a granular staining pattern in cases of typical acute infection . CSF andU test were used to analyse the significance of the findings. A P value of <0.05 was considered significant. In the case of ophthalmological parameters, the values measured from the right eye of each patient were used. PASW Statistics 18  was used for statistical analysis.Multivariate analysis of the results was not possible due to the low number of patients. Instead, Pearson bivariate correlation test and Mann-Whitney n = 22, 96%) patients had an elevated CSF neopterin level compared to those seen in healthy individuals (<5.8 nmol/L) [n = 15) and female (n = 8) patients was 46.9 nmol/L and 43.9 nmol/L, respectively. The neopterin concentration was 63.6 nmol/L and 29.6 nmol in CSF in samples with elevated  or normal  protein level, respectively  (n = 14) had higher CSF neopterin level (58.2 nmol/L) than those negative for CSF PUUV-IgM . The CSF white cell count did not show any association with the neopterin level and there was no difference in the CSF neopterin levels of different age categories. CSF neopterin level correlated with the length of hospitalisation  .CSF samples from 23 patients with acute NE were available for analysis of the neopterin concentration. Most n = 22, 6% patien nmol/L) . The CSF U test) . Patient < 0.05) ; this fir = −0.42, P < 0.05) . There was no association between the blood white cell count and the CSF neopterin level. There was a correlation between the blood thrombocyte level measured in the morning of the lumbar puncture and the CSF neopterin concentration ( < 0.05) . In addiP < 0.01) and the plasma creatinine concentration measured in the morning of the lumbar puncture  correlated with the CSF neopterin concentration  indicating that patients with the most evident tissue oedema had the highest CSF neopterin level. CSF/serum albumin ratio as a marker of tissue permeability was also associated with CSF neopterin concentration (P = 0.01).The highest plasma creatinine level  (An elevated CSF neopterin concentration was associated with a large difference in the refractory properties of the eye when this was first measured during the acute phase and then month after recovery ( < 0.05) . None ofThe patients were analyzed for brain MRI, EEG, and HLA haplotype and the results are described in detail in our previous paper . The numAn elevated CSF protein concentration and a raised white cell count are commonly seen in acute NE and many patients display evidence of intrathecal antibody production against PUUV , 11, 12.Activation of monocyte/macrophage lineage and subsequent cytokine expression leading to T-lymphocyte stimulation may contribute to the pathogenesis of acute NE . The intElevated neopterin levels have been detected in acute dengue fever and high neopterin levels were found especially in those dengue patients with increased tissue permeability . A similIn our study, high neopterin levels correlated with markers of disease severity: high plasma creatinine concentrations and low blood thrombocyte counts were encountered in patients with high neopterin values. Moreover, the elevated CSF neopterin level correlated with the length of hospitalisation especially in male patients. Interestingly, a previous study has found a gender-dependent difference in the cytokine responses to hantavirus infection . It is aIn summary, it seems possible that an inflammatory reaction of the CNS in acute NE is at least partly influenced by the monocyte/macrophage activity. Increased tissue permeability due to inflammatory reaction is most likely essential, but it is also possible that direct PUUV invasion of the CNS may play a significant role. Investigation of mechanisms leading to the injury of the blood-brain barrier and the increased tissue permeability, however, may further explain the biology of CNS disease in acute NE.


We investigated levels of the β-amyloid 1–42 (Aβ42), total tau protein (T-tau) and tau phosphorylated at position threonine 181 (P-tau) in cerebrospinal fluid (CSF) of idiopathic normal pressure hydrocephalus (iNPH) patients and tried to find their clinical implications in the evaluation and treatment of iNPH.Twenty-five possible iNPH patients were prospectively enrolled and their CSF was collected to analyze levels of Aβ42, T-tau and P-tau using ELISA method. Gait disturbance, urinary incontinence, and cognitive impairment were semi-quantified and detailed neuropsychological (NP) test was performed.Eight iNPH patients were classified into the lower CSF Aβ42 group and 17 patients were classified into the higher CSF Aβ42 group. There was no difference in the iNPH grading score and its improvement after LP between the two groups. The lower CSF Aβ42 group showed more deficits in attention, visuospatial function and verbal memory in the baseline NP test and less improvement in phonemic categorical naming and frontal inhibitory function after LP.Our study suggested that concomitant AD in iNPH patients might contribute to lumbar puncture or shunt unresponsiveness, especially in the field of cognitive dysfunction. Idiopathic normal pressure hydrocephalus (iNPH) is characterized by a clinical triad of symptoms including cognitive impairment, gait difficulty, and urinary incontinence along with ventricular enlargement in brain imaging ,2. It isAD and iNPH have different pathomechanism, but recent studies pointed out common pathomechanism between the two diseases ,6. HowevThe aim of this study was to investigate levels of the Aβ42, T-tau and P-tau in CSF of iNPH patients and describe the clinical implications in the evaluation and treatment of iNPH.Among patients who visited the Department of Neurology at the Ajou Medical Center, Suwon, Korea from March 2010 to February 2012, we consecutively recruited 25 patients who satisfied the criteria for possible iNPH. All patients had had brain MRIs and an LP. The clinical criteria for possible iNPH included following: (1) MRI showing ventricular enlargement (2) Any one symptom from clinical triad  which was considered as a symptom compatible with iNPH by the clinician [The CSF of 17 AD patients and 10 normal control subjects which were collected and stored previously at two other hospitals (S.C.H.U.H. and C.A.U.H.) was tested to get a cutoff value of the coexistence of AD. All AD patients met the criteria for probable AD as proposed by the National Institute of Neurological and Communicative Diseases and Stroke and Alzheimer’s disease and Related Disorders Association (NINCDS-ADRDA) . All norWe excluded patients with a history of significant hearing or visual impairment that could render interview participation difficult, as well as those with a history of other neurological disorders , psychiatric illnesses , those taking psychotropic medications, and those with a history of significant alcohol and/or other substance abuse. Each patient provided written informed consent. If patients had impaired decisional capacity, caregivers provided consent and patients provided assent. This study was approved by the Ajou Institutional Review Board.An iNPH scale modified from Larsson et al.  and KrauAll participants underwent LP in the L3-4 or L4-5 interspace to drain 30 ~ 50 ml of CSF to evaluate response to LP from 10:00 to 12:00. During the procedure, 10 ml of CSF was collected in polypropylene tubes after discarding the first 3 ~ 4 ml. Bloody or cloudy samples were rejected. No serious adverse events were reported. The samples were immediately centrifuged for 15 minutes at 2,000 rpm to remove cells and aliquots were stored in polypropylene tubes and immediately frozen at −80°C until analysis. They were thawed just before analysis.CSF T-tau concentration was determined using a sandwich enzyme-linked immunosorbent assay  specifically constructed to measure all tau isoforms irrespective of phosphorylation status, as previously described . P-tau wThe Evans index and white matter hyperintensity were assessed using MRI. The Evans index was defined as the maximal frontal horn ventricular width divided by the transverse inner diameter of the skull and signifies ventriculomegaly if it is 0.3 or greater . White mNeuropsychologists assessed participants’ cognitive functioning via the extensive Seoul Neuropsychological Screening Battery (SNSB)  covering(1) The attention and working memory assessment used the digit span forward and backward tests.(2) The language function assessment employed the Korean version of the Boston Naming Test (K-BNT) .(3) The visuospatial function assessment was the patient’s copy score of the Rey Complex Figure Test (RCFT), neuropsychological assessment in which examinees are asked to reproduce a complicated line drawing, first by copying and then from memory.(4) Memory function was divided into verbal and visual memory. We assessed verbal memory by means of the Seoul Verbal Learning Test (SVLT), the Korean version of the revised Hopkins Verbal Learning Test (HVLT-R), testing participants on the immediate recall, delayed recall, and recognition tasks. To assess visual memory, we tested participants on the RCFT’s immediate recall, delayed recall, and recognition tasks.(5) To assess frontal lobe functioning, we used the contrasting program, go-no go, the semantic and phonemic aspects of the Controlled Oral Word Association Test (COWAT) and Stroop test.We used chi-square, analysis of variance (ANOVA), and Kruskal-Wallis tests to compare demographic data of each group and analysis of covariance (ANCOVA) to compare clinical data and the neuropsychological test percentile scores adjusted by the age, gender and years of education of normative data from general population. Post-hoc analyses with Least Significant Difference (LSD) method were performed for between-group comparisons. Intraclass correlation coefficient was calculated to show the test-retest reliability of ELISA. Receiver operating characteristics (ROC) curve analysis was used to identify the cut-off levels with the optimal combination of specificity and sensitivity. Mann-Whitney test was used to compare the scores of neuropsychological tests between the subgroups of iNPH patients, adjusted for age, sex and duration of education. All statistical analyses were performed using SPSS 13.0 . Null hypotheses of no difference were rejected if p-values were less than .05.Demographic and clinical characteristics and results of statistical analyses are summarized in Table To determine a cut-off level of the coexistence of AD in iNPH patients, ROC curve analysis was performed. CSF Aβ42 was used because it was the only biomarker which was significantly different between AD and control group. The area under the curve was 0.876 with p-value of 0.001 . There was no difference in the iNPH grading score and improvement rate after LP between the two groups , RCFT copy test p = 0.043) and SVLT immediate recall test (p = 0.009) after adjustment for age, sex and duration of education  and color reading test in Stroop test (p = 0.018) after LP compared to the higher CSF Aβ42 group after adjustment for age, sex and duration of education. The mean interval between the first and the second neuropsychological test was 13.2 ± 9.4 days  All three biomarkers for AD diagnosis were significantly different between AD and iNPH. (2) There was no difference in demographic and clinical characteristics including the response to CSF drainage using iNPH grading system between the lower CSF Aβ42 group and the higher CSF Aβ42 group. (3) Comparison of initial neuropsychological tests showed deficits in attention, visuospatial function and verbal memory are more prominent in the lower CSF Aβ42 group than the higher CSF Aβ42 group. (4) Neuropsychological performance improvement before and after CSF drainage were significantly less in phonemic categorical naming and frontal inhibitory function in the lower CSF Aβ42 group than the higher CSF Aβ42 group.In the comparison of Aβ42, T-tau and P-tau between iNPH and AD, Aβ42 was lower and T-tau and P-tau were higher in AD than in iNPH. These results correspond well with earlier studies which reported various CSF biomarkers indicating less AD pathology in iNPH patients than AD patients ,29,30. AExcept for the hippocampal atrophy, all the radiological and clinical symptomatic indicators of iNPH patients including response to CSF drainage did not differ between the two subgroups divided by CSF Aβ42 level. These results are similar to those of previous studies which reported that iNPH patients benefit equally from shunting regardless of the presence of AD pathology -9. RecenAlthough there was no difference in general cognitive function between the two subgroups, the initial detailed neuropsychological tests revealed more deficits in attention, visuospatial function and verbal memory in the lower CSF Aβ42 group. These domains are well known to be impaired in the early course of AD. Therefore these results suggested that AD pathology may impact an additive AD-related cognitive dysfunction in iNPH patients regardless of underlying cognitive dysfunction caused by iNPH. In addition to the initial difference, categorical naming and inhibitory executive dysfunctions in the lower CSF Aβ42 group, which were considered as iNPH-related cognitive dysfunction, were less improved after lumbar puncture compared to the higher CSF Aβ42 group. These results suggested that some portion of the frontal lobe dysfunction in the lower CSF Aβ42 group was possibly caused by the concomitant AD and not improved after lumbar puncture. In contrast, the frontal lobe dysfunction in the higher CSF Aβ42 group was solely caused by the pathophysiology of iNPH and improved more than the lower CSF Aβ42 group. This pattern of improvement after lumbar puncture was not reported before but the similar pattern of post-shunt improvement was noted in a previous study which observed improvement of subcortical dysfunction after shunting .We assumed that memory impairment and visuospatial dysfunction in iNPH were mainly caused by concomitant AD which was defined by lower CSF Aβ42. This assumption was usually correct in pure AD but the correlation of the cognitive dysfunction with CSF biomarkers is more complicated in iNPH. For example, in a previous series of 17 iNPH cases, the visuospatial dysfunction was the prominent cognitive feature which was against the classic view of iNPH as a subcortical, frontal type of dementia . FurtherWe should accept that this study has several limitations. One limitation of this study is its relatively small sample size. Another limitation is lack of analysis of long-term follow-up data such as shunting history. The authors also acknowledged that the possible iNPH criteria is inclusive and the elevated T-tau and P-tau levels might be induced by some different circumstances. In addition, normal control subjects were recruited from the clinic and possibly had cognitive complaint more than those recruited from the cohort. Subjects with cognitive complaint are known to have more AD pathology than those without it . This maOur study suggested that concomitant AD in iNPH patients might contribute to lumbar puncture or shunt unresponsiveness, especially in the field of cognitive dysfunction.There are no financial or non-financial competing interests on this study.TSL, JYC, SAP, YCY, HYL, and SYM carried out the study, analyzed the data and produced the draft. BGK, ISJ and KH improved on the draft and also helped with the recruitment of patients. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/14/66/prepub