Scale of Concerns Regarding Living Kidney Donation of whom 105 donor candidates and their corresponding recipients  were further evaluated with regard to mental health  and quality of life . As hypothesized recipients scored higher on depression and lower on quality of life. Donor candidates intending to donate to their children were significantly less concerned about risks of donation for themselves compared to donor candidates donating to siblings. Our findings highlight the importance of the type of donor-recipient relationship to understand specific concerns of donor candidates and optimize psychosocial assessment and support. From an evolutionary perspective parents lack of concern about their own well-being can be seen as an altruistic behavior to increase children’s fitness at the  expense of their own fitness.Even though the majority of living kidney donor candidates appear in good mental health and show few concerns little is known concerning the influence of the type of donor-recipient relationship on donor candidates’ specific concerns with regard to kidney donation. 136 donor candidates at Virgen del Rocío University Hospital of Seville filled in the  Living kidney donation is a very complex psychological experience for donor candidates as well as recipients. On the one hand, donor candidates may feel under emotional pressure because without their donation recipients’ quality of life and health may further deteriorate , on the Given the importance of this subject in clinical practice we aimed at investigating whether donor candidates specific concerns in relation to kidney donation differ depending on type of donor-recipient relationship. Furthermore, as to date no study investigated mental health and quality of life in donor and recipient candidates in Spain, we took a closer look at these aspects. Previous studies from other European countries and the US on recipients’ quality of life and mental health demonstrated significant pre- to post-transplant improvements . In specWe hypothesized that donor candidates compared to recipients would show significantly lower scores on depression and higher scores on quality of life. Furthermore, we hypothesized that parent donor candidates would show more concerns about recipients and less concerns about themselves compared to donating siblings.Scale of Concerns Regarding Living Kidney Donation . The relationship with their recipient was as follows: parent (39%), partner (33.8%), sibling (20.6%), other (6.6%). The group of recipient candidates was comprised of 105 patients (66 men and 39 women) with a mean age of 43.23 years (SD = 2.82 years). The mean time of duration of illness was 14.74 years (SD = 12.72 years). The causes of kidney failure included chronic glomerulonephritis (49.5%), renal cystic diseases and renal dysplasia (17.1%), other (14.3%), tubulointerstitial nephropathy (10.5%), and chronic renal failure of unknown origin (8.6%).The group of donor candidates was made up of 43 men and 93 women with a mean age of 47.68 years  over 18 years of age, (b) informed consent, (c) no difficulties in understanding the evaluation instruments, and (d) no severe or disabling psychopathological condition. Four donor candidates (two did not wish to participate and two did not understand Spanish) and 35 recipient candidates  had to be excluded. Thus, 136 donor candidates and 105 donor-recipient pairs could be included in the study.t-test to analyze differences in mental health and quality of life between the two paired groups of donor and recipient candidates and independent t-test for the comparison with population samples. To analyze differences in living kidney donor candidates concerns due to type of donor-recipient relationship  we used the Kruskal–Wallis H test followed by the Dunn-test adjusted for multiple comparisons. Furthermore, Cohen’s d was calculated as a measure of effect size for all comparisons in the study.The data were analyzed with the SPSS 22 statistics program. We used the paired Table 1). Regarding specific depressive symptomatology they showed higher scores on worthlessness , loss of energy , changes in appetite , and tiredness or fatigue  .There was no difference between donors and recipients regarding self-reported anxiety. Potential recipients scored significantly higher on depression compared to donor candidates as measured by BDI-II  donor candidates showed less anxiety  and depression . The most relevant differences in depressive symptomatology were as follows: pessimism , worthlessness , loss of energy , concentration difficulty , and tiredness or fatigue . Recipient candidates showed less anxious symptomatology .In comparison to the population samples .Donor candidates compared to recipients showed higher quality of life on the following dimensions: physical functioning, role-physical, bodily pain, general health, vitality, and social functioning (n = 8778) donor candidates showed higher quality of life on general health  and vitality  dimensions. On the contrary, the recipient candidates displayed poorer quality of life on physical functioning , role-physical , general health , and social functioning .In comparison to the population sample (Table 3). Analysis of the different items subsumed under Factor II showed that parent donor candidates worried less about having kidney complications for the rest of their lives, a member of the family not accepting their decision, the donation having repercussions on their daily lives, or that having to live with only one kidney could be detrimental to their job or their health (Table 4).On the basis of donor-recipient relationship donor candidates were divided into four groups. Between these groups there were no differences with regard to gender, age, depression, and anxiety (HADS). Analysis of donor candidates’ concerns displayed no differences with regard to concerns related to recipients’ well-being. In accordance with our hypothesis parent donor candidates showed less concerns relating to themselves (Factor II) compared to donating siblings  and more quality of life . These results are congruent with previous studies which have consistently come to the conclusion that donor candidates’ self-reported mental health as well as quality of life are excellent . The excAnalysis of donor candidates’ concerns found significant differences between parents and siblings. Thus, parents worried less about the negative repercussions of nephrectomy such as kidney complications, problems in daily life, work life and general health problems. Along this line, other studies indicated that parents perceive their donation as a natural gift to their children, while for siblings it could be a moral obligation to meet family expectations . An inteFrom an evolutionary perspective this parental behavior roots in a biologically founded form of altruism . AltruisThere is growing evidence that a comprehensive psychosocial assessment of living kidney donors and recipients is necessary to guarantee the best possible outcome . From a Limitations of the study that need to be addressed include cross-sectional study design that implies there is no post donation assessment to further help demonstrate the importance of the issue. Furthermore, it would have been of interest to compare our results with a control group of healthy individuals . BesidesEthics Committee of the Virgen del Rocío University Hospital of Seville. All subjects gave written informed consent in accordance with the Declaration of Helsinki.MÁP-S-G: Study concept and design, data analysis and interpretation, drafting of manuscript, manuscript revisions, and drafting figures. AM-R: Study concept and design, data analysis and interpretation, manuscript revisions. AL-B: Institutional support, data collection, critical revision of article. RC: Data analysis and interpretation, drafting of manuscript, critical revision of article. MÁP-S-G, AM-R, AL-B, and RC: Final approval of version to be published.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer (SC) and the handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Correlative vibrational spectroscopy and immunohistochemistry reveal astroglial processes co-localised with the lipid-rich shell of Aβ plaques. in situ using a model of AD. We combined FTIR, Raman and immunofluorescence images, showing that astrocyte processes co-localise with the lipid ring surrounding many plaques. We used μFTIR imaging to rapidly measure chemical signatures of plaques over large fields of view, and selected plaques for higher resolution analysis with Raman microscopy. Raman maps showed similar lipid rings and dense protein cores as in FTIR images, but also revealed cell bodies. We confirmed the presence of plaques using amylo-glo staining, and detected astrocytes using immunohistochemistry, revealing astrocyte co-localisation with lipid rings. This work is important because it correlates biochemical changes surrounding the plaque with the biological process of astrogliosis.Recent work using micro-Fourier transform infrared (μFTIR) imaging has revealed that a lipid-rich layer surrounds many plaques in post-mortem Alzheimer's brain. However, the origin of this lipid layer is not known, nor is its role in the pathogenesis of Alzheimer's disease (AD). Here, we studied the biochemistry of plaques  Alzheimer's disease (AD) is a progressive neurodegenerative disease and the most common form of dementia worldwide. There are currently 47 million affected people, a number that is predicted to double every 20 years,in vivo has prompted early attempts of applying vibrational spectroscopy techniques to investigate the molecularity and structure of Aβ plaques in the brain of both humans and mouse models of AD.The lack of a diagnostic tool for AD Significant advances in μFTIR spectroscopic imaging of AD brain have been brought about by Gough and co-workers, showing that it is possible to achieve enhanced spatial resolution in focal plane array (FPA) detection of plaques using synchrotron light sourceAn in-depth investigation of the molecular species involved in the mechanism of Aβ plaque formation is the first step to unravel the pathophysiology of this complex disease. The aim of this work was to investigate the chemical and structural character associated with the distribution of specific compounds within amyloid plaques. Although some hypotheses have previously been made, no definitive conclusion around the origin of the lipid-rich ring surrounding the plaque core has yet been made. We clarified this for the first time in the present work using chemical imaging and correlative immunofluorescence imaging of plaques.In this work, we used a TASTPM transgenic mouse model of AD characterized by Aβ overexpression. TASTPM mice carry a double mutation on the APP and one single mutation on the presenilin-1 gene resulting in severe accumulation of amyloid plaques and cognitive impairment by the sixth month of age.Micro-transmission FTIR images from this location are presented in –1, which is distinctive for intermolecular β-sheet structures.ν scale" fill="currentColor" stroke="none"><path d="M0 1440 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z M0 960 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z"/></g></svg>O)ester) at 1735 cm–1 and CH stretching (ν(CH)) in the range 3003–2805 cm–1 obtained from the same measurement, show lipids as green regions mostly co-localized with the plaques. The blue arc in Stratum Pyramidale (SP), which is the cell body layer, where lipids are less abundant. Stratum Oriens (SO), Stratum Radiatum (SR) and Stratum Lacunosum Moleculare (SLM), all containing non-myelinated components such as axonic and dendritic processes  and sparse cell bodies, have intermediate lipid content and are shown as cyan. The red arc in Protein distribution images  show the–1, generally assigned to α-helix, and a shoulder at 1628 cm–1, associated with β-sheet;–1. The observed spectral change indicates a gradual decrease of protein signals (–1), amide II and the amyloid band  scale" fill="currentColor" stroke="none"><path d="M0 1440 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z M0 960 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z"/></g></svg>O)ester at 1738 cm–1) when going from the core through to the periphery of the plaque. To analyse these variations, difference spectra were calculated (see below). The distinctive structure of Aβ deposits is clearly visualized in  signals  due to t404 cm–1 ) accompaTo confirm that the plaques identified with μFTIR imaging were indeed genuine plaques, we compared the FTIR images directly with immunofluorescence imaging based on amylo-glo staining of the same specimen see . Amylo-g19ex vivo hippocampal sections from WT mice  mice entirely lack plaque pathology. μFTIR imaging applied to Fig. SI-2 reveal nFig. SI-2 do not pλ/2NA = 0.8 μm) but, in general, is a much slower technique restricting the number of plaques that can be analysed. To our knowledge, this is the first time that a side-by-side comparison of Raman with μFTIR has been performed on individual plaques.Combining Raman and infrared imaging is a powerful tool as FTIR can rapidly scan large fields of view so that images of plaques can be made, while Raman microscopy has higher spatial resolution , whilst also showing additional features such as cell bodies (These results show that (1) Raman can reveal the same structures as can be seen with FTIR imaging  scale" fill="currentColor" stroke="none"><path d="M0 1440 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z M0 960 l0 -80 1360 0 1360 0 0 80 0 80 -1360 0 -1360 0 0 -80z"/></g></svg>O stretching at 1738 cm–1), indicating a lower lipid concentration in the core than in the ring around the plaque, in accordance with previous observations.–1, which is shifted at 1654 cm–1 in the ring spectrum. This spectral effect may be attributed to a change in the secondary structure of the proteins in the two sub-regions of the plaque. At these high frequencies, absorption due to the α-helix conformation is expected;–1 (ordered conformation), highlighted by the difference spectrum in –1 due to β-pleated sheet,e.g. α-helix.20To elucidate the origin of the lipid ring around the amyloid plaque core detected by FTIR imaging and Raman microscopy, we performed a second subset of experiments using amylo-glo and immunofluorescent co-labelling with antibodies for astroglia (GFAP). These cell types have previously been reported to cluster around plaques.N = 30 plaques) for all plaques visualised by μFTIR, Raman and immunofluorescence. As the lipid ring has approximately the same width as the astrocyte processes, and they co-localise in the same position around the plaque core, we conclude that this is compelling evidence that the lipid ring is associated with the astrocyte processes.To establish if there was a link between the astrocyte processes and the lipid ring, we compared the ratio of the width of the lipid ring to the diameter of the plaque core for a number of plaques in both the immunofluorescent, μFTIR and Raman images. An example of this measurement can be seen in i.e. membrane extensions) towards the plaque core. This is a feature of astrogliosis in the brain parenchyma.More examples of immunostained plaques can be seen Fig. SI-4 which reca. 10 μm diameter (yellow in the pseudo-colour map). The presence of nearby cell bodies has previously been revealed by synchrotron-based μFTIR imaging but not by globar source μFTIR,Interestingly, we also show how Raman has the spatial resolution to detect cell bodies. In Fig. SI-3c,in situ, in combination with conventional fluorescence stains to visualise plaques and surrounding biological processes. Our results are consistent with the hypothesis that a lipid ring, which is seen surrounding many plaques, is associated with astrocyte processes. This is evidenced by immunohistochemistry images that show astrocyte processes surrounding plaques (stained with amylo-glo) and co-localising with the lipid ring.The chemical structure and formation of amyloid plaques is a much studied, but still controversial topic. Here we have used spectroscopic tools to chemically analyse plaques μFTIR imaging and Raman micro-spectroscopy were applied to study the chemical composition of Aβ plaques in the hippocampal CA1 region of the brain of TASTPM mice, an Aβ-overexpressing transgenic mouse line. Previous studies have used μFTIR imaging for the visualization of amyloid plaques and have found lipid rings surrounding some plaques.Fluorescent labelling for Aβ peptide and astrocytes confirmed that some plaques are clustered with astrocytes; this is paralleled by the observation that some plaques have a lipid-rich layer around the core (detected by FTIR imaging and Raman mapping). Raman maps elucidate the finer details of the plaque structure, revealing small ovoids in the outer rim of the plaque that correspond to the cell bodies of astrocytes. Astrocytic processes radially extend from the cell bodies towards the core of the plaque, co-localizing with the lipid-loaded ring. As for equal volumes the surface/volume ratio (approximately corresponding to the lipid/water ratio in cells) is higher in elongated processes compared to ovoids, we infer that the astrocytic processes surrounding the plaques likely correspond to the origin of the lipid signal detected in this region. This is an important observation, as it reveals that the ring around the plaque can itself be a marker of astrogliosis. It should be highlighted that the lipid signal may also originate from the activated microglia surrounding Aβ plaques;As with microglia activation, astrogliosis is strongly associated with amyloidopathy. Several lines of evidence suggest that while the amyloid-dependent microglial activation is responsible for increased risk and more severe progression of AD,24The ability of μFTIR imaging and Raman microscopy to detect both Aβ plaques and plaque-associated astrogliosis might allow the use of chemical imaging to identify astrogliosis and clustered inflammation in nerve tissue with amyloidosis, with potential for translation into an early diagnostic tool. The biochemical information this brings will likely prove invaluable for further elucidating the mechanisms of AD.In this paper, we have focussed on analysing the chemical composition of plaques in a transgenic mouse model of Alzheimer's disease, using μFTIR imaging and Raman microscopy, with correlative immunofluorescence imaging. We have found that the plaques tend to have a protein-rich core, high in intermolecular β-sheets, surrounded by a lipid ring. This ring correlates with processes from astrocytes , which we propose are the origin of the lipid-rich ring found in μFTIR images and Raman maps. This is a novel finding and adds weight to the hypothesis that plaques cause chronic inflammatory responses to the surrounding tissue, which could potentially be a root cause of neurodegeneration.Swe K670N, M671L) and one on the presenilin 1 gene (M146 V) that can be found in patients affected by familial Alzheimer's disease.ad libitum before being sacrificed.36Animal procedures complied with the UK Home Office Guidelines and the University of Exeter Animal Welfare Ethical Review Board. Male 12 months old Aβ-overexpressing TASTPM (TG) mice and age-matched littermate controls (WT) were used in this study. TASTPM mice carry two mutations on the gene for the amyloid precursor protein . The brain was rapidly removed and acute horizontal slices of 300 μm thickness were cut in a vibratome and suspended in artificial cerebrospinal fluid, as previously described.Three brain sections per animal (five TASTPM and five WT mice) were analysed giving a total of 30 specimens. For two random sections, measurements were rerun to assess their repeatability.2. Characteristic bands of proteins and lipids, principally amide I, amide II, ester carbonyl and CH stretching, were analysed, yielding images with a spatial resolution in the range of 5–10 μm (fingerprint region). These bands constitute the spectral signatures of the main components of amyloid plaques.–1 at a spectral resolution of 4 cm–1 with a zero filling factor of 2, achieving a spectral spacing of approximately 2 cm–1. Prior to all image measurements, a background obtained from a tissue-free region of the substrate was measured by co-adding 64 interferograms. Large images of the whole hippocampus were constructed as mosaics of individual tiles; each tile was selected to be 128 × 128 pixels.Micro-transmission Fourier transform infrared (μFTIR) images were collected with an imaging system consisting of an Agilent Technologies Cary 670 FTIR spectrometer coupled to a Cary 620 FTIR microscope with a 0.62 NA, 15× Cassegrain objective, and a liquid nitrogen-cooled focal plane array (FPA) detector. The detector had 16 384 pixels arranged in a 128 × 128 array. The area imaged in μtransmission mode through the 15× objective corresponds to 704 × 704 μm–1, containing the absorption bands of proteins and lipids, was measured for each detector pixel. To calculate the absorbance of each band, a linear baseline was drawn between the minima either side of the peak and absorbance values above this line were integrated with respect to wavenumber. This enabled chemical images to be obtained .FTIR imaging data are hyperspectral datasets, with two spatial dimensions and a third spectral dimension (wavenumber); each value in the datasets is absorbance of the sample at each combination of position and wavenumber. Absorbance is related to concentration of a chemical constituent through the Beer–Lambert law, thus enabling label-free compositional analysis. In the present work, the whole mid-infrared spectrum between 4000 and 1000 cm–1 grating onto a Renishaw deep depletion CCD camera. The spectral resolution was approximately 7 cm–1. Raman maps were acquired in streamline mode with an exposure time of 55 s per laser line  with step size of 1.4 μm, in the range 2400–450 cm–1. WiRE v. 4.0 software was used for acquisition and manipulation of the data. Accurate calibration of the set-up and focus adjustment of the objective was performed before each series of measurements. Spectra were collected with the focus position 8 μm into the specimen. Cosmic ray removal was applied to each spectrum using the nearest neighbour method. Spectral maps were then analysed by Principal Component Analysis (PCA) using 10 components and spectrum centring + normalization (SNV) pre-processing. In this manner, the first principal component (PC1) corresponds to the average spectrum of the sample. Results were reported as obtained, without any further modification including baseline correction.Raman micro-spectroscopy maps were collected with a Renishaw inVia Raman microscope equipped with an 830 nm laser and a Leica long working distance 50× (NA 0.50) objective. The backscattered light from the sample was dispersed through a 600 gr mmAlternatively, when analysing the Raman maps using SOMs the cosmic rays were removed by the following method: cosmic rays were filtered from the Raman maps by applying a 3 × 3 window two-dimensional median filter to each wavenumber. For the 3 × 3 window used, the centre pixel for that wavenumber is replaced with the median value of all pixels in the window for that wavenumber. After the application of median filtering to each wavenumber, the collected Raman spectra were unfolded to create a large, two-dimensional data matrix where each row corresponds to the Raman spectrum of a single pixel and each column to a single wavenumber. At this stage the spectra were compressed using the Self Organising Maps (SOM) algorithm , mounted with fluoromount (Sigma) and imaged on a Nikon Eclipse EF-800 epifluorescence microscope. Staining was performed as previously reported;F.P. and F.T. conceived, designed and supervised the project. F.T. obtained and characterized the samples. J.C.G.J., J.H., S.M., I.S., F.P. and J.N. performed the experiments. F.P., F.T. and N.S. processed and analysed the data. J.T.B., A.D.R., J.H., J.N. and N.S. helped with the study design and discussion of the results. F.P. wrote the manuscript with input from all other authors.The authors declare no competing financial interests.Supplementary informationClick here for additional data file.


Upregulated GM-CSF levels during RT correlated with longer overall survival (OS) and progression-free survival (PFS). On the other hand, no difference in OS or PFS was seen at different IFN-γ levels. However, the “integrated factor”, computed as the combination of high pre-RT IFN-γ levels and upregulated GM-CSF, correlated with prolonged OS and PFS. Multivariate analyses revealed that GM-CSF levels and the integrated factor were both stronger independent prognostic factors than disease stage. These data demonstrate that GM-CSF levels during RT can be used as a prognostic biomarker for lung and esophageal cancer.The combination of exogenous granulocyte-macrophage colony-stimulating factor (GM-CSF) with radiotherapy (RT) has been demonstrated to strengthen the antitumor immune response. We hypothesized that the variation of GM-CSF during RT was correlated with cancer prognosis. We measured serum levels of GM-CSF and interferon- Lung cancer (LC) and esophageal cancer (EC) are both the most frequently diagnosed cancers and the leading causes of cancer death worldwide . In spitGranulocyte macrophage colony-stimulating factor (GM-CSF) is a glycoprotein mainly secreted by immune cells, fibroblasts, endothelial cells and some tumor cells . Conventγ.Radiotherapy (RT) is an established antitumor treatment. In addition to its cytotoxic effects, it also contributes to the antitumor immune response by promoting the release of tumor cell antigens such as heat shock proteins and high mobility group box 1 after tumor cell necrosis , 7. FurtA total of 126 patients (96 men and 30 women) were enrolled in this study, including 72 (57.1%) in the LC group and 54 (42.9%) in the EC group. The median age was 63 for the LC group (range: 26-81), 65 for the EC group (range: 43-86), and 64 for entire population group (range: 26-86). In the LC group, the number of patients with squamous cell carcinoma (SCC), adenocarcinoma (AC) and small cell lung cancer (SCLC) were 32, 28 and 9, respectively. Almost all EC patients were SCC histology type. There were 26 patients in the LC group and 32 in the EC group with stage II-III cancer, and 46 LC patients and 22 EC patients with stage IV cancer. In the LC group, 45 accepted concurrent chemoradiothearpy and 27 accepted radiotherapy only. On the other hand, for EC groups these numbers were 37 and 17, respectively. Baseline patient features are listed in Table γ level was 62 pg/ml for all patients, 60 pg/ml for the LC group and 62 pg/ml for the EC group. In total, 69 patients showed high IFN-γ levels during RT, 41 belonging to the LC group and 28 to the EC group. Of 57 patients with upregulated GM-CSF, 38 showed high IFN-γ levels. Of all 69 patients with downregulated GM-CSF, 38 showed low IFN-γ levels.Pre- and during RT serum GM-CSF levels were 129 ± 31 pg/ml and 127 ± 30 pg/ml for LC group, 90 ± 20 pg/ml and 93 ± 18 pg/ml for EC group, no significant difference in GM-CSF levels were observed between pre- and during RT for these two groups (p=0.477 and 0.214). In total, 57 patients showed elevated GM-CSF levels during RT, 34 of these belonged to the LC group and 23 to the EC group. The median pre-RT IFN-The median OS was 11 months for the entire population group, 11 months for the LC group and 12.5 months for the EC group. The median PFS was 7 months for all of the 3 groups. In all groups, patients with upregulated GM-CSF had longer OS and PFS than patients with downregulated GM-CSF .γ is an important effector molecule secreted by cytotoxic T cells [γ exert synergistic antitumor immune effects when combined [γ levels. However, there was no difference between patient OS and PFS when separated by IFN-γ levels . Subsequently, we performed survival analysis using the integrated factor of these two cytokines. Patients with upregulated GM-CSF and high pre-RT IFN-γ levels showed the best OS and PFS, while patients with downregulated GM-CSF and low pre-RT IFN-γ levels showed the worst OS and PFS . Survival curves are listed in Figure Because IFN- T cells  and a prcombined , we perfγ levels were an independent prognostic factor only for the entire population group, with a low predictive efficacy . Patient age, gender and treatment strategy were not associated with prognosis in any of the three groups. Detailed information is listed in Table Multivariate analysis suggested that GM-CSF levels were an independent prognostic factor for all three groups . Disease stage was also an independent prognostic factor for all three groups . Furthermore, the integrated factor was also an independent prognostic factor for all three groups . On the other hand, pre-RT IFN-9/L (0.28-3.17*109/L) in pre-RT patients and 1.405*109/L (0.26-3.47*109/L) in during-RT patients for the entire population group. However, proportions of CD4+ effector cells and regulatory T (Treg) cells were not measured. Infiltration of macrophages in irradiated patient pathological samples were not measured either. Other parameters including age, gender, disease stage, white blood cell (WBC) variation, neutrophil (NEU) variation and monocyte (MON) variation showed no correlations with GM-CSF levels. Detailed information is listed in Table In the LC and entire population groups, GM-CSF levels were correlated with lymphocyte (LYM) variation . The median LYM counts were 1.56*10γ also led to improved prognosis. Furthermore, this study described that elevated GM-CSF levels during RT predict longer PFS of the patients than those levels reduced during RT.As a basic cytokine stimulating the immune system, GM-CSF plays its therapeutic role against cancer by potentiating the antitumor effects of other molecules or treatments, such as RT , 18. TheElevated GM-CSF has been reported to act as a tumor suppressor by strengthening antigen presentation to prime tumor-specific effector T cells . Therefo+CD25+Foxp3+ Treg cells in the periphery blood in mouse models [+T effector cells and improved susceptibility of hosts to immune tolerance induction. In patients with head and neck cancers, chemoradiotherapy also resulted in decreased frequency of circulating CD4+ T cells (p < 0.002) and increased Treg cells (p ≤ 0.001) [In this study, LYM upregulation was also tumor suppressive when combined with GM-CSF upregulation during RT, acting in cooperation with the antitumor immune cycle. However, published studies indicated that influence of RT on peripheral blood T cell subset variation is complex. A low dose (2 Gy) of whole-body irradiation significantly enhanced the proportion of CD4e models . This su≤ 0.001) . When op≤ 0.001) . These fet al. showed that high circulating GM-CSF levels were associated with poor prognosis in metastatic colorectal cancer patients [et al., levels of GM-CSF produced by tumor cells correlated with improved survival in colorectal patients [γ is one of the major effector molecules, and also the major cytokine mediating the antitumor immune response [γ levels and GM-CSF levels yielded a superior predictive value than GM-CSF levels alone. This result suggests that high levels of IFN-γ can enhance antitumor immune effects in synergy with GM-CSF. However, since we only enrolled 126 subjects, expanding the number of patients in subsequent studies could further substantiate our conclusions and provide stronger validation for our statistical analyses. Nonetheless, our data demonstrated the prognostic vale of measuring GM-CSF levels during RT in unresectable LC and EC patients. We also provide a basis for utilizing immunotherapy combined with RT as an effective strategy for tumor treatment. However, excessive application of GM-CSF could induce immune suppression through activation of MDSC [GM-CSF is upregulated in many cancers and studies investigating its prognostic value are controversial. For example, GM-CSF secreted by carcinomas increased recurrence and metastasis in head and neck squamous cell cancer and breast cancer , 24. Furpatients . On the patients . Indeed,patients . Howeverpatients , 29. Ourresponse , 7, 30.  of MDSC , 29. TheFrom January 2013 to October 2015, consecutive patients who received radiotherapy at Shandong Provincial Qianfoshan Hospital were enrolled in this study. This study was performed complying with the 1975 Declaration of Helsinki and was approved by the local ethics committee of Qianfoshan hospital. Each subject signed informed consent and provided blood samples at the beginning of and during RT . All patients were diagnosed with EC or LC, with pathological or cytological evidence, and had at least one assessable tumor, which was included in the radiotherapy target volume. Only unresectable locally advanced or advanced cancer patients were enrolled in this study. Tumor stage was verified according to the 7th edition of the American Joint Committee on Cancer TNM classification system . OS was Four milliliters of blood were collected from each subject at the beginning of and during RT, and were processed within 2 h. After centrifuging at 1000 x g for 10 min, packaged serum was stored at -80 °C.γ concentrations were measured by using a solid phase sandwich ELISA kit . All samples were tested in duplicate following the manufacturer's instructions. The detection range was 100-280 pg/ml for GM-CSF and 80-480 pg/ml for IFN-γ. Blood immune cell counts were collected from medical records.Serum GM-CSF and IFN-γ levels was defined as the cutoff value and patients were separated into two groups by that value. Upregulation and downregulation of GM-CSF and IFN-γ were defined by comparison of pre- and post-RT levels of these 2 cytokines for each patient. Survival curves and analysis were performed using the Kaplan-Meier method and log-rank test. To determine the independent prognostic factor, multivariate analysis was carried out using the Cox proportional hazard model, hazard ratios (HRs) and 95 % confidence intervals (95 % CIs). Correlations between GM-CSF levels and clinicopathological variables including age, gender, stage and blood immune cell count variation for all 3 groups were analyzed by applying the Pearson χ2 test. P<0.05 was considered as statistically significant. The forest plot was generated using Stata software, version 12.0 .SPSS 19.0 software  was used to perform data analysis. Patients were separated into 3 groups: EC group, LC group and entire population group. GM-CSF levels were expressed as mean ± SD. The median value of pre-RT IFN-


Neurospecific biomarkers were elevated in pediatric tuberculous meningitis and showed an increasing temporal profile in patients who died, whereas markers of inflammation decreased in all patients regardless of outcome. Secondary injury mechanisms initiated by inflammation likely cause ongoing brain damage. Tuberculous meningitis (TBM) leads to death or disability in half the affected individuals. Tools to assess severity and predict outcome are lacking. Neurospecific biomarkers could serve as markers of the severity and evolution of brain injury, but have not been widely explored in TBM. We examined biomarkers of neurological injury (neuromarkers) and inflammation in pediatric TBM and their association with outcome.Blood and cerebrospinal fluid (CSF) of children with TBM and hydrocephalus taken on admission and over 3 weeks were analyzed for the neuromarkers S100B, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP), in addition to multiple inflammatory markers. Results were compared with 2 control groups: patients with (1) a fatty filum ; and (2) pulmonary tuberculosis (PTB). Imaging was conducted on admission and at 3 weeks. Outcome was assessed at 6 months.Data were collected from 44 patients with TBM , 11 fatty filum controls  and 9 PTB controls . Seven cases (16%) died and 16 (36%) had disabilities. Neuromarkers and inflammatory markers were elevated in CSF on admission and for up to 3 weeks, but not in serum. Initial and highest concentrations in week 1 of S100B and NSE were associated with poor outcome, as were highest concentration overall and an increasing profile over time in S100B, NSE, and GFAP. Combined neuromarker concentrations increased over time in patients who died, whereas inflammatory markers decreased. Cerebral infarcts were associated with highest overall neuromarker concentrations and an increasing profile over time. Tuberculomas were associated with elevated interleukin (IL) 12p40, interferon-inducible protein 10, and monocyte chemoattractant protein 1 concentrations, whereas infarcts were associated with elevated tumor necrosis factor α, macrophage inflammatory protein 1α, IL-6, and IL-8.CSF neuromarkers are promising biomarkers of injury severity and are predictive of mortality. An increasing trend suggested ongoing brain injury, even though markers of inflammation declined with treatment. These findings could offer novel insight into the pathophysiology of TBM. Tuberculous meningitis (TBM) is a severe form of cerebral tuberculosis leading to high rates of death and disability in children . The resQuantification of the degree of cerebral injury is inexact: Disease severity is commonly evaluated by clinical and radiologic findings. However, these have limited utility; several reversible and irreversible factors influence clinical status and imaging findings usually manifest once the damage is already permanent. Advanced tools to assess cerebral injury severity and prognosis are lacking. Inflammatory markers have been studied in TBM ; howeverThis study was approved by the Institutional Review Board of the University of Cape Town (HREC 318/2010). Informed consent was obtained from the parents/guardians of all participants.Over a 3-year period (October 2010–August 2013), study participants from the Red Cross War Memorial Children’s Hospital, Cape Town, were enrolled in this prospective study. TBM cases comprised children admitted for definite or probable TBM according to a published case definition . Cases wSamples from cases included lumbar CSF, ventricular CSF , and serum collected concurrently with clinically indicated procedures on admission and once weekly for 3–4 weeks (Supplementary Data 1). For the fatty filum controls, blood was drawn prior to surgery and lumbar CSF was taken before the dura was opened. Blood from PTB controls was taken before treatment initiation or within 48 hours thereof. Samples were stored at –80°C for batch analysis. Commercially available enzyme-linked immunoassays were used to analyze neuromarkers S100B , NSE  and GFAP (Merck Millipore) according to manufacturer instructions. Interleukin (IL) 1β, IL-1 receptor antagonist (RA), IL-6, IL-10, IL-12p40, tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), IL-8, growth-regulated oncogene (GRO), monocyte chemoattractant protein 1 (MCP-1), interferon-inducible protein 10 (IP-10), macrophage inflammatory protein 1α (MIP-1α), vascular endothelial growth factor (VEGF), and regulated upon activation, normal T-cell–expressed and secreted protein (RANTES) were analyzed on the Bio-Plex platform , using customized Milliplex kits , according to manufacturer instructions. Samples were excluded when they were taken within 48 hours after neurosurgical procedures, were not immediately refrigerated or processed within 12 hours of collection, or exhibited hemolysis or xanthochromia (NSE only) (Supplementary Data 1).As shown in the Supplementary Data 3, hydrocephalus was defined as mild , moderate , or severe . Infarcts were recorded as unilateral or bilateral, and their size was graded as single (lacunar), multiple/large (multiple or large branch infarcts), and large territory , anterior cerebral artery (ACA), posterior cerebral artery (PCA) territories). Tuberculomas were classified by number (single or multiple when >1). Scans were evaluated by 3 assessors blinded to patient outcome.U test with a Holm P value adjustment. The association between initial (admission or week 1 when no admission data were available) neuromarker concentrations and patient characteristics  was evaluated using the χ2 or Fisher exact test. The correlation between neuro- and inflammatory markers and CSF glucose, chloride, protein, and white cell count was examined using Spearman correlation. Using the Kruskal-Wallis test, findings on admission CT scan (Supplementary Data 3) were analyzed in association with initial (admission) CSF neuro- and inflammatory marker concentrations. Moreover, radiologic features overall (admission and follow-up CT/MRI) were examined in association with highest overall concentrations of the neuro- and inflammatory markers, and the change in neuromarker concentrations between admission and week 2  as an indicator of early change.Descriptive statistics were compiled for samples at each time point. Neuromarker concentrations of TBM cases were compared to controls using Mann-Whitney Outcome analysis focused on neuromarkers:U test. Various neuromarker indices including initial, highest in week 1, highest overall throughout hospitalization, and Δ were examined to control for the limitations of each individual index.Univariate analysis: The relationship between neuromarker concentrations and outcome was examined using Mann-Whitney z scores combining all 3 neuromarkers (Z-Neuro) or all 14 inflammatory markers (Z-Inflammatory) for each patient were derived as a statistical approximation of a single index for neurological injury or inflammation; time was added to this analysis to generate 3-dimensional PCA biplots, and mortality was indicated on the plot (Supplementary Data 2).PCA: Receiver operating characteristic (ROC) analysis: ROC curves were constructed to identify the thresholds of highest S100B, NSE, and GFAP as well as ΔS100B, ΔNSE, and ΔGFAP, which best predicted outcome.Multivariate analysis: Logistic regression models for poor outcome were constructed for ΔZ-Neuro, ΔS100B, ΔNSE, and ΔGFAP as these indices demonstrated the strongest outcome association on univariate analysis. Covariates were drawn from admission and radiologic characteristics, which were significantly associated with clinical outcome .Forty-four TBM cases  were enrolled . The culDescriptive statistics for neuromarkers for each time point are shown in P < .05). Neuro- and inflammatory markers were not significantly associated with CSF glucose, chloride, protein, or white cell count.Neuromarker concentrations were not significantly associated with patient demographic or admission characteristics. Only lumbar GFAP was significantly more elevated in patients who were culture positive  or no infarcts on their admission scans .The highest lumbar GFAP and S100B concentrations were greater in moderate-to-severe than in mild hydrocephalus  and large infarcts compared to small ones . Highest ventricular GFAP and NSE were also positively associated with larger infarcts . Lumbar GFAP and NSE concentrations increased from admission to week 2 in patients with infarcts , particularly with large infarcts relative to small . Similarly S100B concentrations increased in patients with larger infarcts (P = .01). Highest lumbar and ventricular GFAP were associated with multiple tuberculomas . No association was demonstrated between neuromarkers and spinal disease.The highest lumbar GFAP and NSE were associated with multiple (P = .04), IP-10 (P < .01), and MCP-1 (P = .02). Bilateral infarcts were positively associated with highest lumbar and ventricular CSF TNF-α , MIP-1α , and IL-6  and IL-8  concentrations , and an increasing trend was significantly predictive of mortality and 6-month outcome   and 6-month outcome (P = .01 and P = .01), and highest overall with mortality (P = .02). Highest lumbar NSE overall and an increasing trend were predictive of mortality  and 6-month outcome . All ventricular NSE indices were strong predictors of mortality and 6-month outcome (P ≤ .01). Highest lumbar GFAP overall and an increasing trend were associated with mortality . Ventricular GFAP was not a predictor of mortality or outcome.The highest lumbar S100B concentrations recorded in week 1 and overall were associated with outcome at 6 months (ctively) . InitialPCA plots of the temporal profile of combined neuromarkers (Z-Neuro) illustrated that neuromarker concentrations in the lumbar CSF decreased over time in patients who survived, but increased in those who died . For neuAn increase in neuromarker concentrations from admission to week 2 predicted mortality with the best combination of sensitivity and specificity ; in partP = .02) and 9 times greater per-unit increase in ΔS100B . Patients with an increase in ΔNSE and ΔGFAP had only slightly higher odds of death  and , respectively. Covariates included in the models were British Medical Research Council staging, symptom duration, age, sex, human immunodeficiency virus status, fever, seizures, culture positivity, hydrocephalus severity, and tuberculomas. Infarcts could not be added because they perfectly predicted death. Only the inclusion of seizures and tuberculomas altered these models (results shown in P = .02), and only slightly higher in patients with an increase in ΔNSE . These relationships were not affected by clinical, admission, or radiologic characteristics.An increase between admission and week 2 in S100B, NSE, GFAP, and Z-Neuro all demonstrated associations with death in multiple logistic regression models . The oddThis study demonstrated the prolonged elevation of CSF S100B, NSE, and GFAP and their association with poor outcome, in particular when they increased over time. These markers may help elucidate the causes of progressive injury in these patients. Neither neuro- nor inflammatory markers were elevated in serum, suggesting that serum reflects little of the injury in the CNS, and that the immune response is compartmentalized to the site of disease. Elevated inflammatory markers in the CSF decreased in all patients regardless of outcome.The highest CSF neuromarker concentrations were observed in the ventricular CSF, consistent with their cerebral origin. Lower lumbar concentrations were likely due to degradation by proteinases as CSF flows down the rostrocaudal gradient of the brain–spine axis . HoweverSerum neuromarker concentrations were low. Various factors may determine the concentration of brain-derived proteins in the blood, including their intrathecal concentration, response to pathology, diffusion across the blood–brain and blood–CSF barrier, and half-life in the blood. S100B, NSE, and GFAP are detectable in the blood early after traumatic brain injury or stroke ; howeverNeuromarker concentrations were not associated with spinal disease, possibly because neuromarkers of spinal origin may be masked by larger concentrations of cerebral origin. The association between severity of hydrocephalus and high GFAP and S100B concentrations suggests that these markers may be sensitive to transient injury due to the mechanical effect of dilating ventricles on the parenchyma, often accompanied by the opposing pressure from brain edema , 31. TheThe association between high initial concentrations of ventricular CSF IFN-γ and TNF-α with mild enhancement and an absence of infarcts on admission scan may represent the early phases of the inflammatory process. In this cohort, tuberculomas and infarcts were negatively correlated, and tuberculomas were predictive of survival whereas infarcts were predictive of death . This maIncreasing neuromarker concentrations in CSF was the best indication of poor outcome, especially ΔS100B, suggesting that cerebral injury in TBM continues to evolve in some patients and leads to poor outcome despite the initiation of anti-TB and steroid treatment. The associated decreasing trend of inflammatory markers in patients who died suggests that it may be less an ongoing immune response that is responsible for the progressive brain injury associated with TBM, and more the secondary pathological processes that are initiated by the inflammatory process and continue to cause tissue injury. These processes may include biochemical and inflammatory mechanisms of secondary brain injury. This highlights the need for not only anti-TB and immunomodulatory drugs, but also better brain protection. More evidence of specific pathophysiological processes leading to an increase in neuromarkers is needed to direct brain management appropriately. If these processes are associated with brain ischemia, simple interventions such as more aggressive treatment of ICP, augmentation of blood pressure, and supplemental systemic oxygenation may improve oxygenation of the brain. Ongoing studies of pharmacological intervention in other forms of brain injury  may be aNeuromarkers have predictive potential, either as point in time measures or, more particularly, over time. The profile over time may also be valuable in evaluating response to novel interventions. Ventricular CSF neuromarker concentrations appeared to be more predictive than lumbar CSF, likely because they arise from the predominant site of injury. In the resource-limited setting, assessment of injury may rely on a single marker; S100B is promising—an increase between admission and week 2 was associated with infarct severity and also strongly predicted mortality.The sample size was modest and the age range too variable to adequately compare cases with age-matched controls; however, the role of age in normative biomarker concentrations remains contentious and there is no clear indication of how age influences normal ranges . More frNeuromarkers in the CSF of patients with TBM provide insight into ongoing cerebral injury and prognosis. They may help direct limited resources and act as surrogate markers for the efficacy of novel interventions. Treatment or injury thresholds should be established for the ventricular and lumbar CSF compartments. Serum is uninformative for examining cerebral inflammation and injury. The peak of inflammation likely occurs early and decreases on treatment. Further examination of the secondary injury processes initiated by the inflammatory process is needed.Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at Supplementary MaterialClick here for additional data file.


Low back pain and neck-shoulder pain are the most reported types of work-related musculoskeletal disorders, and performing heavy lifting at work and working with trunk rotation increase the risk of developing work-related musculoskeletal disorders. Surface electromyography (sEMG) provides information about the electrical activity of muscles. Thus it has the potential to retrieve indirect information about the physical exposure of specific muscles of workers during their actual work. This study aimed to investigate the inter-day reliability of absolute and normalized amplitude of sEMG measurements obtained during repeated standardized reference lifts.3,K), standard error of measurement (SEM) and minimal detectable change in percent (MDC).The inter-day reliability of sEMG of the erector spinae longissimus and trapezius descendens muscles was tested during standardized box lifts. The lifts were performed with loads of 3, 15 and 30 kg from floor to table and from table to table in three conditions, i.e., forearm length (short reaching distance), ¾ arm length (long reaching distance) and forearm length with trunk rotation. Absolute and normalized root mean square (absRMS and normRMS) values were extracted. In line with the guidelines for reporting reliability and agreement studies, we reported relative and absolute reliability estimated by intra class correlation  were similar. A total of 50 out of 56, i.e., 89%, and 41 out of 56, i.e., 73%, of the lifting situations were in the range from moderate to almost perfect for absRMS and normRMS, respectively. The SEM and MDC shoved more variation in the lifting situations performed from floor to table and in the trapezius descendens muscle than in the erector spinae longissimus muscle.The ICCThis reliability study showed that maximum absRMS and normRMS were found to have a fair to substantial relative inter-day reliability for most lifts but were more reliable when lifting from table to table than from floor to table for both trapezius descendens and erector spinae muscles. The relative inter-day reliability was higher for absolute compared with normalized sEMG amplitudes while the absolute reliability was similar. Low back pain and neck-shoulder pain are the most reported types of work-related musculoskeletal disorders in the construction industry  and are During recent years, the technological development has allowed measurements outside the laboratory environment of physical exposure  during the actual working day –13. SurfThe present study aimed to investigate the inter-day reliability of the absolute and normalized amplitude of sEMG measurements obtained during repeated standardized reference lifts. For that purpose, we conducted a study among healthy male subjects testing the inter-day reliability of absolute and normalized root mean square (RMS) values of sEMG recordings during standardized reference lifts in a laboratory environment. The presentation of this reliability study follows the guidelines for reporting reliability and agreement studies (GRRAS) . Of noteTwenty healthy male participants volunteered to participate in the study at Aalborg University, Denmark. Three participants were excluded due to technical problems  with the sEMG equipment. Table In accordance with the Helsinki Declaration, all participants were informed about the objective and the procedures of the study before providing written informed consent to participate. The study was approved by the North Denmark Region Committee on Health Research (N-20160023).All participants attended two sessions with an interval of 13.8 ± 1.1 days to test the inter-day reliability of sEMG measurements during lifting tasks. Prior to and after the lifting tasks, the subjects performed three bilateral isometric MVCs for the trapezius and erector spinae muscles with 1-2 min of rest in between. For the trapezius muscle, the subject performed 90° shoulder abduction against static resistance from the test leader. For the erector spinae muscle, the subjects lay prone with the nose facing the floor on a customized back extension apparatus supporting the subjects’ legs and raised the body from the floor . The sublifting 3, 15 and 30 kg with forearm length reaching distance (short reaching distance), i.e., the length from body center of mass to the center of mass of the box corresponding forearm length, while moving the feet and without rotation of the trunk Fig. .lifting 3 and 15 kg with a ¾ arm length reaching distance (long reaching distance) while moving the feet and without rotation of the trunk Fig. .lifting 3 and 15 kg with a forearm length reaching distance with trunk rotation and without moving the feet Fig. .The subjects lifted a box  with a The weights were determined on the basis of the recommendations made by The Danish Working Agency . Familiahttp://www.seniam.org/) and the standard for reporting sEMG (http://www.isek.org/emg-standards/). All electrodes were placed by the same experienced test leader on both test days. The test leader had experience with the procedure of placing electrodes and was careful to palpate the anatomical landmarks to ensure the correct placement according to the SENIAM guidelines (http://www.seniam.org). Bipolar sEMG electrodes  (skin contact size 30 * 20 mm) were placed longitudinally to the muscle fibers with an inter-electrode distance of 2 cm [12 Ω, CMRR: 100 dB, Nexus10, Mind Media, Netherlands). sEMG recordings were analyzed in Matlab  using a custom-made program. The sEMGs were digitally filtered . Figure max, was obtained for each MVC repetition and then the highest RMS value of the three repetitions was extracted and used for reliability and normalization purposes [The placement of surface electrodes and the recording of the sEMG followed the SENIAM guidelines  were used to comparing RMSThe absRMS and normRMS values are presented in Tables max values for the right and left trapezius were 812 mV (± 360 mV), 747 mV (± 360 mV) and 804 mV (± 442 mV), 699 (± 437 mV) on day one and two, respectively. For the right and left erector spinae the values on day one and two were 311 mV (± 136 mV), 311 (± 97 mV), 324 mV (± 139 mV) and 305 (± 96 mV), respectively. No significant difference was found between day one and day two (P > 0.66). The Pearson’s r values were −0.39, −0.34, 0.20, and −0.17 for the right trapezius, left trapezius, right erector spinae and left erector spinae, respectively . In an sEMG context, the relative reliability can express the degree at which participants maintain their ranking of the level of muscle activation during repeated measurements. The absolute reliability corresponds to the degree to which repeated measurements vary for participants . ConsequVCs Fig. . The facIn the present study, the different lifting conditions influenced the reliability of the sEMG measurements. In general, the highest relative reliability was found for lifting from table to table, e.g., for the erector spinae muscles the ICCs were generally above 0.61 (except one) corresponding to at least moderate reliability . HoweverIn general, the ICCs for the right trapezius muscle in this study were in line with a previous study measuring the sEMG of the trapezius during MVCs in several positions . For theThe loads lifted, i.e., 3, 15 and 30 kg, did not markedly influence the reliability of the sEMG measurements Tables . This isThe absolute reliability of the absRMS and normRMS depicted by SEM% values ranged from 8.94 to 38.61% and from 10.15 to 27.69%, respectively, for the erector spinae muscles and from 20.58 to 68.89% and from 29.26 to 70.44% for the trapezius muscles  The test leader always lowered the box to the starting position and therefore there was no eccentric phase with the external load during the lifts. 2) We aimed at applying the approach in a participative ergonomic intervention. In this randomized controlled trial, we wished to detect the working situations with the highest physical loading regarding high muscular activity based on an entire working day of recordings . FurtherThe recording and processing of the sEMG followed the SENIAM guidelines and ISEK recommendations, and all measurements were carried out by the same experienced test leader. However, we cannot reject some variation with respect to placement of electrodes. This issue is inevitable and common in longitudinal studies. Furthermore, we only recorded sEMG from erector spinae and trapezius. Even though the experimenter checked the quality of all lifts, visually detecting differences in movements and lifting velocity between the different lifts, days and subjects can be difficult. This was especially the case when the lifts were performed with light loads, which are inherently more prone to faster movements. In this study, the participants performed test trials of the lifts before recording the trials, but an entire familiarization session before the actual test day might have increased the reliability. We selected healthy male participants to ensure a homogenous group as workers often report pain , 44 knowThis reliability study showed that maximum absRMS and normRMS were found to have a fair to substantial relative inter-day reliability for most lifts but were more reliable when lifting from table to table than from floor to table both for trapezius descendens and erector spinae muscles. The relative inter-day reliability was higher for absolute compared with normalized sEMG amplitudes while the absolute reliability was similar. In addition, normRMS was more reliable for the erector spinae muscles than for the trapezius descendens muscles.


The purposes of this study were to evaluate the association between total testosterone (TT) deficiency and weakness on multimorbidity in men. Analyses were performed to examine the prevalence of multimobidity among young, middle-aged, and older men, with and without testosterone deficiency. Multivariate logistic models were also used to determine the association between age-specific TT tertiles and multimorbidity, adjusting for key sociodemographic variables, as well as a secondary analysis adjusted for grip strength. Multimorbidity was more prevalent among men with testosterone deficiency, compared to normal TT in the entire group ; however, differences were only seen within young  and older men . Robust associations were found between the age-specific low-TT  and moderate-TT  tertiles (reference high-TT) and multimorbidity. Secondary analysis demonstrated that both low TT  and moderate-TT  were associated with multimorbidity, even after adjusting for obesity  and NGS (OR: 1.21 per 0.05 unit lower NGS). Low TT and weakness in men were independently associated with multimorbidity at all ages; however, multimorbidity was more prevalent among young and older men with testosterone deficiency. Recent studies have also suggested that testosterone deficiency is independently and robustly associated with various obesity-related chronic diseases in men, including type 2 diabetes and cardiovascular disease11. However, there is uncertainty as to what constitutes optimal physiological levels of TT among men across different age categories, and to the effects that varying TT levels have on disease risk12. This debate is partially fueled by inconsistent findings in the literature and differences across expert clinical recommendations, as well as an incomplete understanding of the underlying mechanisms and temporal sequence of events leading to and stemming from testosterone deficiency. For example, the authors of a well-known systematic review assert that although testosterone deficiency is robustly associated with obesity, insulin resistance, low high-density lipoprotein (HDL) cholesterol and elevated triglycerides, low-density lipoprotein (LDL) cholesterol, and plasminogen activator type 1, there is insufficient evidence to demonstrate a causal role of endogenous testosterone deficiency on coronary artery disease13-the leading cause of preventable death among men in the U.S14.The prevalence of total testosterone (TT) deficiency in men increases with age15. That investigation effectively defined “normal ranges” for TT levels in young healthy men, which may help limit misdiagnosis of testosterone deficiency. However, those ranges were derived from non-nationally representative pooled data across cohorts that do not reflect the growing, ethnically-diverse U.S. population, and in which individuals with several morbid conditions were excluded. Therefore, the primary purpose of this study was to evaluate the association between TT deficiency and prevalent chronic multimorbidity in a large, population-representative sample of U.S. men. We also sought to determine a dose-response trend by examining the effect of age-specific TT tertiles on multimorbidity.Harmonized reference ranges for TT were recently established by combining cohort studies in the U.S. and EuropeThe National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The 2011–2012 NHANES survey was chosen based on the wealth of relevant information pertaining to chronic diseases, total testosterone, and direct measures of muscle strength capacity. The analyses were performed in 2016–2017. This survey is unique in that it combines interviews and physical examinations; however, not all participants in the physical exam are included. Of the 2,399 men in the 2011–2012 NHANES survey who were at least 20 years old, 2,161 had complete data for (1) demographic and anthropometric information; (2) valid questionnaire data pertaining to chronic disease diagnoses ; (3) the necessary blood samples obtained for serum TT determination; (4) valid strength data from a handgrip dynamometer; and (5) the necessary examination or laboratory assessments for cardiometabolic disease risk factors. Ethical approval was obtained through the National Center for Health Statistics (NCHS) Research Ethics Review Board (Protocol #2011-17). All procedures followed were in accordance with the ethical standards of the NCHS Research Ethics Review Board, and with the Helsinki Declaration, and informed consent was obtained from all patients included in the study.Socio-demographic characteristics were self-reported during the in-home interview. Age was used as a categorical variable as (1) 20–39.9 years, (2) 40–59.9 years, and (3) ≥60 years old. Race/ethnicity was categorized as: (1) non-Hispanic white, (2) non-Hispanic black, (3) Mexican American or other Hispanic, and (4) Other-including multi-racial. Education was categorized as: (1) less than high school graduate, (2) high school graduate/general educational development (GED) or equivalent, and/or some college or Associate’s degree, and (3) college graduate or above. Marital status was dichotomized as married or not married. Annual household income was categorized as: (1) ≤$24,999, (2) $25,000-$54,999, (3) $55,000-$74,999, and (4) ≥$75,000.2). Standard categories were applied to determine if each participant was obese (≥30 kg/m2). Individuals with BMI <18.5 kg/m2 were excluded, due to the known association between underweight status and chronic disease risk16. Waist circumference was measured to the nearest 0.1 cm at the level of the iliac crest. Standard cut points for abdominal obesity in men (>102 cm) were used.Weight was measured using a digital Toledo scale , and participants only wore an underwear gown and foam slippers. Height was measured using a fixed stadiometer. BMI was calculated as weight in kilograms divided by height in meters squared , stroke, pulmonary disease (emphysema), hypertension, and clinical depression. Clinical depression was dichotomized as a score of ≥10 on the 9-item Patient Health Questionnaire. Scores of 10 or higher have high sensitivity and specificity for identifying major depression in a primary care settinghttps://wwwn.cdc.gov/nchs/data/nhanes/2011-2012/manuals/2011-12_Laboratory_Procedures_Manual.pdf). Resting systolic and diastolic blood pressures were measured three to four times with a mercury sphygmomanometer by trained staff. Fasting and non-fasting measures of HDL-cholesterol, triglycerides, and glucose were measured. Non-fasting serum measures of glycated hemoglobin (HbA1c) were included as a diagnostic test for untreated diabetes, which reflects average plasma glucose for the previous ~three-months.In addition to the aforementioned self-reported health conditions, participants were tested on routine cardiometabolic parameters with physical examination and laboratory assessments. Detailed descriptions of the laboratory protocols are provided in the NHANES Laboratory Procedures Manual 18. Participants with diabetes that were being treated with only insulin alone were excluded, as they were considered likely to have type 1 diabetes. Hypertension was defined as self-reported history of hypertension , a systolic blood pressure ≥140 mmHg, or a diastolic blood pressure ≥90 mmHg. Hypertriglyceridemia was determined as ≥150 mg/dL, and low HDL-cholesterol was determined as <40 mg/dL and <50 mg/dL for men and women, respectively.The diagnostic criterion for diabetes was defined as self-reported diabetes, elevated fasting glucose (≥126 mg/dL), 21, and availability and reliability of the diagnosis within our clinical data.Multimorbidity was defined as the presence of at least two chronic conditions among a list of the nine aforementioned self-reported chronic diseases or examination/laboratory cardiometabolic abnormalities . These conditions were selected in accordance with guidance from the literature pertaining to older adults and adults with disabilitieshttps://www.cdc.gov/nchs/data/nhanes/nhanes_11_12/tst_g_met.pdf). Testosterone deficiency was categorized as <300 ng/dL (10.4 nmol/L)22. Age-category-specific TT tertiles were created for use in the logistic regression analyses, as the: (1) highest TT tertile ; (2) medium TT tertile ; and lowest TT tertiles .TT levels were measured in serum using isotope dilution liquid chromatography tandem mass spectrometry by the National Center for Environmental Health, Centers for Disease Control and Prevention. This method employed LLE extractions of serum to isolate the steroid. Stable Isotope-labeled testosterone is used as an internal standard to correct for sample recovery during the sample preparation process. The assay imprecision is 5% and the method is traceable to an established higher-order testosterone reference method  as strength per body mass.Muscle strength was assessed using a hydraulic handgrip dynamometer . Detailed descriptions of the protocol are provided in the NHANES Muscle Strength/Grip Test Procedure ManualAll statistical analyses were performed using SAS 9.3 . NHANES employs a multistage sampling design. Sample weights were used to adjust for oversampling, survey nonresponse, and post-stratification. Further, we took into account subsample weights since we conducted analyses on persons with non-fasting glucose measure. These weights were used to produce unbiased estimates. To obtain correct variance estimation, information on strata and primary sampling unit (PSU) were also utilized. Differences in these characteristics across age categories and for testosterone deficiency were tested using linear regression (proc surveyreg) and logistic regression (proc surveylogistic) for continuous and categorical variables respectively, after creating appropriate categories and dummy coding for each. Partial correlation statistics were conducted to examine the association between TT and NGS, while adjusting for age, race/ethnicity, education and household income.To assess the odds of multimorbidity in the entire sample, we utilized the univariate and multivariate logistic regression modeling approaches. For model 1, only age-category-specific TT tertiles were entered as the primary exposure variable (reference: High TT tertile). For model 2, further adjustments for known demographic covariates, including age categories, race, education, annual income, and marital status, were included in each model. Lastly, in order to examine whether the association between TT and multimorbidity was explained in whole or part by obesity or NGS capacity, a third model was performed including (1) age-category-specific TT tertiles; (2) all sociodemographic variables; (3) obesity status; and (4) NGS (with units set to 0.05).https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?BeginYear = 2011.All data are publically available and were obtained through the CDC’s National Health and Nutrition Examination Survey website: and older men. Absolute grip strength and NGS were both significantly lower across higher age categories (p < 0.001). Moreover, TT was highest among young men (p < 0.001); however, there were no differences in TT between middle-aged and older men.The descriptive data of all 2,399 men are presented across age categories in Table For the full sample, the mean number of chronic disease risk factors was 1.5 ± 1.3, with hypertension as the most prevalent individual condition (48.6%), followed by hypertriglyceridemia (28%), low HDL-C (26.8%), arthritis (19.7%), diabetes (17.9%), clinical depression (7.4%), CVD (7.2%), stroke (4%), and pulmonary disease (2.5%).The prevalence of multimorbidity was 41.3% for all men; however, there was a significant age association (p < 0.001). For young, middle-aged, and older men, the prevalence of multimorbidity was 17.4%, 44.2%, and 65.3%, respectively. Of the 502 total possible combinations of multimorbidity, we found 58 unique multimorbidity combinations, and the most prevalent combinations were: (a) hypertension and arthritis (n = 107); (b) hypertension and low HDL-C (n = 103); (c) diabetes and hypertension (n = 86); (d) hypertension and hypertriglyceridemia (n = 50); hypertriglyceridemia and low HDL-C (n = 47); and diabetes, hypertension, and arthritis (n = 42).Prevalence of testosterone deficiency (<300 ng/dL [10.4 nmol/L]) was 30.8% for the entire sample, and 22.6%, 35.8%, and 34.6% for young, middle-aged, and older men, respectively. Significant higher prevalences of individual chronic diseases were found between men with testosterone deficiency as compared to men with normal TT (Table Both TT and NGS were robustly associated with multimorbidity (p < 0.001). Secondary analysis demonstrated that TT was significantly correlated to NGS  Fig. , even af24. The dose-response trend we observed remained significant even after adjusting for grip strength, a known, robust predictor of chronic disease and early mortality in men26. Similarly, others have reported reduced all-cause and cardiovascular mortality accompany each 1 standard deviation, or 1 nmol/L, incremental increase in TT, even for men in the eugonadal range27. Further, a large meta-analysis of observational studies  reported a 55% higher all-cause mortality  for studies with baseline TT ≤ 487 nd/dl7, suggesting a threshold for increased mortality that is very near our TT cutoffs for the highest age-category-specific tertiles.The principal findings of this study were that TT deficiency was robustly and independently associated with multimorbidity in a large population-representative sample of U.S. men. Moreover, there was strong evidence supporting a dose-response trend for TT and multimorbidity risk. Specifically, the lowest age-category-specific TT tertile and the middle age-category-specific TT tertile were associated a >3-fold and nearly 75% higher multimorbidity risk, when compared to the highest age-category-specific tertiles of TT. Our results support the findings of several other large population-based prospective studies that indicate increased all-cause mortality and cardiovascular risks in both young and older men within the lowest ranges of TT, in comparison to men in the highest15. This is very likely due to (1) the previous cohort populations, which were mainly men identified as white; (2) exclusion of ~5% of men who exhibited pituitary, testicular or adrenal disease, or who used medications that affect sex-steroid production from the European Male Aging Study, and those with BMI >30 kg/m2 from the Belgium Siblings Study of Osteoporosis15; and (3) the lack of adjustment for important sociodemographic factors such as race/ethnicity, income, education, and marital status. Moreover, the recently published harmonized 2.5th, 5th, 50th, 95th, and 97.5th percentiles were 264, 303, 531, 852, and 916 ng/dL, respectively, for healthy, non-obese men aged 19–39 years. Currently used cutoffs to diagnose TT deficiency (<300 ng/dL [10.4 nmol/L]) would therefore correspond with the 5th percentile of the reference range; however, in our study the 5th percentile among young men aged 20–39 corresponded with a TT of 182 ng/dL.We have also uncovered interesting age disparities in testosterone deficiency and multimorbidity prevalence in our population-representative sample of U.S. men. Specifically, there was a much lower median TT in the youngest age category of men from our study (419 ng/dL), as compared to previous clinical cohort studies which harmonized TT reference ranges from healthy, non-obese men of the same age (533 and 529 ng/dL)28.Moreover, multimorbidity was significantly more prevalent among men with testosterone deficiency, compared to normal TT in the entire group (36.6% vs 55.2%); and yet, these differences seem to have been largely driven by differences in multimorbidity for young and older men. Despite strong evidence of worse chronic disease risk profiles among middle aged men with testosterone deficiency, as compared to middle-aged men with normal TT, the differences in multimorbidity were not statistically different. Collectively, this demonstrates the importance of screening TT among young men, particularly those with existing obesity, diabetes, cardiovascular disease, hypertension, clinical depression, low HDL cholesterol, or hypertriglyceridemia, as each of these conditions were significantly higher in those with testosterone deficiency. This is in accordance with the 2016 American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) Comprehensive Clinical Practice Guidelines for Medical Care of Patients with ObesityIn patients with multimorbidity, early detection can guide treatment as well as slow progression, or potentially halt disease processes entirely. In this study, among young men there was a strong association between low testosterone and multimorbity. It is unlikely that end-stage disease was responsible for this finding, and thus it can be hypothesized that low testosterone may play an early, causal role in chronic disease processes. This warrants further research as it could change screening guidelines for testosterone deficiency, as well as have a significant impact on the rates of disease processes such as hypertension and diabetes in men.29 (even though the study has received criticism primarily due to relatively poor classification of cardiovascular events30), and the findings of two large retrospective studies indicated increased cardiovascular disease risk in men receiving TRT32. While these findings raised initial concerns about cardiovascular safety of TRT, the aforementioned retrospective studies have received extensive scientific criticism33 and calls for retraction from numerous medical societies34. Moreover, they remain at odds with data from several recent meta-analyses that indicate TRT does not increase cardiovascular events in hypogonadal men37, and with findings of a very large retrospective study  that indicated TRT was associated with a 56% lower propensity matched all-cause mortality  and 24–36% lower stroke risk  and MI risk , in comparison to untreated hypogonadal men38. It is also important to note that the recently published NIH-funded T-trials found no differences in cardiovascular-related or other adverse events among men receiving TRT vs placebo39, and there is also recent evidence that TRT is associated with lower mortality rates among diabetic men40.Not surprisingly, nearly all research related to the influence of testosterone deficiency to potentiate risk for secondary muscle and metabolic dysfunction in men has been conducted within an aging-related context. However, the underlying changes in hormonal and metabolic dysregulation leading to multimorbidity should be regarded as a gradual continuous process throughout the lifespan, rather than a discrete outcome or event. Thus, further evaluation of the temporal sequence of these consequences is of particular importance not only for screening efforts to reduce chronic disease, but also for informing early, targeted interventions to treat declining TT or testosterone deficiency in men. In this regard, debate surrounding the cardiovascular safety of testosterone replacement therapy (TRT) persists because the Testosterone in Older Men with Mobility Limitations (TOM) trial was discontinued due to a higher prevalence of cardiovascular-related events in the TRT vs placebo groups41, and that weakness is a known predictor of chronic disease and early mortality, our findings reveal an independent effect of muscle weakness and lower TT on risk for multimorbidity. Future research is needed to better understand the independent and joint effects of low TT and muscular weakness in young adulthood as a risk exposure for multimorbidity tracking into/throughout middle-age and older adulthood.Interestingly, despite that TT and muscle strength are known to be highly associated in menThe design of this study was limited by the cross-sectional design of NHANES, which posed challenges in causal inference, especially with respect to reverse causation. Thus, we are unable to deduce whether low TT leads to higher odds of multimorbidity, or conversely, whether poor chronic health profiles lead to declines in TT levels. Moreover, we were unable to determine if other competing risks or unmeasured confounding  may have influenced the observed estimates. Future longitudinal studies are needed to better understand how declines in TT contribute to unhealthy aging, as well as the extent to which other chronic conditions  may mediate the association between low TT, and multimorbidity and mortality. Third, we did not have access to sex hormone-binding globulin or free testosterone for these men, and thus we could not determine the differential contribution of these compared to TT for prediction of multimorbidity across the age spectrum. Lastly, we found no statistical differences in TT and testosterone deficiency between middle aged and older men, a finding that might be due to an underrepresentation of institutionalized older men.Our results suggest a much higher prevalence of testosterone deficiency occurs in men across the adult age-span than what has been previously reported, and that young and elderly men with testosterone deficiency exhibit a significantly higher multimorbidity risk than their eugonadal counterparts.


Accurate and early diagnosis of neurocysticercosis (NCC) remains a challenge due to the heterogeneity of its clinical, immunological and imaging characteristics. The presence of cysticercus DNA in cerebrospinal fluid (CSF) of NCC patients has been previously detected via conventional PCR assays. To the best of our knowledge, the use of CSF Next-Generation Sequencing (NGS) based pathogen analysis in patients with NCC infection has never been reported.Taenia solium-DNA. This finding was confirmed by a positive reaction to CSF cysticercosis antibodies. After antiparasitic treatment, secondary CSF NGS revealed the DNA index have dropped considerably compared to the initial NGS readings.This study reports the clinical, imaging, and immunological features of a patient initially presenting with several months of headache who further developed a pure sensory stroke. NGS was used to detect the pathogen, and her CSF demonstrated the presence of NGS is a promising tool for the early and accurate diagnosis of central nervous system (CNS) infection, especially in the setting of atypical clinical manifestations. Further studies are required to evaluate the persistence of DNA in the CSF of patients. Taenia solium [T. solium DNA in cerebrospinal fluid (CSF) via NGS.Neurocysticercosis (NCC) is caused by infection of the human central nervous system (CNS) with the larval stage of a solium . The clia solium . Ischemia solium . While aa solium . Here, w2O. Viral encephalitis was suspected and she received acyclovir intravenously (500 mg Q8H for 7 days), but symptoms showed no signs of relief.A 44-year-old female factory worker presented to our clinic complaining of a 1 year history of repeated, temporal and parietal headache characterized by bursting sensations. She had previously presented to a local hospital 6 months prior, in April 2016. The patient’s initial brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) were normal. CSF studies revealed 68 white cells per microliter and a pressure of 310 mmHThe patient visited the local hospital again 3 months later, in July 2016, complaining of an aggravated headache and paroxysmal numbness of her left face and arm. She was diagnosed with an ischemic stroke of the right thalamus and administered oral aspirin 100 mg and atorvastatin calcium 20 mg daily Fig. . Her num2O, white cell count of 40 per microliter, and a protein level of 1171 mg/L. Cerebral magnetic resonance venography (MRV) revealed underdevelopment of her right lateral sinus and sinus thrombosis was considered as a possible etiology. She was treated with low molecular heparin and her headache was slightly relieved. She was then admitted to our hospital for further treatment.She visited the local hospital for the third time 5 days prior to presenting to our hospital due to the severity of her headache on October 26, 2016. Lumbar puncture was remarkable for a CSF pressure greater than 400 mmHThe patient had no significant past medical history, denied a history of blood transfusions and consumption of raw food. Her physical examination was unremarkable, and no abnormal neurologic signs apart from horizontal nystagmus was noted.Mycobacillus Tuberclosis and Latex agglutination test for the cryptococcal capsular antigen were all negative. She underwent three lumbar punctures after admission to our clinic and results revealed a high intracranial pressure and an increased white cell count  while other indices were within normal limits. HIV, syphilis, and Herpes simplex virus-1 and 2 antibodies were absent. In addition, the T-Cell spot test, purified protein derivative test for Echinococcus granulosus. Review of the patient’s previous imaging records revealed several additional anomalies: her pulmonary CT revealed multiple densities in chest wall soft tissue  revealed the arterial system to be normal and confirmed dysplasia of the right lateral sinus Fig. . Cerebrasue Fig. , and hersue Fig. . A diagnsue Fig. . She undCSF was collected via standard procedures. DNA was extracted from 300 μL CSF samples using the TIANamp Micro DNA Kit  and sonicated to a size of 200–300 bps fragments (Bioruptor Pico protocols). DNA libraries were then constructed via end-repaired adaptation added overnight and application of polymerase chain reaction (PCR) amplification to extracted DNA. An Agilent 2100 Bio-analyzer  in combination with quantitative PCR was utilized to quantify DNA libraries. Sequencing was performed using the BGISEQ-100 platform  .http://soap.genomics.org.cn). A control sample from a non-infected patient was obtained and subjected to the aforementioned procedures. The DNA of CSF samples before and after drug treatment was extracted to construct a complementary DNA (cDNA) library for sequencing. The number of reads from the cDNA library of the patient’s CSF was 37,781,754 (before drug treatment) and 19,043,412 (after drug treatment) respectively. Those of the control sample were 25,962,600. As a result of pathogen detection, T.solium was identified as the most predominant parasite with 3.495% coverage of the T.solium genome in the first detection; however this reduced to 0.078% in the second detection after specific drug therapy. No reads of T.solium were detected from control samples. Reads of viruses were also detected in the CSF samples, later identified as human herpesvirus 4 (HHV-4). After drug therapy, the number of HHV-4 reads decreased approximately 20-fold. The results of CSF NGS prior to and after praziquantel therapy are shown in Table Most high-quality sequencing data were generated and computational subtraction of human host sequences was performed using a Burrows- Wheeler Alignment tool . RemainiT. solium infection in a patient with neurocysticercosis (NCC) who presented with several months of headache and paroxysmal left face and arm numbness.To our knowledge, this is the first reported case in which NGS was used to detect Mycobacillus Tuberclosis) and cryptococcus, however, were negative. The CSF NGS revealed several possible pathogens including HHV-4. Also known as Epstein-Barr virus (EBV), HHV-4 is one of the most common human viruses. EBV is able to persist in B lymphocytes of the host for life, but in the vast majority of healthy carriers the virus generally causes no disease [Trichinella zimbabwensis and Echinococcus granulosus, their coverage were very low, and T. zimbabwensis was scarcely reported of causing disease in China. The further CSF parasite antibodies detection confirmed cysticercal antibody positivity but not for the echinococcosis antibody, thus T. zimbabwensis and E. granulosus were not considered as the pathogen in our case. NCC was then finally diagnosed.Initially, extensive investigations using brain MRI and cerebral MRA did not reveal the cause of her headache. CSF cytological and biochemical examination results as well as increased intracranial pressure readings suggested inflammatory changes; thus viral encephalitis was considered as a probable etiology. However, symptoms did not obviously resolve after antiviral therapy. As the patient’s headache aggravated, she developed a pure sensory stroke due to infarction of the right thalamus. Although cerebral MRV revealed right lateral sinus dysplasia, cerebral venous sinus thrombosis was not considered due to the ineffectiveness of anticoagulant therapy. Her following DSA suggested unremarkable findings. Four subsequent lumbar punctures revealed significant intracranial hypertension and a slightly inflammatory CSF profile with elevated white cells and protein levels. Particularly considering the multiple small, ring-enhanced lesions and meningeal enhancement apparent on brain MRI, we focused our attention to the detection of etiologic microorganisms. Routine tests and cultures for bacteria, mycobacteria  infection, especially when the clinical manifestations are atypical. Further studies are required in order to evaluate the persistence of DNA in the CSF of patients.


The ischemic penumbra assessment is essential for the subsequent therapy and prediction of evolution in patients with acute ischemic infraction. Although controversial as a perfect equivalence to penumbra, perfusion-weighted imaging (PWI)-diffusion-weighted imaging (DWI) mismatch may predict the response to thrombolysis. Due to the reliance of PWI on contrast agents, noninvasive alternatives remain an unmet need.We reported a 65-year-old man complained of paroxysmal hemiplegia of his right limbs and anepia for 2 days, whereas the symptoms lasted for about 12 hours when he admitted to the hospital.We diagnosed it as acute ischemic stroke caused by the left middle cerebral artery stenosis.Susceptibility-weighted imaging (SWI), multimodal magnetic resonance imaging (MRI) work-up which includes conventional MRI sequences , DWI, PWI.His DWI-SWI mismatch was comparable to that of DWI-PWI at admission, suggesting that DWI-SWI could predict ischemic penumbra in patient with acute infarction. He refused the digital subtraction angiography examination or stenting, and he was treated with aspirin, atorvastain, and supportive treatment. The patient received a reexamination of the conventional MRI and SWI 11 days later. Expansion of the infarction in the affected MCA territory resulted from the penumbra indicated by the mismatch between DWI-SWI.SWI can be used as a noninvasive alternative to evaluate the ischemic penumbra. Besides, SWI can provide perfusion information comparable to PWI and SWI is sufficient to identify occlusive arteries. Assessment of ischemic penumbra is essential for initiating thrombolytic therapy and for predicting evolution or deterioration in patients with acute ischemic infraction. Although controversial as a perfect equivalence to penumbra, perfusion-weighted imaging (PWI)-diffusion-weighted imaging (DWI) mismatch is considered to predict the response to thrombolysis. Due to the reliance on contrast agents in PWI, noninvasive alternatives remain an unmet need. SWI is capable of providing additional clinical information complementary to conventional magnetic resonance imaging (MRI) sequences. SWI has been extensively used in the evaluation of various neurological disorders, including traumatic brain injury, neoplasms, intracranial calcification, vascular malformations cerebral venous thrombosis, spontaneous hemorrhagic transformation or postthrombolytic hemorrhagic transformation, intraarterial clot, microbleeds or iron deposition associated with neurodegenerative disorders, etc.,2 In addition, due to its ability to mirror the pathophysiology of the acute ischemic stroke, SWI has recently attracted attention in the identification of penumbra, as well as in the prediction of the evolution or the deterioration of acute ischemic infarction.–4In the hypoperfused brain tissue, for example, the increased oxygen extraction fraction via the metabolic compensation mechanism results in the elevation of the ratio of deoxyhemoglobin to oxyhemoglobin of the venous system of the brain, which contributes to the magnetic susceptibility difference between veins and the surrounding ischemic brain tissue. have found that the increased susceptibility due to the elevated deoxyhemoglobin-to-oxyhemoglobin ratio led to the visualization of prominent vein over the affected cerebral hemisphere on SWI. Interestingly, the SWI-DWI and the mean transit time (MTT)-DWI mismatches were found to be associated with deterioration of acute ischemic stroke. In this regard, SWI might illustrate misery perfusion with a compensatory increase of the oxygen extraction, and SWI is potentially a noninvasive alternative to PWI in predicting penumbra. We herein report a case in which SWI was used to evaluate penumbra.Kesavadas et al2Written informed consent was gained from the patient for the publication of the case report and accompanying images. The ethical approval of this study was waived by the ethics committee of The First Hospital of Jilin University because it was a case report.3A 65-year-old man complained of paroxysmal hemiplegia of his right limbs and anepia for 2 days, whereas the symptoms lasted for about 12 hours when he admitted to the Department of Neurology in the First Hospital of Jilin University. MRI was performed with a Siemens 3T Trio Tim scanner  by using a standard head coil. The following MRI sequences were obtained in the axial plane with the following parameters: spin echo (SE) T1WI ; fast spin echo (FSE) T2WI ; FSE inversion recovery (IR) FLAIR: ; DWI ; MRA ; PWI ; and SWI . All these sequences were done with a slice thickness of 6 mm, unless otherwise specified, a gap of 1.2 mm, field of view (FOV) of 256 mm × 256 mm, incentive number of 1. No obvious abnormalities were revealed on T1WI  for the support.