Meningiomas are the most common intracranial tumors. Diagnosis by MRI is generally straightforward, but lack of imaging specificity can present a diagnostic dilemma, particularly in patients with cancer. We report our experience with meningioma identification on Pittsburgh compound B (PiB) PET/CT. Patients who underwent PiB PET/CT from 2006 to 2015 were reviewed to identify those with intracranial tumors. Tumor types were classified by MR appearance, or by pathology when available. Maximum standardized uptake value (SUVmax) measurements of tumor PiB activity were compared across tumor types. 2472 patients underwent PiB PET/CT in the period of interest; 45 patients (1.8%) had probable or definite intracranial tumor. Tumor types were meningioma , vestibular schwannoma , pituitary macroadenoma , metastatic disease , and others . In patients with meningioma, the mean lesion SUVmax was 2.05 (SD 1.37), versus 1.00 (SD 0.42) in patients with non-meningioma tumors (p < 0.01). A receiver operating curve was created for lesion:cerebellum SUVmax ratio, with an area under the curve of 0.91 for a value of 1.68. At or above this ratio, specificity for meningioma was 100% (95% CI 79–100%) and sensitivity was 76% (95% CI 57–90%). PiB PET activity within an intracranial tumor is a highly specific and reasonably sensitive marker of meningioma. Further prospective evaluation is warranted to validate this result as well as to assess the performance of commercially available beta-amyloid radiotracers in meningioma identification. Meningiomas are the most common intracranial tumor in adults. Although diagnosis based on neuroimaging usually is straightforward, this is not the case in patients with a history of cancer, in whom the identification of a dural-based mass raises the question of metastasis, with profound implications for treatment and prognosis. As there are currently over 14 million cancer survivors in the United States, and the prevalence of meningioma in adults is approximately 0.9–3%, , 3. MeniCurrently available imaging techniques such as CT and MRI offer limited specificity for differentiating meningioma from other meningeal lesions. The “dural tail” often considered characteristic of meningioma occurs in other conditions as well, –7 includPittsburgh complex B (PiB) is a benzothiazole derivative developed as a positron emission tomography (PET) imaging agent, specifically designed to bind to beta-amyloid plaques in the brains of patients with Alzheimer’s disease . Since wOur internal review board approved this research in advance. Medical records of all patients who underwent PiB PET/CT of the brain at Mayo Clinic in Rochester, MN from March 2006 through December 2015 were reviewed to identify individuals with intracranial tumors. The vast majority of these patients were participants in the Mayo Clinic Study of Aging (MCSA), which also included at least one non-contrast MRI . Many ofTumors identified on MRI were categorized as probable meningiomas or non-meningiomas based on the assessment of the reporting board-certified neuroradiologist. Tumors classified as probable meningiomas were further reviewed, and included in this analysis if the diagnosis was pathologically confirmed or if the tumor was shown to be enhancing on post-gadolinium MRI, to exclude benign dural calcifications, and if the subject had at least 6 months of follow-up imaging confirming stability to exclude metastases. When intracranial metastatic disease was suspected, the diagnosis was confirmed by surgery. Tumors that were not consistent with meningioma or metastatic disease were categorized based on MRI appearance, location, and pathology when available. Tumors smaller than 5 mm in shortest diameter were excluded from analysis, given that they fall below the generally accepted lower limits of PET/CT resolution.[C-11] PiB PET/CT imaging was performed on a Discovery 690XT or RX PET/CT tomograph . CT imaging was obtained immediately prior to PET acquisition and used for attenuation correction. [C-11] PiB was produced on-site in our cyclotron facility. Production and quality control methods are described elsewhere . PiB PETt-tests and one-way ANOVA were used to evaluate differences in continuous variables between two or more than two groups, respectively. The chi-squared test was used for categorical analyses. Two-tailed statistical tests were used to compute p-values. These analyses, as well as sensitivity/specificity analysis and ROC-curve creation were performed in JMP Pro 12.2.0 .Unpaired 2472 patients underwent PiB PET/CT during the period of interest. 45 patients (1.8%) were identified with probable or definite intracranial tumor. Of these 45 patients, 29 (64%) had definite or probable meningiomas, and 16 (36%) had other tumor types including vestibular schwannoma , pituitary macroadenoma , metastatic disease , intraventricular tumors  and epidermoid .Median age of the 45 patients with intracranial tumors was 74 years (range 51–95). The patients with meningioma were older  than the patients with other tumors . Overall, women represented 58% (26/45) of patients with tumors. Of the patients with meningioma, 69% (20/29) were women, while only 38% (6/16) of patients with other tumor types were women; p = 0.04.Of the 29 patients with definite or probable meningiomas radiographically, two tumors (7%) were pathologically confirmed to represent WHO grade I meningiomas. The remaining 27 (93%) were categorized based on MRI appearance, contrast enhancement, and stability over time. The largest proportion of patients with meningioma  had tumor overlying the cerebral convexities or involving the falx, while 7/29 (24%) had supratentorial skull base tumors and 8/29 (28%) had infratentorial or tentorium-based meningiomas. Tumor thickness ranged from 0.5 to 3.1 cm, with a median thickness of 1.2 cm. Eight tumors (28%) demonstrated at least partial calcification.In patients with meningioma, the mean lesion SUVmax was 2.05 SD 1.37), versus 1.00 (SD 0.42) in patients with non-meningioma tumors (p < 0.01). The mean lesion:cerebellum SUVmax ratio in meningioma was 2.12 (SD 0.70) versus 1.10 (SD 0.30) for non-meningioma tumors (p < 0.01). Figure .37, versOf the 16 patients with non-meningioma tumors, the two patients with metastatic disease  and two of the seven patients with vestibular schwannoma had pathologic confirmation of tumor type; the rest were categorized based on MR imaging appearance. Mean SUVmax did not vary significantly amongst the non-meningioma tumors (p = 0.31), ranging from a low of 0.80 (SD 0.39) for the seven vestibular schwannomas to a high of 1.4 (SD 0.72) for the two metastases. The mean lesion:cerebellum SUVmax ratio likewise did not differ amongst the non-meningioma tumor types (p = 0.50). Ratio values ranged from 0.96 (SD 0.35) for vestibular schwannoma to 1.39 (SD 0.24) for the two intraventricular tumors. Absolute SUVmax values and tumor:cerebellum SUV max ratios for each tumor type are displayed in Table An ROC curve Fig.  was creaAmongst the 29 patients with meningioma, those with larger tumors were more likely to demonstrate a PiB PET SUVmax lesion:cerebellum ratio of 1.68 or above (p < 0.01). The mean thickness of tumors with an SUVmax ratio of 1.68 or above was 1.58 cm, versus a median thickness of 0.79 cm for meningiomas below this threshold. Calcified tumors were less likely to demonstrate high-level PiB uptake (p < 0.01), with only 3 of 8 (37.5%) calcified meningiomas demonstrating an SUVmax ratio of 1.68 or above, compared to 19 of 21 (90.5%) of non-calcified meningiomas. There was no association between SUVmax ratio and either patient age or sex (each p > 0.05).This retrospective analysis suggests that PiB PET/CT can identify meningiomas 5 mm or greater in size with fair sensitivity and differentiate meningioma from other intracranial tumors with excellent specificity. Thus, PiB PET/CT may help resolve a common dilemma in brain tumor diagnosis.An imaging test with the ability to definitively differentiate meningioma from other intracranial tumors would be extremely beneficial to patients. In patients receiving initial staging for cancer in whom a dural-based mass is the only potential distant metastasis, PiB PET/CT may be the difference between offering treatment with curative or palliative intent. If the PiB PET/CT confirms the diagnosis of meningioma, aggressive therapy with curative intent can be offered for the primary tumor without the delay, cost, or morbidity of needle biopsy or craniotomy for mass resection. Conversely, if PiB PET/CT indicates that meningioma is highly unlikely, treatment for metastasis can be offered immediately, preventing further tumor growth and associated neurological symptoms.A number of other PET and SPECT tracers may have roles in meningioma imaging, but they lack the specificity of PiB. FDG is by far the most commonly used PET tracer in cancer, but it has limited utility in brain tumor imaging generally or meningioma specifically because of physiological high FDG activity within the brain and lack of specificity. Agents targeting somatostatin receptors, such as the SPECT agent indium-111 entetreotide (Octreoscan™) and the PET radiopharmaceutical Gallium-68 DOTATATE (NETSPOT™) differentiate meningioma from the surrounding brain, but lack specificity given the presence of somatostatin receptors in other primary CNS tumors  and braiWhile this analysis is by far the largest report of PiB PET findings in patients with intracranial masses, and the first evaluation of the sensitivity and specificity of this tool, additional studies will be necessary in order to translate these findings into clinical practice. First, this was a retrospective analysis that included numerous meningiomas but only a small number of each of the individual non-meningioma tumors. Relatively high lesion:cerebellum PiB PET SUVmax ratios were observed in the vast majority of meningiomas, particularly larger non-calcified meningiomas, demonstrating that this technique demonstrates good sensitivity for meningioma. However, if this technique is to be useful clinically to guide treatment decisions, high specificity will be more important than sensitivity. We demonstrate extremely high specificity in this study, but the analyses are based on comparison of meningioma PiB uptake to that of a heterogeneous collection of intracranial tumors. While this illustrates that PiB PET uptake is not a common feature of non-meningioma intracranial tumors, the specificity observed in this analysis should be confirmed in prospective studies involving a greater numbers of dural metastases, as differentiation of meningioma from metastasis is potentially the most useful application of this technique. Further, all of the meningiomas identified on PiB/PET were either proven to be WHO grade I on pathology or can be inferred to be low-grade by virtue of radiographic stability, so additional evaluation of WHO grade II and III meningiomas is warranted.Our analysis utilized PiB, a beta-amyloid radiotracer widely used in research which is not FDA approved for clinical use and which requires an on-site cyclotron for production due to its short half-life. Several beta-amyloid PET tracers have been approved by the FDA, including florbetapir, florbetaben, and flutemetamol, with varying degrees of homology to PiB. It is not clear whether any or all of these compounds also demonstrate affinity for meningiomas. Future studies evaluating the diagnostic performance of these tracers for meningioma identification will be necessary, and may allow this technique to be used in a larger number of centers.The affinity of PiB, and potentially other of amyloid PET agents, for both meningiomas and beta-amyloid plaques may present issues in image interpretation. The normal pattern of PiB uptake in patients without cerebral beta-amyloid deposition is nonspecific white matter uptake with sparing of the gray matter. As such, PiB uptake in meningiomas stands out from adjacent gray matter. In patients with Alzheimer’s disease, cortical tracer localization may decrease the conspicuity of small meningiomas. Conversely, the presence of a meningioma should not confound the assessment of Alzheimer’s disease, which is characterized by diffuse cortical uptake and loss of the normal gray/white differentiation on PiB PET. However, a meningioma could theoretically lead to erroneous quantification of gray matter PiB activity if inadvertently included in an SUV region of interest.The biological/molecular basis for the binding of PiB to meningioma tissue has yet to be determined. The leptomeninges have been shown to contain deposits of beta-amyloid in both patients with Alzheimer disease and normal controls . Some stIn conclusion, this study suggests that the radiotracer PiB has fairly specific affinity for meningiomas. This finding could potentially have numerous clinical implications, including but not limited to the utility of PiB PET/CT to differentiate meningioma from metastatic cancer or cerebellopontine angle meningioma from vestibular schwannoma.


Both populations consisted mostly of smooth-walled quadriflagellates. They occurred in slush, and shared similar photosynthetic performances (photoinhibition above 1300 µmol photons m–2 s–1), very high levels of polyunsaturated fatty acids  and abundant astaxanthin accumulation, comparable to the red spores of Chlamydomonas nivalis (Bauer) Wille. Physiological differences between the Slovak and Austrian populations included higher levels of α-tocopherol and a 13Z-isomer of astaxanthin in the former. High accumulation of secondary pigments in the Slovak population probably reflected harsher environmental conditions, since the collection was made later in the growing season when cells were exposed to higher irradiance at the surface. Using a polyphasic approach, we compared Chlainomonas sp. with Chlamydomonasnivalis. The latter causes ʻconventionalʼ red snow, and shows high photophysiological plasticity, with high efficiency under low irradiance and no photoinhibition up to 2000 µmol photons m–2 s–1. Its PUFA content was significantly lower (50%). An annual cycle of lake-to-snow colonization by Chlainomonas sp. from slush layers deeper in the ice cover is proposed. Our results point to an ecologically highly specialized cryoflora species, whose global distribution is likely to be more widespread than previously assumed.Based on analyses of multiple molecular markers (18S rDNA, ITS1, ITS2 rDNA,  Our intention was (1) to confirm their close phylogenetic relationship; (2) to reveal details of their cytological adaptations to the snow habitat; (3) to evaluate if the spatial distribution of the population in the ice-cover correlates with the availability of liquid water in the snow; (4) to compare the rates of photosynthesis; (5) to analyse the composition of secondary pigments; and (6) to test whether there are any differences in adaptation strategies between the populations, in terms of fatty acids. Finally, in order to evaluate differences from the snow alga C. nivalis, we investigated the same parameters and metabolites of field samples of C. nivalis from the Tyrolean Alps. These analyses allowed a comprehensive description of this red-snow species of the genus Chlainomonas, which seems to be restricted to extremophilic habitats, including slush layers in lake-ice and glacier surfaces.The aim of this study was to compare the ecophysiology and morphology of two populations of et al.  and Gossenkӧlle Lake  and near Gossenkӧlle Lake (DL07) was investigated in May and June 2016 , Fig. 1.et al. . The spaet al.  was performed and preparation of samples for scanning and transmission electron microscopy (SEM and TEM) were carried out in the same manner as described by Procházková et al. , with thet al.  and from these, a further subsample of 0.5 ml snow meltwater was taken and placed in a Kolkwitz plankton-counting chamber  and processed according to Remias et al. .et al. (rbcL) gene regions were amplified from DNA isolates by polymerase chain reaction (PCR), using existing primers (Supplementary table S1). Amplification and sequencing reactions for these markers were described by Procházková et al. . Five independent biological replicates were measured for LP03, DL06 and DL07. After each light exposure, a saturating pulse was applied to detect the effective photochemical quantum yield of photosystem II. A curve of the relative electron-transport rate (rETR) upon PFD was calculated and fitted by the model according to Walsby (max), initial slope (α) and light saturation point (Ik) were determined . Cells were exposed to photon flux densities (PFDs) of 5, 34, 67, 104, 201, 366, 622, 984, 1389, 1666 and 2018 μmol photons mo Walsby , assuminChlorophylls, carotenoids and tocopherols were extracted and quantified according to Remias & Lütz . Brieflyet al., et al. , and monthly cumulative precipitation (mm) were used. For complete description see the Supplementary text.Chlainomonas sp. was found in late spring 2016 on two still partly ice-covered high-alpine lakes, Ľadové Lake in the High Tatras and Gossenkӧlle Lake in the Tyrolean Alps . This sample was dominated by blood-red mature spores, with a smaller contribution (15%) of young cells in an early stage of development, with green parts of the chloroplasts visible. The habitat conditions of all localities are summarized in Red snow caused by ean Alps . In the ean Alps –5. The tChlainomonas sp. was characterized by LM .The mean cell sizes of the most common, non-collared flagellates of d by SEM –18. A smd by SEM , 16. Foud by SEM , 18. MatChlainomonas sp. was analysed by TEM , and most abundant in the slushy part, in close proximity to the northern lake shore (>10 000 cells ml–1 meltwater) (Supplementary fig. S18). In contrast, the slushy area next to the southern lake shore harboured only one-third as many cells per volume. The spatial variation at the other sampling points of the transect was considerable, ranging from >1500 to <7500 cells ml–1 meltwater.The population densities of ectively . PopulatrbcL showed that the red snow of the ice covers of both lakes (samples LP03 and DL06) was caused by the same species (100% identity between markers of the two populations). Furthermore, 18S rDNA and rbcL sequences were identical to those of Chlainomonas sp. in previous reports  causing red snow on slopes neighbouring Lake Gossenkӧlle was, with the exception of one nucleotide change at ITS2 rDNA, identical to a field sample found at a location 40 km south-west , a slightly higher ETRmax (29.2±0.9), and a two-fold higher Ik value (291±65 μmol photons m–2 s–1) for the latter population. In contrast, C. nivalis showed signs of photoinhibition beginning only at much higher irradiances (2000 μmol photons m–2 s–1); it also showed a lower ETRmax (18.6±1.8) and Ik (76.2±6), but a higher α (0.24). m–2 s–1 . Chlainoformance . In bothChlainomonas sp. in the High Tatras and the Austrian Alps was caused by secondary  carotenoids, which comprised 93% and 88.5% of all pigments, respectively. These pigments were identified as derivatives (likely esters) of the keto-carotenoid astaxanthin . Chlorophyll-a and -b comprised 5% and 8% of all pigments, primary  carotenoids represented 2% and 3.5% in the pigment pool. For astaxanthin, 44.5% (High Tatras) and 31.9% (Alps) occurred as the native 13Z isomer. The overall ratio of astaxanthin to chl-a was 26 and 17 to one, respectively. Other pigment contents are given in Supplementary table S4.The reddish colouration of Chlainomonas sp. had very high levels of polyunsaturated fatty acids , whereas the content of saturated acids (SAFAs) did not exceed 27% or 21% , respectively. The contribution of monounsaturated fatty acids (MUFAs) was low , with oleic acid (18:1 (9Z)) the most abundant. The major PUFAs were α-linolenic acid ), followed by stearidonic acid ) and linoleic acid ). For comparison, C. nivalis had significantly lower levels of PUFAs  ) was the second most abundant MUFA. The major PUFAs for C. nivalis were the same as for Chlainomonas sp. Composition of three major lipid groups differed in saturation of their fatty acids: neutral lipids were composed predominantly of saturated lipids, whereas phospholipids and glycolipids were composed predominantly of PUFAs  from those of Chlainomonas sp. in the nearly 10-fold higher and 3-fold lower contents of vaccenic acid and linoleic acid in Chlamydomonasnivalis.The relative contents of FAs  in three snow-algal field samples are shown in  lipids) . The conof PUFAs . The tot nivalis . ChlamydThe air temperature in close proximity to Ľadové Lake and Gossenkӧlle Lake followed the same pattern over the course of a year (Supplementary fig. S23). The precipitation regime in late spring and early summer differed (Supplementary fig. S24).Chlainomonas sp. groups among the two other cryoflora species of this genus  are available for other Chlainomonas species. In addition, the sole use of the rbcL gene in the phylogeny of Chloromonadinia is problematic because unusual gene substitutions, which occur frequently in this group, may result in misleading taxonomic artefacts  to two algae tentatively assigned as ʻChloromonas sp. TA1ʼ (AB903004.1) and ʻChloromonas sp. TA3ʼ (AB902981.1), which were isolated from red snow at alpine sites in Japan, at an elevation of 2270 m. However, Chlainomonas sp. from Slovakia and Austria represents an independent species from these Japanese snow-algal samples . We refrain from generating a new phylogenetic tree, because for all molecular markers investigated, no new molecular information has become available since the study by Remias et al.  have been found in the slush layers and small pools on the top of the ice cover of Gossenkölle Lake  corresponds to a considerable spatial variation in population densities within the algal bloom, as also shown for C. kolii in New Zealand  over snow with a lower density (SWC 46%)  Procházková, Remias, Nedbalová & Řezanka  appears to tolerate higher light intensities, where it shows very high photosynthetic performance. Under low light, photosynthesis is less efficient; however, both show similar kinetics. In contrast, the ‘terrestrial’ snow alga C. nivalis behaves differently, showing high photophysiological plasticity: high photosynthetic efficiency under low light, but less photoinhibition under high light. As indicated by the Ik, Chlainomonas sp. from the High Tatras needs only half the level of irradiance compared with the Tyrolean population to become saturated. This can be explained by the pronounced temperature stress and associated irradiance stress experienced later in the season for the population sampled at Ľadové Lake , in comparison to the population sampled earlier at Gossenkölle Lake. An increased accumulation of Chlainomonas sp. at the snow surface is expected as a consequence of rain events . Notably, astaxanthin as a bio-indicator was found in the entire profile of a sediment core (32 cm) taken from the deepest point of Gossenkӧlle Lake, representing the last 800 years  screened by Lang et al.  than to arctic field samples associated with the Chlamydomonas nivalis clade  with red-snow blooms is needed to assess the cosmopolitan distribution of this species, the morphology of dispersal cells, and the route(s) of colonization of distant locations. Analysis of multiple molecular markers of the other Chlainomonas cryoflora taxa would help to determine the exact taxonomic position of each species within the clade.Remaining uncertainties about the life cycle of


Background: A systemic immune-inflammation index (SII) based on neutrophil (N), lymphocyte (L), and platelet (P) counts has shown a prognostic impact in several solid tumors. The aim of this study is to evaluate the prognostic role of SII in metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone post docetaxel.Patients and Methods: We retrospectively reviewed consecutive mCRPC patients treated with abiraterone after docetaxel in our Institutions. X-tile 3.6.1 software, cut-off values of SII, neutrophil-to-lymphocyte ratio (NLR) defined as N/L and platelets-to-lymphocyte ratio (PLR) as P/L. Overall survival (OS) and their 95% Confidence Intervals (95% CI) was estimated by the Kaplan-Meier method and compared with the log-rank test. The impact of SII, PLR, and NLR on overall survival (OS) was evaluated by Cox regression analyses and on prostate-specific antigen (PSA) response rates were evaluated by binary logistic regression.Results: A total of 230 mCRPC patients treated abiraterone were included. SII ≥ 535, NLR ≥ 3 and PLR ≥ 210 were considered as elevated levels . At univariate analysis Eastern Cooperative Oncology Group (ECOG) performance status, previous enzalutamide, visceral metastases, SII, NLR, and PLR predicted OS. In multivariate analysis, ECOG performance status, previous enzalutamide, visceral metastases, SII, and NLR remained significant predictors of OS , whereas, PLR showed a borderline ability only .Conclusion: SII and NLR might represent an early and easy prognostic marker in mCRPC patients treated with abiraterone. Further studies are needed to better define their impact and role in these patients. Prostate cancer is the most common cancer and the second cause of death for cancer in men . CastratThe effect of inflammation in prognosis and progression has been shown in patients with mCRPC, and peripheral blood circulating cells  included in inflammation indices have been associated with prognosis in these patients . NeutropIn this retrospective analysis, we aimed to evaluate prognostic implications of SII at baseline and changes during treatment with abiraterone in patients with mCRPC post-docetaxel. In addition, we considered also NLR and PLR value and their respective changes at 4 weeks to try to better define the impact of these inflammatory indexes on mCRPC patients treated with abiraterone.P), neutrophils (N), and lymphocytes (L) counts, was defined as P ×N/L. In order to determine the cutoff value of SII, NLR defined as N/L and PLR as P/L at the baseline data, the X-tile 3.6.1 software  was used.We retrospectively evaluated 230 patients with mCRPC treated with abiraterone in the post docetaxel setting between April 2011 and May 2015 in our seven Institutions. SII, the inflammatory index based on platelets  were not considered for the analysis.Abiraterone was administered according to clinical practice at the dose of 1000 mg once daily and was associated with prednisone 5 mg BID. Patients were treated until disease progression or unacceptable toxicity occurred. All patients provided written informed consent. All recorded PSA test, full blood examinations, including a complete blood count, and scan results were retrospectively collected for these patients, evaluated commonly every 4 weeks for serologic PSA response and as clinically indicated for imaging assessment. PSA response was defined according to the Prostate Cancer Working Group 2 criteria as a decline on serum PSA levels during abiraterone treatment of 50% or more from PSA baseline value maintained for ≥3 weeks . In addiThe primary objective of this study was to evaluate the ability of SII to predict the overall survival (OS) in patients with mCRPC treated with abiraterone in post-docetaxel setting. As patients were treated in clinical practice, radiological assessment was not carried out at pre-determined intervals in most patients, so that radiological progression-free survival (PFS) could not be assessed for all patients.2 or Fisher’s exact test. Differences were considered statistically significant when p < 0.05. OS was calculated from the start of abiraterone until death or last follow-up. The Kaplan–Meier method was used to estimate OS. The log-rank test and Cox proportional hazard regression were used to test for differences between groups. After univariate analysis, a multivariate analysis was carried out by Cox regression model. Estimated hazard ratios (HRs), their 95% confidence intervals (95% CI), and p values were calculated from the Cox proportional hazard regression models. The impact of inflammatory index conversion on survival outcomes was evaluated by the landmark analysis at 4 weeks. All statistical analyses were carried out with SAS statistical software, version 9.4 .Data were summarized by frequency for categorical variables and by median and range for continuous variables. Association between categorical variables was assessed using the χTable 1. The optimal cutoff point was calculated by X-tile 3.6.1 software to determine the best threshold of indices levels to predict OS at 18 months, and for the SII was 535 × 109, for NLR was 3 and PLR was 210. Then, SII ≥ 535, NLR ≥ 3, and PLR ≥ 210 were considered as elevated levels (high-risk groups). Visceral metastases were not associated with SII groups (p = 0.479), whereas a trend versus an association with NLR and PLR groups was reported .A total of 230 mCRPC patients with a median age of 74 years  underwent abiraterone treatment post-docetaxel were included in the study. Among all patients, 35 (15.2%) had visceral metastases, 21 (9.1%) received previous enzalutamide. Patient characteristics at baseline are reported in p = 0.126, p = 0.709, and p = 0.057, respectively), whereas an association with early PSA decline ≥30% was observed for PLR (p = 0.0004), a trend was seen for SII (p = 0.081), with no association with NLR (p = 0.357). We also divided up the two baseline groups (baseline high risk and low risk) of the three parameters  on the basis of the values at 4 week (4-week high risk and low risk), obtaining four subgroups: low–low, low–high, high–low, and high–high. We then compared the 4-week conversion of SII, NLR, and PLR groups with PSA response and early PSA decline ≥30%. PSA response was not associated with 4-week conversions of NLR (p = 0.603), but a trend was observed for SII, and PLR , whereas early PSA decline ≥30% was associated with 4-week conversion of SII and PLR  and a trend was observed with 4-week conversion of NLR (p = 0.114).PSA decline ≥50% during treatment from the baseline value (PSA response) was assessable in 229 (99.6%) of 230 patients, while PSA decline ≥30% at 4 weeks of treatment (early PSA decline ≥30%) was evaluable in 211 (91.7%) cases. PSA response was reported in 92 (40.2%) of 229 evaluable patients, while early PSA decline ≥30% was reported in 93 (44.1%) of 211 evaluable patients. No association was observed among PSA response and SII and NLR, with a trend for PLR . In relation to SII value, the median OS was 21.8 months (95 % CI 18.8–27.4) and 14.7 months (95% CI 11.9–16.8) (p < 0.0001) in patients with baseline SII < 535 or ≥535, respectively . In relation to NLR value, the median OS was 20.4 months (95% CI 17.7–26.4) and 14.7 months  in patients with baseline NLR < 3 or ≥3, respectively . In relation to PLR value, the median OS was 19.0 months (95% CI 16.4–22.3) and 14.4 months  in patients with baseline PLR < 210 or ≥210, respectively . A univariate analysis revealed that Eastern Cooperative Oncology Group (ECOG) performance status, previous enzalutamide, presence of visceral metastases and all inflammatory indexes  were significant predictors of OS (Table 2). In multivariate analysis, among clinical variables, ECOG performance status, previous enzalutamide therapy and presence of visceral metastases remained significant predictors of OS ; whereas, among inflammatory indexes, SII and NLR remained as predictor of OS  whereas PLR showed a borderline ability only .After a median follow-up of 29 months , 156 (67.8%) had died. The median OS was 17.3 months .We studied the above-mentioned four conversion subgroups of SII, NLR and PLR for OS. The high–high group showed a significantly worse OS than low–low group with all inflammatory indices, whereas results in the low–high and high–low groups remained less significant (Table 2). We also confirmed previous data on the OS prediction ability of NLR in these patients (p = 0.068). Our results suggest a possible prominent prognostic role for neutrophil levels, included in SII and NLR, but not in PLR. In our study, there was not a significant predictive role of these inflammatory indexes for PSA response. In a previous study, other authors analyzed the impact of NLR in mCRPC patients treated with abiraterone showing ability to predict PSA response and OS. However, the authors established the PSA response as the primary objective instead of OS, which was not used since most patients were alive at the time of that analysis . The high–high groups showed a significantly worse OS than low–low groups with all inflammatory indices, whereas results in the low–high and high–low groups remained more controversial, even if these latest groups were poorly represented counting from 3.5 to 12.2% in all three inflammatory indexes (Table 3). Another possible limitation for the interpretation of these early changes may be the use of prednisone 5 mg BID in combination with abiraterone, which could influence these inflammatory indexes. In a large study in 755 patients with mCRPC treated with chemotherapy and prednisone 5 mg BID, the conversion of NLR counts from high–low had a significant impact on the OS, whereas the change from low to high did not modify the prognosis , was initially associated with NLR and PLR poor prognosis groups , showing possible correlations between systemic inflammatory activation and more aggressive mCRPC behavior.We also evaluate the potential role of 4-week changes of SII, NLR, and PLR on the prognosis  counts has emerged as a biomarker for assessing prognosis and treatment outcome in mCRPC , MoreoveThe prognostic role of the SII might be elucidated by the function of peripheral N, L, and P and the their relationship with CTC . Our resThe SII biomarker could represent a novel predictive marker of clinical outcome to other treatments such as chemotherapy, radium, radiotherapy, and should be tested in these clinical situations.A potential role for new immune check-point inhibitors in combination with new hormonal therapies in mCRPC has been recently suggested , then thInflammation deserves a pivotal role in prostate cancer carcinogenesis and progression. Our results suggest that SII and NLR can provide clinically meaningful information and might represent an early and easy prognostic marker needing further studies in mCRPC patients.CL and UG designed the study and wrote the manuscript. CL and VC collected data. ES performed the statistical analysis. OC, MA, FMai, EB, FMas, AV, VC, and GF contributed to clinical data collection. All authors revised and approved the manuscript.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.


To evaluate transrectal (TR) and transperineal (TP) approaches for MRI/ultrasound (MRI/US) fusion-guided biopsy to detect prostate cancer (PCa). 154 men underwent multiparametric MRI and MRI/US fusion-guided biopsy between July 2012 and October 2016. 79/154 patients were biopsied with a TR approach and 75/154 with a TP approach. MRI was retrospectively analyzed according to PI-RADS version 2. PI-RADS scores were compared with histopathological results. Descriptive statistics, accuracy, and negative and positive predictive values were calculated. Histopathological results of first, second, and third MRI targeted biopsy cores were compared to evaluate the impact of one verus multiple targeted cores. Detection rates of PCa were 39% for TR biopsy and 75% for TP biopsy. Sensitivity/specificity for tumor detection with PI-RADS ≥ 4 were 81/69% for TR biopsy and 86/84% for TP biopsy. In 31% for TR biopsy and 19% for TP biopsy, PCa was found in the second or third MRI targeted biopsy core only. MRI/US fusion-guided biopsy may be conducted with the TR as well as the TP approach with high accuracy, giving more flexibility for diagnosis and the option for focal treatment of PCa. Over the last ten years, multiparametric MRI (mpMRI) of the prostate has gained rising importance in the diagnosis of prostate cancer (PCa). With mpMRI, high accuracy for the detection of PCa has been reported , 2. PCa Different systems for MRI/US image fusion are available, which allow for transrectal (TR) or transperineal (TP) biopsy or for both , 13. StiWith regard to complications, with TR prostate biopsy, the incidence rate of infection and rectal bleeding is higher  and lesiFurthermore, there are still no clear recommendations if more than one targeted biopsy core per PCa suspect MRI lesion significantly increases the cancer detection rate. A recent study by Schimmoller et al. found only minor benefit when taking a second targeted biopsy core in a cohort of 290 patients who underwent in-bore MRI-guided prostate biopsy .The purpose of our study was to evaluate MRI/US fusion-guided biopsy using the TP or the TR approach with the same fusion system in terms of diagnostic accuracy, PCa detection rates, and feasibility in a clinical setting.Between July 2012 and October 2016, 154 patients with clinical suspicion of PCa underwent MRI/US fusion-guided biopsy of the prostate. Between July 2012 and January 2015, only the TR approach was performed and, until then, 62 patients underwent fusion-guided biopsy. Therefore, 40% of patients from our cohort underwent TR biopsy, irrespective of prostate size, tumor localization according to MRI, negative initial biopsies, or patients' preferences due to unavailability of the TP approach. Since February 2015, both biopsy approaches were performed at our institution. Since then, detailed information and counseling on risks and advantages of the TR and TP approaches were given to the patients under consideration of prostate size, tumor localization according to MRI, negative initial biopsies, and patients' general condition. Under consideration of this information and patients' preferences, 17 patients underwent TR biopsy and 75 patients underwent TP biopsy after February 2015. This retrospective study focuses particularly on a descriptive analysis of clinical parameters in association with the different biopsy settings. In total, 79/154 patients underwent TR biopsy and 75/154 patients underwent TP biopsy. Written informed consent was obtained from each patient for clinically indicated mpMRI and MRI/US fusion-guided biopsy. The local ethical board waived the requirement for obtaining informed consent for this retrospective analysis. 125 patients had at least one negative previous biopsy (1–7 prebiopsies), 16 patients had no previous biopsy, 11 patients were on active surveillance, and in two patients it was unknown whether a previous biopsy had been performed. Patients' characteristics are summarized in b-values = 0–50, 400–600, and ≥800 s/mm2 were used. Dynamic contrast-enhanced (DCE) images were acquired in transverse plane after injection of 0.1 mmol/kg body weight gadoterate meglumine  at a rate of 3 ml/s using a FLASH 3D sequence with an image update rate of 9 s. For details of MRI protocol, please see supplementary Table 1 in Supplementary Material available online at https://doi.org/10.1155/2017/2176471.Multiparametric MRI was acquired according to European Society of Urogenital Radiology (ESUR) guidelines , 18 on aTarget lesions for MRI/US fusion-guided biopsy were chosen in a clinical setting by experienced uroradiologists. Before the publication of PI-RADS version 2 by the American College of Radiology (ACR), ESUR, and AdMeTech Foundation in December 2014, lesions were scored according to PI-RADS version 1 ; since JMRI/US fusion-guided biopsy was performed with the BioJet™ fusion system and software . The technical data and usage of this system have been described previously , 21. In Patients were informed about advantages and risks of TR and TP prostate biopsy. Indication for TR or TP biopsy was adjusted to the clinical setting under consideration of technical availability, localization of lesion, patients' profile, and patients' preferences.TR and TP prostate biopsies were performed by two experienced urologists in the dorsal lithotomy position under antibiotic prophylaxis. Local anesthesia (periprostatic block) was performed in patients with a TR biopsy course and general anesthesia was performed for the TP approach. TR MRI/US fusion was performed using a 3D triplane TR ultrasound system  solely operating with the side-fire function. An endocavity biplane transducer  was used for the TP approach. Biopsy cores with a core length of 22 mm were numbered according to the radiological anatomic sector map as described in the PI-RADS version 1  documentUsing the TP setting, the mean number of biopsy cores per patient was 12 ± 1 (range: 5–12) cores with 3 ± 1 (range: 1–6) cores from targeted biopsy and 8 ± 2 (range: 2–11) cores from additional random biopsy.μg/L, designated as intermediate and/or high-risk tumor groups according to the D'Amico criteria [For each cancer-positive biopsy core, a pathologist determined the Gleason grade and Gleason score (GS). Clinically significant cancer was defined as GS ≥ 7 and/or PSA ≥ 10 criteria . Examplet-tests and values are given as mean ± standard deviation (SD). Descriptive analysis, sensitivity, specificity, and negative predictive value (NPV) and positive predictive value (PPV) of mpMRI in TR and TP cohorts for a PI-RADS score ≥ 4 were evaluated with respect to the dominant lesion in each patient and analysis was performed on a per patient basis. The combined histological result of MRI/US fusion-guided and random biopsy cores served as reference.For statistical analysis, GraphPad Prism software version 6  and SPSS software version 24  were used. Clinical data of patients with and without biopsy-proven PCa as well as patients with TR and TP biopsy approaches were compared using unpaired In our TR cohort, 31/79 patients were diagnosed with PCa (39%) between July 2012 and September 2016. 60/79 patients had untargeted negative prebiopsies, 6 patients were under active surveillance, 12 patients were biopsy-naïve, and in one patient the prebiopsy status was unknown. One patient was excluded from the analysis because the target lesion located in the anterior part of the prostate could not be reached by TR biopsy due to restriction of the needle guide . 664 biopsy cores were taken in total: 271 cores were from targeted biopsy and 393 cores were from additional systematic random biopsies.p < 0.001) and ADC values were significantly lower in tumor-positive lesions . Patients with PCa were significantly older  and prostate volume was significantly lower in the group with PCa . No significant difference was found in PSA levels (12 ± 16 versus 8 ± 4 μg/l), lesion size (14 ± 6 versus 12 ± 5 mm), or body mass index (BMI 28 ± 5 versus 27 ± 4 kg/m2).PI-RADS scores were significantly higher in patients with PCa compared to patients without PCa  target lesions from TR biopsy were located in the anterior half of the prostate; 52/79 (66%) target lesions were in the posterior half. Concordantly, the tumor detection rate was slightly but not significantly lower in the anterior  than in the posterior prostate  = 0.81 : 0.7–0.9)). NPV was 85% and PPV was 63%.26 out of 31 PCa positive biopsies were obtained by targeted biopsy . The cann = 26) revealed that in 18/26 patients PCa was detected with the first biopsy core, in 7/26 with the second biopsy core, and in 1/26 with the third biopsy core. Thus, taking multiple biopsy cores from the target lesion improved cancer detection from 23% with one biopsy core to 32% with two and 33% with three biopsy cores using the TR approach.A subgroup analysis of patients with PCa positive targeted biopsy  between February 2015 and September 2016. 65/75 patients had untargeted negative prebiopsies, five patients were under active surveillance, four patients were biopsy-naïve, and in one patient the prebiopsy status was unknown. 865 biopsy cores were taken: 242 cores were from targeted biopsy and 623 cores from additional systematic biopsies.p < 0.001) and ADC values were significantly lower in tumor-positive lesions . Patients with PCa were significantly older  and prostate volume was significantly lower in the group with PCa . No significant difference was found in PSA levels (17 ± 19 versus 13 ± 13 μg/l), in lesion size (18 ± 7 versus 14 ± 9 mm), or in BMI (26 ± 3 versus 28 ± 5 kg/m2).PI-RADS scores were significantly higher in patients with PCa compared to patients without PCa  dominant lesions were located in the anterior prostate and 16/75 (21%) were located in the posterior part of the organ. Concordantly, the PCa detection rate was significantly higher in the anterior gland  when compared to the posterior gland . NPV was 67% and PPV was 94%.In 54/56 patients with PCa, tumor diagnosis was obtained from targeted biopsy . The cann = 54) revealed that in 44/54 patients PCa was detected with the first biopsy core and in 10/54 patients with the second biopsy core and no additional PCa was found in the third targeted biopsy core. Thus, taking multiple biopsy cores from the target lesion improved cancer detection from 59% with one biopsy core to 72% with two biopsy cores using the TP approach.A subgroup analysis of patients with PCa positive targeted biopsy (p < 0.05) and had more previous biopsies  and higher PSA values  than patients in the TR cohort. Additionally, PI-RADS scores were higher  and size of target lesions was larger  while ADC values were lower  than those in our TR cohort. No significant difference in BMI was observed between the two groups (26 ± 4 versus 27 ± 4). Data are summarized in Our TP cohort was significantly older , while less biopsy cores were needed than with saturation biopsy: 8 ± 3 cores for TR biopsy (3 ± 1 of which from targeted biopsy) and 12 ± 1 cores for TP biopsy (3 ± 1 from targeted biopsy) were taken.When using radical prostatectomy tissue as reference, it has been reported that significant PCa might be missed in 8–24% of patients by mpMRI –30. CancFurthermore, evidence suggested that, in MRI/US fusion-guided biopsy, a two-core biopsy should be performed per target lesion , 31, butn = 62) was performed and TP biopsy was introduced in our institution in February 2015. Initial uncertainty about NPV of mpMRI as well as missing recommendation about cut-off values of PI-RADS scores led to higher indication rates of targeted biopsy, even with lower PI-RADS scores in the initial phase of MRI/US fusion-guided biopsy, when we only used the TR biopsy route. This could be an explanation for our finding that, in our patients that underwent TP biopsy (at later time points after February 2015), PI-RADS scores and lesion size were significantly higher and ADC values were significantly lower than those in our patients that underwent TR biopsy predominantly before February 2015. Furthermore, there was an ongoing optimization of MRI protocol and improvement of workflow, personal learning curve in MRI interpretation, and biopsy planning and biopsy performance. An existing learning curve for prostate MRI interpretation has been described [With the descriptive design of our study , comparing the two cohorts is not intended. We could show that, with one software system, both biopsy routes are feasible and equally effective. Our two cohorts differ in some aspects. In 2012, we started using mpMRI and MRI/US fusion-guided biopsy and procedures  were not standardized due to a lack of recommendations about when to use MRI fusion-guided biopsy in men with clinical suspicion for PCa. Between July 2012 and January 2015, only TR fusion-guided biopsy (escribed –34. Gaziescribed .In our study, one anterior lesion could not be reached with TR approach. Therefore, TP biopsy could be helpful to reach the anterior part of the prostate. In our patient cohort, anterior lesions were more often biopsied with the TP approach. Notably, when comparing the yield of PCa detection within the two cohorts, the percentage of detected PCa located in the anterior half of the prostate was related to the percentage of MRI target lesions in the anterior prostate . TherefoPrevious studies suggested that TR biopsy might hold a higher risk of infection, since faecal bacteria can enter blood circulation after retrieving specimen from the prostate . ParticuLimitations of our study are the retrospective design and solely descriptive analysis of TR or TP biopsy approach in a clinical setting. Patients were not randomized into TR and TP cohort. The decision for one of the two biopsy routes depended on a doctors-patient shared decision, under consideration of patients' preference, prostate size, lesion localization, and technical availability. And, finally, the TP approach has been available since February 2015, which introduced a bias.In conclusion, we demonstrate that MRI/US fusion-guided biopsy has high accuracy for the detection of PCa with both TR and TP approaches. Our biopsy system provides the opportunity to offer both biopsy routes to patients at risk of PCa and to adjust diagnostic strategy to the individual clinical setting. In addition, the TP approach gives the options for fusion-guided focal therapy strategies.Parameters of multiparametric MRI are presented. DCE = dynamic contrast enhancement, DWI = diffusion weighted imaging, FoV = Field of view, TR = repetition time, TE = echo time, TSE = turbo spin echo.


Maytenus procumbens and Ozoroa paniculosa in a butanol-induced testicular dysfunction rat model. The rats in respective experimental groups were orally administered with the extract at 50 and 250 mg/kg bw, daily for 28 days. The cytotoxicity of the extracts was evaluated against HEK293, MCF-7, and HT29 cell lines. The extracts exhibited moderate (LC50 30.3–330.2 μg/mL) to weak (LC50 200.8–438.4 μg/mL) cytotoxicity level on the cancer and normal cells, respectively. While relatively lower serum testosterone levels and total sperm count along with decreased numbers of spermatogonia were noted in the untreated group, all these parameters were improved in the groups treated with the extracts at 250 mg/kg. Improved histomorphological changes of the testes were also observed when compared to the untreated group. While the extracts (at 250 mg/kg) increased serum reduced glutathione content and decreased malondialdehyde content, a relatively higher serum creatinine level was also observed in the treated animals group. The results indicate that the two plant extracts have potential to ameliorate testicular dysfunction.The traditional use of medicinal plants in the management of sexual dysfunctions has a long history. This study investigated testicular dysfunction ameliorative effect of the methanolic roots extracts of The maintenance of normal testicular function is crucial to male's health. Testicular dysfunction is the main underlying cause of male developmental and sexual dysfunctions. It may lead to a decline in fertility and androgen (testosterone) deficiency in males. Testosterone deficiency has debilitating effects  in the quality of life of men , 2. Vari Maytenus procumbens and Ozoroa paniculosa are commonly used by traditional healers in the management of testicular dysfunctions .Despite an increasing number of men's health clinics worldwide and the use of pharmaceutical agents to manage complications of testicular dysfunction, substantial number of men, particularly living in rural areas, continue to consult traditional healers to improve their sexual functioning . The useMaytenus procumbens (L.F.) Loes (Celastraceae), commonly known as Dune Koko (English) and Umakhweni (Zulu), is a densely bush plant (about 6 m in height) native to South Africa and predominant in the KwaZulu-Natal (KZN) province. It is also found in South America, North Africa, and East Asia [ M. procumbens has been reported to possess anticancer activity [ Ozoroa paniculosa (Sond.) R & A Femandes, (Anacardiaceae), commonly known as resin tree (English) and Umfico (Zulu), is an evergreen, semideciduous, small to medium sized single stemmed tree (up to 9 m). The powdered stem bark of O. paniculosa is used by Zulu traditional healers to treat acute inflammatory condition of the chest [ M. procumbens and O. paniculosa against testicular dysfunction in male rats. Effect of the extracts on fertility is not covered in the current study.ast Asia . The leaactivity . Ozoroa he chest . This st M. procumbens and O. paniculosa were collected from Ndumo and Mhlabayalingana, KZN, South Africa, in collaboration with a local traditional healer. The botanical identification of the plants was confirmed by Dr. N.R Ntuli and Dr. T.H.C Mostert at the Botany Department, Zululand University. The plants materials were air-dried and ground to powder. Methanol was used to separately extract  the powdered plants materials. The filtrates were concentrated in vacuo (at 40°C). The obtained methanol-free crude extracts were safely stored at 4°C until use. Fresh working solutions were prepared by reconstituting the crude extract in distilled water just before use.Fresh roots ofPhytochemical analysis  of the plants material was performed following the standard procedures described by Odebiyi and Sofowora . The plaThe phenolic content of the crude extracts was colourimetrically quantified following the Folin-Ciocalteu reagent method . Crude eThe method described by Ordońez et al.  was foll4 cells/mL) were exposed to the extract for 48 h at 37°C. The cells viability was tested with the tetrazolium salt and after 4 h incubation at 37°C, the formed formazan crystals were solubilised with dimethyl sulfoxide (DMSO). The optical density of the solutions was measured at 570 nm using a Mindray-96A microplate reader. Percentage inhibition of cell viability was calculated using the formulaThe cytotoxic effect of the extracts was tested against normal human embryonic kidney (HEK293), human colorectal adenocarcinoma (HT29), and breast cancer (MCF-7) cell lines, using MTT assay . The celApproval for use of laboratory science animals and procedures was issued by the University of Zululand Research Ethics Committee (UZREC 171110-030 PGM 2015/198). Sprague-Dawley rats (150–200 g) of either sex were obtained from the animal unit of the Biochemistry Department, University of Zululand. Rats were kept under standard laboratory conditions . The animals had access to fresh food and drinking water at leisure for the duration of the experiment. The rats were separated according to gender (maximum of four rats per cage) and were allowed to acclimatize for at least five days before the experiment commenced. n-butanol at 25 mg/kg body weight for four days at two-day intervals to induce testicular dysfunction. Four days after the induction of testicular dysfunction, the animals were mated with estrous female rats to establish their baseline sexual performance. The animals were then randomly divided into seven groups (A–G) of five rats per group and put on their respective treatments as shown as follows:  Group A: normal control group, received water (a carrier solvent).  Group B: testicular dysfunction induced (untreated group), received water only.  Group C: testicular dysfunction induced, received sildenafil at 20 mg/kg. M. procumbens.  Group D: testicular dysfunction induced, received 50 mg/kg M. procumbens.  Group E: testicular dysfunction induced, received 250 mg/kg O. paniculosa.  Group F: testicular dysfunction induced, received 50 mg/kg O. paniculosa.  Group G: testicular dysfunction induced, received 250 mg/kgThe effect of the extracts on testicular dysfunction was evaluated using the butanol-induced testicular dysfunction in rat model , with soAll the animals were administered  with their respective drugs daily for 28 days. A group of female rats (150–200 g) received two consecutive subcutaneous injections of progesterone (7.5 mg/kg bw), at 48 h intervals for 96 h to induce estrous before being introduced to male rats. To assess the rats' sexual behavior, each male rat from various treatment groups was individually subjected to one estrous female rat in a separate cage for 30 min. The number of mounts were recorded and compared between the groups. Body weight changes of the male rats were recorded for 28 days at seven days intervals. At the end of the experimental period, the male rats were euthanised under anaesthesia, blood was immediately collected by cardiac puncture, and the testes were removed and weighed. The collected tissue samples were used for biochemical parameters and histological analysis, respectively.Serum levels of testosterone, creatinine, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were determined using standard laboratory procedures . The serum glutathione (GSH) and malondialdehyde (MDA) contents as well as activities of antioxidant enzymes  were estimated using respective commercial activity assay kits (Sigma-Aldrich), suitable for rat samples, following manufacturers' instructions.μL of 1% aqueous nigrosine-eosin Y. The mixture was incubated for 30 min at room temperature to allow staining of the sperm cells. This was followed by placing the sperm suspension (10 μL) on the microscope slides (1 cm2) for sperm counting. The sperm count was performed as per standard procedure using an optical microscope with 400× magnification. The total number of sperm cells was calculated from the following formula:C is number of counted spermatozoa; S is Sum total per animal; V is dilution (104); and CF is factor of the camera (1.25).Epididymides were rinsed in ice-cold 0.01 M phosphate buffer (pH 7.4) and kept at −80°C until used. Sperm count was estimated following the method described by D'Souza  and AdeiTesticles were removed, weighed, and stored in 40% formalin. The tissues were processed routinely and stained with haematoxylin and eosin. Histopathological analysis was carried out by a qualified pathologist  with no prior knowledge of the animal groups and their treatment.p < 0.05. The LC50 values were determined using the Cheburator version 1.2.0 software.Unless stated otherwise, the data were presented as mean ± SEM. The results were analyzed with one-way ANOVA followed by Dunnett's tests using GraphPad Prism (v6.01). The differences were statistically significant where  M. procumbens and O. paniculosa showed the presence of most phytoconstituents that were screened for  in O. paniculosa, a relatively higher FC (0.102 mg/g) in the roots of the plant was recorded.The phytochemical screening of the roots ofened for . It is n M. procumbens and O. paniculosa extracts showed lower lethality (LC50) values of 80.0 and 30.3 μg/mL, respectively, on HT29 cells.The cytotoxic effect of the extracts on the tested cell lines varied from moderate to weak toxicity . Both M.p < 0.05) decrease in serum MDA level, a product of lipid peroxidation.The results of the effect of the extracts on the antioxidant status are presented in  M. procumbens (250 mg/kg) correlated with an observed significant (p < 0.001) increase in the animals' mounting frequency. All the measured parameters were also improved in the sildenafil treated group.The effect of the extracts on testicular weight, serum levels of testosterone, and total sperm count was evaluated and the results are given in  M. procumbens and O. paniculosa in butanol-induced testicular dysfunction in male rats is reported. Alcohol intoxication is linked to decreased serum levels of testosterone, loss of spermatogenic activity, and testicular atrophy [Testicular dysfunction, due to either endogenous or exogenous factors, may result in a decline in male sexual activeness, androgen synthesis, and fertility. An increasing body of evidence supports the use of medicinal plants, parts or whole plant, in the management of testicular dysfunctions –10. In t atrophy , 21. Tes atrophy . The obsThe testicular atrophy is primarily associated with shrinkage of the seminiferous tubules and loss of sperm cells . The obsFurthermore, therapeutic effect of a number of medicinal plants against testicular dysfunction has also been associated with their antioxidant activities . The hig50 ≤ 20 μg/mL), moderately toxic (LC50 = 21–200 μg/mL), or weakly toxic (LC50 = 201–500 μg/mL) [ M. procumbens extract on normal cells is consistent with the report of Ahmed et al. [Despite their efficacy, evaluation of the cytotoxic effects of plants used by traditional healers for medicinal purposes is also crucial. The use of both normal and cancer cells in this study was solely to evaluate general cytotoxic effect of the extracts. Toxicity of crude extracts is categorized into highly toxic (LC0 μg/mL) . The resd et al. . Therape M. procumbens and O. paniculosa have properties to potentially ameliorate testicular dysfunction. The results from this study support the use of the roots of these plants in folk medicine to manage testicular dysfunction and its related complications. While the extracts exhibited potential efficacy against testicular dysfunction, the observed potential cytotoxicity and/or renal toxicity of the extracts suggest that the plants be medicinally used with caution. Evaluation of erectogenic effect of the extracts and isolation of their active compound(s) are recommended for further work.It was concluded that the methanolic root extracts of


Acinetobacter spp. isolated from 2005 to 2016 in different regions of Switzerland.We describe the prevalence of invasive carbapenem-resistant Acinetobacter spp. isolated from blood or cerebrospinal fluid, and further described their temporal and regional fluctuations.Using the Swiss Antibiotic Resistance Centre (anresis) database that includes data from 70% of all hospitalized patients and one third of all ambulatory practitioners in Switzerland, we analysed the number of carbapenem-susceptible and resistant Acinetobacter. Multivariable analyses indicated that the number of carbapenem-resistant isolates (mean 4.8 ± sd 2.12) and carbapenem resistance rates per region per annum (8.4% ± 13.9%) were low and stable over the studied period. Large fluctuations were observed at the regional level, with e.g. the North East region displaying resistance rates twice as high as that found in other regions.From 2005 to 2016, 58 cases of resistant or intermediate strains to carbapenem were observed among 632 cases of invasive Acinetobacter isolates in Switzerland, our results suggest the existence of a diverse pool of A. baumannii species in hospital settings, and confirm the implication of carbapenem-resistant Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB) complex in the vast majority of clinical infections and nosocomial outbreaks with notable regional fluctuations.Despite a relatively stable number of carbapenem-resistant The online version of this article (10.1186/s12879-018-3061-5) contains supplementary material, which is available to authorized users. Acinetobacter genus, the species that mostly present a risk as opportunistic human pathogens are A. baumannii, A. nosocomialis, A. pittii, A. calcoaceticus, A. seifertii and A. dijkshoorniae, which belong to the so-called Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB) complex. Generally, these four species are not well differentiated at the phenotypic level  of 1.00  for both ACB and non-ACB isolates  isolations from 2005 to 2016, was significantly above all other regions in terms of number of resistant isolates, e.g. the comparison with Centre East  taken as the reference region yielded IRR = 2.00 (1.35–2.98), P < 0.001 , P < 0.001). Other regions with 4.9 (sd 2.5) carbapenem-resistant Acinetobacter isolates on average were not significantly different from Centre East (P > 0.05).Generalized Poisson regression of the number of carbapenem-resistant isolates on year (from 2005 to 2016) and across 8 Swiss regions indicated that year has no significant effect on the average of 4.83 (sd 2.13) total Acinetobacter isolates, OR 1.06 (0.98–1.16), P = 0.155; for ACB isolates only, OR 1.08 (0.99–1.19), P = 0.096). Only the North East region  had higher rates on average (OR 6.75 (1.88–43.32), P = 0.012; for ACB isolates, 4.95 (1.24–33.3) P = 0.045) than region Center East . Other regions had resistance rates ranging from 1.3 to 13.0% (2.1 to 19.8% for ACB isolates), which were not significantly different from that of Center East (P > 0.05).Those trends were confirmed when examining resistance rates per year per region Fig. , b, whicAcinetobacter isolates displayed large temporal and regional disparities, both displaying patterns reminiscent of outbreaks: the detailed analysis of the increase in 2010 observed in the North East region was highly suggestive of an outbreak because 5 resistant Acinetobacter isolations, all belonging to ACB, occurred for the whole region within six weeks in the same intensive care unit of burn patients.At a more detailed level of analyses : The number of total resistant isolates in the sensitivity analyses did not significantly increase over time and the North East region displayed higher number of isolates than any other region, considering all Acinetobacter isolates or only ACB isolates , which includes all AST results representing about 70% of all hospitalized patients and one third of all ambulatory practitioners in Switzerland, we report on the first nationwide surveillance study on invasive carbapenem-resistant Acinetobacter isolated from 2005 to 2016 in Switzerland. Importantly, we observed that the resistance rate has stabilized yearly at 8.4%, with large temporal and regional disparities, but without increase over time.A publication by the ECDC of an article entitled “Carbapenem-resistant ettings” , concludA. baumannii and related species in hospital settings in Switzerland, as also observed in France [Acinetobacter isolates, as observed previously in Germany over a 5-year period [A. baumannii in burn patients in hospital settings, as already reported in Switzerland [Our results indicate the existence of a diverse pool of n France . We confr period . Our fintzerland  and in otzerland , 14.http://www.swissmicrobiology.ch). Nevertheless individual laboratories are free to use other guidelines and methods than EUCAST. Although most laboratories initially based their testing on CLSI guidelines, they changed to EUCAST guidelines between 2011 and 2013, with in general an increased use of automated systems over the years. Therefore identification methods may differ between different laboratories. Another limitation is the fact that clinical isolates were classified as “susceptible”, “intermediate”, or “resistant” based on clinical breakpoints. As such, quantitative resistance data are not available for most isolates. This classification indicates the likelihood of a therapeutic success  with a certain antibiotic and thus helps the attending physician to select the best possible treatment. The use of different clinical breakpoints (e.g. EUCAST vs. CLSI) or changing breakpoints over time may therefore influence the results. However with the change from CLSI breakpoints to EUCAST breakpoints (as performed by most of the anresis-laboratories between 2011 and 2013) we would expect a methodology-related increase in resistance rates during this time period, as breakpoints for susceptibility by disc diffusion in EUCAST are higher than in CLSI 2009–2011 . This cAcinetobacter outbreaks, and to limit the endemic establishment of resistant isolates in additional health facilities and across EU regions.Our analyses which cover both multiple years and multiple regions conjointly highlight the usefulness of surveillance approaches that integrate different temporal and spatial resolution levels. Therefore, further surveillance efforts are needed to detect and control Additional file 1:Table S1. Sensitivity analyses of temporal and regional trends in Acinetobacter and in ACB . We compared the effects of year and region on the number of resistant isolates and on resistant rates by considering data sent either by all laboratories or by laboratories that regularly sent data since 2005. (DOCX 22 kb)


Brain consists of plenty of complicated cytoarchitecture. Gaussian-model based diffusion tensor imaging (DTI) is far from satisfactory interpretation of the structural complexity. Diffusion kurtosis imaging (DKI) is a tool to determine brain non-Gaussian diffusion properties. We investigated the network properties of DKI parameters in the whole brain using graph theory and further detected the alterations of the DKI networks in Alzheimer’s disease (AD).Magnetic resonance DKI scanning was performed on 21 AD patients and 19 controls. Brain networks were constructed by the correlation matrices of 90 regions and analyzed through graph theoretical approaches.We found small world characteristics of DKI networks not only in the normal subjects but also in the AD patients; Grey matter networks of AD patients tended to be a less optimized network. Moreover, the divergent small world network features were shown in the AD white matter networks, which demonstrated increased shortest paths and decreased global efficiency with fiber tractography but decreased shortest paths and increased global efficiency with other DKI metrics. In addition, AD patients showed reduced nodal centrality predominantly in the default mode network areas. Finally, the DKI networks were more closely associated with cognitive impairment than the DTI networks.Our results suggest that DKI might be superior to DTI and could serve as a novel approach to understand the pathogenic mechanisms in neurodegenerative diseases. Alzheimer’s disease (AD) is the most frequent neurodegenerative disorder causing cognitive impairment, disabilities and finally death in aged people. The upgraded guidelines recommend that the diagnosis of AD should be based on the psychiatric and neurological signs, imaging findings, and the presence of biomarkers . AccumulGraph theoretical methods provide a powerful approach to quantitative analysis of the organization of network connectivity –9, 12–18A recent neuroimaging study has shown that small world aberrations in structural networks in AD patients were associated with Aβ deposition . Using gHowever, DTI yields only a fraction of the information potentially accessible by diffusion MRI, mainly due to the fact that the DTI is unable to quantify non-Gaussian diffusion . In the DKI has been initially applied to the study of the nervous system, such as normal brain tissue, cerebral infarction, brain tumors, brain trauma as well as Alzheimer’s disease and Parkinson’s disease –35. For The subjects were recruited from Northern Jiangsu People’s Hospital, including twenty-one AD patients and nineteen normal controls (NC). The diagnosis for probably AD made by two experienced neurologists was based on the criteria of the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer’s Disease and Related Disorders Association (NINCDS/ADRDA) . ExclusiThe study was approved by the Ethics Committee of Northern Jiangsu People’s Hospital, Yangzhou University, and all participants or their guardians signed informed consent forms before MRI scanning.2) along 30 diffusion gradient directions using a single-shot EPI sequence. DKI sequence parameters were: TR = 5800 ms, TE = 100 ms; FOV = 240 × 240 mm2; matrix = 100 × 100; voxel = 2.4 × 2.4× 4 mm3; 35 axial slices. 3D T1WI images of the whole brain were acquired using the BRAVO sequence, the imaging parameters were: TR = 8.2 ms; TE = 3.2 ms; TI = 450 ms; flip angle = 12°; FOV = 256 mm × 256 mm; matrix = 256 × 256; voxel = 1 × 1 × 1 mm3; 160 slices.Images were acquired in a 3.0 T GE Discovery MR750 scanner  system with an 8-channel head coil. DKI images were acquired with 3 b-values  [DKI data were processed by using Matlab R1202b and Diffusion Kurtosis Estimator (DKE) (cts/dke) . Data wects/dke) . The DT-cts/dke) ; and KT-cts/dke) , 43. Of cts/dke) . The datEach individual high-resolution structural image (T1 image) was first coregistered to the FA image in the diffusion space using a linear transformation. The transformed structural image was then mapped to the T1 template of the Montreal Neurological Institute (MNI) space using a nonlinear transformation . The resGM network was defined as a correlation network based on each DKI parameter measurement. A regional parameter was computed as the average value of all voxels within the region. The interregional correlation matrix of each group was then obtained by calculating the correlation coefficients across individuals between the regional parameters of every pair of regions using Pearson’s correlation. Therefore, AD and control groups achieved a parameter matrix for each DKI metric respectively. The grey matter network contained N nodes and K edges, which included 90 cortical and sub-cortical regions in the AAL atlas (45 for each hemisphere) , the parhttp://www.nitrc.org/projects/panda) [To construct DKI WM network, the brain nodes were also defined by the AAL atlas. Each edge represented the connecting fiber that linked a couple of brain nodes. The weights of the edges were defined as FN, mean fiber length and mean diffusion measures, including FA, MD, Ad, RD, MK, RK, AK and KFA. All the image processes of kurtosis diffusion network construction were manipulated using PANDA (s/panda) .http://www.nitrc.org/projects/gretna/) [Each correlation matrix was thresholded over a wide range of sparsity (6% -40%), and the properties of the resulting graphs at each threshold value were estimated. Subsequent indicators were calculated in the Gretna (gretna/) .Small world measures of a network (Cp and Lp) were originally proposed by Watts and Strogatz . For botThe significance threshold was set top ≤0.05 for all analyses. All continuous variables were tested for normal distribution within groups using the Kolmogorov–Smirnov test. Differences between AD subjects and NC regarding demographical data , MMSE and MoCA scores were calculated as follows: the chi-square test was used for categorical variables; the t-test was used for continuous normally distributed variables.To determine the differences in GM graph network parameters between groups, a nonparametric permutation test method was used . First, To determine the between-group differences in the small world properties and network efficiency of the WM networks, an analysis of covariance (ANCOVA) was performed on each diffusion metric. Age and gender were taken as covariates in this model. The relationship between the network metrics and MMSE and MoCA scores in the patient group was analyzed by the partial correlation analysis.p = 0.07) and gender (p = 0.8) of AD patients and controls. For the neuropsychological tests, there were significant differences in MMSE and MoCA scores between the two groups  for the NC and AD groups. The images of the group level interregional correlation matrices using DKI metrics of MK, KFA, AK and RK are shown in Fig. We found the small world attributes of GM networks with MK, KFA, AK and RK metric in the normal elder subjects and AD patients over a wide range of sparsity (6% ~ S ~ 40%)  in comparison with the matched random networks. The small-worldness values calculated from all DKI indices were larger than 1, the values with FA, MD, Ad, RD, MK, RK, AK and KFA were 1.57, 1.50, 1.28, 1.54, 2.04, 1.65, 2.96, 1.70 in AD patients, respectively, and were 1.32, 1.57, 1.32, 1.76, 1.47, 1.33, 1.72, 1.43 in controls, respectively  of each cortical region in both groups. When the betweenness value of a node was more than 1.5 times the average betweenness of the network (bi>1.5), the node was considered as a hub . In the For the MK metric of DKI networks over a wide range of sparsity, AD patients showed increased Lp and decreased Cp compared with controls  and cognitive performance. Partial correlation analysis with age and gender as confounding covariates were separately performed for the AD group. The results showed that KT metrics had closer ties with cognitive functions than DT metrics, particularly for FN, MK, KFA and AK metrics  DKN presented small world characteristics in the brains of both healthy subjects and AD patients. (2) GM network of AD patients tended to be a less optimized network. (3) AD WM networks showed increased Lp and decreased Eg for FN, by contrast, decreased Lp and increased Eg for the other diffusion metrics of MK, RK, AK, KFA, FA, MD, RD and Ad. (4) Regional hubs decreased in AD. (5) Kurtosis parameters had stronger associations with cognitive impairment in AD patients than the DT-derived parameters.Alterations of small world topological properties in AD have been demonstrated by using different modalities such as Electroencephalogram (EEG), Magnetoencephalogram (MEG), fMRI, structural magnetic resonance imaging (sMRI) and DTI in plenty of previous studies. However, there are inconsistent findings about the small world properties. Most structural connectivity networks exhibited increased Lp in AD-related networks. For example, by sMRI and DTI network analysis, Cp and Lp were showed significantly increased in AD patients compared to the controls , 9. On tThe connectivity weights of the white matter networks were defined with the DT and KT metrics that represented distinct biological significance. The weighted networks retain the biophysical information in the graph model. MK reflects the general tissue complexity and the lesion heterogeneity . AK is mIn our findings, divergent features in WM network alterations presented in AD brains with increased Lp and decreased Eg for FN, on the contrary, for most of the diffusion metrics such as MK, RK, AK, KFA, FA, MD, RD and Ad with decreased Lp and increased Eg findings. In addition, most of the DKI metrics showed significant decreases in Cp in the AD group. Increased Lp implied the diminished information propagation ability of the fiber tract, and similar findings were demonstrated in previous studies using DTI and fMRI , 63, 64.We assumed that the index of FN and the other sides of DKI reflected different aspects of the brain. DKI could quantify the deviation of water molecule diffusion from the Gaussian distribution in contrast to DTI Gaussian model. All the DKI metrics reflect microstructure complexity from various diffusion models, and when damaged, for example due to deposition of amyloid plaques and tangles, the well-organized and complex microstructures changed as well as the relevant kurtosis value . HoweverIn contrast to most diffusion MRI studies that focus merely on white matter networks, our study paid attention to changes in both GM and WM networks. In our work, we constructed GM network based on each DKI parameter measurement and found small word properties, which is consistent with previous studies based on cortical thickness . The altWe contrasted the KT- with DT-derived networks. Firstly, our findings revealed impairment in grey matter networks by KT-derived metrics in AD patients, which is not assessable with DT-derived indices. Secondly, for the between-group comparison in the white matter networks Table , all KT-Our findings suggested the wide range of pathological detection of kurtosis might provide more information than diffusion tensor by determining intrinsic microstructural properties with non-Gaussian measurements.Hub nodes play an important role in transferring information between different parts of the brain network, which determines the integration efficiency of the neural information and the stability of the network structure in the networks. Our results showed that hub regions were mostly involved in the default mode in the control group, which were consistent with the previous work . In contOur study has some limitations. At first, our sample size is limited. Secondly, the exact relationship between varied indices of DKI and the complexity of brain remains not entirely clear. The reliability and reproductivity of the DKI networks remain to be confirmed in further studies.We observed interesting small world properties with DKI in human brain and impaired small world networks in the AD pathology, and divergent WM network features were demonstrated in AD brains. In addition, the damage of DKI networks was associated with cognitive performance. DKI parameters might have the superiority to DTI and could be used as a neuroimaging marker for AD by characterizing the microstructure of WM and GM.


Previous studies demonstrated that cardioembolism (CE) was prone to develop hemorrhagic transformation (HT), whereas hyper-permeability of blood–brain barrier (BBB) might be one reason for the development of HT. We, thus, aimed to investigate whether the BBB permeability (BBBP) was higher in CE stroke than other stroke subtypes in acute ischemic stroke (AIS) patients.hypo). CE was diagnosed according to the international Trial of Org 10172 in Acute Stroke Treatment criteria. Receiver operating characteristics (ROC) curve analysis was used to determine predictive value of rPShypo for CE. Logistic regression was used to identify independent predictors for CE.This study was a retrospective review of prospectively collected clinical and imaging database of AIS patients who underwent CT perfusion. Hypoperfusion was defined as Tmax >6 s. The average relative permeability-surface area product (rPS), reflecting the BBBP, was calculated within the hypoperfusion region (rPShypo was 65.5 (35.8–110.1)%. Ninety-seven (51.9%) patients were diagnosed as CE. ROC analysis revealed that the optimal rPShypo threshold for CE was 86.71%. The value of rPShypo and the rate of rPShypo>86.71% were significantly higher in patients with CE than other stroke subtypes (p < 0.05), after adjusting for the potential confounds.A total of 187 patients were included in the final analysis . Median rPSThe extent of BBB disruption is more severe in CE stroke than other stroke subtypes during the hyperacute stage. Cardioembolism (CE) is one of the major causes of ischemic stroke and its outcome is usually worse than other stroke subtypes . StudiesCT perfusion (CTP) is a modern dynamic imaging technique that can evaluate BBBP by generating permeability-surface area product (PS) maps. Most studies focused on the relationship between BBBP and HT, while few explored the association between BBBP and stroke subtypes. Therefore, we aimed to assess the association between BBBP and CE, especially BBBP in the hypoperfusion region where most HT occurs.We reviewed our consecutively collected patients with acute ischemic stroke who received intravenous thrombolysis (IVT) between July 2011 to January 2016. We then enrolled patients who (1) underwent CTP before IVT suggesting acute anterior circulation stroke; (2) baseline hypoperfusion (defined as Tmax >6 s) volume >10 ml. Exclusion criteria: (1) image quality was insufficient for analysis; (2) bilateral ischemic stroke. Intravenous alteplase was administered according to the international guidelines   score, and onset-to-imaging time (OIT).Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria: large-artery atherosclerosis (LAA), cardioembolism (CE), small-artery occlusion (SAO), acute stroke of other determined etiology (ODE), and stroke of undetermined etiology (UDE) , including non-enhanced head CT scan , and volume perfusion CT (VPCT) . VPCT consisted of 26 consecutive spiral acquisitions of the brain from the base to the top of the skull, and were divided into four parts: (1) 2 scans with 3 s cycle time; (2) 15 scans with 1.5 s cycle time; (3) 4 scans with 3 s cycle time; and (4) 5 scans with 6 s cycle time. A 60-ml bolus of non-ionic contrast medium  was used at a flow rate of 6 ml/s, followed by a 20 ml saline chaser at 6 ml/s.Cerebral blood flow (CBF) and Tmax were automatically calculated from CTP data with commercially available software . CTP-derived PS color maps were also automatically generated by MIStar permeability model based on the adiabatic approximation of tissue homogeneity model –10. A thhypo and rPShypo, respectively.Baseline hypoperfusion regions in the ischemic hemisphere were automatically outlined by MIStar on Tmax maps as regions of interest (ROI)s in each slice separately. These ROIs were manually checked and corrected by an experienced neuro-radiologist (Xinfa Ding) and two trained observers (Chang Liu and Feina Shi) who were blinded to other study data. We then superimposed these ROIs on the PS maps and CBF maps by each slice (thickness = 10 mm), respectively, to calculate mean PS and CBF values within all ROIs. The mean PS and CBF were measured by squared voxels. PS represents the rate of iodinated contrast extravasation from the intravascular to the extravascular space through a damaged BBB, and is influenced by CBF at the condition of ischemia. Therefore, it is more appropriate to use relative permeability-surface area product  to represent BBBP in stroke patients , 15. TheHemorrhagic transformation was defined as presence of hemorrhagic infarction (HI) or parenchymal hematoma (PH) at 24 h after treatment according to European Cooperative Acute Stroke Study criteria .hypo for CE. Chi-square test was used to compare the dichotomous variables between two groups, while independent samples Mann–Whitney U test was used for non-normal distributed continuous variables. We performed multivariable logistic regression analysis to assess independent predictors of CE. Results are reported as odds ratios with 95% confidence intervals (CIs). A significance level of 0.05 was used to assess statistical difference. All statistical analyses were performed using SPSS Version 19.0 .Median (25th–75th percentile) for non-normal distributed continuous variables and frequency (percentage) for categorical variables were used. Receiver operating characteristics (ROC) curve analysis was used to determine predictive value of rPSn = 24) and diagnosis of bilateral ischemic stroke (n = 19)]. A total of 187 remaining patients were included for the final analysis, of which 158 patients underwent IVT alone and 29 patients had IVT combined with endovascular therapy. The median age was 73 (61–80) years, and 75 (40.1%) were female. Median baseline NIHSS score was 12 (7–16), and median OIT was 163 (96–240) min. rPShypo ranged from 4.2–321.4% and its median value was 65.5 (35.8–110.1)%. Demographic and clinical characteristics of patients included in and excluded from the current study were comparable .Of 230 patients who met inclusion criteria, 43 patients were excluded [poor image quality due to excessive motion during imaging and trouble in contrast injection which affected measurement of PS  patients were diagnosed as CE, of whom 16 patients did not have atrial fibrillation: 2 had mechanical prosthetic valves, 3 had dilated cardiomyopathy, 1 had mitral annulus calcification, 9 had congestive heart failure, 1 had myocardial infarction. Numbers of patients diagnosed as LAA, SAO, ODE, and UDE were 43 (23.0%), 0. 1 (0.5%) and 46 (24.6%), respectively. 14 patients were diagnosed as non-CE-presenting atrial fibrillation, among whom 11 patients were classified as A1-S0-C1-O0-D0, and 3 patients were classified as A1-S3-C1-O0-D0 according to ASCOD classification .hypo threshold for CE of 86.71%, with an area under the curve of 0.642 , and this yielded a sensitivity of 44.3% and a specificity of 80.0%. As showed in Table p < 0.05). The platelet counts and leukocyte counts were lower in CE group (both p < 0.05). Baseline NIHSS, infarct volume and hypoperfusion volume were comparable between groups, while baseline mismatch ratio was significant lower in CE group (p = 0.033). Compared with non-CE group, CE group had lower CBFhypo (p = 0.032) and greater rPShypo (p = 0.001). CE group had higher rate of HT than non-CE group (p = 0.038), while the rates of HI and PH were comparable.Receiver operating characteristics analysis revealed an optimal rPShypo as well as rPShypo > 86.71% were independently associated with CE .Since atrial fibrillation was highly correlated with CE, it was not selected for adjustment in the binary logistic regression. Table hypo than those with other stroke subtypes.To the best of our knowledge, this is the first study to evaluate the association between quantitatively assessed BBBP and stroke subtypes at hyperacute stage. We found that patients with CE had significantly higher baseline rPSPreviously, a qualitative study found CE was independently associated with BBB disruption, which was defined as the presence of an intraparenchymal hyperdense area exhibited on non-enhanced CT immediately after endovascular therapy . In our BBB permeability is elevated in hypoperfusion region as a result of loss of CBF, oxygen, and nutrients , while cOur finding about the hyper-permeability of BBB in CE patients may suggest that the application of BBB protecting drugs is helpful especially for CE patients in the future. Interestingly, a recent study found that BBB disruption was reversible after reperfusion , althougOur study had several limitations. First, the retrospective design might have a potential risk of selection bias. All patients in this study received IVT. Because treatment should not affect pretreatment BBBP as well as stroke subtype, the results should not be affected by the selected patients. About 10% patients in our study were excluded because of inadequate image quality for the assessment of PS. The measurement of PS is based on arterial input function (AIF) curve and venous output function (OVF) curve. Most defective AIF and OVF curve are due to excessive motion during imaging and trouble in contrast injection, which are unavoidable in practice. Second, patients with hypoperfusion volume less than 10 ml were not included in this study. One reason is for its low signal-to-noise ratio; another is that when drawing ROIs in such small areas, relatively larger manual measurement error may be introduced. Third, the CTP measurement technique used in this study was first-pass with a short acquisition time (74.5 s). Previous studies suggested that it was better to use BBBP estimated from the delayed phase , 35. HowIn conclusion, the current study demonstrated that BBBP in the hypoperfusion region was higher in CE patients than other stroke subtypes, indicating severe BBB disruption in cardioembolic stroke. Further prospective studies are needed to confirm this finding.All subjects had given written informed consent prior to the study, and the protocols had been approved by the human ethics committee of the Second Affiliated Hospital of Zhejiang University School of Medicine. All clinical investigations have been conducted according to the principles expressed in the Declaration of Helsinki.CL drafted and revised the manuscript, participated in study concept and design, conducted the statistical analyses, analyzed, and interpreted the data. ML participated in study concept and design, data interpretation, and made a major contribution in revising the manuscript. FS, ZC, and SY participated in the study design and made contribution in revising the manuscript. CL, FS, and XD participated in the data acquisition and analysis.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.