Comparative effectiveness and cost-effectiveness of natalizumab and fingolimod in rapidly evolving severe relapsing-remitting multiple sclerosis in the United Kingdom

AIM

To evaluate the real-world comparative effectiveness and the cost-effectiveness, from a UK National Health Service perspective, of natalizumab versus fingolimod in patients with rapidly evolving severe relapsing-remitting multiple sclerosis (RES-RRMS).

METHODS

Real-world data from the MSBase Registry were obtained for patients with RES-RRMS who were previously either naive to disease-modifying therapies or had been treated with interferon-based therapies, glatiramer acetate, dimethyl fumarate, or teriflunomide (collectively known as BRACETD). Matched cohorts were selected by 3-way multinomial propensity score matching, and the annualized relapse rate (ARR) and 6-month-confirmed disability worsening (CDW6M) and improvement (CDI6M) were compared between treatment groups. Comparative effectiveness results were used in a cost-effectiveness model comparing natalizumab and fingolimod, using an established Markov structure over a lifetime horizon with health states based on the Expanded Disability Status Scale. Additional model data sources included the UK MS Survey 2015, published literature, and publicly available sources.

RESULTS

In the comparative effectiveness analysis, we found a significantly lower ARR for patients starting natalizumab compared with fingolimod (rate ratio [RR] = 0.65; 95% confidence interval [CI], 0.57-0.73) or BRACETD (RR = 0.46; 95% CI, 0.42-0.53). Similarly, CDI6M was higher for patients starting natalizumab compared with fingolimod (hazard ratio [HR] = 1.25; 95% CI, 1.01-1.55) and BRACETD (HR = 1.46; 95% CI, 1.16-1.85). In patients starting fingolimod, we found a lower ARR (RR = 0.72; 95% CI, 0.65-0.80) compared with starting BRACETD, but no difference in CDI6M (HR = 1.17; 95% CI, 0.91-1.50). Differences in CDW6M were not found between the treatment groups. In the base-case cost-effectiveness analysis, natalizumab dominated fingolimod (0.302 higher quality-adjusted life-years [QALYs] and £17,141 lower predicted lifetime costs). Similar cost-effectiveness results were observed across sensitivity analyses.

CONCLUSIONS

This MSBase Registry analysis suggests that natalizumab improves clinical outcomes when compared with fingolimod, which translates to higher QALYs and lower costs in UK patients with RES-RRMS.

Pyrocumulonimbus affect average stratospheric aerosol composition

Pyrocumulonimbus (pyroCb) are wildfire-generated convective clouds that can inject smoke directly into the stratosphere. PyroCb have been tracked for years, yet their apparent rarity and episodic nature lead to highly uncertain climate impacts. In situ measurements of pyroCb smoke reveal its distinctive and exceptionally stable aerosol properties and define the long-term influence of pyroCb activity on the stratospheric aerosol budget. Analysis of 13 years of airborne observations shows that pyroCb are responsible for 10 to 25% of the black carbon and organic aerosols in the "present-day" lower stratosphere, with similar impacts in both the North and South Hemispheres. These results suggest that, should pyroCb increase in frequency and/or magnitude in future climates, they could generate dominant trends in stratospheric aerosol.

Nucleic Acid Preservation Card Surveillance Is Effective for Monitoring Arbovirus Transmission on Crocodile Farms and Provides a One Health Benefit to Northern Australia

The Kunjin strain of West Nile virus (WNV_KUN) is a mosquito-transmitted flavivirus that can infect farmed saltwater crocodiles in Australia and cause skin lesions that devalue the hides of harvested animals. We implemented a surveillance system using honey-baited nucleic acid preservation cards to monitor WNV_KUN and another endemic flavivirus pathogen, Murray Valley encephalitis virus (MVEV), on crocodile farms in northern Australia. The traps were set between February 2018 and July 2020 on three crocodile farms in Darwin (Northern Territory) and one in Cairns (North Queensland) at fortnightly intervals with reduced trapping during the winter months. WNV_KUN RNA was detected on all three crocodile farms near Darwin, predominantly between March and May of each year. Two of the NT crocodile farms also yielded the detection of MVE viral RNA sporadically spread between April and November in 2018 and 2020. In contrast, no viral RNA was detected on crocodile farms in Cairns during the entire trapping period. The detection of WNV_KUN and MVEV transmission by FTA^TM cards on farms in the Northern Territory generally correlated with the detection of their transmission to sentinel chicken flocks in nearby localities around Darwin as part of a separate public health surveillance program. While no isolates of WNV_KUN or MVEV were obtained from mosquitoes collected on Darwin crocodile farms immediately following the FTA^TM card detections, we did isolate another flavivirus, Kokobera virus (KOKV), from Culex annulirostris mosquitoes. Our studies support the use of the FTA^TM card system as a sensitive and accurate method to monitor the transmission of WNV_KUN and other arboviruses on crocodile farms to enable the timely implementation of mosquito control measures. Our detection of MVEV transmission and isolation of KOKV from mosquitoes also warrants further investigation of their potential role in causing diseases in crocodiles and highlights a “One Health” issue concerning arbovirus transmission to crocodile farm workers. In this context, the introduction of FTA^TM cards onto crocodile farms appears to provide an additional surveillance tool to detect arbovirus transmission in the Darwin region, allowing for a more timely intervention of vector control by relevant authorities.

Towards a More Simplified Approach for Evaluating Strength of Evidence in Health Technology Assessments

It is imperative to thoroughly evaluate the safety, effectiveness, and cost-utility of a new medical device prior to the widespread adoption of the technology. Health technology assessment (HTA) is a systematic evaluation of the benefits and harms of a health technology that aims to inform healthcare policy decisions, improve utilization of cost-effective new technologies, and prevent the adoption of devices with harmful or doubtful value for the health system. Even though dozens of organizations perform HTAs, there is no universally accepted criterion for conducting, reporting, and deriving conclusions from an HTA. Thus, there are considerable discrepancies in the methodologies among HTAs such that the same device with the same underlying clinical evidence is often endorsed by one agency but not another, leading to inconsistencies in healthcare coverage policy decisions. Here, we propose a more simplified and unified approach for summarizing clinical effectiveness and safety outcomes for HTAs. We developed a short, semi-quantitative scoring tool that can be used to provide an overall evaluation of evidence strength in HTAs consisting of five categories: (a) the number of randomized controlled trials (RCTs) that have been performed using the technology, (b) the risk of bias among RCTs, (c) the effect size observed for the key effectiveness outcome, (d) the effect size observed for the key safety outcome, and (e) the generalizability of outcomes observed in RCTs to those observed in real-world clinical use. Utilization of this simplified semi-quantitative framework may simplify the HTA process and improve the consistency of the resulting recommendations.

A versatile reverse genetics platform for SARS-CoV-2 and other positive-strand RNA viruses

The current COVID-19 pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We demonstrate that despite the large size of the viral RNA genome (~30 kb), infectious full-length cDNA is readily assembled in vitro by a circular polymerase extension reaction (CPER) methodology without the need for technically demanding intermediate steps. Overlapping cDNA fragments are generated from viral RNA and assembled together with a linker fragment containing CMV promoter into a circular full-length viral cDNA in a single reaction. Transfection of the circular cDNA into mammalian cells results in the recovery of infectious SARS-CoV-2 virus that exhibits properties comparable to the parental virus in vitro and in vivo. CPER is also used to generate insect-specific Casuarina virus with ~20 kb genome and the human pathogens Ross River virus (Alphavirus) and Norovirus (Calicivirus), with the latter from a clinical sample. Additionally, reporter and mutant viruses are generated and employed to study virus replication and virus-receptor interactions.

Here the authors describe a simple reverse genetics method that relies on overlapping cDNA fragments for generation of positive-strand viruses including SARS-CoV-2 and characterize them in vitro and in vivo.

Replication Kinetics of B.1.351 and B.1.1.7 SARS-CoV-2 Variants of Concern Including Assessment of a B.1.1.7 Mutant Carrying a Defective ORF7a Gene

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiological agent of COVID-19, is a readily transmissible and potentially deadly pathogen which is currently re-defining human susceptibility to pandemic viruses in the modern world. The recent emergence of several genetically distinct descendants known as variants of concern (VOCs) is further challenging public health disease management, due to increased rates of virus transmission and potential constraints on vaccine effectiveness. We report the isolation of SARS-CoV-2 VOCs imported into Australia belonging to the B.1.351 lineage, first described in the Republic of South Africa (RSA), and the B.1.1.7 lineage originally reported in the United Kingdom, and directly compare the replication kinetics of these two VOCs in Vero E6 cells. In this analysis, we also investigated a B.1.1.7 VOC (QLD1516/2021) carrying a 7-nucleotide deletion in the open reading frame 7a (ORF7a) gene, likely truncating and rendering the ORF7a protein of this virus defective. We demonstrate that the replication of the B.1.351 VOC (QLD1520/2020) in Vero E6 cells can be detected earlier than the B.1.1.7 VOCs (QLD1516/2021 and QLD1517/2021), before peaking at 48 h post infection (p.i.), with significantly higher levels of virus progeny. Whilst replication of the ORF7a defective isolate QLD1516/2021 was delayed longer than the other viruses, slightly more viral progeny was produced by the mutant compared to the unmutated isolate QLD1517/2021 at 72 h p.i. Collectively, these findings contribute to our understanding of SARS-CoV-2 replication and evolutionary dynamics, which have important implications in the development of future vaccination, antiviral therapies, and epidemiological control strategies for COVID-19.

COVID-19 in Australia: our national response to the first cases of SARS-CoV-2 infection during the early biocontainment phase

BACKGROUND

On 31 December 2019, the World Health Organization recognised clusters of pneumonia-like cases due to a novel coronavirus disease (COVID-19). COVID-19 became a pandemic 71 days later.

AIM

To report the clinical and epidemiological features, laboratory data and outcomes of the first group of 11 returned travellers with COVID-19 in Australia.

METHODS

This is a retrospective, multi-centre case series. All patients with confirmed COVID-19 infection were admitted to tertiary referral hospitals in New South Wales, Queensland, Victoria and South Australia.

RESULTS

The median age of the patient cohort was 42 years (interquartile range (IQR), 24-53 years) with six men and five women. Eight (72.7%) patients had returned from Wuhan, one from Shenzhen, one from Japan and one from Europe. Possible human-to-human transmission from close family contacts in gatherings overseas occurred in two cases. Symptoms on admission were fever, cough and sore throat (n = 9, 81.8%). Co-morbidities included hypertension (n = 3, 27.3%) and hypercholesterolaemia (n = 2, 18.2%). No patients developed severe acute respiratory distress nor required intensive care unit admission or mechanical ventilation. After a median hospital stay of 14.5 days (IQR, 6.75-21), all patients were discharged.

CONCLUSIONS

This is a historical record of the first COVID-19 cases in Australia during the early biocontainment phase of the national response. These findings were invaluable for establishing early inpatient and outpatient COVID-19 models of care and informing the management of COVID-19 over time as the outbreak evolved. Future research should extend this Australian case series to examine global epidemiological variation of this novel infection.

Older Sepsis Survivors Suffer Persistent Disability Burden and Poor Long-Term Survival

As in-hospital sepsis mortality has decreased, more “sepsis survivors” are progressing into poorly characterized long-term outcomes. The purpose of this study was to describe the current epidemiology of sepsis in older adults compared to middle-aged and young adults. Design: Prospective longitudinal study with patients categorized into young (≤ 45 years), middle-aged (46-64 years) and older (≥ 65 years) patient groups. 328 sepsis patients were characterized by a) baseline demographics and predisposition factors, b) septic event, c) hospital outcomes and discharge disposition, d) 12-month mortality and e) Zubrod Performance status, physical function and cognitive function at three, six and 12-month follow-up. Follow-up visits were not completed due to death (in 68) and withdrawal of consent (in 32). Compared to young and middle-aged patients, older patients had: 1) significantly more comorbidities at presentation (example chronic renal disease 6% vs 12 % vs 21%), intra-abdominal infections (14% vs 25% vs 37%), septic shock (12% vs 25% vs 36%) and organ dysfunctions, 2) higher 30 day mortality (6% vs 4% vs 17%) and fewer ICU free days (median 25 vs 23 vs 20), 3) more progression into CCI (22%, vs 34% vs 42%) with higher poor disposition discharge to non-home destinations (19% vs 40% vs 62%), 4) worse 12-month mortality (11% vs 14 % vs 33%) and, 5) poorer Zubrod Performance status and objectively-measured physical and cognitive functions with slight improvement over 12 month follow-up. Conclusion: Compared to younger patients, older sepsis survivors suffer with both a higher persistent disability burden and 12-month mortality.

Innovations in Geroscience to enhance mobility in older adults

Aging is the primary risk factor for functional decline; thus, understanding and preventing disability among older adults has emerged as an important public health challenge of the 21st century. The science of gerontology - or geroscience - has the practical purpose of "adding life to the years." The overall goal of geroscience is to increase healthspan, which refers to extending the portion of the lifespan in which the individual experiences enjoyment, satisfaction, and wellness. An important facet of this goal is preserving mobility, defined as the ability to move independently. Despite this clear purpose, this has proven to be a challenging endeavor as mobility and function in later life are influenced by a complex interaction of factors across multiple domains. Moreover, findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. For these reasons, behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. Other pharmaceutical interventions, such as oxytocin, and complementary and alternative interventions, such as massage therapy, may enhance physical function both through direct effects on biological mechanisms related to mobility, as well as indirectly through modulation of cognitive and socioemotional processes. Thus, the purpose of the present review is to describe evolving interventional approaches to enhance mobility and maintain healthspan in the growing population of older adults in the United States and countries throughout the world. Such interventions are likely to be greatly assisted by technological advances and the widespread adoption of virtual communications during and after the COVID-19 era.

Lipid intensive drug therapy for sepsis pilot: A Bayesian phase I clinical trial

OBJECTIVES

Cholesterol may be protective in sepsis. Patients with early sepsis may have critically low cholesterol levels that are associated with poor outcomes. The study objective was to test the safety of a fish oil-containing lipid injectable emulsion for stabilizing early cholesterol levels in sepsis.

METHODS

Phase I Bayesian optimal interval design trial of adult patients with septic shock (Sequential Organ Failure Assessment score ≥4 or vasopressor dependence). Using sequential dose escalation, participants received 2 doses of 1.0 to 1.6 g/kg of lipid emulsion (Smoflipid 20% lipid emulsion) within 48 hours of enrollment. Cholesterol levels, function, and organ failure were assessed serially during the first 7 days of hospital admission.

MEASUREMENTS AND MAIN RESULTS

A total of 10 patients with septic shock were enrolled. One patient withdrew for social reasons. Another patient had an unrelated medical complication and received 1 drug dose. Of 9 patients, mean age was 58 years (SD 16), median Sequential Organ Failure Assessment was 8, and 28-day mortality was 30%. No serious adverse events related to lipid infusion occurred. The six occurrences of non-serious adverse events possibly related to lipid infusion included hyperglycemia (1), elevated triglycerides (3), anemia (1), and vascular access redness/pain (1) for all doses. The mean change in total cholesterol levels from enrollment was -7 (SD 16.6) at 48 hours and 14 (SD 25.2) at 7 days.

CONCLUSIONS

Fish oil-containing lipid emulsion administration during early septic shock was safe. Further studies are needed to assess effects on cholesterol levels, function, and organ failure.

CLINICAL TRIAL REGISTRATION

NCT03405870.

A Case of Japanese Encephalitis with a Fatal Outcome in an Australian Who Traveled from Bali in 2019

A severe case of Japanese encephalitis virus (JEV) infection, resulting in fatality, occurred in an unvaccinated Australian male traveler from Bali, Indonesia, in 2019. During hospitalisation in Australia, patient cerebrospinal fluid (CSF) yielded JEV-specific IgM antibodies and RNA, and an isolate of the virus. Ongoing transmission of JEV in Bali underscores this pathogen as a public health risk and the importance of appropriate health, vaccination and mosquito avoidance advice to prospective travelers to the region.

Chronic Critical Illness Patients Fail to Respond to Current Evidence-Based Intensive Care Nutrition Secondarily to Persistent Inflammation, Immunosuppression, and Catabolic Syndrome

BACKGROUND

Sepsis-induced multiple-organ failure (MOF) has plagued surgical intensive care units (ICUs) for decades. Early nutrition (principally enteral) improves hospital outcomes of high-risk ICU patients. The purpose of this study is to document how the growing epidemic of chronic critical illness (CCI) patients responds to adequate evidence-based ICU nutrition.

METHODS

This retrospective post hoc subgroup analysis of an ongoing sepsis database identified 56 CCI patients who received early, adequate nutrition per an established surgical ICU protocol compared with 112 matched rapid-recovery (RAP) patients.

RESULTS

The matched CCI and RAP groups had similar baseline characteristics. Serial biomarkers showed that CCI patients remained persistently inflamed with ongoing stress metabolism and that despite receiving evidence-based protocol nutrition, they had persistent catabolism and immunosuppression with more secondary infections. More CCI patients were discharged to poor nonhome destinations (ie, skilled nursing facilities, long-term acute care, hospice) (81% vs 29%, P < 0.05). At 12-month follow-up, CCI patients had worse functional status by Zubrod score (3.17 vs 1.62, P < 0.001) and Short Physical Battery Testing (4.78 vs 8.59, P < 0.02), worse health-related quality of life by EQ-5D-3L descriptive measures (9.07 vs 7.45, P < 0.003), and lower survival (67% vs 92%, P < 0.05).

CONCLUSIONS

Despite early, adequate, evidence-based ICU nutrition, septic surgical ICU patients who develop CCI exhibit persistent inflammation, immunosuppression, and catabolism with unacceptable long-term morbidity and mortality. Although current evidence-based ICU nutrition may improve short-term ICU outcomes, novel adjuncts are needed to improve long-term outcomes for CCI patients.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Septic pericarditis and pericardial abscess secondary to a migrating foreign body in a dog

Abscess formation in the pericardial space has been described as a rare complication of trauma, congenital defects, penetrating foreign body, or extension of local myocardial infection in the dog. Presented here is a case of a juvenile dog with septic pericardial effusion secondary to an isolated intrapericardial abscess. Surgical pericardiectomy was successful in removing the abscess and nidus for septic effusion in this patient, and histopathology of the abscess tissue was suggestive of foreign plant material migration as the nidus for abscess formation. Recheck echocardiogram at the six-month postoperative period showed no recurrence of pericardial effusion or abscessation. Although abscess formation and septic pericarditis secondary to foreign body migration is an uncommon cause for large volume pericardial effusion, this should be considered as a differential particularly in a young and previously healthy dog.

Chemical evidence of inter-hemispheric air mass intrusion into the Northern Hemisphere mid-latitudes

The East Asian Summer Monsoon driven by temperature and moisture gradients between the Asian continent and the Pacific Ocean, leads to approximately 50% of the annual rainfall in the region across 20–40°N. Due to its increasing scientific and social importance, there have been several previous studies on identification of moisture sources for summer monsoon rainfall over East Asia mainly using Lagrangian or Eulerian atmospheric water vapor models. The major source regions for EASM previously proposed include the North Indian Ocean, South China Sea and North western Pacific. Based on high-precision and high-frequency 6-year measurement records of hydrofluorocarbons (HFCs), here we report a direct evidence of rapid intrusion of warm and moist tropical air mass from the Southern Hemisphere (SH) reaching within a couple of days up to 33°N into East Asia. We further suggest that the combination of direct chemical tracer record and a back-trajectory model with physical meteorological variables helps pave the way to identify moisture sources for monsoon rainfall. A case study for Gosan station (33.25°N, 126.19°E) indicates that the meridional transport of precipitable water from the SH accompanying the southerly/southwesterly flow contributes most significantly to its summer rainfall.

Mechaniation a Large Register of First Order Patient Data

In any medical record system it is necessary to link the present record of a patient to his past records in the same or other institutions. This is usually accomplished by establishing patient registers. We have studied the patient register of the Los Angeles County General Hospital (approximately 1000 000 cases) and found it feasible to mechanize this file. It is therefore realistic to contemplate development of interagency health information systems in metropolitan regions.

Fumarase Deficiency: A Safe and Potentially Disease Modifying Effect of High Fat/Low Carbohydrate Diet

Fumarate hydratase deficiency (FHD) caused by biallelic alterations of the FH (fumarate hydratase) gene is a rare disorder of the tricarboxylic acid cycle, classically characterized by encephalopathy, profound psychomotor retardation, seizures, a spectrum of brain abnormalities and early death in childhood. Less common milder phenotypes with moderate cognitive impairment and long-term survival have been reported. In addition, heterozygous mutations of the FH gene are responsible for hereditary leiomyomatosis and renal cell cancer (HLRCC). There is currently no recommended disease modifying treatment for FHD and only isolated reports of unsuccessful dietary modifications. Herein, we describe the safe and possibly disease modifying effect of a high fat, low carbohydrate diet in a 14-year-old female with severe FHD.

Splenic trauma: WSES classification and guidelines for adult and pediatric patients

Spleen injuries are among the most frequent trauma-related injuries. At present, they are classified according to the anatomy of the injury. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic derangement, and the associated injuries. The management of splenic trauma patients aims to restore the homeostasis and the normal physiopathology especially considering the modern tools for bleeding management. Thus, the management of splenic trauma should be ultimately multidisciplinary and based on the physiology of the patient, the anatomy of the injury, and the associated lesions. Lastly, as the management of adults and children must be different, children should always be treated in dedicated pediatric trauma centers. In fact, the vast majority of pediatric patients with blunt splenic trauma can be managed non-operatively. This paper presents the World Society of Emergency Surgery (WSES) classification of splenic trauma and the management guidelines.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

World Journal of Emergency Surgery reviewer acknowledgement 2015

The editors of World Journal of Emergency Surgery would like to thank all our reviewers who have contributed to the journal in volume 10 (2015).

The evolution of nutritional support in long term ICU patients: from multisystem organ failure to persistent inflammation immunosuppression catabolism syndrome

Multiple organ failure (MOF) is an evolving pathologic phenotype that plagues intensive care units globally. This manuscript aims to depict the evolution of single organ failure through multiple organ failure, ending in the newest phenotype called persistent inflammation, immunosuppression, catabolism syndrome (PICS). Among the other MOF phenotypes discussed are systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome. Along with a review of the four phenotypes of MOF there is a review of the current literature on nutritional supplementation. Discussed in these sections are possible etiologies for the various progression of MOF, total enteral nutrition (TPN) versus early enteral nutrition (EEN), early versus late parenteral nutrition, glycemic control, and new enteral formulas. Finally, as the newest phenotype, PICS, has evolved we try to make inferences from similar pathologic states to recommend nutritional support that has proven beneficial.

Potential Health Risk of Herbal Distillates and Decoctions Consumption in Shiraz, Iran

Concentration of 26 elements in 16 different herbal distillates and 5 herbal decoctions, were determined using inductively coupled plasma-mass spectrometry (ICP-MS). The elemental content of five raw herbal materials used for making decoctions and seven distilled and boiled residues were also evaluated by inductively coupled plasma optical emission spectrometry (ICP-OES). The results indicated that herbal products display a wide range of elemental concentrations. Compared with world health regulations, the concentrations of the elements in herbal distillates and decoctions did not exceed the recommended limits. The analysis of herbal extracts did not show a significant transfer of toxic elements during decoction preparation. Comparison of elemental content among fresh herbal material and herbal distillate and decoction of the same herb showed that, besides the elemental abundance of herbal organs, the ionic potential of elements also play an important role in elemental content of herbal products. Based on the results of the research, it seems that most health benefits attributed to herbal products (especially herbal distillates) are more related to their organic compounds rather than elemental composition. Calculated hazard quotient (HQ) and hazard index (HI) were used to evaluate the noncarcinogenic health risk from individual and combined metals via daily consumption of 100 ml of herbal distillates and 250 ml of herbal decoctions. Both HQs and HI through consumption of herbal distillates and herbal decoctions (except Valerian) were below 1. Apparently, daily consumption of herbal distillates and decoctions at the indicated doses poses no significant health risk to a normal adult.

Ecotoxicological risk of polycyclic aromatic hydrocarbons (PAHs) in urban soil of Isfahan metropolis, Iran

Concentration, distribution, probable sources, and health risks of 16 polycyclic aromatic hydrocarbons (PAHs) were investigated in 52 soil samples collected within a radius 50 km from Isfahan metropolis center. Total concentration of PAHs ranged from 57.70 to 11,730.08 μg/kg averaging 2,000.56 μg/kg. Spatial PAH profiles were site-specific and higher concentration of PAHs was observed in the vicinity of industrial zones within Isfahan metropolis. The molecular indices, ring classes, and principal component analysis indicated that the sources of PAHs were both geogenic and pyrogenic. The incremental lifetime cancer risks of exposure to soil PAHs for adults and children living in the study area were 2.3×10(-2) and 2.2×10(-3), respectively. The results suggest that current PAHs levels in Isfahan metropolis soil are highly carcinogenic and may hold a serious health risk for local resident.

Heavy metals fractionation in surface sediments of Gowatr bay--Iran

In this study, the chemical speciation of heavy metals and their distribution in surface sediments of Gowatr bay, southeast Iran, are investigated. Modified Bureau Commune de Reference of the European Commission (BCR) sequential extraction technique was applied to assess Cu, Pb, Zn, Mn, Ni, Co, Cr, V, and Fe in the four fractions of five surface sediment samples. Calculated contamination factors (C(i)f) indicate considerable to very high degree of contamination for Cu and Cr, and very high degree for Zn and Ni. Maximum contamination degree (Cd) also suggests serious anthropogenic pollution at two sites. The dominance of average concentration of Cu, Pb, Zn, and Mn in non-residual fractions indicates higher ecological risk within Gowatr bay. Conversely, Ni, Co, Cr, Fe, and V mainly exist in residual phase and hence pose no immediate ecological risk. Calculated individual contamination factors (ICFs) indicate the highest risk of Cu, Pb, Zn, and Mn at two investigated sites. Global contamination factor (GCF) reveals that Pasabandar harbor is highly impacted by metal pollutants.

Reviewer acknowledgement

Contributing reviewers

Is there value in plasma cytokine measurements in patients with severe trauma and sepsis?

For the past thirty years, since IL-1β and TNFα were first cloned, there have been efforts to measure plasma cytokine concentrations in patients with severe sepsis and trauma, and to use these measurements to predict clinical outcome and response to therapies. The numbers of cytokines and chemokines that have been measured in the plasma have literally exploded with the development of multiplex immune approaches. Dozens of relatively small cohort studies have shown plasma cytokine concentrations correlating with outcome in sepsis and trauma. Despite what appears to be a consensus that plasma cytokine concentrations should be useful in the clinical setting, only two cytokines, IL-6 and procalcitonin, have approached routine clinical use. IL-6 has been used as a research tool for entry into sepsis-intervention trials, while procalcitonin is being used clinically at a large number of institutions to distinguish sepsis from other inflammatory processes. For most cytokines, the relative lack of sensitivity and specificity of individual or multiplex cytokine measurements has hindered their utility to predict clinical trajectory in individual patients. The problem rests with a general misunderstanding of cytokine biology, failing to appreciate the general paracrine nature of these mediators, the presence of binding proteins, chaperones and inhibitors in the plasma, and the rapid clearance of these proteins by binding to cell receptors and clearance predominantly by the kidney. The future of using plasma cytokine measurements as an indicator of sepsis/trauma severity or predicting outcome is generally behind us, although there is optimism that procalcitonin measurements may ultimately prove to have utility in the diagnosis of severe sepsis.

Fluctuations of MS births and UV-light exposure

BACKGROUND

Patients with multiple sclerosis (MS) are more frequently born in spring when compared to autumn. Fluctuation of UV-light has been hypothesized to drive this phenomenon.

AIM

To assess the correlation between fluctuation of sunlight and birth season in persons with MS.

METHODS

For this record-linkage study, we collected from the international MSBase and the Italian MS iMed-web databases the dates of birth of 11,415 patients with MS from 36 centres from 15 countries worldwide and compared these to dates of live-births from national registries. From all participating sites, we collected data on UV-light fluctuation and assessed its correlation with seasonal fluctuation in MS births.

RESULTS

Compared with the reference cohort, an increased proportion of persons with MS were born in spring and a decreased proportion in autumn (odds ratio (OR) to be born in spring versus autumn = 1.158, χ² = 36.347, P < 0.001). There was no significantly increased fluctuation of MS births with increased quartile of ambient UV-light fluctuation (Ptrend = 0.086).

CONCLUSION

Seasonal fluctuation of MS births as found in this worldwide cohort of patients with MS did not correlate with variation in seasonal fluctuation of UV-light. Most likely, it results from a complex interplay between fluctuation of sunlight, behavioural factors, other environmental factors and (epi)genetic factors.

Evaluation of potentially toxic metals pollution in the sediments of the Kor river, southwest Iran

This study is carried out to evaluate potentially toxic metal concentrations (As, Cd, Cr, Cu, Hg, Mo, Ni, Pb, and Zn) together with their spatial distribution, degree of pollution, and potential ecological risk in Kor river sediments (southwest Iran) using sediment quality guidelines, geoaccumulation index (I geo), Hakanson potential ecological risk index (RI), and standard methods of statistical analysis. The study area stretches some 140 km from the Drodzan Dam to Bakhtegan Lake, a stretch of river where different industrial and domestic activities (e.g., petrochemical complex, oil refinery, industrial meat processing complex, Marvdasht city sewage) and ecological value overlap with each other. Calculated geoaccumulation index indicate that 50 % of the stations are moderately to very extremely polluted. The potential ecological risk for nine investigated metals in Kor river is Hg (948) > Mo (51.9) > Ni (37.8) > Cd (29.8) > As (22) > Cu (16.6) > Pb (13.3) > Zn (3.3) > Cr (1). Results show that sediments in parts of Kor river sediments are heavily affected by effluents discharged from industrial plants and other parts are affected by agriculture and urban runoff from nearby lands. These phenomena may cause a risk of secondary water pollution under sediment disturbance and/or changes in the physical-chemical characteristics of the aquatic system.

The frequency of CSF oligoclonal banding in multiple sclerosis increases with latitude

BACKGROUND

With the advent of MRI scanning, the value of lumbar puncture to assess oligoclonal band (OCB) status-for the diagnosis of multiple sclerosis (MS) is increasingly uncertain. One major issue is that the reported frequency of cerebrospinal fluid (CSF)-restricted oligoclonal banding for the diagnosis of MS varies considerably in different studies. In addition, the relationship between OCB positivity and disease outcome remains uncertain, as reported studies are generally too small to assess comparative disability outcomes with sufficient power.

METHODS

In order to further investigate variation of OCB positivity in patients with MS, we utilized MSBase, a longitudinal, Web-based collaborative MS outcomes registry following clinical cohorts in several continents and latitudes. We also assessed whether OCB positivity affects long-term disability outcome.

RESULTS

A total of 13,242 patient records were obtained from 37 MS specialist centres in 19 different countries. OCB status was documented in 4481 (34%) patients and 80% of these were OCB positive. The presence of OCB was associated with degree of latitude (p = 0.02). Furthermore, the outcome of patients negative for CSF-specific OCB was significantly better in comparison to the OCB positive patients, as assessed by Expanded Disability Status Scale change (p < 0.001).

CONCLUSIONS

The results of this study indicate that latitude could explain some of the inconsistencies in OCB status reported in different populations. The study confirms that OCB positivity in MS is associated with a worse long-term prognosis.

Speciation and phytoavailability of heavy metals in contaminated soils in Sarcheshmeh area, Kerman Province, Iran

Heavy metal content in soil and the most abundant indigenous plant species (Artemisia sieberi) in Sarcheshmeh area is investigated. Sequential extraction analysis is carried out and phytoavailable fractions of selected heavy metals are also determined. The results show that heavy metals in the study area are potentially bioavailable. Calculated transfer factor (mean value for Cu: 5.7; As: 8.9; Pb: 4.1; Mo: 7.2; Cd: 1.9; and Zn: 1.8) and heavy metal concentration in plant species indicate that metal contamination is already transferred to Artemisia sieberi which proved to behave like an accumulator plant and hence poses a serious threat to local population. Contamination is mostly the result of three decades of ore smelting at the Sarcheshmeh copper complex.