Hemp seeds are rich in polyunsaturated fatty acids as well as other bioactive compounds. Using dietary hemp seeds as late gestation and lactation supplementation for sows and early life supplementation for piglets, we found that the indicators of oxidative status were improved in both sows and offspring. Besides the significant improvement in the antioxidant defense system of the sows, our assessment of dietary intervention resulted in an array of increased antioxidative status markers for their progeny. In addition, this could be translated into increased adaptability to the upcoming weaning stage. This study shows the antioxidant effect of a dietary hemp seed diet rich in ω-6 polyunsaturated fatty acid (PUFA) on oxidative status in sows during late gestation and lactation and their offspring. Ten pregnant sows were divided into two groups and fed either a control diet (CD) or a hemp diet (HD) containing 2% hemp seed meal for a period of 10 days before farrowing and 5% throughout the lactation period (21 d). After farrowing, 16 of their resulting piglets were divided into two groups: control group CD (eight piglets derived from control sows) and HD group (eight piglets derived from HD sows), respectively. Blood collected from sows and piglets at day 1, 7 and 21 was used for the measurement of antioxidant enzymes , superoxide dismutase (SOD), glutathione (GPx)), nitric oxide production (NO), lipid peroxidation (thiobarbituric acid reactive substances—TBARS), reactive oxygen species (ROS) generation and total antioxidant capacity (TAC) in plasma. The results showed a significant improvement in the oxidative status of sows fed HD throughout lactation compared with CD. Similarly, in piglets, HD positively influenced the activities of antioxidant enzymes, TAC and NO levels and significantly decreased lipid peroxidation in plasma until weaning, in comparison with the CD group. This study suggests the potential of hemp seed diet to improve the overall antioxidant status of the lactating sows and their progeny.  Escherichia coli [Nigela sativa  extracts, in doses equivalent to 0.0, 1.5 and 4.5 g extract kg−1 to weanling piglets, reduced the levels of naturally occurring E. coli in the jejunal and rectal contents [Macleaya cordata (Wild) R. Br. extracts to feed for nursery and growing pigs decreased diarrhea occurrence and increased their weight gain [E. coli (ETEC) improved their average daily gain [Sanguinaria canadensis [At weaning, the changes in the piglets’ environment (separation from the sow), nutrition (switch from milk to solid feed) and regrouping (mixing with piglets from other litters) are significant and stressful . Weaninghia coli . Alternahia coli ,7 in pighia coli ,9,10. Suhia coli . For inscontents . The addght gain ,14. Deviily gain . Also, rily gain  and Sangnadensis  inhibitenadensis ,19. Incrnadensis . These anadensis . This wanadensis . Similarnadensis ,22,23. Bnadensis . Also, Hnadensis .(Cannabis sativa L.) is one of the many plants rich in bioactive compounds that have been exploited for health food and medicinal purposes [Hemp purposes ,26,27. Rpurposes . Hemp sepurposes ,30,31. Tpurposes , terpenopurposes . They arpurposes ,34,35,36purposes ,38,39. 2O2-mediated oxidative stress by increasing the gene expression of antioxidant enzymes in HepG2 cells [Few studies have looked at the effects of hemp seeds on oxidative status and health in the diets of pigs and other animals. However, Prociuk et al. (2006) have shown the beneficial effects of dietary hemp seeds in hypercholesterolemic rabbits following cardiac ischemia/reperfusion injury , which cG2 cells . It is gG2 cells ,48. LipiG2 cells ,50. OxidG2 cells . During G2 cells ,53. At tG2 cells ,55. In lG2 cells . Besides the large numbers of free radicals and reactive oxygen species, oxidative stress leads to the imbalanced generation of important molecules in the body . As suchWith regard to the health status of suckling piglets, several studies have found beneficial effects. Thus, the report of Xie et al. (2015) showed that piglets derived from sows fed a chitosan oligosaccharide supplemented diet during late gestation and lactation had reduced hypoglycemia and an increased growth rate . SimilarThe present study was designed to assess the effects of dietary hemp seed inclusion on oxidative status in the plasma of sows and resulting progeny. Hemp seed was included in the diet of sows from late gestation through lactation as an early life intervention for piglets to better deal with stress during weaning. Antioxidant enzyme activities, total antioxidant capacity, nitric oxide, ROS and TBARS concentration were measured at individual time points. Animals were cared for in accordance with the Romanian Law 206/2004 and the EU Council Directive 98/58/EC for the handling and protection of animals used for experimental purposes. The study protocol was approved by the Ethical Committee of the National Research-Development Institute for Animal Nutrition and Biology, Balotesti, Romania . All animals remained healthy during the experimental period and no veterinary drugs were used.This study is part of a wider experiment , where After farrowing, 16 of the resulting piglets were divided into two groups: control group CD (8 piglets derived from control sows) and HD group (8 piglets derived from HD sows), respectively. Starting on day 10 after birth, piglets had ad libitum access to the control or hemp diets (1.5% hemp seed inclusion), they were studied until day 21 (weaning day).Pelleted diets were formulated to be isoproteic and isocaloric and to meet all nutritional requirements specific to TOPIGS hybrid  and at eAR) using the Folin–Ciocalteu and 2,2-diphenyl-1-picrylhydrazyl (DPPH) methods. The polyphenol profile was determined by high performance liquid chromatography coupled with mass spectrometry (LC–MS). The extraction procedure involved a maceration step in a mixture of methanol-acetone-water  for 24 hours at 37 °C under continuous shaking according to the method of Teh et al. (2014) [The gross chemical composition of hemp and experimental feed was analyzed according to the Romanian Standardization Association (ASRO) methods: dry matter (SR ISO 6496:2001), crude protein (SR EN ISO 9583-2:2009), fat (SR EN ISO 6492:2001), crude fiber (SR EN ISO 6865:2002) and ash (SR EN ISO 2171:2010) [. (2014) .®, Arzergrande, Italy) and processed within one hour after collection by centrifugation at 2500 rpm, for 10 min, at 4 °C . Plasma samples were frozen immediately after collection and stored at −80 °C until analysis and were used for the measurement of antioxidant enzymes catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx), total antioxidant capacity (TAC), nitric oxide production (NO), lipid peroxidation ((tpc) and reactive oxygen species (ROS).Blood samples were aseptically collected by venipuncture  from the jugular vein from sows 10 days before farrowing , immediately after farrowing (day 1) and on day 7 and 21 of lactation as well as from piglets on day 1, 7 and 21 after birth. Blood was collected into 9-mL Vacutainer tubes containing 143 U/mL of lithium heparin  per 100 g of sample [The TPC from hemp seed and experimental feed compounds was determined using the Folin–Ciocalteu method previously described by Arnous et al. (2002). It is a colorimetric in vitro assay of polyphenolic antioxidants, which uses gallic acid (known polyphenol) as the reference standard. A volume of 5 µL of undiluted sample was mixed with 795 µL of distilled water and 50 µL of Folin–Ciocalteu reagent; after exactly 1 min, 150 µL of 20% Naf sample . AR) was measured using the stable radical DPPH as described by Arnous et al. (2002). Briefly, an aliquot of 25 μL of diluted sample was added to 975 μL of DPPH solution (60 μM in methanol) and vortexed, the absorbance was read at 515 nm at t = 0 and t = 30 min. Results were expressed as µM Trolox equivalents (TE) [The antiradical activity (Ants (TE) . The chromatographic measurements were performed using a complete HPLC Agilent 1200 system using a C18 Eclipse XDB column . The HPLC system was coupled to a mass spectroscopy detector, Agilent 6110 single quadrupole . The analytical mobile phase consisted of 0.1% acetic acid in water (solvent A) and 0.1% acetic acid in acetonitrile (solvent B). The compounds were separated using gradient elution with 0.5 mL/min flow at 25 °C for 30 min as follows: 5% solvent B for 2 min, increased to 40% until min 18 min, increased to 90% until 20 min, maintained at 90% for 4 min, decreased to 5% until 25 min, followed by another 5 min at 5 % for reconditioning. Chromatograms were recorded at 280 and 340 nm. Mass spectra were acquired in the positive ESI mode: 3000 V, 300 °C, 8 L/min nitrogen flow, m/z:100−1000, full-scan. Data acquisition was achieved using the ChemStation software (Agilent Technologies). The results were expressed as µg catechin equivalents (CE) /mL extract.PUFAs were measured in hemp seeds and diets as fatty acid methyl esters (FAME) by gas chromatography using a Perkin Elmer-Clarus 500 gas chromatograph, fitted with a Flame Ionization Detector and capillary separation column with high polar stationary phase Agilent J&WGC Columns, method described by Hăbeanu et al. (2014) . 2O2 concentration. The produced formaldehyde is measured colorimetrically with 4-amino-3-hydrazino-5-mercapto-1,2,4-triazole  as a chromogen. “Purpald specifically forms a bicyclic heterocycle with aldehydes, which upon oxidation, changes from colourless to purple” [+ per minute at 25 °C. The CAT assay kit intra-assay coefficient of variation (CV) was 3.8% and the inter-assay CV was 9.9%. We obtained an intra-assay CV of 8.43% and an inter-assay CV of 13.02%. The SOD assay kit intra-assay CV was 3.2% and the inter-assay CV was 3.7%. We obtained an intra-assay CV of 9.31% and an inter-assay CV of 17.08%. The GPx assay kit intra-assay CV was 5.7% and the inter-assay CV was 7.2%. We obtained an intra-assay CV of 10.47% and an inter-assay CV of 15.02%.Catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx) activities were measured using standardized kits  according to the manufacturer’s instructions. The absorbance was measured using a Tecan microplate reader . Catalase activity was measured at 540 nm and the results were expressed as nmol/min/mL. The method is based on the reaction of an enzyme with methanol in the presence of an optimal H purple” . One uniPlasma lipid peroxidation was analyzed as previously described by Ohkawa et al. (1979) . The TBA2+ is reduced by antioxidant to Cu+. The resulting Cu+ specifically forms a colored complex with a dye reagent. The color intensity at 570 nm is proportional to TAC in the sample. Briefly, 20 µL of undiluted plasma or Trolox standard solution along with 100 µL working reagent was added to a 96-well microplate, mixed by tapping and incubated at room temperature for 10 min according to the manufacturer’s recommendations. The absorbance of the reaction was read at 570 nm using a microplate reader (Tecan Infinite M200) [Total antioxidant capacity in plasma was assayed using a QuantiChrom kit . The assay measures total antioxidant capacity in which Cute M200) . Results2− concentration. Briefly, 80 µL of appropriately diluted sample (plasma) was mixed with 10 µL of enzyme cofactor mixture and 10 µL of nitrate reductase mixture. Then, the plate was covered and incubated for 3 h at room temperature. Subsequently, 50 µL of Griess Reagent R1 followed immediately by 50 µL of Griess Reagent R2 was added to each of the wells. The color was allowed to develop for 10 min at room temperature. Absorbance was read at 550 nm using a microplate reader (Tecan Infinite M200). Results (NO) were expressed based on a NaNO2 standard curve with a concentration range of 0 to 100 µM [Nitric oxide (NO) levels in plasma were evaluated using the Nitrate/Nitrite Colorimetric Assay Kit , according to the manufacturer’s instructions. The first step of the assay is the conversion of nitrate to nitrite using nitrate reductase. Further, the addition of the Griess Reagents converts nitrite into a purple azo compound. The absorbance measurement of this azo chromophore accurately determines NOo 100 µM . The NO The determination of ROS in plasma was evaluated using 20 μM 2′,7′- dichlorodihydrofluorescein diacetate (DCF-DA) which undergoes hydrolyzation by cellular esterases to produce DCF . The reaction of DCF with ROS forms fluorescent DCF. Fluorescence signal was measured after 4 h in 96-well black plates at an excitation wavelength of 485 nm and emission wavelength of 528 nm using a microplate reader (Tecan Infinite M200). Results are expressed as fluorescence arbitrary units (a.u.). We obtained an intra-assay CV of 8.36% and an inter-assay CV of 11.83%.TM from SAS. Repeated measurements analysis (repeated ANOVA) was performed to investigate the statistical differences between groups for all analyzed parameters employing the Restricted Maximum Likelihood (REML) method. The repeated measures design reduces the variance of estimates of treatment-effects, allowing statistical inference to be made with fewer data. The model effects were diet (CD or HD), time  and their interaction (D × T) in order to evaluate the overall treatment effect. Each sow was considered an experimental unit. For piglets, the statistical model included litter as a random effect. Values of p < 0.05 were considered significant. All data are expressed as mean ± standard error of the mean (SEM). All the results were submitted to SAS University Edition software  and JMP 11 Statistical DiscoveryAR) was measured in both the control and hemp diets as well as in hemp seed. The results from The total polyphenol content (TPC) and the antiradical activity  in similar amounts in both the control and the hemp seed diets (5% inclusion).The polyunsaturated fatty acid (PUFA) profiles were previously reported by Hăbeanu et al. (2018) . PUFAs rSimilar to the profile of polyphenols, cannabinoids were analyzed by LC–MS and the results were expressed as mg cathechin equivalents/100 g feed. The profile obtained for HD (5% inclusion) included several cannabinoids such as cannabigerol (CBG—66.09 mg CE/100g feed), cannabigerolic acid (CBGA-46.85 mg CE/100g feed), ∆9-tetrahydrocannabinol (∆9-THC-48.16 mg CE/100g feed) and ∆9-tetrahydrocannabinolic acid (∆9-THCA–28.65 mg CE/100g feed), which accounted for a total of 164.4 mg CE/100 g of feed. Animal performance (average daily feed intake and average weight gain) was described in detailed by Habeanu et al. (2018) . Brieflyp = 0.15) immediately after farrowing (day 1), but decreased significantly on day 7 (p = 0.06). Similarly, HD reduced the plasma TBARS levels in sows with significant main effects of D (p < 0.0001 *), T (p < 0.0001 *) and D × T (p = 0.0048 *) during the lactation period as shown in Main effects of diet (D), time (T) and their interaction (D × T) for the markers associated with oxidative status in lactating sows were assayed. Reactive oxygen species (ROS) in the plasma of sows fed HD diet did not decrease (on day 7 a. This dp = 0.0003 *) and D × T (p = 0.04 *). The hemp diet increased NO synthesis in HD sows compared to CD sows during lactation (p = 0.0014 *) and time . The D × T interaction (p = 0.0039 *) shows that the pattern over time was different for the two diets, with a delayed decrease in NO in HD sows. At the same time, the plasma total antioxidant capacity (TAC) increased significantly both at day 7 and day 21 c. The imactation d, reflecp < 0.0001 *), it registered elevated levels in HD sows compared to the control fed sows, as revealed by the main effect of D (p = 0.0005 *) (p < 0.0001 *), whereas only a trend was noticed for the D × T interaction (p > 0.05) (p = 0.0001 *), but the increase for HD was greater than the increase for CD   was assayed in the plasma of sows from late gestation through lactation day 21. Our results  show a s.0005 *) a. The pl > 0.05) b. Simila.0002 *) c. p < 0.0001 *), with a tendency for lower levels of ROS in HD piglets  (p = 0.0015 *) (Reactive oxygen species (ROS) levels decreased in time in the plasma of piglets irrespective of the treatment. The decreasing trend during lactation reflects a significant effect of time for both HD and CD piglets ( > 0.05) a. The pl.0015 *) b. p = 0.0002 *), but decreased over time. On the contrary, the decrease in CD piglets was observed only from day 7 to 21  levels were higher overall in HD piglets compared to the control  and decreased over time, whereas SOD activity for CD piglets did not change over time   a. The ac.0198 *) b. On day.0198 *) c.Cannabis sativa L.) is an example and, besides its other industrial uses, it is a good source of PUFAs, polyphenols, tocopherols, proteins, vitamins, minerals, etc. [Current challenges in livestock production refer to the increasing competition for natural resources, as well as to the development of strategies focused on replacing antibiotics as dietary growth promoters . After tls, etc. . In this study, we showed that the inclusion of hemp seed in the diet of late gestation sows and during the suckling period of piglets influences the systemic oxidative status of both sows and offspring by increasing antioxidant enzyme activities, total antioxidant capacity and nitric oxide synthesis, and by decreasing the lipid peroxidation in plasma. The hemp seed used in our work has fallen into the already mentioned ,38,39 lep = 0.0048 *), suggesting the efficacy of the diet (D) rich in active compounds and the time of utilization (T). By contrast, there were no differences in ROS between the two groups. A possible explanation might be that TBARS measures the products in the terminal phase of lipid peroxidation, while ROS are produced as intermediary products and could appear in both the initiation and the propagation phases [p = 0.04 *) observed for TAC indicates that the response to diet over time is different between the two groups. Taken together, in our study, we assume from the observed changes of TBARS, TAC and NO levels in plasma that HD exerts a preventive effect towards the action of free radicals. Also, Tan et al. (2015) found that dietary oregano essential oil, known for its antioxidant activity, significantly reduced serum lipid peroxidation in sows on day 1 of lactation [In the present study, we have identified that the effects of the two diets are different in terms of lipid peroxidation measured in the plasma of sows, as indicated in n phases ,82. Hencactation . p = 0.0064 *). As in the case of TBARS and NO, feeding HS during gestation contributed to an increased level in SOD activity at farrowing (day 1) compared to the control. A decrease in SOD activity was observed at day 7 irrespective of the diet, but dietary HS was able to increase its activity on day 21 when compared to CD. By contrast, the effect of HD on CAT activity was noted only at the end of the lactation period (day 21). Although HD significantly increased GPx activity during the lactation period, the D × T interaction was not significant. Research involving PUFA highlighted these beneficial effects. For example, investigating the influence of PUFAs as a dietary intervention during gestation and lactation, Shen et al. (2015) observed that sows fed a fish oil supplemented diet rich in PUFAs during late pregnancy and lactation showed an overall positive increase in plasma total antioxidant capacity and activities of GPx and SOD [Our study indicated that HS provided a higher level of PUFAs to the experimental diet. PUFAs are known for their capacity to increase the gene expression and activity of several antioxidant/detoxifying enzymes . Indeed, and SOD . In a si and SOD . As obse and SOD . It has  and SOD . All the and SOD .Polyunsaturated fatty acids (PUFAs) appear to interact with the metabolism of the L-arginine–nitric oxide (NO) system  and, in Besides PUFAs, the potential effects of cannabinoids are not to be overlooked. For instance, Borreli et al. (2013) investigated the effect of a hemp extract containing cannabigerol (CBG), a non-psychotropic cannabis-derived cannabinoid, in a murine model of colitis . Their aThe second step of this study was to assess the effect of the hemp diet on the oxidative status of piglets. Stressful events like weaning play a major negative role in modern livestock production . It has In our experiment, the comparison between the piglets derived from sows fed either HD or CD, revealed a significant diet effect on antioxidant enzyme activities. SOD activity in HD piglets was higher overall than CD (steady levels), showing a decreasing trend towards the end of the suckling period. A notable aspect is the magnitude of enzyme activity for SOD and CAT in the first day of lactation in piglets derived from HD sows in comparison with the control group which might be a consequence of feeding hemp during gestation. Elevated SOD activity and total antioxidant capacity was also noticed by Avramovic et al. (2012) and Lionetti et al. (2012) as an effect of dietary ω-3 fatty acid supplementation ,98. HempAs suggested so far, the most important of our findings is the link between the sows and progeny, evidenced by the similar trend in NO synthesis and GPx activity over the entire experimental period. On the other hand, we observed that ROS was not influenced by hemp, neither in sows nor in piglets over time. In piglets, we observed a decrease in ROS levels, while, in sows, there was no difference in ROS evolution over time. Also, TBARS was the highest on day 1 in sows, while it rose over time in piglets. Nevertheless, the inclusion of HS in the diet of sows had an overall positive influence on the antioxidant status markers in piglets.Finally, future research would be helpful to understand the effects of dietary hemp seeds in terms of the most efficient moment of intervention.The present experimental approach had some limitations. Firstly, the experiment was done in a small experimental farm employing the rationale of maximizing animal utilization. The small number of piglets used herein (only 16) resulted from a subsequent assignment of the rest of the progeny to other dietary hemp inclusion rates during growing and finishing-fattening periods. Also, data from four piglets were discarded due to unavailable blood samples at day 21. Aside from the fact that the piglets in our study had ad libitum access to the solid feed, their main nutrient source was the milk suckled from the sows. In this case, their intake is reflected through the reported average daily gain (ADG).From a statistical point of view, linear, quadratic and cubic polynomials analysis would have been considered but, because the study design involved the same sows and litters and measurements at different time points, the repeated measurements was chosen as the best for a relevant and most appropriate statistical approach.Another study limitation of this research was the use of TBARS as an indicator of lipid peroxidation, while other alternatives might be available, such as the potential use of the oxidant status index (pro-oxidants/antioxidants). There are many controversies as to whether TBARS is appropriate for assessing oxidative status as TBARS is not specific for MDA and MDA itself represents an end product of lipid peroxidation. An ultra-high-performance liquid chromatography (UHPLC) method for MDA determination would be more appropriate, but this is still being set up in our laboratory. However, additional parameters  were measured in conjunction with TBARS. The TBARS test is perceived as an important indicator of oxidative status. The study lacks the assessment of an additional treatment group fed a diet containing all the constituents of hemp excluding the polyunsaturated fatty acids (PUFAs). Nevertheless, the observation that hemp seed was able to improve the overall oxidative status markers in sows and their offspring indicates that hemp seed is an efficient alternative dietary approach.Our study revealed the positive effect of hemp diet on antioxidant enzyme activities together with increased TAC and NO production, as well as an improvement in TBARS levels in sows. Similarly, the elevated state of antioxidant defense system and increase in NO production in relationship with the low TBARS levels during lactation might lead to a better response of piglets receiving HD to weaning. This hypothesis deserves further investigation as to whether they could be correlated. The descriptive findings on plasma levels could be perceived as increased adaptability of piglets towards maintaining an increased antioxidative systemic status with regard to the upcoming challenge of weaning. Collectively, the results obtained in this study provide new insight into the beneficial effects of the dietary addition of hemp seeds as early life intervention.


The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity  to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled Erreygers was − 0.085 (CI: -0.108 to − 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant , indicating no change in inequalities in multimorbidity prevalence over the study period.Multimorbidity prevalence in 2011/12 was 33.5% and the CA pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.The online version of this article (10.1186/s12939-018-0800-6) contains supplementary material, which is available to authorized users. An increasing number of adults in high-income settings have been diagnosed with multiple coexisting chronic conditions , also knMultiple studies from high-income settings have shown that multimorbidity is concentrated among persons from lower socio-economic ranks –17. MultTo address these gaps, we undertook a comprehensive examination of inequalities in multimorbidity prevalence in Ontario, Canada. Our key research objectives were to: 1) quantify household income inequalities in multimorbidity prevalence among adults in Ontario, 2) identify the relative contribution of key determinants of multimorbidity to this inequality including socio-demographic, socio-economic, lifestyle and health system factors; and 3) assess whether these disparities were widening, and whether the drivers contributing to this inequality were changing over time.We used  survey data and linked health administrative information that is routinely collected in Ontario. The use of this data was authorized under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board. The study is reported according to the RECORD guidelines .Residents of Ontario, Canada aged 18 years and older that participated in any of four cycles of the Canadian Community Health Survey (CCHS) – 2005, 2007/08, 2009/10 and 2011/12 – and whose responses were linked to population-based health administrative databases were included in the study. Each survey was analyzed separately, unless otherwise stated .https://datadictionary.ices.on.ca/Applications/DataDictionary/Default.aspx).The CCHS is administered by Statistics Canada to Canadians aged ≥12 years living in private dwellings, and is representative of 98% of the Canadian population. The CCHS does not include into its sampling frame persons living on Reserves or Crown Lands, institutionalized residents or members of the Canadian Forces. Detailed methodology of the survey and sampling strategy are described elsewhere , 24. PerWe used health administrative data  to determine the prevalence of 17 high-impact chronic conditions for each individual at time of their survey response. Consistent with previous studies of multimorbidity in Ontario , 25–27, “what is your best estimate of the total income received by all household members, from all sources, before taxes and deductions, in the past 12 months?”). We focused specifically on (household) income as a marker of socioeconomic status to measure inequality because the rich-poor income gap is widening in most countries [We used household income from CCHS responses to measure socio-economic status  population mean of the outcome , y is the outcome mean of the ith individual, and Ri is the individuals rank in the income distribution. Values range from −1 to + 1, corresponding to a concentration of the outcome  among the poorer or wealthier population, respectively, where larger values (approaching −1 or + 1) indicate greater inequality, and a value of zero indicates equality. Because multimorbidity is dichotomous, we applied the Erreygers correction (CErreygers), which multiplies C by 4 times the weighted mean of the health outcome [Erreygers were derived using the methods described by O’Donnell et al. [For each cycle, we transformed income data into cumulative rank probabilities (ridit scores) ranging from 0 (highest income) to 1 (lowest income), with values reflecting the midpoint of the cumulative proportion of the (weighted) population in each income group. Using this variable we quantified inequalities in multimorbidity for each CCHS cycle, first, using the Concentration Index (C) . This re outcome . Standarl et al. .Wagstaff et al.  showed tMultiple sensitivity analyses were performed to assess the robustness of these decomposition analyses. Analyses were repeated using different reference categories in the multivariable probit model , performn = 500) to analyses. All data management was conducted using SAS Enterprise Guide version 6.1  and all analyses were performed using Stata/MP version 13.1 (StataCorp).Lastly, to confirm changes in inequality over the study period, we quantified the relative index of inequality (RII) and slope index of inequality (SII). These measures are recommended for assessing trends in health disparities , 55. FirOf 134,395 Ontario respondents across 4 cycles of linked CCHS and administrative data, 122,002 (91% of sample) were adults, and 113,627 (93% of adults) had complete information across all variables for analysis. A higher proportion of adult respondents excluded (vs. included) from analyses were age 75+ years, female, from the lowest income quintile and had prevalent multimorbidity. Table Erreygers are shown in the last row of Table Erreygers indicates a greater concentration of multimorbidity among persons with low household income, although the smaller CErreygers value in the 2011/12 survey suggests that inequality was less pronounced.The measured CErreygers decomposition of multimorbidity prevalence in the most recent (2011/12) and baseline (2005) surveys. Results from the 2007/08 and 2009/10 surveys are available in the Additional file k*x̅k/μ), the CErreygers of each determinant, and the relative contribution of each determinant to measured inequality. For example, for persons aged 75+ in the 2011/12 CCHS cycle: the difference in conditional probability of multimorbidity (vs. 18–34 age group) was 77.3%; this group represented 7.4% of the total population (from Table k*(4*μ) = − 0.061); and their contribution to measured income inequality was 55.6%.Table recent 201/12 and Erreygers from − 0.012 to 0.093); the opposite pattern was found for enrolment in a FHG (increased in enrolment from 23.6 to 27.7% and shift in CErreygers from 0.029 to − 0.042).Individual determinants with the largest contribution to the observed pro-rich inequality in the 2011/12 CCHS cycle included low household income , older age , being divorced, separated, widowed or single (15.2%), and physical inactivity (10.8%). The relative contribution of each of these determinants to measured inequality increased from the decomposition analysis conducted using the 2005 CCHS survey data. For example, older ages (75+ years) were less concentrated among the low income (vs. 2005) but the elasticity  increased between cycles; for non-married persons, the elasticity increased, as did the concentration of non-married individuals among lower income groups. In contrast, variables that contributed negatively to inequality in the latter survey included being middle-aged , having higher household income (− 10.5% for quintile 4), enrolment in a FHO (− 11.5%) and being born outside of Canada (− 7.8%). Of note, the growth in FHO enrolment between surveys (from 3.3 to 42.1%) corresponded with a greater concentration among higher household income  among inactive persons in Ontario, and that inactivity was increasingly concentrated among lower incomes. Socioeconomic gradients in inactivity have been documented in other high-income jurisdictions , althougThe contribution of health system variables to overall inequality, including health region of residence and enrolment in a primary care model, were small. All participants of the study had universal access to medically necessary care; however, enrolment into a primary care model is voluntary. The negative contributions for this determinant in particular suggest that holding all else constant, persons enrolled in these models (particularly FHNs) are less likely to be multimorbid and of higher household income, which has been previously documented , 45. LasThe results from the decomposition were robust to multiple sensitivity analyses. Other strengths of the research include the use of a large sample size, survey weights that are reflective of Ontario’s population, and high survey response rates. Our results are likely to be generalizable to other high-income jurisdictions with comparable universal health care systems. Validated algorithms were also used to ascertain disease status; linked survey and administrative data enabled this inclusion. There are limitations of this research that are worth noting, however. Variables were defined using routinely-collected health administrative and survey data which are subject to known limitations , 23. ForThis study confirms a pro-rich income gap in multimorbidity prevalence that has persisted over time. This gap is driven primarily by income, increasing age, marital status (not being married or common-law) and physical inactivity. Additional research to uncover the root causes of co-existing chronic conditions and to develop and evaluate the effectiveness of prevention strategies are warranted to Acknowledgements.We thank IMS Brogan Inc. for use of their Drug Information Database.Additional file 1:Table S1. Multimorbidity prevalence (standard deviation) by determinant. Table S2. Decomposition results from 2007/08 and 2009/10 CCHS surveys. Table S3. Sensitivity Results. (DOCX 49 kb)


OB/B/SB) of branched GDGTs shows a significant inverse correlation with water content, suggesting that marine waters have a major influence on the microbial communities inhabiting wetland sediment. Such an assumption was confirmed by the distinct lipid pattern of three low water content (<5%) samples collected in an area isolated from tidal flushing. The other isoprenoidal ether lipids, such as iGDDs, OH-GDGTs and OH-GDGTs, have a similar distribution as iGDGTs, indicating a common biological source, so do the corresponding non-isoprenoidal ether lipid series with bGDGTs. The BIT value increases with increasing distance from the sea, which implies that the BIT index can be probably applied to trace past sea level change in costal wetland settings. The reconstructed temperature from TEX86 shows significant offset from observed data, but only little deviation for the MBT/CBT calculated temperature. This suggests that the MBT/CBT has the potential to reconstruct past temperatures in coastal wetland settings.Coastal wetlands are terrestrial-marine transition zones harboring diverse active microbial communities. The origins of diverse glycerol ether lipids preserved in coastal wetlands are rarely investigated. 16 surface sediments were collected from the coastal wetland at Guangrao (GR), Changyi (CY) and Xiamen (XM), where both climate and sedimentary environment show significant differences. Ten groups of glycerol ether lipids, including isoprenoidal and branched glycerol dialkyl glycerol tetraethers (iGDGTs and bGDGTs), isoprenoidal and branched glycerol dialkanol diethers (iGDDs and bGDDs), hydroxylated isoprenoidal GDGTs and GDDs (OH-GDGTs and OH-GDDs), overly branched GDGTs (OB-GDGTs), sparsely branched GDGTs (SB-GDGTs), hybrid isoprenoid/branched GDGTs (IB-GDGTs) and a tentatively assigned H-shaped branched GDGTs (H-B-GDGTs) were detected and quantified. Sediments collected in the north (Guangrao and Changyi) contain, in general, a lower abundance of GDGT (3.7–55.9 ng/g sed) than samples from south . iGDGTs and bGDGTs are the predominant components at all sites and account for 17.2–74.3% and 16.1–75.1% of total ether lipids, respectively. The relative abundance of iGDGTs decreases but that of bGDGTs increases with the distance from sea, suggesting a marine vs. terrestrial origin of iGDGT and bGDGTs, respectively. In addition, the methylation index (MI The environment and climate change can cause the vegetation and biota communities changing correspondingly4  are membrane-crossing bipolar lipids commonly synthesized by most Archaea and a few bacterial species. GDGTs found in various geological environments are of two main types: the archaeal isoprenoidal glycerol dialkyl glycerol tetraethers (iGDGTs) and the non-isoprenoidal branched glycerol dialkyl glycerol tetraethers (bGDGTs), which are likely produced by soil bacteria4 Fig. . Recentl. 7 Fig. . The pre86 , MBT/CBT , were established to trace the sea surface temperature (SST), mean annual air temperature (MAAT) and soil pH, respectively11. These molecular proxies have been applied in many studies for reconstructing the past climate or environmental change15. BIT (Branched and Isoprenoid Tetraether index) is a proxy to estimate the relative abundance of terrestrial versus marine organic matter in sediments16. A new methylation index (MIOB/b/SB), defined by the degree of methylation of OB-, B- and SB-GDGTs was proposed to trace the anoxic environment8.GDGT based proxies, such as TEXChina has the fourth longest coastlines in the world – around 18,000 km, presenting a large variety of ecosystems from the tropical to sub-tropical to temperate realms. The coastal ecosystems include mangroves, coral reefs, beaches, cliffs and salt marshes, and correspondingly, the coastal wetland in different regions is different. How microbial communities adapt to the coastal wetland ecosystems and whether the GDGTs-related proxies can be applied for environmental study is unknown. The correlation between microorganisms and wetland environment change and their interactions have not been well studied. In this work we investigated the lipids distribution in China coastal wetland to study the impact of various environmental factors on glycerol ether lipid producing microorganisms, and further testified the applicability of GDGT based proxies.We collected 16 surface sediments (at a depth from 0 to 2 cm) from China coastal wetland in different regions  is about 12.6 °C, mean annual precipitation (MAP) ~568.5 mm and the mean annual evaporation (MAE) ~1754.5 mm (http://cdc.cma.gov.cn/). However, the micro-environment in these two regions shows a little difference. For example, the pH in GR wetland is higher than that in CY . The warm and humid climate in XM wetland is distinctive of that in CY and GR. The vegetation in XM wetland is dominated by mangrove.CY and GR wetlands locate at the Shandong province in northeastern China, where the climate (e.g. temperature and precipitation) is mainly controlled by Siberian-Mongolia High Winter Monsoon, accompanying with some influence of East Asian Summer Monsoonet al.19 in MARUM Center for Marine Environmental Sciences, Bremen, Germany. The total lipid extract (TLE) was stored at −20 °C.All the samples were dried by a freeze dryer before extraction and homogenized with a pestle and mortar. 16 samples from China coastal wetland were extracted using a modified Bligh and Dyer protocol as described by Sturt n-hexane/propan-2-ol  for HPLC-MS analysis. The lipids were analyzed by a Dionex Ultimate 3000 Ultra-High Performance Liquid Chromatography (UHPLC) coupled to a Bruker maXis ultra-high resolution quadrupole time-of-flight mass spectrometer (qTOF-MS), equipped with an APCI II source. The method was described in detail by Becker et al.20. Compound separation was achieved using two coupled Acquity BEH Amide columns  maintained at 50 °C. GDGTs were eluted using the following gradient with eluent A [n-hexane] and eluent B [n-hexane: isopropanol ] at 0.5 ml min−1: the initial gradient was 3% B to 5% B in 2 min, followed by increasing B 10% Bin 8 min, to 20% in 10 min, to 50% in 15 min and 100% in 10 min. The column was washed with 100% B for 6 min at 0.6 ml min−1. Finally, the column was equilibrated with 3% B for 9 min. Detection of glycerol ether lipids was achieved using positive ion APCI, while scanning a m/z range from 150 to 2000. Each compound was detected using the corresponding [M + H]+ in the extracted ion chromatogram . The concentration of each compound was calculated based on the peak area integration of [M + H]+ versus the peak area of C46 GTGT standard. The final concentration can only be considered semi-quantitative because we did not determine the response factors for GDGTs vs. the C46 GTGT standard.An aliquot of TLE of each sample was dissolved in 100 µL Ten groups glycerol ether lipids were detected in China coastal wetland sediments, including isoprenoidal GDGTs (iGDGTs), isoprenoidal glycerol dialkanol diethers (iGDDs), hydroxylated isoprenoidal GDGTs and GDDs (OH-GDGTs and OH-GDDs); branched GDGTs (bGDGTs), branched GDDs (bGDDs), overly branched GDGTs (OB-GDGTs), sparsely branched GDGTs (SB-GDGTs), hybrid isoprenoid/branched GDGTs (IB-GDGTs) and a tentatively assigned H-shaped branched GDGTs (H-B-GDGTs). The glycerol ether lipids concentration in CY and GR sediments is in the range of 4.1–60.5 ng/g dry sediment, which is more than one magnitude lower than XM sediments, 294.6–1147.4 ng/g. Among all the glycerol ether lipids, iGDGTs and bGDGTs are the dominant component, count together for more than 80% of total ether lipids, in all analyzed sediments Fig. .Figure 3In general, the lipids in the sediments collected from the three drier sites  where the water content (WC) is <5% exhibit a very distinct distribution pattern from those in the other sites Fig. , Table 1The branched GDGT distribution pattern can be divided into three groups. Group I refers to the three sites with water content <5% in CY wetland, Group II refers to the sites except the lower water content sites in the north wetland and Group III refers to the sites in the south wetland (XM). Group I is characterized with the highest abundance of bGDGT-II. Group II is characterized with the higher abundance of bGDGT-I, II and III. Group III is characterized with the highest abundance of bGDGT-I Fig. .23, and the bGDGTs are likely produced by anaerobic bacteria thriving predominantly in soil and peat24. Later studies also revealed unknown microbial sources in specific marine and lacustrine settings27. The distribution of iGDGTs versus bGDGTs  and euryarchaeotaGTs Fig.  indicate28. This phenomenon suggests that the iGDGTs in coastal wetland have either different sources or different correlation to certain environmental factors. As we known, the relative abundance of iGDGT-1, 2, 3 and cren. iso. is higher in soil Thaumarchaeota group29. The high relative abundance of iGDGT-1, 2, 3 and cren. iso. in the three sites with WC < 5% may be contributed to the soil thaumarchaeota group (including group I.1a and I.1b) blooming, which suggests the micro-organisms could change their group to adapt to the environment change. The higher abundance of cren. iso. in most samples from north wetland is also due to the low marine thaumarchaeota. The result suggests that the arid environment caused by higher evaporation in north can cause the micro-organisms change.The iGDGTs distribution is characterized with lower relative abundance of cren. iso. in south wetland, which is different from the iGDGTs distribution in sea surface sediments that the relative abundance of iGDGT-1, 2, 3 and cren. iso. increased with the decreasing latitude30. The significant difference of bGDGTs distribution in drier and wetter sediments  was performed for the lipids distribution in the samples analyzed. Obviously, the three samples with WC lower than 5% show significant difference with other ones based on whether iGDGTs or bGDGTs distributions  were interpreted as potential biosynthetic intermediates and/or degradation products of the corresponding GDGTs31. The correlation between other minor glycerol ether lipids and predominant glycerol ether lipids in north wetland is different from that in south. In north wetland, the minor glycerol ether lipids, including H-B-GDGT, IB-GDGT, OB-GDGT, SB-GDGT, OH-GDGT and OH-GDD have no significant correlation with iGDGT and bGDGT , the concentrations of iGDD and bGDD show significant correlation with their corresponding tetraethers, iGDGT and bGDGT Table . Our resGT Table . However37. The BIT values are in the range of 0.2–0.9, which suggests the higher relative contribution of terrestrial OM. Obviously, the BIT value increases with the increasing distance from sea whether in north wetland or in south wetland  in marine and lacustrine environmentnd Figs.  and 2. Tnd Figs. . The res86 in coastal environment is constrained for the terrestrial input and the BIT index value is used to assess the bias of the reconstructed SST39. The BIT values in the research samples are higher than 0.2, which indicates that the TEX86 may not be applied in coastal wetland. Actually, the reconstructed temperature from TEX86 shows a large bias to the instrumental MAT, and the residual temperature is from −6.3 °C to 17.0 °C, and the bias in the north appears higher than that in the south wetland, especially in the three drier samples  cannot be applicable in the wetland, especially in the north wetland.The application of TEX40 is close to the instrumental MAT except the three samples with WC < 5% in CY wetland  of OB-GDGT, bGDGT and SB-GDGT  if the three dry samples excluded  is much higher than that in sandy-mud wetland (CY and GR). Among all ether lipids, the iGDGT and bGDGT are all the predominant compositions, and they account for 17.2–74.3% and 16.1–75.1% of total ether lipids.OB/B/SB) of branched GDGTs shows a significant inverse correlation with water content, suggesting that marine waters have a major influence on the microbial communities inhabiting wetland sediment.The source of ether lipids are not only controlled by climate but also influenced by the micro-environment. In the three wetlands, the relative abundance of iGDGTs decreases with the distance increasing from sea, while that of bGDGT increases, which suggests that the iGDGT mainly originate from marine environment and bGDGT mainly originate from terrestrial organisms. However, the microbial communities in the three regions show a little difference. In XM wetland, the iGDGT mainly originate from marine thaumarchaeota group I.1a, while in CY and GR wetlands, the iGDGT originate not only from marine thaumarchaeota group I.1a but also from soil thaumarchaeota group, especially in the three dry sites (WC < 5%). The significant different distribution of bGDGT in dry and wet sediments suggests that the bGDGT in the two type samples may come from different species, which further suggests that the water content losing in the same region can compel the microbial communities change correspondingly. Among the minor glycerol ether lipids, the iGDD, OH-GDGT and OH-GDGT appear to have the similar biological origin with iGDGT, and IB-GDGT, OB-GDGT, SB-GDGT and bGDD show the similar origin with bGDGT in the samples with WC > 5%. In addition, the methylation index (MI86 could not be applicable to trace the temperature change due to the high soil organisms’ input. On the contrary, the MBT/CBT has the potential to trace the paleotemperature if the wetland has not been disturbed by human activities.The BIT value increases with the increasing distance from sea, which means that the BIT value can be used to trace the relative distance from sea, and which can further be used to trace the sea level change, especially in the area with high evaporation. The TEX


Use of 18-FDG PET–CT is increasing in patients with head and neck cancer, enabling the identification of metastases or synchronous malignancies, but also ‘incidental’ disease. We aimed to establish the rate of ‘incidental’ findings resulting from 18-FDG PET-specific imaging, that would not have been otherwise identified on other imaging, in patients with head and neck cancer undergoing staging or surveillance of disease.18-FDG PET–CT was performed for investigation or surveillance. Case notes were reviewed retrospectively. Unexpected findings identifiable on CT imaging alone, or by FDG-PET were recorded. For those only identifiable with FDG-PET, findings were divided into either ‘incidental’ or ‘intentional’, and benign or malignant.93 patients underwent 18- FDG PET–CT. 86.0% had new pathology identified. 3.2% had a new malignancy identified. 37.6% had new findings on FDG-PET that would not have been identified on CT alone: 5.4% had ‘intentional findings’ (metastasis), and 32.3% had ‘incidental findings’ . 1.1% had a new malignancy on FDG-PET alone.Intentional and incidental findings are likely on 18-FDG PET–CT. Whilst important for patient management, there is an associated emotional and financial cost, which needs acknowledgement and further investigation. Annually, head and neck cancer (HNC) affects 700,000 people worldwide and over 9000 in the UK . Within The role of 18-fluorodeoxyglucose positron emission tomography–computed tomography (18-FDG PET–CT) has continued to increase, in part because the sensitivity and specificity for identifying the primary site and extent of nodal disease is improved compared to other forms of radiological investigation. This is due to the combination of structural assessment using the CT component, alongside the metabolic component using the FDG tracer.This is of particular importance when the primary site is not identified at the initial investigation. Indeed, NICE advocates 18-FDG PET–CT early in the diagnostic pathway for these patients . Also inA further advantage of 18-FDG PET–CT is that the whole body is imaged. This is in contrast to traditional imaging techniques which typically cover only the primary site and chest, with or without the upper abdomen. In particular, chest imaging is typically performed looking for either a synchronous lung cancer or metastatic spread, both of which would influence management options.benign ‘incidental’ findings.It is also recognised that 18-FDG PET–CT may identify incidental findings both within the neck and chest, but also out of the field of traditional imaging. Some of these findings will represent previously unrecognised malignant processes. Conversely many of these findings will represent These ‘incidental’ findings will often require additional investigations incurring an additional health economic burden as well as a psychological concern for the patient.This is the first study in the UK HNC population to investigate the rate of incidental findings in patients undergoing 18-FDG PET–CT investigation. We aimed to ascertain the rate and nature of incidental findings reported on 18-FDG PET–CT in our population.Tertiary head and neck cancer centre in a UK teaching hospital.Inclusion criteria: This was a retrospective case-control study of consecutive patients presenting to the HNC unit over a 15-month period. Those that were investigated with 18-FDG PET–CT either as part of the investigation prior to definitive treatment or for monitoring of disease response were included in the study. Patients were excluded if they did not have a (suspected) malignant process of the head and neck, or had a thyroid malignancy.A case file review was performed and information collected regarding age, sex, primary site, nodal disease, pathology final staging and, for oropharyngeal SCC, P16 status.The 18-FDG PET–CT reports were analysed and findings, as interpreted by the reporting radiologist, recorded. Findings were reviewed by a further consultant radiologist as to whether they would have been found on CT (which would have been performed as part of staging in HNC patients), or if they were noted due to their FDG avidity.New findings specifically found by the FDG-PET element of the scan, were divided into ‘intentional findings’ , and ‘incidental findings’ .Specific recommendations for follow-up or further investigations of incidental findings as suggested by the reporting radiologist were recorded. Statistics were descriptive.236 consecutive patient notes were reviewed, who presented to the HNC clinic as above. 119 had undergone 18-FDG PET–CT and were, therefore, included in the study. 26 further patients were excluded as above, leaving 93 patients in the study.Of those included having 18-FDG PET–CT, the mean age was 60 (34–85). 75 (80.6% of patients undergoing 18-FDG PET–CT as above) were male. Table 56 (60.2%) were diagnosed with an SCC of the oropharynx. Of these, 42 (75.0%) were positive for p16 and 5 were negative. There were nine patients for whom the p16 status could not be found. After investigation, five patients were classified as having cancer of the unknown primary (CUP). All were SCC in one or more neck nodes. Of the eight (8.5%) patients with salivary gland tumours, seven were in the parotid and one was in the submandibular gland. The histological diagnoses for these tumours were both benign and malignant: pleomorphic adenoma (2), Warthin’s tumour, SCC (2), neuroendocrine carcinoma, ductal carcinoma, basal cell adenocarcinoma. There was one (1.1%) malignant melanoma presenting in the ear.The 93 patients underwent a total of 145 scans (mean 1.56/patient).Of the 93 patients, 80 (86.0%) had a new finding on at least one scan that was beyond local associated lymphadenopathy. Figure 72 patients  had findings that would have been found on CT imaging alone. 35  had at least one previously unknown finding that was specifically shown by FDG-PET. In the case of malignant findings, this included findings that would have been considered benign on CT imaging alone.5 patients  had metastatic, i.e. ‘intentional findings’. These included bone, lung, and axillary and parotid nodes.30 patients  had ‘incidental findings’. 29 of these patients had benign findings, which included colorectal changes ; lung nodes, nodules and inflammatory/infectious changes (6); prostate changes (4); biliary inflammation (3); sebaceous cysts (2); reactive axillary nodes (2); arthropathy (2); contralateral tonsillar changes ; oesophagitis (1); thyroiditis (1). In one patient , FDG-PET demonstrated a hot thyroid nodule that was not seen on CT and was subsequently found to be a Thy 5 papillary cancer.To better determine ‘incidental findings’, in some cases the reporting radiologist was noted to have made recommendations as to further investigations. In those with FDG-PET identified ‘incidental findings’, these included biopsies/fine needle aspiration (3), colonoscopy/flexible sigmoidoscopy (9), PSA (3), and CT chest (3), MRI brain (1), making a total of 19 patients .Two further patients had a previously undiagnosed synchronous malignancy identified—these were oesophageal and lung. Of note, the oesophageal lesion was identified as malignant on CT imaging, but the FDG-PET avidity heightened suspicion in this patient.Twelve (12.9%) patients had metastatic disease that would have been identified on CT imaging alone. Sites included bone, adrenal, lung, liver, parotid, axilla, contralateral tonsil and other lymphoma sites.Benign findings that would have been identified on CT imaging alone included: lung nodes/nodules and other changes including lung granulomas, emphysema, atelectasis, pneumonia, pleural plaques; hepatobiliary and pancreatic disease; diverticular disease; coronary calcification; hiatus hernia; abdominal wall hernias; orthopaedic changes; renal cysts and urolithiasis; adnexal/ovarian cysts and uterine fibroids.HNC is increasing in incidence with patients presenting at earlier ages. Assessment of patients increasingly involves 18-FDG PET–CT. Advantages include improved sensitivity and specificity compared to other imaging modalities . 18-FDG 86.0% of patients had a new finding, of which 43.8% were specifically found on FDG-PET images. An increased cost to the health service is raised, as 20.4% were recommended to undergo further investigation. Only one  was found to be malignant following further investigation. Incidental findings, or the possibility of incidental findings, may raise health anxiety in patients, particularly as they are already likely to be anxious whilst undergoing investigation into HNC. Our results show that the majority of incidental findings specific to FDG-PET are benign, which may be of reassurance to patients. Clearly any counselling would need to be specific to the nature of findings in question.The FDG-PET element of the scan was noted to add confidence to a malignant/metastatic new finding on CT in some cases. For example, differentiating benign pulmonary nodules from metastasis, or aiding in the identification of an oesophageal tumour, which although commonly demonstrated by CT, was considerably more conspicuous with FDG-PET.This is the first UK study to report on incidental findings on 18-FDG PET–CT in HNC patients. The authors were able to find one other study investigating the same topic specifically in head and neck cancers. This was undertaken in the USA, where Britt et al. report rates of 14.6% suspected malignancy, with 4.1% (12/293) confirmed new unrelated malignancy  , a rate In a large study in China, Wang et al. report a rate of 8% proven, unrelated/unexpected second malignancies in patients undergoing 18-FDG PET–CT who underwent ‘complete’ follow-up . These rWith the increasing use of 18-FDG PET–CT this study represents important information when planning treatments. The reference cost of the imaging does not account for the additional procedures needed to investigate the incidental findings. In a small percentage these findings are malignant processes that require management. However, the majority of findings are benign processes. It is possible that in certain situations these findings could result in delayed cancer treatment whilst those investigations are performed, and this should be investigated in further, larger studies. Furthermore, the psychological burden on the patient in instances such as this has not been measured but needs to be considered in future studies.The results presented in this UK-based study may facilitate the counselling of patients in clinic prior to undergoing 18-FDG PET–CT for HNC. With further investigation, the results may be applicable when planning provision and funding of healthcare resources.We have demonstrated an overall rate of synchronous malignant incidental findings on 18-FDG PET–CT performed for HNC that is similar to other authors, of 3.2%. We have demonstrated a rate of FDG-PET pickup of malignant findings that would not have been identified on CT imaging alone, of 1.1%.In 43.8% of patients with new findings, FDG-PET identified disease that would not have been identified on CT imaging alone. Non-CT identifiable benign disease was found in 31.2%, and synchronous malignancy in 1.1%. Some benign findings underwent further investigation to confirm their benign nature. This raises a psychological and financial cost.Whilst 18-FDG PET–CT is clearly of use in investigating proven or suspected HNC, due to its whole-body nature, other benign pathologies are likely to be found. This carries a psychological and financial burden to the patient and health service, which requires further investigation and should be borne in mind when counselling patients.


Physical activity is effective in preventing chronic diseases. However, the impact of different durations of exercise on human health is unknown, especially among people with diabetes or prediabetes.  To explore the relationship between high MET hours per week and the change in glomerular filtration rate (eGFR) in the total population and different subgroups. 2.  A total of 43767 individuals from eight provinces, in China, were recruited. Logistic analysis was used to investigate the association. Participants were divided into 3 groups based on MET hours per week. The primary outcome was an eGFR ≤ 90 mL/min/1.73 m2. Logistic regression analysis revealed that more than 7.5 MET hours per week  was associated with the higher risk of the decreased eGFR even after adjusting for confounding factors . After adjusting for confounding factors, in stratified analyses, there still existed a significant relationship among participants aged from 55 to less than 65 years, but not among participants younger than 55 or older than 65 years. Similarly, there existed a positive association between high MET hours per week and the decreased eGFR in participants without diabetes and prediabetes, but not in participants with diabetes or prediabetes, and the interactions of age and diabetic states were found. However, there was no significant difference in women or men.  The average eGFR was 100.10 (92.43-106.43) mL/min/1.73 More than 7.5 MET hours per week  was associated with decreased eGFR among participants aged from 55 to less than 65 years and participants without diabetes and prediabetes, but not among participants aged younger than 55 years and older than 65 years and participants with diabetes or prediabetes. The importance of planning individualized physical activities is highlighted. Haskell et al. confirmed that moderate physical exercise can help with weight loss and the reduction of the risk of cardiovascular diseases (CVD) . PhysicaKidney disease, as one of the main causes of death, can lead to an increased incidence of CVD . It is rThere are some studies that showed moderate-intensity exercise could be beneficial to reduce the risk of CVD in patients with chronic kidney disease . HoweverThis cross-sectional study was part of the REACTION Study, an ongoing longitudinal study, designed to investigate the association between diabetes and the risk of cancer among the Chinese population, reported previously . Partici2. On the standard questionnaire, all participants provided their average amounts of time per week that they carried out the different groups of activities, including low-intensity, moderate-intensity, and vigorous-intensity activities based on the short version of the International Physical Activity Questionnaire (IPAQ). According to IPAQ, the energy expended for different intensity exercises was estimated in MET hours per week, and all these different intensity exercises were also summed to account for the total energy expenditure weekly.Data were collected by the same trained staff, according to standardized operational procedures. All the participants completed a standard questionnaire with the assistance of the trained staff. The questionnaire included education level, lifestyle, physical activity, smoking status, drinking status, medical history, and family history of tumors and DM. Regular smokers were defined as those who smoked at least one cigarette per day. Occasional smokers were participants who smoked less than one cigarette per day or less than 7 cigarettes per week. Regular drinkers were defined as participants who had consumed alcohol at least once a week for over six months. Occasional drinkers were defined as participants who drank less than once a week. Height and weight were clinically measured (when participants were wearing light clothing), and body mass index (BMI) was calculated using the formula BMI = weight (kg)/height (m)After a resting period of five minutes, participants' blood pressure and pulse were measured three times with intervals of one minute in a seated position. The pulse rate was measured while the blood pressure was recorded. After at least 12 hours of fasting overnight, the first fasting blood samples of all the participants were obtained. Patients without a history of DM underwent a 75 g oral glucose tolerance test; they were required to drink 300 mL of a glucose solution containing 75 g of glucose within 5 minutes, and after 2 hours, the second venous blood sampling was performed. All blood samples were centrifuged for 30 minutes and stored at -80°C by the professional staff. Blood glucose, blood lipids, triglycerides (TGs), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and serum creatinine were detected by the automatic enzyme method. This cross-sectional study is part of the REACTION study, using the baseline data, and the design and methodology of the REACTION study have previously been described in detail , 12.The variables were defined as follows: hypertension (any self-reported history of hypertension or systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg), diabetes (fasting blood glucose (FBG) ≥ 7.0 mmol/L and postprandial blood glucose (PBG) ≥ 11.1 mmol/L simultaneously or any self-reported history of diabetes), cardiovascular events , any self-reported family history of tumors, and any self-reported family history of DM. According to the WHO criteria, prediabetes was defined as follows: 6.1 ≤ FBG < 7.0 mmol/L or 2 h PG < 11.1 mmol/L. And prediabetes was divided into 3 groups as follows: impaired fasting glucose (IFG): 6.1 ≤ FBG < 7.0 mmol/L and 2 h PG < 7.8 mmol/L; impaired glucose tolerance (IGT): FBG < 6.1 mmol/L and 7.8 ≤ 2 h PG < 11.1 mmol/L; and IFG+IGT: 6.1 ≤ FBG < 7.0 mmol/L and 7.8 ≤ 2 h PG < 11.1 mmol/L.Based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) showed as According to the minimum recommendations provided by the American College of Sports Medicine and American Heart Association, we classified the participants into 3 groups based on MET hours per week as follows: <7.5 MET hours per week that equals <150 minutes per week of moderate-intensity physical activity, ≥7.5 MET hours per week <21, and ≥21 MET hours per week that equals ≥420 minutes per week of moderate-intensity physical activity on the basis of the Institute of Medicine recommendation , 15.2. The secondary outcome was the decreased eGFR as a continuous variable.The primary outcome was the loss of renal function, which was defined as eGFR ≤ 90 mL/min/1.73www.empowerstats.com, X&Y Solutions Inc., Boston, MA) and R (http://www.R-project.org). A p value < 0.05 (2-sided) was considered statistically significant.All statistical analyses were performed using Empower(R)  for continuous variables of nonnormal distribution. Category variables are expressed as percentage (%). The continuous variables of nonnormal distribution were analyzed using the Kruskal-Wallis test. The category variables were tested using the chi-square test. Linear regression analysis was conducted to detect the relationship between different MET hours per week and eGFR as a continuous variable. A logistic regression model was built to investigate the correlation between different MET hours per week and renal dysfunction which was defined as eGFR ≤ 90 mL/min/1.73justment , 17. We 2. We found that age, sex, region, education level, SBP, pulse, HDL, LDL, TG, FBG, PBG, eGFR, smoking status, drinking status, hypertension history, DM history, cardiovascular events, medication history, family history of tumors, and family history of DM were significantly different between different MET hours per week groups. Participant demographics and hematology data are shown in A total of 43767 participants were included in our study. The average age was 56.84 (51.16-63.00) years. A total of 30.84% of the participants were male and 69.16% were female. DM, hypertension, and cardiovascular events were observed in 14.66%, 31.54%, and of 4.21% of the participants, respectively. A total of 8945 (20.44%) individuals had the decreased eGFR defined as an eGFR ≤ 90 mL/min/1.73p for trend: 0.0047). In model I, there still existed the association after further adjustment for age and BMI, and when we further adjusted for a variety of confounding factors in model II, the association between MET hours per week and the risk of the decreased eGFR remained robust . The same trend can be detected when eGFR is a continuous variable, and this is shown in As shown in p for trend = 0.0035). Similarly, there existed a stronger association in women, and compared to men, in fully adjusted model II, the negative association between MET hours per week and continuous eGFR was significant in women .As shown in p for trend < 0.0001), in participants aged from 55 to less than 65 years.As shown in p for trend: <0.0001), but there was still no significant association among participants with diabetes or prediabetes. Additionally, we further investigated the association between MET hours per week and the risk of decreased eGFR among participants with prediabetes. Prediabetes was divided into 3 groups based on WHO criteria IFG, IGT, and IFG+IGT, and the results are shown in Β = −0.76, 95% CI ; ≥21: Β = −0.87, 95% CI , p for trend = 0.0344), but we did not investigate a relationship among participants with IFG or IFG+IGT.The combination of the propensity score and multivariable model was used to analyze the association between MET and eGFR, including total population and subgroups. In order to further adjust for confounding factors, a logistic regression model adjusted for the propensity score was also used and the results are consistent with our previous results, which are presented in Supplementary Materials .The above results showed that the association between MET hours per week and the risk of decreased eGFR can be modified by age and diabetes status, and we found significant interactions with age and diabetes states as shown in This cross-sectional study shows that higher MET hours per week is significantly associated with the risk of decreased eGFR. After further investigation, the study indicates that the results vary in different subgroups of age and diabetic states. Compared to participants engaged in less than 7.5 MET hours per week , those taking part in more than 7.5 MET hours per day  are more likely to have a decreased eGFR, suggesting renal dysfunction probably, especially in participants aged from 55 to less than 65 years or those without diabetes and prediabetes.Some studies showed that physical activity is beneficial to reducing mortality . HoweverThe relationship might be partially explained by the following mechanisms. Due to excessive physical activity causing oxidative stress , 21, theIn some studies, excessive physical activity was associated with the low degree of inflammation. The elevated levels of neutrophils, monocytes, and leucocytes indicated a slightly greater degree of inflammation after high-intensity physical activity . Long duIn addition, renal tubular hypoxia is one of the important reasons of renal dysfunction. If physical activity is excessive, such as more than 60 minutes per day of moderate-intensity exercise, visceral hypoperfusion may occur. Kidney hypoperfusion is likely due to renal tubular hypoxia, and more than 21 MET hours per week might cause a decrease in renal blood flow leading to low perfusion of the kidneys, resulting in a decreased eGFR .The above results of this cross-sectional study highlight 2 significant points for renal function protection. Firstly, long duration of exercise (more than 150 minutes per week of moderate-intensity or more than 60 minutes per day of moderate-intensity exercise) might not be appropriate for everyone. Individuals' exercise plan should be considered based on individuals' health conditions. Secondly, people aged from 55 to less than 65 years or without diabetes and prediabetes should maintain less than 150 minutes per week of moderate-intensity exercise to keep healthy. However, for those aged younger than 55 and older than 65 years or with prediabetes and diabetes, 60 minutes per day of moderate-intensity exercise may be a good recommendation to help them keep fit.Our study is unique as the sample size was large. We conducted stratified analyses that fully explored not only the relationship between different MET hours per week and decreased eGFR but also the interaction. Though the confounding factors were adequately adjusted for as possible as we can, particularly in terms of sociological factors, region, and education level, it is possible that unmeasured variables are involved in that association between MET hours per week and the risk of decreased eGFR. Due to the study design, the changes occurring while carrying out the exercise were not monitored and the mechanism underlying the association between high MET hours per week and decreased eGFR was not explored.In conclusion, more than 7.5 MET hours per week  is associated with decreased eGFR. There is a clear association in participants aged ≥55 and <65 years and populations without diabetes and prediabetes, but not in populations aged <55 years or ≥65 years and those with prediabetes or diabetes. Duration of exercise may need to be individualized, to ensure optimal treatment in subgroups of different diabetic states. The positive effect of exercise may depend on the optimal duration of exercise based on individuals' conditions. Should we just tell our patients to do some exercise to help them keep fit or provide individuals' exercise plan in detail based on their condition?


Vitamin D plays critical role in the female reproductive system. It seems that vitamin D is associated with clinical pregnancy outcomes of assisted reproductive technologies (ART), but its role remains elusive. This study is aimed to establish whether vitamin D is associated with clinical outcomes of in vitro fertilization (IVF).The cross-sectional study was carried out from January 1st 2017 to December 31st 2017. A total of 848 patients who had indications for IVF were enrolled. The patients were classified by serum 25 (OH) D quartiles. The outcome parameters of IVF were compared in each group, including normal fertilization rate, high quality embryo rate, clinical pregnancy rate, implantation rate and live birth rate.r = 0.85, P < 0.001). The levels of FF vitamin D were significantly higher than the levels of serum vitamin D (P < 0.001). Normal fertilization rates were significantly different among four groups (P = 0.007). The group of women with the highest serum 25 (OH) D levels had the highest normal fertilization rate. However, the clinical pregnancy rate, implantation rate and live birth rates were not significantly different among the four groups when the age, BMI, AMH, seasons of blood drawing, COH protocol, high quality embryo rate and number of embryos transferred were adjusted. In addition, we found that serum 25 (OH) D levels were significantly higher in patients received IVF than patients received R-ICSI (P = 0.013).The median 25 (OH) D concentration was 15.25 ng/ml. Serum 25 (OH) D levels in women varied with the seasons. We found that serum 25 (OH) D levels were higher in autumn than other seasons, and the lowest level occurred in spring. Follicular fluid (FF) vitamin D levels were positively correlated with serum vitamin D levels  contains supplementary material, which is available to authorized users. Vitamin D is a fat-soluble steroid hormone. It has an important role in Calcium-Phosphate (Ca-P) homeostasis and bone metabolism , 2. VitaVitamin D exerts effect by binding with the nuclear vitamin D receptor. Vitamin D receptors have been identified in many tissues, including the ovary, uterus, placenta and the pituitary . These dSo far, there were many studies investigating the association between vitamin D level and the clinical outcomes of ART, but the data are inconclusive. Some studies found that vitamin D could improve the outcomes of ART –24. In cThis was a retrospective cohort study. We have retrospectively reviewed the data of all patients, who underwent their in vitro fertilization (IVF) cycle at Yantai Yuhuangding Hospital from January 1st 2017 to December 31st 2017. The study protocol was approved by the Ethical Committee of Yantai Yuhuangding Hospital. The study conformed to the “Declaration of Helsinki for Medical Research involving Human Subjects”. Patient characteristics and cycle parameters were obtained from patient medical records.Only one IVF cycle of each patient was selected within the study time frame. None of the patients received vitamin D supplements. Patients were excluded if they were diagnosed with premature ovarian in sufficiency or if they were treated with intracytoplasmic sperm injection (ICSI) or rescue ICSI (R-ICSI). To avoid confounders, women whose plasma total 25 (OH) D measurements exceeded 4 weeks prior to entering their IVF cycle were excluded from the study, since the season impacts on the serum 25 (OH) D concentrations in Yantai.All patients undergoing IVF cycles receive luteal phase gonadotrophin-releasing hormone (GnRH) agonist protocol or GnRH-antagonist protocol. In luteal-phase gonadotrophin-releasing hormone (GnRH) agonist protocol, low- or regular- euprolide was used to make pituitary desensitization beginning in the luteal phase. In GnRH-antagonist protocol, GnRH-antagonist ganirelix was used when the dominant follicle reached 12 mm in diameter, estradiol concentrations were>150 pg/ml and/or luteinizing hormone concentrations were >10 IU/L. During gonadotrophin stimulation, serum estradiol, progesterone and luteinizing hormone, follicle size measurements, and endometrial thickness were monitored until the day of human chorionic gonadotropin (hCG) trigger injection. When two leading follicles reached a mean diameter of 18 mm, hCG was given to trigger ovulation. Oocytes were retrieved transvaginally 34–36 h after hCG administration. IVF was performed. Ultrasound-guided fresh embryo transfer was performed on the third day after oocyte retrieval, and excess viable embryos were cultured to blastocyst stage and cryopreserved for subsequent frozen embryo transfer (FET) cycles. The number of embryos transferred was one or two depending on the number of available embryos. Fresh embryo transfer was cancelled if the embryo and endometrium were not synchronous or women had a high risk of ovarian hyperstimulation syndrome and factors seriously affecting embryo implantation. The obtained embryos were graded depending on published criteria . The embTotal 25 (OH) D was measured before entering IVF cycle. The measurement of total 25 (OH) D levels was performed using a chemiluminescence immunoassay (DiaSorin). The intra- and inter- assay coefficients of variations were 10 and 15%, respectively.Sixty-two serum samples were obtained on the oocyte retrieval day and were kept frozen at − 80 °C. FF had been also collected from the same 62 patients. FF aspiration was performed from the first follicle on oocyte retrieval day. FF was centrifuged at 3000 g for 10 min. The supernatant was stored at − 80 °C for subsequent assay. Serum and FF 25 (OH) D levels were measured by a chemiluminescence immunoassay (DiaSorin).The levels of serum vitamin D varied significantly in different seasons because of the different exposure to sunlight  D concentrations in quartiles and treatment outcomes of IVF cycle while adjusting for potential confounding factors.The primary outcome was clinical pregnancy rate. It was defined as the presence of an intrauterine sac confirmed by ultrasound at 6 weeks of gestation. Secondary outcomes were: live birth rate, implantation rate and (2 PN) fertilization rate.The continuous variables were presented as mean ± SD, and the proportions were presented as percentages. The Kruskal-Wallis test was used for continuous variables. The chi-square test was used for categorical variables.Receiver operating characteristic (ROC) curves were used to analyze the predictive value of serum vitamin D levels on clinical pregnancy rate, live birth rate and fertilization rate. Low fertilization rate (LFR) was defined as normal fertilization rate below 30% as it was a clinical standard for ICSI to promote normal fertilization rate. Spearman’s test was used to evaluate the correlation between serum vitamin D levels and FF vitamin D levels.2 levels on the day of hCG, number of oocytes retrieved, number of mature oocytes, the percentage of top quality embryos, endometrial thickness, serum progesterone levels on the day of hCG and the number of embryo transferred.A univariate and multivariate logistic regression analysis was applied to analyze the relationship of vitamin D and clinical outcomes of IVF. The variables that were evaluated as potential confounders included: age, BMI, AMH, type of infertility, previous pregnancy, seasons when samples were taken, the type of treatment protocol, duration of stimulation, EP<0.05 was considered to be statistically significant.The data were analyzed by use of the SPSS-12.0 software. Overall, 848 patients were included in this study Fig. . Of the p = 0.099 and p = 0.134, respectively). 25 (OH) D concentrations were significantly related to seasons when the samples were taken (P<0.001). Serum 25 (OH) D levels were higher in autumn than other seasons, and the lowest level occured in spring . However, the levels of vitamin D were positively related to normal fertilization rates (p = 0.007). A similar relationship was observed between vitamin D status and the fertilization rates (P<0.001) after adjusting for potential confounders .Table p = 0.013) . The levels of FF vitamin D were significantly higher than the levels of serum vitamin D (P < 0.001)  Fig. . In addi Fig. . IP<0.001), stimulation protocol (p = 0.027), endometrial thickness (P = 0.002), number of oocytes retrieved (p = 0.02), number of mature oocytes (p = 0.024) and high quality embryo rate (p = 0.001). AMH, peak estradiol, number of larger follicles and embryos transferred were greater in the live birth group, but they did not achieve statistical significance. Only age (P<0.001) and endometrial thickness (P = 0.008) were significantly associated with clinical pregnancy. The number of larger follicles, oocytes and embryos transferred were higher in the clinical pregnancy group, but they did not achieve statistical significance.Table As shown in Table p = 0.0007). However, for pregnancy rate and birth rate, the area under the ROC curve was 0.521 and 0.523 respectively, demonstrating poor performance for the prediction of pregnancy and live birth.The predictive value of vitamin D regarding normal fertilization rate, pregnancy rate and live birth rate were analyzed by ROC curve Fig. . After aIn this large retrospective cross-sectional study, 848 women underwent 848 IVF cycles. The serum 25 (OH) D concentrations were between 4.92 and 39.51 ng/ml. The median 25 (OH) D concentration was 15.25 ng/ml. Serum vitamin D levels significantly vary in different seasons because of the different exposure to sunlight. Serum 25 (OH) D levels were higher in autumn than other seasons, and the lowest level occurred in spring  D and clinical pregnancy or live birth. This is in agreement with the majority of studies –30, 33. Even if our study is retrospective, there are still several strengths. The primary strength is the large number of participants. There were only 59–202 patients in previous reports , 33–36, Some limitations of this study must be considered though. Firstly, this study is a retrospective observational study, we cannot exclude all confounding factors. However, we adjusted the potential confounding factors for a wide range to provide reassurance of the validity of our findings. Secondly, we did not measure the vitamin D levels of couples, since serum 25 (OH) D correlates within the partners of infertile couples . MoreoveIn summary, we found that vitamin D was positively related to fertilization rate. However, vitamin D was unrelated to clinical pregnancy or live birth in this retrospective cohort study. In this study, patients had serum 25 (OH) D concentrations between 4.92 and 39.51 ng/ml. FF vitamin D levels were positively correlated with serum vitamin D levels. The levels of FF vitamin D were significantly higher than the levels of serum vitamin D. The relationship of vitamin D and outcomes of ART should be studied in future large randomized controlled trials.Additional file 1:Table S1. Patients characteristics in four seasons. (DOCX 16 kb)


Hyperlactatemia is known to be associated with adverse outcome in critical illness. In this study, we attempted to identify if hyperlactatemia on emergency department (ED) arrival is a reliable predictor for in-hospital mortality in necrotizing fasciitis (NF) patients.A prospective cohort study of hospitalized patients with NF was conducted in two tertiary teaching hospitals in Taiwan between March 2010 and March 2018. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. Sequential organ failure assessment (SOFA) scores were calculated during the first 24 h after admission. All collected data were statistically analyzed.P < 0.001), even after adjustment for age and SOFA score . Multivariate regression analysis showed that a high blood lactate level  and a high SOFA score  were independent risk factors for in-hospital mortality in NF. Blood lactate achieved an area under-the-receiver-operating-characteristic curve (AUC) of 0.79 (P < 0.001) for predicting mortality that was similar to that of SOFA score . Blood lactate displayed a sensitivity of 62% and a specificity of 86% in predicting mortality at the optimal cutoff value of 5.80 mmol/l.Of the 707 NF patients, 40 (5.66%) died in the hospital. The median (interquartile range) blood lactate level in all NF patients was 3.6 mmol/l (2.2–4.8). The blood lactate level upon ED arrival was significantly associated with mortality (odds ratio [OR] = 1.35; 95% confidence interval [CI], 1.30–1.46; In necrotizing fasciitis patients, hyperlactatemia on ED arrival is independently associated with in-hospital mortality. NF patients with hyperlactatemia on ED arrival should be closely monitored for signs of deterioration and consider early and aggressive intervention to prevent mortality. Necrotizing fasciitis (NF) is a serious form of infection involving rapidly spreading inflammation and extensive necrosis of the skin, subcutaneous tissue, and superficial fascia . The treLactate is generated by the skeletal muscle, erythrocytes, the brain, and the gut. In a normal setting, aerobic metabolism converts pyruvate through the citric acid cycle to generate 38 molecules of ATP. This process is facilitated by the enzyme pyruvate dehydrogenase, an ample supply of oxygen and substrate (glucose), and functioning mitochondria. In relative oxygen-deficient states, anaerobic metabolism fails to convert pyruvate to acetyl-CoA through the citric acid cycle. Instead, two molecules of ATP and two molecules of lactate are generated by the conversion of pyruvate to lactate using the enzyme lactate dehydrogenase . In healThe institutional review board of two hospitals approved this prospective study. In all, 707 patients were enrolled based on two criteria, (1) surgically proven diagnosis of NF and (2) treatment received between March 2010 and March 2018 in our hospital. All patients were assessed by emergency physicians as soon as they were admitted. They received broad-spectrum antibiotic treatment for anaerobic and aerobic bacteria as well as early surgical debridement including fasciotomy or primary amputation post-diagnosis. Each patient’s medical record was screened for documentation of NF to confirm the diagnosis. Blood samples were collected in the ED upon arrival, and the lactate levels were determined. SOFA scores were calculated during the first 24 h after admission. Baseline demographic characteristics, laboratory findings, and serum lactate were compared between survivor and non-survivor groups.To determine the blood lactate level at ED arrival, a peripheral venous sample was collected in the first hour upon patient arrival to ED. The sample was collected directly into a tube containing anticoagulant. The blood concentration of lactate was measured immediately using an automatic biomedical blood gas analyzer  as part of a routine panel of blood gas tests in our clinical laboratory with the electrode method, and it was expressed in millimoles per liter (mmol/l). The coefficient of variation was 7.5% at the low level and 5.0% at the high level. The normal range is 0.5–2 mmol/l. The laboratory investigators were blinded to the sample sources and clinical outcomes.Sequential organ failure assessment (SOFA) is one of the scoring systems used for assessing the severity of disease in critically ill patients and predicting their outcome , 18. Thi3 μL at the ED; anemia, hemoglobin less than 10 mg/dL at the ED; and episodes of SpO2 < 90%, oxygen saturation less than 90% at the ED. Prothrombin time test, hemoglobin, platelet counts, blood gas test, serum lactate, albumin, sodium, creatinine, and CRP (C-reactive protein) were assessed by first laboratory analyses in ED.We reviewed charts and recorded variables including age, systolic and diastolic blood pressure at triage, comorbidities, discharge diagnosis, and mortality or survival on discharge. Patients with in-hospital mortality were defined as a death occurring in the hospital after admission, also known as “non-survivor group,” otherwise as “survivor group.” We defined these variables as follows: episodes of hypotension, episodes of systolic blood pressure less than 90 mmHg at the ED; hypothermia, body temperature less than 36 °C at the ED; hyperthermia, body temperature ≥ 38 °C at the ED; acidosis, pH less than 7.35 in arterial blood gas test at the ED; coagulopathy, a prolonged prothrombin time test  result greater than 1.5 at the ED; thrombocytopenia, platelet counts less than 100 × 10U test was used to determine the differences between the two groups, and the Kruskal-Wallis H test was used to analyze the differences among groups. Univariate binary and multivariate logistic regression analyses were performed to investigate whether blood lactate was independently associated with in-hospital mortality. Analysis of the area under the curve (AUC) of the Receiver Operating Characteristic (ROC) curve was constructed to assess the predictive strength. Sensitivity, specificity, and positive and negative likelihood ratios and predictive values were calculated at different cutoff values. Optimal cutoff points to maximize both sensitivity and specificity were also determined. Differences with P values < 0.05 were considered to be statistically significant.Statistical analyses were done by using SPSS 20.0. Assumptions of normality and homogeneity of variance were first checked. For continuous variables with a skewed distribution, descriptive results were expressed as medians and interquartile ranges. The Mann–Whitney P < 0.001). SOFA scores in non-survivors were also significantly higher than those in survivors, which were calculated during the first 24 h after admission. In the analysis of initial variables recorded at ED, there were statistically significant differences with serum albumin , serum creatinine , and CRP level .Of the total 707 NF patients, 40 (5.66%) died in the hospital. Patients who were discharged to home were considered to have a favorable outcome. The demographic and clinical characteristics and laboratory findings on the ED arrival are compared between survivors and non-survivors in Table P < 0.001). A significant increase in the SOFA scores (P < 0.001), incidence of acidosis, coagulopathy, episodes of hypotension, and the serum creatinine, glucose, and CRP concentrations were associated with increases in the blood lactate levels. In contrast, the serum albumin concentrations (P < 0.001) were significantly decreased with increases in the blood lactate levels.Blood lactate was detectable with a range of 0.4–19.3 mmol/l in 707 samples. The median blood lactate level measured upon ED arrival was 3.6 mmol/l. Among the NF patients, 562 (79.5%) had a lactate concentration > 2.0 mmol/l., including 275 (38.9%), 141 (19.9%), 84 (11.9%), and 62 (8.8%) who had lactate concentrations of 2.1–4.0, 4.1–6.0, 6.1–8.0, and greater than 8.0 mmol/l, respectively. A comparison of the demographic, clinical characteristics and the laboratory findings collected upon ED arrival and SOFA score among NF patients with different concentrations of serum lactate is shown in Table P < 0.001). The association of blood lactate levels with in-hospital mortality remained significant after adjusting for age and SOFA score . Multivariate logistic regression analysis identified blood lactate , serum albumin , and SOFA score  as independent factors that were significantly associated with in-hospital mortality in NF. The Hosmer-Lemeshow goodness-of-fit test for the multivariate logistic regression model was not significant (P = 0.611), indicating that the model adequately fits the data. Furthermore, the association between blood lactate levels and in-hospital mortality remained significant after adjusting for SOFA score and serum albumin .Univariate binary and multivariate logistic regression analyses were performed to investigate whether the blood lactate level upon ED arrival was independently associated with in-hospital mortality Table . Age, SOn = 707) for in-hospital mortality (n = 40) was assessed (Table P < 0.001). This AUC is similar to SOFA score  for predicting the in-hospital mortality. The P value for the comparison of both AUCs was 0.218. Combining blood lactate levels with SOFA score improved the predictive performance , which is better than blood lactate alone (P = 0.008), but not significantly better than SOFA score alone (P = 0.115). The sensitivity and specificity of the blood lactate levels and SOFA scores at the optimal cutoff value to predict in-hospital mortality are shown in Table The predictive ability of blood lactate levels from NF patients upon ED arrival , which might be explained by the discrepancy in the timescales for these two methods. Notably, the primary aim of the study was to evaluate the predictive value of blood lactate, when measured as a screening method at ED arrival, to predict mortality in patients with NF. Thus, serial changes in the lactate levels during the first 24 h of admission or post-surgical intervention were not evaluated. Trends in lactate concentration over time reflect the clinical response of patients to resuscitation and surgical intervention. Serial measurements of lactate levels might improve the sensitivity and specificity of this prognostic test [The limitations of the present study include a temporal mismatch in evaluating mortality indicators. We compared the prognostic performance of a lactate value obtained on ED arrival to a SOFA score, which considers a range of values and includes the worst values obtained in the first 24 h of admission. The prognostic accuracy of the combination of blood lactate level and SOFA score was not significantly better than the use of SOFA score alone (tic test –42. FurtAnother limitation of the study is that during the blood collection period, a substantial number of patients might receive treatment with epinephrine under condition with bradycardia or shock. Epinephrine is known to affect lactate levels . UnfortuOur study indicates that the blood lactate levels upon ED arrival were significantly associated with mortality in NF, even after adjusting for age, serum albumin, and SOFA score. A high level of blood lactate upon ED arrival was independently predictive of in-hospital mortality in the NF patients. These findings extend the knowledge of blood lactate as a clinical biomarker of mortality in critical illness.