Explaining species range size pattern is a central issue in biogeography and macroecology. Although several hypotheses have been proposed, the causes and processes underlying range size patterns are still not clearly understood. In this study, we documented the latitudinal mean range size patterns of terrestrial mammals in China, and evaluated whether that pattern conformed to the predictions of the Rapoport's rule several analytical methods. We also assessed the influence of the mid-domain effect (MDE) and environmental factors on the documented range size gradient.Distributions of 515 terrestrial mammals and data on nine environmental variables were compiled. We calculated mean range size of the species in each 5° latitudinal band, and created a range size map on a 100 km×100 km quadrat system. We evaluated Rapoport's rule according to Steven's, mid-point, Pagel's and cross-species methods. The effect of the MDE was tested based on a Monte Carlo simulation and linear regression. We used stepwise generalized linear models and correlation analyses to detect the impacts of mean climate condition, climate variability, ambient energy and topography on range size. The results of the Steven's, Pagel's and cross-species methods supported Rapoport's rule, whereas the mid-point method resulted in a hump-shaped pattern. Our range size map showed that larger mean latitudinal extents emerged in the mid-latitudes. We found that the MDE explained 80.2% of the range size variation, whereas, environmental factors accounted for <30% of that variation.Latitudinal range size pattern of terrestrial mammals in China supported Rapoport's rule, though the extent of that support was strongly influenced by methodology. The critical factor underlying the observed gradient was the MDE, and the effects of climate, energy and topography were limited. The mean climate condition hypothesis, climate variability hypothesis, ambient energy hypotheses and topographical heterogeneity hypotheses were not supported. Spatial patterns of species range sizes and their underlying mechanisms at large scales are hot topics in macroecology, biogeography and biodiversity conservation The methods used to depict latitudinal gradients in range size greatly influence differences in the magnitude and perceptions of the measured patterns Ideally, studies on species distribution pattern should encompass large areas at macro-scale; misleading results may be obtained if research is limited to an overall area that provides only partial coverage Our study covered the mainland and two largest islands (Taiwan and Hainan islands) of China. Thus limits for inclusion of data in the present study spanned 18 through 54° N latitude and 73 through 135° E longitude.et al. (2004), Sheng et al. (2005), Pan et al. (2007) and the Vertebrate Species Information Database of our research group An exhaustive database of distributions of 625 mammal species, encompassing 13 orders, 55 families and 235 genera, was originally complied following IUCN For each species, we recorded the maximum and minimum latitudes of its distribution. Further, the mid-point and latitudinal range of each species was calculated as the average and difference between the maximum and minimum latitudes respectively. To evaluate the relationship between mean species range and latitude, the total latitudinal gradient was divided into eight bands of 5° latitudinal intervals. In addition, we rasterized the range maps into equal-area grids of 100 km×100 km To evaluate the effects of environmental factors, we used nine predictive variables that were collapsed into the four grouped environmental variables reported below, all of which were processed into 100 km×100 km equal-area grids. Coastal cells were excluded if they contained <50% of the land masses.http://www.worldclim.org/The data on annual mean temperature  and annual precipitation  were compiled at a 1 km×1 km resolution from WorldClim 1.4 at http://www.worldclim.org/We used temperature annual range , temperature seasonality  and precipitation seasonality  as predictors of climate variability. These data were compiled at a 1 km×1 km resolution from WorldClim 1.4 at http://www.csi.cgiar.org/http://www.data.ac.cn/Potential evapotranspiration  for the years 1950–2000 were overlain on 1 km×1 km grids using data from CGIAR Consortium for Spatial Information (CGIAR-CSI) at http://srtm.csi.cgiar.org/) with 1 km×1 km resolution as indicators of topography and its heterogeneity We extracted altitude  and altitude range  data from a global digital elevation model . Second, we processed generalized linear models (GLMs) between mean latitudinal range sizes and four groups of environmental variables separately over the 100 km×100 km quadrat system to explain the environmental impacts on range size gradient We tested the impacts of two factors: (1) the MDE and (2) environmental effects. First, we detected the MDE by comparing the observed latitudinal range pattern with the null model built by reshuffling species ranges based on an empirical distribution range model Our statistical analyses were carried out in SAS Version 9.1 and SPSS Version 13.0. The spatial analyses were conducted in ESRI ArcGIS 9.2.n = 515), with the median of 9.58°. The distribution of range size was formally right-skewed   revealed that the null model explained 80.2% of the range size variation.Our results indicated an obvious and important impact of MDE in shaping the latitudinal gradient of range size. The Monte Carlo simulations (null model) indicated a hump-shaped range distribution of size variation (lr = −0.831) and AP (lr = −0.666) were strongly negatively related to latitude, whereas, TAR (lr = 0.964) and TS (lr = 0.957) were strongly positively related to latitude (mr = 0.522) and NDVI (mr = 0.453) with range size were strongly positive, whereas, the residual coefficients of those relationships were <0.4 , Bhattarai & Vetaas (2006), Feng et al. (2006) and Hausdorf (2006) all reported that different methods could lead to variation in the results obtained In this study, the results obtained with Steven's method, Pagel's method and the cross-species method revealed significant overall positive trends, which support Rapoport's rule . The midThe mid-point method provided results that corresponded most directly with those apparent from visual examination of the mean range size map, but did not support Rapoport's rule . The mapet al. (2004) argued that the mid-domain peaked pattern may occur in the absence of any contributing heterogeneity in underlying environmental factors Colwell et al. (2001), Diniz-Filho et al. (2002), Hawkins & Diniz-Filho (2002), Sanders (2002) and Moreno et al. (2008) reported findings that were inconsistent with the MDE The results of our study revealed a hump-shaped latitudinal range size gradient, and detected marked impacts of the MED . Our resMean range size may be correlated with environmental variables. Climate and the variation therein have been reported to be deterministic of species range sizes In this study, climate, ambient energy and topography contributed minimally to the observed variation in range size, while AP, TS and NDVI accounted for substantial proportions of the observed variation , Table 2


The objective of this study was to describe aetiology and case fatality of fever among inpatients in a tertiary care hospital in South India.This was an observational, prospective study conducted in a tertiary care hospital in Vellore, Tamil Nadu, India. Between July 2nd 2007 and August 2nd in 2007, adult patients admitted to the hospital with temperature ≥ 38.0°C were included consecutively and followed during the hospitalisation period. Demographic and clinical data were collected and analysed for each patient. Associations were sought between death and various clinical and demographic variables.One hundred patients were included, 61 male and 39 female. Mean age was 37.5 (range: 16 to 84) years. Mean fever duration was 5.4 (range: 0.1 to 42.9) weeks.E. coli sepsis, Plasmodium falciparum malaria (5%) including three patients with mixed P. vivax infection, scrub typhus (5%), typhoid fever (4%), cryptococcal meningitis (4%) including three HIV positive patients, endocarditis (3%) including two patients with Staphylococcus aureus sepsis, spleen abscess (2%), amoebic liver abscess (2%), sepsis undefined focus (1%), HIV infection (1%), hepatitis B (1%), rubella (1%), peritonitis (1%) and cholecystitis (1%).The following infectious aetiologies were recorded: tuberculosis (19%), lower respiratory infection (11%) including three with sepsis, urinary tract infection (10%) including three with Non-infectious causes of fever were diagnosed in 15%, including systemic lupus erythematosus in four and malignancy in six patients. Cause of fever remained unknown in 13%.Case fatality during hospitalisation was 7% (7/100). Six of those who died were male. Five fatalities had bacterial sepsis, one spleen abscess and malignancy, and one had lymphomalignant disorder.Diabetes and increasing age were significant risk factors for fatal outcome in unadjusted analyses, but only increasing age was a risk factor for death in adjusted analysis.P. falciparum was identified in all malaria cases, and this rapidly fatal infection should be considered in patients with acute undifferentiated fever in India.A high number of tuberculosis and bacterial infections and a high case fatality rate from sepsis were found in this cohort, underlining the importance of microbiological diagnostics and targeted antimicrobial treatment in the management of fever.  Infectious diseases are leading causes of morbidity and death in tropical countries. The World Health Organization (WHO) reports that each of the main infectious aetiologies  and neonatal infections), cause between 1.05 and 0.24 million deaths respectively per year in low income countries[In resource-limited settings fever may be treated empirically or self-treated due to lack of access to diagnostic tests. HoweverNevertheless, there are only a limited number of studies from India reporting on the aetiology of fever, and reliable surveillance data are not available. The maiThe study was conducted in a 1750-bed tertiary care referral hospital in Vellore, Tamil Nadu, South India.This was a prospective observational study among inpatients. Inclusion criteria were adult patients admitted to the hospital with fever of unlimited duration, with temperature ≥ 38.0°C upon admission. Co-morbidity was not an exclusion criterion. Patients were included consecutively during the four-week period from July 2nd 2007 to August 2nd 2007.Data were collected from hospital records, medical staff, and patients by a researcher not involved in patient care.Demographic data, including age and gender, were recorded prospectively, as well as clinical data including fever duration, length of stay in hospital, human immunodeficiency virus (HIV) infection, antibiotic treatment before hospital admission, history of chronic disease, symptoms and findings, treatment, final diagnoses and deaths.Leptospira IgM ELISA , Panbio Dengue Duo IgG/IgM Cassette , Widal Ag kit , Cryptococcus antigen Latex test , HIV Abbot Axsym Ag/Ab combo , Genescreen HIV Ag/Ab , HIV TRIDOT , Abbot Axsym-HBsAg ver 2 , HBsAg EIA , Abbot Axsym – Anti HCV , Ortho HCV 3.0 ELISA .Radiological, biochemical and microbiological tests performed were registered. Tests had been ordered according to the discretion of the treating physicians, and no additional tests were conducted for the purposes of the study. Blood cultures were processed through automated "BacT Alert" Biomerieux inc. Malaria was diagnosed with microscopy slides stained with Leishman stain (Fisher scientific) and with quantitative buffy coat method (QBC) . Further were the following microbiological tests used: Scrub typhus Detect IgM ELISA , When more than one diagnosis explaining fever had been noted in the records, the most probable aetiology  was registered as the main aetiological diagnosis.Data were recorded in a standardized clinical registration form.For the patients who died, data were quality controlled from the hospital records retrospectively.The association between death as a dependent variable and age, gender, fever duration, HIV infection and diabetes as explanatory variables were analysed by unadjusted and adjusted binary logistic regression analysis. The statistical analyses were performed using SPSS 18.0.The study was approved by the Regional Ethics Committee of Norway and the Institutional Research Board at the study hospital in India.One hundred patients were included, 61 male and 39 female. Mean age was 37.4 years (range 16–84 years). Mean fever duration was 5.4 (range 0.1- 42.9) weeks. Clinical characteristics are presented in Table Aetiological diagnoses, and associations with HIV infection and with sepsis, are shown in Table Mycobacterium tuberculosis detected in sputum samples, and for two of these it was a multi-drug resistant strain. Two patients had M. tuberculosis identified in lymph node biopsies. Two patients had findings consistent with TB on chest X-ray, and six on computer tomography (CT). One TB patient was also diagnosed with hepatitis C, and one with urinary tract infection (UTI). Seven patients were diagnosed with TB meningitis, five on the basis of biochemical analyses of cerebrospinal fluid (CSF). All CSF cultures were TB negative. Two patients had findings consistent with meningeal involvement on CT scans.Among patients diagnosed with TB (n = 19) six patients had Bacterial infections other than TB were diagnosed in 38 patients, and pathogens identified by culture are shown in Table Three out of 11 patients diagnosed with lower respiratory infection (LRI) died of sepsis. Diagnosis was confirmed in six patients by chest X-ray and in two by CT. One patient had Gram-negative rods in sputum, two patients had lung abscess.E. coli sepsis. Nosocomial UTI was found in 10 patients with other main causes of fever.Among 10 patients diagnosed with UTI, based on urine microscopy and culture, three had Plasmodium falciparum malaria was found in 5 patients based on Quantitative Buffy Coat (QBC) and thin and thick blood smears. Among these, three patients were diagnosed with mixed P. vivax infection. Parasitaemia in the range between 5% and 15% was recorded in three patients.Scrub typhus (n = 5) was diagnosed based on positive Weil Felix and positive IgM ELISA in one patient, while four were diagnosed based on symptoms and findings . One of these patients also had positive HBsAg.All patients diagnosed with cryptococcal meningitis (n = 4) had cryptococcal Ag detected in CSF. One had disseminated infection with cryptococci isolated from blood, urine and CSF cultures. CT was negative in all four patients. Three of these patients had known untreated HIV, and among these one also had TB. One was HIV negative and had TB.Salmonella typhi (n = 3) or Gram-negative rods (n = 1) in blood culture. One patient had Gram-negative rods in blood culture and S. typhi in bone marrow biopsy.Typhoid fever (n = 4) was diagnosed based on positive typhi-dot rapid test (n = 3), Widal (n = 2) and culture (n = 4). All patients had Staphylococcus aureus in blood culture and one of these patients died. One patient was culture negative. Two had rheumatic heart disease.Among patients with endocarditis (n = 3), two had Enterococcus spp. in blood culture.Spleen abscess (n = 2) was diagnosed based on clinical and radiological findings, and one of these died; one had Among patients diagnosed with sepsis (n = 9), five patients died. Microbiological and clinical information among these are shown in Tables Amoebic liver abscess (n = 2) was diagnosed based on clinical findings and abdominal ultrasound.Five among seven patients with malignancy had lymphoid malignant disorder (LMD) based on biopsy from bone marrow, skin or lymph node, and among these one patient died who had spleen abscess as an infectious aetiological diagnosis of fever. One had adenocarcinoma in lung and brain, and one had leiomysarcoma. Systemic lupus erythematosus (n = 4) was diagnosed based on dsDNA, anti-nuclear antibodies and biochemical tests. Five patients had other non-infectious aetiological diagnoses as shown in Table Diagnostic yields among radiological and microbiological tests performed in this cohort are shown in Table Results were not available from 45% of chest x-rays and 29% of blood cultures at the time of discharge. Serology results for scrub typhus and leptospirosis were not available for 45% and 40% of tests performed, respectively.Case fatality in this study was 7% (7/100). Characteristics, findings and treatment among patients who died in hospital are shown in Table In unadjusted analysis, diabetes and increasing age were significant risk factors for a fatal outcome, while only age was found to be a risk factor for death in adjusted analysis Table . Among mIn this study among a cohort of patients admitted to a tertiary care hospital in South India with fever, bacterial infections 38%) and TB 19%) were the most common aetiological diagnoses. Mean fever duration was high (5.4 weeks), and therefore the relatively high prevalence of TB is not surprising and is consistent with other hospital based studies reporting aetiology of prolonged fever in India. One study among 100 patients with fever of unknown origin (PUO) in Calcutta reported that TB (53%), neoplasms 17%) and collagen vascular disorders (11%) were the dominant causes[% and col% and TB % were thBacterial infections and sepsis were associated with all the deaths recorded in this cohort, except for one patient who died due to malignancy. Not surprisingly among patients with severe bacterial infections, older age was a significant risk factor for death. In general, bacterial sepsis is probably undertreated in tropical countries for several reasons, including unspecific diagnosis of fever, high prevalence of multi-resistant microbes, lack of blood culture facilities, and widespread use of counterfeit drugs. This may explain the high case fatality reported in African patients with fever incorrectly treated as malaria. In IndiP. vivax infections (n = 97) compared with P. falciparum (n = 70) was reported[P. falciparum infections. A malaria prevalence of 17% among patients hospitalised with acute undifferentiated fever was reported from Vellore, India in 2010, and, among these, 57% were due to P. falciparum[P. falciparum predominance has been reported from Central India[Malaria is known to be severely underreported and insufficiently controlled in India,14, and reported. In our alciparum. A similal India,20.Pneumocystis jiroveci pneumonia (7% and 13%) as the most common causes[The ratio of infectious causes of fever compared with non-infectious causes is usually higher among immunocompromised patients than immunocompetent individuals, as previously reported in two studies from hospitalized patients in India and Thailand,22. In tn causes,22. In oScrub typhus and dengue virus infection, which typically cause acute fever, were diagnosed in 5% and 0% of the patients respectively. These figures are low compared with 48% and 7%, respectively, reported from a prospective study among patients from the same hospital in 2010. This diBrucella serology was not performed, and since blood cultures need three weeks incubation to detect Brucella spp., this is another example of an infection that potentially may have been overlooked.The prevalence of leptospirosis in the area is known to be high; Chrispal et al. detected 12 cases of leptospirosis among hospitalised cases of fever (3%) in 2010, and a seroprevalence of approximately 70% has been reported in exposed risk groups, such as rice mill farmers, in the area. LeptospP. falciparum malaria (2%), while 19% had fever of unknown aetiology[The aetiology of fever among travellers to the tropics differs from that among residents due to pattern of exposure and immunity, as was shown in a study among 1743 western travellers with fever imported from the tropics in Belgium, where TB was diagnosed in only 2%. In thisetiology. A studyetiology.The pattern of fever aetiology found in this study would not be representative for the causes of fever in the general population. There are three main limitations explaining this. The selection of patients admitted to a tertiary care hospital in India is biased as a result of factors such as severity of disease, gender and accessibility. In this study only adults where included, while children would expect to have different fever aetiologies due to exposure and immunity. Entomological factors cause seasonal and geographical variations in vector borne diseases in India, and our study selecting patients during a dry month of the year in South India would not incorporate such variations.Further studies are needed, both population- and hospital based, in order to provide more evidence based information about the prevalence of infectious diseases in India.P. falciparum was identified in all malaria cases, and this rapidly fatal infection should be considered in all patients with acute undifferentiated fever in India.A high number of bacterial and TB infections were found in a cohort of adult patients admitted to a tertiary care hospital with fever in South India, and there was a relatively high case fatality rate from sepsis. This underlines the importance of establishment of relevant microbiological diagnostics and targeted antimicrobial treatment in the management of fever. Written informed consent was obtained from the patients for the publication of this report.The authors declare that they have no competing interests.SKA, CNH, KM, NL and DM designed the study. Collection of prospective data was performed by SKA and CNH, supervised by DM and PR. Statistical analyses were performed by GEE and KM. All authors contributed to interpretation of results and revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/355/prepub


H7N9 posed potentially serious health challenges for Chinese society. The previous SARS outbreak in this country was accompanied by contradictory information, while worries about wide-spread influenza led to discrimination worldwide. Early understanding of public threat perceptions is therefore important for effective public health communication and intervention.We interviewed 1011 respondents by phone two weeks after the first case. Questions examined risk awareness and media use, beliefs about the emergence of the threat and those most at risk, anxiety about infection and preventive and avoidant behaviours.Results demonstrate moderate levels of anxiety but relatively high levels of trust towards government officials. Threat emergence was associated with hygiene levels, temperature change, floating pigs in the Huangpu River and migration to the city. Anxiety predicted both recommended and non-recommended behavioural changes.Comparatively high levels of trust in Chinese government advice about H7N9 contrast positively with previous pandemic communications in China. Anxiety helped drive both recommended and non-recommended behaviours, with potentially important economic and social implications. This included evidence of 'othering’ of those associated with the threat (e.g. migrants). Findings emphasise the need to manage public communications early during new influenza outbreaks. Partialril 2013 . FurtherPrevious research has indicated that lay beliefs about disease origins and those most at risk, and cultural perceptions about the purchase and preparation of birds, influence disease reporting, individual self-care and avoidance behaviours -9. The cPrevious work has also stressed the significance of source credibility in the context of risk and health communication . In receM age 49.5 (SD 16.8)), using random digit dialing of home phones. Total H7N9 confirmed laboratory cases/fatalities in Mainland China during this time ranged from 43/11 (April 12th) to 96/18 [Ethical approval was received from the relevant IRB board  at Fudan University. We interviewed 1011 participants in the Shanghai region between April 12 and April 20th 2013  = .79) and combined as 'Anxiety’. Outcome variables were divided into behaviours recommended by the Chinese Ministry of Health  and avoiF  = 142.5, p = .001).Respondents most associated H7N9 with poor hygiene or climatic changes Table . At leasRespondents demonstrated low to moderate anxiety about H7N9 (Mean = 1.7/4). Forty-one respondents (4%) were 'worried a great deal’ about personal infection, 121 (12%) worried 'quite a lot’, 264 (26%) worried a little and 582 (58%) not worried. Regarding concern about their family being infected 83 (8%) were 'worried a great deal’, 169 worried 'quite a lot’, 260 (26%) worried a little and 498 (49%) not worried. Sixty-seven percent (642) thought it unlikely that they personally would be infected, 310 (31%) that this was 'a little likely’ and 11 (1%) that this was very likely. Since the H7N9 outbreak, 97 (10%) had been thinking a great deal more about life and death, 400 (40%) a little more about this and 500 (50%) no more than usual. Finally, 42 (4%) reported that H7N9 had brought a lot of difficulty to their daily life, 284 (28%) some difficulty, 120 (12%) a little difficulty and 562 (56%) no difficulty.p = .20; for only social media OR = 1.21, 95% CI .87-1.68, p = .26)Table Table p < .001) and death awareness . The purchase of Western medicine was also associated with anxiety  and death awareness .Table Large populations and high population density make it critical to understand public responses to novel influenza viruses in China. Mixed messages from official sources can produce confusion, permitting anxiety to spread rapidly within families and communities, and reducing important behavioural change . In thisRespondents associated temperature changes, the poultry trade and unexplained local events (e.g. floating pigs) with H7N9. Associations with seasonal and climatic variations in influenza, also suggested in the research literature , imply hThe present study had some limitations. The telephone interview format employed meant we could not contact those without home phones and limited the length of the survey. As those without home phones are more likely to be temporary migrants within the city we were consequently less able to draw from a migrant population for our study. High levels of trust towards the government may reflect the relatively large number of respondents in our sample aged 65 or over. Data was from self-reports and therefore behaviour cannot be independently verified (e.g. hand washing behaviours). The need for immediate data collection reduced sample size, while random dialling potentially limited response rate.At the time of writing there has been little evidence of human-to-human transmission of H7N9. Nevertheless our findings have important implications for clinicians and those working in health communication. Local expertise was particularly valued by our respondents, suggesting the efficacy of a new government strategy to provide rapid, transparent information. Other national authorities elsewhere may learn from this example when faced with emergent influenza threats. At the same time, even at this early stage of the pandemic threat, respondents reported buying preventive medicines, particularly local products. Public officials need to be aware that increased public anxiety may rapidly produce medical shortages. 'Common sense’, lay beliefs about those at risk, and appropriate behaviours to adopt to avoid infection influence adherence and self-care, but are rarely considered by practitioners. Perceptions of enhanced risk from some groups, such as those from outside a city, may cause socially disruptive behaviours, particularly if threat levels increase. This emphasises the continuing need for clear risk communications in order to abate potential discrimination and public disorder during influenza threat.All authors report no competing interest disclosures.Study concept and design: RG, SS. Acquisition of data: SS. Analysis and interpretation of data: SS, RG, Drafting of the manuscript: RG, SS. Statistical analysis: RG, SS. Critical revision of the manuscript for important intellectual content: RG, SS. Final approval of manuscript: RG, SS. Obtained funding: SS. Administrative, technical, or material support: SS. Study supervision: SS. SS had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/8/prepub


A 40-year-old patient was referred to Clinic of Endocrinology due to hypophosphatemia causing pain, cramps, and weakness of muscles. Moreover, his bone mineral density was very low. The previous treatment with phosphorus and active vitamin D metabolites was ineffective. In lab tests the hypophosphatemia, hyperphosphaturia, and elevated FGF23 levels were found. Somatostatin receptor scintigraphy (SRS) showed increased radiotracer uptake in the right maxillary sinus and CT scans confirmed presence of tumor in this localization. Biopsy and cytological examination created suspicion of mesenchymal tumor—glomangiopericytoma. Waiting for surgery the patient was treated with long acting Somatostatine analogue, and directly before operation short acting Octreotide and intravenous phosphorus were used. Histology confirmed the cytological diagnosis and the phosphatemia return to normal values in 10 days after the tumor removal. T-scores and Z-scores <−3). Patient was treated for more than one year with calcitriol 1 μg, alfacalcidol 1 μg, calcium 1000 mg, and phosphorus 1500 mg per day. This medication had no effect on serum concentrations of phosphorus and only a moderate effect on clinical symptoms. Patient was under dental treatment (caries and periodontitis). At admission the levels of CPK, calcium, and PTH were normal; 25OHD3 level raised to 29.1 ng/dL  despite using only little amount of D3 contained in Ca/D3 preparations apart from active metabolites. Alkaline phosphatase (AP) was slightly elevated  and serum phosphorus concentration was very low . 24 h urine collection showed high phosphorus excretion . Bone mineral density was still very low: lumbar spine T-score = −3.1 and femoral neck T-score = −3.9. The level of phosphaturic agent FGF23, assessed by Enzyme-linked immunosorbent assay (ELISA) was high . Therefore tumor-induced hypophosphatemia was diagnosed and searching of FGF-producing tumor was initiated.A 40-year-old man was referred to Clinic of Endocrinology due to prolonged, deep hypophosphatemia causing pain, cramps, and weakness of proximal muscles. One year before, during the previous hospitalization  primary muscle disease had been excluded and diagnosis of osteomalacia had been established. Diagnosis was made on basis of symptoms, low calcium and phosphorus level , and very low 24 h calcium urine excretion (80 mg/24 h). PTH was then surprisingly normal that is, 57 pg/mL , and 25OHD3 level was undetectable (<4 ng/mL). There were no fractures in patient's medical history; however bone mineral density was very low , showed increased radiotracer uptake in the right maxillary sinus , performed using ry sinus . On CT try sinus , and fusry sinus . Biopsy ry sinus . On the On the basis of confirmed Octreotide uptake in tumor, we ordered long acting Somatostatin analogue (Sandostatin LAR 30 mg). Two days after the injection phosphorus level increased from 0.5 to 0.68 mmol/L. Directly before the surgery, we additionally used intravenous phosphorus and repeated injection of Somatostatin (Sandostatin) twice daily—phosphorus level increased to 0.75 mmol/L. After the removal of tumor serum phosphorus levels increased to normal values in 10 days on oral preparations only. Histology confirmed the diagnosis of glomangiopericytoma. Unfortunately, we have not had an opportunity to repeat the FGF23 measurement after operation as in Poland these assays are made very rarely in highly specialized medical centers.T-score = 0.4) and osteopenia (T-score = −1.7) in femoral neck. Muscle function is normal, all symptoms reported previously retreated. Repeated SRS-scans did not show any lesions with high radiotracer uptake. The only medications at present are vitamin D3 2000 IU and calcium preparations  per day.Six months after the operation the phosphorus level achieves 1.1 mmol/L. The bone mineral density raised significantly: DEXA measurements revealed normal BMD in lumbar spine  is a rare condition associated with hypophosphatemia, myopathy, and systemic bone demineralization caused by renal phosphate wasting in conditions of excessive production of fibroblast growth factor 23 (FGF23) by neoplasmatic, most often, benign lesions. FGF23 producing tumors are usually very small; therefore their identification can be difficult. The second reason for difficulties of tumor finding is wide variety of its localization—all regions and organs of body could be the site of it . AuthorsAfter the proper recognition of tumor site of our patient a problem has occurred: according to anesthesiologist's wish we had to achieve at least near to lower range of limits of phosphorus blood concentration. It was necessary for safety of anesthesia and proper function of respiratory muscles after the extubation. Basing on high Octreotide uptake in tumor, we decided to use the long acting analogue of Somatostatine, followed by short acting Octreotide in order to amplify the effect of medication on the phosphorus blood levels. We found similar cases in the literature; unfortunately most authors described that Sandostatin analogues allowed to decrease FGF-levels but failed to restore normal phosphorus level –12. In o


HIV-positive women have an increased risk of invasive cervical cancer but cytologic screening is effective in reducing incidence. Little is known about cervical screening coverage or the prevalence of abnormal cytology among HIV-positive women in Ukraine, which has the most severe HIV epidemic in Europe.Poisson regression models were fitted to data from 1120 women enrolled at three sites of the Ukraine Cohort Study of HIV-infected Childbearing Women to investigate factors associated with receiving cervical screening as part of HIV care. All women had been diagnosed as HIV-positive before or during their most recent pregnancy. Prevalence of cervical abnormalities  among women who had been screened was estimated, and associated factors explored.p<0.01 for 1st/2nd trimester diagnosis and APR 0.42, 95% CI 0.28–0.63 p<0.01 for 3rd trimester/intrapartum diagnosis). Among those with a cervical screening result reported at any time (including follow-up), 21% (68/325) had a finding of cervical abnormality. In adjusted analyses, Herpes simplex virus 2 seropositivity and a recent diagnosis of bacterial vaginosis were associated with an increased risk of abnormal cervical cytology (APR 1.83 95% CI 1.07–3.11 and APR 3.49 95% CI 2.11–5.76 respectively).Overall, 30% (337/1120) of women had received a cervical screening test as part of HIV care at study enrolment (median 10 months postpartum), a third (115/334) of whom had been tested >12 months previously. In adjusted analyses, women diagnosed as HIV-positive during (vs before) their most recent pregnancy were significantly less likely to have a screening test reported, on adjusting for other potential risk factors  0.62, 95% CI 0.51–0.75 In this high risk population, cervical screening coverage as part of HIV care was low and could be improved by an organised cervical screening programme for HIV-positive women. Bacterial vaginosis testing and treatment may reduce vulnerability to cervical abnormalities. Ukraine has the highest adult HIV prevalence in Europe, estimated at 1.6% in 2007 Regular cytologic screening can effectively reduce the incidence of invasive cervical cancer by up to 80% on a population level In Ukraine, cervical screening is recommended six-monthly for all women of childbearing age We aimed to explore coverage of cervical screening as part of HIV care in a cohort of HIV-positive childbearing women in Ukraine receiving care at HIV/AIDS Centres, and to identify factors associated with an abnormal finding.The Ukraine Cohort Study of HIV-infected Childbearing Women (“Women’s Cohort”) is an ongoing study established in December 2007. HIV-infected women who had recently given birth  and were receiving care at one of five participating regional HIV/AIDS Centres in Ukraine  were enrolled with informed consent Maternal socio-demographic information was collected as part of the ECS (clinician-completed questionnaire) and at enrolment in the Women’s Cohort (woman-completed questionnaire). Clinical information, including data on cervical screening, was provided by the clinician at enrolment and thereafter when a woman returned to the HIV/AIDS Centre for care. Data collection was opportunistic and dependent on routine clinic visits; according to policy, clinic visits should be at least three monthly for women on ART and six-monthly for those not on treatment, but in practice follow-up intervals could be much longer. All clinicians providing care at the HIV/AIDS Centres were gynaecologists. Only information on screening tests received as part of HIV care was available to them and reported in this study.Results of cervical cytology were reported according to the 2001 Bethesda System as negative for intraepithelial lesion or malignancy , low-grade squamous intraepithelial lesion (LSIL)  1) and high-grade squamous intraepithelial lesion (HSIL)  History of IDU was classified by self-report, clinical assessment or abstinence syndrome in the neonate. HIV clinical status was defined according to the World Health Organization (WHO) clinical staging criteria (advanced and severe symptomatic HIV disease corresponding to WHO stages 3 and 4 Chlamydia Trachomatis (‘chlamydia’) by enzyme immunoassay on endocervical swab; Trichomonas vaginalis (TV) by microscopy.Genital infections diagnosed with the following methods during the most recent pregnancy or postnatally (up to date of enrolment) were reported: bacterial vaginosis (BV) by Gram stain microscopy in 99% and by symptoms in 1%; vulvo-vaginal candida by Gram stain microscopy in 77%, culture in 14% and symptoms in 10%; Of the five centres participating in the study, analyses were limited to Odessa, Kiev and Donetsk, as Kriviy Rig and Mykolaiv did not report any cervical screening.2 and Fisher’s exact tests for categorical variables were used to investigate univariable comparisons. Univariable and multivariable Poisson regression models with a robust variance estimate were fitted to estimate unadjusted and adjusted prevalence ratios (PRs and APRs) of having a cervical screening test reported at postnatal study enrolment, and of an abnormal finding (LSIL or HSIL). The models for having a test reported were fitted including all women and also restricted to those diagnosed prior to conception of their most recent pregnancy. The PRs and APRs thus estimated provide a more interpretable measure of effect than those resulting from odds ratios obtained with logistic regression models, which may be inflated where outcomes are common, and control for under-dispersion and confounding which depends on the measure of effect p<0.1) were included in the multivariable models. In analyses of factors associated with an abnormal finding, all variables known to be associated with invasive cervical cancer and available in our dataset were included a priori in the models  infection, chlamydia infection and CD4 count) p<0.10).The χSexually transmitted infections (STIs) and genital infections  were not considered in the analyses of factors associated with having a cervical screening test reported due to problems with interpretation of potential associations, particularly in terms of direction of effect, e.g. cervical screening could have prompted investigation for infections and vice versa. However, associations between STIs/genital infections and cervical abnormality were explored as some infections are known risk factors for invasive cervical cancer.At the time of analysis, only 21% (233/1120) of women had follow-up data available reflecting the recent establishment of this cohort, long follow-up intervals among women not receiving ART, and also possible loss to follow-up. As women with follow-up were not representative of the cohort as a whole with respect to health-seeking behaviours, follow-up data were omitted from analyses.Data were managed in an Access 2003 database  and statistical analyses were performed in Stata version 11.0 .A total of 1120 women were enrolled at Odessa, Kiev and Donetsk centres from December 2007 to March 2011, at a median of 10 months postpartum (83% (924/1120) at ≥12 weeks postpartum). Median age at enrolment was 27.3 years . HIV diagnosis occurred a median of 1.5 years  prior to enrolment. For two-thirds (665/971), this was during their most recent pregnancy and for one third (306/971) prior to conception. Women diagnosed <6 months before enrolment  accounted for 7% (69/970).3. Almost half  were multiparous at enrolment. Of those who reported being sexually active postnatally, 88% (699/794) reported use of condoms, most  as their only method of contraception.Almost all (971/972) women were born in Ukraine and 23% (257/1120) had a history of IDU, about a third (89/255) of whom had a sex partner who also injected drugs. Of those without an IDU history, 12% (88/716) reported a sex partner who injected drugs. Overall a third (299/872) were seropositive for hepatitis C virus (HCV), 55% (163/299) of whom had an IDU history. A quarter (279/1111) did not know the HIV status of their partner, 39% (434/1111) were in a concordant partnership, 29% (317/1111) in a discordant partnership and 7% (81/1111) had no current partner. Of the 76% (851/1120) of women tested for chlamydia, 25% (215/851) were positive, of whom 78% (164/211) had at least one STI in addition to chlamydia and HIV (mostly HSV-2). Overall, 18% (197/1109) had advanced or severe symptomatic HIV disease (WHO stages 3 or 4), and 27% (255/959) had a CD4 count ≤350 cells/mm2 = 31.06 p<0.01). Of the 783 women with no test at baseline, 22% (n = 176) had follow-up data available, of whom 39% (68/176) had been screened at follow-up.Cohort characteristics by cervical screening test receipt are shown in p = 0.87). In univariable analyses, age, marital status, number of previous pregnancies, IDU history, WHO clinical stage, timing of HIV diagnosis, affordability of contraception and centre were significantly associated with having a screening test at the HIV/AIDS Centre , but not on adjusting for year and centre (p = 0.44 and p = 0.48 respectively), and were therefore excluded from the multivariable model. HCV seropositivity is omitted from There was no significant change over time in the proportion of women with a screening test reported as part of HIV care at study enrolment  (rd trimester or intrapartum. Women with one previous pregnancy (vs ≥2) were less likely to have a test reported (p = 0.05).In the multivariable model, there were significant differences in reporting of cervical screening tests by centre  , and womp = 0.06) (p = 0.14), however women ≥27 years were significantly more likely to have a test reported than those <27 years when a binary variable was used .In order to investigate factors associated with being screened at the HIV/AIDS Centre among women with longest exposure to HIV care, a sub-analysis was conducted limited to the 306 women diagnosed with HIV before their most recent pregnancy. In this group, 44% (136/306) of whom had a cervical screening test result reported at enrolment, age, marital status, self-reported affordability of contraception, HIV disclosure and centre were significantly associated with reporting of a test result in univariable analyses . In the  = 0.06) . The fou2 = 7.04, p<0.01). Women with a cervical screening test reported were also more likely to have been tested for BV  and HSV-2 antibodies (85% (285/337) vs. 67% (521/783) of those without a screening test, χ2 = 37.96, p<0.01).Although not considered in Poisson regression analyses for reasons specified in the methods, BV was more common among women with a cervical screening test result reported than among those without (22% (67/311) vs 14% (59/420) respectively, χn = 54) LSIL and 4% (n = 14) HSIL). Results were not available for 4% (12/337) of those tested, presumably because the sample was inadequate. In total, 38% (123/325) of women with a screening test result reported at enrolment had the test conducted on the same day as a positive sample was taken or diagnosis made for at least one of: chlamydia, gonorrhoea, syphilis, HSV-2, candida, TV or BV. Among the 68 women who only had a test reported at follow-up, prevalence of cervical abnormalities was 31% (21/68).At enrolment, among the 30% with a screening test result reported, prevalence of cervical abnormalities at the most recent test was 21% (68/325) overall  may mean findings are not generalisable to the cohort as a whole. Nevertheless, the 21% prevalence of abnormal findings on cytologic screening was comparable to the 23% prevalence of LSIL/HISL among 285 HIV-positive women recruited from a patient programme in Brooklyn from 1990–93 There was a high prevalence of a number of co-factors implicated in the aetiology of cervical cancer in this cohort, including smoking, chlamydia and HSV-2 infections Women in poorer socioeconomic groups are less likely to be screened for cervical abnormalities in the US In Eastern Europe 70% of cervical cancer cases are attributed to vaccine-preventable HPV types 16 and 18 Lack of data on cervical HPV infection or sexual risk behaviours precluded more detailed exploration of the association between BV and LSIL/HSIL. False positives or negatives cannot be ruled out, particularly as a quarter of the samples were taken in pregnancy, 10% at <12 weeks postpartum and 38% on the same day as a positive sample for a genital infection In conclusion, cervical screening coverage of this high risk population as part of HIV care is low. An organised programme where women are invited to attend the HIV/AIDS Centre for cervical screening could increase coverage, particularly among marginalised women. BV testing and treatment could potentially reduce vulnerability to cervical abnormalities.


Conventional reoperative mitral valve surgery by median sternotomy has several difficulties. We performed mitral valve replacement (MVR) under ventricular fibrillation (VF) through right mini-thoracotomy with three-dimensional videoscope for avoiding the problems.Between 2006 and 2011, we performed 257 cases of MVR, in which 125 cases underwent isolated MVR. Ten cases of patients underwent reoperative MVR under VF through thoracotomy with three-dimensional videoscope (Group I), and 27 cases of patients underwent reoperative conventional MVR through median sternotomy (Group II). We retrospectively reviewed the outcomes and compared Group I with Group II. Preoperative left ventricular ejection fraction (LVEF) was significantly lower , and significantly higher Euro SCORE was found in Group I .Although Group I required cooling and rewarming time, average operative times was significantly shorter in Group I , and cardiopulmonary bypass times and average VF times in Group I and aortic cross-clamp times in Group II were equivalent. There was no significant difference in the average of postoperative maximum creatine kinase (CK)-MB. In-hospital mortality was 0/10 (0%) and 1/27 (3.7%), and postoperative paravalvular leakage occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. Two patients underwent reoperation for bleeding in Group II. Intensive care unit stay in Group I was significantly shorter than in Group II .The higher risk of preoperative background in Group I had no effect on the operation. Mitral valve surgery under VF through right mini-thoracotomy can be an alternative procedure for reoperation after conventional various cardiothoracic surgeries. Conventional reoperative mitral valve replacement (MVR) has several challenges and difficulties in the dissection of broad adhesions to the apex, prevention of injury of the bypassed graft and right ventricle, aortic clamp and myocardial protection. The right thoracotomy approach under ventricular fibrillation (VF) can avoid all these problems -3. ReopeFrom January 2006 through September 2011, 257 patients underwent MVR at the Sakakibara Heart Institute of Okayama. Isolated MVR  was performed in 125 patients and 132 patients underwent concomitant procedures. In the isolated MVR cases, 10 cases were non-clamp reoperative MVR via right mini-thoracotomy under VF using three-dimensional videoscope, 27 cases were conventional reoperative MVR via median sternotomy under cardiac arrest, 20 cases were initial MVR via right mini-thoracotomy under cardiac arrest, 64 cases were initial conventional MVR via sternotomy under cardiac arrest and 4 cases were patients who had initial MVR via partial sternotomy under cardiac arrest. We reviewed this non-clamp reoperative MVR (Group I: n = 10), and compared the outcomes with conventional reoperative MVR through median sternotomy (Group II: n = 27). Table The mean age was not significantly different , and the mean body surface area was also not significantly different  in 4 patients, coronary artery bypass grafting (CABG) in 2 patients, redo MVR in one patient, aortic valve replacement (AVR) in one patient, mediastinitis after MVP in one patient, and CABG with Bland-White-Garland syndrome in one patient . In GrouContinuous data were presented as mean ± standard deviation, and were analyzed using a Mann–Whitney test for independent data and a Wilcoxon signed rank test for paired data as appropriate. Categorical variables are given as a count and percentage of patients and compared using χ-square or Fisher’s exact test. A probability value of less than 0.05 was considered significant. All data were analyzed using the Statistical Analysis Systems software JMP 9.0 .After intubation with a double lumen endotracheal tube, transesophageal echocardiography was used for cardiac monitoring. The chest was opened through a right mini-thoracotomy (skin incision ≤ 10 cm) under one lung ventilation at the 4th anterolateral intercostal space. The endoscopic port was placed at the right 5th anterior intercostal space and used as a CO2 port. Intracardiac operation was performed under three-dimensional videoscope support. An arterial catheter was inserted from the right femoral artery, and venous cannulae were placed through the right femoral vein and the right internal jugular vein. In elderly patients, axillary artery could be used for arterial cannulation. Cardiopulmonary bypass was then instituted using a system for vacuum-assisted venous drainage. The pericardium was opened vertically, just 1cm medial to the right phrenic nerve. Left atrial venting was initiated through the right upper pulmonary vein. After cooling to 27–30°C, MVR was performed by conventional left atriotomy under VF. Intracardiac operation was performed using instruments for minimally invasive mitral surgery under video support. After a prosthetic valve was sewn into place in standard fashion, the left atriotomy was closed with opening the prosthetic valve by inserting a rubber catheter through the valve to left ventricle for de-airing. The de-airing and rewarming was completed, and cardioversion was performed. After recovery to normal sinus rhythm, cardiopulmonary bypass was terminated and the femoral cannulae were removed. A right pleural chest tube was positioned, and the incision was closed.Cardiopulmonary bypass (CPB) was standing by and the chest was opened through median sternotomy. An arterial catheter was inserted from the right femoral artery, and venous cannula was placed through the right femoral vein. After another venous cannula was placed through the superior vena cava and CPB was established, we performed dissection of adhesion to apex. Cardiac arrest was achieved by using ascending aorta clamping and antegrade cardioplegia. MVR was performed by conventional fashion.Average operative time was significantly shorter in Group I . CPB times, average VF times in Group I and aortic cross-clamp times in Groups II were equivalent. The mean of reperfusion times after cardioversion in Group I was longer than the mean of reperfusion times after declamp in Group II . The average of intraoperative minimum body temperature were 27.7 ± 1.4°C in Group I and 33.7 ± 1.5°C in Group II. There were no significant differences in the average of postoperative maximum creatine kinase (CK), CK-MB and glutamic oxaloacetic transaminase (GOT). There was no case with requiring intra-aortic balloon pumping in both groups. The perioperative data of the two groups are shown in Table In-hospital mortality was 0/10 (0%) and 1/27 3.7%) for Groups I and II. Cause of death in Group II was sepsis. Postoperative paravalvular leakage and late cardiac tamponade occurred in 0/10 (0%) and 1/27 (3.7%), and stroke occurred in 1/10 (10%) and 1/27 (3.7%) for Groups I and II. The patient with stroke in Group I had cerebellar hemorrhage requiring emergent craniotomy at 6 days after operation. After the operation, the patient recovered well. Although 2 patients underwent reoperation for bleeding in Group II, there was no reoperation for bleeding in Group I. New onset atrial fibrillation occurred in 0/10 (0%) and 3/27 (11.1%) for Groups I and II. There was no significant difference of average times of postoperative ventilation, and postoperative hospital stay . Intensive care unit (ICU) stay in Group I was significantly shorter than Group II . Although postoperative LVEF was lower in Group I , postoperative NYHA classification was equivalent . There were no significant differences in improvement rate of cardiac function. Table .7% for GConventional reoperative MVR has several challenges and difficulties. In a detailed review of the STS database, it was demonstrated that the risk of mortality for isolated MVR increased from 5.09% to 9.25% in the presence of a previous cardiac operation . These fRecently, minimally invasive cardiac surgery (MICS) for mitral valve surgery has been developed. MICS was associated with a mortality rate similar to that for open sternotomy cases, reduced length of intensive care unit and hospital stays, fewer blood transfusions, and a faster return to normality compared with conventional operative approaches ,13. SimiIn our study, although Group I required cooling and rewarming time, average CPB times were equivalent to Group II. The operation time in Group I was shorter than Group II, and the process of operation was very smooth in Group I. The average of postoperative maximum CK, CK-MB and GOT were not significantly different, and the lower preoperative EF and larger amount of preoperative mitral regurgitation in Group I had no effect on the operation. These data demonstrated intraoperative myocardial protection under mild hypothermia and VF was not an inappropriate myocardial protection strategy compared to cardiac arrest with cardioplegic solution. As there was no hospital mortality, postoperative paravalvular leakage, and reoperation for bleeding in Group I, the risk of complications was lower compared to Group II. The stroke occurred in Group I was not due to thromboembolism or arterial cannulation, but small cerebral aneurysm. Although there was no significant difference of average times of postoperative ventilation, and postoperative hospital stay, ICU stay in Group I was significantly shorter than Group II. Moreover, although preoperative Euro SCORE in Group I was significantly higher, postoperative course in Group I were thought to be satisfactory compared to Group II. These results suggest that reoperative MVR under VF through right mini-thoracotomy is a reasonable alternative to redo sternotomy for patients with previous sternotomy.This study has several limitations. First of all, this study was not a randomized study, and the number of patients of cohort was small to prove the efficacy of this procedure. Secondly, pathological data of myocardium was not obtained and we cannot evaluate the damage of myocardium histogenetically. Finally, these procedures were performed by two different surgeons, and the bias cannot be denied.This early clinical experience suggests that the outcomes of reoperative MVR under VF through right mini-thoracotomy were acceptable as one of effective options for patients who required reoperative mitral valve surgery.MVR: Mitral valve replacement; VF: Ventricular fibrillation; LVEF: Left ventricular ejection fraction; LVDd: Left ventricular diastolic dimension; LVDs: Left ventricular systolic dimension; NYHA: New York Heart Association; MVP: Mitral valvuloplasty; CABG: Coronary artery bypass grafting; AVR: Aortic valve replacement; CPB: Cardiopulmonary bypass; CK: Creatine kinase; GOT: Glutamic oxaloacetic transaminase; ICU: Intensive care unit.The authors declare that they have no competing interests.AH and MK acted in conception and design. AH acted in data analysis and interpretation. AH and GC acted in manuscript writing. MK, GC, TT, and HY acted in revision of the article. All authors read and approve the final manuscript.


To the Editor: Staphylococcus pseudintermedius is a coagulase-positive species in the S. intermedius group. Previously misidentified as S. intermedius, S. pseudintermedius is now recognized as a leading cause of opportunistic infection in dogs  , could serve as a source of MRSP because of their pervasiveness, their propensity toward close contact with humans, and the fact that they are the source of several other zoonotic diseases (R. norvegicus) in Vancouver, British Columbia, Canada.The potential for zoonotic transmission and concerns that MRSP could be mistaken for other methicillin-resistant staphylococci  gene (mec-associated direct repeat unit (dru typing) (www.clsi.org/). The study was approved by the University of British Columbia Animal Care Committee.Swabs were placed in 2 mL of enrichment broth containing 10 g/L tryptone T, 75 g/L sodium chloride, 10 g/L mannitol, and 2.5 g/L yeast extract and incubated for 24 h at 35°C. Aliquots of 100 µL were streaked onto mannitol salt agar with 2 µg/mL oxacillin and incubated at 35°C for 48 h. Suspected staphylococcal isolates were subcultured onto Columbia blood agar and identified according to colony morphologic appearance, Gram staining, and catalase reaction. Tube coagulase-positive isolates were speciated by using a multiplex PCR specific for the thermonuclease . All isolates tested demonstrated resistance to multiple antimicrobial drug classes (MRSP was isolated from 5 (2.1%) of 237 rats trapped. However, lack of standardized screening methods for MRSP could have resulted in underestimation of MRSP prevalence. Of the 5 isolates, 3 were  classes .dru type from rats suggests that MRSP might be transmissible between dogs and rats. This possibility is not surprising given the potential for direct and indirect contact between these species. Indeed, rat-to-dog transmission of other bacterial pathogens has been recognized (dru type not previously detected in methicillin-resistant staphylococci suggests that these isolates might have evolved independently of methicillin-resistant staphylococci in other animal species.Carriage of MRSP has not been identified in wild rats; therefore, the epidemiologic and public health implications of these findings are difficult to determine. However, the isolation of a common dog-associated Rat carriage of MRSP does not prove that rats are capable of transmitting the bacterium to humans; however, rats are a source of other zoonotic pathogens (In 2011, MRSA was detected in bedbugs from Vancouver’s Downtown Eastside (


Acacia nilotica, Bacopa monnieri, Commiphora wightii, Ficus religiosa, Glycyrrhiza glabra, Hemidesmus indicus, Salvadora oleoides, Terminalia bellirica, Terminalia chebula and Withania somnifera) collected from environmentally diverse regions of Haryana and Rajasthan states in North-Western India. Concentration of all heavy metals, except Cr, was within permissible limits in the tested stem and leaf samples. Leaf samples had consistently more Cr compared to respective stem samples with highest concentration in leaf samples of Bacopa monnieri (13.19 ± 0.0480 ppm) and stem samples of Withania somnifera (4.93 ± 0.0185 ppm) both collected from Bahadurgarh , Haryana. This amount was beyond the permissible limit of 2.0 ppm defined by WHO for raw herbal material. Other two most perilous metals Pb (2.64 ± 0.0260) and Cd (0.04 ± 0.0274) were also recorded in Bahadurgarh region, although below permissible limits. Concentration of Hg remained below detectable levels in all the leaf and stem samples tested. These results suggested that cultivation of medicinal plants and other dietary herbs should be curtailed near environmentally polluted especially industrial areas for avoidance of health hazards.The increasing prevalence of environmental pollution, especially soil contamination with heavy metals has led to their uptake in the human food chains through plant parts. Accumulation and magnification of heavy metals in human tissues through consumption of herbal remedies can cause hazardous impacts on health. Therefore, chemical profiling of nine heavy metals  was undertaken in stem and leaf samples of ten medicinal plants ( Herbal medicines being natural are preferred over synthetic remedies by a major section of the world. Since times immemorial, ancient Indians, Egyptians, Chinese and others have employed a variety of plants and plant products for curing all kinds of ailments. Approximately, 25000 plant based formulations are available in the indigenous medical texts  which are ubiquitous in nature, cause serious harmful effects on living organisms , cause kidney damage and liver dysfunction , are toxic to skin, bones and teeth  and have adverse effects on memory and reproductive system  collected from environmentally diverse regions of North Western India (Haryana and Rajasthan states) using AAS. The collection sites were shortlisted on the basis of presence of contaminated soil and atmospheric polluting units  whereas the medicinal plants were selected on the basis of their significant importance in the Ayurveda along with their frequent utilization in novel pharmaceutical preparations, preparation of traditional drug formulations, food supplements and their diverse medicinal properties. General description and economic importance of medicinal plants undertaken in the present study is given in Table This study was designed to investigate the levels of nine heavy metals  in leaf and stem samples of ten medicinal plants  for 3 hours in a water bath maintained at 70°C for dissolving the contents until a clear brownish solution was obtained using wet digestion method. After cooling, these solutions were reconstituted to 20 ml volume with deionized autoclaved water. Each sample was filtered using whatmann filter paper  and stored in closed acid-washed glass vials. The stored samples were further used for analysis of heavy metals using flame atomic absorption spectroscopy. All experiments were done in triplicate for precision and accuracy of the results. Concentration of each metal was determined from absorbance value of each replicate and articulated in ppm on a dry-weight basis of the plant sample. Finally data was subjected to standard error calculation using SAS 9.3Atmosphere and soil are continuously being polluted with chemicals and heavy metals due to dynamic development of industries and motorization along with extensive use of pesticides and fertilizers. In turn, these pollutants and heavy metals are getting deposited in the plants growing in the polluted areas, which subsequently enter the human food chain via plant parts and/or extracts. Results of analysis of nine heavy metals  done in stem and leaf samples of ten medicinal plant species are summarized in Tables 3 due to continuous exposure to manganese dust and fumes. In the present study, a wide variation occurred in Mn concentration in stem and leaf samples, with highest content in the stem samples of T. bellirica (6.13 ppm) and leaf samples of A. nilotica (3.16 ppm) collected from Fathebad and Jhunjhunu, respectively. Mn concentration was more in the stem samples, ranging from 1.65 fold in A. nilotica to 7.03 fold in W. somnifera, compared to respective leaf samples except C. wightii wherein leaf samples accumulated more Mn  to 4.93 ± 0.0185 ppm (W. somnifera) in the stem samples while it varied from 8.53 ± 0.0317 (C. wightii) to 13.19 ± 0.0480 ppm (B. monnieri) in leaf samples. Cr concentration was 2.39 (H. indicus) to 5.03 (B. monnieri) fold more in leaf samples compared to respective stem samples. Lead (Pb) is highly hazardous for plants, animals and microorganisms. Continuous consumption of fertilizers, fuel combustion and sewage sludge are the major reasons leading to escalation in Pb pollution. The plant tissues tested (stem and leaf) contained extremely lower concentrations of Pb compared to the permissible limit of 10 ppm defined by WHO  is known as an essential trace element which acts as cofactor for many enzymes. It is less toxic than any other metal, however, can cause neurological disorders if its concentration exceeds 5 mg/mn Figure . All thed by WHO . MaximumA. nilotica stem samples (25.30 ± 0.1464 ppm) and W. somnifera leaf samples (17.44 ± 0.0202 ppm) collected from Jhunjhunu and Bahadurgarh, respectively. However, all concentrations were within the permissible limits. On the other hand, Annan et al.,  in stem samples compared to respective leaf samples.Iron (Fe) is an important trace element and iron-protein mixtures play a vital role in metabolism in all living organisms. However, Fe overdose has been one of the leading reasons of death caused by toxicological agents in children younger than 6 years of age. Individuals demonstrate signs of gastro-intestinal toxicity after ingestion of more than 20 mg/kg iron while moderate intoxication occurs when ingestion of elemental Fe exceeds 40 mg/kg and ingestions exceeding 60 mg/kg can cause severe toxicity and may be lethal also  collected from Bahadurgarh region, whereas, it remained undetected in stem samples of A. nilotica (Jhunjhunu), C. wightii (Mahendergarh) and S. oleoides (Churu). Cd concentration was comparable in stem and leaf samples of other plants except T. bellirica and H. indicus wherein Cd concentration was 5–7 fold more in leaf samples. Nickel (Ni) and Cobalt (Co) are trace elements required for a variety of biological processes. Ni is directly coordinated by proteins, whereas, Co is mainly used as a component of vitamin B12  is another hazardous heavy metal which can cause significant reduction in plant yield at concentrations ranging from 5–30 mg/kg. Recently, it is gaining more attention due to wide occurrence in water, soil, milk, dietary products, medicinal plants and herbal products. The major sources leading to accumulation of cadmium in soil and plants are phosphate fertilizers, non-ferrous smelters, lead and zinc mines, sewage sludge application and combustion of fossil fuels. All the samples analyzed in this study had Cd concentration within the acceptable range of 0.3 ppm recommended by WHO  for raw W. somnifera (8.93 ± 0.0264 ppm), followed by C. wightii (7.74 ± 0.0802 ppm) while in leaf samples highest content was found in B. monnieri (4.80 ± 0.0907 ppm) followed by H. indicus (4.18 ± 0.0212 ppm). Concentration of Zn was 2.0–3.7 folds more in stem samples of C. wightii, T. chebula and W. somnifera, while it was comparable in stem and leaf samples of other species tested. In Canada, 0.2 ppm has been prescribed as the limit of mercury (Hg) in raw herbal material, whereas in finished herbal products it is 0.02 mg/day. In China and Singapore however, 0.5 ppm limit has been proposed by WHO  is an essential component of thousands of proteins in plants, although it is toxic in excess quantities. Maximum amount of zinc was found in stem samples of d by WHO . Hg concd by WHO  evaluateAzadirachta indica and Hyptis suaveolens. Gajalakshmi et al.,  in the present study can be attributed to fast industrialization, higher vehicle density and rapid urbanization. Princewill-Ogbonna and Ogbonna  also repWithania somnifera showed highest bio-accumulation of metals as compared to Ocimum sanctum, Cassia fistula, and Azadirachta Indica.The present study concluded that bio-accumulation of heavy metals increased with rise in their trophic levels, therefore, constant utilization of the herbs and vegetables may escort its metal level in humans as also reported by Akinola et al., . Highly Medicinal plants are sources of a large number of active principles of herbal and modern medicine. Indian people have a tremendous passion for medicinal plants and use them for a wide range of health related applications from a common cold to cancer and treatment of poisonous snake bites to a cure for genetic disorders like muscular dystrophy. India has one of the richest herbal medical cultures in the world that is of tremendous contemporary relevance ensuring health security to millions of people. However, continuous increase in environmental pollution is leading to built up of these pollutants including heavy metals in the plant parts which eventually enter the human food chain. Therefore, regular screening of raw material is must to check the levels of these pollutants in the plant parts and extracts before using them for human consumption. The present investigation clearly demonstrated the variation in heavy metal concentration depending upon the collection sites. Different countries have proposed different national limits for various heavy metals in raw herbal materials e.g the minimum permissible limits for arsenic, lead, cadmium, mercury and chromium are 5.0, 10.0, 0.3, 0.2 and 2.0 ppm respectively in Canada while the same are 2.0, 10.0, 1.0, 0.5 ppm respectively in China, and the limit has not yet been prescribed for chromium WHO, . However


Body fluid proteome is the most informative proteome from a medical viewpoint. But the lack of accurate quantitation method for complicated body fluid limited its application in disease research and biomarker discovery. To address this problem, we introduced a novel strategy, in which SILAC-labeled mouse serum was used as internal standard for human serum and urine proteome analysis. The SILAC-labeled mouse serum was mixed with human serum and urine, and multidimensional separation coupled with tandem mass spectrometry (IEF-LC-MS/MS) analysis was performed. The shared peptides between two species were quantified by their SILAC pairs, and the human-only peptides were quantified by mouse peptides with coelution. The comparison for the results from two replicate experiments indicated the high repeatability of our strategy. Then the urine from Immunoglobulin A nephropathy patients treated and untreated was compared by this quantitation strategy. Fifty-three peptides were found to be significantly changed between two groups, including both known diagnostic markers for IgAN and novel candidates, such as Complement C3, Albumin, VDBP, ApoA,1 and IGFBP7. In conclusion, we have developed a practical and accurate quantitation strategy for comparison of complicated human body fluid proteome. The results from such strategy could provide potential disease-related biomarkers for evaluation of treatment. Body fluid proteome generally is the most informative proteome from a medical viewpoint. Almost all tissues in the body communicate with body fluid and release their contents into it, especially upon damage or death . This co18O-labeling, iTRAQ) and label-free strategy. Both of these methods were widely used in quantitative proteomics analysis but also had some limitations. Label-free quantification was quite simple and straightforward, but the precision and accuracy were limited [18O-labeling leaded to variability in peptide spacing, and the mass offset of 2 Da was not sufficient to optimally separate the isotopic envelopes for differential quantification. iTRAQ technology provided an extensive quantification method that could be used in almost all kinds of samples with great utility. But because of the additional multiple steps of iTRAQ method, such as sample preparation and efficiency of chemical tagging, there was also some variability in this method. Besides, the reporter ions in MS/MS spectrum would influence the peptide identification [Multiple analytical approaches have been developed based on separation of proteins in-gel  or gel-free platform utilizing various methods including labeling  method provided a comprehensive, robust, and accurate solution for quantitative proteomics analysis. But it is thought to be unsuitable for analyzing tissue and body fluid samples. Hence, a lot of other metabolic labeling methods were introduced in an alternative way such as protein standard absolute quantification (PSAQ), stable isotope-labeled proteome (SILAP), and secretome-derived isotopic tag (SDIT) strategies. However, PSAQ uses full-length isotope-labeled proteins as isotope-dilution standards for MS-based quantification of target proteins in complex matrices. It was difficult for the accurate quantitation of large numbers of serum proteins. In addition, it seems more appropriate for the combination of PSAQ and SRM (PSAQ-SRM) to allow highly accurate biomarker quantitation in serum samples. Serum mixed with SILAC-labeled secretome of culture cells (SILAP and SDIT) was easy to manipulate and quantify large numbers of serum proteins. However, serum contains all tissue proteomes as subsets. It was not adequate to use one or several kinds SILAC labeled secretome of cultured cells as standards in quantitative serum proteomic studies.In this paper, we have proved that the serum from SILAC mouse could also be used as internal standards to quantify human serum and urine. With this novel strategy, we performed the quantitative proteomics analysis by extensive multidimensional separation coupled with tandem mass spectrometry (IEF-LC-MS/MS) for the urine from Immunoglobulin A nephropathy (IgAN) patients treated and untreated. As the quantification standards display the same biochemical features as urinary samples, they can be spiked into the samples at early stages of the analytical process, which can avoid differences that yielded in digestion and nonspecific losses suffered during extensive sample processing between internal standard SILAC mouse and human samples. In conclusion, our research provided a comprehensive and accurate solution for human body fluid analysis.4HCO3), and iodoacetamide (IAA) were purchased from Bio-Bad . The Lys-C enzyme was purchased from Wako . Acetonitrile (HPLC grade) was obtained from Merck . Formic acid was obtained from Aldrich . All the water used in the experiments was prepared using a Milli-Q system . The 13C6-lysine labeled mouse serum (MT-LYSC6-MSE) was purchased from Cambridge Isotope Laboratories, Inc.Urea, tris, sodium dodecyl sulfate (SDS), dithiothreitol (DTT), ammonium bicarbonate . Six normal urine samples were pooled together. The concentrate was frozen at −80°C until use.The 24 h urine samples were collected from six healthy subjects. Informed consent was obtained from each person in written format and approved by Longhua Hospital, Shanghai University of Traditional Chinese Medicine Review Committee. Volume of 200 ml urine from each person was concentrated by the acetone precipitation approach  with somThe urine from IgAN patients with and without glucocorticosteroid treatment was collected and prepared as mentioned earlier for urine from healthy persons . The patμg human sample was mixed with 150 μg SILAC-labeled mouse serum sample and then transferred to a 10K filter and centrifuged at 10,000 g for 20 min at 20°C. so, 200 μL UA buffer  was added, and the sample was centrifuged at 10,000 g for 20 min again. This step was repeated once. The concentration was then mixed with 100 μL of 50 mmol/L IAA in UA buffer and incubated for an additional 40 min at room temperature in the dark. Next, the IAA was removed by centrifugation at 10,000 g for 20 min. Following two rounds of dilution in 200 μL of UA buffer and centrifugation, 200 μL of 50 mmol/L NH4HCO3 was added to the sample, which was then centrifuged at 10,000 g for 20 min. This step was repeated twice. Finally, 100 μL of 50 mmol/L NH4HCO3 and Lys-C  was added, and the mixture was incubated at 37°C for 20 h. The digested peptide mixtures were collected for further analysis.The sample digestion was processed by FASP procedure as described previously . BrieflyI-based peptide OFFGEL separation was performed as previously reported [μL of sample was loaded in each well. Electrofocusing of the peptides was performed at 20°C and 50 μA until the 100 kVh level was reached. After focusing, the rinses in each well were pooled with their corresponding peptide fraction. All fractions were evaporated by centrifugation under vacuum and maintained at −20°C. Prior to MS analysis, the samples were desalted onto an Empore C18 47-mm Disk. Immediately prior to nano-LC, the fractions were suspended in 20 μL of H2O containing 0.1% (v/v) TFA.The preported . The 310µm × 150 mm, Column Technology Inc., CA, USA) was used. The HPLC solvents used were 0.1% formic acid (v/v) aqueous (A) and 0.1% formic acid (v/v) acetonitrile (B). The reversed-phase gradient was from 2% to 40% mobile phase B in 180 min at 120 µL/min flow rate before the split and 250 nL/min after the split. A linear ion trap/Orbitrap (LTQ-Orbitrap) hybrid mass spectrometer  equipped with an NSI nanospray source was used to for MS/MS experiment with ion transfer capillary of 200°C and NSI voltage of 1.80 kv. Normalized collision energy was 35.0. The mass spectrometer was set that one full MS scan (m/z 400–1800) was acquired in the Orbitrap parallel ten MS/MS scans in the linear ion trap on the ten most intense ions from the full MS spectrum with the following Dynamic Exclusion settings: repeat count 2, repeat duration 30 seconds, and exclusion duration 90 seconds. The resolving power of the Orbitrap mass analyzer was set at 60,000 for the precursor ion scans (m/Δm 50% at m/z 400). The m/z (445.120025) was used as an internal lock mass and calibrant ions in the full MS scan.A Surveyor liquid chromatography system , consisting of degasser, MS Pump, and auto sampler, equipped with an analytical C18 column . The quantile normalization [All statistical analyses were conducted in the R environment  and principal component analysis (PCA) were then performed for the concentrations of these significant peptides, respectively (Figures Then, the limma package in R environment was used to find significant changed peptides between two groups. As a result, 9 and 44 peptides were selected, respectively, in shared peptides and human-only peptides with  Figures . In the To further analyze the proteins influenced by the treatment and reveal their association with IgA nephropathy, a detailed literature search was performed. And the significant proteins associated with nephropathy were listed in Complement C3 is the most significant decreased protein after treatment in our result. IgA nephropathy is characterized by IgA deposition, and it is frequently accompanied by complement C3. The serum IgA/C3 ratio is taken as a diagnostic marker for the progression of IgAN . And serAlbumin is the most famous indicator for renal disease , 32, 33.Besides, we have also found four proteins, which are vitamin D binding protein , 35, cerOn the other side, there were some proteins of overexcretion in the urine of treatment group, including Annexin A1, Cystatin-A, Angiotensinogen, Gamma actin-like protein, and Zinc-alpha-2-glycoprotein. Most of these proteins had never been reported as nephropathy biomarkers or only found to be significant in large-scale expression analysis , 39. As In this work, we proved that SILAC-labeled mouse serum could be used as internal standard for human body fluid proteome analysis. It provided comprehensive and reliable quantitative results and could specifically address the obstacles in this field. With the application of this strategy in patient samples, we can obtain valuable findings in biomarkers discovery for monitoring disease progression and evaluating therapeutic efficacies.


Urate is a natural antioxidant and may prevent CNS tissue damage and the clinical manifestations of experimental autoimmune encephalitis. Results from clinical studies are conflicting and the contribution of urate to the pathogenesis of Multiple Sclerosis (MS) remains uncertain.To evaluate serum urate levels in MS patients and their relationships with clinical, demographic and MRI variables.Levels of non-fasting serum uric acid and creatinine were determined by an automated enzymatic assay and glomerular filtration rate was assessed in 245 MS patients, in 252 age/sex-matched neurological controls (NC) and in 59 Healthy controls (HC).Median serum urate levels did not differ between MS patients (3.8 mg/dL), HC (4.0 mg/dl) and NC (4.0 mg/dL). Serum urate levels were lower in females than in males in all groups (p = <0.0001). In female-MS, serum urate levels (3.2 mg/dL) were lower compared to those in female HC  and NC , whereas in male-MS they(4.8 mg/dL) did not differ from those in male HC (4.5 mg/dl) and NC (4.8 mg/dL). Urate concentrations trended to be lower in Clinically isolated syndromes suggestive of MS (3.7 mg/dL) and in relapsing MS (3.7 mg/dL), compared to patients with progressive MS , and in patients with an annual relapse rate (ARR) >2 (3.3 mg/dL) than in those with an ARR ≤2: 3.9 mg/dL; p = 0.05). Significant lower serum urate levels were found in females than in males in all clinical MS subtypes (p<0.01), separately evaluated. Female sex  was the most significant determinant of serum urate concentrations in MS patients on multivariate regression analysis.Our findings suggest that low urate levels could be of significance in predominantly inflammatory phases of MS even at the early stage and mainly in females. Multiple Sclerosis (MS) is a neurologic disease of unknown aetiology characterized by inflammation, demyelination and diffuse axonal degeneration throughout the central nervous system. Uric acid is the main end-product of purine metabolism and circulates in humans at high concentrations, near the limits of its solubility. In the last ten years several studies evaluated serum urate levels in patients with MS, reporting conflicting results; In this cross-sectional study we evaluated non-fasting serum levels of uric acid and glomerular filtration rate in MS patients and in age and sex matched healthy (HC) and neurological controls (NC). Potential associations between urate levels and demographic, clinical, laboratory and magnetic resonance imaging (MRI) variables were also assessed in MS group.We enrolled all consecutive patients with a diagnosis of Clinically Isolated Syndromes (CIS) suggestive of MS, or of MS, according to the revised Mc Donald’s criteria of 2005, NC (n = 252) and HC (n = 59) were matched by sex and age with the MS patients. HC were healthy volunteers, whereas NC were recruited during the same time period among patients who were admitted to the same neurological clinics for symptoms as vertigo, dizziness, syncope, radicular or non radicular pain, or minor head trauma. After a complete neurological assessment and central and peripheral diagnostic tests, all patients were classified as having labyrinthitis (n = 64), neurosis (n = 92), radiculopathy (n = 27), vasovagal syncope (n = 37) and minor head trauma (n = 32).All subjects gave their written informed consent to the study, which was approved by the institutional review board of the University of Bari.We excluded subjects with a medical history of comorbidities , and patients with acute medical conditions  and alcohol abuse, in the previous three months. MS patients, NC and HC were caucasic in origin and resident in the same geographic area. No subject was vegetarian.Levels of non-fasting serum uric acid and creatinine were determined using an automated enzymatic assay. Kidney function was evaluated using an estimate of the glomerular filtration rate, based on the formula proposed by Levey et al, which incorporates serum creatinine, age, sex and race. Disability status was assessed using the Expanded Disability Status Scale (EDSS) score. A natural log transformation of the parametric data was carried out to better meet the assumption of normality, because urate levels were not normally distributed. Student’s t-test and analysis of variance (ANOVA) were used for parametric data, and chi-square and Fisher’s test were used to analyze non-parametric data. Post-Hoc analysis with Bonferroni’s test were performed for multiple comparison of Urate levels in MS , HC and NC stratified by gender.We studied the association between MS/NC status and urate levels in several logistic regression models, using serum urate levels as both a continuous and a categorical covariate in the model. When urate levels were considered as a categorical variable, we stratified their distribution into tertiles, using the bottom tertile as the reference group. Because of the different distribution of urate levels across gender we also calculated sex-specific tertiles. In the multivariate analyses, data were adjusted for age, sex, and glomerular filtration rate.Simple and multivariate linear regressions were used to study the association between urate levels and glomerular filtration rate, age, sex, disease phenotype , disease duration, ARR, EDSS score and MRI disease activity, in MS patients. In all statistical analyses, the level of statistical significance was set at p = 0.05. All statistical analyses were performed with SPSS version 16.0 for Windows .The study was carried out on 245 MS patients , 252 NC  and 59 HC . In MS group, median disease duration was 25.3 months (range: 0.4–406.1), median EDSS score was 2.5 (1–8). Median ARR in patients with RR and SP MS was 0.7 (0.06–5.7). Seventy-eight patients (34%) showed at least one MRI Gd enhancing lesion. Thirty-one percent (77) was in a relapsing phase.2) between the three groups. Mean and median serum urate levels did not significantly differ between MS patients (3.9±1.3 and 3.8 mg/dL), NC (4.1±1.3 and 4.0 respectively) and HC (4.0±1.2 and 4.0 mg/dl). Multivariate logistic analyses showed that, even if higher urate levels were less likely associated with MS , this finding was not statistically significant (p = 0.26); similar results were obtained considering urate levels as a categorical variable : 0.7 :95% CI: 0.4–1.2; p for trend: 0.18).No significant differences were found in median age  and sex (p = 0.4) distribution and in median glomerular filtration rate .We also evaluated serum urate levels in MS patients, stratifying MS according to clinical phenotypes. Urate concentrations in CIS patients  and in RR MS  were lower compared to patients with progressive MS . However, the difference was not significant when compared to HC (4.0 mg/dL) and NC (4.0 mg/dl). Stratifying MS subtypes by gender,  B the diIn Multivariate regression model  revealedThe most relevant finding of this cross-sectional study is that low serum urate levels are associated with female MS predominantly at the early stage and during the relapsing phase of the disease. In fact we found that serum urate levels were significantly lower in female MS compared to males MS and also to female HC and NC. In addition we demonstrated lower serum urate levels in clinical phenotypes with more prominent inflammation, such as CIS and RR MS, and the lowest levels in RR female MS, which were more frequently associated with higher ARR in comparison with RR male MS. Moreover multivariate analyses clearly showed that female sex was the most significant determinant of serum urate concentrations in MS, after adjustment for demographic, clinical, MRI variables and glomerular filtration rate.These findings are in agreement with previous studies showing that the low serum urate concentrations in MS are associated with female gender A great number of studies evidenced that the neuroinflammation that occurs in several neurologic disorders, including MS, directly induces the production of nitric oxide and superoxide, leading to a vast increase in peroxynitrite formation. Uric acid is a natural anti-oxidant and a peroxynitrite scavenger and accounts for up to 60% of the free radical scavenging activity in human blood. Several reports previously investigated serum urate levels in patients with MS compared with neurological and healthy controls, with conflicting results. The correlation between urate levels and clinical and paraclinical disease activity and disability has been also evaluated, with conflicting results Several limitations of our study however deserve discussion. First, the study has a cross-sectional design that prevents us to assess a temporal relationship between the decrease in serum urate levels and MS course; the change in urate concentrations might not be a primary event, but rather represents an epiphenomenon related to its scavenging activity; however the trend for lower urate levels observed in patients with CIS seems to indicate that the decrease in urate concentrations is present since the earliest stage of the disease. Second, this is a clinical based study from a tertiary center and therefore our case-series may not be completely representative of the whole MS population, since cases with a more severe phenotype less likely come to the attention of a tertiary center. Third, we did not use sophisticated analytical methods able to assess other purine compounds such as hypoxanthine, xanthine that could add further useful information about cell energy imbalance, mitochondrial dysfunction and ATP consumption.Finally, we did not collect information on study participants’ body mass index. Urate levels positively correlate with age, sex, renal function and body mass index, and malnutrition is a major determinant of lower serum urate concentrations. In conclusion, our findings favours the view that low urate levels could be of significance in predominantly inflammatory phases of MS even at the early stage and mainly in females.Future longitudinal studies with a prospective design and using more sophisticated analytical methods should be conducted on large cohorts to clarify the effective role of urate in MS, and to evaluate if the change in urate levels may be used to predict the development of the progressive phase of MS.