Natural ocean iron fertilization and climate variability over geological periods.

Marine primary producers are largely dependent on and shape the Earth's climate, although their relationship with climate varies over space and time. The growth of phytoplankton and associated marine primary productivity in most of the modern global ocean is limited by the supply of nutrients, including the micronutrient iron. The addition of iron via episodic and frequent events drives the biological carbon pump and promotes the sequestration of atmospheric carbon dioxide (CO2 ) into the ocean. However, the dependence between iron and marine primary producers adaptively changes over different geological periods due to the variation in global climate and environment. In this review, we examined the role and importance of iron in modulating marine primary production during some specific geological periods, that is, the Great Oxidation Event (GOE) during the Huronian glaciation, the Snowball Earth Event during the Cryogenian, the glacial-interglacial cycles during the Pleistocene, and the period from the last glacial maximum to the late Holocene. Only the change trend of iron bioavailability and climate in the glacial-interglacial cycles is consistent with the Iron Hypothesis. During the GOE and the Snowball Earth periods, although the bioavailability of iron in the ocean and the climate changed dramatically, the changing trend of many factors contradicted the Iron Hypothesis. By detangling the relationship among marine primary productivity, iron availability and oceanic environments in different geological periods, this review can offer some new insights for evaluating the impact of ocean iron fertilization on removing CO2 from the atmosphere and regulating the climate.

Research and Scholarship During the COVID-19 Pandemic: A Wicked Problem.

This study focuses on the impacts of the COVID-19 pandemic on research and scholarship at a research university in the United States. Building on studies in higher education policy, we conceptualized the COVID-19 pandemic as a 'wicked problem' that is complex, nonlinear, unique, and requiring urgent solutions. Wicked problems highlight pre-existing struggles, and therefore, recent challenges in higher education inform the methods and the findings of this study. Qualitative and quantitative survey data from 408 faculty, staff, and students explicate the reasons for reduced research output and adaptations made for increased or sustained productivity, health, and wellness that influenced research activities. The analysis showed that most respondents experienced reduced productivity mostly due to increased work responsibilities, limited access to research fields, and inadequate resources. Despite self-reported reduced productivity, participants from the University we studied experienced increases in funding during the pandemic. Thus, the findings also reported on the adaptations for sustained or increased productivity. These included new research pursuits, participation in conference and learning opportunities across geographic regions, and purchase of computer equipment/accessories for home offices. A small percentage of respondents mentioned improved health and well-being; however, many linked reduced research activities to health and well-being issues such as anxiety and fear about the pandemic and being overwhelmed due to work and home-life expectations. Knowledge of the challenges and opportunities presented within the first year of the pandemic can provide a basis for solutions to wicked problems higher education may face in the future.

MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level.

Background: Controversy exists regarding the best predictive model of liver transplant waiting list (WL) mortality. Models for end-stage liver disease-glomerular filtration rate assessment in liver disease (MELD-GRAIL) and MELD-GRAIL-Na were recently described to provide better prognostication, particularly in females. We evaluated the performance of these scores compared to MELD and MELD-Na. Methods: Consecutive patients with cirrhosis waitlisted for liver transplant from 1998 to 2017 were examined in this single-center study. The primary outcome was 90-d WL mortality. MELD, MELD-Na, MELD-GRAIL, and MELD-GRAIL-Na at the time of WL registration were compared. Model discrimination was assessed with area under the receiver operating characteristic curves and Harrell's C-index after fitting Cox models. Model calibration was examined with Grønnesby and Borgan's modification of the Hosmer-Lemeshow formula and by comparing predicted/observed outcomes across model strata. Results: The study population comprised 1108 patients with a median age of 53.5 (interquartile range 48-59) y and male predominance (74.9%). All models had excellent areas under the receiver operating characteristic curves for the primary outcome (MELD 0.89, MELD-Na 0.91, MELD-GRAIL 0.89, MELD-GRAIL-Na 0.89; all comparisons P > 0.05). Youden index cutoffs for 90-d mortality were as follows: MELD, 19; MELD-Na, 22; MELD-GRAIL, 18; and MELD-GRAIL-Na, 17. Variables associated with 90-d mortality on multivariable Cox regression were sodium, bilirubin, creatinine, and international normalized ratio. There were no differences in model discrimination using Harrell's C-index. All models were well calibrated; however, divergence between observed and predicted mortality was noted with scores ≥25. Conclusion: There were no demonstrable differences in discrimination or calibration of GRAIL-based models compared with MELD or MELD-Na in our cohort. This suggests that GRAIL-based models may not have meaningful improvements in discriminatory ability when applied to other settings.

Exploring Variability of Trichodesmium Photophysiology Using Multi-Excitation Wavelength Fast Repetition Rate Fluorometry.

Fast repetition rate fluorometry (FRRf) allows for rapid non-destructive assessment of phytoplankton photophysiology in situ yet has rarely been applied to Trichodesmium. This gap reflects long-standing concerns that Trichodesmium (and other cyanobacteria) contain pigments that are less effective at absorbing blue light which is often used as the sole excitation source in FRR fluorometers-potentially leading to underestimation of key fluorescence parameters. In this study, we use a multi-excitation FRR fluorometer (equipped with blue, green, and orange LEDs) to investigate photophysiological variability in Trichodesmium assemblages from two sites. Using a multi-LED measurement protocol (447+519+634 nm combined), we assessed maximum photochemical efficiency (F v /F m ), functional absorption cross section of PSII (σ PSII ), and electron transport rates (ETRs) for Trichodesmium assemblages in both the Northwest Pacific (NWP) and North Indian Ocean in the vicinity of Sri Lanka (NIO-SL). Evaluating fluorometer performance, we showed that use of a multi-LED measuring protocol yields a significant increase of F v /F m for Trichodesmium compared to blue-only excitation. We found distinct photophysiological differences for Trichodesmium at both locations with higher average F v /F m as well as lower σ PSII and non-photochemical quenching (NPQ NSV ) observed in the NWP compared to the NIO-SL (Kruskal-Wallis t-test df = 1, p < 0.05). Fluorescence light response curves (FLCs) further revealed differences in ETR response with a lower initial slope (α ETR ) and higher maximum electron turnover rate ( E T R P S I I m a x ) observed for Trichodesmium in the NWP compared to the NIO-SL, translating to a higher averaged light saturation E K (= E T R P S I I m a x /α ETR ) for cells at this location. Spatial variations in physiological parameters were both observed between and within regions, likely linked to nutrient supply and physiological stress. Finally, we applied an algorithm to estimate primary productivity of Trichodesmium using FRRf-derived fluorescence parameters, yielding an estimated carbon-fixation rate ranging from 7.8 to 21.1 mgC mg Chl-a-1 h-1 across this dataset. Overall, our findings demonstrate that capacity of multi-excitation FRRf to advance the application of Chl-a fluorescence techniques in phytoplankton assemblages dominated by cyanobacteria and reveals novel insight into environmental regulation of photoacclimation in natural Trichodesmium populations.

Australian fire nourishes ocean phytoplankton bloom.

An unprecedented devastating forest fire occurred in Australia from September 2019 to March 2020. Satellite observations revealed that this rare fire event in Australia destroyed a record amount of more than 202,387 km2 of forest, including 56,471 km2 in eastern Australia, which is mostly composed of evergreen forest. The released aerosols contained essential nutrients for the growth of marine phytoplankton and were transported by westerly winds over the Southern Ocean, with rainfall-induced deposition to the ocean beneath. Here, we show that a prominent oceanic bloom, indicated by the rapid growth of phytoplankton, took place in the Southern Ocean along the trajectory of fire-born aerosols in response to atmospheric deposition. Calculations of carbon released during the fire versus carbon absorbed by the oceanic phytoplankton bloom suggest that they were nearly equal. This finding illustrates the critical role of the oceans in mitigating natural and anthropogenic carbon dioxide releases to the atmosphere, which are a primary driver of climate change.

Split-Thickness Skin Grafting: A Primer for Orthopaedic Surgeons.

Soft-tissue defects pose a unique challenge to the treating orthopaedic surgeon. Such defects are commonly encountered after orthopaedic injuries or infection, and the management of these wounds varies significantly. Skin grafting has gained popularity in the management of such soft-tissue defects due to its ability to provide coverage, re-epithelialize, and have a relatively high success rate. One of the most frequently used types of skin graft in orthopaedics is the split-thickness skin graft (STSG). Understanding the proper indications, technique, and management of the STSG foreshadows its success or failure. This review focuses on the indications, technique, alternatives, and complications surrounding the utilization of the STSG in the management of orthopaedic injuries.

Outwelling of total alkalinity and dissolved inorganic carbon from the Hooghly River to the adjacent coastal Bay of Bengal.

The seasonal variability of the lateral flux of total alkalinity (TAlk) and dissolved inorganic carbon (DIC) of the tropical Hooghly estuary is analyzed in this work. In situ observations of water temperature, salinity, dissolved oxygen, TAlk, and pH were measured in four different stations of the Hooghly estuary. It was measured once every month during 2015-2016, and subsequently, DIC was estimated. A carbon budget was constructed to quantify carbon flows through the freshwater-marine continuum of the Hooghly estuary, and plausible impacts on the adjacent coastal ocean, the northern Bay of Bengal, were examined. The biogeochemical mass balance box model was used to compute the seasonal flow of carbon flux, and subsequently, the annual budgeting of lateral fluxes of TAlk and DIC to the adjacent coastal ocean was carried out. The net annual TAlk and DIC flux from the Hooghly estuary to the adjacent coastal ocean were 4.45 ± 1.90 × 1011 mol and 4.59 ± 1.70 × 1011 mol, respectively. The net annual DIC flux of the Hooghly estuary is about 30 to 60 times higher than surface area integrated air-water CO2 flux, which is an indication of promoting acidification in the adjacent coastal ocean. The present study indicates that the lateral DIC flux has increased substantially in the Hooghly estuary during the last two decades. The increase in inorganic carbon load in the Hooghly estuary due to the enhanced discharge of inorganic and organic matter load in the upper reaches of the estuary led to this increase in lateral DIC flux. The results strongly establish the need of having such regional studies for better understanding the estuarine carbon dynamics, and its role in controlling the adjacent coastal ocean dynamics.

Experimental Techniques to Assess Coral Physiology in situ Under Global and Local Stressors: Current Approaches and Novel Insights.

Coral reefs are declining worldwide due to global changes in the marine environment. The increasing frequency of massive bleaching events in the tropics is highlighting the need to better understand the stages of coral physiological responses to extreme conditions. Moreover, like many other coastal regions, coral reef ecosystems are facing additional localized anthropogenic stressors such as nutrient loading, increased turbidity, and coastal development. Different strategies have been developed to measure the health status of a damaged reef, ranging from the resolution of individual polyps to the entire coral community, but techniques for measuring coral physiology in situ are not yet widely implemented. For instance, while there are many studies of the coral holobiont response in single or limited-number multiple stressor experiments, they provide only partial insights into metabolic performance under more complex and temporally and spatially variable natural conditions. Here, we discuss the current status of coral reefs and their global and local stressors in the context of experimental techniques that measure core processes in coral metabolism (respiration, photosynthesis, and biocalcification) in situ, and their role in indicating the health status of colonies and communities. We highlight the need to improve the capability of in situ studies in order to better understand the resilience and stress response of corals under multiple global and local scale stressors.

Differential Impact of Extended Criteria Donors After Brain Death or Circulatory Death in Adult Liver Transplantation.

Using grafts from extended criteria donors (ECDs) and donation after circulatory death (DCD) donors is a strategy to address organ shortage in liver transplantation (LT). We studied the characteristics and outcomes of ECD and DCD grafts. We retrospectively studied consecutive adults who underwent deceased donor LT between 2006 and 2019. ECD was defined using modified Eurotransplant criteria. Our primary outcomes were graft and patient survival. A total of 798 grafts were used for LT, of which 93.1% were donation after brain death (DBD; 59.9% were also ECD) and 6.9% were DCD grafts (49.1% were also ECD). Among DBD graft recipients, donors having >33% liver steatosis or 3 ECD criteria resulted in poorer graft survival. Otherwise ECD graft recipients had similar graft and patient survival compared with non-ECD graft recipients. DCD graft recipients also had similar patient survival compared with DBD recipients. However, DCD grafts from an ECD appeared to have worse outcomes. DCD graft recipients experienced higher rates of early allograft dysfunction (50.9% versus 24.7%; P < 0.001) and ischemic biliopathy (16.4% versus 1.5%; P < 0.001) compared with DBD graft recipients. Use of DBD grafts from ECDs did not impact outcomes unless there was significant donor steatosis or 3 Eurotransplant criteria were met. DCD graft recipients have similar patient survival compared with DBD graft recipients as long as the donor was not an ECD. We recommend that DBD donors with 3 or more ECD features or >33% steatosis and DCD donors with any ECD features be used with caution in adult LT.

Metabolic performance and thermal and salinity tolerance of the coral Platygyra carnosa in Hong Kong waters.

Stress-tolerant coral species, such as Platygyra spp., are considered to be well adapted to survive in marginal reefs, but their physiological response to short term exposure to abnormally high temperature and lowered salinity remains poorly understood. Using non-invasive techniques to quantitatively assess the health of Platygyra carnosa (e.g. respiration, photosynthesis, biocalcification and whiteness), we identified the plasticity of its energetics and physiological limits. Although these indicators suggest that it can survive to increasing temperature (25-32 °C), its overall energetics were seriously diminished at temperatures >30 °C. In contrast, it was well adapted to hyposaline waters (31-21 psu) but with reduced biocalcification, indicating short term adaptation for expected future changes in salinity driven by increased amounts and intensities of precipitation. Our findings provide useful insights to the effect of these climate drivers on P. carnosa metabolism and thus better forecast changes in their health status under future climate change scenarios.

Future HAB science: Directions and challenges in a changing climate.

There is increasing concern that accelerating environmental change attributed to human-induced warming of the planet may substantially alter the patterns, distribution and intensity of Harmful Algal Blooms (HABs). Changes in temperature, ocean acidification, precipitation, nutrient stress or availability, and the physical structure of the water column all influence the productivity, composition, and global range of phytoplankton assemblages, but large uncertainty remains about how integration of these climate drivers might shape future HABs. Presented here are the collective deliberations from a symposium on HABs and climate change where the research challenges to understanding potential linkages between HABs and climate were considered, along with new research directions to better define these linkages. In addition to the likely effects of physical (temperature, salinity, stratification, light, changing storm intensity), chemical (nutrients, ocean acidification), and biological (grazer) drivers on microalgae (senso lato), symposium participants explored more broadly the subjects of cyanobacterial HABs, benthic HABs, HAB effects on fisheries, HAB modelling challenges, and the contributions that molecular approaches can bring to HAB studies. There was consensus that alongside traditional research, HAB scientists must set new courses of research and practices to deliver the conceptual and quantitative advances required to forecast future HAB trends. These different practices encompass laboratory and field studies, long-term observational programs, retrospectives, as well as the study of socioeconomic drivers and linkages with aquaculture and fisheries. In anticipation of growing HAB problems, research on potential mitigation strategies should be a priority. It is recommended that a substantial portion of HAB research among laboratories be directed collectively at a small sub-set of HAB species and questions in order to fast-track advances in our understanding. Climate-driven changes in coastal oceanographic and ecological systems are becoming substantial, in some cases exacerbated by localized human activities. That, combined with the slow pace of decreasing global carbon emissions, signals the urgency for HAB scientists to accelerate efforts across disciplines to provide society with the necessary insights regarding future HAB trends.

Impact of Having a Planned Additional Operation at Time of Liver Transplant on Graft and Patient Outcomes.

Advances in liver transplantation (LT) have allowed for expanded indications and increased surgical complexity. In select cases, additional surgery may be performed at time of LT rather than prior to LT due to the significant risks associated with advanced liver disease. We retrospectively studied the characteristics and outcomes of patients who underwent an additional planned abdominal or cardiac operation at time of LT between 2011-2019. An additional operation (LT+) was defined as a planned operation performed under the same anesthetic as the LT but not directly related to the LT. In total, 547 patients were included in the study, of which 20 underwent LT+ (4%). Additional operations included 10 gastrointestinal, 5 splenic, 3 cardiac, and 2 other abdominal operations. Baseline characteristics between LT and LT+ groups were similar. The median total operating time was significantly longer in LT+ compared to LT only (451 vs. 355 min, p = 0.002). Graft and patient survival, intraoperative blood loss, transfusion of blood products, length of hospital stay, and post-operative complications were not significantly different between groups. In carefully selected patients undergoing LT, certain additional operations performed at the same time appear to be safe with equivalent short-term outcomes and liver graft survival as those undergoing LT alone.

Effects of increasing temperature and acidification on the growth and competitive success of Alexandrium catenella from the Gulf of Maine.

Climate driven increases in ocean temperature and pCO2 have the potential to alter the growth and prevalence of future Harmful Algal Blooms (HABs), but systematic studies on how climate drivers influence toxic algal species relative to non-toxic phytoplankton are lacking. In particular, little is known about how future climate scenarios will affect the growth of the toxic dinoflagellate Alexandrium catenella, which is responsible for the paralytic shellfish poisoning (PSP) events that threaten the health and economy of coastal communities in the Gulf of Maine and elsewhere. The growth responses of A. catenella and two other naturally co-occurring dinoflagellates in the Gulf of Maine-Scrippsiella sp., and Amphidinium carterae-were studied in mono and mixed species cultures. Experimental treatments tested the effects of elevated temperature (20 °C), lower pH (7.8), and the combination of elevated temperature and lower pH on growth rates relative to those in near-current conditions (15 °C; pH 8.1). Growth rates of A. catenella decreased under elevated temperature and lower pH conditions, a response that was largely attributable to the effect of temperature. In contrast, growth rates of Scrippsiella sp. and A. carterae increased under elevated temperature and lower pH conditions, with temperature also being the primary driver of the response. These trends did not change substantially when these species were grown in mixed cultures (A. catenella + Scrippsiella sp., and A. catenella + A. carterae), indicating that allelopathic or competitive interactions did not affect the experimental outcome under the conditions tested. These findings suggest that A. catenella blooms may become less prevalent in the southern regions of the Gulf of Maine, but potentially more prevalent in the northeastern regions of the Gulf of Maine with continued climate change.

Insensitivities of a subtropical productive coastal plankton community and trophic transfer to ocean acidification: Results from a microcosm study.

Ocean acidification (OA) has potential to affect marine phytoplankton in ways that are partly understood, but there is less knowledge about how it may alter the coupling to secondary producers. We investigated the effects of OA on phytoplankton primary production, and its trophic transfer to zooplankton in a subtropical eutrophic water (Wuyuan Bay, China) under present day (400 µatm) and projected end-of-century (1000 µatm) pCO2 levels. Net primary production was unaffected, although OA did lead to small decreases in growth rates. OA had no measurable effect on micro-/mesozooplankton grazing rates. Elevated pCO2 had no effect on phytoplankton fatty acid (FA) concentrations during exponential phase, but saturated FAs increased relative to the control during declining phase. FA profiles of mesozooplankton were unaffected. Our findings show that short-term exposure of plankton communities in eutrophic subtropical waters to projected end-of-century OA conditions has little effect on primary productivity and trophic linkage to mesozooplankton.

The successional formation and release of domoic acid in a Pseudo-nitzschia bloom in the Juan de Fuca Eddy: A drifter study.

Blooms of Pseudo-nitzschia species are frequent, but presently unpredictable, in the Juan de Fuca Eddy region off the coasts of Washington (US) and British Columbia (Canada). This upwelling eddy region is proposed to be the bloom commencement site, before cells are entrained into the coastal surface currents. During a shipboard study, we characterized the different stages of the Pseudo-nitzschia bloom development from its initiation and intensification, to its eventual sinking and dissipation. Specifically, we followed a water mass using lagrangian ARGOS-tracked drifters released at the eddy water mass and quantified production of dissolved and particulate domoic acid, and the physiological status of the Pseudo-nitzschia cells with regards to photosynthesis, nutrient needs and sinking rates, along with its relationship with competing species - in this case, the marine euglenoid, Eutreptiella spp. The drifter study allows for an interpretation of the presence or absence of Pseudo-nitzschia and domoic acid against active environmental factors - particularly copper and iron.

Characterization of oceanic Noctiluca blooms not associated with hypoxia in the Northeastern Arabian Sea.

Intense blooms of the heterotrophic dinoflagellate, green Noctiluca scintillans, have been reported annually in the Northern Arabian Sea since the early 2000s. Although not known to produce organic toxins, these blooms are still categorized as a harmful due to their association with massive fish mortalities. Recent work has attributed these blooms to the vertical expansion of the oxygen minimum zone, driven by cultural eutrophication from major coastal cities in western India. As diatoms are preferred prey of green Noctiluca scintillans, more frequent blooms of this mixotroph will likely impact the productivity of important fisheries in the region. The present study uses a satellite algorithm to determine the distribution of both diatom and green Noctiluca blooms in the Northeastern Arabian Sea from 2009 to 2016. The results from shipboard microscopy of phytoplankton community composition were used to validate the satellite estimates. The satellite algorithm showed 76% accuracy for detection of green Noctiluca and 92% for diatoms. Shipboard measurements and data from biogeochemical-Argo floats were used to assess the relationship between oxygen concentrations and green Noctiluca blooms in the Northeastern Arabian Sea. Regardless of the presence of a Noctiluca bloom, the dissolved oxygen in the photic zone was always >70% saturated, with an average oxygen saturation >90%. The variability in the relative abundance of diatoms and green Noctiluca is not correlated with changes in oxygen concentration. These findings provide no evidence that cultural eutrophication has contributed to the decadal scale shifts in plankton composition in the Northeastern Arabian Sea oceanic waters. Conversely, the climatic warming of surface waters would have intensified stratification, thereby reducing net nutrient flux to the photic zone and decreasing silicate to nitrate ratios (Si:N); both factors that could increase the competitive advantage of the mixotroph, green Noctiluca, over diatoms. If so, the decadal-scale trajectory of phytoplankton community composition in the Northeastern Arabian Sea may be a harbinger of future climate-driven change in other productive oceanic systems.

The fatty acid content of plankton is changing in subtropical coastal waters as a result of OA: Results from a mesocosm study.

Ocean Acidification (OA) effects on marine plankton are most often considered in terms of inorganic carbon chemistry, but decreasing pH may influence other aspects of cellular metabolism. Here we present the effects of OA on the fatty acid (FA) content and composition of an artificial phytoplankton community (Phaeodactylum tricornutum, Thalassiosira weissflogii, and Emiliania huxleyi) in a fully replicated, ∼4 m3 mesocosm study in subtropical coastal waters (Wuyuan Bay, China, 24.52°N, 117.18°E) at present day (400 µatm) and elevated (1000 µatm) pCO2 concentrations. Phytoplankton growth occurred in three phases during the 33-day experiment: an initial exponential growth leading to senescence and a subsequent decline phase. Phytoplankton sampled from these mesocosms were fed to mesozooplankton collected by net haul from Wuyuan Bay. Concentrations of saturated fatty acids (SFA) in both phytoplankton and mesozooplankton remained high under acidified and non-acidified conditions. However, polyunsaturated fatty acids (PUFA) and monounsaturated fatty acids (MUFA) increased significantly more under elevated pCO2 during the late exponential phase (Day 13), indicating increased nutritional value for zooplankton and higher trophic levels. Indeed, uptake rates of the essential FA docosahexaenoic acid (C20:5n3, DHA) increased in mesozooplankton under acidified conditions. However, mesozooplankton grazing rates decreased overall with elevated pCO2. Our findings show that these selected phytoplankton species have a relatively high tolerance to acidification in terms of FA production, and local mesozooplankton in these subtropical coastal waters can maintain their FA composition under end of century ocean acidification conditions.

Algae as nutritional and functional food sources: revisiting our understanding.

Global demand for macroalgal and microalgal foods is growing, and algae are increasingly being consumed for functional benefits beyond the traditional considerations of nutrition and health. There is substantial evidence for the health benefits of algal-derived food products, but there remain considerable challenges in quantifying these benefits, as well as possible adverse effects. First, there is a limited understanding of nutritional composition across algal species, geographical regions, and seasons, all of which can substantially affect their dietary value. The second issue is quantifying which fractions of algal foods are bioavailable to humans, and which factors influence how food constituents are released, ranging from food preparation through genetic differentiation in the gut microbiome. Third is understanding how algal nutritional and functional constituents interact in human metabolism. Superimposed considerations are the effects of harvesting, storage, and food processing techniques that can dramatically influence the potential nutritive value of algal-derived foods. We highlight this rapidly advancing area of algal science with a particular focus on the key research required to assess better the health benefits of an alga or algal product. There are rich opportunities for phycologists in this emerging field, requiring exciting new experimental and collaborative approaches.

Epidemiology and outcomes of primary sclerosing cholangitis with and without inflammatory bowel disease in an Australian cohort.

BACKGROUND & AIMS: Epidemiological data on primary sclerosing cholangitis (PSC) outside the Northern hemisphere are limited. Similarly, the impact of inflammatory bowel disease (IBD) on PSC outcomes remains unclear. We aimed to study the epidemiology and outcomes of PSC patients with and without IBD in an Australian cohort. METHODS: We retrospectively studied PSC patients attending two tertiary referral hospitals over 20 years. Diagnosis of PSC was made according to international guidelines by positive cholangiography and/or liver biopsy (for small duct PSC) with supporting clinical and laboratory evidence. RESULTS: Of 208 PSC patients (61% male) were studied (2271patient-years follow-up). The median age of PSC diagnosis was similar for PSC-IBD and PSC-only patients (40 years vs 42 years, P = .35). All 33 deaths occurred in PSC-IBD patients while there were no deaths in PSC-only patients (21% vs 0%, P < .01). However, there were no significant differences in liver transplantation (PSC-only 25% vs PSC-IBD 31%, P = .45) and transplant-free survival between PSC-only and PSC-IBD patients (P = .43). On multivariate Cox regression, only elevated international normalized ratio (INR) was associated with a greater risk of death or liver transplant (HR 2.0, 95% CI 1.1-3.6, P = .02). Development of gastrointestinal malignancy was higher in the PSC-IBD group compared to PSC-only group (22% vs 2%, P < .01). CONCLUSION: Australian PSC patients have similar characteristics compared to European and North American cohorts. IBD is a significant predictor of gastrointestinal malignancies. Deaths were more common in PSC-IBD but overall transplant-free survival remained similar in PSC-IBD and PSC-only groups. An elevated INR was an independent predictor of death or liver transplantation.