Increasing evidence from epidemiologic studies suggest that oxidative stress may play a role in adult glioma. In addition to dietary antioxidants, antioxidant and weak estrogenic properties of dietary phytoestrogens may attenuate oxidative stress. Our hypothesis is that long-term consumption of dietary antioxidants and phytoestrogens such as genistein, daidzein, biochanin A, formononetin, matairesinol, secoisolariciresinol and coumestrol, may reduce the risk of adult glioma.Using unconditional logistic regression models, we compared quartiles of consumption for several specific antioxidants and phytoestrogens among 802 adult glioma cases and 846 controls from two study series from the San Francisco Bay Area Adult Glioma Study, 1991 – 2000, controlling for vitamin supplement usage, age, socioeconomic status, gender, ethnicity and total daily calories. For cases, dietary information was either self-reported or reported by a proxy. For controls, dietary information was self-reported. Gender- and series- specific quartiles of average daily nutrient intake, estimated from food-frequency questionnaires, were computed from controls.Significant p-values (trend test) were evaluated using significance levels of either 0.05 or 0.003 . For all cases compared to controls, statistically significant inverse associations were observed for antioxidant index (p < 0.003), carotenoids , daidzein (p = 0.003), matairesinol (p < 0.05), secoisolariciresinol (p < 0.003), and coumestrol (p < 0.003). For self-reported cases compared to controls, statistically significant inverse associations were observed for antioxidant index (p < 0.05) and daidzein (p < 0.05).Our results support inverse associations of glioma with higher dietary antioxidant index and with higher intake of certain phytoestrogens, especially daidzein. Epidemiologic evidence from studies of dietary antioxidant intake and adult glioma support a role for oxidative stress in gliomagenesis. Several studies have shown that antioxidant consumption from fruits and vegetables may be protective against adult glioma -4. Most If oxidative stress is involved in brain tumor development, then dietary intake of nutrients of fruits and vegetables with antioxidative and estrogenic properties may reduce the risk of adult glioma. We addressed this hypothesis by comparing nutrient intake between incident glioma cases and controls of the San Francisco Bay Area Adult Glioma Study, 1991–2000.Human subject methods were approved by the University of California Committee on Human Research, approval number H6539-04956. Informed consent was documented through subject signature on the approved consent document.The San Francisco Bay Area Adult Glioma Study, 1991–2000, is described in detail elsewhere . BrieflyIn both series, controls were identified by random digit-dialing and frequency matched to cases on ten-year age groups, gender, and ethnicity . Initial sampling units included area code, 3-digit prefix, and 2 digits of cases' phone numbers. Eligible matches were found for each sampling unit through 2 digit suffixes generated from random number tables [Eligible cases or next-of-kin and controls were sent a letter and telephoned to schedule an in-person interview at subjects' home or other location of their choice . InterviThe series I questionnaire consisted of 79-item food-frequency questions modified from the US National Cancer Institutes' (Block's) Health Habits and History Questionnaire  and the Similarly, eligible cases or next-of-kin and controls were sent a letter and telephoned to schedule an in-person interview at subjects' home or other location of their choice. Interviews were conducted with consenting subjects or their proxies when cases were not available due to death or disability. Rather than a self-administered diet questionnaire as in series I, interviewers asked the diet questions in series II. As in series I, all questions were asked for the year prior to glioma diagnosis for cases and for the previous year for controls in series II.The series II diet questionnaire consisted of 96 food-frequency questions modified from the US National Cancer Institutes' (Block's) Health Habits and History Questionnaire  and inclFor the purposes of assessing major differences of dietary consumption comparing eligible participants to eligible non-participants, an abbreviated questionnaire was administered to some unwilling to participate in the full interview. In a 5-minute phone interview, the abbreviated questionnaire asked basic demographic and dietary (including vitamin supplement use) questions.For both series, only one value was assigned for each food frequency choice by converting the unit of year, month or day to the number of times per day. For ranges of frequencies, the mid-value was assigned before conversion, e.g. 2.5 times per month was assigned if the '2–3 per month' category was given. Intake of each food item was converted to grams consumed per day by applying an appropriate algorithm for each series as described in the following: For series I, the frequency and an assigned gender- and age-specific medium portion size were multiplied against a nutrient database to produce grams consumed per day for each food item. The assigned gender- and age-specific medium portions were based on the Block and colleagues' National Cancer Institute's Health Habits and History Questionnaire Personal Computer System Packet . For serAdditionally for both series, a total daily antioxidant index intake was calculated by summing the product of grams consumed over all food items and units of antioxidant index per gram from an antioxidant index database for fruit, vegetable, juice and tea food items. We constructed the antioxidant index database based on data from Wang and colleagues   was used for all statistical analyses. Demographic distributions of cases were compared to those of controls using t-tests or analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Means and standard errors as well as geometric means with upper and lower 95% confidence limits for daily consumption of total antioxidant index as well as various individual antioxidants and phytoestrogens adjusted for total calories were generated with general linear models for all cases, self-reporting cases and controls using SAS procedure GLM. Logistic regression models estimated odds ratios for quartiles of consumption of antioxidant index or each nutrient adjusting for age (continuous), gender, ethnicity (White versus other), socioeconomic status (combined income and education categories), and total calories (continuous). Thus, to adjust for total energy intake, we employed the standard multivariate method . In addiCase-control comparisons were analyzed separately by series since data on nutrient and antioxidant index intake was collected by different methods between study series. Because comparison of series-specific odds ratios and corresponding 95% confidence showed that odds ratios were largely in the same direction and their corresponding 95% confidence intervals overlapped between series, we also conducted combined series case-control comparisons with a study series indicator variable as a necessary covariate in logistic regression models. Gender- and series- specific quartile cutpoints were determined for the antioxidant index or nutrient intake levels based on food consumption among the controls. Test for trend were computed for case-control odds ratios of antioxidant index or nutrient quartiles. Results are described for p-values generated based on a 5% significance level and two-sided hypothesis tests. Finally, a Bonferroni correction for 16 simultaneous comparisons (an antioxidant index plus 15 nutrients) was applied to emphasize results based on a 0.003 (= 0.05/16) significance level.The total number of subjects from both series that were identified as eligible to participate in the San Francisco Bay Area Adult Glioma Study, 1991–2000, includes 1,110 cases and 1,284 controls. Participation was greater among eligible cases (79%–80% for series I and II) than among eligible controls  [Information on vitamin type (multi-vitamin or antioxidant), asked for series II, was not considered during the analyses because the reported data did not appear to reflect a reasonable distribution of supplement types. In addition, differential absorption rates between supplements and foods prevent the combination of nutrients from supplement types with that from foods consumed. Therefore, all vitamin supplement analyses only considered intake (yes or no). Results of an abbreviated diet questionnaire for comparisons of participants and non-participants, showed that vitamin use among controls adjusted for age, gender, and ethnicity was similar for participants and non-participants . Interestingly, the percent of cases  that regularly consumed vitamin supplements was significantly lower than that of controls  nutrients estimates closely approximate reference values in previous studies. Finally, although we report findings that were statistically significant at the 0.05 level, because of multiple comparisons, the actual p-values are likely to be higher than those calculated. For this reason, we also emphasize statistically significant results at the 0.003 level after applying a Bonferroni correction for 16 simultaneous comparisons.We previously discussed in detail major potential sources of bias in these case-control dietary data . BrieflyDue to methodological differences in data collection between series, we presented the data separately by series. Because the direction and 95% confidence limits of odds ratios were similar across series, we also performed combined series analyses since increasing the sample size increases the power to detect statistically significant findings. It should be noted that our combined series analysis is similar to a meta-analysis, a common epidemiologic practice, with the advantage of having the raw data to directly estimate associations from the combined data. Combined series odds ratios were generated with addition of a series indicator covariate in the logistic regression models. Additionally, because of the many limitations with retrospective dietary assessment, we focus on results that were reasonably consistent in magnitude and statistical significance between all cases versus controls and self-reporting cases versus controls. For those nutrients with such consistent findings, the odds ratios for highest to lowest quartiles of intake tended to be further from the null among subjects without reported supplement use than those with such use. These findings could indicate that distributions of dietary choices of people taking supplements are more similar regardless of case-status.Despite the many caveats inherent in retrospective dietary assessment, our findings, in light of previous epidemiologic and mechanistic studies, support the growing evidence of a role for oxidative stress in adult glioma. Vitamin C is a water soluble, well known scavenger of hydroxyl radicals that inhibits oxidative DNA lesions such as 8-hydroxydeoxyguanosine . We obseFor carotenoid consumption, more consistent results have been observed among studies of brain tumor risk. We observed an inverse association of carotenoid consumption with glioma risk, which is consistent with other studies ,28 incluWe observed statistically significant inverse associations for consumption of several phytoestrogens suggesting protective effects. The most consistently significant inverse association was observed for daidzein. Our results also suggest protective effects against gliomas for formononetin, matairesinol, secoisolariciresinol, and coumestrol. Vaya and colleagues  showed tFurthermore, the influence of phytoestrogens on pro-inflammatory mediators may be a result of estrogen receptor-dependent activities. Recent evidence from several studies supports that estrogen receptors, and especially estrogen receptor-beta, down-regulates iNOS and COX-2 gene expression ,6. InterThe observed inverse associations suggest a protective role against gliomagenesis for consumption of foods rich in antioxidants and certain phytoestrogens, especially daidzein. In light of the growing evidence supporting a role for oxidative stress in gliomagenesis, future studies in brain tumor research should focus on reactive nitrogen and oxygen species to further clarify their roles as well as identifying targets of treatment and prevention of glioma.The author(s) declare that they have no competing interests.We, the authors, are noted for the following significant contributions toward this study: ML for the overall idea; MW and ML for the study design; MW and RM for the collection of data; JDS and RM for analysis of data; NTB for writing the manuscript; and both ML and MW for advice and consultation.The pre-publication history for this paper can be accessed here:Supplmental_Table1, "Case-control distributions for quartiles of nutrient consumption; San Francisco Bay Area Adult Glioma Study, 1991–2000", 133 KBClick here for file


EHP 114:1547–1552; Boyles et al.][.Dietary folic acid supplementation in women of childbearing age has been a major public health success story, reducing the incidence of neural tube defects (NTDs) by an estimated 50–70%. The CDC currently recommends that all women of childbearing age eat a diet high in folic acid or take a daily multivitamin with 0.4 mg of folic acid each day, with higher intake from before conception through the first three months of pregnancy. In light of a new analysis of NTDs and folate pathway genes, however, that blanket recommendation may need to be fine-tuned If these results are confirmed, it appears there may be a subgroup of women in whom folic acid supplementation is actually positively associated with the formation of NTDs in their offspring—a startling finding the authors acknowledge to be counterintuitive. Counterintuitive or not, the study may have uncovered individuals susceptible to adverse outcomes stemming from overactivity in the folate metabolism pathway during a critical stage of embryonic neurodevelopment.The researchers analyzed the genomes of 304 families where at least one individual had an NTD. They focused their analysis on 28 single-nucleotide polymorphisms (SNPs) in 11 genes known to be involved in the folate metabolism pathway, and stratified the genomic results by potential gene–gene interactions and by whether the mothers had taken folate-containing nutritional supplements prior to conception.BHMT ) gene were significantly associated with NTDs, and that the significance was strongest with mothers who took folate supplements before conception. The group also found an associative gene–gene interaction: significance increased in the BHMT rs3733890 SNP when the data were stratified by preferential transmission of one particular MTHFR allele from parent to offspring. However, MTHFR, the most widely studied gene implicated in NTD research, was not found to be a significant single risk factor.The results showed that certain SNPs in the betaine-homocysteine methyltransferase (BHMT polymorphism may create a genetic variant that promotes overactivity of the folate metabolic cycle, given the high folate levels achieved during supplementation. This overactivity may inappropriately silence growth factors necessary for proper neural tube closure. Whether this potentially important polymorphic anomaly is grounded in analytic methodology or in actual biology, further research is clearly indicated.The authors speculate that the stratification method they employed may have inadvertently grouped families by one or more unidentified cofactors correlated with folate supplementation, or that the NTDs are known to be complex multifactorial disorders arising from an array of genetic and environmental interactions. In their various physiologic manifestations, they are either profoundly disabling or fatal. Although the preventive effect of folic acid supplementation is undeniable, its protective mechanism of action is still poorly understood. And if the results of this study are replicated and confirmed, the public health directives concerning folic acid supplementation may need to be revised.


While existing reviews have identified significant predictors of nursing home admission, this meta-analysis attempted to provide more integrated empirical findings to identify predictors. The present study aimed to generate pooled empirical associations for sociodemographic, functional, cognitive, service use, and informal support indicators that predict nursing home admission among older adults in the U.S.nursing home placement," "nursing home entry," "nursing home admission," and "predictors/institutionalization." Any reports including these key words were retrieved. Bibliographies of retrieved articles were also searched. Selected studies included sampling frames that were nationally- or regionally-representative of the U.S. older population.Studies published in English were retrieved by searching the MEDLINE, PSYCINFO, CINAHL, and Digital Dissertations databases using the keywords: "Of 736 relevant reports identified, 77 reports across 12 data sources were included that used longitudinal designs and community-based samples. Information on number of nursing home admissions, length of follow-up, sample characteristics, analysis type, statistical adjustment, and potential risk factors were extracted with standardized protocols. Random effects models were used to separately pool the logistic and Cox regression model results from the individual data sources. Among the strongest predictors of nursing home admission were 3 or more activities of daily living dependencies , cognitive impairment , and prior nursing home use .The pooled associations provided detailed empirical information as to which variables emerged as the strongest predictors of NH admission . These results could be utilized as weights in the construction and validation of prognostic tools to estimate risk for NH entry over a multi-year period. The cost of nursing home (NH) care for persons 65 years of age and over is estimated to be roughly 150 billion dollars by 2007 in the United States (U.S.). About 62% of this cost in the U.S. is assumed by public, taxpayer-financed sources such as Medicaid and Medicare . The conSeveral comprehensive literature reviews have summarized studies predicting NH admission among older adults -9. TheseWhile there is some consensus regarding the identification of singular factors that predict NH admission for older adults 1 year or more into the future, there are several limitations in existing research. One is the reliance on samples that are not representative of the older U.S. population. This weakness is apparent not only in individual studies, but also systematic reviews of predictors of NH entry as attempts to integrate existing findings often include non-representative data sources along with representative ones -7. This Most studies of NH admission focus on the factors that antedate entry by several years and serve as early warning signs of those at greatest risk for entry. This study systematically reviews the long-term predictors of NH admission  for U.S. older adults in the community. Deriving estimates of prediction based on generalizable data sources may inform the development of useful prognostic tools to help identify who is at-risk for NH entry at some time point in the future. For example, the generation of pooled empirical associations via a meta-analysis of this type could serve as empirical weights in the development of predictive algorithms of NH admission for community-residing older adults .The findings of this meta-analysis can confirm significant predictors of NH admission identified in prior, well-executed systematic reviews -7. Howevnursing home placement," "nursing home entry," "nursing home admission," and "predictors/institutionalization." Any reports including these key words were retrieved. The principal author, who has helmed several studies on NH admission in dementia [Published analyses were initially located through a search of the MEDLINE, CINAHL, PSYCINFO, and Dissertation Abstracts/Digital Dissertation databases using the following key terms: "dementia ,18, screA standardized extraction protocol was used. Inclusion criteria were as follows: 1) NH entry was an outcome in the analysis; 2) the study was conducted within the U.S. due to the diverging care philosophies, regulatory environment, and service delivery approaches of NH care in other countries; 3) the study design was longitudinal in order to allow for a predictive analysis of NH admission; 4) the sample was general, as opposed to disease-specific ; 5) the sample resided in a community setting, such as at home alone or with relatives, as opposed to a healthcare setting ; and 6) the sample was regionally- or nationally-representative of the U.S. population of older adults in order to maximize the generalizability of the pooled estimates. The screening protocol also extracted date of publication, source of publication, author, sample size, percentage of older adults (65 years of age and over) and women in each sample, and type of data collected . For eligible studies the principal author extracted data for each reported predictor of NH admission, including regression coefficients, standard errors, odds/hazard ratios, and lower/upper confidence intervals. Data on study design included analysis type, length of follow-up, classification of long- or short-stay NH admissions, and analytic unit of predictors .P < .05 indicating that study results were heterogeneous [Results were integrated with random effects models, as these models consider both within- and between-study variation when deriving pooled empirical associations . Heterogogeneous . Sets ofA detailed variable cross-walk identified individual predictors of NH admission and their operational meaning across individual studies. This allowed for a much clearer interpretation of results in the meta-analysis, as pooled estimates for each predictor were based on variables that were closely operationalized or measured across studies as opposed to variables that were grouped in more general categories . Almost all the studies included only reported adjusted estimates; therefore, these estimates were used for pooling purposes. Results from logistic regression models (odds ratios) and Cox regression/survival models (hazard ratios) were analyzed separately, as these two approaches address related but different questions. Logistic regression models explore whether NH admission occurred or not, whereas Cox regression models examine the time to NH admission. Meta-analysis procedures were conducted separately for each analysis type to further clarify the meaning of pooled empirical associations .In a few instances, multiple studies from the same data source provided empirical information on a predictor of interest. When this occurred, the principal author compared the competing studies to identify the presence of seven important study characteristics: 1) more comprehensive adjustment used in the analysis ; 2) greater sample size; 3) longer follow-up; 4) use of clinical rating of functional or cognitive data; 5) use of objective data on NH admission ; 6) categorization of admission included ; and 7) use of multiple levels of predictors . The study that included a greater number of these criteria was selected for the meta-analysis.Of 4,597 abstracts initially screened, 3,861 were excluded because these studies did not consider predictors of NH admission, were evaluations of pharmacological or non-pharmacological interventions, or took place in settings other than the community . A final total of 77 reports were considered across these 12 data sources.Pooled together at their capacity, the 12 data sources represent 178,056 older adults  also appeared to increase the risk of NH admission. Older adults who were married or had more living children had lower odds to enter NHs, whereas older adults who lived alone had nearly twice the odds to be admitted. Older adults with an available caregiver had greater odds to enter a NH, which is in contrast to some conclusions of the importance of informal care -7. ThoseIndicators of functional and cognitive impairment were among the strongest predictors of NH admission. Older adults who indicated 3 or more ADL dependencies had considerably greater odds to enter NHs. The presence of cognitive impairment, assessed through either proxy/other subjective measures or 4 or more errors on clinically validated short screening tools such as the Short Portable Mental Status Questionnaire  were strIncreased age and Caucasian race/ethnicity were predictive of earlier NH entry in the Cox regression results whereas being married and owning a home were associated with delayed admission . Older adults with 3 or more ADL dependencies had approximately 3.25 times the odds to enter a nursing over a 2–6 year interval. Similarly, elderly patients with 4 or more errors on a short screening tool   had moreThe findings in this meta-analysis suggest that once certain functional or cognitive thresholds are reached, future risk of NH admission increases substantially (net a host of other factors). As suggested in prior research, intervention in the earlier stages of a chronic disease trajectory that offers respite and support to older adults or their caregiving families may help to potentially delay NH entry ,48. HoweThe results may offer useful prognostic information for clinicians, families, and older patients. For example, the significant predictors from the current meta-analyses could be converted into a practical screening tool of NH admission risk. A series of single dichotomous codes  could be applied for each indicator and then further weighted according to the effect size reported here. Summing these numbers and standardizing the sum would create a "risk score" on a 0–10 metric that offers guidance as to whether a geriatric patient is at risk for NH entry in the future. An almost identical algorithm has been utilized to predict NH admission in a smaller, clinic-based sample of persons with Alzheimer's disease where presence of a particular risk factor was calculated  and multiplied with the coefficient value of that risk factor as a weight (derived from Cox regression models) . The pro2 of .40–.42) [Approaching the prediction of future NH admission in terms of a threshold model may provide improved accounting of risk. Studies that have incorporated cut-points on functional or cognitive variables have generally accounted for greater variance in NH entry (Cox-Snell R.40–.42)  and the Future descriptive and clinical research could approach NH placement as less of an endpoint and instead as an important transition where timing of NH admission, type and characteristics of the institution, and preplacement factors all operate to influence outcomes after admission. Relatively little research has explored these issues or has considered data at these variable levels of analysis when examining the impact of the NH transition on key health outcomes ,50. By bRelying on multiple and representative sources of data, we have identified a number of indicators that predict NH admission over multi-year intervals. A lack of informal support or socioeconomic resources appeared to strongly precipitate entry. The most powerful predictors were those functional variables with identified cut-points, such as ADLs or cognitive impairment. The findings suggest a threshold effect in certain functional or cognitive dimensions that may signal the initiation of the admission process. As expected, the results here confirm those reported in prior well-designed, systematic reviews, where ADL dependencies, cognitive impairment, non-Caucasian race/ethnicity, prior NH admission, and social support/caregiving factors are identified as important precursors of entry -7. HowevThe author(s) declare that they have no competing interests.JEG conducted the database search, screened and extracted data for the meta-analysis, prepared extracted data for the meta-analysis procedures, and had primary responsibility in writing this article.SD conducted the meta-analyses, provided JEG with visual illustrations of the pooled results, and provided critiques and guidance in the Methods and Results section of the article. She also participated in the writing of this paper.KAA obtained the majority of studies used in the meta-analysis, assisted JEG in managing and filing these studies for the purposes of the meta-analysis, and also reviewed the article for editing purposes.RLK provided conceptual guidance throughout the meta-analysis, assisted JEG in the review of extracted data, edited sections throughout the manuscript (particularly the Introduction and Discussion), and aided JEG in interpreting the clinical significance of the results. He also participated in the writing of this paper.The pre-publication history for this paper can be accessed here:


To determine the importance of IgM antibodies against phosphorylcholine (aPC), a novel protective factor for cardiovascular disease (CVD), in a population with a non-western life style as compared with a Swedish control group.Risk factors for cardiovascular disease were determined in a group of 108 individuals aged 40–86 years from New Guinea and 108 age-and sex-matched individuals from a population based study in Sweden. Antibodies were tested by ELISA. aPC IgM levels were significantly higher among New Guineans than among Swedish controls (p < 0.0001). This difference remained significant among both men and women when controlled for LDL and blood pressure which were lower and smoking which was more prevalent in New Guineans as compared to Swedish controls (p < 0.0001). aPC IgM was significantly and negatively associated with age and systolic blood pressure among Swedish controls and with waist circumference among New Guineans. aPC IgM levels were significantly higher among women than men in both groups. The proportion of the saturated fatty acid (FA) myristic acid in serum cholesterol esters was negatively but polyunsaturated eicosapentaenoic acid and also lipoprotein (a) were positively associated with aPC IgM levels.IgM-antibodies against PC, which have atheroprotective properties, are higher in a population from Kitava, New Guinea with a traditional lifestyle, than in Swedish Controls, and higher among women than men in both populations tested. Such antibodies could contribute to the low incidence of cardiovascular disease reported from Kitava and could also provide an explanation as to why women have a later onset of CVD than men. The population from Kitava, Trobriand Islands, Papua, New Guinea, is virtually uninfluenced by the dietary habits and sedentary lifestyle that are common in developed countries. Even though controlled studies of atherosclerosis have not been performed in this population, available evidence indicates that cardiovascular disease is very uncommon. PreviouRecent evidence indicates that atherosclerosis, the main cause of cardiovascular disease (CVD) is an inflammatory disease characterized by immune activation in the artery wall,5. It isOne such factor that could promote inflammation and immune activation in the artery wall is oxidized low density lipoprotein (OxLDL). Early studies indicated that OxLDL can induce activation of monocytes/macrophages, endotheThe role of antibodies against OxLDL (aOxLDL) has been debated,11. It wMany biological effects of OxLDL are caused by platelet activating factor (PAF)-like lipids and/or lysophosphatidylcholine (LPC) in OxLDL -19 whereWe recently demonstrated that aPC of IgM subclass is a protection factor for human atherosclerosis in patients with hypertension. We hereSerum samples were obtained from 108 subjects aged 40–86 years from Kitava, Trobriand Islands, Papua New Guinea, and from 108 age-matched Swedish population based control subjects. Both surveys were approved by the Ethical committee at the University of Lund. The Kitava study was given ethical approval by the National Medical Research Advisory Committee of Papua New Guinea (PNG). It was approved by other PNG national and provincial bodies and at the community level by the inhabitants and their chiefs.The Kitavans are primitive horticulturalists who were essentially uninfluenced by western dietary habits at the time of the survey in 1990. From a The Swedish controls consisted of Caucasians (and very few immigrants), half of whom were living in the countryside and the other half in the small town of Skara. The survey was conducted in 1993–94 among a random sample from the population census register stratified by age and sex. SelecteStandard methods were used for measurements of weight, standing height, waist circumference, triceps skinfold (TSF) thickness, upper mid-arm circumference (MAC) and serum levels of total cholesterol (TC), high density lipoprotein cholesterol (HDL), triglycerides (TG) and uric acid -25. BlooClinical characteristics of the two study populations are presented in Table Polysorp F96 microtiter immuno-plates were purchased from Nunc (Roskilde Denmark), PC-BSA (Phosphorylcholine-Bovine Serum Albumin) was purchased from Biosearch Technologies, Inc .IgM antibodies to PC-BSA were determined by enzyme-linked immunosorbent assay (ELISA) essentially as described. BrieflyPlates were incubated overnight at 4°C and washed as described above. Alkaline phosphatase conjugated goat anti-human IgM (diluted 1:7000 in the sample buffer) were added at 100 μl/well and incubated at 4°C overnight. After five washings, color was developed by adding the alkaline phosphatase substrate (PNPP) at 100 μl/well and incubating the plates for 60 min at room temperature in the dark. The plates were read in an ELISA Multiscan Plus spectrophotometer  at 405 nm. All samples were measured in duplicates a single assay and the coefficient of variation was below 10–15%.U test and categorical variables were compared using chi-square tests. General linear model (GLM) was applied using the statistical software SPSS version 12.02 for Windows to test analysis of variance and investigate group differences and interaction effects of group and gender on aPC IgM levels. Associations between aPC IgM levels and traditional risk factors were determined using Pearson correlations for normally distributed variables and Spearman rank correlations for skewed variables. In addition, linear regression analysis was conducted with aPC IgM levels as dependent variable. Additional analysis of co-variance were made for aPC IgM levels while adjusting for the traditional cardiovascular risk factors smoking, blood pressure (BP), body mass index (BMI), and lipid levels. Data are presented as means (standard deviation). The level of statistical significance was set at a value of P < 0.05.Variables were tested for normality. Groups with skewed variables were compared using the non-parametric Mann-Whitney's Table Correlation analysis between aPC IgM levels and traditional riskfactors for all participants and for Kitava and Skaraborg populations separately are presented in Table A multivariate linear regression including group , gender , presently smoking (no/yes), systolic BP, BMI and LDL lipid levels and triglycerides was performed and results are presented in Table Table Analysis of covariance (ANCOVA) was performed to investigate if the difference in aPC IgM between the New Guinean and the Swedish group would remain significant after controlling for the CVD risk factors that were significantly different between the groups. The difference in aPC Igm between the New Guinean and Swedish population remained significant after adjusting for smoking, systolic BP, total cholesterol and BMI  = 5.7, p = .02).In addition to the 108 individuals from Kitava that were matched with Swedish controls over 40, we also had access to an additional 68 Kitavan individuals under the age of 40. In the whole group from Kitava , additional separate analysis and measurements were made, that were not accessible for the Swedish control population. aPC IgM levels were associated with waist  and upper arm muscularity as represented by AMC  and MAC . However, BMI was not significantly associated with aPC in this population . Among blood lipids, only apo (a) was associated with aPC IgM . BP measurements, electrolytes, and transaminases, were not associated with aPC. There were significant associations between aPC and certain fatty acids (FA) in serum cholesterol esters: saturated FA C 14:0 (myristic acid) was negatively  but polyunsaturated FA C 20:3n-6 was positively associated with aPC levels . C14:0 and C20:3n-6 were significantly (and negatively) associated with each other . Kitavans over the age of 40 had lower levels of aPC than those under 40 years old (.98(.28) vs 1.07(.23), p = .03) but this association did not quite reach significance when aPC IgM and age as a continuous variable was used (r = -.14 p = 0.06). A stepwise regression model with aPC IgM as dependent variable, showed Lp(a), waist, and CE 20:3 to be significantly and independently associated to aPC IgM.th and 90th percentile) is associated with a favourable outcome in ultrasound measurements of atherosclerosis prospectively and thus is a protection factor for atherosclerosis development in both women and men with hypertension and aPC IgM levels. The diet in Kitava is rich in saturated myristic acid which is reported to raise LDL-levels and which, in our study, was negatively associated with aPC levels. In contrast a polyunsaturated FA, dihomo-gama-linolic acid 20:3n-6 was positively associated with aPC. It could be hypothesized that exposure to easily oxidized FA e g in the gut immune system could elicit more robust aPC IgM levels, in contrast to saturated FA which are not oxidized. However, a caveat is that only some and not all FA showed this association pattern and further studies are needed to clarify if these associations are of importance. It may be relevant in this context to consider the fact that serum lipid levels are not optimal in the Kitavans, and higher than in some other non-western populations. which pThere was a strong positive association between aPC IgM levels and Lp(a), which is interesting, since this lipoprotein is known to react with a monoclonal antibody against oxLDL that also recognized PC, and much PC exposed on LDL in the circulation is present on Lp(a). Mean levels of Lp(a) did not differ between Kitava and Sweden. Since tPathogens exposing immunogenic PC include both bacteria like S Pneumoniae and various forms of nematodes, and one possibility that deserves further exploration is that increased exposure to some infections in New Guinea promoting aPC-related immune response could protect against atherosclerosis.Smoking was significantly more prevalent among new Guineans of both sexes, than in Swedish controls. Cigarette smoking is associated with an increased risk of stroke and IHD within most westernized populations, but in countries like Japan and China the prevalence of CVD has been low, despite extensive smoking. It is therefore possible that smoking is better tolerated in individuals who are not exposed to other risk factors.In summary, our findings indicate that high titers of IgM antibodies against PC, which we recently described as being a protective factor for atherosclerosis, are mor


DRD2) TaqI A polymorphism.Conflicting associations with heroin dependence have been found involving the A1 allele of dopamine D2 receptor gene  who frequently used non-opioid substances, and 145 control subjects .P = 0.011, odds ratio = 5.48, 95% CI 1.26–23.78). Although the A1 allele was not associated with heroin dependence in the entire sample, the frequency of A1 allele was higher in male patients than in male controls . A logistic regression analysis showed an interaction between DRD2 alleles and gender .The A1-A1 genotype was detected in 7.1% of patients and 1.4% of controls (DRD2 TaqI A polymorphism contribute to variations in the risk of heroin dependence, while single alleles contribute only in males.Our results indicate that, in Spanish individuals, genotypes of the  A better understanding of the etiology of heroin dependence is crucial for improving the prevention and treatment of this severe mental disorder. Genes that could be risk factors for heroin dependence have not been consistently identified; however, genetic epidemiology studies have shown that they do have an impact. These studies, with one exception , also suDRD2) could be involved in heroin dependence and other SUD as a nonspecific genetic factor, because opioids and other substances of abuse induce some of their rewarding effects through the mesolimbic dopamine system ). The logistic regression analysis revealed an interaction between DRD2 alleles and gender . In this case, the logistic regression analysis did not reveal an interactive effect of DRD2 genotypes and sex (data not shown).Allelic and genotypic comparisons within gender showed statistically significant differences only in males Tables  and 3. UDRD2 contributes to the variation in the risk for heroin dependence in Spanish individuals. The A1-A1 genotype was significantly associated with heroin dependence in the entire sample, while the A1 allele was associated only in males. Accordingly, the conclusion of a series of meta-analyses is that DRD2 TaqI A polymorphism is associated with SUD, particularly with severe SUD [The present case-control study shows that vere SUD . We consDRD2 A1 allele [Regarding specific studies on opioid use disorders, our findings agree with two previous reports from Australia  and Iran1 allele ; and wit1 allele .Patients who participated in the studies showing negative results ,20 were In the other previous study in which genetic associations were detected, all participants were males . As thisDRD2 A1 allele and cannabis use disorders have not been published. Moreover, nonspecific genetic factors account for a larger fraction of the variance of cannabis use in females (59%)[DRD2 A1 allele with alcohol dependence [Moreover, gender comparisons in the present study showed that cannabis use was more frequent in males than in female patients, and the same trend was found regarding alcohol use. These differences suggest that our decision to include patients who use non-opioid substances in the study maximised the odds for detecting genetic associations more in males than in females. However, associations between the les (59%) than in les (59%). Male-lipendence  and tobapendence  have beeFinally, the present study has the following limitations:P < 0.008) when the Bonferroni correction was applied to the six genetic comparisons performed  The findings of the present study may not be generalizable, because all study participants belonged to the same population. Still, Spaniards are closely related to the other European populations, and one would not expect to find many differences in the genetic architecture of susceptibility to heroin use.1) The associations found could be related more to the progression and severity of heroin dependence than vulnerability to this disorder , becaused Tables  and 3; hDRD2 TaqI A polymorphism in Spanish subjects of European origin. According with our results, the A1-A1 genotype of the DRD2 TaqI A polymorphism is associated with heroin dependence regardless of gender, while the A1 allele is associated with heroin dependence only in males. These results must be considered taking into account two aspects of the participant selection. First, heroin-dependent patients who participated in the present study were not excluded if they reported non-opioid substance use. Second, the most of cases and controls were males.To our knowledge, this is the first study performed in Latin Europe regarding the genetic associations of heroin dependence. The study was aimed to examine the association of heroin dependence with the DRD2: dopamine D2 receptor geneSUD: substance use disordersThe author(s) declare that they have no competing interests.JP made substantial contributions to the conception and design of the study, the interpretation of data, and drafting of the manuscript. MB made substantial contributions to the conception and design of the study, oversaw genotyping, and helped to draft the manuscript.JT made substantial contributions to the conception and design of the study, assisted with the analysis and interpretation of the statistical data, and revised the manuscript. NS performed the statistical analyses, contributed to the interpretation of the statistical data, and revised the manuscript. VV and FC assisted with statistical analyses, contributed to the interpretation of the statistical data, and revised the manuscript. EB and EL participated in recruiting part of subjects and phenotyping of subjects. ER performed the genotyping analyses. EA made substantial contributions to the conception of the study, and helped to draft the manuscript. All authors read and approved the final manuscript.


Systematic reviews and meta-analyses of test accuracy studies are increasingly being recognised as central in guiding clinical practice. However, there is currently no dedicated and comprehensive software for meta-analysis of diagnostic data. In this article, we present Meta-DiSc, a Windows-based, user-friendly, freely available (for academic use) software that we have developed, piloted, and validated to perform diagnostic meta-analysis.Meta-DiSc a) allows exploration of heterogeneity, with a variety of statistics including chi-square, I-squared and Spearman correlation tests, b) implements meta-regression techniques to explore the relationships between study characteristics and accuracy estimates, c) performs statistical pooling of sensitivities, specificities, likelihood ratios and diagnostic odds ratios using fixed and random effects models, both overall and in subgroups and d) produces high quality figures, including forest plots and summary receiver operating characteristic curves that can be exported for use in manuscripts for publication. All computational algorithms have been validated through comparison with different statistical tools and published meta-analyses. Meta-DiSc has a Graphical User Interface with roll-down menus, dialog boxes, and online help facilities..Meta-DiSc is a comprehensive and dedicated test accuracy meta-analysis software. It has already been used and cited in several meta-analyses published in high-ranking journals. The software is publicly available at  Accurate diagnosis forms the basis of good clinical care, as without it one can neither prognosticate correctly nor choose the right treatment. Indeed, a wrong diagnosis can harm patients by exposing them to inappropriate or sub-optimal therapy . Thus stCurrently, there is only one test accuracy meta-analysis package, Meta-Test , which aWe, therefore, developed, piloted and validated a comprehensive, Windows-based test accuracy meta-analysis software, Meta-DiSc, which is presented in this article, with a worked example.. Its installation is simple, guided by onscreen instructions. The programme has a user-friendly interface with roll-down menus, dialog boxes and online HTML compiled help files. These help files include a user manual and a description of the implemented statistical methods.Meta-DiSc software was created in Microsoft Visual Basic 6, and some mathematical routines have been linked from the NAG C mathematical library . The sofMeta-DiSc allows data entry into its datasheet in three different ways: a) directly by typing data into the datasheet using the keyboard, b) copying from another spreadsheet (e.g. Microsoft Excel) and pasting into Meta-DiSc datasheet, or c) importing text files from other sources . Several variables can be defined in the datasheet, including study identifiers, accuracy data from each study  and study level co-variates, such as those defining population spectrum or methodological quality of the studies.Once the data have been entered into the datasheet of Meta-DiSc, various statistical analyses can be implemented Figure . The impWhen describing accuracy results from several studies, it is important to get an indication of the magnitude and precision of the accuracy estimates derived from each study, as well as to assess the presence or absence of inconsistencies in accuracy estimates across studies (heterogeneity). As accuracy estimates are paired and often inter-related , it is necessary to report these simultaneously . One accMeta-DiSc computes accuracy estimates and confidence intervals from individual studies and shows results either as numerical tabulations or graphical plots in two formats: a) forest plots, for sensitivities, specificities, LRs or dOR, with respective confidence intervals; and b) plots of individual study results in ROC space, with or without an sROC curve.negative correlation between sensitivities and specificities (or a positive correlation between sensitivities and 1-specificities), which results in a typical pattern of "shoulder arm" plot in a sROC space [Exploring heterogeneity is a critical issue to a) understand the possible factors that influence accuracy estimates, and b) to evaluate the appropriateness of statistical pooling of accuracy estimates from various studies. One of the primary causes of heterogeneity in test accuracy studies is threshold effect, which arises when differences in sensitivities and specificities or LRs occur due to different cut-offs or thresholds used in different studies to define a positive (or negative) test result. When threshold effect exists, there is a OC space . It is wpositive correlation would suggest threshold effect.Meta-DiSc allows assessment for threshold effect in three different ways: a) visual inspection of relationship between pairs of accuracy estimates in forest plots. If threshold effect is present, the forest plots will show increasing sensitivities with decreasing specificities, or vice versa. The same inverse relationship will be apparent with LR positive and LR negative; b) representation of accuracy estimates from each study in a sROC space – a typical "shoulder arm" pattern would suggest presence of threshold effect; and c) computation of Spearman correlation coefficient between the logit of sensitivity and logit of 1-specificity. A strong Apart from variations due to threshold effect, there are several other factors that can result in variations in accuracy estimates amongst different test accuracy studies in a review. These reasons include chance as well as variations in study population (e.g. severity of disease and co-morbidities), index test , reference standard, and the way a study was designed and conducted . Since sMeta-DiSc allows users to test for heterogeneity amongst various studies in two different ways: a) Visual inspection of forest plots of accuracy estimates. If the studies are reasonably homogeneous, the accuracy estimates from individual studies will lie along a line corresponding to the pooled accuracy estimate. Large deviations from this line will indicate possible heterogeneity; b) statistical tests, including Chi-square and Cochran-Q, which are automatically implemented during analysis to evaluate if the differences across the studies are greater than expected by chance alone. A low p-value will suggest presence of heterogeneity beyond what could be expected by chance alone. In addition to these heterogeneity statistics, Meta-DiSc computes the inconsistency index (I-squared) which has been proposed as a measure to quantify the amount of heterogeneity .If substantial heterogeneity is found to be present from the analyses detailed above, then reasons for such heterogeneity can be explored by relating study level co-variates  to an accuracy measure, using meta-regression techniques. The accuracy measure that is normally used is dOR, as it is a unitary measure of diagnostic performance that encompasses both sensitivity and specificity or both LR positive and LR negative. Using dOR as a global measure of accuracy is a suitable method to compare the overall diagnostic accuracy of different tests . HoweverMeta-DiSc implements meta-regression using a generalization of Littenberg and Moses Linear model ,13 weighMore advanced meta-regression techniques such as Hierarchical sROC model  and bivaStatistical pooling is not always appropriate or necessary in every systematic review of test accuracy studies. However, when used appropriately, pooling can provide useful summary information. The necessary precondition for simple pooling (weighted averaging) of each of sensitivities, specificities, LR positives and LR negatives, is that the studies and results are reasonably homogeneous . If heterogeneity due to threshold effect were present, the accuracy data can be pooled by fitting a sROC curve and summarising that curve by means of the Area Under the Curve (AUC) or using other statistics such as the Q* index   Meta-DiSc allows pooling of various summary measures within subgroups defined by study level co-variates with the help of a filter utility.Meta-DiSc has comprehensive functionality for statistical pooling: a) It allows pooling of sensitivities, specificities, LR positive and LR negative each separately, using either fixed or random effect ,20 model methods ,20 to esWherever possible, the results of the above statistical procedures were validated using different general purpose statistical software such as STATA (ver 8.2) and SAS (8.2) using actually published and simulated data sets Table .We illustrate the various procedures that Meta-DiSc implements in a case-study of ultrasound test in the diagnosis of uterine pathology ,22. UltrA systematic review of test accuracy studies identified 57 studies. Figure As the first step in the analysis, we have used Meta-DiSc to present accuracy measures from each individual study in forest plots for sensitivities figure , specifiexplicit threshold of 5 mm was used in these studies, there can still be an implicit threshold effect due to, for example, variation in the interpretation of the test results. Therefore, within this subgroup with an explicit threshold of 5 mm, it is still recommended that the above explorations for threshold effect are undertaken. We performed such analyses for this subgroup in Meta-DiSc, and found no evidence of further threshold effect (data not shown). There are a number of other more advanced methods not implemented in Meta-DiSc that allow to incorporate explicitly information about tests thresholds defined between or within studies [The next step is the representation of sensitivity against 1-specificity from each study in a ROC space figure , which c studies .As the next step, heterogeneity arising from factors other than threshold effect is explored. We performed a visual exploration of the forest plots of accuracy measures for these 21 studies as well as statistical tests for heterogeneity (Meta-DiSc output not shown). In addition, possible sources of heterogeneity across the studies were explored using meta-regression analysis with the following co-variates as predictor variables: use or non-use of hormone replacement therapy (HRT); technique of ultrasound measurement (single or double layer); and population enrolment (consecutive or other). Results are shown in Table The final step in the analysis is pooling if this is considered appropriate. We illustrate pooling of the LRs for negative test results in one homogenous subgroup of studies of non-HRT users, with a test threshold of ≤ 5 mm, and using a single layer technique Figure . FinallyMeta-DiSc allows description of individual study results; exploration of heterogeneity with a variety of statistics including chi-square, I-squared and Spearman correlation tests; implements meta-regression techniques to explore the relationships between study characteristics and accuracy estimates; performs statistical pooling of sensitivities, specificities, likelihood ratios and diagnostic odds ratios, using fixed and random effects models, both overall and in subgroups; and produces high quality figures, including forest plots and summary receiver operating characteristic curves that can be exported for use in manuscripts for publication.Meta-DiSc is an evolving software. As new diagnostic meta-analytic methods become established over time, they will be implemented into the program in the future. For example, bivariate method of pooling sensitivity and specificity  is curreMeta-DiSc is a comprehensive and dedicated test accuracy meta-analysis software. All computational algorithms in it have been validated through comparison with different statistical tools and published meta-analyses. Its use and citation in several meta-analyses published in high-ranking journals is evidence of external validation of its high quality -28..The software is publicly available at Operating system: The software runs on Windows based personal computers (Windows 95 or higher) with Pentium-class processor or equivalent, with minimum of 32 MB of RAM and minimum of 20 MB of hard disk space. SVGA color monitor; minimum 800 × 600 screen resolution and 256 colors.Licence: Freeware for academic use.The author(s) declare that they have no competing interests.JZ conceived the idea. AM, VA and JZ developed the software. AC and KSK tested the software on a number of reviews and gave suggestions for improvements. All authors participated in preparing this manuscript.The pre-publication history for this paper can be accessed here:Meta-Disc data set. This file contains simulated data. It is provided to help users to validate statistical procedures shown in table Click here for fileSTATA data set. This file contains simulated data. It is provided to help users to validate statistical procedures shown in table Click here for file


Birth defects are a leading cause of neonatal and infant mortality in Italy, however little is known of the etiology of most defects. Improvements in diagnosis have revealed increasing numbers of clinically insignificant defects, while improvements in treatment have increased the survival of those with more serious and complex defects. For etiological studies, prevention, and management, it is important to have population-based monitoring which provides reliable data on the prevalence at birth of such defects.We recently initiated population-based birth defect monitoring in the Provinces of Mantova, Sondrio and Varese of the Region of Lombardy, northern Italy, and report data for the first year of operation (1999). The registry uses all-electronic source files  and a proven case-generation methodology, which is described.The data were checked manually by consulting clinical records in hospitals. Completeness was checked against birth certificates by capture-recapture. Data on cases were coded according to the four-digit malformation codes of the International Classification of Diseases, Ninth Revision (ICD-9). We present data only on selected defects.We found 246 selected birth defects in 12,008 live births in 1999, 148 among boys and 98 among girls. Congenital heart defects  were the most common , followed by defects of the genitourinary tract  (particularly hypospadias in boys), digestive system  and central nervous system , orofacial clefts  and Down syndrome . Completeness was satisfactory: analysis of birth certificates resulted in the addition of two birth defect cases to the registry.This is the first population-based analysis on selected major birth defects in the Region. The high birth prevalences for septal heart defect and hypospadias are probably due to the inclusion of minor defects and lack of coding standardization; the latter problem also seems important for other defects. However the data produced are useful for estimating the demands made on the health system by babies with birth defects. Birth defects are relatively common, affecting 3% to 5% of live-births in the United States  and 2.1%Around 40% to 60% of birth defects are of unknown origin; 20% are attributed to a combination of heredity and other factors; 7.5% to single gene mutations; 6% to chromosome abnormalities; and 5% to maternal illnesses, such as diabetes or infection, or use of anticonvulsant or other drugs [The prevalence rate of birth defects is increasingly used as an indicator of exposure to teratogens of various kinds, particularly pesticides but also pharmaceuticals .Registries and surveillance systems are the only way to obtain population-based data on birth defects, since birth certificates have been shown to be inadequate . We set A birth defect is defined by the registry as a structural or chromosomal anomaly present at birth and recognized during the first year of life. The registry records all birth defects in live births. However, the present analysis concerns selected defects: those considered major by Rasmussen et al  and the For inclusion in the registry• The child must be born live• The mother must be resident in Mantova, Sondrio or Varese Province when the child is born.• The defect must be on the ICD-9 list • The defect must be diagnosed before the child's first birthdayPopulation-based case ascertainment employs automated registration from electronic mortality files, hospital discharge files, and pathology files. Mortality files are provided by the local health authorities of the three provinces. Hospital discharge files, provided by the health department of the Region of Lombardy, contain records from all hospitals in Italy. This is important as many congenital anomalies are diagnosed prenatally and the women give birth at specialist hospitals outside the study areas. Pathology reports are obtained from pathology departments in the three provinces and from some outside. To ensure maximum completeness, information for a given calendar year is collected up to December of the succeeding year (data registration may occur in the year following diagnosis).The Birth Defect Registry uses the proven Open Registry software -16 to ge• Electronic files are extracted from the source information systems, standardized, and loaded into Open Registry tables.• Records pertaining to a single individual from various sources are linked by proven linkage algorithms • Birth defect records are generated from the tables.• Birth defect records are manually checked against paper sources to eliminate false positives and check diagnosis accuracy.Open Registry loads the three data source files and in addition loads a fourth electronic data file, the Social Security List (SSL) of the Lombardy region. The SSL contains the name, surname, date of birth, sex, residence code and a unique social security number, of all persons living in the Lombardy Region. Registry staff launch queries to check that all the necessary data are available and have the correct format (for example the program checks that the ICD-9 disease code has four digits). Routines standardize the data to a single format and pass them automatically to an Oracle table. Once loaded into Oracle tables, automatic checks for consistency are performed . Open Registry routines then scan the records and select those with disease codes indicating birth defects. Specifically, the software selects records with ICD-9 codes from 740 to 759 inclusive.The next step is to link the records selected in the previous step so as to generate a single record for each case. To facilitate this Open Registry makes use of the SSL with a unique social security number for each case. The social security number renders data linkage straightforward but if it is missing or erroneous, other identifiers can be used. Open Registry incorporates the proven Epilink record linkage software  that empFollowing data linkage, Open Registry automatically generates a single personal data record for each case, together with one or more linked birth defect records, each with details of a single birth defect. A second birth defect record will be present if a given case has second birth defect. The disconnection between personal and clinical information helps ensure privacy, and is required by Italian legislation.Each birth defect record is then checked manually against paper records from the hospitals that performed the diagnosis in order to eliminate false positives and correct any discrepant birth defect code.Finally, all cases are reviewed by a pediatrician specialized in pathology and genetics, to ensure recognition of syndromes in children with multiple anomalies.We used the capture-recapture technique  to estimThe Lombardy birth defect registry project was approved by the Ethical Committee of the National Cancer Institute. The project was then approved by the Privacy Guarantee Authority . Strict safeguards have been established to prevent unauthorized use of records. The highest level of confidentiality is maintained for all identifying information.Mantova has an area of 2,339 sq km, population of 376,000 and birth rate 8.4/1,000; Sondrio has an area of 3,212 sq km, population 177,500 and birth rate 9.2/1,000; Varese has an area of 1,198 sq km, population 821,000 and birth rate 9.2/1,000. The three Provinces contain 15% of the total population of the Region of Lombardy, whose birth rate is around 9.6/1,000 per year.A total of 246 congenital malformations were identified among the 12,008 live births in 1999. Among boys there were 148 malformations, giving a prevalence rate at birth of 241.9/10,000, and among girls there were 98 birth defects giving a birth prevalence rate of 166.4/10,000. Prevalence rates at birth for selected congenital malformations are shown in Tables One case of spina bifida with hydrocephalus  and one without hydrocephalus  were registered with associated prevalence rates at birth of 1.7/10,000 for females and 1.6/10,000 for males. Reduction deformities of brain were reported for four girls  and one boy . Congenital hydrocephalus was reported for 3 boys and 4 girls . No cases of anencephalus or encephalocele were reported.Five congenital anomalies of eye were recorded in girls  and five in boys . The most common were congenital cataract , and five congenital anomalies of eyelid/lachrymal system . One girl had congenital glaucoma . Congenital cataracts are reported to account for 30% of congenital eye malformations in live babies, and have an estimated incidence of 1 to 10,000 births . In boysCongenital anomalies of the heart affected more infants born in the study area than any other type of birth defect: 59  in girls and 50 in boys . The two most common types of heart malformations were ventricular septal defect (VSD) and atrial septal defect (ASD). There were 4 ASD cases  and 42 VSD cases (71.3/10 000) in girls, and 9 ASD cases  and 28 VSD cases  in boys.Four cases of transposition of the great arteries were registered in girls  and four in boys . We found nine cases of aortal coarctation, six in boys  and three in girls ; two cases of tetralogy of Fallot  in girls and one  in a boy; three female cases of endocardial cushion defect  and only one case in boys ; and one female case of Ebstein's anomaly .We found 13 cases of orofacial cleft, three in girls  – one with cleft palate, one with cleft lip and one with both anomalies – and 10 in boys – five with cleft palate , two with cleft lip  and three with both .Esophageal atresia and esophagotracheal fistula usually occur together, but in about 10% of cases they occur separately. Four girls  had these defects: two had atresia with fistula; one had atresia only and one – fistula only. One boy  had esophageal atresia alone.One girl  and 12 boys  had hypertrophic stenosis of pylorus, a sex ratio consistent with that in the literature .We found two boys with small intestine atresia  and two with intestinal malrotation , one of which associated with congenital duodenal stenosis.One boy  and one girl  had anal agenesis; in the latter rectovestibular fistula was associated: she underwent surgical correction soon after birth.Hirschsprung's disease was diagnosed in three boys  and one girl .Hypospadias is the most common developmental anomaly of male urogenital organs. The mild forms  are common, while only severe hypospadias  are usually registered. We included both severe and mild forms of hypospadias, a total of 31 cases . One case of epispadia was found (data not shown).Three boys had renal agenesis, , one with a family history of Potter's syndrome. Three boys had cystic kidney disease . Among girls, one had renal agenesis  and three had cystic kidney disease .Structural limb anomalies include dysplasias, reduction defects, and duplication defects with supernumerary limb elements. Most human limb defects appear to have a multifactorial etiology. Among boys, we had four cases of polydactyly  and seven of syndactyly .Among girls we found three cases of polydactyly  . One girl had left hallux agenesis  and another girl had osteochondrodystrophy .In congenital diaphragmatic hernia one of the pericardioperitoneal canals fails to close so the developing abdominal viscera to bulge into the pleural cavity. We had four cases of this defect, three boys  and one girl . One of the boys had associated lung hypoplasia and the girl had associated lung agenesis. Two of the boys died soon after birth of severe pulmonary insufficiency.Four boys  and six girls  had trisomy 21 or Down syndrome, the most commonly reported congenital autosomal anomaly.One boy had Prader Willi Syndrome  resulting from deletion of a region of human chromosome 15 (15q11-q13). This syndrome is diagnosed by DNA methylation analysis, fluorescence in situ hybridisation and identification of DNA polymorphisms .Table The completeness analysis was conducted only on babies born in Varese Province because birth certificates from the other two areas were not available. We had 398 birth defects from Varese, considering all malformations, not only the selected ones for the analysis, but birth certificates identified only 25 defects, including 2 not contained in the registry. Using the capture-recapture method we estimated that there were 431 malformations in Varese  did not change our prevalence data as these are not among the selected malformations considered in this analysis.Use of birth certificates to check completeness added two new cases to the Lombardy birth defects registry. The quality and the completeness of birth certificates is known to vary considerably . We founWe discuss our birth defects prevalence findings in relation to those from three other birth defect registries: Georgia USA , Hawaii The overall prevalence at birth of the 40 selected congenital defects in our study area in 1999 was 204.9/10,000. This compares with 223.9/10,000 for the birth defects registry of Georgia USA in 1995–1999 .in utero are aborted [Cardiovascular system defects were by far the most common birth defects in our population. Prevalence rates for these defects were grossly similar to rates published previously , except  aborted . These f aborted .We found rates of 6.7/10,000, 3.3/10,000 and 7.5/10,000 for transposition of great arteries, endocardial cushion defects, and coarctation of aorta, respectively. These figures compare with lower birth prevalences for transposition of great arteries in Finland , and a higher rate for endocardial cushion defect  but lower rates for transposition of great arteries  and coarctaction of aorta  in Georgia. In cases of complete transposition, the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle, and there is an associated ventricular septal defect, which in all eight of our registered cases was large. Botto et al.  observedWe found low birth prevalence rates for tetralogy of Fallot  and hypoplastic left heart syndrome  compared with the corresponding figures of 3.3/10,000 and 4.7/10,000 in Finland, 4.5/10,000 and 3.2/10,000 in Georgia, and 3.1/10,000 and 1.5/10,000 in Hawaii. Our rate of 2.5/10,000 is comparable with other European prevalence rates of 2.56/10,000 and 2.45/10,000 for Central-Eastern France and Sweden respectively . The stuThe birth prevalence of hypospadias varies widely  . We founThe study by Pierik et al.  addresseThe comparability of reported rates for hypospadias is poor, however there may be an important underlying geographic variation which cannot be properly addressed until ascertainment and diagnostic criteria (inclusion or exclusion of minor cases) are standardized . HypospaOur overall figure for Down syndrome was 8.3/10,000. Other published population-based rates for this syndrome are higher   than found in other registries . For hydrocephalus the combined male-female rate was 5.8/10,000 in our registry, and varied from 3.2 to 11.6 in the other population-based registries . The reaFacial clefts are a heterogeneous group of easy-to-recognize non-fatal birth defects . They arThe birth prevalence for esophageal atresia  was similar in our study to that reported in Finland , whereas that of small intestine atresia was higher  in our population than in the Finnish . Prevalence in Georgia, (1968 to 1989) has been reported as 2.8/10,000 overall, but higher in black infants  .Hirschprung's disease is relatively easy to diagnose, so higher birth prevalence in our population  compared to Georgia's  and Hawaii's  is probably due to genuinely higher birth prevalence of this defect in our population. Although this disease is inherited, environmental factors may be responsible for sporadic cases .The birth prevalences of unilateral and bilateral renal agenesis have been reported at 10/10,000 and 2.5/10,000 respectively . At the Our study, limited to selected major birth defects, is the first to provide population-based data on the prevalence rates at birth of congenital anomalies in defined populations in north-western Italy.The methods used for data collection and case generation are proven to be ones that incorporate ample quality checks. Comparison with an independent source (birth certificates) suggests good completeness and quality. However in order to obtain a dataset that is as complete as possible, we plan to start using birth certificates as an additional data source. We expect to begin registering defects in elective terminations in the near future, as many defects are now identified prenatally and the exclusion of aborted cases complicates the identification of environmental factors in the etiology of these conditions . As manyThe author(s) declare that they have no competing interests.G. Tagliabue conceived the study, participated in its design, verified diagnoses and complete case ascertainment, performed the analyses, and drafted the manuscript.P. Contiero participated in conceiving, designing and analyzing the study, oversaw data collection and record linkage and reviewed the manuscript.S. Fabiano, A. Maghini, A. Tittarelli performed automated data acquisition and standardization, and executed record linkage between the information sources.E. Frassoldi, E. Costa, D. Gada abstracted clinical information from clinical records.D. Vergani, M. Bellotti performed quality checks on the diagnoses generated by the defects registry.R. Tessandori, S. Pisani, M. Gambino, F. Caramaschi, P. Crosignani performed a critical evaluation of the analysis and of the study design.All authors have read and approved the final manuscript.


The hydrophilic bile acid ursodeoxycholic acid (10–20 mg/kg/d) is today regarded as the first line treatment for intrahepatic cholestasis of pregnancy. Delivery has been recommended in the 38th week when lung maturity has been established.Intrahepatic cholestasis of pregnancy (ICP) is a cholestatic disorder characterized by (i) pruritus with onset in the second or third trimester of pregnancy, (ii) elevated serum aminotransferases and bile acid levels, and (iii) spontaneous relief of signs and symptoms within two to three weeks after delivery. ICP is observed in 0.4–1% of pregnancies in most areas of Central and Western Europe and North America, while in Chile and Bolivia as well as Scandinavia and the Baltic states roughly 5–15% and 1–2%, respectively, of pregnancies are associated with ICP. Genetic and hormonal factors, but also environmental factors may contribute to the pathogenesis of ICP. Intrahepatic cholestasis of pregnancy increases the risk of preterm delivery (19–60%), meconium staining of amniotic fluid (27%), fetal bradycardia (14%), fetal distress (22–41%), and fetal loss (0.4–4.1%), particularly when associated with fasting serum bile acid levels > 40  Intrahepatic cholestasis of pregnancyObstetric cholestasis Recurrent jaundice of pregnancyPruritus gravidarumIcterus gravidarumIdiopathic jaundice of pregnancyIntrahepatic cholestasis of pregnancy (ICP) is a cholestatic disorder characterized by pruritus, elevated serum aminotransferases and bile acid levels with onset in the second or third trimester of pregnancy, and spontaneous relief of signs and symptoms within two to three weeks after delivery ,2.In the first description of ICP in 1883, Ahlfeld described maternal pruritus and jaundice in the last trimester of pregnancy disappearing after delivery [ICP has been observed in almost all ethnic groups, but there is relevant geographical variation in the incidence of ICP ,4. The iPruritus is the primary clinical symptom of ICP. Pruritus may be mild and tolerable for some patients, but may also be very severe and disabling. It may considerably impair the patient's quality of life causing sleep deprivation, psychological suffering and even suicidal thoughts. Pruritus is most severe in the evening, with a predilection for the palms of the hands and soles of the feet, and is not associated with any specific skin lesions. It usually presents in the third trimester, after 30 weeks of gestation, but rare cases developing as early as 6 to 10 weeks have been described ,13,14. Mμmol/L [μM in late gestation and normal serum liver tests has recently been defined as asymptomatic hypercholanemia of pregnancy (AHP) [The main biochemical alterations are elevations of serum bile acids and aminotransferase activities . Serum tμmol/L -25. In Iμmol/L ,26-28. Ocy (AHP) ,30. The cy (AHP) ,10,16,31cy (AHP) ,13. Serucy (AHP) .Maternal prognosis is good and symptoms resolve rapidly after delivery, accompanied by normalization of serum liver tests . Persistμmol/L [et al., submitted). Interestingly, most recent data show a marked decrease in fetal complications [μmol/L the frequency of meconium passage was 44% compared to 22% in a group with only mild ICP [ICP increases the risk of preterm delivery up to 19–60%) [–60% 9,33,34, mecμmol/L . Fastingications ,39-42 poications ,35,43. Tications ,45. The ications . In a prmild ICP .The etiology of ICP is not completely understood and is still under discussion. Genetic and hormonal factors, but also environmental factors may contribute to the pathogenesis of ICP . Familiaα-hydroxylated steroids to 3β-hydroylated steroids [β-D-glucuronide, and sulfated progesterone metabolites have been shown to cause cholestasis [in vitro [in vitro by transcriptional mechanisms [Clinical evidence supports an etiologic role for estrogens in the initiation of ICP ,53,54. Isteroids ,55,56. Slestasis , but thein vitro -60. In achanisms .Thus, mutations in genes encoding hepatobiliary transport proteins as well as abnormal metabolites impairing hepatobiliary carriers may be involved in the pathogenesis of ICP.The seasonal variation, the incomplete recurrence in subsequent pregnancies, as well as the decrease in the prevalence of ICP in high-incidence regions in association with improved nutritional supply suggest that exogenous factors such as nutritional factors like selenium deficiency may contribute to ICP ,63.μmol/L (and elevated serum transaminases), (iii) spontaneous relief of signs and symptoms within two to three weeks after delivery and (iv) absence of other diseases that cause pruritus and jaundice. Liver biopsy is not necessary for the diagnosis and histopathology is not diagnostic, showing centrilobular cholestasis without inflammation and bile plugs in hepatocytes and caniculi without bile duct dilatation or injury [The diagnosis of ICP is based on (i) pruritus of cholestasis, (ii) elevated fasting serum bile acids > 10 r injury ,64.st trimester from hyperemesis gravidarum, in the 3rd trimester from acute fatty liver of pregnancy, HELLP , pre-eclampsia, eclampsia, and in all trimesters from viral hepatitis, alcoholic hepatitis, drug-induced hepatitis, biliary obstruction, hyperbilirubinemic states, primary biliary cirrhosis and primary sclerosing cholangitis [A number of other disorders may erroneously be interpreted as ICP during pregnancy, making exclusion of diseases associated with pruritus without cholestasis or with pruritus with cholestasis important. The differential diagnosis of ICP with pruritus (and elevation of serum bile acid levels) only includes skin diseases and specific dermatoses of pregnancy, allergic reactions, renal pruritus and hematological disorders such as Hodgkin's disease and polycythemia rubra vera. ICP with elevation of serum liver tests should be distinguished in the late 1langitis ,47.The primary objective of pharmacologic treatment in ICP is to alleviate maternal symptoms and improve fetal outcome. Antihistamines, benzodiazepines, phenobarbital, opioid antagonists, dexamethasone, epomediol, S-adenosyl-L-methionine and cholestyramine have been used but not introduced into clinical practice because of limited efficacy and/or tolerability ,32,39.μmol/L at study entrance. In contrast, dexamethasone did not alleviate pruritus, and serum bile acids and bilirubin were less effectively reduced compared to the UDCA group. However, no differences in fetal complications were detected, possibly due to the fact that fetal complications were less frequently observed in the whole study population than in previous studies [Currently, the hydrophilic bile acid ursodeoxycholic acid (UDCA) is the most effective treatment for ICP. In an open, randomized, parallel group study, 84 symptomatic patients with ICP were randomized to either UDCA, 8–10 mg/kg body weight per day, or cholestyramine, 8 g per day, for 14 days. Relief of pruritus was significantly more pronounced in the UDCA group and serum alanine and aspartate aminotransferase activities and endogenous serum bile acid levels were more effectively lowered after UDCA therapy. In addition, delivery occurred closer to term in patients treated with UDCA . A secon studies . In a re studies ,41. A re studies . UDCA se studies -42. The  studies ,66. In p studies ,66. ThisIn addition to effects of UDCA on the maternal liver, UDCA restores the impaired maternal-placental bile acid transport across the trophoblast. This could be mediated by enhanced expression of plasma membrane transporters involved in the excretory role of the placenta and would prevent structural alterations of the trophoblast induced by maternal cholestasis ,21.th week of gestation has been observed to reduce fetal risk, delivery has been recommended in the 37th to 38th week in ICP. In most severe cases (before the era of UDCA treatment), delivery has been initiated even at 36 weeks gestation as soon as lung maturity had been established [UK Guideline for Obstetric Cholestasis 2006, "there are insufficient data to support or refute the popular practice of 'early' (37 weeks of gestation) induction of labour aimed at reducing late stillbirth. The timing and risks of delivery should, therefore, be discussed on an individual basis."Since conventional antepartum testing does not reliably predict fetal mortality and induction of labor in the 38ablished ,34,67. A


The prevalence of asthma and allergy, defined as immunologically mediated hypersensitivity, is increasing. It is estimated that more than 20% of the world's population has IgE-mediated allergic diseases. The scale of the clinical problem is immense. The World Health Organization estimates that asthma affects nearly 150 million people worldwide, and more than 180,000 deaths each year are due to asthma. Approximately US$20 billion is spent globally each year on allergic rhinitis, including medications, time off work, and clinician consultations. The cost of allergy drugs alone is estimated to be US$8 billion per annum.While allergy prevalence is increasing, the causal risk factors are still unknown. Matthias Wjst and colleagues investigated whether the spatial (latitude) and temporal (birth month) distribution of risk factors might offer insight into the mechanism of disease.Previous studies have already shown that birth month is a risk factor associated with allergy; as the authors point out, birth month, used as a proxy for early allergen exposure, might be associated with upper respiratory infections during winter months. Studies have also associated geographical latitude with allergy. But some experts have noted that latitude, a proxy for ultraviolet solar exposure, might also reflect climatic differences, genetic influences, or even cultural differences in the raising of children.In this study, Wjst and colleagues tried to further understand the effects of latitude and birth date on the prevalence of allergy defined by markers such as allergic rhinitis, sensitization to grass or dust, and total IgE levels. They distributed a questionnaire to 20– to 44–year-old individuals in 54 centers across Europe, North Africa, India, North America, Australia, and New Zealand. Altogether, data from 200,682 participants were analyzed. The median prevalence of allergic rhinitis was 22%, but with a substantial variation across centers. They found allergic rhinitis decreased with geographical latitude, but there were many exceptions. There was no increase in prevalence during certain winters, and no altered risk by birth month, except borderline reduced risks in September or October. Altogether, the authors concluded that there was no major risk by being born in a particular month or during a particular season. There may be relevant birth month effects in single centers, but a global effect was questionable.Previous research on the effect of birth month has also shown mixed results: differing studies have found associations that were positive, negative, or simply unclear.But the authors noted that one difference of their study compared with others was the higher age of the subjects—interviewees were born between 1945 and 1973—and suggested that it might be possible that there are more marked symptoms in children that were being lost in adulthood.Most previous studies have shown an association with allergic sensitization, indicating subclinical effects that gained importance only when occurring in combination with additional risk factors. One of the main advantages of this study—a standardized allergen test protocol—might, thus, be a disadvantage since the effects of local allergens might have been missed. Another methodological restriction might have been the use of self-reported “hay fever.” This term may be used in a different way across Europe, said the authors.Data on the geographical distribution of allergic diseases are rare, and, hence, this study is valuable. However, a previous meta-analysis has shown negative association of latitude and symptoms of allergic rhinitis, with a −0.05% decrease per degree. In this study, symptoms of allergic rhinitis decreased with geographical latitude on a worldwide scale, but not when the analysis was restricted to Europe alone. One intriguing possibility, which needs further work, is that a risk factor within language borders might be more relevant than geographical latitude alone in determining the distribution of allergic diseases.