To explore this relationship of hOGG1 polymorphism and the susceptibility for bladder cancer and the impact of smoking exposures, a cumulative meta-analysis was performed in this study.Bladder cancer results from complex interactions between many genetic and environment factors. The polymorphism Ser326Cys in hOGG1, Ser326Cys polymorphism and bladder cancer”. Seven case–control studies were identified, including 2474 patients and 2408 controls. Four of them provided the analysis of smoking effects, with 1372 smokers and 947 non-smokers. The odds ratios (ORs) and associated 95 % confidence intervals (CIs) were calculated using fixed- or random- effects models.We extracted the data from the Pubmed database up to January 9, 2012 using the search phrases “hOGG1 326Cys allele and bladder cancer risk, the meta-analysis did not reveal a significant effect in the additive model , the recessive genetic model  or the dominant genetic model . Similarly, no significant relationship was observed in the stratified analysis by ethnicity, study design and Hardy-Weinberg equilibrium . In the non-smokers, however, hOGG1 326Cys allele significantly increased the risk for bladder cancer and the ORs in the additive model, homozygote contrast and recessive genetic model were 1.59 (p = 0.02), 2.53(p = 0.003) and 2.41(p = 0.0005), respectively. Nevertheless, in the smoker subgroup, similar findings could not be found in all genetic models .Regarding the overall association between the hOGG1 326Cys allele and bladder cancer was significant in non-smoker population, while was non-detectable in common or smoker populations. This meta-analysis suggests that the hOGG1 Ser326Cys polymorphism may be a risk factor for bladder cancer without exposure to smoking. Further functional studies are needed to elucidate the gene polymorphism-bladder cancer relationship and gene-environment interactions.The association between the  The occair gene ,9. It enogenesis .hOGG1 genes, the Ser326Cys polymorphism has received much attention in recent years. It is an amino acid substitution of serine (Ser) with a cysteine (Cys) in exon 7 of hOGG1 gene [Among the many polymorphisms of GG1 gene ,12, and GG1 gene -16. In pGG1 gene -23, presHerein, we performed a meta-analysis on the previously reported studies, and investigated whether the Ser326Cys polymorphism increases the bladder cancer risk. Specifically, a stratified analysis was used to study the Ser326Cys polymorphism-bladder cancer relationship in general population, smoker and non-smokers, and people with different ethnic backgrounds.hOGG1 Ser326Cys polymorphism and bladder cancer risk in the PubMed database. A literature search was conducted using the search terms “human 8-oxoguanine DNA glycosylase,” “hOGG1,” “OGG1,” “OGG,” “polymorphism,” “genetic variation,” and “bladder cancer”. Review articles and reference cited in the searched studies were examined to identify additional published articles. The listed articles were assessed to determine whether they should be included in the meta-analysis. For studies with overlapping data published by same investigators, only the most recent or complete study was included. Conference abstracts, case reports, editorials, review articles, and letters were excluded. Studies included in the meta-analysis were required to meet the following criteria: 1) an unrelated case–control design was used, 2) genotype frequency was available, and 3) there is an evaluation of the hOGG1 Ser326Cys polymorphism and bladder cancer risk.We searched all published studies  investigating the association between the hOGG1 Ser326Cys polymorphism. Ethnic backgrounds were categorized as either Caucasian or Asian, and smoker status (smoker or non-smoker) was additionally recorded for the stratified analysis. Smokers included current smokers and former smokers. Non-smokers had never smoked.Two separate investigators reviewed and extracted data from all of the eligible publications independently, according to the inclusion and exclusion criteria listed above. The following information was extracted from each study: first author, year of publication, country of study population, genotyping method, genotype frequency, and the experimental design used to assess the effect of the hOGG1 Ser326Cys polymorphism and the risk of bladder cancer using a number of methods. We evaluated the risk of the additive model , dominant model (Cys/Cys + Cys/Ser versus Ser/Ser), recessive model (Cys/Cys versus Cys/Ser + Ser/Ser) and the homozygote contrast (comparison of Cys/Cys versus Ser/Ser), respectively.The meta-analysis evaluated the overall association between the p < 0.05. Sensitivity analysis was carried out by including and excluding studies not in HWE [p < 0.10. The heterogeneity was quantified by the I2 metric, which is independent of the number of studies used in the meta-analysis  [pheterogenity ≥ 0.10, or random-effects (RE) models with pheterogenity < 0.10 [Hardy–Weinberg equilibrium (HWE) was tested using the Chi-squared test and it was considered statistically significant when t in HWE . The hett in HWE  and was geneity) . Publicageneity) . The comy < 0.10 .p < 0.05 was considered statistically significant. Meta-analysis was performed using the Review Manager 5.0 software and Egger’s test was performed with STATA version 7.0.The overall association was measured by determining the OR with a corresponding 95% confidence interval (CI). The statistical significance of the overall OR was determined using a Z-test; hOGG1 Ser326Cys on muscle invasion of bladder cancer, and the studies by Wu et al. [After title and abstract screening, 10 case–control studies were found, however the studies by Kim et al..  only demu et al.  and Huanu et al.  , Gangwau et al.  and Mittu et al.  containeu et al. ,31. ThusP = 0.006).In total, 2474 bladder cancer cases and 2498 controls were included in the meta-analysis. We conducted subgroup analysis classified by ethnicity, hospital-based and HWE population. A summary of selected study characteristics is listed in Table Four of the seven eligible studies provided data on smoker and non-smoker subjects ,21,23,31hOGG1 326Cys polymorphism and bladder cancer risk are shown in Table hOGG1 326Cys allele in the additive model did not have significantly increased risk for bladder cancer compared to those carrying the 326Ser allele  in the additive model. Similarly, no significant difference in bladder cancer risk was found between the patients with a Cys/Cys genotype and those with a Ser/Ser genotype  in homozygote contrast. This was also the case for Cys/Cys versus Ser/Cys + Ser/Ser in the recessive genetic model  and for Cys/Cys + Ser/Cys versus Ser/Ser in the dominant genetic model  (Table The heterogeneity results and the determined association between the p > 0.05). Furthermore, no statistically significant conclusions were found for hospital-based subjects in the various statistical models . When meta-analysis of studies in HWE was conducted, no significant correlation was detected in any type of statistical model, either .These seven studies were analyzed by stratified analysis. However, no increased risk was detected in Asians or Caucasians either in the additive model, the homozygote contrast, the recessive model, or the dominant model . Similarly, this association was found in the homozygote contrast  and the additive model  . This finding suggests a dominant effect of hOGG1 326Cys on bladder cancer risk among the non-smokers.In the non-smoker population, a significant association was found between the I2 = 64%, Pheterogeneity = 0.02). Then, the random-effects (RE) models were used to evaluate the combined ORs when necessary. Sensitivity analysis was performed both by sequential removal  of individual studies and cumulative statistics on the comparisons of worldwide subjects. The combined ORs of the hOGG1 Ser326Cys polymorphism were not influenced by either the addition or removal of any individual study, such as the study from Narter et al. [Significant heterogeneity between studies was observed in some comparisons, and the detailed data were shown in Table r et al.  with thehOGG1 Ser326Cys polymorphism and bladder cancer.Funnel plots were performed to assess the publication bias in this meta-analysis and showed a symmetrical inverse funnel shape (data not shown). The funnel results suggested that the selection of publications was an unlikely source of bias in the meta-analysis of the association between the hOGG1 gene is a key gene in the BER pathway and DNA repair process, and the Ser326Cys polymorphism is reported to be a functional variation in the hOGG1 gene.DNA damage generated by different carcinogenic agents can be repaired primarily through base excision repair (BER) pathway, composed of many DNA repair genes. Common polymorphisms in DNA repair genes may alter protein function and the possibility to repair damaged DNA. Defects in DNA repair pathways may lead to genetic instability and carcinogenesis ,33. The hOGG1 Ser326Cys polymorphism, a number of studies have investigated the genetic effect of this polymorphism on bladder cancer susceptibility. In the eligible studies, the percentage of 326Cys allele was 0.523 in the Korean population (n = 153), 0.464 in the Japanese population (n = 251), and 0.290 in the Indian population (n = 250), while it was 0.280, 0.240, 0.237 and 0.250, respectively, for the Caucasian population in Turkey (n = 100), USA (n = 600), Spain (n = 1018) and Turkey (n = 36). Considering these inconsistent findings, we performed a meta-analysis on these studies to quantify the available data and generate a robust estimate of the effect of the Ser326Cys polymorphism on bladder cancer. Meta-analysis has been proved to be a powerful method from a relatively large number of subjects [Since the original identification of the subjects ,35.hOGG1 Ser326Cys polymorphism in relation to bladder cancer susceptibility. Three studies found an increased risk for bladder cancer associated with the 326Cys allele [In this study, we analyzed the data from seven available case–control studies. The results are conflicting about the role of the s allele ,23,31, ts allele ,21, and s allele ,22.hOGG1 Ser326Cys polymorphism lacks association with bladder cancer risk in such common population.When all the eligible studies were pooled into analysis, it failed to uncover any evidence that there was an association between the Ser326Cys polymorphism and bladder cancer susceptibility overall. No statistical evidence was found in a recessive model, either in a dominant model, an additive model or a homozygote contrast. Moreover, the association of the Ser326Cys polymorphism and bladder cancer could not be found in Asians or Caucasians using various models. Either in the hospital-based subpopulation or the population in HWE, no significant conclusion were found. Taken together, it may be concluded that hOGG1 Ser326Cys polymorphism and bladder cancer risk. This association was confirmed in the additive model, homozygote contrast and recessive genetic model, with the OR values of 1.59 (p = 0.02), 2.93 (p = 0.003) and 2.41 (p = 0.005), respectively. However, when the parallel analysis was performed in smokers, no significantly statistical conclusions were found in all genetic models .Cigarette smoking is a major risk factor for bladder cancer, and the association between smoking status and bladder cancer risk remains a point of controversy. Some studies have found that cigarette smoking was more strongly associated with increased risk of invasive bladder cancer than with low-grade superficial bladder cancer . Even amhOGG1 Ser326Cys estimates, since the frequencies of variant alleles altered with different smoking behaviors [hOGG1 Ser326Cys polymorphism and bladder cancer risk might alter under different smoking status. Actually, when the eligible studies were pooled into meta-analysis, a significant risk was shown in the non-smoker subgroup, but not in the smoker subgroup. Therefore, the genetic effect may be more dominant in those who have not been exposed to an environmental risk factor. Notably, the results should be interpreted with caution, since only limited studies are included in this part of analysis.It is well established that the carcinogenesis of bladder cancer is a result of the interaction between environmental factors and genetic background. Besides the role of genetic variants, smoking behavior shows a major effect on the bladder cancer susceptibility . Smokingehaviors ,21,23,31hOGG1 Ser326Cys and bladder cancer risk among overall studies, and Asian, Caucasian and hospital-based subpopulation. In addition, one study from Karahalil et al. [hOGG1 Ser326Cys polymorphism were not influenced by any individual study. All of these suggest that well-designed and prospective studies with larger sample sizes should be conducted to clarify the role of hOGG1 Ser326Cys polymorphism in bladder carcinogenesis.The limitations of the present study include that 6 out of the 7 studies in this meta-analysis are hospital-based and only 1 is population-based, and the heterogeneity and publication bias may exist due to the limited sample size, and the variation in the genotyping methods and experimental designs. Moreover, the real function of the Ser326Cys polymorphism may have an effect only under special conditions of cellular oxidative stress or tumor types . Among tl et al.  was not Ser326Cys polymorphism lacks association with bladder cancer risk in common population, but specifically increases the susceptibility for non-smoker populations. Further studies are needed, especially to investigate the effect of the gene-environment interaction.In summary, our meta-analysis suggests the The authors declare that there are no competing interests.CJ participated in collection of data and manuscript preparation. ZL and HC performed the statistical analysis. CJ and HC participated in study design and critically revised the manuscript. CL and HG participated in study design and manuscript preparation. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/12/335/prepub


Factors associated with liver stiffness (LS) are unknown and normal reference values for LS have not been established. Individuals at high risk for alcoholic (ALD) and non-alcoholic fatty (NAFLD) liver disease need to be non-invasively discriminated during routine health checks. Factors related to LS measured using a FibroScan and normal reference values for LS are presented in this report.We measured LS using a FibroScan in 416 consecutive individuals who presented for routine medical checks. We also investigated the relationship between LS and age, body mass index (BMI), liver function (LF), alcohol consumption, and fatty liver determined by ultrasonography. We identified individuals at high-risk for ALD and NAFLD as having a higher LS value than the normal upper limit detected in 171 healthy controls.The LS value for all individuals was 4.7 +/- 1.5 kPa (mean +/- SD) and LS significantly and positively correlated with BMI and LF test results. The LS was significantly higher among individuals with, than without fatty liver. Liver stiffness in the 171 healthy controls was 4.3 +/- 0.81 kPa and the upper limit of LS in the normal controls was 5.9 kPa. We found that 60 (14.3%) of 416 study participants had abnormal LS. The proportion of individuals whose LS values exceeded the normal upper limit was over five-fold higher among those with, than without fatty liver accompanied by abnormal LF test results.Liver stiffness could be used to non-invasively monitor the progression of chronic liver diseases and to discriminate individuals at high risk for ALD and NAFLD during routine health assessments. A large body of evidence supports the importance of liver biopsies for understanding the progression of chronic liver disease . AlthougTo distinguish nonalcoholic steatohepatitis (NASH) from NAFLD in routine practice is difficult. Efforts have been made to diagnose NASH using various imaging studies and blood tests, but the outcome has remained inadequate .The FibroScan  is a new transient elastometer that can noninvasively measure LS ,12. CorrVarious clinical factors other than fibrosis itself, including necroinflammation of the liver, cholestasis and congestive heart failure can affect LS regardless of the severity of fibrosis ,14. HoweThe present study explores factors related to LS, establishes normal reference values for LS in healthy individuals, and determines whether LS can help to identify individuals at high-risk for ALD and NAFLD.This study enrolled 423 consecutive Japanese individuals between the ages of 20 and 68 years , who presented for annual medical checkups at our health examination centre between July 2004 and April 2006. We excluded individuals with a history of any liver or cardiac diseases  and those who were under treatment for such conditions. We also excluded those with platelet counts < 150,000/μL. A medical history was obtained from each of the 423 persons, who then underwent a physical examination, a chest X-ray, electrocardiography and standard laboratory tests including FBS and HbA1c. Seven were excluded because LS could not be measured due to extensive intercostal subcutaneous tissue depth. Finally, 416 individual  were enrolled in this study. All participants provided written informed consent to participate in this study, which proceeded according to the Declaration of Helsinki and under the approval of our institutional review board.We used ultrasonography to diagnose fatty liver based on hepatorenal contrast visualization, increased ultrasonographic signals in the liver parenchyma and decreased signals from deep areas of the liver. We also confirmed the absence of space-occupying lesions in the liver. Stiffness was measured in the right lobe of the liver accessed using a FibroScan through the intercostal spaces of participants placed in the dorsal decubitus position with the right arm in maximal abduction. Technical and procedural details have been described ,20. In bHeight and weight were measured and BMI was calculated. To further assess the impact of body weight, we assigned the 416 participants into groups based on BMI < 23, 23 to ≤ 25, and > 25. The thickness of the intercostal subcutaneous tissues was measured only to confirm whether LS could be measured. Daily amounts and duration of alcohol consumption were evaluated using a formal, written questionnaire and total amounts of consumed alcohol were calculated as quantities of pure alcohol. Since alcohol consumption of ≤ 20 g of per day is prerequisite for a definition of NASH, we assigned the 416 participants into groups based on daily alcohol consumption of ≤ 20 and > 20 g/day  . Liver fThe participants were separated based on LF tests results and the presence or absence of fatty liver into Group 1 (N = 260), normal LF and no fatty liver; Group 2 (N = 32), abnormal LF and no fatty liver; Group 3 (N = 60), normal LF and fatty liver; Group 4 (N = 59), abnormal LF and fatty liver.We counted platelets and calculated the AST to platelet ratio index (APRI) to determine the relationship between LS and apparent liver fibrosis in all participants .2, normal LF, no findings of fatty liver by ultrasonography and daily alcohol consumption ≤ 20 g/day. We defined being overweight and obesity based on the World Health Organization (WHO) criteria for the Western Pacific Region as BMI ≥ 23 and ≥ 25 kg/m2, respectively [We selected healthy control candidates based on the following criteria: BMI < 23 kg/mectively ,24. Nonet-test. Differences among more than three groups were analyzed using the analysis of variance (ANOVA) when variables were normally distributed, followed by multiple comparisons. Categorical data were compared using the χ2 test and the Cochran-Armitage test for trends. Both univariate and multivariate analyses were performed using logistic regression models. P < 0.05 was considered to represent a statistically significant difference. Data were statistically analysed using JMP 9.01 software .Continuous variables are expressed as means ± SD. The relationship between LS and each variable was assessed using Pearson's correlation coefficient and LS was compared between two groups using the unpaired Student's Table Liver stiffness values were significantly higher in males than in females among all participants , but did not significantly differ between healthy control males and females .x2 = 14.31, p = 0.0008) also significantly differed among the three groups. The Cochran-Armitage test for trend also showed a linear trend for proportions across these groups .Liver stiffness significantly correlated with BMI in all participants Table . Mean LSx2 = 37.54, p < 0.0001; Figure Values for LS were significantly higher among individuals with, than without fatty liver. Ratios of those with LS above normal upper limit significantly differed . The Cochran-Armitage test for trend also showed a linear trend in proportions across the four groups  of the 416 participants had higher LS. We also found that LS significantly differed between the presence and absence of fatty liver  when the participants were assigned to four groups based on the results of LF tests. In addition, LS was the highest in Group 4, and higher in Group 3 than in Group 1 according to multiple comparisons Figure . NineteeFigure Univariate analysis found that BMI, alcohol consumption, abnormal LF test results, fatty liver and APRI were associated with LS.We excluded abnormal LF test results and fatty liver as confounding factors in multivariate analysis because these can result from a higher BMI or habitual alcohol consumption. We also excluded APRI because this merely reflected serum levels of AST in this study population. Finally, we included BMI and alcohol consumption in the multivariate analysis model.2: odds ratio (OR), 2.21; 95% confidence interval (CI), 1.06-4.46; p = 0.033; ≥ 25 kg/m2: OR, 3.25; 95% CI, 1.62-6.43; p = 0.001) was the only independent predictor of higher LS , habitual alcohol consumption and abnormal LF test results are important factors associated with a higher LS. We then selected those who met our criteria for normal controls based on these findings.One of the major reasons for the higher LS in individuals with a high BMI seemed to be liver steatosis caused by NAFLD or ALD. Mean liver stiffness was higher in individuals with, than without fatty liver, but the distribution of LS widely overlapped between the two groups. We speculated that factors in addition to steatosis would be involved in increased LS. We considered that the mechanisms involved in the increase in the LS in our study population might be related to inflammatory cell invasion, liver cell degeneration and liver fibrosis as well as steatosis, all of which have been pathologically demonstrated in patients with NASH and ALD . Whether2 in this study. However, if the upper limit was based on the WHO global criteria for obesity of BMI ≥ 25 kg/m2, [The normal upper limit of LS was determined based on patients with a BMI < 23 kg/m5 kg/m2, , then LSDaily or total alcohol consumption significantly and positively correlated with γ-GTP levels in our study population (data not shown) as described ,30. The The present study found that LS was related to AST and ALT levels or APRI, which significantly correlates with stage of fibrosis and with a higher correlation coefficient than platelet count or AST levels alone in patients with chronic hepatitis C infection . Because2 = 100.69, p < 0.0001). Alcohol consumption also significantly associated with abnormal LF test results . We assumed that being overweight and habitual alcohol consumption can cause abnormal LF tests results and fatty liver, so BMI and alcohol consumption were included in the multivariate logistic regression model. Finally, BMI was identified, as the only independent predictor of higher LS and LS was significantly higher even in the group with BMI 23 - 25 kg/m2. Although interpreting LS might be subject to ethnic differences, we considered that our BMI criteria were appropriate for inclusion among normal reference values. Cobbold et al. have highlighted some issues regarding LS and BMI [Univariate analysis indicated that BMI, alcohol consumption, LF test results and fatty liver status were associated with LS. Among these, the three BMI categories were significantly associated with fatty liver (χ and BMI .Table Kim et al.  establisLiver disorders are usually screened during routine medical checkups or in clinical practice using LF tests and ultrasonography. Figures While investigations of the pathogenesis of various liver diseases are important, liver biopsies are not always feasible because of adverse effects, and were unobtainable from our population from an ethical standpoint. Nevertheless, our reference values for LS would be useful to select candidates for liver biopsy and thus decrease the rate of unnecessary procedures.In conclusion, our study uncovered several factors that are associated with LS, and showed that measuring LS is a non-invasive, simple and efficient method of identifying individuals at high risk for ALD and NAFLD. Future studies should investigate pathological factors other than fibrosis that influence LS in clinical populations.ALD: alcoholic liver disease; ALT: alanine aminotransferase; APRI: ratio of aspartate 2-oxoglutarate aminotransferase to platelet ratio index; AST: aspartate 2-oxoglutarate aminotransferase; BMI: body mass index; γ-GTP: gamma-glutamyltranspeptidase; HF: heart failure; LF: liver function; LS: liver stiffness; MS: metabolic syndrome; NAFLD: nonalcoholic fatty liver disease; NASH: nonalcoholic steatohepatitis.The authors declare that they have no competing interests.MB carried out this study, participated in the conception and design of the study. KF conceptualized, edited the manuscript for important intellectual content and has read and approved the final version of the manuscript. HB performed participated in the analysis and interpretation of the data. KK performed participated in the analysis and interpretation of the data. KS performed participated in the analysis and interpretation of the data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/11/70/prepub


A single nucleotide polymorphism (SNP) in the second intron of human TERT (hTERT), rs2736100, acts as a critical factor in hTERT synthesis and activation. The rs2736100 SNP was found to be associated with susceptibility to many cancers. Recently, inhibition of telomerase and marked telomere shortening were determined to be closely associated with the increasing severity of atherosclerosis. The association between the SNP of rs2736100 and the presence of atherosclerosis was evaluated in 84 atherosclerosis patients and 257 healthy controls using multivariate logistic regression analyses. The proportion of the GG genotype in atherosclerosis patients (17.9%) was significantly higher than in the control group (9.7%). Eight variables, including age, gender, cholesterol, high density lipoprotein, homocysteine, total bilirubin, indirect bilirubin, and rs2736100 GG genotype, were associated with atherosclerosis with odds ratios of 1.88, 2.11, 1.66, 0.23, 1.27, 1.29, 1.53, and 1.74, respectively, using multivariate logistic regression analyses. Homozygous GG was demonstrated to be associated with the presence of atherosclerosis in our population. TTAGGGA telomere is a region of repetitive nucleotide sequences at the end of each chromatid of most eukaryotic organisms that protects the end of the chromosome from deterioration or from fusing with neighboring chromosomes The telomere length of a species is determined by the heredity and frequency of cell division Human TERT (hTERT) is located in 5p15.33 Atherosclerosis is the principal cause of myocardial infarction, stroke, and peripheral vascular disease, and accounts for nearly half of all mortality in developed countries To assess genetic polymorphisms related to atherosclerosis, we recruited 84 ethnic Han Chinese patients  with atherosclerosis who were unrelated consecutive inpatients at the People's Hospital of Yuxi City, China between November 2010 and November 2012. To obtain an estimate of the genetic distribution of the reference allele in the general population in China, we also randomly obtained DNA samples from 257 healthy individuals who visited People's Hospital of Yuxi City  with no history of atherosclerosis. The review board of People's Hospital of Yuxi City approved this study . Written informed consent was obtained according to the guidance of the Chinese National Ethics Regulation Committee. Participants were simultaneously informed of their right to repeal consent by themselves or their kin, caretakers, or guardians.Patients were diagnosed with atherosclerosis according to American Heart Association guidelines Genomic DNA was extracted from 100 µl of whole blood using the QIAamp DNA Blood Mini Kit  according to the manufacturer's instructions. Extracted DNA was dissolved in 20 µl of 10 mM Tris-HCl buffer (pH 8.0) containing 1 mM EDTA, and DNA samples were stored at −30°C until use.5′-ACGTTGGATGTGACACCCCCACAAGCTAAG-3′) and R (5′- ACGTTGGATGACAAAGGAGGAAAAGCAGGG-3′) to amplify the specific hTERT fragment that covers rs2736100  according to the manufacturer's user guide. We used the primers F  mass spectrometry to measure directly the mass of the extension product(s) and then correlates the detected mass with a specific genotype. The extension primer sequence is u is the upper uth percentile of the standard normal distribution; P is the proportion of patients with atherosclerosis when X = 1; β* is the size of the effect of an SNP; and R2 is the multiple correlation coefficient (we used 0.009 based on our data) relating X with the following covariates: age, male gender, cholesterol, high density lipoprotein, homocysteine, total bilirubin and indirect bilirubin We used a multivariate logistic regression model to calculate the statistical power required to detect the contribution of a SNP to atherosclerosis risk while including other known risk factors for atherosclerosis. SNP status was assigned as X = 0, 1, or 2, which represent homozygous for an allele, heterozygous, or homozygous for a different allele, respectively. The required sample size, n, for the multivariate logistic regression analysis was calculated using the following formula 2 tests. Associations between the genotype of each locus and the presence of atherosclerosis were evaluated using χ2 tests. The Cochran–Armitage test was used to test for trends. Possible confounding effects among these variables were adjusted using a multivariate logistic regression model, and the ORs and 95% confidence intervals (CIs) were calculated. P<0.05 was considered significant in the two-tailed tests. The Hardy–Weinberg equilibria of alleles at individual locus were evaluated using the HWE program.3 (ftp://linkage.rockefeller.edu/software).Associations between the clinical parameters , uric acid, homocysteine, total bilirubin, γ-glutamyltransferase, indirect bilirubin, and rs2736100 genotype) and the presence of atherosclerosis were evaluated using Student's t-tests, Mann–Whitney U tests, and χOf the 84 atherosclerosis patients, 66 were male and 18 were female, with an age range from 36 to 79 years and a median age of 62 years. Of the 257 healthy individuals, 153 were male and 104 were female, with an age range from 18 to 58 years and a median age of 34 years. As shown in ftp://linkage.rockefeller.edu/software). The allele frequency in the atherosclerosis and control groups was in Hardy-Weinberg equilibrium (P>0.05), suggesting that allele frequencies in the case and control populations remain constant in their genetic background. The proportion of the GG, GT, and TT genotypes in atherosclerosis patients were 17.9%, 57.1% and 25.0%, respectively. The proportion of the GG, GT, and TT genotypes in control group were 9.7%, 66.5% and 23.7%, respectively. The proportion of the GG genotype in atherosclerosis patients (17.9%) was significantly higher than in the control group (9.7%)  . There wP = 0.041), cholesterol ≥4.4 mmol/L (P<0.001), low-density lipoprotein ≥2.38 mmol/L (P = 0.002), apolipoprotein B ≥0.69 mmol/L (P<0.001), lipoprotein (a) ≥163 mg/L (P<0.001), uric acid ≥333 µmol/L (P<0.001), homocysteine ≥15.78 µmol/L (P<0.001), total bilirubin ≥13.20 µmol/L (P<0.001), γ-glutamyltransferase ≥33.31 U/L (P<0.001), indirect bilirubin level ≥9.17 µmol/L (P<0.001), and high-density lipoprotein ≤1.08 mmol/L (P = 0.001) were significantly associated with the presence of atherosclerosis by Student's t-tests, Mann–Whitney U tests, and χ2. To eliminate any possible multicollinearity between or among variables, collinearity diagnostics were performed before further statistical analysis. cholesterol, low-density lipoprotein and apolipoprotein B displayed collinearity, thus only cholesterol was included in following multivariate logistic regression analyses to avoid multicollinearity among cholesterol, low-density lipoprotein and apolipoprotein B.The rs2736100 GG homozygote . Eight variables, including age, gender, cholesterol, high density lipoprotein, homocysteine, total bilirubin, indirect bilirubin, and rs2736100 GG genotype, were included in the final model with odds ratios of 1.88 (≥50 yrs vs. <50 yrs), 2.11 , 1.66 (≥4.4 mmol/L vs. <4.4 mmol/L), 0.23 (≥1.08 mmol/L vs. <1.08 mmol/L), 1.27 (≥15.78 µmol/L vs. <15.78 µmol/L), 1.29 (≥13.20 µmol/L vs. <13.20 µmol/L), 1.53 (≥9.17 µmol/L vs. <9.17 µmol/L) and 1.74 (GG vs. TT) , respectReports have shown that rs2736100 acts as a critical factor in hTERT synthesis Of the clinical parameters, cholesterol, low-density lipoprotein and apolipoprotein B displayed collinearity, this is due to the biochemical relation between serum lipids and apolipoproteins. So we only input cholesterol into the multivariate logistic regression analysis. Cholesterol and high-density lipoprotein were demonstrated to be positively and negatively associated with arteriosclerosis which consistent with current reports SNP assessments are now included in genome-wide association studies and replicate models to identify disease susceptibility loci. This methodology is currently the best choice, although it is time consuming and costly


IDQ™ targeted metabolomics technology, including acylcarnitines, amino acids, glycerophospholipids, sphingolipids and hexose in 100 healthy individuals from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study who had provided two fasting blood samples 4 months apart. Overall, serum reliability of metabolites over a 4-month period was good. The median ICC of the 163 metabolites was 0.57. The highest ICC was observed for hydroxysphingomyelin C14:1 (ICC = 0.85) and the lowest was found for acylcarnitine C3:1 (ICC = 0). Reliability was high for hexose (ICC = 0.76), sphingolipids , amino acids  and glycerophospholipids . Among acylcarnitines, reliability of short and medium chain saturated compounds was good to excellent (ICC range: 0.50–0.81). Serum reliability was lower for most hydroxyacylcarnitines and monounsaturated acylcarnitines . For most of the metabolites a single measurement may be sufficient for risk assessment in epidemiologic studies with healthy subjects.Metabolomics is a promising tool for discovery of novel biomarkers of chronic disease risk in prospective epidemiologic studies. We investigated the between- and within-person variation of the concentrations of 163 serum metabolites over a period of 4 months to evaluate the metabolite reliability expressed by the intraclass-correlation coefficient . The analyses were performed with the BIOCRATES Absolute The “omic” sciences – including genomics, proteomics and metabolomics, among others - are promising novel approaches that may be useful in prospective epidemiologic studies to screen various targets at once with the aim to identify candidate biomarkers for the estimation of the risk of chronic diseases, such as cardiovascular disease or diabetes. Metabolomics systematically identifies and quantifies low-molecular weight compounds that are intermediates or endpoints of metabolism. Because metabolites may change rapidly in response to physiologic perturbations, they may represent more proximal reporters of intermediary or disease phenotypes than e.g. proteins To address this issue, the present study aimed to evaluate the reliability, expressed by the intraclass-correlation coefficient (ICC) The total sample consisted of 100 healthy participants who were evenly distributed according to gender with a mean age of 56.1 years Table 1.Mean serum metabolite concentrations ranged from 0.01 µmol/L for a number of acylcarnitines to 5207 µmol/L for hexose. On average, the serum reliability of 163 metabolites was good with a median ICC of 0.57. The highest reliability was observed for hydroxysphingomyeline SM(OH)C14:1 (ICC = 0.85) and the lowest was found for acylcarnitine C3:1 (ICC = 0). The ICCs for the individual metabolites according to their subclasses are presented in Tables S1 and S2). 29 of the metabolites, most of them monounsaturated- and hydroxyacylcarnitines, next to few glycerophospholipids, showed very low serum concentrations that were below the limit of detection (LOD) of the analytical method. After excluding these metabolites from the ICC calculation, the overall corrected median ICCcorr was 0.59, and in specific for acylcarnitines median ICCcorr was 0.52 and for glycerophospholipids median ICCcorr was 0.59.Among metabolite subclasses Figure 1, to illustrate their contribution to the ICC. For example, the acylcarnitines C4 and C16 had very similar within-person variances ; however, their ICCs were different   Table 2,This study, investigating the reliability of 163 serum metabolites under fasting conditions using a commercially available kit in a healthy sub-sample of the population-based EPIC-Potsdam cohort over a 4-month period, observed an acceptable reliability for most of the metabolites. Reliability was fair to excellent for hexose, all of the amino acids, saturated short- and medium chain acylcarnitines and most of the sphingomyelins and glycerophospholipids. The results support the concept that these metabolites are reliable candidates for risk assessment in prospective epidemiologic studies with one blood sample collection, as a single measurement appropriately reflects their long-term concentration in individuals. Few compounds revealed higher variability, such as hydroxyacylcarnitines and monounsaturated acylcarnitines, which imply restrain conditions in the design of epidemiologic studies.A single assessment of a biochemical indicator may be susceptible to short-term variation and not reflect true long-term exposure. The ICC, as the ratio of between-person variance and total variance (sum of between- and within-person variances), reflects reliability very well as it considers both between- and within-person variability. A high ICC can be obtained by low within- and/or high between-person variance. A low ICC is attributable to high within- and/or low between-person variance. Random measurement error generally tends to decrease correlation and regression coefficients in epidemiologic studies toward 0 and bias relative risks toward 1. To assess long-term exposure using a single blood measurement, as it is often the case in large epidemiologic studies, the between-person variance should account for most of the observed variability in the biomarker concentration, whereas within-person variance should be relatively low Reliability studies often focus on technological improvement of biochemical assays, sample handling or storage conditions We found low within-person variance and excellent reliability of hexose concentrations. Hexose includes various monosaccharides containing 6 carbons, e.g. glucose, fructose and galactose, among others. Hormonal control mechanisms immediately respond to feeding, postprandial and fasting states and ensure that blood sugar concentrations are contained within a narrow range over-time.Table S2.Acylcarnitines represent esterified fatty acid derivates that occur in the process of fatty acid translocation into the inner mitochondrial membrane which is the limiting step for β-oxidation. Acylcarnitines can efficiently pass into the cytosol and subsequently into the blood stream. Blood acylcarnitine concentrations, therefore, reflect the substrate flux through β-oxidation. Increased acylcarnitine concentrations have been associated with type 2 diabetes mellitus previously Phosphatidylcholines belong to the group of membrane phospholipids that consist of a glycerol core which carries a choline head group and two fatty acid residues. Lysophosphatidylcholines usually originate from hydrolysis of the sn-2 fatty acid and transesterification by phospholipase A2 and, therefore, only carry one fatty acid. De-novo synthesis and redistribution from plasma membranes may impact phosphatidylcholine and lysophosphatidylcholine concentrations in blood The strength of our study was that we assessed reliability in a wide spectrum of metabolites including different classes of compounds. Furthermore, the detection assay for these metabolites represents a modern high-throughput technique that has already been approved and standardized, and can be applied to future metabolome analysis. We also used a sub-sample of a large population-based prospective cohort study for this reliability investigation, therefore, ensuring a high precision for the results of the ICCs. The participants of this study were free-living, and thus, their exposure to various external factors differed reflecting a real life situation.Our study had some limitations. The estimation of within-person variation (% CV) was based on only two time point measurements. This was a trade-off for the large sample size of the present study. To account for this limitation we included a long time span between the two measurements of metabolite concentrations where participants were free-living and thus, exposed to several external factors that could have affected stability of metabolite concentrations. The present study included fasting healthy subjects. Reliability of metabolites may be different for people with existing chronic disease and in situations in which fasting status is not possible to obtain. Future studies are warranted to further investigate the metabolite reliability in different  populations.We were primarily interested to study the reliability of metabolites for risk assessment using a single blood measurement, as is usually the case in large scale epidemiologic studies. Therefore, we did not investigate in detail possible sources of within- or between-person variance. We are aware of a need to evaluate the impact of genetic and non-genetic factors on these variance components, which should be the aim of future studies. Some metabolites, especially of the acylcarnitine group, showed lower serum concentrations than the LOD of the assay system; thus, the observed low ICCs could also be explained by technological limitation. Beyond biologic variability, the total variance of the biomarker concentrations depends on the precision of the measurement. Although most metabolites were measured with relatively high precision, the coefficients of variations were larger for a few metabolites, which may explain the lower reliability for some of these markers. Thus, the reliability depends on the assay system, and, although we used a validated kit, the reliability of the metabolites measured here may be different when other systems are used. Although reliability was low for some of the metabolic markers when analysed separately as in our analysis, this does not exclude the possibility that these markers may still be useful when investigating the impact of metabolic profiles on disease risk.In conclusion, we found fair to excellent reliability for most of the metabolites, including short- and medium chain acylcarnitines, amino acids, hexose and phospholipids in free-living healthy subjects. Our results suggest that a single assessment of these metabolites may be sufficient for risk assessment in prospective epidemiologic studies. In contrast, reliability was lower for monounsaturated- and hydroxyl-acylcarnitines and few glycerophospholipids, which is most likely explained by their low serum concentrations in healthy individuals that exceed the assay's detection limit at the present time. This may limit their use for risk assessment when based on a single measurement.All of the EPIC-Potsdam participants gave written informed consent and the study was approved by the ethics committee of the medical association of the state of Brandenburg, Germany.The EPIC-Potsdam cohort was recruited from the general population and consists of 27,548 participants mainly aged 35–65 years at time of recruitment between 1994 and 1998 IDQ™ p150 kit . The samples were prepared according the manufacturers protocol and the assay procedures have been described in our previous work Table S1. The median analytical variance was 7.3% within-plate CV and 11.4% between-plate CV. It was determined by measuring 230 replicates (46 plates each containing 5 replicates) of one female serum sample and is reported in detail in Table S2. The AbsoluteIDQ™ p15 kit has previously been applied in metabolomic studies in humans .Serum concentrations of 163 metabolites were determined using a targeted metabolomic approach with the AbsoluteThe metabolomic measurements allowed simultaneous quantification of 163 metabolites including 41 acylcarnitines (Cx:y), 14 amino acids, 1 hexose, 92 glycerophospholipids (lysophosphatidylcholines (lysoPC), diacyl- and acyl-alkyl- phosphatidylcholines (PC)), and 15 sphingolipids (SMx:y) in a one-step analysis.Table S1. Lipid side chains were abbreviated as Cx:y, where x equaled the number of carbons in the side chain and y denoted the number of double bonds. The technology was limited as it could not detect the distribution of the carbon atoms among 146 different fatty acids and the exact position of the double bonds in complex lipids. All glycerophospholipids were phosphatidylcholines (PC), that were further differentiated with respect to ester (a) and ether (e) bonds, where two letters implied that two fatty acids are bond to glycerol , while one letter  and the prefix ‘lyso’ indicated the presence of a single fatty acid residue; e.g. lysoPCaC24:0  = lysophosphatidylcholine acyl C24:0 (lignoceric acid). Sphingolipids were sphingomyelins (SM) and hydroxysphingomyelins (SM(OH)). All acylcarnitines were naturally occurring L-isomers abbreviated according to the fatty acid that was bond (e.g. C2 = acetyl-L-carnitine). DL-carnitine was abbreviated as C0. Amino acids were presented according to standard three letter abbreviations.The detailed nomenclature is provided in IDQ™ p150 kit showed values below LOD. However, it was important to measure those as well, as their concentrations may increase drastically in disease or upon environmental challenge A substantial part of the metabolites determined by AbsoluteP<0.05 for two-sided testing.The metabolite serum concentrations were not normally distributed as indicated by Kolmogorov-Smirnov test, but right-skewed. Therefore, the concentrations were log-transformed and reported as geometric means and 95% confidence intervals (CIs). Student's paired t-test was used to compare the concentrations of each metabolite measured 4 month apart. Variance components were estimated with a one-way random effects model and subject ID as the random variable (SAS procedure: PROC ANOVA) Table S1Biochemical Names and Quantification Ranges of 163 Metabolites Measured with the BIOCRATES Absolute IDQ Targeted Metabolomics Technology. Footnote: Abbreviations: LOD, limit of detection; LLOQ, lower limit of quantification; ULOQ, upper limit of quantification. aThe quantification range was determined by BIOCRATES and adopted from the Manual: “AbsoluteIDQ™ p150 kit – Analytical Specifications” .(DOC)Click here for additional data file.Table S2Analytical Variance of 163 Metabolites Measured with the BIOCRATES Absolute IDQ Targeted Metabolomics Technology. Footnote: Abbreviations: CV, coefficient of variation; LOD, limit of detection. aAnalytical variance was determined by measuring 5 replicates on each of the 46 plates containing the EPIC-samples  and reported as CV%. Note: higher CVs are mainly observed for metabolites that show very low concentrations and are below the LOD of the assay. bMetabolite concentration was below the assay's LOD.(DOCX)Click here for additional data file.


MBL) plays a key role in the human innate immune response. It has been shown that polymorphisms in the MBL2 gene, particularly at codon 54 , impact upon host susceptibility to Candida infection. This systematic review and meta-analysis were performed to assess the association between MBL2 codon 54 genotype and vulvovaginal candidiasis (VVC) or recurrent VVC (RVVC). Studies were searched in MEDLINE, SCOPUS, and ISI Web of Science until April 2013. Five studies including 704 women (386 cases and 318 controls) were part of the meta-analysis, and pooled ORs were calculated using the random effects model. For subjects with RVVC, ORs of AB versus AA and of BB versus AA were 4.84  and 12.68 , respectively. For subjects with VVC, OR of AB versus AA was 2.57 . This analysis indicates that heterozygosity for the MBL2 allele B increases significantly the risk for both diseases, suggesting that MBL may influence the women's innate immunity in response to Candida.Mannose-binding lectin ( Candida species, especially Candida albicans, remain a significant problem worldwide [Vulvovaginal candidiasis (VVC) and recurrent vulvovaginal candidiasis (RVVC), both caused by overgrowth of orldwide . It is eorldwide . Moreoveorldwide , which corldwide .C. albicans cell wall, leading to phagocytosis and killing of the invading fungus [per se an important innate anti-Candida defense through the expression of the CLR dectin-1 and several TLRs [Candida, thus increasing the host susceptibility to (R)VVC [Different components of the innate immune system, such as the Toll-like receptors (TLRs) and C-type lectins (CLRs), play a major role in the recognition of molecular patterns on the g fungus . This alral TLRs . Nonetheo (R)VVC .MBL) is able to trigger the complement cascade by recognizing and binding to carbohydrate moieties on the surface of microorganisms in general [C. albicans in particular [MBL2 gene result in three different allelic variants , which lead to nonfunctional monomers in homozygotes or reduce the amount of functional monomers in heterozygotes [MBL is rather similar, the structural MBL2 gene variants B, C, and D are often pooled and referred to collectively as O [MBL2 gene promoter polymorphisms, G-550C (H/L), G-221C (Y/X), and C+4T (P/Q), have been described, giving rise to combinations that are associated with different levels of MBL protein, such as high (HY), intermediate (LY), and low (LX) levels [B, C, and D SNPs, these combinations form seven common “secretor haplotypes” that ultimately define the serum MBL concentrations, that is, high with the HYPA, LYQA, and LYPA haplotypes and low with the LXPA, HYPD, LYPB, and LYQC haplotypes [Among CLRs, the soluble, opsonic, multimeric mannose-binding lectin  levels . As linkplotypes .MBL2 codon 54 polymorphism has been associated with reduced vaginal concentrations of MBL [B was also more frequent in women with recurrent bacterial vaginosis [MBL serum levels were found in women suffering from RVVC than in healthy women [MBL may be effective in the acute-phase defense against this condition [As most frequent in healthy Caucasians , the MBLs of MBL , 15 and s of MBL , 16–18 bs of MBL  patientsaginosis , suggesthy women , indicatondition .MBL codon 54 gene polymorphism enhances the risk of (R)VVC in adult women. We listed all the case-control studies to show the evidence in the literature on the association of the variant allele B carriage with the occurrence of vulvovaginal Candida infection.To attempt to clarify this matter, therefore, we performed a systematic review and meta-analysis to determine whether the presence of This paper was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .MBL gene polymorphism” OR “MBL2 gene polymorphism” OR “protein C” or “mannose-binding lectin”). All searches were limited to human subjects without language, study design, or publication status restrictions. The reference lists of retrieved articles were also screened to find relevant articles that were not identified by the initial search strategy. Moreover, the MEDLINE was searched monthly after April 2013 to identify any newly published studies. Searching was performed by two independent reviewers (BN and AR).The electronic databases MEDLINE, SCOPUS, and ISI Web of Science (since initiations to 30 April 2013) were searched for relevant studies using the following terms: mycosis AND  the outcome was VVC or RVVC, and there were at least two comparison groups, for example, (R)VVC versus control groups ; (iii) frequencies of alleles B (variant) and A (wild-type) were assessed in both cases and controls; (iv) the allele B frequency in the control group did not deviate from the Hardy-Weinberg equilibrium (HWE) at P ≤ 0.01; and (v) participants were nonpregnant women.Any study was considered to be eligible for inclusion in our systematic review and meta-analysis if it met the following criteria: (i) the MBL2 genotypes in cases and controls. To allow appropriate comparison of all studies, cases and controls were classified as AA (MBL2 codon 54 wild-type genotype), AB (MBL2 codon 54 heterozygous genotype), or BB (MBL2 codon 54 homozygous genotype). Any disagreement was settled by consensus between the two reviewers. If no agreement could be reached, it was solved through discussion with a third reviewer (SB).Data were extracted independently by two reviewers (BN and AR) who developed a customized database for data extraction. For each study, the following information was collected: first author, year and location of the study, average age, ethnicity, number of participants, number of cases and controls, and frequency of the Two reviewers (BN and BP) independently examined the quality of each included study through a checklist modified from a previously published meta-analysis of molecular association studies, using a risk of bias score based on both epidemiologic and genetic issues . Six domCandida infection together with a mycological culture positive for Candida species.The outcomes of interest were VVC and RVVC, which were defined according to original studies. Briefly, RVVC was diagnosed if women had four or more culture-documented episodes of VVC during a 12-month period before enrolment. VVC was diagnosed if women had symptoms consistent with a vaginal I2 lying between 0% and 100%, where values less than 40% suggest that homogeneity is good for the reliability of meta-analysis [P value less than 0.05 was considered statistically significant.The odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the meta-analysis. A random effects model, using the reciprocal of the variance as the weighting factor, was applied throughout to provide a more conservative estimate of the effect size and to take into account between-study variation . Statistanalysis . To evalanalysis . To furtanalysis . All anaOur initial literature search yielded a total of 242 references, of which 70 from MEDLINE, 151 from SCOPUS, and 21 from ISI Web Science. After screening the titles and abstracts, 220 studies were excluded, because they were not considered relevant to the study topic or because of duplication in the searched databases, leaving 22 potentially eligible studies. After reading the full texts, 17 studies were discarded because they did not meet the above-specified inclusion criteria, and only 5 studies –18 were n = 386) ranged from 27 to 36 years and across the controls (n = 318) from 25 to 33 years. The nonpregnancy was one of the inclusion criteria for all the studies, followed by the absence of diabetes mellitus, immunodeficiency, or use of immunosuppressive medications for 2 of 5 studies [n = 307) or VVC (n = 79) according to standard diagnostic guidelines, whereas all of controls were matched to the cases at least for age. Genotype frequencies in all of the control groups did not deviate from values predicted by HWE (data not shown).Characteristics of each case-control study included in our meta-analysis are summarized in  studies , 15. AllMBL2 allele genotypes, while the description of controls was clearly accessible in 2 of 5 (40%) studies [The study quality was satisfactory overall, and the selected studies had low risk of bias from ascertainment of (R)VVC and the  studies , 18, so  studies –17.MBL2 codon 54 polymorphism and RVVC. Candida infection comparing subjects with AA genotypes and those with AB or BB genotypes. Applying the random effects model yielded the pooled ORs for AB versus AA or BB versus AA of 4.84  and 12.68 , respectively. As the OR for AB versus AA was shown to be highly heterogeneous, this finding was explored by means of Galbraith's test and, then, we singled out the study of Babula et al. [AB versus AA was 3.16 . Taken together, our results suggested that women carrying AB or BB genotypes had 5 times and 13 times higher odds of RVVC than those carrying the AA genotype.All of the 5 studies included in our meta-analysis have reported association between a et al.  as a maia et al.  was omitMBL2 codon 54 polymorphism and VVC [Candida infection comparing subjects with AA genotypes and those with AB genotypes, because of the lack of homozygous BB genotype subjects across the selected studies. Applying the random effects model yielded the pooled OR for AB versus AA of 2.57 , suggesting that women carrying the AB genotype had 2-time higher odds of VVC compared with those carrying the AA genotype.Two of the 5 studies included in our meta-analysis reported association between  and VVC , 17.  FiMBL codon 54 gene polymorphism is significantly associated with both the fungal diseases. In particular, possessing the MBL variant allele B heterozygous genotype increases the susceptibility of women to RVVC or VVC compared to healthy controls, while the risk of RVVC is also increased for women carrying the allele B homozygote genotype. These results suggest that heterozygosity for the MBL2 allele B, causing an MBL structural defect [This meta-analysis of accessible, published data derived from 5 studies considering cases of RVVC and/or VVC showed that l defect , confersMBL serum levels [MBL2 may have different clinical implications [MBL is thought to transudate from the blood circulation into the female genital tract, this could account for the level variations seen in vulvovaginal fluids according to the individual's MBL2 genotypes [MBL concentrations [Although genotypic analyses can be used as surrogates for m levels , it was ications . As the enotypes . It is atrations .B heterozygotes, and only 3% of patients was allele B homozygotes, but not all the RVVC women who had a reduced level of MBL in their vaginas did carry the codon 54 variant allele. Thus, if deficient vaginal levels of MBL are argued to contribute to vaginal Candida proliferation in women with RVVC, unfortunately in that study, no women with a first episode of acute VVC were included to rule out that MBL deficiency is a general feature of vulvovaginal Candida infection [MBL concentrations were higher in women with VVC (47 of 51) than in controls, but not in women with RVVC (6 of 6) suggesting that MBL may increase during a first attack of Candida vaginitis but that subsequent attacks decrease the immune system susceptibility to the fungus.In one study , almost nfection . In anotnfection , vaginalCandida at the vaginal mucosa surface, it is also conceivable that one patient with a wild-type allele for the MBL2 54 polymorphism can have a promoter combination  that down-regulates MBP, thereby expressing low levels of functional protein. On the other hand, the MBL2 structural gene variants alone could be responsible for diminished binding of the MBL protein to Candida cells via its lectin domain, at the early phase of defense against Candida during vaginal infection by the fungus [MBL structural and promoter gene polymorphisms with the occurrence of VVC or RVVC, as well as the role of multiple genetic factors in determining the increased susceptibility to RVVC [However, if low MBP concentrations would lead to impaired opsonophagocytosis of e fungus . NeverthMBL polymorphism would confer some relative benefits to the host, particularly women in the reproductive age when innate immune mechanisms are relatively more important than adaptive immune mechanisms [MBL, both protective and detrimental, in the vaginal environment, could be envisaged to take into account the susceptibility to and the type of outcome  of Candida infection. As opposed to the primary RVVC, an idiopathic form with no known predisposing factors [Candida infection, despite the natural protective immune mechanisms which are engaged to limit fungal burden and inflammation at the vaginal mucosa level [C. albicans [MBL [MBL2 B allele carrier status may predispose to either VVC or RVVC is schematized in As resistance and tolerance are complementary host antifungal defense mechanisms that are likely operating in the vaginal mucosa , a balanchanisms . In this factors , acute V factors . These fsa level  and, on albicans . Lastly,ans [MBL , 31, 32,Candida infection, should lead to more valid pooling results, though there was no sufficient information to this regard. Finally, despite the record of moderate heterogeneity for the pooled estimates, we believe that this meta-analysis could significantly contribute to the understanding of the pathogenesis of (R)VVC.Some limitations of the present meta-analysis should be considered. First, although the review was carried out following rigorous analytical methods and thus biases were due to the selection of studies and less likely due to data extraction, we believe that the quality of the review may have been affected by the fact that only 5 studies were evaluable for the meta-analysis. Second, some of the included studies contained small numbers of cases, including a very low number of RVVC cases, and the backgrounds of patients varied across the included studies, particularly in the two studies involving white and nonwhite Brazilian patients. All of this would result in the lack of power for detection of gene effects, thus requiring further updated meta-analysis provided that more studies are published in the literature. Third, adjusting our estimates for potential confounding factors, such as the well-known risk factors for mucosal B allele of MBL polymorphism might have more risk of developing vulvovaginal candidiasis. As RVVC is likely polygenic and/or multifactorial, further studies with larger sample sizes are required to confirm the role of MBL2 polymorphisms in association with Candida vulvovaginitis. As RVVC may be virtually untreatable, a better deciphering of anti-Candida host defense mechanisms in the vagina is crucial to design novel immunotherapeutic strategies in order to optimize and/or replace conventional antifungal treatments.In summary, our results showed that women carrying the


To compare by meta-analysis the efficacy and safety of sirolimus-eluting and bare-metal stents in coronary artery disease (CAD) patients with diabetes.PubMed, MEDLINE and EMBASE were searched from 1971 to 2012. Data on the efficacy and safety of sirolimus-eluting and bare-metal stents in patients with diabetes were collected. A meta-analysis was then performed on a total of 1 259 CAD patients with diabetes from six studies. The odds ratio (OR) was used for comparison. Subgroup analysis was performed according to the sample size, year of study, subjects’ geographic area and study method.p < 0.01] and target-lesion revascularisation . There was no difference for myocardial infarction  or mortality . Subgroup analysis showed a significant difference for overall risk of major cardiac events between SES and BMS when the sample size was ≤ 90 , when it was a randomised control trial (RCT) , or when it was performed on European subjects . The sensitivity was not different when one study was removed at a time.Compared with those in the bare-metal stent group (BMS), the subjects in the sirolimus-eluting stent (SES) group had a reduced risk for major cardiac events [OR 0.42, 95% confidence interval (CI): 024–0.74, Our study confirmed that SES are safer and more effective than BMS in CAD patients with diabetes, as far as major cardiac events are concerned. However, longterm outcome and restenosis rate has been very discouraging.7For coronary arterial disease (CAD) patients with diabetes, the outcome, efficacy and safety of SES and BMS remain controversial,26To clarify this controversy, in this study, we performed a meta-analysis and subgroup analysis, along with heterogeneity and publication-bias analysis, and compared the major cardiac events, target-lesion revascularisation, myocardial infarction and mortality rate in CAD patients with diabetes who were treated with SES or BMS.PubMed, MEDLINE, EMBASE, Springer, Elsevier Science Direct, Cochrane Library and Google scholar were searched. The following keywords were used, ‘sirolimus-eluting stents’, ‘baremetal stents’, ‘coronary arterial disease’, ‘diabetes’, ‘diabetic’, ‘safety’, ‘efficacy’, ‘study’ and ‘trial’. The time period was limited from 1 January 1971 to 31 December 2012. The language published in was limited to English only. References of the articles were also checked for additional studies.Studies included were randomised, controlled trials (RCT) and non-RCT conducted in coronary artery disease patients with diabetes treated with SES or BMS (studies with these two methods compared), regardless of the sample size. Excluded studies were those investigating patients with CAD or DM in only case reports or review articles, duplicated articles, and those with no comparison of SES and BMS.After the investigators were trained, the data-mining form was developed and modified. The data included study details such as first author, year of study, year of publication, geographical area of subjects, demographics of subjects, and events with follow up after being treated with SES or BMS. According to the standard protocol, two investigators (A and B) mined the data independently, which was reviewed by the third one (C). Discrepancies were resolved through internal and external discussions .p < 0.05 was regarded as statistically significant. Meta-analysis was performed in fixed- or random-effect models.Analysis was performed with software review manager 5.1  and comprehensive meta-analysis ; Z-test. Cochrane’s Q-statistic was used to assess within- and betweenstudies variations. A p < 0.10 on the Q-statistic was regarded as heterogeneity across the studies. I2 was also used to test heterogeneity with the formula:Odds ratios (OR) and 95% confidence intervals (CI) were estimated in each study. Pooled ORs were obtained using the Mantel-Haenszel method in a fixed-effect model, and the DerSimonian-Laid method in a random-effects model.I2= (Q-df)Q ×100%I2 < 25% means no heterogeneity; I2 = 25–50% means moderate heterogeneity; I2 > 50% means large or extreme heterogeneity.27where The random-effects model was also used for evaluating the possibility of heterogeneity of studies. Publication bias was evaluated with Egger’s test and funnel plots,As shown in The characteristics of the included studies are presented in p < 0.01) for SES versus BMS. This suggests that, after the data had been pooled, SES were more effective than BMS in CAD patients with diabetes. However, there was publication bias .The efficacy of SES versus BMS is presented in p < 0.01) for overall events, suggesting that SES had a better outcome compared with BMS, with a greater reduction in risk for major cardiac events. However, there were heterogeneities between the studies  and publication bias, as shown in t = –4.19, p < 0.05).As shown in p < 0.01) for SES versus BMS, suggesting that SES had a better revascularisation rate for target lesions compared with BMS. However, there were heterogeneities between the studies  and publication bias .As shown in p > 0.05) for SES versus BMS, suggesting that the overall risk for myocardial infarction was not significantly different between these two groups. There was no heterogeneity between the studies  but there was publication bias .As shown in p > 0.05) for SES versus BMS, suggesting that the overall risk of mortality was not significantly different between the groups. There was no publication bias  or heterogeneities between the studies .As shown in p < 0.01, I2 = 77%, p < 0.1). The pooled OR was 0.61 .Subgroup analyses were stratified by sample size, subjects’ geographical area and study method. As shown in p < 0.01, Q2 = 3.71, I2 = 46%, p > 0.1). The pooled OR was 0.37 .The pooled OR was 0.45 . The pooled OR was 0.87 .The pooled OR was 0.28 (95% CI: 0.19–0.42, By removing one study at a time, a sensitivity analysis was performed and the model was rerun to determine the effect on each estimate. It showed that the above meta-analysis estimates did not change significantly after removal of each study, implying that these results were statistically reliable.A growing number of studies has shown the efficacy and safety of SES versus BMS for treating CAD patients with diabetes,These results are consistent with a recent study that suggested a significant reduction in target-vessel revascularisations with SES, but with similar mortality rates.Another recent study conducted in Europeans confirmed the efficacy of SES compared with BMS, along with comparable mortality rates and myocardial infarctions,Heterogeneity is one major concern with regard to the validity of meta-analyses.We further conducted subgroup analysis according to sample size, ethnicity and study method. It demonstrated that in the studies where sample size was ≤ 90, method was a RCT and population was European, the overall major cardiac events were significantly different between the SES and BMS groups. Heterogeneity between the studies was decreased after stratifying the samples. No significant heterogeneity was observed with RCTs, suggesting an RCT is important for good results. More high-quality RCTs are therefore warranted.Another concern for meta-analyses is publication bias, due to selection of the studies included. In this study, using funnel plots and Egger’s test,This meta-analysis suggested that, compared with BMS, SES are more effective and safer for reducing major cardiac events in CAD patients with diabetes. This may indicate the direction for future trials and clinical implementation.


OR) for the 5-HTTLPR S allele and discontinuation status. A random effects meta-analysis provided no evidence that the S allele was associated with increased odds of discontinuation from SSRIs in Europeans  but in East Asians there was evidence of a reduced odds of discontinuation . There was a suggestion of small study bias (p=0.05). This meta-analysis provides no evidence of an association between 5-HTTLPR and discontinuation from antidepressant treatment in Europeans. The low number of studies in East Asian samples using SSRIs reduces confidence in our evidence that the S allele decreases the odds of discontinuation in this population. At present, there is no evidence of an association between 5-HTTLPR and discontinuation from SSRI treatment in a European population with further studies required to investigate its effects in different populations.There is evidence that 5-HTTLPR is associated with response following treatment from selective serotonin reuptake inhibitors (SSRIs). The short (S) allele has reduced serotonin transporter expression, compared to the long (L) allele, and has been reported to be associated with poorer response in Europeans, with the effect in other populations unclear. However the published literature is inconsistent. A systematic review and meta-analysis was performed to investigate the effect of 5-HTTLPR on discontinuation from antidepressant treatment. Data were obtained from 17 studies including 4309 participants. The principal outcome measure was the allelic odds ratio ( However, long-term treatment is required for antidepressants to successfully alleviate the symptoms of depression. Individuals who stop antidepressant treatment prematurely may not benefit from treatment and are at a higher risk of relapse . The mosSelective serotonin reuptake inhibitors (SSRIs) are the first choice antidepressant due to their superior adverse effect profile. SSRIs increase the levels of serotonin in the synaptic cleft by binding to the serotonin reuptake transporter (5-HTT), preventing the reuptake and subsequent storage or degradation of serotonin. This leads to the accumulation of serotonin in the synaptic cleft, which in turn may cause adaptive changes in both serotonergic and noradrenergic neurotransmission and downstream neural adaptation, helping to alleviate the symptoms of depression . SSRI-inin vitro compared to the S allele (The serotonin transporter gene-linked polymorphic region (5-HTTLPR) modulates transcriptional activity of 5-HTT. 5-HTTLPR is a 44 base pair insertion–deletion polymorphism which can exist as a long (L) variant of a 16 repeat sequence or a short (S) variant of 14 repeats. The L allele is associated with higher levels of transcription S allele . TherefoS allele  and unipS allele  it is imThe association between 5-HTTLPR and antidepressant treatment has been subject to numerous studies with the majority investigating the outcome of response. In general, data on the number of discontinuations is collected but rarely published with regards to 5-HTTLPR. in vivo have not consistently reported the L allele to be associated with an increase in transporter binding sites , concluded that in Europeans 5-HTTLPR may be a predictor of antidepressant response and remission, while in East Asians it does not appear to play a major role . An earlTo build on the work of previous meta-analyses we decided to investigate the association between 5-HTTLPR and the number of individuals who discontinue antidepressant treatment. Our outcome of discontinuation includes individuals who discontinued antidepressant treatment for any reason. We chose our outcome of discontinuation as it does not require an individual to make a potentially complex psychosocial judgement on the reason of discontinuation. Additionally, examining discontinuation is often used to study comparative acceptability of medication . Ideally22.1OR) for the 5-HTTLPR S allele and discontinuation status. Ancestry was coded as European, East Asian, or other. If the study reported results by ancestry or was a randomised controlled trial (RCT), each population or randomised group was treated as a separate sample.Studies in which depressed individuals received antidepressant medication and data on discontinuations were reported by 5-HTTLPR polymorphism status were included. The principal outcome measure was the allelic odds ratio  from the first date available in each database up to 18 September 2012 using the search terms “5-HT”, “5-HTT”, “SERT”, “serotonin”, “transporter”, “SLC6A4”, “5-HTTLPR”, “antidepressant”, “SSRI”, “SRI” or “reuptake inhibitor”. The full search strategy is available in Supplementary 2.3ORs and associated 95% confidence intervals (CI) were calculated. Random-effects models are more conservative than fixed-effects models and assume that the true effect size could vary from study to study. The significance of the pooled OR was determined using a Z-test, and heterogeneity between studies was assessed with chi-squared goodness of fit and the I2 statistic. The I2 statistic quantifies the percentage of total variation across studies due to heterogeneity rather than chance variation. The higher the I2 statistic, the more between-study heterogeneity, with the values of 25%, 50%, and 75% considered as low, moderate, and high heterogeneity, respectively  model and the individual and pooled ectively . High beSE ln OR  and analSE ln OR . An asymSE ln OR . We repo33.1n=11) and RCT's (n=6))  published between 2003 and 2011, were identified by the search strategy and included in the meta-analysis .A total of 17 studies ) , compris3.23.2.1OR 0.95, 95% CI 0.79–1.14, p=0.55) or in the sub-group analyses in the SSRI group  or other antidepressant group . There was evidence of moderate heterogeneity  which remained when the SSRI group was considered separately . Analysis by different genotype models did not substantially alter the results (results available on request). Excluding any individual study, any study not in HWE  were included. We found no evidence that the S allele was associated with discontinuation from antidepressant treatment overall  or in the SSRI group  or other antidepressant group . There was evidence of moderate heterogeneity  which remained when the SSRI group was considered separately . These results are displayed graphically in A total of 15 independent samples  were included. We found no evidence that the S allele was associated with increased odds of discontinuation from antidepressant treatment overall , and when comparing LL homozygotes with S allele carriers (LL vs. SL/SS) .A total of 4 independent samples  were included. The study by 3.2.4p=0.3; data available by request).We investigated an outcome of discontinuations specifically due to adverse effects in Europeans receiving SSRI treatment  when all studies were included, although this test has low statistical power given the small number of studies. Evidence of small study bias no longer remained when only European studies were included (p=0.34). There was no evidence between individual study effect size estimate and year of publication (p=0.55), mean sample age (p=0.91), study size (p=0.32), percentage male (p=0.55) or study duration (p=0.30) when all studies were included, or when restricted to European only studies (results available on request).Visual inspection of a funnel plot of all studies indicated asymmetry, suggesting that some small studies reporting an association between the S allele and increased risk of discontinuation may be missing .To our knowledge, this is the first meta-analysis to assess the association of 5-HTTLPR genotype with discontinuation following SSRI treatment. Our results find no evidence of an association between 5-HTTLPR and discontinuation from SSRI treatment in a European population. This supports the findings from the three largest studies on a predominantly European population  included in this meta-analysis mean that further studies are required to investigate its effects before we can draw any firm conclusions. There was evidence of considerable heterogeneity even within Europeans treated with an SSRI. The cause of this heterogeneity is unknown as there was substantial consistency in the diagnostic criteria as well as antidepressant agents used.A allele, this stratification did not substantially alter results when analysing the whole STAR*D sample. However, it did alter the results of a sub-group analysis of white, non-Hispanic individuals with adverse effect burden as the outcome  highlights the need for greater research in this area before we can make any definite conclusions on its potential clinical importance. A meta-analysis of approximately 5400 European individuals would be required to determine whether 5-HTTLPR has at least a 15% change in risk of discontinuation from SSRI treatment. Future studies should report adverse effects and discontinuation alongside the more customary efficacy measurements in order to improve our knowledge of the 5-HTTLPR and its effect on outcomes following antidepressant treatment.AC is funded by the Wellcome Trust. The Wellcome Trust had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.AC performed the electronic search which was checked in duplicate by GL, SL or MM. All authors contributed to the drafting of the review.There are no relevant conflicts of interest to declare.


Glycemic index (GI) and glycemic load (GL) have been associated with coronary heart disease (CHD) risk in some but not all cohort studies. We therefore assessed the association of GI and GL with CHD risk in prospective cohorts.2 and quantified by I2. Subgroups included sex and duration of follow-up. Ten studies (n=240 936) were eligible. Pooled analyses showed an increase in CHD risk for the highest GI quantile compared with the lowest, with RR=1.11  and for GL, RR=1.27 (95% CI 1.09 to 1.49), both with evidence of heterogeneity . Subgroup analyses revealed only a significant modification by sex, with the female cohorts showing significance for GI RR=1.26 (95% CI 1.12 to 1.41) and for GL RR=1.55 (95% CI 1.18 to 2.03).We searched MEDLINE, EMBASE, and CINAHL  and identified all prospective cohorts assessing associations of GI and GL with incidence of CHD. Meta-analysis of observational studies in epidemiology (MOOSE) methodologies were used. Relative measures of risk, comparing the group with the highest exposure  to the reference group , were pooled using random-effects models, expressed as relative risk (RR) with heterogeneity assessed by χHigh GI and GL diets were significantly associated with CHD events in women but not in men. Further studies are required to determine the relationship between GI and GL with CHD in men. Cohort studies have also shown an association between low GI diets26 and reduced development of hyperglycemia and diabetes, further implicating the GI in the progression to CHD.26 This dietary pattern is also likely to have the additional advantage of reduced LDL cholesterol by lower intake of SFAs and dietary cholesterol.Carbohydrates with differing physical form, particle size, chemical structure, and fiber content alter the rate of starch digestion and their physiological response. The glycemic index (GI) was developed to characterize the rate of digestion of a carbohydrate food compared with a reference carbohydrate food.27 published cohort studies in the last decade have produced mixed results for the associations of GI and GL with CHD.31 We therefore undertook a systematic review and meta-analysis of prospective cohort studies with healthy populations at baseline to determine whether associations exist between GI and GL with CHD.Despite the proposed physiological mechanisms,32 Electronic databases  were searched by 2 individuals independently; searches were supplemented by manual searches through the reference lists of original publications and review articles. The following search terms were used: ([Glycemic or Glycaemic Index] or [Glycemic or Glycaemic Load]) and (CHD or Cardiovascular Disease or CVD or MI) and (Prospective or Cohort). Titles and abstracts were initially reviewed to identify relevant reports by 2 independent reviewers ; reviewers conducted a subsequent full-text assessment of all studies in which there was uncertainty about the assessment of relevance. Disagreements regarding eligibility were resolved through discussion with 2 additional adjudicators (D.J.A.J/R.J.D.).We conducted separate searches for all prospective cohort studies that assessed potential associations between glycemic index or load and primary incidence of CHD  in adults. We followed the meta-analysis of observational studies in epidemiology (MOOSE) guidelines for this report.36 with bread scale=glucose scale/0.7),37 as well as risk estimates with corresponding CIs.Two reviewers  independently reviewed and extracted relevant data employing a standardized pro forma sheet with the first author and year of publication used as study identifiers for convenience. Data extracted from each cohort included information about sample size, population characteristics (age and sex), country of origin, follow-up duration, method of collecting dietary information, outcome measures, exposure quantification, and analytical methods, including adjustment parameters used for confounding factors. The most complete multivariate adjusted risk estimates from eligible studies assessing GI and GL associations with CHD events with their corresponding confidence intervals (CIs) were extracted to provide the main end points. All authors of eligible reports were contacted to acquire any missing data for each exposure level including number of events, person-years, mean or median dose of GI and GL  and quantified by the I2 statistic. Regardless of P value, sensitivity analyses were performed to identify sources of heterogeneity.38 Potential publication bias was assessed visually by inspecting funnel plots of effect size against the standard error and formally tested using Begg's and Egger's tests in STATA.40 Our a priori stratified analyses included sex and duration of follow-up, that is, whether studies were more or less than 10 years, consistent with the 10-year Framingham Risk Score41 approach, and analyzed using meta-regression in STATA. Statistical significance was defined as P<0.05 for all comparisons, except for Cochrane's Q (χ2), where significance was set at <0.10.Data were analyzed using Review Manager (RevMan) 5.1.4  and STATA version 11.0 . The natural log-transformed relative risks of CHD events (including MI) with corresponding standard errors comparing the highest exposure level with the reference group from each cohort, irrespective of the number of quantile divisions in the original analysis, were pooled in separate analyses for GI and GL. The generic inverse variance method with random-effects models in RevMan were used to allow for heterogeneity assessment. Interstudy heterogeneity was tested by Cochrane's Q  used either a semiquantitative or quantitative Food Frequency Questionnaire (SFFQ or FFQ),42 but 3 used 4- or 7-day diet records or diet history interviews for food consumption patterns.43 All studies used the International Tables of Glycemic Index for assessing the GI of different foods; 334 used the 1995 iteration,45 643 used the 2002 iteration,46 and 135 used the 2008 iteration. One study33 further supplemented the 2002 International GI tables with GI values for 159 local food items that were tested at an academic institution following the International GI table methodologies. The majority of the included reports provided dietary pattern data for GL quantiles. The dietary patterns across the different quantiles of GL were similar between studies, with a trend of increasing carbohydrate and decreasing protein and fat content at higher GL quantiles (The study characteristics and their diet compositions are shown in uantiles .P=0.09) but with significant evidence of heterogeneity . Sensitivity analyses identified the Grau et al43 report on men as the largest contributor to heterogeneity. The removal of this study changed the risk estimate for the association of GI with CHD  and also improved the precision of the estimate and eliminated much of the heterogeneity . A priori stratification revealed no significant modification of association for the duration of follow-up analysis with cohorts of ≥10 years43 (RR=1.08 [95% CI 0.89 to 1.31]) versus those of <10 years42 (RR=1.13 [95% CI 0.97 to 1.31]) as subsets (β=0.95 [95% CI 0.71 to 1.26]), both with evidence of heterogeneity . Sex, however, was a significant modifier of the association of GI with CHD , whereas the male cohorts43 showed no association , with no significant evidence of heterogeneity in either subset.P=0.002), with significant heterogeneity , for the highest level of GL exposure  relative to the lowest . Sensitivity analyses identified the Grau et al43 and Sieri et al33 reports on women as the largest contributors to heterogeneity when removed individually. The removal of Grau et al43 somewhat reduced the estimate of the association of GL with CHD , as did the removal of Sieri et al33 . Similar to the GI analyses, no modification in the association was revealed by the duration of follow-up analysis, ≥10 years43 (RR=1.26 [95% CI 1.01 to 1.59]) versus <10 years42 (RR=1.29 [95% CI 1.02 to 1.63]) with β=0.99 (95% CI 0.68 to 1.44), with evidence of heterogeneity  for both subgroups. Congruent with the GI analysis, sex was a significant modifier of the association of GL with CHD , whereas in the male cohorts,43 the association was not significant . There was significant evidence of heterogeneity in the female subset but not in the male subset.P>0.115 for all). However, in the visual inspection of the GI funnel plot, the Grau et al43 report on men appears to be an outlier and in the GL funnel plot, and the Grau et al43 report on women appears to be an outlier (outside the pseudo 95% confidence limits).Funnel plots for each of the overall analyses were inspected for presence of publication bias  and 5. N47 and Black American44 men, positive benefits for cardiovascular events were seen related to consumption of lower GI foods. We demonstrated an overall increased relative risk of CHD of 11% in the comparison of the highest versus lowest quantile of GI and a 27% increased relative risk of CHD for the highest versus the lowest quantile of GL. The effect was seen only in women with 26% increased relative risk of CHD for GI and 55% for GL.We believe that this analysis represents the most comprehensive meta-analysis of the data presented as quantiles of GI and/or GL. However, we were unable to include 2 studies in this analysis because of the expression of results as either the substitution of low GI carbohydrates for SFAs, rather than dietary GI analysis, or the incremental association of dietary GI with CHD rather than quantile presentation . These studies indicated that in Danish47 and 1 from the United States,44 both of which demonstrated adverse effects of high GI foods or diets on CHD outcomes in men. Furthermore, the 1 study43 of men in the present analysis that showed a near-significant deleterious effect of low-GI diets was also responsible for the heterogeneity in the analysis. This study differed from the other studies of men in several respects. The proportion (54%) of smokers was almost twice that of the other studies, and BMI was somewhat lower (25.3 versus 26.1 kg/m2); men with lower BMIs have been shown to be less susceptible to the effects of GI on CHD risk.48 There may also be another potential explanation for the difference between men and women, possibly a result of differences in diet reporting. For example, if women report more precisely, there would be less measurement error and hence better power. In addition, there may be more homogeneity (insufficient heterogeneity) in the diets of men and therefore a lack of the necessary power to detect potentially important relationships between dietary GI/GL and CHD risk in men.The sex difference in the CHD response to the glycemic index was unexpected and may be the result of the larger total number of subjects in the female cohorts  than in the male cohorts  and our inability to include 2 studies, 1 from Denmark50 Higher glycemic index diets tend to reduce circulating HDL-C concentrations and thus disproportionately increase CHD risk in women, especially when postmenopausal.51 At the same time, high-GI diets may raise TG levels,52 which may also carry more risk for CHD in women than in men.54Despite these reservations there are reasons why women may be potentially more vulnerable to high glycemic index diets. Part of the protection that women have from CHD may be related to their high HDL-C levels.55 Conversely, acarbose, the α-glucosidase inhibitor that converts dietary carbohydrate to a low glycemic index form, has been shown to prevent hypertension and CHD events in the STOP NIDDM trial.56Other factors that in general may contribute to the increased CHD risk with high-GI diets are blood pressure and CRP, both of which may be raised by high-GI diets.57 There has also been emerging evidence on the positive effects of low-GI diets on CHD risk factors such as oxidative damage58 and inflammation22 in overweight/obese and type 2 diabetic individuals, respectively. In addition, meta-analyses of low-GI RCTs have shown beneficial effects on body weight and lipid profiles in obese and overweight subjects21 as well as on glycemic control in type 2 diabetic subjects.59The link between low GI and GL diets and lower CHD risk is also substantiated by randomized clinical trials (RCTs) assessing the effects of dietary strategies low in GI and GL with low saturated fat content. A systematic review of such RCTs in overweight and obese subjects found that replacing refined carbohydrates with low-GI complex carbohydrates conferred more beneficial effects on CHD lipid risk factors when compared with complex starchy carbohydrates with higher GI.60 or later due to reduction in the rate of atheroma formation secondary to oxidative damage.61The current studies do not suggest a latency effect of GI or GL on CHD risk. Because no studies have a time frame shorter than 6 years, it is not possible to determine whether the effect is early, possibly from alterations in clotting factors,62 However, only 2 studies29 were available to assess CHD outcome at the time of that analysis.An earlier meta-analysis that assessed the effect of dietary GI on several health outcomes including diabetes, CHD, and cancer also concluded that low-GI diets were protective for diabetes, CHD, and colon and breast cancers.43 or the Sieri et al33 reports on women were removed. The Grau et al43 report was visually an outlier on the publication bias funnel plot, which could potentially be a result of the difference in the analytical approach, using restricted cubic splines in Grau et al,43 compared with the methods of analyses used in other reports. We could not find an explanation for the heterogeneity in the overall GL analysis due to the Sieri et al33 report on women.In general, the glycemic index and glycemic load data were in agreement, although the magnitude of the CHD risk was greater based on the difference between the extreme quantiles of glycemic load. In the overall GL extreme quantile analysis there was significant heterogeneity that became nonsignificant when either the Grau et al47 because of lack of necessary data, and the heterogeneity in the overall analyses, especially in the likely underpowered analyses of men. Another inherent limitation of observational analyses is the potential problem for residual confounding as well as the possibility of overadjusting, which remains an area of debate in epidemiology.63 Perhaps, the most common limitation in meta-analyses of dietary studies is the combination of dietary data collected using multiple instruments. Although no change was found in our overall conclusions with post hoc sensitivity analyses removing the 443 reports with food diaries and interviews, because of the time frame of published reports, the GI and GL data were still compiled from various data sources. As such, our findings should be considered with caution, and further studies should be undertaken to allow sufficient power for subgroup analyses of dietary data sources.The weaknesses of the present study include the limited number of studies, the inability to include potentially relevant studies36 Finland,35 Denmark,43 Sweden,42 Italy,33 and the United States,34 the majority of the population was white, limiting the racial diversity of this meta-analysis. However, it is noteworthy that our systematic review captured a report on African American men that, although not included because of lack of necessary data , showed that a 5-unit increase in GI conferred a 16% increase in CHD risk.44 Further studies are required with a wider range of ethnic groups and more racial diversity both in women and especially in men because cohorts of men were likely underpowered.Although the reports included men and women from Holland,The strength of our study included the use of random-effects models to allow assessment of heterogeneity to guide the sensitivity analyses. We further believe that our systematic review was strengthened by our efforts to acquire as much data as possible by contacting all study authors to include all relevant studies in our analyses.We conclude that a reduction in the glycemic index and glycemic load may favorably affect CHD outcomes in women. Further studies are required to determine the effect of the glycemic index and load on CHD risk in men.