ACADM (gene encoding MCAD enzyme) genotypes that have never been identified in clinically ascertained patients. It could be hypothesised that residual MCAD enzyme activity can contribute in risk stratification of subjects with variant ACADM genotypes.Since the introduction of medium-chain acyl coenzyme A dehydrogenase (MCAD) deficiency in population newborn bloodspot screening (NBS) programs, subjects have been identified with variant We performed a retrospective cohort study of all patients identified upon population NBS for MCAD deficiency in the Netherlands between 2007–2010. Clinical, molecular, and enzymatic data were integrated.ACADM genotype. In patients with classical ACADM genotypes, residual MCAD enzyme activity was significantly lower  when compared to subjects with variant ACADM genotypes . Patients with  neonatal presentations before diagnosis displayed residual MCAD enzyme activities <1%. After diagnosis and initiation of treatment, residual MCAD enzyme activities <10% were associated with an increased risk of hypoglycaemia and carnitine supplementation. The prevalence of MCAD deficiency upon screening was 1/8,750 .Eighty-four patients from 76 families were identified. Twenty-two percent of the subjects had a variant ACADM genotypes and may contribute to risk stratification. Subjects with variant ACADM genotypes and residual MCAD enzyme activities <10% should be considered to have the same risks as patients with classical ACADM genotypes. Parental instructions and an emergency regimen will remain principles of the treatment in any type of MCAD deficiency, as the effect of intercurrent illness on residual MCAD enzyme activity remains uncertain. There are, however, arguments in favour of abandoning the general advice to avoid prolonged fasting in subjects with variant ACADM genotypes and >10% residual MCAD enzyme activity.Determination of residual MCAD enzyme activity improves our understanding of variant  Medium-chain acyl-Coenzyme A dehydrogenase (MCAD E.C.1.3.99.3]) deficiency (OMIM 201450) is the most common inherited disorder of mitochondrial fatty acid oxidation. The MCAD enzyme is responsible for the first step in the mitochondrial β-oxidation of CoA esters of medium-chain length fatty acids, and, and4], ed cases. The latevalence, it is iACADM genotypes. These newborns are currently regarded patients, in whom follow-up and dietary treatment are initiated similarly to the group with classical ACADM genotypes. This study demonstrates the prognostic value of residual MCAD enzyme activity in newborns with hyperoctanoylcarnitinaemia and a variant ACADM genotype. Residual MCAD enzyme activities <10% were associated with clinical symptoms, regardless of ACADM genotype. Clinical symptoms or classical ACADM genotypes have thus far not been reported in subjects with residual MCAD enzyme activities ≥10%. For all positively screened newborns with any form of MCAD deficiency, basic principles of the treatment are parental instructions, cautious clinical follow-up, and application of an emergency regimen. In subjects with variant ACADM genotypes and ≥10% residual MCAD enzyme activities, the necessity to avoid overnight fasting is debatable.Population-wide NBS programs identify newborns with hyperoctanoylcarnitinaemia and variant ACADM: Gene encoding medium-chain acyl-CoA dehydrogenase; C0: Free carnitine; C8:0: Octanoylcarnitine; C10:0: Decanoylcarnitine; C8:0/C10:0: Ratio between octanoylcarnitine and decanoylcarnitine concentrations; MCAD: Medium-chain acyl-CoA dehydrogenase; NBS: Newborn bloodspot screening; PPA: Phenylpropionic acid; PP-CoA: Phenylpropionyl-CoA.The authors declare that they have no competing interests.CML Touw participated in data collection, analysis and interpretation, generation of the figures, in writing of the manuscript, and approved of the final version. GPA Smit conceived the study, participated in writing the manuscript, and approved the final version. M de Vries, JBC de Klerk, AM Bosch, G Visser, MF Mulder, ME Rubio-Gozalbo, KE Niezen-Koning, B Elvers, RJA Wanders, and HR Waterham participated in data collection, and approved of the final version. DJ Reijngoud conceived the study, participated in writing the manuscript, and approved of the final version. TGJ Derks conceived the study, participated in analysis and interpretation of the data, in writing of the manuscript, and approved of the final version.


The aim of the present study was to assess the association by using meta-analysis.Studies on the association of vascular endothelial growth factor (VEGF) gene A systematic search of electronic databases  was carried out until Sept 18, 2013. The pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) were used to assess the strength of the association.-460T/C: 6 studies including 932 cases and 722 controls; -2578C/A: 6 studies including 1,071 cases and 1,137 controls) were involved in this meta-analysis. Significant association was found for -460T/C polymorphism , but not for -2578C/A polymorphism (P>0.05). Similar results were found in the subgroup analysis.Eleven studies (VEGF gene -460T/C polymorphism, but not -2578C/A polymorphism. Further case-control studies based on larger sample size are still needed, especially for -2578C/A polymorphism.This meta-analysis demonstrates that DR is associated with  Diabetic retinopathy (DR) is the most common vascular complication of type 1 and type 2 diabetes mellitus characterized by increased vascular permeability, hemostatic abnormalities, increased tissue ischemia and neoangiogenesis . To dateVEGF is markedly upregulated in the eyes of the patients with DR, and VEGF antagonists can reduce retinal vascular permeability and neovascularization, which suggest that VEGF play an important role in the pathogenesis of DR [VEGF is considered a plausible biological candidate for DR. Human VEGF gene is located on chromosome 6p21.3, and is highly polymorphic [VEGF gene -460T/C (rs833061) and -2578C/A (rs699947) polymorphisms and DR risk [Vascular endothelial growth factor (VEGF), a 45 KDa homodimeric glycoprotein, is secreted from various types of cells within the eye . VEGF isis of DR ,8. Thus,ymorphic . Many in DR risk -21. HoweVEGF gene -460T/C and -2578C/A polymorphisms and DR risk.Meta-analysis is a means of increasing the effective sample size under investigation through the pooling of data from individual association studies, thus enhancing the statistical power of the analysis for the estimation of genetic effects . The aimVEGF gene -460T/C and -2578C/A polymorphisms and DR risk . No language restrictions were applied. The keywords used for the search were “vascular endothelial growth factor OR VEGF”, “diabetic OR diabetes”, “retinopathy” and “gene OR allele OR polymorphism OR variation OR mutation”. Additional studies were identified by a hand search of references of original studies and review articles on the association of VEGF gene polymorphisms with DR. Analyses were performed for all cases with any form of DR compared with all diabetic without retinopathy. Eligible studies were selected according to the following explicit inclusion criteria: (1) evaluated the association between VEGF gene -460T/C or -2578C/A polymorphism and DR risk; (2) were a case-control study based on unrelated individuals; (3) sufficient genotype data were presented to calculate odds ratios (ORs) and 95% confidence intervals (CIs). When there were multiple publications from the same population, only the largest study was included. When a study reported the results on different ethnicities, we treated them independently.This meta-analysis was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Statement, issued in 2009 . A systeTwo reviewers independently extracted the data with the standard protocol. Potential disagreements were resolved by discussion. The following items were collected from each study: the ﬁrst author’s name, year of publication, source of publication, racial ancestry, polymorphisms, the number of cases and controls, the available genotype and allele frequency information, diagnostic method of DR, and duration of diabetes. If original genotype frequency data were unavailable in relevant articles, a request for additional data were sent to the corresponding author.VEGF gene -460T/C and -2578C/A polymorphisms and DR risk. The pooled OR was calculated for dominant model, recessive model and allele comparisons. The existence of heterogeneity between studies was ascertained by the Chi square-test based Q-statistic [I2=100%×(Q-df)/Q [I2≥50%) [P<0.05 was considered representative of statistically significant publication bias. We performed subgroup analysis by ethnicity. We also performed subgroup analysis by types of DR if individual data were available. Studies not in HWE were subjected to a sensitivity analysis. All statistical analyses were performed using the software Review Manager 4.2  and Stata 10.0 . Two-sided P<0.05 was considered statistically significant.Allele frequencies for genetic polymorphisms in each study were determined by allele counting method. Hardy-Weinberg equilibrium (HWE) was assessed in each study by the Chi-square test. ORs with 95%CIs were calculated to assess the strength of the association between tatistic . We also(Q-df)/Q . The poo(Q-df)/Q . The keyI2≥50%) . The potI2≥50%) . If therI2≥50%) . P<0.05 VEGF gene polymorphisms; 84 were not conducted in patients with DR). Twenty-six papers were retrieved and evaluated for compliance with the inclusion criteria. Of these papers, 15 were ineligible for the following reasons: 14 papers presented data on other polymorphisms, and 1 paper did not provide complete data [-460T/C: 6 studies including 932 cases and 722 controls; -2578C/A: 6 studies including 1,071 cases and 1,137 controls) [The selected study characteristics are summarized in ete data . Finallyontrols) -15,17-21ontrols) .VEGF gene -460T/C and -2578C/A polymorphisms and DR risk is shown in The summary of the meta-analysis for VEGF gene -460T/C polymorphism with DR risk were included in the analysis. The C allele was considered as the risk variant. A significant association between -460T/C polymorphism and DR risk was identified . To evaluate the race-specific effect, we conducted the subgroup analysis by ethnicity. Similar results were found in Asian population . Meanwhile, we conducted the subgroup analysis by types of DR. Similar results were found in patients with proliferative diabetic retinopathy .Six studies (932 cases and 722 controls) examining the association of VEGF gene -2578C/A polymorphism with DR risk and were included in the analysis. The A allele was considered as the risk variant. We found no association between -2578C/A polymorphism and DR risk . Similar results were found in Asian population  and Caucasian population .Six studies  investigated the association of -460T/C polymorphism  and -2578C/A polymorphism  were basically symmetric (funnel plots not shown), and Egger’s linear regression test and Harbord’s test did not indicate asymmetry of these plots (P>0.05). However, Egger’s linear regression test and Harbord’s test were not applied for -2578C/A polymorphism in Caucasian population due to the small number of studies. Publication bias was assayed by visual funnel plot inspection, Egger’s linear regression test  and Harb-460T/C polymorphism, meta-regression indicated that ethnicities (P=0.008) and types of DR (P=0.082) may contribute to heterogeneity. HETRED analysis indicated that the study by Suganthalakshmi et al. [I2=0.0%, Pheterogeneity=0.44). For -2578C/A polymorphism, meta-regression indicated that ethnicities (P=0.064) and year of study (P=0.022) may contribute to heterogeneity. HETRED analysis indicated that the study by Abhary et al. [I2=0.0%, Pheterogeneity=0.45).As shown in i et al.  and the i et al.  contribui et al. ,21, assoy et al.  and the y et al.  contribuy et al. ,20, asso-460T/C: C versus T: OR=1.37, 95%CI=1.15-1.65, P=0.0006, Pheterogeneity=0.03; TC+CC versus TT: OR=1.41, 95%CI=0.85-2.34, P=0.19, Pheterogeneity=0.005; CC versus TT+TC: OR=2.03, 95%CI=1.16-3.54, P=0.01, Pheterogeneity=0.17; -2578C/A: A versus C: OR=1.24, 95%CI=0.92-1.66, P=0.15, Pheterogeneity=0.002; CA+AA versus CC: OR=1.29, 95%CI=0.89-1.88, P=0.17, Pheterogeneity=0.004; AA versus CC+CA: OR=1.31, 95%CI=0.79-2.16, P=0.30, Pheterogeneity=0.04). The sensitivity analysis indicated that results of our study are stable and reliable.We conducted the sensitivity analysis excluding the studies not in HWE, which did not change the present results  were involved in this meta-analysis. Significant association was found for -460T/C polymorphism, but not for -2578C/A polymorphism. These results are strengthened by the facts that similar results were found in the subgroup analysis and that excluding the studies not in HWE gave us similar results. To our knowledge, the present meta-analysis is the first to assess the association between -460T/C polymorphism and DR. For -2578C/A polymorphism, in 2009, Abhary et al. [Over the past three decades, the number of people with diabetes mellitus has more than doubled globally, making it one of the most important public health challenges to all nations . DR occuy et al.  retrievey et al. ,20 and pVEGF gene -460T/C polymorphism and DR risk. Recently, many growth factors have been implicated in having a role in the development of diabetic microvascular complications [VEGF, one of the most common growth factors, can increase the permeability of the microvasculature, stimulate angiogenesis, and enhance collateral vessel formation [VEGF expression is implicated in many disease pathologies, and VEGF levels have been found to be markedly elevated in the vitreous and aqueous fluids in the eyes of patients with DR [VEGF may play an important role in the pathogenesis of DR. VEGF gene comprises a 14 kb-coding region with eight exons and seven introns [VEGF gene, and some polymorphisms influence levels of VEGF protein expression [VEGF gene -460T/C polymorphism, one of the most frequently seen polymorphisms, is located at the -460 position in the promoter region. VEGF gene promoter region contains multiple regulatory elements, which involved in the regulation of VEGF gene expression, and -460T/C polymorphism C allele showed 70% increased promoter activity over T allele [-460T/C polymorphism may increase expression of VEGF, resulting in a increased susceptibility to DR. Of course, the detailed mechanisms need further study. Additionally, the association may result from linkage disequilibrium with another functional polymorphism in the gene. Our results are further strengthened by the evidence from longitudinal data. In 2007, Al-Kateb et al. [VEGF gene polymorphisms, and their study provided strong evidence that more than one polymorphism in VEGF was independently associated with the risk of developing DR. In the current study, we did not detect a significant association between -2578C/A polymorphism and DR. However, evidence from HapMap database indicates that there is linkage disequilibrium between -460T/C and -2578C/A polymorphisms. Thus, further studies based on larger sample size are still needed to explore the association between -2578C/A polymorphism and DR.We detected a significant association between ications . VEGF, oormation . Dysregu with DR . VEGF ma introns . Many popression . VEGF geT allele ,37. Therb et al.  utilizedSeveral specific details merit consideration in the current meta-analysis. First, only published studies were included in this meta-analysis. Meanwhile, Egger’s linear regression test and Harbord’s test were not applied for -2578C/A polymorphism in Caucasian population due to the small number of studies. Thus, publication bias may occur. A second consideration is signiﬁcant between-study heterogeneity was detected in some comparisons. Disease and population may contribute to the heterogeneity. For -2578C/A polymorphism, when excluding the two studies ,20 that VEGF gene -460T/C polymorphism, but not -2578C/A polymorphism. Due to the aforementioned limitations, further case-control studies based on larger sample size are still needed, especially for -2578C/A polymorphism.In conclusion, this meta-analysis demonstrates that DR is associated with Checklist S1Prisma checklist.(DOC)Click here for additional data file.


The variations of the circle of Willis (CW) are clinically important as patients with effective collateral circulations have a lower risk of transient ischemic attack and stroke than those with ineffective collaterals. The aim of the present cadaveric study was to investigate the anatomical variations of the CW and to compare the frequency of prevalence of the different variations with previous autopsy studies as variations in the anatomy of the CW as a whole have not been studied in the Indian subcontinent.The external diameter of all the arteries forming the CW in 225 normal Sri Lankan adult cadaver brains was measured using a calibrated grid to determine the prevalence in the variation in CW. Chisquared tests and a correspondence analysis were performed to compare the relative frequencies of prevalence of anatomical variations in the CW across 6 studies of diverse ethnic populations.We report 15 types of variations of CW out of 22 types previously described and one additional type: hypoplastic precommunicating part of the anterior cerebral arteries (A1) and contralateral posterior communicating arteries (PcoA) 5(2%). Statistically significant differences (p < 0.0001) were found between most of the studies except for the Moroccan study. An especially notable difference was observed in the following 4 configurations: 1) hypoplastic precommunicating part of the posterior cerebral arteries (P1), and contralateral A1, 2) hypoplastic PcoA and contralateral P1, 3) hypoplastic PcoA, anterior communicating artery (AcoA) and contralateral P1, 4) bilateral hypoplastic P1s and AcoA in a Caucasian dominant study by Fisher versus the rest of the studies.The present study reveals that there are significant variations in the CW among intra and inter ethnic groups , and warrants further studies keeping the methods of measurements, data assessment, and the definitions of hypoplasia the same. Based on anatomical -4 and raSeveral studies ,16-19 ha225 postmortem brains  were obtained following ethical approval from the Ethics Committee of the Faculty of Medicine, Colombo from medicolegal autopsies in individuals aged between 18 and 73 years who have died of causes unrelated to the brain. The brains were removed from the cranial cavity and fixed in 10% formaldehyde for a minimum period of two weeks. The arteries comprising the CW together with the basilar artery and its minute branches arising from the main vessels were then carefully removed from the base of the brain. Blood was carefully washed out from the CW with isotonic saline. Line diagrams of all 225 circles were obtained, including photographic records in some cases.Segments were taken from the following corresponding regions: right and left internal carotid arteries (ICA) close to their distal ends, precommunicating and postcommunicating part of the anterior cerebral arteries (A1), (A2) and the posterior cerebral arteries (P1), (P2) close to their origin, right and left posterior communicating arteries (PcoA) at their middle point and anterior communicating artery (AcoA) (with its variations if present) at its middle point. Transverse sections were cut (at 40 um) from each of the segments obtained as stated above in a plane that was perpendicular to the vessel ; a random 'section' was then obtained from the water bath and three measurements of the external diameter were performed on each section by the first Author under a stereomicroscope equipped with a micrometer-calibrator . The calculated average was then recorded as the value for each artery. Arteries where the external diameter was less than 1 mm, were documented as <1 mm. The equipment was standardised according to the manufacturer's specifications.In the present study, the CW was defined as "typical CW" Figure  only if:i.e. ICA, A1, AcoA, PcoA and P1 arteries) were present.1. All the component vessels  Figure , in ordeet al.,1979, [et al., 1985 [There are many anatomical variations of the CW, their classification into a few clearly arranged groups is hardly possible, we classified variations of CW using 22 Types as defined by Lazorthes l.,1979,  and Eftel., 1985 ,16-19 anIn order to study the relationship of the anatomical variations of the CW between the studies in Caucasian dominant  analysis was also performed to better assess study similarities and dissimilarities and also, for those studies that differ, to determine which configurations are primarily responsible for the difference. This was done using correspondence analysis. Correspondence analysis (proposed by Benzecri (1969)  and subset al.,1979, [et al., 1985 [We report 15 types of variations of CW out of 22 types previously described by Lazorthes l.,1979,  and EfteType 1-"Typical CW": 32(14%); Type 3 - Hypoplastic AcoA: 32(14%); Type 4 - Unilateral hypoplastic PcoA: 26(11.5%); Type 5 - Unilateral hypoplastic PcoA and AcoA: 15(7%); Type 6 - Bilateral hypoplastic PcoAs, 52(23%); Type 7 - Bilateral hypoplastic PcoAs and hypoplastic AcoA: 37(16%).The global chi-squared test was highly significant (p < 0.0001), indicating differences among the studies. The pairwise p-values are given in Table Thereafter, a correspondence analysis was used to study the degree of (dis)similarities among the studies; Figure Both the chi-squared analysis Table  and the Table However, the methods and definition of hypopolasia differ among anatomical studies in the literature, which may hamper the comparison of these studies. Establishing an international standard method for nomenclature on the variation and for quantitative measurement of the diameters of all the component vessels of the CW and quantitatively define hypoplasia would make it possible for comparison of data with studies in diverse populations.The present study reveals that there are significant variations in the CW among intra and inter ethnic groups , this is of clinical importance and warrants further studies to ascertain the influence of genetic, racial, regional, environmental and hemodynamic factors or a combination of any of the above keeping the methods of measurements, data assessment, and the definitions of hypoplasia the same.AcoA: Anterior communicating artery; ACA: Anterior cerebral artery; A1: pre communicating part of ACA; A2: post communicating part of ACA; CW: circle of Willis; ICA: Internal carotid artery; PCA: Posterior cerebral artery; P1: pre communicating part (P1) of PCA; P2: post communicating part (P2) of PCA; PcoA: Posterior communicating artery.The authors declare that they have no competing interests.KRDS carried out the data extraction, performed the analysis and drafted the manuscript. RS helped out with the data extraction WSLG and RWJ supervised the study and participated in its coordination and drafted the manuscript. DA did the statistical analysis and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/11/5/prepub


Genetic factors in the pathogenesis of cardiomyopathies have received a lot attention during the past two decades. Angiotensin I converting enzyme (ACE) insertion/deletion (I/D) polymorphisms were found to be associated with cardiomyopathies. However, the previous results were inconsistent. The current meta-analysis aims to examine the association of ACE I/D polymorphisms and dilated cardiomyopathy (DCM) or hypertrophic cardiomyopathy (HCM).Eight studies on DCM (1387 controls and 977 patients) and eight studies on HCM (1055 controls and 827 patients) were included in this meta-analysis.P = 0.03).The overall data showed no significant association between ACE I/D polymorphism and DCM risk. Further subgroup analysis by ethnicity also did not find a significantly increased risk for D allele carriers among East Asians and Europeans. However, the overall analysis suggested that the D allele carriers might be associated with increased risk of HCM (DD/ID vs. II: OR = 1.69, 95% CI 1.04–2.74, In summary, the meta-analysis indicated that certain ACE I/D polymorphism might be associated with HCM but not DCM susceptibility. Given the limited sample sizes, further large multicenter case-control investigation is needed. Dilated cardiomyopathy (DCM), which is characterized by ventricular chamber enlargement and systolic dysfunction with normal left ventricular wall thickness, leads to progressive heart failure, arrhythmias, and sudden or heart failure related death. Previous family studies revealed that 20% to 50% of idiopathic DCM had a familial origin, suggesting genetic factors might play an important role in the disease pathogenesis. Several genes encoding the components of the renin-angiotensin-aldosterone system (RAAS) have been revealed to be associated with cardiovascular diseases, including hypertension, myocardial infarction, ischemic stroke, and cardiomyopathy. To date, no large-scale studies have assessed the association between ACE I/D polymorphisms and DCM or HCM. This lack of knowledge emphasizes the importance of the present meta-analysis. Thus, we performed this meta-analysis to clarify this inconsistency between ACE I/D polymorphisms and DCM or HCM.A computerized search of PubMed and the Cochrane Library published before November 2012 was conducted. Only studies published in English were considered. Furthermore, the references of the relevant studies were also searched. The google scholar website was also searched. When the same patient population was included in different reports, only the study with complete data was used in this meta-analysis. We used the following key words for searching for the relevant reports: angiotensin I converting enzyme, dilated cardiomyopathy, hypertrophic cardiomyopathy, variant and polymorphism. Two reviewers (J.M Yang and C Zhang) independently searched the titles, abstracts, and full-texts to determine whether the data met the inclusion criteria. Conflicts were resolved by consensus.The studies included in the meta-analysis must meet all the following three criteria: (1) evaluating the association of ACE I/D polymorphism with DCM or HCM; (2) using case-control design; (3) providing sufficient data upon genotype counts.All the patients were excluded for ischemic cardiomyopathy and severe coronary obstruction for DCM, and potential stimulus such as hypertension, ischemic ischemic heart disease, valvular heart disease, congenital malformations of the heart or vessels, and intrinsic pulmonary disease for HCM.For each study, the following information was extracted: the first author’s name, publication date, region and ethnicity of participants, sample size of cases and controls, source of controls, myocardial biopsy, genotype distribution in cases and controls.P<0.10 was considered to be significant heterogeneity. In this study, a random effects model was used because of the presence of heterogeneity. Because the number of included studies was <10, we did not assess the publication bias (www.cochranehandbook.org).All the statistical analyses were performed by Review Manager version 5.1. Crude odds ratios (ORs) and 95% confidence intervals (CIs) were used to assess the association strength between ACE I/D polymorphism and DCM or HCM risk. We also tested the heterogeneity among the included reports and A total of 316 studies were screened and 299 studies were excluded after reading titles and abstracts. One study by Harn HJ et al. was excluded because of lacking full-text. For the two overlapping studies, P = 0.13; DD vs. ID/II: OR = 1.27, 95% CI 0.93–1.74, P = 0.13; DD vs. II: OR = 1.44, 95% CI 0.88–2.36, P = 0.14). Similarly, in the subgroup analysis by ethnicity, no significantly increased risk was found for D allele carriers among East Asians and Europeans. . However, patients with DD genotype did not showed significant risk of HCM compared with II genotype  or I allele carriers . In the subgroup analysis by ethnicity, no statistically increased risk was found for D allele carriers among Japanese. , which induces cell proliferation, migration and hypertrophy, and enhances the proinflammatory cytokines and matrix metalloproteinases. Thus, overexpression of Ang II plays a powerful role in cardiomyopathy. Studies have demonstrated blocking Ang II is beneficial to patients with cardiomyopathy or heart failure. Previous studies have found that ACE I/D polymorphisms are related with plasma Ang II levels. ACE I/D polymorphisms have been extensively examined for a variety of clinical endpoints, such as hypertension, coronary artery disease Several limitations should be considered. First, some genetic defects were known in HCM or DCM. However, all the included studies did not present such information, which might affect the analysis results. Second, heterogeneity among the included studies may affect the interpretation of the results of the meta-analysis. Third, most of the sample sizes of the referenced studies are relatively small, which might weaken the meta-analysis results. Furthermore, lamin A/C mutations in DCM and sarcomeric mutations in HCM contribute a lot to cardiomyopathy risk. Overall, the present meta-analysis suggested that certain ACE I/D polymorphism might be associated with HCM but not DCM susceptibility. The findings of the current study may add benefit to risk stratification strategies in patients with HCM and may encourage further study focusing on the effect of ACE I/D polymorphisms on HCM and risk. These results also suggest a potential treatment approach by regulating RASS in HCM patients. However, given the small sample sizes in this meta-analysis, further large random case-control studies are needed for further confirmation.


Age-related white matter changes (WMC) are considered manifestation of arteriolosclerotic small vessel disease and are related to age and vascular risk factors. Most recent studies have shown that WMC are associated with a host of poor outcomes, including cognitive impairment, dementia, urinary incontinence, gait disturbances, depression, and increased risk of stroke and death. Although the clinical relevance of WMC has been extensively studied, to date, only very few clinical trials have evaluated potential symptomatic or preventive treatments for WMC. In this paper, we reviewed the current understanding in the pathophysiology, epidemiology, clinical importance, chemical biomarkers, and treatments of age-related WMC. Age-related white matter changes (WMC) are prevalent findings among the elderly.WMC are considered to be etiologically related to cerebral small vessel disease and are important substrates for cognitive impairment and functional loss in the elderly .AlthoughThe literature search was conducted using the National Center for Biotechnology Information (NCBI) PubMed/Medline to identify relevant articles related to WMC that were published until June 2011. We used the following keywords for the search: white matter, white matter changes, white matter lesions, leukoaraiosis, white matter hyperintensities, and small vessel disease. The articles were included in this paper if (1) the journal article was published in English and (2) they were related to epidemiology, pathophysiology, neuroimaging, genetics, clinical phenotypes, biomarkers, and treatment of WMC. Further searches on bibliographies in the main articles and relevant papers were performed.WMC are almost endemic in community elderly with prevalence ranging from 50% to 98% –6. In st3 in subjects with no lesions, 0.2 (0.0–1.1) cm3 in subjects with punctuate lesions, 2.7 (0.5–5.9) cm3 in subjects with early confluent lesions, and 9.3 (7.1–21.0) cm3 for individuals with confluent WMC at baseline [Age-related WMC are not static lesions. The lesions may progress, or even regress, over time. Several longitudinal studies have investigated the rate and predictors for progression of WMC –47. Perhbaseline . In AD abaseline . Sachdevbaseline . Other fbaseline .Pathologically, WMC are characterized by partial loss of myelin, axons, and oligodendroglial cells; mild reactive astrocytic gliosis; sparsely distributed macrophages as well as stenosis resulting from hyaline fibrosis of arterioles and smaller vessels . NowadayAnother mechanism is blood-brain barrier dysfunction. Small vessel alterations could lead to damage of the blood-brain barrier and chronic leakage of fluid and macromolecules in the white matter . IncreasVascular risk factors, especially hypertension, cause lipohyalinosis of the media and thickening of the vessel walls, which attributes to narrowing of the lumen of the small perforating arteries and arterioles nourishing the deep white matter . The perRecently, postmortem Medical Research Council Cognitive Function and Ageing Study using RNA microarray and pathway analysis found that 8 major pathways in which multiple genes showed altered RNA transcription  and WMC represented areas with a complex molecular phenotype . Xu et aOther mechanisms hypothesized to be involved in the pathophysiology of WMC encompassing dysfunction of vasomotor reactivity and autoregulation –69, chroTherefore, the pathophysiology of WMC is complex and may be multifactorial. Further studies should address more on how these different pathways interact with each other.WMC are ill defined hypodensities on CT. On MRI, which is more sensitive than CT on delineating the lesions, they appear as hypointensities on T1-weighted imaging and hyperintensities on T2-weighted imaging, proton density and fluid-attenuated inversion recovery sequences (FLAIR) . The FLAAs to the assessment of WMC severity, various visual rating scales have been proposed. The visual rating scales are quick and easy to perform on different quality of scans . HoweverNowadays, fully automated techniques and semiautomated segmentation methods become increasingly available. Different from the visual rating scales, volumetric measurement is more accurate and provides continuous data without ceiling effect. However, it is more time-consuming with higher requirement of expertise and excellent quality of MRI, which limits its use for research purpose. Overall, volumetric method is preferred over visual rating scales for longitudinal studies.Large amounts of evidence shows that WMC are associated with cognitive impairment  showed WMC and/or lacunes in the basal ganglia, white matter, or brainstem, without significant nigral lesions . StudiesStudies had shown that WMC were associated with urgency urinary incontinence –135. A cLines of evidence suggested that WMC are associated with late life depression , 137–144P < 0.001) and increased risk of death (HR 2.0 (1.6–2.7), P < 0.001) [The WMC increased the risk for stroke , 149 and< 0.001) . In pati< 0.001) . WMC wer< 0.001) , 153. WMC were not benign but predict poor clinical and functional outcomes. Some studies also indicated that they, especially DWMC, were associated with migraine , 155. An12, and vitamin B6) required for homocysteine metabolism may promote hyperhomocyst(e)inemia [Homocysteine is a dietary sulphur-containing amino acid derived as an intermediate during the metabolism of methionine . Nutritie)inemia . Perini e)inemia . Many ste)inemia –172.Inflammatory biomarkers as intercellular adhesion molecule-1 (ICAM-1) , 174, anThe WMC are predictors for poor clinical outcomes and important substrates for vascular dementia. The European Task Force on age-related WMC recommended that clinical trials on cerebral small vessel disease should target those with severe WMC and use its progression as surrogate marker in clinical trials . Albeit The Epidemiology of Vascular Ageing MRI study has shown a positive linear relationship between BP and severity of WMC . DufouilAn open-label study  and a poAlthough most studies paid attention to lower BP in hypertension, noted that low BP was a risk factor for WMC as well . Anothern = 102) or simvastatin 20 mg daily (n = 106) for 2 years. Simvastatin group did not slow the progression of WMC volume compared with the placebo group, but in those with severe WMC at baseline, the median volume increase in the simvastatin group (1.9 cm3) was less compared with that in the placebo group . However, in this study, treatment probably prevented WMC progression among those with severe WMC at baseline was based only on subgroup analysis upon a small subset of subjects. Furthermore, the subjects of this study belonged to a high-risk group in that all our subjects had concurrent MCA stenosis. Hence, the findings may not be applicable to patients with less vascular burden or to those with WMC but without concurrent MCA stenosis.Statins have long been demonstrated to reduce cardiovascular events and ischemic stroke among patients with coronary heart disease . WhetherFurthermore, a recent cross-sectional study showed that low cholesterol had more severe WMC in acute stroke patients . Other sN-methyl-D-aspartate (NMDA) receptor antagonists (memantine) have been approved for treatment of AD. Kavirajan and Schneider reviewed three donepezil, two galantamine, one rivastigmine, and two memantine placebo-controlled, randomized, double blinded trials, it showed that cognitive effects on the AD assessment scale-cognitive subscale (ADAS-cog) were significant for all drugs, and post hoc analyses of donepezil tails suggested greater improvement in patients with cortical and territorial lesions compared with those with predominantly subcortical small vessel disease related lesions [Acetylcholinesterase inhibitors  and  lesions . By cont lesions , 189. Wi lesions . Yet, giCerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a genetic form of subcortical vascular dementia. A recent multicentre, 18-week, placebo-controlled, double-blind, randomized parallel-group trial using donepezil in 168 CADASIL patients revealed that donepezil had no effect on the vascular ADAS-cog score in CADASIL patients with cognitive impairment. Improvements were noted only on several measures of executive function, which might possibly suggest that cholinergic pathways were involved in the executive function . OverallAnother more recent randomized, international, multicenter, 24-week trial in 974 probable or possible vascular dementia patients who received donepezil 5 mg/d or placebo found that donepezil improved the vascular ADAS-cog score but not global function . Howevern = 4089) or B vitamins  with a median followed-up duration of 3.4 years. Although vitamin treatment was not significantly more effective than placebo in reducing the incidence of the composite primary endpoint of stroke, myocardial infarction, or vascular death, in the subgroup analyses, homocysteine lowering might have preferential benefit in small vessel disease patients (risk ratio 0.80 (95% CI : 0.67–0.96)) [Lines of evidence have shown that hyperhomocysteinemia was associated with WMC through endothelial dysfunction –172. Whe7–0.96)) . The VITWMC are common in elderly, and they are not benign. More extensive WMC are associated with a host of poor clinical outcomes. Although WMC have been shown to be associated with small vessel disease, age, and other vascular risk factors, the exact mechanisms explaining such association are still uncertain. To date, data on the effectiveness of various treatments  in preventing WMC progression were derived mainly from subgroup analyses. Randomized studies dedicated in evaluating treatments for preventing WMC progression and its clinical correlates are thus urgently needed. Although some studies have suggested the efficacy of nimodipine, nicardipine, and memantine in subcortical vascular dementia, further randomized controlled studies are needed to clarify their effectiveness and safety.


To evaluate the maternal, paternal, and fetal genotype contribution to preeclampsia.We combined the analysis of polymorphisms of the GSTP1, eNOS, and LPL genes – affecting biotransformation enzymes and endothelial function – in a cohort of 167 preeclamptic and normal control trios  comprising a total of 501 samples in the Greek population, never analyzed before by this approach.105/Val105, the eNOS Glu298Asp and the LPL-93 polymorphisms, statistically significant differences were found between the two groups. However, the transmission rates of the parental alleles to neonates studied by the transmission disequilibrium test, disclosed no increased rate of transmission to preeclampsia children for the variant alleles of Val105 GSTP1, 298Asp eNOS, and -93G LPL.For the frequency of the GSTP1 IleThese novel data, suggest that interaction of all three types of genotypes , reveals no effects on the development of preeclampsia, but provide the impetus for further studies to decipher the individual contribution of each genetic parameter of preeclampsia. Preeclampsia represents the clinical expression of a complex metabolic disorder during pregnancy, affecting 3–10% of all pregnancies . The maiGlutathione S-transferase P1 (GSTP1), endothelial nitric oxide synthase (eNOS), and lipoprotein lipase (LPL) constitute three major detoxification enzymes that have been studied in pregnancy, as putative predisposing factors to preeclampsia ,11.Glutathione S-transferase P1 transfers aliphatic, heterocyclic radicals, epoxides, aren oxides substrates, and xenobiotics to glutathione . GlutathNitric oxide (NO) and its signaling cascade are important for the placental function and particularly for the regulation of blood flow and vasomotor tone . It is sLPL hydrolyzes and releases the free fatty acids from the very low-density lipoproteins (VLDL) and chylomicrons . LPL defA large Swedish cohort population study showed that maternal genes may contribute to preeclampsia by 35%, fetal genes by 20%, while 13% was attributable to the couple effect, 32% to undetermined factors and less than 1% to shared sibling environment . The fetTo this end, and based on previous data, we designed a case–control study to evaluate the contribution of maternal and paternal–fetal components for the risk of preeclampsia, by analyzing the effects on preeclampsia risk of the three relatively common polymorphisms of the GSTP1, eNOS, and LPL genes in a cohort of preeclamptic and normal control trios  belonging to a different ethnic population (i.e. Greek) never analyzed previously by this approach. We hypothesized that these gene polymorphisms might constitute a basis for the triggering events leading to preeclampsia, by affecting the activity of biotransformation enzymes (GSTP1 and eNOS) in detoxifying processes and/or the endothelial function (LPL).The prospective case–control study enrolled 167 unrelated pregnant women participating as trios , 51 (30.95%) with preeclampsia, and 116 (69.05%) healthy pregnant women, as controls. Thus, the total population studied comprised of 501 samples. Subjects were recruited from the Obstetric Clinic of the First Department of Obstetrics and Gynecology, at the University of Athens School Medicine. All pregnant women were on singleton pregnancy, while the fetuses of polypara preeclamptic women were fathered by the same father. Participants' mean age was 27.6 + 4.7 years. None of the women were on medication, except of a subgroup of cases, requiring regimen for maintaining normotensive status. Each participating individual provided informed consent. Institutional Review Board approval for the study was obtained by the University Hospital Ethics Committee.Basic demographic and clinical parameters, such as gestational age, height, body weight and body mass index (BMI) before pregnancy, systolic and diastolic blood pressure, liver enzymes, urine protein, serum creatinine, platelet count, right upper quadratic pain, edema, and visual disorders, were recorded for all subjects. All pregnant women underwent serum and urine specimen analysis before labor.Preeclampsia was defined as the occurrence, after the 20th gestational week, of systolic blood pressure greater than 140 mm Hg and of diastolic blood pressure greater than 90 mm Hg on two or more recording times with at least 4 h apart, combined with proteinuria with urine protein excretion greater than ≥0.3 g/day or ≥2 + on one voided dipstick testing of midstream urine. Women with hypertension prior to pregnancy, diabetes mellitus, renal or cardiac disease, were excluded from the study.On the basis of the aforementioned criteria, the definitive diagnosis for preeclampsia was made at or after the 26th gestational week, while following delivery, 5 ml of venous blood was drawn from each one of the triplet  and collected in EDTA-containing tubes. The samples were stored at −80°C until analyzed. Every triplet was studied for eNOS, GSTP1, and LPL polymorphisms.Genomic DNA was extracted from whole blood using the NucleoSpin Blood Kit , according to the instructions of the manufacturer. The procedure typically resulted in the isolation of 50–200 ng of genomic DNA.Polymorphisms for glutathione S-transferase P1 (GSTP1), endothelial nitric oxide synthase (eNOS), and lipoprotein lipase (LPL) genes were detected by a combination of polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) assays, using appropriate restriction enzymes as described previously ,23,29. T2 (25 mM), 1 µl Taq DNA polymerase (5 u/µl), and 5 ng/µl DNA template. Amplification was carried out with 5 min initial denaturation at 95°C, followed by 35 cycles of denaturation at 95°C for 30 s, primer annealing at the appropriate temperature for each primer for 30 s, and extension at 72°C for 1 min.The PCR reaction was carried out in a total volume of 30 µl in a PTC-200 Peltier Thermal Cycler . The PCR reaction mixture contained 3 µl 10 × reaction buffer, 1 µl dNTP mix (10 mM of each dNTP), 1 µl forward primer (25 pmol), 1 µl reverse primer (25 pmol), 1.8 µl MgClFor GSTP1, the PCR yielded a 176-bp product, and following digestion with the restriction enzyme BsmA I, an isoschizomer of Alw26 I , yielded a 93-and a 83-bp product for the G/G genotype, a 176-, a 93-, and a 83-bp product for the A/G genotype, while the enzyme did not cut the normal A/A genotype sequence .For eNOS, the PCR yielded a 152-bp product, which, after digestion with the restriction enzyme Ban II (New England BioLabs), yielded a 98-and a 54-bp fragment for the normal G/G genotype, a 152-, a 98-and a 54-bp fragment for the T/G genotype, while the PCR product with the T/T genotype was not digested .For the LPL-93 polymorphism, the PCR yielded a 149bp product, which following digestion with the restriction enzyme Ban II, yielded a 93-and a 56-bp fragment for the G/G genotype, a 149-, a 93-, and a 56-bp fragment for the T/G genotype, while the PCR product with the normal T/T genotype was not digested .2 Fisher's exact test were applied accordingly. For the statistical analysis of the polymorphisms, the χ2 Fisher's exact test was used. The number of parental–fetal allele transmissions compared to the number of transmissions expected by chance was studied using the transmission disequilibrium test (TDT) [P < 0.05.For the statistical analysis, the nonparametric tests of two-sample Wilcoxon matched-pairs rank-sum test and the χst (TDT) . The levThe initial total population studied comprised of 504 individuals  from each trio. Because of the lack of information for one child, 167 trios were finally evaluated for genotyping.P < 0.001), as shown in P < 0.001), headache (P < 0.001), visual disorders (P < 0.001), and urine protein (P < 0.001), were found to be statistically significant between the two groups, using the χ2 Fisher's exact test.The main demographic and clinical features of the two groups of pregnant women  are shown in We next studied the distribution of the frequencies of GSTP1, eNOS, and LPL genotypes in the subgroups of the mothers, fathers, and children of the preeclampsia and normal control groups. The comparisons were performed using the Fisher's exact test. The distribution of the polymorphic variants of the three genes in the preeclampsia trios and the normal control group is shown in 105 allele, although previously reported to be associated with preeclampsia [P = 0.013 and P = 0.001, respectively). It is noteworthy, that no homozygote for the Val105 allele was found among the fathers of the preeclampsia trios . No homozygote individual for the 298Asp/298Asp genotype was found in the group of preeclamptic mothers and fathers.For the eNOS Glu298Asp polymorphism, a similar pattern of frequency distribution was observed . The freP = 0.047), while no statistically significant difference was documented between the subgroups of fathers (P = 0.317) or of the children (P = 0.153).For the -93LPL polymorphism of the promoter region, the frequency of the variant -93G allele was higher in mothers (4.9%), fathers (1.9%), and children (2.9%) of preeclamptic pregnancies compared to the normal control subgroups. However, when the frequencies of the individual subgroups of preeclampsia were compared to those of the normal controls, a statistically significant difference was documented only for the mothers , indicating that there is no difference in the rate of transmission of the common lle105 allele versus the variant allele Val105 to preeclampsia children.For the GSTP1 polymorphism, a total of 56 transmissions of the variant ValP = 0.677). Therefore, there is no increased transmission of the variant 298Asp allele to the preeclampsia children.For the eNOS polymorphism, 87 transmissions of the variant 298Asp allele and 151 transmissions of the common 298Glu allele were observed in a total of 119 parents. The TDT test was not statistically significant (P = 1.00). Therefore, the data suggest no increased transmission frequency of the variant allele to preeclampsia children.For the -93LPL polymorphism, six transmissions of the variant -93G allele and 16 transmissions of the common -93T allele were observed in 11 parents. The TDT test was not found to be statistically significant  can indeed increase the risk for preeclampsia ,42. More105 polymorphism was associated with severe preeclampsia because of the production of a GSTP1 enzyme with reduced detoxifying capacity [105/Val105 genotype in maternal and fetal samples in a South African population, but with no proportional increase in preeclampsia. It has also been speculated that the GSTP1 variant contributes to preeclampsia phenotype despite the fact that the frequency of the Ile105/Val105 and Val105/Val105 genotypes was not significantly different between the preeclampsia and the control group [It is therefore evident that a comprehensive approach is needed to decipher the mechanisms of susceptibility to preeclampsia, by encompassing all the genetic components involved in the formation of placenta . This new approach has been used so far in a single study to address the effect of the paternal contribution, by studying the GSTP1 gene polymorphism in a cohort of 113 preeclampsia trios in the Dutch population . The patcapacity ,16,45,46capacity  has repool group .On the basis of these limited and conflicting studies, we designed this study to evaluate more systematically the contribution of maternal, paternal, and fetal components for the risk of preeclampsia, by selecting three gene polymorphisms, affecting the activity of biotransformation enzymes, such as GSTP1 and eNOS, and the endothelial function, such as LPL, in an ethnic population (i.e. Greek) never analyzed previously by this comprehensive approach. We hypothesized that detoxification and endothelial function-linked paternal gene variants inherited by the fetus are expressed in the fetal–placental unit, and under a specific background of maternal genotype, they might trigger a hyperoxidative status, which is eventually manifested as preeclampsia.The genotypic distribution and the frequencies of the three polymorphic alleles between the preeclampsia and the normal control trios revealed several informative features between the two groups.105 allele interestingly was found to be higher in mothers and fathers of normal pregnancies compared to the preeclampsia group, a finding nonconsistent with previous data [105, disclosed no difference in the rate of transmission versus the common Ile105 allele to preeclamptic children. These data are in contrast to those performed on the Dutch population [For the GSTP1 polymorphism, the frequency of the variant Valous data . Furtherpulation . These dpulation ,49,50.For the eNOS polymorphism, the frequency of the variant 298Asp allele was found to be statistically significant between the two groups of trios, exhibiting higher frequency in the control group. Furthermore, the TDT test applied to 87 transmission patterns was not statistically significant. These data represent the first attempt to evaluate the contribution of all three types of eNOS genotypes in a preeclamptic group. Previous studies, using analysis of simple maternal genotypes, have associated the 298Asp allele with severe preeclampsia in some  but not In addition, a different polymorphism of the eNOS gene within intron 4  has been shown to be associated with preeclampsia in a defined ethnic group . The oddRegarding the frequency distribution and the effect of paternal–fetal transmission of the LPL gene polymorphic genotypes, consistent frequency differences of the two alleles between the subgroups of the two categories were documented, with the frequency of the variant -93G allele being higher in mothers, fathers, and children of preeclamptic pregnancies. These data are consistent with previous findings in Caucasian women concerning the frequency and association of the variant -93G allele with preeclampsia ; howeverSince dyslipidemia, a state that predisposes to preeclampsia, reflects a multifactorial and multigene disorder, it is not surprising that the limited data so far on -93LPL polymorphism, based solely on the analysis of maternal genotypes, have led to inconsistent results, suggesting either association to preeclampsia ,29,53 orIn conclusion, we have used a comprehensive approach for the delineation of the individual maternal, paternal, and fetal genotypes for the risk of preeclampsia, utilizing for the first time the combined analysis of three key gene polymorphisms, affecting the activity of biotransformation enzymes (GSTP1 and eNOS) in detoxifying processes and/ or the endothelial function of placenta (LPL) in a different ethnic population never analyzed before by this approach.105 allele is not sufficient to clearly confer an increased risk for preeclampsia, neither the eNOS polymorphism with the variant 298Asp allele, nor the LPL gene polymorphism with the -93G variant allele.These novel data, based on the transmission test for linkage disequilibrium (TDT), suggest that analysis of the interaction of all three types of genotypes  from the preeclampsia and control groups reveals variable effects. The GSTP1 polymorphism with its variant ValOur studies using a different approach, document the molecular and racial heterogeneity of preeclampsia, and provide the impetus for further studies involving (i) the analysis of additional genomic regions revealed by genome scan meta-analysis  and (ii)


Introduction of calcineurin-inhibitor (CNI) has made transplantation a miracle in the past century. However, the side effects of long-term use of CNI turn out to be one of the major challenges in the current century. Among these, renal dysfunction attracts more and more attention. Herein, we undertook a meta-analysis to evaluate the efficacy and safety of calcineurin-inhibitor (CNI) minimization protocols in liver transplant recipients with CNI-related renal dysfunction.We included randomized trials with no year and language restriction. All data were analyzed using random effect model by Review Manager 5.0. The primary endpoints were glomerular filtration rate (GFR), serum creatinine level (sCr) and creatinine clearance rate (CrCl), and the secondary endpoints were acute rejection episodes, incidence of infection and patient survival at the end of follow-up.P<0.00001; I2 = 0%). Likely, sCr level was significantly lower in the CNI minimization group . However, CrCl was not significantly higher in the CNI minimization group . Both acute rejection episodes and patient survival were comparable between two groups . However, current CNI minimization protocols may be related to a higher incidence of infections .GFR was significantly improved in CNI minimization group than in routine CNI regimen group (Z = 5.45, CNI minimization can preserve or even improve renal function in liver transplant patients with renal impairment, while sharing similar short term acute rejection rate and patient survival with routine CNI regimen. With 1-year liver allograft survival rates now exceeding 80% Multiple factors have been reported to be involved in chronic renal impairment in liver transplant recipients Herein, we performed a meta-analysis of the available literature to better understand the efficacy and safety of CNI minimization protocols in liver transplant patients with CNI-related renal dysfunction. This data provide important insight capable of better informing clinical physicians regarding the treatment of CNI-related renal dysfunction.Before data collection, two general protocols were designed to be compared: CNI minimization regimen and routine CNI regimen. To limit publication bias, we included published trials with no language or year restrictions. Initial searches of MEDLINE, EMBASE databases and the Cochrane Database of Systematic Reviews included terms: calcineurin-inhibitor, cyclosporin A, tacrolimus or FK506, minimization, withdrawal, reduction, elimination and liver transplantation.To be included, trials had to be randomized, not confounded by additional therapeutic differences between the two protocols. Trials should compare renal function of liver transplant recipients receiving routine CNI regimen versus CNI minimization regimen for CNI-related renal impairment. To limit the renal function in a comparable range, we only included patients with glomerular filtration rate (GFR) under 60 ml/min, serum creatinine level (sCr) more than 1.5 mg/dl or creatinine clearance rate (CrCl) under 70 ml/min before enrollment according to the National Kidney Foundation (NKF) recommendation for chronic kidney disease (CKD) and the staging index used in clinical practice. To make sure that routine CNI regimen and CNI minimization protocols are practiced as their names, in each trial the CNI dose in the minimization group should be initially reduced by at least 25% of the dose as is used in the routine regimen group to achieve a lower target trough levels, or CNI were completely withdrawn and converted to non-CNI based protocols.A quality assessment was carried out for all the retrieved RCTs. Quality in a systematic review essentially refers to the absence of biases. To assess the methodological validity of the studies included in this review the following aspects were evaluated: allocation concealment, intention to treat analysis or not, blinding and description of handling of missing data. Articles were assessed by two reviewers (DW and YS) independently. Disagreements were resolved by consultation with a third reviewer (ZG).For the trials included in our meta-analysis, we sought data for demography information, renal function , acute rejection (AR), incidence of infections , varicella zoster virus (VZV), herpes simplex infection and nasopharyngitis, bronchitis, pneumonia, stomatitis events and urinary tract infection (UTI)), and patient survival for all patients. The primary outcomes of our meta-analysis were renal function, and the secondary outcomes were AR, incidence of various infections and patient survival. The data were extracted by two investigators (YK and YS) independently. The conduct and reporting were in accordance with the Quality of Reporting of Meta-Analyses statement.2.For every outcome, we used the statistical software Review Manager 5.0  to analyze the collected data and to compare each treatment group with the routine CNI regimen group. The primary outcomes  and the secondary outcomes  were analyzed as continuous and dichotomized variables using random effect model, and their results were reported as mean difference  and odds ratio , respectively. The statistic strength was measured by overall effect size Z and heterogeneity index IWe included 32 trials with 1383 patients in the current meta-analysis, including 10 RCTs In general, the methodological quality of the included 10 RCTs was not bad. However, only 3 studies described the allocation sequences. And 3 studies used the intention-to-treat analysis to avoid detection and attrition bias. All RCTs except one were open-labeled study. P<0.00001; I2 = 0%). While in sirolimus subgroup, the improvement of GFR over routine CNI regimen group was not statistically significant . In total, in the included RCTs, GFR was significantly improved in CNI minimization group as compared to routine CNI regimen group . Similarly, a meta-analysis of the included observational trials regarding GFR . And in sirolimus subgroup, the improvement of GFR over the routine CNI regimen group was also significant . Collectively, in the included observational studies, GFR was significantly improved in the CNI minimization group .Firstly, we conducted a meta-analysis of 10 RCTs regarding GFR in patients receiving CNI minimization (including MMF and sirolimus subgroups) versus routine CNI regimen, which was shown in shown in  demonstrP<0.0001; I2 = 0%). While in sirolimus subgroup, the decrease of sCr level was not statistically significant in comparison with routine CNI regimen group . Collectively, in the included RCTs, the sCr level was significantly decreased in CNI minimization group . In addition, a meta-analysis of the included observational trials regarding sCr level . And in sirolimus subgroup, there was a significant decrease of sCr level compared to routine CNI regimen group . And in everolimus subgroup, the sCr level was also significantly decreased . Totally, in the included observational studies, the sCr level was significantly decreased in CNI minimization group .Then, we conducted a meta-analysis of sCr of patients receiving CNI minimization (including MMF and sirolimus subgroups) versus routine CNI regimen, which was shown in Cr level  showed tP = 0.22; I2 = 0%). And in sirolimus subgroup, once again, we could not document a significant improvement of CrCl , neither did we in everolimus subgroup . In total, in the included RCTs, CrCl was not significantly improved in CNI minimization group over routine CNI regimen group . In contrast, a meta-analysis of the included observational trials regarding CrCl . While in everolimus subgroup, improvement of CrCl over routine CNI regimen group was not significant . Totally, in the included observational studies, CrCl was significantly improved in CNI minimization group .Finally, we conducted a meta-analysis of CrCl of patients receiving CNI minimization  versus routine CNI regimen, which was shown in ing CrCl  showed tTo evaluate the safety of CNI minimization protocols, we then compared acute rejection episodes, incidence of infections and patient survival between CNI minimization and routine CNI regimen group.P = 0.89; I2 = 28%; sirolimus subgroup: Z = 0.28, P = 0.78; I2 = 21%; everolimus subgroup: Z = 0.01, P = 0.99; I2 not applicable; and total: Z = 0.01, P = 0.99; I2 = 0%) . While in sirolimus subgroup, the infection incidence was significantly higher than in routine CNI regimen group . In total, the infection incidence was significantly higher in CNI minimization group .We also conducted a meta-analysis of the incidence of various infections between two groups shown in . The difP = 0.67; I2 = 0%; sirolimus subgroup: Z = 0.59, P = 0.56; I2 not applicable; everolimus subgroup: Z = 0.47, P = 0.64; I2 not applicable; and total: Z = 0.28, P = 0.78; I2 = 0%)  nephrotoxicity and chronic  nephrotoxicity. Whereas acute nephrotoxicity is reversible by withdrawal of the CNI, chronic nephrotoxicity due to CNIs is thought to be irreversible and even progressive In the current meta-analysis , both GFR and sCr comparison presented a significant improvement of renal function in CNI minimization group in both RCTs and observational studies analysis. Although there was significant improvement of CrCl in CNI minimization over routine CNI regimen in observational studies, we could not document such improvement in RCTs analysis. According to the National Kidney Foundation recommendation, GFR is the best estimate of kidney function and is used in the NKF staging of CKD, thus it is rational to conclude that CNI minimization is capable to restore renal function of liver transplant patients with CNI-related renal impairment.To explore whether CNI reduction is safe in liver transplant recipients, we performed a meta-analysis of acute rejection episodes, infection rates and patient survival. There was no significant difference in acute rejection episodes between CNI minimization and routine CNI regimen, suggesting the immunosuppression effect was not compromised in patients taking on CNI minimization. However, the incidence of infections is higher in CNI minimization group than in routine CNI group, although most studies did not provide the exact incidence of specific infections, suggesting increased immune load by CNI minimization protocols when introducing MMF or mTORis. On the other hand, there was no significant difference in patient survival between two groups, which can be interpreted in three ways. Firstly, the follow-up durations of these studies are not long enough to show any change of the survival rate. Secondary, the improvement in renal function is not sufficient enough to alter patient survival Notably, the CNI minimization protocols in the included studies are heterogenous. Since the additional drugs and different combinations can alter the outcomes, we divided them into 3 subgroups, namely MMF-based, SRL-based and ERL-based subgroups. In both meta-analysis of RCTs and observational trials, the MMF-based regimen presents an obvious benefit on renal function protection. It has been reported that replacement of CNI by MMF in liver transplant patients with renal dysfunction can also improve other CNI associated side-effects, such as hypertension and hyperuricemia In addition, mTORis are potent anti-proliferative agents that have clear therapeutic potential in liver transplantation Undoubtedly, there are some limitations in the current meta-analysis as others. Firstly, we included studies using different regimens without comparing between themselves, it make us difficult to figure out which combination is the best one although the current data show that the MMF-based CNI minimization protocol received the greatest supports. Secondly, most of the studies we included didn't undertake follow-ups longer than 12 months, giving us insufficient data on how CNI minimization would affect long-term graft or patient survival. Finally, as shown in In conclusion, this meta-analysis included all current relevant studies from various countries covering different populations. It can make up to the shortage of small sample size and limited population of individual studies, providing stronger evidence on the clinical application of CNI minimization protocols. It is convincing that CNI minimization can improve renal function in liver transplant patients with CNI-related renal impairment, while has an equal or similar effect on acute rejection and patient survival as routine CNI regimen. However, it should be cautious to use SRL-based minimization regimens in patients with high risks of infections. Studies in the future should try to figure out whether this improved renal function can prolong long-term patient or graft survival, and which minimization protocol is the standard one in various combinations.Figure S1Meta-analysis of CNI minimization versus routine CNI regimen in GFR . In MMF and sirolimus subgroups, GFR was significantly higher than in the routine CNI regimen group, so was in the total analysis. Z = total effect size, I2 = heterogeneity index. Columns in green represent the mean difference of each study and column size represents the study weight in the analysis. Lanes represent the 95% CI of each study. Diamonds in black represent the overall effect size and diamond width represents the overall 95% CI.(TIF)Click here for additional data file.Figure S2Meta-analysis of CNI minimization versus routine CNI regimen in sCr . In MMF, sirolimus and everolimus subgroups, the SCr was significantly decreased in CNI minimization group, so was in the total analysis. Z = total effect size, I2 = heterogeneity index. Columns in green represent the mean difference of each study and column size represents the study weight in the analysis. Lanes represent the 95% CI of each study. Diamonds in black represent the overall effect size and diamond width represents the overall 95% CI.(TIF)Click here for additional data file.Figure S3Meta-analysis of CNI minimization versus routine CNI regimen in CrCl . In MMF subgroup, CrCl was significantly higher in the CNI minimization group than in the routine CNI regimen group. In everolimus subgroup, improvement of CrCl over routine CNI regimen group was not statistically significant. In the total analysis, the CrCl was significantly improved in CNI minimization group. Z = total effect size, I2 = heterogeneity index. Columns in green represent the mean difference of each study and column size represents the study weight in the analysis. Lanes represent the 95% CI of each study. Diamonds in black represent the overall effect size and diamond width represents the overall 95% CI.(TIF)Click here for additional data file.


Close adaptation of the prosthesis to the bone is the key to achieving optimal stability and fixation for total hip arthroplasty (THA). However, there have been no adequate studies of bone morphology, especially in different races. The aim of this study was to analyze the geometry of the acetabulum and proximal femur of people from South China, based on three-dimensional reconstruction, and to detect differences between different population subsets. CT scans were performed on 80 healthy volunteers (160 hips) from South China, comprising 40 males (80 hips) and 40 females (80 hips). The images were imported into Mimics 10.01 to perform 3D reconstruction. THA-associated anatomical parameters were measured and compared with other published data. In comparison with published data, it seemed that people from South China have smaller acetabular abduction angle, larger acetabular supro-inferior diameter, larger neck-shaft angle, smaller offset, thinner femoral shaft and more proximal isthmus, which needed to be further confirmed. There were significant differences between the genders in most parameters. As significant differences in canal flare index (CFI) and distal canal flare index (DCFI) were found between genders, it was concluded the most significant differences lay in the isthmus of the femur. Among the femora, according to Noble’s classification we identified more normal types and fewer stovepipe and champagne-flute types than expected from the literature, indicating that uncemented prostheses would be suitable for most people from South China. Our findings reveal that simply choosing the smallest of a series of prostheses would not necessarily provide a good fit, due to the different trends from the proximal to the distal part of the femur. Significant variation exists in THA-associated anatomy between genders and population subsets. It is therefore imperative that each patient receives individual consideration rather than assuming all patients have the same anatomy, especially for different races. Total hip arthroplasty (THA) has been proven to be a good choice for many disorders of the hip et al.et al.As part of the development of surgical technique, a series of related studies have been carried out. Noble Yet, despite the published data, there are no adequate data on bone morphology, especially in different races. We found that, in our clinical practice using imported prostheses, the two adjacent sizes of prosthesis may be too large and too small, or in some cases the distal component may be suitable while the proximal component was too small. We hypothesized that the THA-associated geometry was different between genders, and that of people from South China, especially enlargement of the endosteal dimensions, differed significantly from the Caucasian model according to which the implants were designed. The aims of this study were to (1) investigate and describe the geometry of the acetabulum and proximal femur of people from South China, (2) investigate variations in the acetabulum and proximal femur among different individuals, and (3) determine whether the sizes of the acetabulum and proximal femur were related to demographic data, such as gender and age, based on three-dimensional (3D) reconstruction which was a more credible method.This study was approved by the ethics committee of Nanfang Hospital and signed informed consent was obtained from each patient. In this study, the included population was a nonrandomized, healthy group of volunteers. The inclusion criteria were as follows: people from Guangdong and Guangxi province of China , having no hip disorders. Pregnant women and people with the following signs of the hip were excluded: pain, deformity, abnormal movement, claudication, rheumatic fever, rickets, rheumatoid arthritis, osteoarthritis, osteonecrosis of the femoral head, fracture or previous surgery.Eighty individuals  were recruited in this study. One hundred and sixty scanned hips were available for analysis. The average age was 31.38 (20–45) years, the average height was 167.25 (151–185) cm, and the average weight was 59.99 (40–80) kg. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2000.All patients were scanned following an identical protocol using a 64-slice multi slice spiral CT . Patients were placed in the supine position. The lower limbs were fully extended, fixed in neutral rotation with toes pointed up, and strapped to prevent movements during acquisition. CT scans were taken with a contiguous thickness of 0.625 mm, from the anterior superior spine to the top of the patella, with settings of 120 kV and 80 mA. Images from each CT scan were saved as DICOM images and recorded on a separate CD-ROM.The DICOM images were imported into Mimics 10.01 software  to perform 3D reconstruction. The bone geometry was calculated automatically based on radiodensity and stored as a contour map. The contours from sequential images were connected using triangular surface tiles to create 3D models, which could then be displayed in any position or orientation. Using the software, the following steps were performed to create 3D bone reconstructions: contrast adjustment (0–350), thresholding (226–1821), region growing, editing masks, editing masks in 3D, calculating polylines, cavity filling, boolean operations, morphology operations and 3D calculations. Images in the horizontal, coronal and sagittal planes were defined. The center of the acetabulum and femoral head rotation was deduced in the software by fitting a sphere through the surface of the femoral head.The following parameters were measured: anteversion angle (AAVA), abduction angle (AABA) and supro-inferior diameter (ASD) of the acetabula; the femoral anteversion angle (FAVA), neck-shaft angle (NSA), diameter of the femoral head (FHD), offset, medial-lateral diameter and antero-posterior diameter of the bone medullary cavity at a plane 20 mm above , at the midpoint , and 20 mm below the lesser trochanter , the internal (IID) and external diameter (IED) of the isthmus, and the position of the isthmus (IP). Canal flare index (CFI) was calculated as the ratio between the medial-lateral canal width 20 mm above the midpoint of the lesser trochanter and the isthmus width To perform the above measurement, several key points need to be located. Spherical fitting was performed to the femoral head, and the center of the sphere was regarded as the center of the femoral head. The axes of the femoral shaft and neck were calculated as the center of polylines of the endosteal cavity, and the intersection of the two axes was regarded as the break point between the shaft and neck. Other points were located according to their coordinates along certain axes, which meant the points with minimum or maximum coordinates were chosen. For example, when measuring the internal diameter of the isthmus, all coordinates of points on the medullary cavity were exported, and the two points with maximum and minimum coordinates along the X axis were chosen.The intraclass correlation coefficient (ICC) was applied to assess the reliability: 0.00 to 0.20, poor; 0.21 to 0.40, fair; 0.41 to 0.60, moderate; 0.61 to 0.80, substantial; and 0.81 to 1.00, perfect. In order to ensure the reliability of the results, 40 cases  were selected randomly, and two authors performed the measurements on these cases twice each with an interval of one month.t test, otherwise a non-parametric test was applied. Pearson correlations were used to determine the relationships between different anatomic parameters. In correlation analysis, the data of only one side was selected randomly. Results of different studies were compared by ANOVA. P-values <0.05 were considered significant.Distribution of the values was assessed using descriptive statistical analysis. Normally-distributed data were compared using Student’s Measurement reliability was satisfactory with ICC varying from 0.72–0.93 for different indicators. The measurement results were characterized by a normal distribution after normality testing. The acetabulum was anteverted 20.09° (2.56°) and abducted 49.32° (3.77°), with an average supro-inferior diameter of 58.74 mm (4.20 mm). These findings are summarized in Several studies have been performed to analyze the bone structure . Throughvs. offset, P = 0.908) to 0.833 . Weaker correlations were generally observed between most of the parameters. Significant correlations were detected between variables describing the canal width in the vicinity of the lesser trochanter, consistent with the studies of Dai et al.et al.Considering the correlation between diameters at different levels of the proximal femur with age and height , the corIn addition to relieving pain, the objective of THA is to achieve good reconstruction of the hip et al.et al., there were more normal types (85% vs. 83%) but fewer stovepipe types (7.5% vs. 9%) or champagne-flute types (7.5% vs. 8%).Given the wide individual variability in THA-associated anatomical bone structure, it should be noted that one procedure/implant could cure one patient’s hip disorders but worsen another’s. Small changes during osteotomy or in implant design could either drastically improve or worsen the outcome of the procedure. The variability in bone morphology is consistent with the consensus that the geometry of the femur is determined by a series of genetic and environmental factors, such as race, sex, age, and life-style. These influences appear to lead to unique bone geometries, as characteristic of each individual as any other feature of human anatomy Good clinical results and midterm survival rates of cementless THA have been published et al.Surgeons are always trying to restore the original position of the center of the femoral head to ensure maintenance of leg length and reestablishment of the original balance joint forces. Thus femoral components must be available in a range of neck lengths  for each separate stem size. Improving the design of the epiphyseal section of the implant becomes a necessity. Observations in this study showed variation of the neck shaft angle of 27.53°, which is consistent with the results of Clark It was noteworthy that, in this study as well as those discussed above, gender differences existed in most of the parameters, and were of the same magnitude, implying that surgeons should take the slight variations between male and female geometry into account when planning and performing THA. The results highlight the importance of determining normal values for the acetabular orientation of the different genders Anatomic measurements based on CT images are reported to be convenient and rapid for routine diagnosis, as well as for preoperative analysis if necessary The application of 3D reconstruction in studies has numerous advantages over cadaver specimens: greater number of cases, accessible demographic data, ideal magnification and spatial orientation of the bone structure. By means of digitization, points can be clearly marked and their placement may be corrected a posteriori, if needed.The characteristics of this study can be summarized as aiming at different races and precision of measurements. The availability of THA-associated geometric data allows guidelines to be developed for the procedure and assessment of the match between the bone and the prosthesis. It is imperative that each patient should be considered individually even while assumed to have the same anatomy


EPHX1, NQO1 and PON1 are three genes encoding proteins directly involved in the detoxification of potential carcinogens.The interplay between genetic susceptibility and carcinogenic exposure is important in the development of haematopoietic malignancies. EPHX1, rs1800566 NQO1 and rs662 PON1 in 215 patients with lymphoma and 214 healthy controls.We have studied the prevalence of three functional polymorphisms affecting these genes rs1051740 EPHX and NQO1 polymorphisms did not show any correlation with disease. In contrast, the GG genotype in the PON1 polymorphism was found to be strongly associated with the disease : 1.8-7.7; p < 0.001). According to the pathological diagnosis this association was related to follicular (p = 0.004) and diffuse large B-cell (p = 0.016) lymphomas.Genotype frequencies for PON1 GG genotype in rs662 polymorphism could be a risk factor for B-cell lymphomas.Despite the fact that further confirmation is needed, this study shows that the  The development of lymphomas including Hodgkin’s (HL) and non-Hodgkin’s lymphoma (NHL) is, to a great extent, the result of a combined effect of genetic susceptibility and environmental factors. Xenobiotic metabolizing enzymes, such as EPHX1, NQO1 and PON1, play a role in the detoxification of potential carcinogens from chemical industries as well as endogenous compounds. AlthougTo our knowledge, few studies have analysed polymorphisms in genes coding for xenobiotic metabolism enzymes  in lymphoma or leukeBlood samples were obtained from 215 lymphoma Caucasian patients −194 NHL and 21 HL residents of either Murcia or Cartagena, in the Southeast of Spain. Lymphoma classification and diagnose was based in the 2008 World Health Organization classification of lymphoma. Our stux) as NO2, sulfurdioxide (SO2), chlorine (ClH) volatile organic compounds (VOCs) as benzene and mercaptans and particulate matter smaller than 10 microns (PM10) were amongst the most common pollutants in that area. Previous studies have confirmed a higher cancer incidence in this area compared with both the national average and the neighbouring municipalities[The geographical area under study included a specific zone  with many chemical plants comprising one of the highest densities of heavy chemical industries in Spain-18 inclupalities,20.Total genomic DNA was obtained from blood samples using the automatic DNA extraction system Maxwell 16 and DNA extraction kit for blood samples (cat: AS1010)  according to the manufacturer’s instructions. DNA was quantified by UV absorbance using the Biophotometer by Eppendorf .NQO1 and PON1 polymorphisms were determined by allelic discrimination using TaqMan probes and a 7500 F real-time PCR thermocycler both provided by Applied Biosystems . For the EPHX polymorphism we used the amplifluor SNPs genotyping system .t-test was used to compare mean age of cases and controls and Yeats-corrected Pearson χ2 test was used to evaluate statistical significance of genotype distribution in cases and controls. Given that xenobiotic metabolizing enzymes would behave as possible tumor suppressor by eliminating potential carcinogens, a recessive model for the p-value calculation was preferred, however the main results were also studied following dominant and co-dominant models. Hardy-Weinberg, linkage disequilibrium (LD) and joint effect analyses of the studied polymorphisms were performed using the online program Shesis Page [Sample size reached in our series was optimum according to the sample size estimation for a gene-only study obtained with Quanto v.1.2 program . Statistsis.php).The main demographical features of patients and controls are shown in Table EPHX and two for NQO1. The genotype frequencies in the study population were EPHX1: TT 54.8%, TC 36.7%, CC 8.5%; NQO1: CC 59.5%, CT 35.0%, TT 5.4% and PON1: AA 42.7%, AG 47.3%, GG 10.0%, consistent with the Hardy-Weinberg equilibrium  and similar to the HapMap-CEU (European) frequencies : 1.8-7.7; p < 0.001) . When restricting for males and females p values were 0.016 and 0.054, respectively. However, no significant differences were obtained when the dominant model was used for any of the polymorphisms (data not shown).As shown in Table In order to ascertain the possible combined effect of the genotypes a joint effect analysis was performed and showed that the only significant combination was T-C-G for EPHX1, NQO1 and PON1 polymorphism, respectively rendering an OR of 1.73  . Exposition of wild type human bone marrow cells to hydroquinone (HQ) trigger an increase of NQO1 protein and activity, not induced in TT carriers[NAD(P)H dehydrogenase, quinone 1, a 2-electron reductase encoded by carriers. Moreovecarriers. Some aucarriers,30,31 ancarriers,32 wherecarriers-35.PON1 a gene located in 7q21.3, hydrolyzes the toxic oxon metabolites of several organophosphorous insecticides, as well as nerve agents, aromatic esters and a variety of aromatic and aliphatic lactones[PON1 rs662 polymorphism consists of an A-to-G substitution that causes a Gln-to-Arg change at residue 192 (Q192R). Humbert et al. found that the allele encoding arginine has high-activity plasma paraoxonase, whereas glutamine at this position specifies a low-activity variant[Paraoxonase 1, encoded by lactones. The PON variant. The rol variant and lympPON1 was associated with lymphoma risk, being the GG genotype related with increased susceptibility to lymphoma in general, and to FL and DLBCL in particular. This finding is concordant with that reported by Kerridge et al. analysing DNA extracted from archival tumour specimens from a population of 169 NHL cases and 205 controls[In our work, we studied the functional germline polymorphisms rs1051740, rs1800566 and rs662 in lymphoma patients and controls. Although the study subjects come from the same geographical area, important aspects concerning the source of cases and controls have to be taken into account. First, the controls do not represent exactly the general population since they are blood donors and second there is a degree of heterogeneity in the cases since they comprise several types of lymphoma that may be caused by different etiological factors. We found that rs1051740 or rs1800566 in EPHX1 and NQO1 were not related with lymphoma susceptibility as previously reported by others[controls, rs26470controls in the hcontrols. InteresPON1 polymorphism and lymphoma risk although this finding should be confirmed in larger and independent series.This is the first study demonstrating a relationship between the germline rs662 DLBCL: Diffuse large B-cell lymphoma; EPHX1: Epoxide hydrolase 1; FL: Follicular lymphoma; HL: Hodgkin’s lymphoma; HQ: Hydroquinone; NHL: Non-Hodgkin’s lymphoma; LD: Linkage Disequilibrium; NQO1: NAD(P)H dehydrogenase, quinone 1; PCR: Polymerase chain reaction; PON1: Paraoxonase 1; SNP: Single nucleotide polymorphisms.The authors declare that they have no competing interests.PCZ: Conception and design of the study, DNA extraction and manuscript drafting; JRC and DTM: Genetic analysis and interpretation of data; IE, MDGM and EPC: Analysis and interpretation of clinical data, JTS: Statistical analysis; RGC: DNA extraction and data analysis, JC, VV and MPG: Critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/228/prepub