Copy number variation is now recognized as an important class of risk factor for several child psychiatric disorders. In this article, we first explain what copy number variants (CNVs) are. We then consider key findings and what these have told us about the etiology of these conditions. Finally, we discuss whether these findings can yet translate into clinical practice.There are multiple types of genetic alterations that contribute to human variability, many of which have yet to be fully characterized or properly understood. This genetic variation can involve differences in the DNA nucleotide sequence as well as changes in chromosome structure. Single nucleotide polymorphisms (SNPs) are common variants of individual nucleotide sequence that are frequently observed in the population (>1%). CNVs are a type of structural variant involving alterations in the number of copies of specific regions of DNA, which can either be deleted or duplicated. These chromosomal deletions and duplications involve fairly large stretches of DNA  but can range considerably in size as well as prevalence. As is the case for other types of genetic mutations, some CNVs are inherited whereas others spontaneously arise de novo. To date, most CNV research in psychiatry has focused on rare forms of copy number variation that occur with a frequency of <1%.There are several well-characterized rare developmental phenotypes caused by CNVs of known pathogenicity, such as Velocardiofacial, Prader-Willi, and Smith-Magenis syndromes. Although the role of most CNVs is far less clear, there is now growing evidence that the genetic architecture of more common psychiatric and neurodevelopmental conditions includes different types of both common and rare genetic variation.Risk factors for complex disorders tend to be of small effect size (odds ratios of <2), and this has certainly proved to be the case for individual SNPs. Conversely, the types of CNVs that have been found to be associated with neurodevelopmental and psychiatric disorders have been of considerably greater effect size.3Psychiatric disorders mainly have a complex, multifactorial etiology. Apart from some infrequent exceptions , a single risk, whether genetic or environmental, is neither necessary nor sufficient to result in disorder. Thus, typical of all complex disease epidemiology, many carriers of risk CNVs will not display a psychiatric or neurodevelopmental phenotype, and not all those affected will possess the risk variant. As an analogy, although cigarette smoking is a well-established risk factor of large effect size, not all smokers develop lung cancer, and not all individuals with lung cancer have smoked. There are likely multiple types of risks and pathways that lead to the same child psychiatric disorder.Genetic data from parents are required to identify whether variants are inherited or have arisen de novo. So far, although CNVs have been found to be both inherited and de novo in origin, much interest has focused on de novo mutations. Such mutations are associated with risk of ASD, ID, and schizophrenia but would not contribute to the familial transmission of these disorders. Increased paternal age has been found to be associated with some types of mutations, as well as with risks of both ASD and schizophrenia. Rare de novo CNVs do not, however, necessarily explain all the observed paternal age effect.Although ASD, ADHD, schizophrenia, and ID have clinically distinctive defining features, one key and consistent finding is that the CNVs associated with each of these disorders show significant overlap with each other.The chromosomal regions that harbor CNVs observed to be associated with psychiatric disorder are located at multiple genomic regions on many different chromosomes, and each deletion or duplication often encompasses several genes. So, are these simply randomly distributed mutations, or are their locations significant? Multiple types of evidence suggest that CNV locations provide meaningful clues to the neurobiology of these disorders. Genes code for proteins that are involved in different biological processes. The functions of different genetic elements are not fully understood; however, genetic findings can be used to make inferences about the biological processes involved. Although there are some methodological limitations to this approach, consistent patterns of findings are emerging. The rare CNVs found to be associated with ASD, ADHD, schizophrenia, and ID all seem to span genes that converge on meaningful biological processes. For example, CNV studies of ASD, schizophrenia, and ID have strongly implicated disrupted synaptic function. Studies of ADHD have suggested involvement of nicotinic acetylcholine receptor pathways, glutamatergic transmission , and genes involved in neural development.To interpret CNV findings in a clinically meaningful way is challenging. Essentially it is difficult to prove causal pathogenic effects. Moreover, most child psychiatric disorders, including those that have been found to be associated with CNVs, are multifactorial in origin and not caused by a single risk factor. In many cases, the presence of a specific CNV will not necessarily imply that it played a role in causing disorder, and, for some CNVs, carriers can be unaffected. Inferring causality is further complicated by the high levels of comorbidity between different child psychiatric and developmental disorders. Furthermore, incomplete penetrance, pleiotropic risk effects, and de novo mutations make estimating the risk of disorder recurrence particularly complex. The etiological role of environmental factors and gene–environment interplay in complex disorders should also not be overlooked—nor should the contribution of other classes of genetic variant.Advances in techniques for detecting submicroscopic chromosomal abnormalities have meant screening for rare CNVs in idiopathic ID has become increasingly commonplace. Rare, syndromic forms of ASD and other psychiatric disorders will likely require similar types of assessment and counseling. However, for most children who are under the care of child psychiatrists, it seems unlikely that routine CNV testing will become established practice in the near future for the majority of individuals unless perhaps they also have ID or multiple developmental morbidities. Prevention and treatment strategies based directly on genetics also remain distant.Nonetheless, the establishment of CNVs as risks for psychiatric disorders is an important breakthrough. The findings highlight commonalities across different neurodevelopmental disorders. The genes indexed by CNVs are beginning to provide valuable biological insights and clues to patterns of altered brain development and function that accompany disorders such as ASD, ADHD, and schizophrenia. CNV findings, by shedding light on pathogenesis, can contribute to progress in developing novel interventions and risk modification strategies that target relevant risk processes in the nearer future.


CSF biomarkers represent an underutilized but valuable approach to understanding the interactions of HIV and the CNS and to more objective diagnosis and assessment of disease activity. Both hypothesis-based and discovery methods can be useful in advancing the definition and use of these biomarkers.Central nervous system (CNS) infection is a nearly universal facet of systemic HIV infection that varies in character and neurological consequences. While clinical staging and neuropsychological test performance have been helpful in evaluating patients, cerebrospinal fluid (CSF) biomarkers present a valuable and objective approach to more accurate diagnosis, assessment of treatment effects and understanding of evolving pathobiology. We review some lessons from our recent experience with CSF biomarker studies. We have used two approaches to biomarker analysis: targeted, hypothesis-driven and non-targeted exploratory discovery methods. We illustrate the first with data from a cross-sectional study of defined subject groups across the spectrum of systemic and CNS disease progression and the second with a longitudinal study of the CSF proteome in subjects initiating antiretroviral treatment. Both approaches can be useful and, indeed, complementary. The first is helpful in assessing known or hypothesized biomarkers while the second can identify novel biomarkers and point to broad interactions in pathogenesis. Common to both is the need for well-defined samples and subjects that span a spectrum of biological activity and biomarker concentrations. Previously-defined  Infection of the central nervous system (CNS) begins during primary systemic infection and continues throughout its untreated course . Immune activation is critical to general systemic progression and also contributes to organ injuries from a variety of ‘nonAIDS-related’ diseases  concentrations. These serve as indicators or vectors of these pathogenetic components; other terms that have been used for these types of biomarkers are orthogonal biomarkers and endophenotypes , it is important to emphasize the value of this class of diagnostic markers in neurological disease complicating HIV infection  CSF’s proximity to the brain and spinal cord with which it exchanges molecular components, and thus allows sampling of the brain microenvironment . This is particularly at issue with viral and inflammatory biomarkers and less so with neural biomarkers that originate in the brain and not meninges, though spinal nerve roots may also potentially ‘contaminate’ CSF with neuronal breakdown products in the presence of neuropathies.It is also pertinent to emphasize some of the biological pitfalls of interpreting CSF findings in HIV infection, particularly with regard to HIV and immune biomarkers. This relates to the mixed origin of these molecules This distinction of compartment origin may be critical to interpretation. For example, HIV RNA can be measured in the CSF of nearly all untreated patients with detectable plasma viral loads, dating from the earliest sampling during acute infection through the chronic phase and in the presence of HAD with underlying HIVE , an accurate longitudinal perspective is often difficult to obtain during a single clinic visit or at the start of a clinical trial where only a ‘snapshot’ is available. Biomarkers of active CNS disease potentially can also be used as surrogate clinical trial endpoints, much like plasma HIV RNA and blood CD4+ T cells are used in studies of systemic disease treatment. Obviously, these clinical applications require robust and reproducible analytical methods and established reference standards. Hence, initial approaches as emphasized in this review need to be followed by more rigorous validation studies so that a CSF biomarkers can also provide important insight into pathogenesis, measuring component biological processes that are not apparent either clinically or by other measurements, including blood studies or neuroimaging. Studies of pathogenesis may also focus on several biomarkers simultaneously, aiming to define not only their role in our association with an aspect of disease production but also their interactions. Hence, while clinical studies often strive for parsimony and the value of one or only a few measures, pathogenesis studies may look at a broader spectrum of biomarkers to understand different components of disease. Both novel and established biomarkers may provide insight into underlying mechanisms and how these mechanisms relate to different stages or manifestations of CNS HIV infection and resultant disease. Studies of pathogenesis may also seek to identify therapeutic targets beyond virus replication, including ‘adjuvant’ strategies that seek to mitigate components of pathogenesis other than simple reduction in infection.Approaches to biomarker studies can be classified on the basis of a number of features. Here we review two different approaches and illustrate these with two of our recent studies, one targeted and hypothesis-directed and the other using an untargeted discovery design Table .Table 2TOur ongoing targeted, hypothesis-directed study is typical of an approach in which candidate biomarkers are examined for their possible clinical application . Biomarkers included in this type of study are often selected on the basis of blood biomarkers that might also be useful in CSF, observations made in cell culture or animal studies, or theoretical promise related to a particular facet of disease. Using data extracted from this study, we illustrate results measuring the three cardinal guide biomarkers listed earlier Fig. . HIV RNAAs shown in Fig. Because the biomarkers were defined at the initiation of study, they address an articulated or implied hypothesis—the association of the biomarker with a particular aspect of disease evolution. Typical of this type of study, it used a cross-sectional, observational structure drawing on archived samples from a relatively large number of subjects, though not as large as other more definitive studies. The results illustrate a number of important features of advancing disease as described in the legend of Fig. While the initial analytical approach compared the defined subject groups, analysis can also be extended to examine interrelations among the measurements across the larger subject sample. Analysis of one or a few novel biomarkers using multiplex assays is relatively straightforward at this exploratory level because of the circumscribed number of variables examined. This type of cross-sectional design can be supplemented by longitudinal studies to define the natural history and progression or response to therapy of individual subjects . This strategy, for the time being, ignores the important issue of using biomarkers to define milder CNS disease in untreated and treated subjects that has been classified under the Frascati criteria as minor neurocognitive disorder (MND) and asymptomatic neurocognitive impairment (ANI) defined by similar impairment levels on formal neuropsychological testing (Antinori et al. In practice defining the biomarkers related to MND and ANI conditions presents a formidable problem. These conditions are etiologically and pathogenetically more heterogeneous and ambiguous (Heaton et al. This illustrative second study was not limited by a priori hypotheses and used high-throughput proteomics, a discovery-based approach to identify novel protein biomarkers and identify their possible relationships (Angel et al. However, using this approach how does one then analyze and interpret such a heterogeneous group of subjects with different baseline states, variable timing of and responses to ART and different number of samplings? For our initial analysis we used the three cardinal biomarkers listed earlier and examined how they correlated with features of the proteome over the entire sample set. This allowed us to identify proteins that varied in concentration with these markers, and thus were associated with changes in infection, immune activation-inflammation and neural injury as defined by these guides, thereby providing important context for the measured changes in these identified proteins and an initial description of their correlations and biological pathway relations. We also more directly examined correlations among the identified proteins themselves (Angel et al. Among the differences in this type of discovery study and the hypothesis-based study as described above, is that the large number of identified proteins present a formidable informatics and analytical challenge. The use of the guide biomarkers allows an initial view of the proteome that can then be extended to an increasingly broad perspective by building on these associations. Thus, these initially defined endophenotypes serve as a scaffold for extended explorations. Figure Cross-sectional design can also be used for pathogenetic studies, and indeed the cross-sectional study described earlier represents one phase of a broader study that began with definitions of guide biomarkers, has been extending to additional predefined biomarkers, and is now being further extended through proteomic analysis. In this study, differences in the proteome between groups and across the entire sample can be analyzed in relation to these defined guide biomarkers.Once this type of study reveals a series of pathogenetically interesting proteins, the challenges then include: ‘validating’ the general findings using more quantitative assays, most often immunoassays, applied to some of the salient proteins; reproducing the salient findings independently using an independent sample set or experimental paradigm; and finally beginning to explore causality in the various relationships suggested by the correlations and pathways. In this sense, this type of exploratory methodology is only the beginning of pathogenetic exploration, but nonetheless invaluable. Similarly, identified proteins that appear attractive as clinical biomarkers need to be characterized further using simpler, more quantitative and eventually reproducible assay methods that can be broadly applied in clinical settings.Whatever approach is taken to characterize CSF biomarkers in HIV infection, a critical requirement is the careful and clear classification of study subjects and samples. This is a common feature of both hypothesis-driven and discovery methods. There is more than one structural approach to this issue. This includes the use of biologically meaningful, well-defined subject groups for cross-sectional analyses as illustrated above with the subject divisions across the spectrum of systemic progression, transition to HAD and treatment. Longitudinal studies may also rely on patient classifications, but also can benefit from a defined structure that includes similar baseline characteristics, interventions and scheduled assessments that allow subject or time groupings for analysis. The second approach, using independent biomarkers to classify samples, is generally more flexible and can be used for either primary or secondary analysis.Figure Despite the early recognition of the importance of CNS HIV infection and its link to brain injury, diagnosis and management has been limited by the lack of objective measures of disease. While CSF biomarkers have already been useful in defining the natural history of these linked processes and their responses to treatment, they have been underexploited for pathogenetic study and have found very limited use in the clinic for either patient management or clinical trials. While there is clear need for further characterization of already-studied biomarkers and discovery of additional useful biomarkers, it is also time to undertake studies that validate available CSF biomarkers and open the way for their use in clinical practice either as single markers or using a combinatorial approach (Gisslen et al.


However, most studies reported inconclusive results. A meta-analysis was conducted to investigate the association between polymorphism in the PAI-1 gene and asthma susceptibility.A number of studies assessed the association of −675 4G/5G polymorphism in the promoter region of Databases including Pubmed, EMBASE, HuGE Literature Finder, Wanfang Database, China National Knowledge Infrastructure (CNKI) and Weipu Database were searched to find relevant studies. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the strength of association in the dominant model, recessive model, codominant model, and additive model.P = 0.008), 4G/4G vs. 4G/5G+5G/5G , 4G/4G vs. 5G/5G , 4G/5G vs. 5G/5G , and 4G vs. 5G .Eight studies involving 1817 cases and 2327 controls were included. Overall, significant association between 4G/5G polymorphism and asthma susceptibility was observed for 4G4G+4G5G vs. 5G5G (OR = 1.56, 95% CI 1.12–2.18, PAI-1 gene was a risk factor of asthma.This meta-analysis suggested that the −675 4G/5G polymorphism of  Asthma is one of the most common chronic diseases affecting an estimated 300 million people worldwide P<0.0001) PAI-1, a key regulator of the fibrinolytic system, is involved in various physiological functions and associated with many diseases. Kelly et al. PAI-1 gene is located on chromosome 7 (q21.3–q22), where a locus related to serum IgE levels has been mapped PAI-1 promoter, has been identified. The 4G/5G polymorphism is a major genetic determinant of plasma PAI-1 levels PAI-1 gene and the risk of asthma The human PAI-1 gene variants and asthma. This was, to our knowledge, the first meta-analysis of the association between PAI-1 polymorphism and asthma susceptibility.Considering a single study may lack the power to provide reliable conclusion, we performed a meta-analysis to investigate the precise relationship between the Pubmed, EMBASE, HuGE Literature Finder, Wanfang Database, China National Knowledge Infrastructure (CNKI) and Weipu Database were all searched . The following terms were used in searching: (asthma or asthmatic) and (plasminogen activator inhibitor-1 or PAI-1 or SERPINE1) and (polymorphism or mutation or variant). No publication date or language restrictions were imposed. All the searched studies were retrieved, and their references were checked as well for other relevant publications. Review articles were also searched to find additional eligible studies.PAI-1 gene and asthma risk, (2) using a case-control design, (3) genotype distributions in both cases and controls should be available for estimating an odds ratio (OR) with 95% confidence interval (CI), and (4) genotype distribution of control group must be consistent with Hardy–Weinberg equilibrium (HWE). Studies were excluded if one of the following existed: (1) not relevant to PAI-1 or asthma, (2) the design based on family or sibling pairs, (3) genotype frequencies or number not reported, and (4) reviews and abstracts. For overlapping studies, only the one with the largest sample numbers was included.Studies fulfilling the following selection criteria were included in this meta-analysis: (1) evaluation of the 4G/5G polymorphism in Two investigators (Nie and Li) independently reviewed full manuscripts of eligible studies, and the relevant data were extracted into predesigned data collection forms. We verified accuracy of data by comparing collection forms from each investigator. Any discrepancy was resolved by discussion or a third author (Xiu) would assess these articles. The following variables were collected from each study: first author's name, year of publication, original country, ethnicity, sample size, asthma definition, genotyping method, atopic status, and genotype numbers in cases and controls.Z test, and P<0.05 was considered as statistically significant. We first estimated with the dominant model (4G4G+4G5G vs. 5G5G) and recessive model (4G4G vs. 4G5G+5G5G) and then evaluated codominant model (4G4G vs. 5G5G and 4G5G vs. 5G5G). We also estimated the risks of additive model (4G vs. 5G).The strength of the association between the 4G/5G polymorphism and asthma risk was measured by OR and 95% CI. The statistical significance of OR was analyzed by Q-test. I2 was also used to test the heterogeneity among the included studies. A P value>0.10 for the Q-test indicates a lack of heterogeneity among the studies, then the pooled OR estimate of each study was calculated by the fixed-effects model (the Mantel-Haenszel method). Otherwise, the random-effects model (the DerSimonian and Laird method) was used. In addition, a Chi square-test was used to determine if observed frequency of genotype in control population conformed to HWE expectations.The heterogeneity between the studies was assessed by the Chi square-test based Cochrane To evaluate the ethnic-specific, age-specific, and atopic-specific effects and to explore sources of heterogeneity, subgroup analyses were performed by ethnicity, age, and atopic status. Sensitivity analysis was performed through sequentially excluded individual studies to assess the stability of the results. Asymmetry funnel plots were used to assess potential publication bias. The Begg's test All statistical tests were performed by using the Revman 5.1 software  and STATA 11.0 software .Table S1. Genotype numbers and HWE examination results are listed in Table S2.2 was 27.08 and P = 0.0007 in a random effects model. In addition, the I2 value was 70%, suggesting significant heterogeneity. Therefore, the random-effects model was used for synthesis of the data. The overall OR for 4G4G+4G5G genotypes versus 5G5G genotypes (dominant model) was 1.56 (95% CI 1.12–2.18) and the Z test for overall effect was 2.65 (P = 0.008). This result suggested that individuals who carry the 4G allele may have a 56% increased asthma risk compared with 5G5G homozygote. When all the studies were pooled into meta-analysis using other genetic models (Table S3), there was also significant association between 4G/5G and asthma risk .As shown in P = 0.02) but not among Caucasians  in dominant model (4G4G+4G5G vs. 5G5G). Thus, Asian carriers of the 4G allele may have an increased risk of asthma. In the subgroup analyses by age, significant associations were found among adults , suggesting that adults carriers of 4G allele may have a 61% increased risk of asthma. Subgroup analyses were also performed by atopic status. Significant increased risk of asthma was found among atopic asthma patients . The result suggested that the 4G allele carriers (4G4G+4G5G) have an increased risk of atopic asthma compared with those individuals with the 5G5G homozygote. Furthermore, the heterogeneity was decreased significantly in atopic subgroup in every genetic model, suggesting atopic status was the potentially important source of heterogeneity. Summary results of other genetic comparisons are listed in Table S3.In the subgroup analyses by ethnicity, significant associations were found among Asians .Publication bias was assessed by Begg's funnel plot and Egger's test. The shape of the funnel plot showed slightly asymmetric in the 4G4G+4G5G vs. 5G5G comparison genetic model, suggesting the possibility of publication bias Figure 3PAI-1 deficient mice. In a murine allergic rhinitis model, the immune response appeared to be a dominant Th2 response in WT mice; however, in PAI-1 deficient mice, the Th2 response was shifted to a Th1-dominant response, suggesting a key role of PAI-1 in allergic inflammation PAI-1 deficient mice compared with WT mice PAI-1 gene, the 4G/5G polymorphism has been extensively studied. The 4G/4G genotype has been linked to higher PAI-1 level, compared with the 5G/5G genotype, with the heterozygous genotype associated with intermediate levels Asthma is a genetically complex disease caused by multiple genetic and environmental factors and is the result of the interaction of multiple genetic and environmental factors PAI-1 gene promoter and asthma risk. The results indicated that −675 4G/5G polymorphism was a conspicuous high risk factor for developing asthma in the overall study populations. In the subgroup analysis by ethnicity, no significant association was found in Caucasians in dominant model. However, asthma risk was increased in Asians (P = 0.02), suggesting a possible influence among environmental exposures and different genetic backgrounds. Cho et al. PAI-1 gene may be associated with the development of asthma in children. However, significant associations were only found in adults (P = 0.03). Since this meta-analysis included only one study using children population, the positive association between children and asthma could not be ruled out because studies with small sample size may have insufficient statistical power to detect a slight effect. Additional future studies should be performed focusing on children with asthma. Subgroup analysis was also performed among atopic status patients. Significant increased risk of asthma was found in these patients (P<0.00001), suggesting a possible role of PAI-1 in the etiology of allergic asthma. In addition, all atopic status patients were Caucasians. More studies are warranted to further validate atopic status difference in the effect of this polymorphism on asthma susceptibility, especially in Asians.This current meta-analysis of 8 studies including 1817 cases and 2327 controls systematically evaluated the association between −675 4G/5G polymorphism in the As the publication of findings often depends on the expectation of researchers, false-negative results may be suppressed or false-positive results magnified The present meta-analysis had several limitations that must be taken into account. First, the number of available studies that could be included in this meta-analysis was moderate. Therefore, the results could be influenced by the factors like random error. Second, the overall outcomes were based on individual unadjusted ORs, while a more precise evaluation should be adjusted by other potentially suspected factors including age, sex, and environmental factors. Third, because of the complex nature of asthma, it is unlikely that a SNP in one single gene would be obviously associated with an increase in asthma risk, without consideration of any other polymorphic susceptible genes. Kowal et al. PAI-1 4G/5G polymorphism and asthma susceptibility. It provided evidence of the association between PAI-1 −675 4G/5G polymorphism and asthma risk, supporting the hypothesis that the PAI-1 −675 4G/5G polymorphism may be a susceptibility marker for asthma. However, additional large case-control studies are required to validate our findings. Future analyses should be conducted in large-scale cohorts and should study the potential effect modification by age and atopic status in different populations. Moreover, gene-gene and gene-environment interactions should also be considered in future studies.To our knowledge, this study was the first comprehensive meta-analysis to assess the relationship between the Table S1Characteristics of the 9 case-control studies included in meta-analysis.(DOC)Click here for additional data file.Table S2Distribution of PAI-1 genotype among patients with asthma and controls included in the meta-analysis.(DOC)Click here for additional data file.Table S3Summary of different comparative results.(DOC)Click here for additional data file.


Congenital talipes equinovarus (clubfoot) can present in 2 forms: “syndromic”, in which other malformations exist, and the more common “idiopathic” form, where there are no other associated malformations. We analyzed the epidemiology of congenital talipes equinovarus in the Sicilian population, looking for potential etiological factors.Among the 801,324 live births recorded between January 1991 and December 2004, 827 cases were registered . Control infants were randomly selected from a historical cohort of live births without any major congenital malformations.A positive family history of clubfoot, gender, and maternal smoking were found to be risk factors for clubfoot. Patients with clubfoot were born most frequently during the period January–March. No association was found between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity.Our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors. Congenital talipes equinovarus (CTEV), usually known as ‘clubfoot’, is the most common congenital orthopedic disease. Its etiology is unknown but appears to be complex . The incCTEV can present in 2 forms. In severe syndromic CTEV, other malformations are present such as spina bifida, spinal muscular atrophy, sacral agenesis, or arthrogryposis. Associated features may also include joint laxity, congenital dislocation of the hip, tibial torsion, ray anomalies of the foot, and the absence of some tarsal bones. In idiopathic CTEV—the more common form—the anomaly is isolated or may be associated with minor malformations. There may be a family history of foot anomalies.The diagnosis of CTEV is based on clinical examination   and is sStudies on the epidemiology of CTEV could provide a basis for identifying potential risk factors. Thus, the aim of the present study was to determine the epidemiology of congenital talipes equinovarus in the Sicilian population and to describe the characteristics associated with the disease.Sicily, with a population of 5.6 million and about 50,000 births each year, had a Sicilian register of congenital malformations (ISMAC) between 1991 and 2004. In 2004, ISMAC was suspended and the register started again under new organization. We reviewed the database for notification of idiopathic CTEV. Case information included defect diagnosis, laterality of the defect, and presence of minor associated anomalies. In addition, data on infant and maternal health and demographics were collected. The infant variables collected included sex and birth weight, gestational age, and the number of months since birth. The maternal and pregnancy information collected included maternal and paternal age, family history, maternal history of pregnancy, exposure of the mother to illicit drugs or alcohol during the index pregnancy, maternal education, and ethnicity.Control infants were randomly selected from a historic cohort of live births without any major congenital malformations; these infants had been enrolled previously to study other covariates in newborns (unpublished data). Controls were selected to achieve a ratio of 2 control infants per case, matched by year of birth.To compare the annual number of newborns with congenital clubfoot with the total number of live births in Sicily between 1991 and 2004, we used official reports concerning native data from the Italian National Institute of Statistics (ISTAT). The cumulative incidence was calculated as the ratio between the number of children with clubfoot born each year and the number of native births during the same period. For the estimated incidence, the 95% confidence intervals (CIs) were thus calculated.Differences in covariates of interest between the clubfoot group and the control group were tested using the Chi-square test for categorical variables and Student’s t-test or Mann-Whitney U-test for abnormally distributed continuous variables. Categorical data are presented as frequency and percentage while continuous data are reported as mean (SD).To assess seasonal variation, we analyzed the monthly distribution of clubfoot deformities over the year (monthly cumulative incidence). The methodology of analyzing circular data has been described elsewhere . In brieUnadjusted odds ratios (ORs) and the associated 95% CI for risk of clubfoot by different strata of maternal and paternal age, family history, pregnancy maternal history, maternal exposure to illicit drugs or alcohol during the index pregnancy, maternal education, and ethnicity were calculated. A multivariate logistic regression analysis was conducted to identify independent risk factors of clubfoot and adjusted ORs and associated 95% CI were calculated. A backward, stepwise selection approach using covariates found to be significant by univariate analysis was employed in the modeling strategy.All statistical tests were two-tailed and a p-value of < 0.05 was considered significant. Variables found to be associated with the dependent variable in univariate analyses  were included in multivariate regression models. Data were entered into Microsoft Excel for Windows . Statistical analysis was performed using SPSS for Windows release 17.0.Between January 1991 and December 2004, 827 cases  were recorded. Among the 801,324 newborns recorded in Sicily between 1991 and December 2004, the birth prevalence of children affected by clubfoot was 1.03 per 1,000 births . The anoThe seasonal variation in children with clubfoot peaked at 37º, corresponding to birth in the winter period (January to March) . The strWhen we compared the demographic characteristics  of the cUnivariate logistic regression revealed no association between clubfoot and reproductive history, peri-conceptional maternal drug exposure, maternal education, or ethnicity, but sex of the child, maternal smoking, and familial history of clubfoot were statistically significantly associated with higher risk of clubfoot (data not shown). After adjusting for covariates, sex (odds ratio (OR) = 0.68, CI: 0.56–0.81; p < 0.001), smoking  and familial history  were found to be independent predictors of clubfoot .We found a cumulative incidence of congenital clubfoot in Sicily during the period 1991–2004 that was similar to that reported for Italy (unpublished data). We also found a decrease in the cumulative incidence during the last years of the observation period. However, we cannot assess whether this is because of under-reporting. Although it is difficult to provide a definite answer, we consider our study to be important because it is one of the few studies to investigate cumulative incidence and prevalence of clubfoot with assessment of possible risk factors.We found an incidence of CTEV of 1.03 per 1,000 live births, making it the fifth most common congenital malformation after cardiovascular anomalies , hypospadias , malformations of the urinary tract , and Down’s syndrome . CTEV was most often bilateral, and if unilateral, it more often involved the right side. Earlier studies have found the same . MoreoveSeasonal variation in the incidence of idiopathic clubfoot has been reported, with different results . The reaAlthough it has been widely accepted that clubfoot is multifactorial in origin, genetic factors clearly play a central role. In a study on identical twins, the concordance was 33% . MoreoveMost previous studies have reported a correlation between maternal smoking during pregnancy and the incidence of CTEV, suggesting an important role for vascular disruption or compromise . The rolAmong other risk factors reported in the literature, early amniocentesis (in the thirteenth week of gestation) has been demonstrated to increase the risk of talipes equinovarus compared to chorionic villus sampling performed at the same gestational time . IncreasIn Sicily, the number of children affected with clubfoot who are reported annually is decreasing despite an overall increase in congenital pathologies. It is likely there are multiple causes, with both genetic and environmental factors playing roles. At least in some cases, the phenotype may result from a threshold effect of different factors acting together. There is evidence that the development of bone, joints, connective tissue, innervation, vasculature, and muscle may each be implicated in the pathophysiology, and a disturbance of the overall process of medial rotation of the fetal foot may be the common pathway.Our study should be considered in light of some limitations. First, there is a risk of underestimation of the true incidence due to missed cases. Our data were collected prospectively, however, and since practically all children in Italy are born in hospital, we believe that the number of cases missed was very small. Secondly, several important covariates  were not included in our data.To sum up, our findings emphasize the importance of birth defects surveillance programs and their usefulness in investigating potential risk factors. On the other hand, there is a lack of multiple surveillance programs in the Sicilian setting, as well as in other Italian regions. Given a national representative sample, multiregional studies are needed to provide greater statistical power to investigate risk factors and provide the opportunity to identify variation between different surveillance areas.


In a previous study, we showed that individuals who had participated in oil clean-up tasks after the wreckage of the Prestige presented an increase of structural chromosomal alterations two years after the acute exposure had occurred. Other studies have also reported the presence of DNA damage during acute oil exposure, but little is known about the long term persistence of chromosomal alterations, which can be considered as a marker of cancer risk. We analyzed whether the breakpoints involved in chromosomal damage can help to assess the risk of cancer as well as to investigate their possible association with DNA repair efficiency. Cytogenetic analyses were carried out on the same individuals of our previous study and DNA repair errors were assessed in cultures with aphidicolin. Three chromosomal bands, 2q21, 3q27 and 5q31, were most affected by acute oil exposure. The dysfunction in DNA repair mechanisms, expressed as chromosomal damage, was significantly higher in exposed-oil participants than in those not exposed (p= 0.016). The present study shows that breaks in 2q21, 3q27 and 5q31 chromosomal bands, which are commonly involved in hematological cancer, could be considered useful genotoxic oil biomarkers. Moreover, breakages in these bands could induce chromosomal instability, which can explain the increased risk of cancer (leukemia and lymphomas) reported in chronically benzene-exposed individuals. In addition, it has been determined that the individuals who participated in clean-up of the oil spill presented an alteration of their DNA repair mechanisms two years after exposure. Prestige foundered and spilled more than 67,000 tons of the tanker´s oil, which contaminated more than 1,000 km of the coast of Galicia (North-West Spain). In response more than 300,000 clean-up workers were mobilized. The fact that the oil had a high content of aromatic hydrocarbons (50% by weight), saturated hydrocarbons, heavy metals, resins and asphaltenes, which are classified by the International Agency for Research on Cancer [Prestige oil. In 2002, the oil tanker Prestige accident [Prestige oil spill [Genotoxic studies conducted on populations exposed to the clean-up of oil spills are scarce -10. Two accident ,3, and sil spill -10. Diffil spill -9, whileil spill ,10. Not il spill -9. No inil spill -15. ThesThe aim of the present study is to identify if there are specific chromosomal regions especially affected by oil exposure in the same chromosomal preparations of individuals in which an increase of chromosomal damage was found . In addiPrestige disaster. The project was approved by the Ethics Committee on Clinical Research of Galicia and all participants provided written informed consent. In this study, an accurate selection of individuals highly exposed to the oil was performed ,16. OnlyPeripheral blood (PB) was cultured in supplemented RPMI-1640 medium  and then harvested according to standard procedures. For the study of chromosomal bands, PB standard culture at 37°C for 72h was used. The cytogenetic banded preparations previously studied in 91 exposed and 46 non-exposed individuals  were re-For the study of DNA repair efficiency, PB obtained in the same extraction was cultured at 37°C for 96h, and aphidicolin (Sigma Aldrich), an inhibitor of DNA polymerase α and other polymerases, was added to the cultures 24h before harvesting at a final concentration of 0.2µM. The cellular suspension was keep frozen until cytogenetic results without aphidicolin were obtained. Dysfunction in DNA repair mechanisms was studied only in randomly selected female subsamples because women were more prevalent than man is both the samples of exposed and non-exposed individuals . A totalCriteria for cytogenetic evaluations were determined according to the International System for Human Cytogenetic Nomenclature . A generalized estimating equation, GEE [To identify which chromosomal bands were involved in chromosomal damage using standard culture, two statistical methods were used. First, the Fragile Site Multinomial method, FSM version 995, -20, specion, GEE , was usevs. 1, 8 and 14 in non-exposed). To identify those chromosomal bands that significantly expressed breakpoints in exposed and non-exposed participants, two statistical methods were used. In the first one, the FSM method, the number of breaks required to consider a band as being non-randomly affected was four or more. The most affected bands in the exposed group were 2q21, 3q27 and 5q31 (vs. none in non-exposed). On the other hand, the second statistical method, using the chi-square test, was applied considering the relative length of chromosomal bands identified as 1p34.1, 2q21, 3q27, 4q33, 9q13, 12q11, 13q11, 17p12 and 18q11.2 bands in exposed vs the 9q13 band in non-exposed individuals. It is interesting to note that only 2q21 and 3q27 were considered to be bands affected by both methods.A total of 9,520 and 4,859 metaphases from standard culture were analyzed in 91 exposed and 46 non-exposed individuals, respectively. vs. non-exposed individuals (p= 0.023), and almost the same findings were observed in relation to apparently structural CAs (p= 0.024). Chromosomal damage  was also statistically higher in exposed than in non-exposed individuals (p= 0.016). Due to the large number of chromosomal lesions induced by aphidicolin, their average number is shown per 100 metaphases in Prestige oil exposure. The present study, carried out on the same individuals, shows that a few chromosomal bands exist in the human genome which are particularly sensitive to breakage in acute oil exposure. Furthermore, we also found that the increase in chromosomal damage is due to the existence of a statistically significant reduction of DNA repair efficiency in exposed as compared to non-exposed individuals. A previous study reported by our group  has reveStructural CAs are considered to be a highly informative biomarker for detecting adverse health effects, such as the risk of developing cancer ,13,14. Ihttp://www.ncbi.nlm.nih.gov/). Although not all fragile sites may be equally involved in cancer development, it is known that they are vulnerable targets for various oncogenic agents, and their damage may potentially produce consequences for genomic integrity [in vivo in CAs related to tumor development [http://www.ncbi.nlm.nih.gov/), in these bands we can find genes involved in different cellular processes , DNA repair (ERCC3 at 2q21), proto-oncogenes , tumor suppressor genes , and one gene is involved in the apoptotic process (DND1 at 5q31). Results of the present study support the hypothesis that the oil components, some of them considered to be carcinogenic, may induce mutations, mainly due to breakages in specific chromosome regions . The 11q23 band, while especially sensitive to benzene and commonly involved in hematopoietic malignance [Our results show that the 2q21 and 3q27 bands are especially affected in exposed individuals when both the FSM method and an additional method that takes into account the relative bands’ lengths were used, while 5q31 was considered affected only when the FSM method was employed. These bands correspond to regions where fragile sites  are located according to the human genome browsers like NCBI  reported in chronically benzene-exposed individuals. In addition, our results suggest that the increase in chromosomal damage in these individuals could be a consequence of the reduction of DNA repair efficiency


BDKRB2 +9/−9 polymorphism was associated to the transcriptional activity of the receptor. In this scenario, the main aim of this study was to evaluate the association of the BDKRB2 +9/−9 polymorphism with diabetes mellitus risk in the Brazilian general population. This study included 1,032 subjects of the general urban population. Anthropometrical, blood pressure, biochemical, and genotype analyses for the BDKRB2 +9/−9 bp insertion/deletion polymorphism were performed. Individuals carrying +9/+9 or +9/−9 genotypes had higher glucose values  and higher frequency of diabetes mellitus  compared to individuals carrying −9/−9, adjusting for age and gender. In addition, higher diabetes mellitus risk was associated to presence of the +9/+9 or +9/−9 genotypes . Our data suggest that the BDKRB2 +9/-9 polymorphism may act as a genetic modulator of glucose homeostasis. It was previously associated to insulin sensitivity, glucose uptake, and insulin secretion, and, in this study, data suggest that the polymorphism may increase susceptibility to chronic metabolic conditions such as diabetes in the Brazilian population.Some mechanisms have been proposed to explain the role of bradykinin on glucose homeostasis and some studies reported that the  Bradykinin (BK) is a nonapeptide formed by the action of a serine protease called kallikrein. The kallikrein produces kinins which are largely released into interstitial fluid, blood, and glandular tissue, in particular by the pancreas. Several studies have demonstrated the role of BK in the modulation of important physiological effects such as inflammation, vascular permeability, hypotension, edema, smooth muscle contraction, and glucose homeostasis, and most of these actions are mediated by the B2 receptor (B2R) , 2. Recently, some mechanisms have been proposed to explain the role of BK on glucose homeostasis. Studies have reported that BK enhances the tyrosine phosphorylation of IRS1 and thus improves the binding affinity of IRS1 with the P85 regulatory subunit of PI3K, which increases the translocation of GLUT4 to the plasma membrane [BDKRB2). The presence (+9 bp) rather than the absence (−9 bp) of a 9-base pair sequence was associated to lower gene transcriptional activity [BDKRB2 +9/−9 polymorphism with diabetes mellitus risk in the Brazilian general population. B1 or B2 receptors mediate the effects of BK. It has been accepted that almost all of the physiologically significant effects of BK, including the metabolic ones, are exerted by activation of the B2R . Based oactivity , 7. The Pardo in Portuguese), or Black [ This study included 1,032 subjects of the general urban population selected from the Hearts of Brazil Project (HBP). The design was a transversal and multicenter observational cohort study. The universe of the HBP consisted in the set of inhabitants of Brazilian urban centers with more than 100,000 inhabitants. The HBP sample plan was calculated as 2,500 interviews, distributed in 72 cities from the 5 regions of the country proportionally to the number of inhabitants, per gender and age range, based on data from IBGE (Brazilian Census). In the selected cities, the “households” constituted the second-stage units, with one interview per household. Subjects were separated in self-declared “racial/color” subgroups, according to Brazilian Census, as White, Intermediate  and diastolic blood pressure (DBP), respectively. Hypertension was defined as mean SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg or use of anti-hypertension drugs [ Weight, height, and waist were measured according to a standard protocol. Body mass index (BMI) was calculated and obesity defined as BMI ≥ 30 kg/mon drugs . Fastingon drugs .BDKRB2 +9/−9 bp insertion/deletion polymorphism was performed by polymerase chain reaction followed by restriction fragment length polymorphism (PCR-RFLP) as previously described [ Genomic DNA was extracted from peripheral blood leukocytes following a salting-out method. Genotypes for the escribed . QualityP ≤ 0.05. Categorical variables were presented as percentage, whereas continuous variables were presented as mean ± standard deviation. Differences in the categorical and continuous parameters according to genotypes for the BDKRB2 polymorphism were tested by chi-square test and Student's t-test, respectively. Logistic regression analyses were performed to evaluate the association of the BDKRB2 polymorphism with diabetes mellitus plus adjustment for covariates.  Statistical analyses were carried out using the SPSS 19.0 software , with the level of significance set at P = 0.46, χ2 = 0.54). Demographic and clinical data of the studied population samples are shown in P = 0.04, resp.) and higher frequency of diabetes mellitus  compared to individuals carrying −9/−9, adjusting for age, gender, and BMI (P = 0.03) . However, individuals carrying +9/+9 or +9/−9 genotypes had higher glucose values  .BDKRB2 +9/−9 polymorphism is associated with fasting glucose values and with diabetes mellitus risk in the Brazilian population. These genetic associations, although exploratory regarding casual relations, may have a role in the generation of hypothesis to be tested in more controlled studies.  The main finding of this study was that the  In recent years, numerous studies have demonstrated the important biological role of BK in the modulation of various physiological conditions mediated through its binding to B1 and B2 receptors . Some investigations confirmed the key role of BK on insulin sensitivity , glucoseFinally, Yang and Hsu, studying rat pancreas, showed that the infusion of BK increased the insulin release by beta cells. Furthermore, the BK optimized insulin release stimulated by glucose . In thisBDKRB2 +9 allele with lower gene transcriptional activity [ Considering the pivotal role of B2 receptor in the physiological actions of BK, studies evaluating this genetic variant with metabolic phenotypes are still scarce in the literature. Our findings are supported by functional studies in the literature –17. Moreactivity , and insactivity . Thus, iBDKRB2 gene may constitute not only a link between biomechanical transduction and diabetes condition, but may also be a fundamental gateway for both epidemiological and mechanistic studies involving diabetes, hypertension, and renin-angiotensin system hyperactivity. Second, our examination of glucose has its limitations against the gold standard. However, the classification of the diabetes condition was made according to criteria recommended [ There are some limitations in our study. First, we were not able to specifically determine the molecular alteration responsible for the observed association. Nonetheless, in the described scenario, our data plus literature data are well grounded and provide evidence that the ommended . Finallyommended , 20.BDKRB2 +9/−9 polymorphism may act as a genetic modulator of glucose homeostasis. It was previously associated to insulin sensitivity [ In conclusion, our data suggest that the sitivity , glucosesitivity , and inssitivity  and, in


Genetic variation in glutathione S-transferases (GSTs) may contribute to lung cancer risk. Many studies have investigated the correlation between the Glutathione S-transferase T1 (GSTT1) null genotype and lung cancer risk in Asian population but yielded inconclusive results.heterogeneity<0.001 and I2 = 62.0%). Sub-group analysis revealed there was a statistically increased lung cancer risk in ever-smokers who carried the GSTT1 null genotype . It was also indicated that GSTT1 null genotype could increase lung cancer risk among population-based studies . The positive association was also found in studies of sample size (≤500 participants) .We performed a meta-analysis of 23 studies including 4065 cases and 5390 controls. We assessed the strength of the association of GSTT1 with lung cancer risk and performed sub-group analyses by source of controls, smoking status, histological types, and sample size. A statistically significant correlation between GSTT1 null genotype and lung cancer in Asian population was observed (OR = 1.28, 95% CI = 1.10, 1.49; PThese meta-analysis results suggest that GSTT1 null genotype is associated with a significantly increased risk of lung cancer in Asian population. Lung cancer is the most common malignancy worldwide. It is a leading cause of cancer death in men and women in the United States GSTs contain a variety of function isozymes, which are involved in the metabolic detoxification of reactive electrophilic compounds To determine the correlation between GSTT1 null genotype and lung cancer risk in Asian population, we performed this meta-analysis by summarizing reported case–control studies, calculating the estimate of overall lung cancer risk and evaluating influence of smoking status and histological types.Eligible case-control studies included in our analysis were extracted by electronic search of databases  and manual search of references of relative articles and reviews. Search terms were keywords relating to the GSTT1 gene  in combination with words related to lung cancer  and polymorphism or variation. The last research was performed on January 6, 2013. All relevant reports identified were included with no restriction.The major inclusion criteria were (a) case–control studies or cohort studies; (b) investigating the association between GSTT1 null genotype and lung cancer risk; (c) Asian population; (d) available genotype distribution information in cases and controls or odds ratio (OR) with its 95% confidence intervals (CIs). The major reasons for exclusion of studies were (a) reviews and repeated literatures; (b) case-only studies; (c) studies without detail genotype frequencies.Data of eligible studies were extracted independently by two investigators and the following data were collected: name of first author, year of publication, country where the study was conducted, age, sex, histological types, source of control, number of cases and controls, genotype frequency in cases and controls. Histological types were classified as squamous cell carcinoma (SqCC), adenocarcinoma (AC), small cell carcinoma (SCC) and others. All eligible studies were defined as hospital-based (HB) or population-based (PB) according to the control source. The two investigators directly extracted genotype frequency or estimated odds ratio of the papers. Discrepancies were discussed among all authors until they reached consensus on each item.2 presented variation in OR attributable to heterogeneity ORs with 95% CIs were used to measure the strength of association of GSTT1 null genotype with lung cancer risk. The pooled ORs of GSTT1 null genotype mentioned above was compared with GSTT1 present genotype between cases and controls. A 95% CI was used for statistical significance test and a 95% CI without 1 for OR indicating a significant increased or reduced cancer risk. Sensitivity analyses were performed to identify individual study’ effect on pooled results and test the reliability of results. The fixed effects model (Mantel-Haenszel method) was used when there was no significant heterogeneity; otherwise, the random-effects model (the Der Simonian and Laird method) was utilized As shown in heterogeneity<0.001 and I2 = 62.0%, heterogeneity = 0.003 and I2 = 56.8%) but not in hospital-based studies  (heterogeneity = 0.02 and I2 = 58.1%), while we did not found any significant association in non-smokers  but not in studies of sample size (>500 participants)  . When stSensitivity analysis was performed to assess the influence of each individual study on the pooled OR by deleting one single study each time, and there was no substantial change in the corresponding pooled OR . Begg’s We performed this meta-analysis to explore the association of GSTT1 genotype with lung cancer in Asian population. In this meta-analysis, 23 eligible studies, including 4065 lung cancer cases and 5390 controls, were identified and analyzed. The results suggested that GSTT1 null genotype carriers had an increased risk of lung cancer in Asian population. This meta-analysis was based on all published data and had enough statistical power to detect a modest difference.At present, many studies have investigated the association between GSTT1 null genotype and cancers, such as oral carcinoma In the sub-group analysis of smoking status, there was a significant association in ever-smokers, while no association found in non-smokers. Cigarette smoking is a high risk factor of lung cancer. It may be related to the important role of GSTT1 deletion polymorphism in the metabolism of polycyclic aromatic hydrocarbons contained in cigarette smoking. In addition, in the sub-group of squamous cancer which was strongly associated with smoking, there was no significant association, although 2 individual studies reported GSTT1 null genotype increased lung cancer risk The heterogeneity was not detected by meta-regression. However, through sub-group analyses, we found the heterogeneity might come from source of controls and sample size. When studies were stratified by source of controls and sample size, we conducted heterogeneity test to explore the source of heterogeneity . We alsoIn this meta-analysis, we included 4065 cancer cases and 5390 controls, which can provide enough statistical power and strengthened the reliability of our results. There are some limitations inherent in this meta-analysis. Firstly, individual data was not available and a more precise analysis should be conducted on other covariates such as age, sex, and environmental exposure. Secondly, the number of studies included for sub-group analysis of histological types and smoking status was small. Thirdly, the heterogeneity is difficult to exclude. It may be decided by confounding factors, such as gender, age, genetic diversities, different risk factors in life styles, and the exposure to different environmental factors which are difficult to collect completely.In summary, this meta-analysis suggests that GSTT1 null genotype is associated with a significantly increased risk of lung cancer in Asian population. To confirm this result, large scale case-control studies with detailed individual information are required.Figure S1Forest plot for the association between GSTT1 null genotype and lung cancer risk in Asian population on stratification by source of controls.(TIF)Click here for additional data file.Figure S2Forest plot for the association between GSTT1 null genotype and lung cancer risk in Asian population on stratification byhistological types. SqCC: squamous cell carcinoma; AC: adenocarcinoma; SCLC: small cell carcinoma.(TIF)Click here for additional data file.Figure S3Sensitivity Analyses. The pooled odds ratios were calculated by omitting each data set at a time(TIF)Click here for additional data file.Table S1PRISMA checklist.(DOC)Click here for additional data file.


Previous studies have shown a consistent association between long-term use of mobile and cordless phones and glioma and acoustic neuroma, but not for meningioma. When used these phones emit radiofrequency electromagnetic fields (RF-EMFs) and the brain is the main target organ for the hand-held phone. The International Agency for Research on Cancer (IARC) classified in May, 2011 RF-EMF as a group 2B, i.e. a ‘possible’ human carcinogen. The aim of this study was to further explore the relationship between especially long-term (>10 years) use of wireless phones and the development of malignant brain tumours. We conducted a new case-control study of brain tumour cases of both genders aged 18–75 years and diagnosed during 2007–2009. One population-based control matched on gender and age (within 5 years) was used to each case. Here, we report on malignant cases including all available controls. Exposures on e.g. use of mobile phones and cordless phones were assessed by a self-administered questionnaire. Unconditional logistic regression analysis was performed, adjusting for age, gender, year of diagnosis and socio-economic index using the whole control sample. Of the cases with a malignant brain tumour, 87% (n=593) participated, and 85%  of controls in the whole study answered the questionnaire. The odds ratio (OR) for mobile phone use of the analogue type was 1.8, 95% confidence interval (CI)=1.04–3.3, increasing with >25 years of latency (time since first exposure) to an OR=3.3, 95% CI=1.6–6.9. Digital 2G mobile phone use rendered an OR=1.6, 95% CI=0.996–2.7, increasing with latency >15–20 years to an OR=2.1, 95% CI=1.2–3.6. The results for cordless phone use were OR=1.7, 95% CI=1.1–2.9, and, for latency of 15–20 years, the OR=2.1, 95% CI=1.2–3.8. Few participants had used a cordless phone for >20–25 years. Digital type of wireless phones  gave increased risk with latency >1–5 years, then a lower risk in the following latency groups, but again increasing risk with latency >15–20 years. Ipsilateral use resulted in a higher risk than contralateral mobile and cordless phone use. Higher ORs were calculated for tumours in the temporal and overlapping lobes. Using the meningioma cases in the same study as reference entity gave somewhat higher ORs indicating that the results were unlikely to be explained by recall or observational bias. This study confirmed previous results of an association between mobile and cordless phone use and malignant brain tumours. These findings provide support for the hypothesis that RF-EMFs play a role both in the initiation and promotion stages of carcinogenesis. In May, 2011, the International Agency for Research on Cancer (IARC) at WHO evaluated the carcinogenic effect to humans from radiofrequency electromagnetic fields (RF-EMF). It included radiation from mobile phones, and from other devices that emit similar non-ionising electromagnetic fields. It was concluded that RF-EMF is a group 2B, i.e. a ‘possible’ human carcinogen  with the most common benign brain tumour, meningioma, suggesting specificity for these other tumour types. However, it should be noted that in Interphone a reduced risk was found for glioma among regular users of mobile phones but an increased risk was found in the highest cumulative exposure group, >1,640 h . Clearlyet al , Cardis We first provide some background to the development of the wireless technology because of its relevance to understanding the nature of exposures and exposure assessments.The Nordic countries were among the first countries in the world to widely adopt wireless telecommunications technology. Analogue phones  were introduced in the early 1980s using both 450 and 900 Megahertz (MHz) frequencies. NMT 450 was used in Sweden from 1981, but closed down on 31 December, 2007; NMT 900 operated during 1986–2000.http://www.pts.se/upload/Rapporter/Tele/2011/sv-telemarknad-halvar-2011-pts-er-2011-21.pdf). Worldwide, an estimate of 5.9 billion mobile phone subscriptions was reported at the end of 2011 by the International Telecommunication Union .The digital system  using dual band, 900 and 1,800 MHz, started to operate in 1991, and it now dominates the market. The third generation of mobile phones, 3G or UMTS , using 1,900/2,100 MHz RF fields has been introduced worldwide in recent years, and in Sweden in 2003. Currently, the fourth generation, 4G , operating at 800/2,600 MHz, and Trunked Radio Communication (TETRA 380–400 MHz) are being established in Sweden and elsewhere in Europe. Nowadays mobile phones are used more than landline phones in Sweden (Desktop cordless phones (DECT) have been used in Sweden since 1988, first using analogue 800–900 MHz RF fields, but since the early 1990s using a digital 1,900 MHz system. They are very common, overtaking phones connected to landlines. Also, these devices emit RF-EMF radiation when used and should be equally considered as mobile phones when human health risks are evaluated.The old analogue phones in Sweden, the so called NMT, had an output power of 1 W and were very seldom down-regulated giving lower RF-EMF emissions when used since the distance between the base stations was several kilometers. The GSM phones are transmitting in a pulsed mode, active 1/8 of the time, and with a maximum output power of 2 W. This could be downregulated depending on the distance to the base stations. A typical mean value for the average output power is around 50–60 mW. The phone always starts the call with the maximum power before going down in power. The digital cordless phones operate in pulsed mode with a duty cycle of 1/24, the peak power is 250 mW. It is only the newer models that have regulation of the output power. The old ones always stayed with peak 250 mW, giving a time average of about 10 mW.et al  and exposure to radiation fields from these phones (not merely access to or ownership of) in the general population is most evident after 2003 .To obtain results for longer exposure periods of wireless phone use, we conducted an entirely new study on brain tumours. In this article, we present the most recent results for malignant brain tumours. Updated results and discussions of this research area can be found elsewhere ,19. The Sweden comprises six administrative medical regions each having a cancer registry; annually, these registries are linked to the national Swedish cancer register. The reporting to us of newly diagnosed brain tumour cases varied between these six regions, from once a month to once a year from one region (Umeå). In our previous studies covering the time period 1997–2003, we received reports on new cases as these arose, or one to two times per month. For logistical reasons, this was not possible in the present study for the different cancer registries.The inclusion criteria specified both men and women aged 18–75 years at the time of brain tumour diagnosis (ICD-7 code 193.0) during the period 2007 to 2009. Furthermore, the diagnosis had to be verified histopathology for all cases and only living cases were included in the study. The cases were reported to us from population-based cancer registries from across all regions of Sweden. For administrative reasons, the Gothenburg region could be included for only the years 2008 and 2009. All patients, both with a malignant or a benign brain tumour, were included in the whole study. Once the inclusion criteria were satisfied, the attending physician was contacted for permission to include the case in the study. The present publication presents results for cases with a malignant brain tumour.The Swedish Population Registry was used for identification of controls. One control matched on gender and in 5-year age groups was used for each case, both malignant and benign brain tumour cases. All controls were recruited from the same source population  as the cases. Controls were only selected to the finally included living cases. They were assigned the same year as the diagnosis of the respective case as the cut-off in assessing exposure. Thus, the same methods were used as in our previous studies ,13.Use of wireless phones, both mobile and cordless, was assessed by a self-administered questionnaire supplemented over the phone. Both cases and controls received an introduction letter and were asked if they were willing to participate and answer the included questionnaire. To get as high response rate as possible two reminders were sent. All mobile phones in Sweden have had either prefix 010  or prefix 07 . Thus by asking for the prefix it was possible both to verify use of a mobile phone and the type. The questionnaire also contained a number of other questions on, for example, occupational history, exposure to different agents, smoking habits, medical history including hereditary risk factors, and exposure to ionizing radiation. All questions were supplemented over the phone by the interviewer at the same time. A structured protocol was used for all questions as a prompt. The written questionnaire was evaluated and further interviews were made according to the protocol. Most subjects were also phone interviewed to clarify different aspects in the questionnaire. There was no difference regarding supplementary interviews according to being a case (75% supplemented) or a control (70% supplemented). Adjusting for whether or not a supplementary interview was performed did not change the results of the logistic regression analysis.The ear that had mostly been used during calls with mobile and/or cordless phones was assessed by separate questions; >50% of the time for one side, or equally much for both sides. After informed consent from the patients, medical records including computer tomography (CT) and/or magnetic resonance imaging (MRI) were used to define tumour localization. The matched control was assigned the same side as the tumour of the respective case using the same method as in previous studies ,12,13,17All questionnaires received a unique identity number that did not indicate case or control status. Thus, the interviewer was blind to case or control status throughout data processing. The interviewers used a structured protocol that avoided questions that could reveal if the interviewee was a case or a control. All information was coded and entered into a database. A random sample of the questionnaires was coded twice by two independent persons with similar results. Being a case or control was revealed only during the statistical analyses.All analyses were done using StataSE 12.1. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using unconditional logistic regression analysis including the whole control sample  to increase the power in the study. This was possible since adjustment/stratification was made for the two matching variables .The unexposed category consisted of people who reported no use of mobile or cordless phones, or a latency period ≤1 year (amount of time between first use of the phone and year of diagnosis). As noted earlier, the same year as for each case diagnosis was used for the corresponding control as the cut-off for exposure accumulation. Furthermore, because of the low number of unexposed cases, a further criterion was used, i.e. regardless of latency being ≤1 year, cumulative use ≤39 h (3rd percentile) of wireless phones in total among the controls was also used as cut-off for the referent group of ‘no exposure’ among cases and controls. The 3rd percentile was chosen to approximately correspond to one working week.A latency period ≤1 year was used, as in our previous studies, to make it possible to analyse a late effect (promotion) in brain tumour genesis ,13. NoteLatency was analysed using six time periods, >1–5 years, >5–10 years, >10–15 years, >15–20 years, >20–25 years and >25 years. Cumulative use of the phone types was analysed in quartiles based on use of wireless phones in total among the controls . Wald's test was performed to analyze the trend of the ORs across the quartiles of the phone types. Latency and cumulative use were also analysed as continuous variables  to further explore the dose-response relations.Adjustment was made for the matching variables gender, age (as a continuous variable) and year of diagnosis. In addition, adjustment was made for socio-economic index (SEI) divided into four categories . Note that laterality of the tumour was not available for all cases, e.g., for midline tumours, or for tumours in both hemispheres (n=38). These were dropped from the laterality analysis together with controls (n=306) matched to cases without laterality data in the whole material. Laterality analysis was not made for the whole group of wireless phone users since the side differed for mobile phone and cordless phone for some of the included persons using both phone types .Restricted cubic splines were used to visualize the relationship between cumulative use and latency of wireless phones and malignant brain tumours. Adjustment was made for the same variables as in the logistic regression. Four knots were used at the 5th, 35th, 65th and 95th percentiles as suggested by Harrell . A p-valMost of the participating cases with a benign brain tumour (n=814) had meningioma (n=709). These results will be presented in another publication. As a further step to evaluate potential recall or observational bias the meningioma cases in the same study were used as the reference entity to the cases with malignant brain tumour, c.f. Hardell .In Medical records and reports to the cancer registries were used to classify tumour histopathology. Of the 683 cases of malignancy, 593 (87%) answered the questionnaire; 350 were men and 243 women. In For the total sample of 1,601 cases, an equal number of matched controls received a questionnaire. Note that one case had two tumours, astrocytoma grade IV and meningioma and another case had ependymoma and acoustic neuroma. Of the included controls, 1,368 (85%) answered the questionnaire, 564 were men and 804 women. The mean age was 52 years for cases with malignant brain tumour  and 55 years for all controls . Of the cases with meningioma 200 were men and 509 were women. The mean age was 57 years .In Use of digital 2G phones gave an overall OR=1.6, 95% CI=0.996–2.7. In the latency group >1–5 years, an OR=1.8, 95% CI=1.01–3.4 was calculated. Lower ORs were obtained in the latency groups >5–10 years and >10–15 years increasing to an OR=2.1, 95% CI=1.2–3.6 with latency >15–20 years, which was the longest latency interval.The results for digital 3G phones showed highest risk in the >5–10 years latency group, OR=1.6, 95% CI=0.5–4.9. This result was based on low numbers and no long-term users existed since this technology is new. One case and no control reported use of only a 3G phone.A similar pattern as for digital 2G phones was found for use of cordless phones with increased risk in the shortest latency period, then dropping off and again increasing in the latency group >15–20 years to an OR=2.1, 95% CI=1.2–3.8. Only 6 cases and 13 controls reported use of cordless phone with latency >20–25 years, so these results are less reliable.In We further show results for all wireless phone use combined. An increased risk was found overall with an OR=1.7, 95% CI=1.04–2.8, increasing in the shortest latency period >1–5 years to an OR=2.6, 95% CI=1.4–5.0, then decreasing somewhat with increasing latency; but with the highest risk is in the longest latency period >25 years with an OR=3.0, 95% CI=1.5–6.0.In Overall, in Cumulative use of wireless phones was analysed in quartiles based on use of wireless phones in total among the controls, see The ORs increased to statistically significant per 100 h of cumulative use for all types of phones except for UMTS (3G) with borderline significance, see In In Most types of malignant brain tumours were glioma (n=546). Separate analysis of that group of tumours gave similar results as for the whole group of malignant brain tumours. Mobile phone use with latency >25 years resulted in an OR=2.8, 95% CI=1.4–5.7 (data not shown). Also, for cordless phone use, the results were similar as in the overall analysis. Thus, with a latency >15–20 years, an OR=1.9, 95% CI=1.05–3.5 was found.The main result of this study was a statistically significant increased risk for malignant brain tumours associated with use of wireless phones, OR=1.7, 95% CI=1.04–2.8. The risk increased further in the latency group >1–5 years, but lower ORs were found in the latency groups >5–10 years and >10–15 years. With longer latency periods, the OR increased further with highest risk in the latency group >25 years, OR=3.0, 95% CI=1.5–6.0. From No case or control had used a digital mobile phone with latency >25 years. Only 6 cases and 13 controls had used a cordless phone with latency >20–25 years, so the results for cordless phones with longest latency time were less reliable. Only one case had used only a 3G phone, so firm conclusions about the risk with 3G mobile phone use are not possible from this study. Regarding the use of digital 2G mobile and cordless phones, the OR increased per year of latency with statistically borderline significance. This was explained by the fact that the risk increase was U-shaped in relation to latency period. A further illustration is given in the restricted cubic spline plot showing a borderline statistically significant non-linear relationship, see Regarding long-term use of wireless phones and the association with brain tumours, it has not been possible to study longer latency periods than >10 years previously since the technology is too recent. This is the first study to examine effects with a latency time >25 years. This was for analogue phones. Regarding digital 2G mobile phones, the longest duration of latency was >15–20 years. The longest latency for use of cordless phones was >20–25 years with few subjects in that category. The results in this study indicate an early effect in brain tumour genesis seen both for analogue and digital phones, an initiator. Regarding digital phones, we found also a late effect in tumour development, a promoter.Of interest is that we found that the risk was elevated among those who reported using only digital 2G mobile phones and only cordless phone, see Cumulative use of wireless phones in our present study was divided into quartiles based on cumulative use of wireless phones overall among controls. For all phone types, the highest risk was found in the fourth quartile >2,376 h of cumulative use. This corresponds to about 40 min of wireless phone use per day for 10 years. There was a statistically significant trend for the different phone types, mobile phone use overall, and wireless phones overall. An especially elevated OR was calculated for analogue phone use, OR=7.7, 95% CI=2.5–24, in the fourth quartile. Also, 3G mobile phone use resulted in increasing risk, highest in the fourth quartile, but based on low numbers and no statistically significant trend (p=0.28). These results are also reflected in Clearly, digital mobile and cordless phones increase the risk of malignant brain tumours in our present study, as well as in our previous studies. For use of digital type wireless phones only, we found an OR=1.7, 95% CI=1.01–2.7. This finding is consistent with our previous result for the study period 1997–2003. Use of digital mobile and cordless phones yielded an OR=1.4, 95% CI=1.1–1.8 in that study . FurtherFurthermore, it should be noted that for the study period 1997–2003, we found an increased risk of malignant brain tumours in the latency period >5–10 years for users of wireless phones of the digital type. Thus, digital 2G phones yielded an OR=1.7, 95% CI=1.2–2.2, and for cordless phones, an OR=1.5, 95% CI=1.1–2.0 in that latency group . These rIn summary, our results are consistent with an early effect in carcinogenesis (initiator) by analogue mobile phones, and both an early (initiator) and late (promoter) effect by wireless phones of the digital type.In Interphone (data not shown), a statistically significant increased risk for glioma was seen in the group 2–4 years for regular use, with 1–1.9 years use as reference category, OR=1.68, 95% CI=1.16–2.41 . The higThe highest absorption of RF-EMF emissions from a handheld phone is on the same side of the brain  as the phone is used . HighestA mean duration of mobile phone use of 2.8 years was reported in a study from USA . OverallIn a record linkage study from Denmark mobile phone subscribers from January 1, 1982, until December 31, 1995, were identified from the computerized files of the two Danish operating companies, TeleDenmark Mobil and Sonofon, which partly also funded the study. It has produced four articles that we have made a thorough review of . We concThe present study included cases of malignant brain tumours diagnosed during 2007–2009 from across Sweden. For the cases diagnosed during 1997–2003 in our previous study , the preRecall and observational bias might be an issue in case-control studies. We investigated in more detail the possibility of that in one of our previous studies . Reportiet al . As mentioned above we have found an association with use of wireless phones also among the deceased cases . Furtheret al . An incrMost of the deceased cases in the present study had a diagnosis of glioblastoma multiforme, WHO grade IV. The median survival in that patient group is less than one year . We havehttp://www.socialstyrelsen.se/statistik/statistikdatabas).We included only cases with a histopathological diagnosis of a brain tumour. We asked the six regional cancer registries not to report cases with only a clinical diagnosis. The reason was that we wanted to insure a confirmed diagnosis of the brain tumour for separate analyses for each tumour type. If necessary, we supplemented the histopathological reports with records from pathology departments around the country after informed consent from the respective case. Thus, we were able to classify all brain tumours based on WHO codes, see An advantage of this study was the fairly high response rate among both cases and controls. The response rate was 87% n=593) among the eligible cases. Of the controls, 85%  participated. These response rates were similar to those in our previous studies on malignant brain tumours, 85%  among cases and 84%  among controls 93 among ,40.Our study was not designed to include a mini-interview on the use of wireless phones among non-responding cases and controls as done in parts of the Interphone study; we had no ethics clearance for that. Certainly, it would have been of value to verify the use of mobile phones by operator data on the phone traffic. We had no possibility to do this since we did not obtain valid information on the operator used over the years in spite of asking. Furthermore, use of cordless phones, an important source of RF-EMF exposure, is not possible to validate by operator data.In view of the fact that practically everybody is using a wireless phone of some type today, it is not possible to obtain a large enough ‘unexposed’ group for meaningful statistical calculations. We, therefore, in addition to a latency ≤1 year, used the 3rd percentile (39 h) of cumulative time as a cut-off. Another option to obtain more ‘unexposed’ individuals would have been to change the cut-off for latency. However, doing this would limit the possibility of studying a late effect (promotion) in brain tumour genesis. Furthermore, it is difficult to find users that have been using only one single technology, i.e. NMT, GSM, UMTS, etc. Most users have used several technologies, and those with 3G phones who reported such use may have been unaware that the phone might have been operating on a 2G net for voice, if that was available. The analysis must be viewed with these facts in mind.In the unconditional logistic regression analysis, all controls, both to cases with malignant and benign brain tumours, were used so as to maximise the statistical power. Analysis using conditional logistic regression yielded overall for wireless phones OR=2.1, 95% CI=1.1–3.7 versus OR=1.7, 95% CI=1.04–2.8 using unconditional logistic regression, see More women than men were included as controls. This was because all controls in the study were included in the analysis. Among the cases with benign brain tumour, meningioma was about 2.5 times more common among women than men, an expected number. Thus, adjustment for gender was necessary.There is no generally accepted mechanism by which RF-EMF exposure produces changes in DNA. The energy level associated with exposure is too low to cause direct DNA strand breaks and DNA crosslinks. However, DNA damage can be caused by cellular biochemical activities such as free radicals. Several studies indicate that RF-EMFs increase free radical activity in cells ,43. ThisIn a recently published study, it was demonstrated that RF-EMF exposure induced the formation of oxidative base damage in a mouse spermatocyte-derived cell line . This waWe know little about the earliest events in the genesis of glioma in humans for obvious reasons. However, progression of glioma has been studied in a large series of tumours of different malignancy grades. Patients with low-grade glioma have been followed with later progression to high-grade glioma . Thus, sInitiation and promotion have different effects on the incidence of brain tumours. An initiating effect would have the most direct effect on the incidence. Our results indicate that such an effect would be apparent after more than a 20-year use of mobile phones, and thus be too early to be found in cancer registries. On the other hand, if the exposure acts as a promoter, this would decrease latency time for already existing tumours, giving a temporary, but not a continuous, increase in incidence. In addition, it must be noted that any such effect on tumour development is limited by the magnitude of the shift of the age-incidence function and its slope for the respective tumour type .In conclusion, this study confirmed previous results of an association between use of mobile and cordless phones and malignant brain tumours. The risk was highest for ipsilateral use and tumours in the temporal lobe. The results are consistent with initiation carcinogenesis for analogue phones, and both initiation and promotion carcinogenesis for digital wireless phones.


To investigate whether the polymorphism rs800292  in the complement factor H gene is associated with polypoidal choroidal vasculopathy (PCV) and the genetic difference between PCV and neovascular age-related macular degeneration (nAMD), in Asian populations.A comprehensive literature search was performed in PubMed, Medline, Web of Science, and reference lists. A system review and meta-analysis of the association between I62V and PCV and/or nAMD were performed from 8 studies involving 5,062 subjects. The following data from individual studies were extracted and analyzed: 1) comparison of I62V polymorphisms between PCV and controls; 2) comparison of I62V polymorphisms between PCV and nAMD. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using fixed-effects models. The Q-statistic test was used to assess heterogeneity, and Egger’s test was used to evaluate publication bias. Sensitivity analysis and cumulative meta-analysis were also performed.1 for genotype GA+GG versus homozygous genotype AA was 3.18 , the OR2 of heterozygous genotype GA versus AA was 2.29 , the OR3 of homozygous genotype GG versus AA was 4.42 , and the OR4 of allele G versus A was 2.04 . Sensitivity analysis indicated the robustness of our findings, and evidence of publication bias was not observed in our meta-analysis. Cumulative meta-analysis revealed that the summary ORs were stable. There was no significant difference in every genetic model between PCV and nAMD .The I62V polymorphism showed a significant summary OROur analysis provides evidence that the I62V polymorphism is associated with an increased risk of PCV. The variant of I62V could be a promising genetic biomarker of PCV in Asian populations. Polypoidal choroidal vasculopathy (PCV) is a hemorrhagic and exudative macular disorder that is characterized by inner branching choroidal networks with surrounding polypoidal dilatation of the choroidal vessels, which can be clearly demonstrated by indocyanine green angiography PCV can occur in any gender or race, but it is more commonly seen in Asians than in Caucasians, accounting for 24.5% of patients with findings suggestive of neovascular age-related macular degeneration (nAMD) in the Chinese population PCV is categorized by some experts as a subtype of nAMD, There are also significant differences in angiographic and optical coherence tomography features between PCV and nAMD. Histopathological studies suggest differences in the anatomical details of the associated vascular abnormalities in the retina and choroids and the relative role of VEGF. These similarities and differences have been a subject of much interest and debate regarding whether the vascular abnormality in PCV represents neovascularization or a phenotype distinct from choroidal neovascularization (CNV). The etiology of PCV remains largely unknown. It is known as a multifactorial disease due to multiple environmental risk factors and genetic factors or to the interactions between these. The phenotypic similarities between PCV and nAMD lead to the hypothesis that genes involved in AMD may also play a role in PCV. This meta-analysis was conducted according to the PRISMA guidelines. Studies were included only if they fulfill all of the following five criteria: (1) All patients had a complete ophthalmic examination, including fundus photography, and fluorescent or indocyanine green angiography (ICG). The diagnostic criteria of PCV was based on these clinical features and ICG showing a branching vascular network terminating in polypoidal swelling. The diagnostic criteria of nAMD based on the clinical features and grading were classified using a standard grid suggested by the International Age-related Maculopathy Epidemiologic Study Group for age-related maculopathy. (2) Study design was limited to case-control study, cohort study, or population-based epidemiologic survey, not a review, case report, or editorial comment. (3) The major study objective was to evaluate the association between CFH I62V polymorphism and PCV and/or nAMD. (4) Raw data of allele or genotype frequencies or counts available. Allele was A/G, and the genotypes covered AA, AG, and GG. (5) For studies published by the same group on the same gene and markers, only the most recent report or the report with the largest sample size was included for analysis.Two reviewers (Z.Y.W. and K.K.Z.) independently extracted the data and evaluated the quality. The following variables were extracted from each study: the name of the first author, year of publication, ethnicity, phenotype of cases evaluated, sample size, mean age and sex ratio of study participants, and allele and genotype distributions in cases and controls. If publications listed allele and genotype counts stratified according to the PCV sub-phenotype, they were combined into one case group.Independent review and resolution by a third reviewer (P.Q.Z.) was sought if the two reviewers disagreed.1 for (GG+GA) versus AA, OR2 for GA versus AA, OR3 for GG versus AA, and OR4 for allele G versus A.Hardy-Weinberg Equilibrium (HWE) was tested by the exact test to compare the observed genotype frequencies with the expected genotype frequencies within the control subjects. 2I statistic. P value <0.1 was considered statistically significant for the Q-statistic test. 2I ranges between 0% and 100%  and larger values represent increasing heterogeneity. The fixed-effects estimates were described in the text for originally homogenous or post hoc homogenized datasets. If there was evidence of between-study heterogeneity, random-effects estimates were described. Between-study heterogeneity was assessed by the Q-statistic test and http://ims.cochrane.org/revman. Accessed June 30, 2013). All other statistical analysises were performed using Stata software . All tests were 2-tailed. A P value <0.05 was considered statistically significant except for the test of between-study heterogeneity.To assess the publication bias and small-study bias, a funnel plot of the data was applied. In addition, Egger’s test was used to detect publication bias. A total of 113 relevant studies were identified by our initial search, of which 8 studies were eligible for inclusion in the review. Allele and genotype distributions for the I62V polymorphism from individual studies are shown in 1 for the risk allele (GA+GG) versus AA was 3.18 , pooled OR2 for GA versus AA was 2.29 , pooled OR3 for GG versus AA was 4.42 , and pooled OR4 for the risk allele G versus A was 2.04   . The het1 = 0.92, OR2 = 0.96, OR3 = 0.90, OR4 = 0.94) was found in each genetic model , OR2 (P = 0.10), OR3 (P = 0.11) and OR4 (P = 0.82).We assessed publication bias using Egger’s test. No statistically significant evidence of publication bias was detected for the ORCFH I62V and PCV has been hindered in low frequency of variant alleles and small sample sizes in studies. To overcome these barriers, we performed a systematic meta-analysis to summarize the evidence to date regarding the association between CFH I62V and PCV, representing a pooled total of 6 case-control and 1 cohort studies between PCV and Control, 5 case-control studies between PCV and nAMD, involving 5,062 subjects.The reliable assessment of the association between Our meta-analysis focused on the association between the CFH I62V polymorphism and PCV risk specifically. The results indicate a strong association between CFH I62V and PCV with no evidence of publication bias. The ORs of all comparisons supported the view that I62V is a risk factor for PCV in Asian populations, and these results also showed that the G allele might be a PCV-causing locus and that the GG homozygote genotype (4.4-fold) had a stronger effect than the GA heterozygote genotype (2.3-fold) with a significant dose response correlation. In individuals carrying at least one copy of the risk allele, disease risk was increased by 3.2-fold.In addition, sensitivity analyses by iteratively removing one study at a time including one study not observing HWE 1 = 0.92, OR2 = 0.96, OR3 = 0.90, OR4 = 0.94) in our study.CFH is a critical negative regulator of the alternative pathway of the complement system. It binds to C3b, promotes the decay of C3 convertase, and serves as a cofactor for the factor I–mediated proteolytic inactivation of C3b, resulting in the inhibition of the complement cascade. Our meta-analysis did not found any heterogeneity in each of the OR. To minimize the bias of our research, we did not use the option of language limitation on PubMed, Medline, or Web of Science, and all previous studies that met our criteria were included. The study must be published in peer-reviewed journals; second, we collected the nAMD data in our studies, excluding the data of dry AMD and other type of wet AMD, such as Retinal angiomatous proliferation; third, all studies which fulfill the inclusion criteria were conducted with subjects of Asian ancestry, 5 studies were conducted in Japan, 1 study was conducted in China, 1 study was conducted in Singapore, 1 study was conducted in Thailand. We didn’t find any evidence or study about CFH I62V and PCV with subjects of Caucasian, Africa and other populations based upon our search strategy. Chen et al Several limitations of this meta-analysis should be acknowledged. First, there were a limited number of original studies, and all reports were on Eastern Asians. There were no reports on research involving Caucasian, Africa or other populations. These conclusions remain to be confirmed by further research. Second, because the allele and genotype data were not available in several studies, In conclusion, our analysis provides evidence that the CFH I62V polymorphism is associated with an increased risk of PCV in the Asian population. We found that Asian patients with the CFH I62V variant might have a higher risk of developing PCV compared with controls. Our results expand the number of confirmed PCV susceptibility loci for Asian populations and provide a better understanding of the genetic architecture underlying disease susceptibility. The potential for preclinical prediction in future genetic testing may advance by combined evaluation of inherited susceptibility with previously established loci. Further investigations are necessary to confirm the roles of the CFH I62V polymorphism reported in a limited number of original studies. Genetic analysis might provide timely preclinical prediction, prevention, and treatment for PCV.Checklist S1PRISMA checklist.(DOC)Click here for additional data file.Flow Diagram S1PRISMA Flow Diagram.(DOC)Click here for additional data file.