No clear consensus has been reached on the alpha-adducin polymorphism (Gly460Trp) and essential hypertension risk. We performed a meta-analysis in an effort to systematically summarize the possible association.heterogeneity<0.0001) in all subjects. Meta-analysis under other genetic contrasts still did not reveal any significant association in all subjects, Caucasians, East Asians and others. The results were similar but heterogeneity did not persist when sensitivity analyses were limited to these studies.Studies were identified by searching MEDLINE and EMBASE databases complemented with perusal of bibliographies of retrieved articles and correspondence with original authors. The fixed-effects model and the random-effects model were applied for dichotomous outcomes to combine the results of the individual studies. We selected 22 studies that met the inclusion criteria including a total of 14303 hypertensive patients and 15961 normotensive controls. Overall, the 460Trp allele showed no statistically significant association with hypertension risk compared to Gly460 allele (P = 0.69, OR = 1.02, 95% CI 0.94–1.10, POur meta-analysis failed to provide evidence for the genetic association of α-adducin gene Gly460Trp polymorphism with hypertension. Further studies investigating the effect of genetic networks, environmental factors, individual biological characteristics and their mutual interactions are needed to elucidate the possible mechanism for hypertension in humans. Essential hypertension (EH) is a major global public health problem which affects a large proportion of adult population worldwide. The occurrence and development of EH are regarded as a complex multifactorial disorder resulted from genetic and environmental factors, as well as their interactions Adducin is a ubiquitously expressed heterodimeric cytoskeleton protein composed of two subunits (α-subunit and either β- or γ-subunit) which are encoded by three genes  located on different chromosomes To identify all studies that examined the association of alpha-adducin Gly460Trp polymorphism with hypertension, we conducted a systematic computerized literature search of PubMed and EMBASE databases (up to May 2010) using the following various combinations of keywords and subject terms: ‘adducin’ OR ‘ADD’, ‘polymorphism’ AND ‘hypertension’. We also retrieved additional studies through the MEDLINE option ‘related articles’. Search results were limited to articles in English and studies on human subjects without country restrictions. Only research articles were included. When studies from the same research group with overlapped population were found, only the one with larger population was included to avoid data duplication. The full text of the retrieved articles was scrutinized to decide whether information on the topic of interest was included. References of the retrieved publications were screened. If an article reported results on different ethnicity subpopulations, each subpopulation was treated as a separate study in our meta-analysis. Studies included in the meta-analysis had to meet all the following criteria: (a) using an unrelated case–control design , (b) have available genotype frequency, (c) genotype distribution of control population must be consistent with Hardy–Weinberg equilibrium (HWE). Hypertension was defined as systolic BP (SBP) ≥140 mmHg and/or diastolic BP (DBP) ≥90 mmHg and/or treatment with anti-hypertensive medication.In order to extract the information needed, all articles were reviewed and separately collated by two independent investigators  who checked for any discordance and reached a consensus. If they could not come to an agreement, a third one adjudicated the disagreements. The following information was collected on the genotype of Gly460Trp according to different kinds of ethnicities. First author, year of publication, country and racial descent of the subjects included, study design and characteristics were described in 2 was also calculated to evaluate the variation which was caused by heterogeneity rather than by chance, and higher values of the index indicate the existence of heterogeneity The strength of the association of Gly460Trp with hypertension was measured by odds ratio (OR) corresponding to 95% confidence interval (CI) which was calculated according to the method of Woolf http://www.ihg.gsf.de/cgi-bin/hw/hwa1.pl).Sensitivity analyses were conducted by sequential deleting a single study each time in an attempt to identify the potential influence of the individual data set to the pooled ORs. In addition, an estimate of potential publication bias was carried out by the funnel plot, in which the standard error of log (OR) of each study was plotted against its OR. An asymmetric plot suggested possible publication bias. Funnel-plot asymmetry was assessed by the method of Egger's linear regression test Analyses were performed using the software Review-Manager 4.2  and Stata version 10.0 . All P-values were two-sided.HWE = 0.000522), as well as in the population of Asian provided in Ramachandran et al. HWE = 0.001644). Thus, those two studies were excluded. Seven papers did not provide relevant data or the data provided were not sufficient, we have contacted corresponding or original authors by e-mail in order to obtain the raw data. Two of them have replied and offered the necessary data The initial search strategy for hypertension susceptibility related to the alpha-adducin SNP yielded 152 potentially relevant references in PubMed and 158 in EMBASE, most of which were overlapping. In addition, we supplemented the search with a hand search of reference lists from published literature (117 articles). After the subsequent screening, 30 studies were identified for recruitment in the light of the inclusion criteria A total of 14303 hypertension patients and 15961 controls were investigated. Population-based and hospital-based studies were all included in our meta-analysis. Twelve studies were population-based heterogeneity<0.0001) (heterogeneity = 0.0003) (heterogeneity = 0.04) (heterogeneity = 0.01)  , dominan 0.0003) , recessi = 0.04) , and hom = 0.01) . Similar = 0.01) .Sensitivity analyses were conducted to assess whether each individual study affected the final results. The findings revealed that no individual study affected the results in all subjects. In the subgroup analysis, three independent studies  .To the best of our knowledge, this is one of the largest systematic review of the literature by means of a meta-analysis to date investigating the association between alpha-adducin Gly460Trp polymorphism and EH. Compared with the recent case-control study and meta-analysis by Niu et al. + handling (sodium transport and reabsorption) rather than the salt-sensitive form of EH. Among white hypertensive patients in Italy, five salt sensitivity studies conducted by BP response to acute salt loading test  and chronic diuretic treatment effect were performed by the same research group, which showed evidence to support the role of 460Trp in salt-related hypertension In 1997, Cusi et al. first reported that 460Trp allele of alpha-adducin was associated with hypertension in human subjects, particularly in a salt-sensitive form of EH Furthermore, it is important to highlight that, EH is a complex polygenic disease responsive to environmental factors. A single polymorphism or gene likely has weak effects on the individual's phenotype, because multiple genes and genetic interactions have been implicated in the regulation of BP. A family study from van Rijn et al. + sensitivity, makes the relationship between BP and exchangeable body Na+ stronger, reduces renal perfusion, and compromises the buffering effects of the large arteries on both systolic and diastolic pressure Moreover, environmental factors and individual biological characteristics ought not to be neglected. The former include, most importantly, salt intake, smoking, alcohol consumption, etc. For instance, Yamagishi et al. pointed out that the α-adducin TrpTrp genotype was associated with higher systolic BP among men with a higher sodium intake heterogeneity = 0.34, I2 = 10.4%, allele comparison)   , while cparison) . There wThe results of the present meta-analysis should be interpreted within the context of its limitations. First, this meta-analysis only focused on papers published in the English language, so some local literature biases were inevitable. Second, not all the control subjects were age- and sex- matched to cases in the studies included in our meta-analysis, which was likely one of the causes for heterogeneity. In addition, another potential confounding effect is that some of the young normotensive controls might develop hypertension later in their life. Perhaps using stricter criteria for the selection of normal controls, such as normotensive subjects aged 55–60 years or older, could exclude the false-negative controls In conclusion, our meta-analysis suggested that the Gly460Trp polymorphism in ADD1 was not associated with susceptibility to hypertension even upon stratification by ethnicity or diagnostic criteria. Based on our discussion and the results from the meta-analysis, we may conclude that the Gly460Trp polymorphism is probably not a genetic indicator for increased risk of hypertension. To better understand the potential mechanism for hypertension in humans, future research should be carried out to explore the effect of genetic networks, environmental factors, individual biological characteristics and their mutual interactions.Table S1Detailed characteristics of eligible studies considered in the meta-analysis(0.10 MB DOC)Click here for additional data file.Table S2Diagnostic standard of each study, the distribution of Gly460Trp genotypes and alleles among hypertension of cases and controls, and P-values of HWE in controls(0.09 MB DOC)Click here for additional data file.


Brain-Derived Neurotrophic Factor (BDNF) is a neurotrophin which plays survival- and growth-promoting activity in neuronal cells and it is involved in cellular plasticity mechanisms as it controls activity dependent synaptic transmission. A functional polymorphism  in the pro-region of BDNF, which affects the intracellular trafficking of proBDNF has been associated with memory and cognitive deficits as well as to an increased susceptibility for several psychiatric disorders especially those with a neurodevelopmental origin. To date, no study has evaluated the influence of the Val66Met polymorphism on BDNF levels in a peripheral system that may reflect fetal neurodevelopment. Therefore we investigated in amniotic fluids (AF) obtained from 139 healthy women during 15-17 week of pregnancy, BDNF protein levels in correlation with the Val66Met polymorphism.Interestingly we found a significant BDNF protein levels reduction in 55 Met carriers  (p = 0.002) as compared to 84 non carriers , and no effect of fetus gender, maternal age or gestation week on BDNF levels has been observed.These results, although explorative, indicate that during fetal life the Val66Met genotype might influences BDNF protein levels in AF supporting the involvement of this polymorphism in behavioral and functional brain individual differences in the adulthood. Brain-Derived Neurotrophic Factor (BDNF) is a neurotrophin widely expressed in the brain, which regulates neuronal survival, growth and connectivity during development and participates in synaptic plasticity mechanisms throughout adult life . BDNF haBDNF protein is first synthesized as a glycosylated precursor (proBDNF) that is then converted intracellulary to mature BDNF protein, the latter being stored and released upon cell stimulation . An aminFurthermore, the Val66Met polymorphism has also been widely investigated as a genetic susceptibility risk factor for a large spectrum of neuropsychiatric disorders, in particular those with a neurodevelopmental origin -17 leadiTo date, at our best knowledge, no study has evaluated the putative influence of the Val66Met polymorphism on BDNF levels during pregnancy, a period during which fetal brain development appears vulnerable to external stimuli. In fact, it is well accepted that adverse events occurring during fetal life have profound and persistent effects on brain functions and may represent risk factors for psychopathologies later in life ,23.Therefore the aim of this study was to analyze putative functional effects of the BDNF Val66Met polymorphism in the fetal environment investigating correlation between BDNF protein levels and genotype in a sample of AFs obtained at the 15th-17th gestational week of physiological pregnancies.2 = 0.55, p = 0.46, HWE program, John Ott version 1.10). Since all the studies that evaluated the functionality of this polymorphism assembled Val/Met individuals with Met/Met and it has also been demonstrated that the Met allele has a dominant effect, we performed our analyses subdividing our study-sample into carriers  and non carriers  of the Met allele.The BDNF fetal genotype distribution in our study population was 3.6% (5/139) for Met/Met, 36% (50/139) for Val/Met and 60.4% (84/139) for Val/Val. Genotype distribution had no deviation from Hardy-Weinberg equilibrium ; there was also a similar fetal gender distribution among carriers and non carriers of the Met allele .We subsequently evaluated BDNF levels in AFs and we found that BDNF protein levels were significantly lower in Met allele carriers when compared to non carriers. In fact, as shown in Figure This study represents the first evidence of an effect of the BDNF Val66Met polymorphism on protein levels during the 15-17 weeks of pregnancy.Egan and colleagues  have shoFurthermore, studies analyzing gene-environment interactions ,31 reporIt is well known that human brain undergoes complex morphological and functional changes during fetal development. In particular, during the first and second trimester of pregnancy, cortical subplate reaches its peak of development, and cortical neurogenesis, characterized by proliferation, migration and organization of neuronal connections, is predominantly taking place ,23. TherIn parallel, circulating BDNF levels in fetus could reflect those in the brain since a correlation between blood BDNF levels and the cortical protein expression has been observed during neurodevelopment in rats . In thisSome limitations of our study have to be mentioned. The data about AF BDNF levels are from one point in time, and the relationship between BDNF genotype and AF BDNF levels may be different at other times during gestation. Additionally, this study is correlational in nature and we cannot draw any definitive statements about the consequences of BDNF Val66Met genotype on AF protein levels. Larger studies in wider and better characterized samples are needed to confirm these findings.In conclusion, this study represents the first evidence of the functionality of the BDNF Val66Met polymorphism in the fetal environment showing a correlation between the genotype and BDNF protein levels in AF during neurodevelopment. Although these results are explorative, they support a role of this polymorphism in the individual differences in brain morphology and function, and in mental disorder susceptibility.All the 139 amniotic fluid samples used in the study were obtained by amniocentesis performed between the 15 and 17 weeks of pregnancy  for fetal karyotype analysis requested by mothers for their advanced age . The inclusion/exclusion criteria were: healthy women with Caucasoid origin, fetuses with 46 XX or 46 XY karyotypes, no infections or complications during the previous gestational weeks and during the amniocentesis. The fetus gender was so distributed: 73 males and 61 females.After amniotic fluid collection, each sample was centrifuged: the supernatant (AF) not necessary for alpha fetoprotein dosage was taken anonymously and stored at -80°C. Pellet fractions  were cultured firstly in Amniochrome medium, which was replaced after 6-7 days with RPMI supplemented with 2 mM L-glutamine and 20% of Fetal Bovine Serum (FBS) as for routinely karyotype analysis. The leftover of AFc not necessary for karyotype analysis was collected anonymously without name or other detail, but with a number and bar-code. The study protocol has been approved by the local ethic committee (CEIOC).DNA was isolated from AF cells using TRIZOL reagent, according to the manufacturer' protocol (Invitrogen) and was quantified by Spectrophotometer . Primer pairs used to amplify the sequences containing Val66Met were: BDNF forward primer: AGGTGAGAAGAGTGATGACC and BDNF reverse primer: CTGGACGTGTACAAGTCTGC.The PCR reactions were performed in a final volume of 25 μl with 2 μl of genomic DNA (100 ng/μl), 0.1 μl of each primers pairs (100 μmol/ul), 0.7 mM of each dNTPs (Eppendorf), 0.5 μl of MgCl2 2 mM, 1.25 units of Taq Polymerase (Bioline) and buffer supplied by the manufacturer (Bioline). The PCR products were then sequenced using an ABI BigDye Terminator Cycle Sequencing Kit and by 3130 XL DNA Sequencer Analyzer (Applied Biosystem).BDNF levels in AF samples (n = 139) were measured by ELISA method using the human BDNF Quantikine kit . The BDNF content was expressed as equivalent of human recombinant BDNF protein (pg of BDNF protein/ml of AF). The minimum detectable dose of the assay is typically less than 20 pg/ml.Analysis was performed using Statistical Product and Service Solutions 13.0 Version (SPSS). Results are given as mean value ± standard deviation. The Mann-Whithney test was used to evaluate differences in quantitative variables. The Pearson coefficient was used to evaluate bivariate correlations.AC Study design, data analyses and manuscript writing; LB-C Study design, data analyses and manuscript writing; RZ, SM, biochemical analyses; FC, EM genotyping analyses; EM, DB sample collection and clinical characterization; SB, MAR and MG Study design and manuscript critical revision. All the authors have contributed and approved the final manuscript.


Gene–environment interaction is an important aspect in the development of coronary artery disease (CAD). The mutation (677C-T) of methylenetetrahydrofolate reductase (MTHFR) gene results in a decrease of the enzyme activity that leads to mild hyperhomocysteinemia. Elevated plasma level of homocysteine has been recognized as an independent risk factor for cardiovascular disease. A case–control study was designed to assess whether the prevalence of some MTHFR gene polymorphisms have any role in the development of CAD.The study included unrelated 217 cases with CAD and 255 healthy controls. DNA was extracted from peripheral blood. MTHFR genotypes were identified by seeing the presence or absence of 677C→T mutation obtained by PCR followed by Hinf1 restriction digestion. Multiple logistic regression analysis was carried out to find association between studied genotypes and lifestyle as well as biochemical risk factors.The T allele was found to be associated with the disease. Significant associations were found with smoking, hypertension, diabetes, and family history of CAD.The results indicate that MTHFR 677C-T polymorphism has significant association with CADs in the population of eastern India. It has been predicted that cardiovascular diseases will increase rapidly in India, and this country will be the host to more than half the cases of heart disease in the world within the next 15 years. IschemicS-adenosylmethionine (SAM), the universal methyl group donor. Homocysteine acts at the intersection of two metabolic pathways, the transsulfuration pathway and the remethylation cycle. Homocysteine is either transsulfurated to cystathionine or remethylated to methionine depending on methionine supplied by diet.[Homocysteine is an emerging new risk factor for cardiovascular disease. Systematic reviews of observational (cohort and case–control) studies have consistently shown a strong, positive, and dose-related association between the serum concentration of total homocysteine (tHcy) and the risk of stroke, which is independent of other vascular factors6 The ter by diet. Methylen by diet. The huma by diet. The C to by diet. Elevated by diet. but the  by diet.15 The ma by diet.16 A poin by diet. Homozygo by diet.19 and it by diet.To the best of our knowledge, this is the first study to report on probable association of certain MTHFR polymorphisms as predisposing factors in the development of the CAD and their interactions with relevant biochemical and lifestyle factors in the population of eastern India.A total of 217 clinically diagnosed cases with CADs were chosen from the outdoor of Cardiology Department of Ramakrishna Mission Seva Pratishthan. A total of 255 age- and sex-matched healthy controls were taken for the study with no heart-related complains. All subjects underwent coronary angiography to confirm the presence of the disease.Detailed history regarding their clinical, lifestyle, and socioeconomic conditions were collected. Detailed status of the relevant biochemical parameters was noted from their recent investigations.Informed written consents were obtained from all subjects. All the study subjects were Bengali, Indian and belonged to the same ethnic group. The research protocol was approved by the ethical and research advisory committee of the institution.Blood samples, 2–3 mL, were collected from each individual in an EDTA vial.Genomic DNA was extracted from peripheral blood leukocytes by salting out method.et al.[MTHFR genotype study was carried out to identify the presence of 677C→T mutation as described by Frosst et al. The PCR The mutation 677C-T creates a Hinf1 recognition sequence, and the product was digested into 175 bp and 23 bp fragments. The products of restriction digestion were separated on a 3% agarose gel and visualized by ethidium bromide staining. Genotypes of all individuals were noted as CC: 198 bp; CT: 198 bp, 175 bp, 23 bp; and TT: 175 bp, 23 bp.All the results were checked twice in double blind.P values were calculated. A value of P < 0.05 was considered as statistically significant. Extent of other risk factors was compared between cases and controls and across genotype levels. The stepwise logistic regression analysis was performed with the SPSS Statistical Package (version 14) for the determination of the independent risk factors for CAD. Multivariate logistic regression was used to obtain the OR estimate and 95% CI for the main effects of smoking and main enzyme genotype. An adjustment was made for the potential confounding effects of age, sex, alcohol consumption, tobacco consumption, family history, coexistence of hypertension, diabetes, etc. Dummy variables were created each representing the combination of category and genotype. In addition, interaction terms including duration or amount of exposure were evaluated for statistical significance.To test for significance of observed interactions, likelihood ratio tests were conducted using a Chi-square test. The odd-ratios (OR) for different association models were calculated with 95% confidence interval (CI) and simultaneously Different lifestyle as well as demographic characteristics of the subjects are shown in P < 0.02).Biochemical parameters such as HDL, LDL, serum cholesterol, and serum triglyceride were shown in Distribution of different MTHFR genotypes and the allele frequencies of the study groups were shown Tables  and 4, wP < 0.10).Interactions among different polymorphisms of MTHFR gene and age, sex, diabetes, hypertension, positive family history, different forms of tobacco use and alcohol intake were summarized with a view to increase the risk of CADs . It was Several studies have showed the positive and negative associations of different MTHFR gene polymorphisms and various forms of CVDs. Risk factors and as well as genetic factors also play an important role in the development of CAD. As per smoking and alcohol intake is concerned, our results partially support some of the previous works. We obseret al, reported that C677T mutation in the heterozygous or homozygous state is a potential risk factor for cardiovascular events. Gulec et al,[et al,[Some authors suggested that the 677C-T mutation in the MTHFR gene is a potential risk factor for cardiovascular diseases. Frosst ec et al, found a ec et al, A study ec et al, Limited ec et al,–28 Nair l,[et al, reportedl,[et al, A study l,[et al, Another l,[et al, The aim l,[et al, Both hypl,[et al,34 Howevel,[et al,35 and ouIn spite of several precautions, our study has certain limitations. Our study was hospital-based and could result in biased selection in place of random sampling. It has been suggested that studies with hospital controls can provide lower risk estimates, since diseases of controls could be associated with the polymorphisms under study. On the other hand, 217 individuals in no way represent a population status. Therefore, the study is to be continued with more number of study cases. Thus, the associations and the underlying mechanisms of lifestyle factors with the metabolic enzymes gene polymorphisms still need further studies with large-scale (population-based) samples and modified designs.


Levels of hsCRP were higher among subjects affected by CAD who suffered a repeat coronary event as compared to those who remained event free and subjects in the top quartile of hsCRP (>3.58 mg/L) were found to have a fourfold higher risk. In conclusion, hsCRP appears to be an independent predictor of recurrent CAD events in Asian Indian population.Inflammation plays a pivotal role in all stages of atherosclerosis. Numerous inflammatory, lipid, and cytokines markers have been associated with coronary artery disease (CAD) risk but data directly comparing their predictive value are limited. Studies were carried to elucidate the role of high-sensitivity C-reactive protein (hsCRP), other inflammatory as well as lipid markers and their associations. Among 1021 subjects, comprising 774 CAD affected members from Indian Atherosclerosis Research Study (IARS), plasma hsCRP levels showed strong correlation with inflammatory markers, namely, IL6 ( Inflammation plays a major role in the pathophysiology of atherosclerosis –4. Many CRP is an acute-phase reactant belonging to the pentraxin family. It is almost exclusively produced in the hepatocytes under the control of cytokines , althougThe Indian Atherosclerosis Research Study (IARS) is an ongoing, family-based, epidemiological study initiated in 2004 to investigate the prevalent genetic, traditional, and environmental factors associated with CAD in a cohort of Asian Indians in their home country. Novel biomarker discovery is one of the many specific objectives of this large-scale prospective study. The families in the IARS were enrolled from two cities: Bangalore in south India and Mumbai in western India. Subjects were recruited through a proband treated for CAD and its complications. A proband was eligible for recruitment when he was older than 60 (men) or 65 (women) years at onset of CAD. This was done in order to identify families with early onset CAD. All probands had a positive family history of CAD/CVD. We defined CAD-affected individuals as those who had documented evidence of an acute coronary syndrome with or without angiographic evidence of CAD and/or had undergone revascularization procedures. Probands' family members (both affected and unaffected by CVD) were subsequently enrolled into the study, provided they were aged 18 years or above at the time of recruitment. There was no upper age limit for any of the nonproband recruits. Subjects with present or past major illnesses such as cancer, cardiomyopathy, rheumatic heart disease, liver or renal disease and concomitant infection were excluded from the study. All participants gave their written informed consent to participate in the study, which was approved by the local ethics committee. A detailed case record form containing information on demographics, anthropometry, and medical history of diabetes, hypertension, and CVD was completed for all participants. A general physical examination was performed, along with measurement of vital parameters. Relevant information was obtained by personal interviews with subjects and from medical records. Prevalence of diabetes, hypertension, and CVD was ascertained based on self-report of physician's diagnosis and/or use of prescription medications along with medical records of diagnosis and therapy. Patients were followed up via telephone calls once every year. This follow-up data was collected during conversation with the patients themselves and all clinical data, including current medical therapy was judiciously recorded.All the biomarker assays were performed in accordance to standard protocols at the central research facility of the Thrombosis Research Institute (TRI) at Bangalore. Serum total cholesterol and triglyceride were estimated by standard enzymatic analysis using reagents, standards and controls from Randox Laboratories Ltd. . The concentrations of high-density lipoprotein (HDL)-cholesterol were estimated after precipitation of non-HDL fractions with a mixture of 2.4 mmol/L phosphotungstic acid and 39 mmol/L magnesium chloride. The concentrations of low-density lipoprotein (LDL)-cholesterol were calculated using the Fridewald formula. Apolipoproteins A1 and B100  were estimated by immunoturbidimetry method. Analyses were carried out on a Cobas-Fara II Clinical Chemistry Autoanalyser . Three commercial controls purchased from Randox Laboratories, one from Orion Diagnostica for apolipoproteins and a normal human serum pool (NHP) prepared in-house was run with every batch of assays. The interassay coefficients of variation (CV) for the commercial controls and NHP ranged from 4.9% to 7.0% for total cholesterol, 6.1% to 7.7% for triglyceride, 7.1% to 12.2% for HDL-cholesterol, 3.3% to 5.2% for Lp(a), 9.9% to 14.2% for apolipoprotein A1, and 10.7% to 13.9% for apolipoprotein B100.Plasma interleukin (IL)-6 level was measured by enzyme-linked immunosorbent assay ; the interassay CV for NHP was 4.3%. Plasma hsCRP level was measured using the Roche latex Tina quant kit ; the CV of NHP was 7.85%. Levels of secretory phospholipase A2 (sPLA2) were determined using a sandwich immunometric assay  and the interassay CV of NHP was 5.37%. Plasma fibrinogen and FVII:C activity were measured in clotting assays on an Automated Coagulation Analyser . The reagents, calibrators, and controls were purchased from IL . A commercial control and pooled normal human plasma (NHP) prepared in-house from citrate plasma of 30 healthy volunteers were run with every batch of assay. The interassay CV of the commercial control and NHP were 5.7% and 5.9%, respectively, for fibrinogen and 5.9% and 11.6%, respectively, for FVII:C. The values of fibrinogen and FVII:C for the commercial control were within the pre-assigned ranges in every batch of assay.P-value of less than.05 was considered statistically significant. Variables that showed a skewed distribution were log transformed before carrying out further statistical analysis. For the purpose of clarity, the untransformed mean and standard error of the mean (SEM) are shown in tables. Differences between continuous variables were assessed using Student's t-test and those between categorical variables using the chi square test. Analysis of covariance was also used to test for significance after adjusting for potential confounding variables. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated using conditional logistic regression analysis.All statistical analyses were performed using SPSS version 12. A A total of 518 families comprising 2318 individuals were recruited into Phase I of the IARS. Fasting venous blood samples for biomarker analysis were collected from each one of the 2318 individuals recruited into phase 1 of the IARS. hsCRP levels were assayed in 1021 out of the above 2318 collected samples. The selection of samples for the study was random. Levels of CRP are known to vary across body mass index (BMI) and gender. However, adjustment for both of these variables as also for statins did not reveal a significant difference in the CRP titres between affected and unaffected individuals . P = .13), indicating that application of AHA-CDC guidelines for CRP classification may not hold true for all populations.The unadjusted and adjusted correlation coefficients for hsCRP are shown in n = 91) had significantly higher levels of hsCRP than affected subjects who remained event free (3.98 ± 0.56 versus 2.9 ± 0.17 (mg/L); P = .009). Over 70% of CAD-affected individuals who suffered a repeat event were in the top quartile of hsCRP titres . 115 individuals had a new coronary event, irrespective of their baseline disease status (CAD affected or unaffected). CAD-affected subjects who suffered a recurrent event . This risk persisted even after adjusting for traditional risk factors such as gender, diabetes, hypertension, BMI, and lipids , PPReopterin . Interesd lipids , Model 5Our findings indicate that in the Asian Indian population, individuals in the top quartile of hsCRP have an approximately threefold higher risk of reinfarction, even after adjustment for traditional CAD risk factors thus implying that hsCRP may have additional utility for effective risk stratification in this high risk ethnic population. This may strengthen the case towards a recommendation of routine measurement of hsCRP along with lipids for improving risk prediction and identification of high-risk individuals. The AHA-CDC has devised guidelines for the classification of subjects as mild, intermediate and, high risk based on hsCRP levels. However, this classification is based on data obtained in Caucasian populations, and there is significant variation in hsCRP level based on ethnic origin , 49–52. Our data indicate that high levels of hsCRP provide additional predictive value to the traditional risk factors in identififying CAD-affected subjects who could develop a recurrent coronary event. Hence, it appears that routine measurement of hsCRP levels may provide better stratification of CAD risk in this population. However, it is important to carry out large-scale population-based studies in order to modify and adapt the existing AHA-CDC guidelines so as to accurately specify CAD risk in various ethnic populations.V. S. Rao: concept, planning, study and assay design, data analysis and interpretation, study management and manuscript composition; N. B. Kadarinarasimhiah: biomarker assays; S. John and S. Hebbagodi: data analysis, J. Shanker: study management and manuscript revision V. V. Kakkar: concept, manuscript revision and overall guidance.


MCPH1 and ASPM contribute to variations in human brain size and its correlates. We measured general mental ability, head circumference and social intelligence in 644 Canadian adults . The gene polymorphisms were assessed from buccal DNA; mental ability by Wonderlic Personnel Test and Multidimensional Aptitude Battery; head circumference by stretchless tape; and social intelligence by prosocial attitude questionnaires. Although all measures were construct valid and the allele frequencies showed expected population differences, no relationship was found between the genes and any of the criteria. Among Caucasian 18–25 year olds, for example, the two mental ability tests correlated with each other , with head circumference  and with prosocial attitudes .We test the hypothesis that polymorphisms of the brain regulator genes  Microcephalin (MCPH1) on chromosome 8p23 and abnormal spindle-like microcephaly associated (ASPM) on chromosome 1q31, attracted much attention when reported to be (i) associated with autosomal recessive primary microcephaly, (ii) positively accelerated in molecular evolutionary rate through the simian line leading to Homo sapiens, and (iii) under recent positive selection in modern humans  allele, was estimated to have arisen approximately 37 000 years ago (95% CI: 60 000–14 000 years ago), about the time symbolic behaviour became widespread in Europe, while the favoured D allele for ASPM was estimated to have arisen approximately 5800 years ago (95% CI: 14 000–500 years ago), about the time cities developed in the Near East. The D alleles for both MCPH1 and ASPM now exist in high frequency. Both genes were hypothesized to confer a selective advantage such as increased brain size and general mental ability (GMA).Two newly discovered genes, r=0.20 with external head circumference and r=0.40 with MRI measured brain volume . They were paid Canadian $40 (approx. US $32) for a 2-h testing session. Between February and April 2005, 405 people were recruited from a university subject pool and by local advertisements; another 239 were later recruited from an employment agency.K Scale  were coded: AA for the homozygous non-D allele, AD for the heterozygous alleles and DD for the homozygous D allele.One of the authors (Trudy Ann Bons) administered the tests in small groups. Participants completed questions on handedness, demographic background and social intelligence, then the Wonderlic (12 min) and the 10 MAB subtests (7 min each). Finally, they provided two DNA buccal swabs, one from inside each cheek. The DNA was genotyped according to standard procedures as published previously. Three genotypes of the MCPH1 had an overall frequency of 84% and was in Hardy–Weinberg equilibrium among all population groups and among Caucasians was more often in homozygote than heterozygote form. Similarly, the D allele of ASPM had an overall frequency of 32% and was in Hardy–Weinberg equilibrium among all population groups and among Caucasians was more often in heterozygote and less often in homozygote form. These are similar to the initial reports by Null results were found across all ways of examining the 644 participants, despite evidence showing the measures were construct valid. The allele frequencies, means and s.d.s of the measures are shown in r=0.78, N=476, p<0.001) and, as an aggregate g factor, with head circumference , Altruism  and Mini-K . The two prosocial attitudes scales correlated with each other , but not with head circumference.  Regardless of sample, a principal components analysis of the Wonderlic and the 10 MAB subtests showed loadings of 0.69 or higher on the first factor. Each individual's g factor score was also calculated based on the first component as this factor is the one most likely to show a genetic effect . Neither eliminating the heterozygotic AD category nor combining it with the DD category showed the AA versus DD comparisons to be significant (FS<1.00). Nor did the effect emerge when examining the relation in a variety of other ways including combining the two genes, or all the samples.To eliminate the confounding effect of population stratification, our main analysis was limited to Caucasians, which are by far the largest of our constituent samples. ASPM and MCPH1 and individual differences in head circumference, GMA or social intelligence. The absence of evidence was noted even in the analysis of the full sample (N=644) despite stratification effects due to ethnicity that would have biased the results in favour of finding a genetic effect . Null findings can arise due to procedural problems, but in this study, the variables showed construct validity and expected measurement properties. Moreover, the null results join one other based on 120 MRI-measured brain volumes  provides only 95% power to exclude an association that accounts for 2% of the variance. Given that genetic effect sizes turn out to be extremely small, typically 0.1%, and contribute interchangeably and additively (


Recently it has been reported an association between adenosine deaminase genetic polymorphism and coronary artery diseases. Gender differences in the degree of this association have been also observed. These observations prompted us to study the possible joint effects of BW, ADA, and gender on the susceptibility to coronary artery diseases. 222 subjects admitted to hospital for nonfatal coronary artery diseases, and 762 healthy consecutive newborns were studied. ADA genotypes were determined by DNA analysis. A highly significant complex relationship has emerged among ADA, birth weight, and gender concerning their role on susceptibility to coronary artery diseases in adult life. Odds ratio analysis suggests that low birth weight is more important in females than in males. ADA Recently an association between Adenosine Deaminase (ADA) genetic polymorphism and Coronary Artery Disease (CAD) has been reported ; subjectADA is a polymorphic enzyme present in all mammalian tissues . It is cAdenosine is an important local hormone regulating blood flow, neurotransmission, physiology of smooth muscle, and platelet aggregation. In the liver adenosine counteracts insulin action by activating A2B receptors .ADA and CD26 are colocalized on T-cell surface, but not inside cells. Cells expressing ADA and CD26 on the surface are much more resistant to the inhibitory effects of adenosine.Through the regulation of glucose metabolism, genetic variation of adenosine concentration due to ADA polymorphism may have an important role in intrauterine development and bilirubin metabolism in the newborn.Severe ADA deficiency is a systemic metabolism disorder associated to organ dysfunction . The pos222 subjects admitted consecutively to the Hospital for non fatal CAD were studied. 762 consecutive newborn infants were considered as controls. All subjects were Italians from the White population of Central Italy.ADA phenotype/genotype was determined by DNA analysis in CAD subjects  and by sReliable information on Birth Weight was obtained in 126 subjects with CAD.Chi-square test of independence, correlation analysis, and principal component analysis were carried out by SPSS package . PrincipIn the following tables the pattern of correlations among the three variables has been analyzed in details.In Correlation analysis shows that the pattern of correlations among BW, gender, and ADA in subject with CAD is significantly different from that observed in healthy subjects. ADA*2 allele is less represented in CAD males as compared to females but such difference is evident in subjects with a relatively low birth weight only. On the other hand a direct association between BW, and CAD is observed in females only. Moreover CAD females carrying the ADA*2 allele shows a lower BW compared to ADA*1/*1 females but such association is not observed in males. Overall, this indicates a complex interaction involving gender, BW and ADA concerning their effects on susceptibility to CAD. Statistical analysis suggests that in males prevails the effect of ADA polymorphism, while in females prevails the effect of BW.1 that influences ischemic preconditioning [The lower activity of ADA*2 allele compared to ADA*1 results in higher concentration of adenosine that in turn may exert a positive role on cardiac function. This may represent a possible explanation of the negative association between ADA*2 allele and CAD. Indeed ecto-ADA interacts with Adenosine Receptors Aitioning –16. Moreitioning .The developmental origin of adult diseases theory postulates that foetal undernutrition increases the susceptibility to coronary artery disease and allied disorders in later stages of life . The invIn this context based on the association of ADA polymorphism with peculiar neonatal events we have proposed another line of investigation .We have shown that ADA genetic variability influences neonatal bilirubin levels. In particular ADA*2 allele is more represent in newborns with high serum bilirubin level as compared to newborns with low level , 22. On We have observed that the proportion of carriers of ADA*2 allele in newborns who have undergone phototherapy for high bilirubin level during the first few days of life is higher as compared to those who have not undergone such treatment , 22. On Since the newborn is particularly susceptible to oxidative damage, the effect of ADA*2 allele on bilirubin level could result in a protection against oxidative damage and in turn in long-term positive effect on the protection towards CAD in adult life. Hormonal diversity could be responsible for gender differences. These differences, however, could be the expression of different clinical severity leading to different rates of mortality between sexes. Indeed our cases include nonfatal CAD only, and we have no information on fatal cases.The present observations should be confirmed in another clinical setting before drawing definitive conclusion. An important limitation is due to lack of case fatality rate that might be different between sexes influencing the degree of correlations observed in our cases.


Strongyloides stercoralis is a neglected soil-transmitted helminth species, and there is a lack of parasitologic and epidemiologic data pertaining to this parasite in China and elsewhere. We studied the local occurrence of S. stercoralis in a village in Yunnan province, China, and comparatively assessed the performance of different diagnostic methods.S. stercoralis prevalence of 11.7%. Males had a significantly higher prevalence than females , and infections were absent in individuals <15 years of age. Infections were only detected by the Baermann (highest sensitivity) and the Koga agar plate method, but neither with the Kato-Katz nor an ether-concentration technique. The examination of 3 stool samples rather than a single one resulted in the detection of 62% and 100% more infections when employing the Koga agar plate and the Baermann technique, respectively. The use of a mathematical model revealed a ‘true’ S. stercoralis prevalence in the current setting of up to 16.3%.Multiple stool samples from a random population sample were subjected to the Kato-Katz method, an ether-concentration technique, the Koga agar plate method, and the Baermann technique. Among 180 participants who submitted at least 2 stool samples, we found a S. stercoralis is endemic in the southern part of Yunnan province and that differential diagnosis and integrated control of intestinal helminth infections needs more pointed emphasis in rural China.We conclude that  Strongyloides stercoralis, the causative agent of strongyloidiasis, and yet this is a neglected tropical disease. The diagnosis of this parasite requires specialized techniques (e.g. Baermann and Koga agar plate method), but these are rarely employed in epidemiologic studies. We assessed the occurrence of S. stercoralis in a rural part of southern Yunnan province, China, and compared different diagnostic methods. At least two stool samples were obtained from 180 randomly selected individuals, and examined with four diagnostic approaches, including the Koga agar plate and the Baermann technique. Twenty-one individuals were infected with S. stercoralis . Males were more often infected than females . Infections were absent in children below the age of 15 years. The Baermann technique showed a higher sensitivity than the Koga agar plate method, and the examination of multiple stool samples improved the diagnostic performances of both methods. The use of a mathematical model suggested a ‘true’ S. stercoralis prevalence of 16.3%. There is a need to further study the epidemiology of strongyloidiasis in other parts of China, and control measures are required in settings with high prevalences as observed in this area.An estimated 30 million to 100 million people are infected with the parasitic worm  Ascaris lumbricoides, Trichuris trichiura and the hookworms  are the most widespread species Strongyloides stercoralis is another and even more neglected soil-transmitted helminth, although an estimated 30–100 million people are infected worldwide S. stercoralis occurs transcutaneously and can be perpetuated over long periods by autoinfection S. stercoralis-infected immunocompetent people can be inconspicuous or even absent, but hyperinfection involving the gastrointestinal and pulmonary system is possible. Potentially fatal disseminated infections are seen in immunocompromised individuals, for example, as a result of immunosuppressive drugs or following human T-cell lymphotropic virus type 1 (HTLV-1) infection Soil-transmitted helminthiases are caused by infections with intestinal nematodes, of which S. stercoralis is endemic in tropical and temperate zones but accurate information on the geographic distribution and the global burden of strongyloidiasis is lacking. An important underlying reason is that one of the most widely used diagnostic approaches in helminth epidemiology, i.e., the Kato-Katz method S. stercoralis. Moreover, microscopic examination of direct fecal smears, often used in endemic settings, has a low sensitivity S. stercoralis larvae include the Koga agar plate method S. stercoralis has been studied in some detail. In different investigations carried out among schoolchildren and adults in northern and central Thailand, prevalences ranging between 2.3% and 28.9% were found S. stercoralis has also been investigated in other Asian countries, including Japan PubMed database (http://www.pubmed.gov) where the following search strategy “strongyloides OR strongyloidiasis AND China” resulted in only 6 hits; 3 case reports, 1 study on animal strongyloidiasis, 1 global review, and 1 old publication that looked at single and multiple species parasitic infections among 15,952 Chinese using direct-smear examinations In East Asia and Thailand in particular, the epidemiology of S. stercoralis by screening multiple stool samples from the same individuals and comparatively assessed the performance of different diagnostic methods.Here, we report findings from a cross-sectional parasitologic and questionnaire survey carried out in a random population sample in a rural setting of southern Yunnan province, China. We investigated the occurrence of S. stercoralis, as both species have the same way of transmission), and (ii) it is readily accessible by project car to assure a rapid transfer of stool samples to the nearby laboratory. Details of the study village and the population sample have been presented elsewhere The study was carried out in Nongyang village, located in Menghai county, Xishuangbanna prefecture, Yunnan province, China (21.81° N latitude and 100.35° E longitude). The village was selected because (i) the hookworm prevalence in this area is known to be high  were contacted in batches of 20–30 families per week, and all members were invited to participate in the survey. The aim and procedures of the study were explained, and an informed consent sheet was signed by the head of the household or a designated literate substitute. Pre-tested individual and household questionnaires were administered to obtain demographic , behavioral  and occupational data, as well as information about the living conditions . Next, pre-labeled plastic containers for stool sample collection were handed out to all participants and their ability to recognize their names was checked. Each morning, filled containers were collected and replaced by empty ones for stool collection on the following day. This procedure was repeated with the goal to obtain 3 stool samples from each individual.The stool samples were stored at ambient temperature and transferred to the laboratory within 2 hours post-collection. They were processed by the Kato-Katz technique S. stercoralis larvae (L1-stage). The Koga agar plates were freshly prepared once per week and kept at 4°C in humid conditions pending utilization. A hazelnut-sized stool sample was placed in the middle of the plate and the covered plates were incubated in a humid chamber for 2 days at 28°C. All plates were rinsed with 12 ml SAF solution, the eluent centrifuged and the sediment examined under a microscope. Recovered larvae were differentiated to distinguish S. stercoralis L3 larvae from hookworm larvae. Samples were considered positive if larval or adult S. stercoralis were observed.Specifically, a single Kato-Katz thick smear was prepared from each stool sample and examined within 1 hour of preparation. Helminth eggs were counted separately to obtain parasite-specific infection intensity estimates. For the Baermann test, an apricot-sized stool sample was placed on a gauze-lined mesh in a glass funnel equipped with a rubber tube and a clamp, covered with deionised water and illuminated from below with a bulb. After 2 hours, the lowest 50 ml of the liquid were drained, centrifuged and the sediment examined under a microscope for S. stercoralis according to the Koga agar plate and the Baermann methods were calculated by means of a mathematical model presented and used elsewhere Questionnaire data were entered in EpiData version 3.0  and statistical analyses were carried out in STATA version 9.2 . Prevalence estimates for At completion of the study, free treatment with compound mebendazole  was offered to all inhabitants of the village by staff of the local parasite control station.The institutional review boards of the National Institute for Parasitic Diseases  and the Swiss Tropical Institute  approved the study. As mentioned before, written informed consent was sought from household heads or appropriate literate substitutes.In total, 283 individuals from 71 families participated in the survey . At least 1 stool sample of sufficient quantity to perform the various diagnostic tests was available from 234 individuals (82.7%). Two or 3 samples were submitted by 180 individuals (63.6%) and subsequent analyses were performed on this cohort. There were 98 females (54.4%) and the age of the participants ranged from 4 to 84 years. Among those aged 15 years and above, 92.0% were farmers, the others were students. The illiteracy rate in the same age group was 67.2%. The majority of those aged 14 years and below attended school (58.5%), whereas the remaining individuals were either pre-school children (26.8%) or had never attended school.A. lumbricoides (93.3%), T. trichiura (88.9%) and hookworms (87.8%) were found. Here, we focus on the S. stercoralis results. Stool examination utilizing the Koga agar plate and the Baermann technique resulted in the identification of 19 and 21 S. stercoralis infections, respectively. As summarized in S. stercoralis infections detected by the Koga agar plate method were also diagnosed by the Baermann technique, whereas 2 infections were identified by the latter method only. Thus, the observed infection prevalence of S. stercoralis, according to Baermann was 11.7%. The Kato-Katz method and the ether-concentration technique on SAF-conserved stool specimens failed to identify even a single infection with S. stercoralis.Fourteen different parasite species were identified, 7 helminths and 7 intestinal protozoa. Very high prevalences of S. stercoralis was significantly higher among males than females  = 1, p = 0.011) and increased with age, albeit not significantly . No infections were found among participants <15 years, whereas the highest prevalence was recorded in those aged 15–24 years (19.6%). S. stercoralis infections were not found among students of any age. No additional risk factors for a S. stercoralis infection could be identified. Neither protective measures against infection, such as wearing shoes (odds ratio (OR) = 0.64, p = 0.516), nor hygiene behavior, e.g., hand washing before eating  or after defecation , willingness to see a doctor in case of illness  or presence of domestic animals  were associated with infection status.S. stercoralis prevalence increased from 7.3% to 11.7% when using the Koga agar plate method (an increase of 62%), and from 7.0% to 14.0% in the case of the Baermann method (an increase of 100%). Whilst using Koga agar plates, larvae were detected with equal frequencies in only 1, 2 or all 3 stool samples from infected individuals, the Baermann method often failed to detect larvae in multiple samples from the same person. Using the results of the Koga agar plate method and a mathematical model developed by Marti and Koella S. stercoralis prevalence of 12.3%. The corresponding value for the Baermann technique was 16.3%. The probability of correctly identifying infected individuals by analyzing single stool samples was estimated at 0.63 and 0.48 for the Koga agar plate and the Baermann technique, respectively.Indicators of the diagnostic performance of the Koga agar plate and the Baermann methods, in relation to different sampling efforts, are presented in S. stercoralis infection was identified by the Koga agar plate method among those participants who submitted stool samples of insufficient quantity to concurrently perform the Baermann test. Combined, the Koga agar plate and the Baermann technique identified 30 S. stercoralis infections among 254 individuals who submitted at least 1 stool sample of sufficient quantity to perform at least the Koga agar plate test, resulting in an observed prevalence of 11.8%.S. stercoralis in China, and to our knowledge the performance of different diagnostic approaches has never been assessed in this setting. We carried out an in-depth study in a random population sample from a small village in Yunnan province in the south-western part of China. The collection of multiple stool samples and their screening by the Koga agar plate and the Baermann techniques revealed a prevalence of S. stercoralis of 11.7%.There is a paucity of parasitologic and epidemiologic investigations pertaining to S. stercoralis. Future studies should investigate the effect of time from stool evacuation to laboratory examination with an emphasis on S. stercoralis. Third, a mathematical model S. stercoralis when compared to the results of 3 stool specimens subjected to either the Koga agar plate or the Baermann technique. The application of other diagnostic methods, such as the charcoal coproculture method, which includes a culture step before harvesting the larvae by the Baermann method, and serology, might detect additional infections. Yet, based on our previous experience, we are confident that the approach taken in the current study (multiple stool samples and different diagnostic methods) detected S. stercoralis infections with a high sensitivity. Nonetheless, serological methods suitable to also identify very light infections should be used in future studies to further investigate the conspicuous absence of infections among children.It is conceivable that the observed prevalence still underestimates the ‘true’ prevalence, which is justified on the following grounds. First, in the absence of a diagnostic ‘gold’ standard, it is not possible to determine how often larvae failed to emigrate from the stool sample, or actually resided on the surface of the agar plate, but were not recovered. With regard to the Baermann technique, it is possible that some larvae had not yet reached the water, or settled to the ground of the funnel when the water was drained after 2 hours of exposure to light. Second, a recent study carried out in rural Malawi showed that a delay of 3 hours or more between evacuation of stool specimens by humans and processing/examining of stool samples in the laboratory resulted in a considerably decreased sensitivity of hookworm diagnosis S. stercoralis infections matched the previously presented epidemiologic patterns from neighboring countries. The 21 infections diagnosed by the Baermann approach originated from 18 families, suggesting that mis-attribution was certainly not a major issue. We also assume that the participation of only 63.6% of the eligible villagers did not affect the representativeness of the sample since the age and sex distribution of these 180 individuals was similar to the remaining 103 people who failed to provide at least 2 stool samples of sufficient quantity.On the other hand, the collection of stool samples over several days under limited supervision by our research team bears the risk of mixing up collection containers at the household level. This would result in the attribution of samples from one infected person to different household members who might not be infected, thus inflating the prevalence. We are confident that this issue did not distort our data, as we provided detailed explanations to all study participants about the importance of stool collection using the designated containers, and checked the ability of at least one household member to recognize each name on the pre-lab containers. Moreover, the age and sex distribution of Concerning the recovery of larvae from the agar plates, an attempt was made to first visually inspect the plate for larval tracks and characteristic signs of fungal and bacterial growth, but the high prevalence of hookworm larvae necessitated the recovery of the actual larvae for microscopic examination. In some cases signs of larval activity were noted, but no larvae could be recovered. Contrarily, it was shown that larvae can be present even if no signs of their activity can be detected on the surface of the agar plate S. stercoralis in Yunnan province. The overall prevalence of S. stercoralis (11.7%) is similar to reports from northern Thailand We are not aware of previous community-based studies focusing on S. stercoralis infections. Different methods are therefore employed for the parasitological diagnosis of this helminth but they are often poorly standardized and their performance has rarely been assessed comparatively. In one of the few available studies that compared the diagnostic performance between the Koga agar plate and the Baermann method, the former technique was superior to the Baermann technique S. stercoralis infections, but compared to the Baermann and Koga agar plate methods, their sensitivity was considerably lower S. stercoralis is also well known It is commonly assumed that even if multiple stool samples are available, no single diagnostic technique can detect all S. stercoralis. Nevertheless, the obvious importance of S. stercoralis for public-health has yet to prompt new research into the epidemiology and control of this neglected helminth infection in China and elsewhere. In this connection, the importance of differential diagnosis of soil-transmitted helminth infections must be emphasized, particularly in view of the large-scale administration of albendazole and/or mebendazole that usually show good efficacy against A. lumbricoides and hookworms (only moderate efficacy against T. trichiura), but commonly fail to clear S. stercoralisS. stercoralis in adjacent parts of Yunnan province with different environmental, socio-economic and ethnic characteristics, and will also investigate current and future treatment options. Finally, we encourage other groups who focus their research on helminths, not to neglect S. stercoralis any longer.Over the past decades, profound demographic, ecologic and socio-economic changes have occurred across China


The protocol included the administration of the Community Screening Instrument for Dementia , and the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) verbal fluency (VF), word list memory  and recall  tests. Only those free of dementia were included in the analysis.Older people, and those with less education performed worse on all four tests. The effect of sex was much smaller and less consistent. There was a considerable effect of site after accounting for compositional differences in age, education and sex. Much of this was accounted for by the effect of region with Chinese participants performing better, and Indian participants worse, than those from Latin America. The effect of region was more prominent for VF and WLM than for COGSCORE and WLR.Cognitive assessment is a basic element for dementia diagnosis. Age- and education-specific norms are required for this purpose, while the effect of gender can probably be ignored. The basis of cultural effects is poorly understood, but our findings serve to emphasise that normative data may not be safely generalised from one population to another with quite different characteristics. The minimal effects of region on COGSCORE and WLR are reassuring with respect to the cross-cultural validity of the 10/66 dementia diagnosis, which uses only these elements of the 10/66 battery. Rapid demographic ageing around the world has important implications for health and social care. Cognitive decline and dementia have a high individual impact and are strongly age-associated , so thatThe data presented in this paper were drawn from the 10/66 Dementia Research Group's cross-sectional surveys of older people carried out in seven urban and four rural sites in five Latin American countries, China and India. The primary objective was to generate site-specific norms for the cognitive test battery used in the 10/66 studies comprising tests of general cognitive function, verbal fluency and immediate and delayed verbal recall. Further objectives were: a) to assess the independent influences of age, educational level and gender and their homogeneity across sites, and b) to assess the extent to which variance attributable to site could be attributed to the effects of region and/or rural versus urban residence.The design of the 10/66 Dementia Research Group (DRG) baseline population-based studies has been described in detail [For this analysis we considered the following socio-demographic measures as independent variables: participants' age divided into four groups , sex, and education level divided into five groups , completed primary, completed secondary, and tertiary). Age of participants was formally established during interview from stated age, official documentation, informant report and, in the case of discrepancy, age according to an event calendar.The 10/66 cognitive assessment battery was drawn principally from the Community Screening Instrument for Dementia (CSI 'D') developed by the Ibadan-Indianapolis study group  specificThe analysis described here focussed on the four main tests included in the 10/66 cognitive test battery:1) Global cognitive function: The Community Screening Instrument for Dementia (CSI 'D')  includes2) Memory: The 10/66 battery includes two elements of the CERAD 10 word list learning test: world list memory (WLM) and word list recall (WLR), testing immediate and delayed recall respectively. WLR has been reported to be of particular value in distinguishing early dementia from normal aging . WLM and3) Verbal fluency (VF): the animal naming verbal fluency task  from theThe CERAD neuropsychological battery has been adapted for use in India , Korea , Brazil The study was carried out in compliance with the Helsinki Declaration and all participants provided informed consent. The study was considered and approved by the appropriate Research Ethics Committee at King's College London (Institute of Psychiatry and South London & Maudsley NHS Trust (references 076/03 and 209/01) after approvals at all participating sites .2) in each cognitive test accounted for by age, education, gender and site. We further sought to investigate the variance accounted for by site by substituting this variable with two further variables sub-classifying sites into region (Latin America versus (a) China, and (b) India) and rural or urban location. The effect of region  is summarised as adjusted means and mean differences with 95% confidence intervals for the two contrasts: China versus Latin America and India versus Latin America. All analyses were carried out using STATA 9.2  on release 1_5 of the 10/66 baseline dataset.For this analysis, all participants who had received a diagnosis of dementia according to either DSM-IV  or 10/66Response rates for the sites were as follows: Cuba 94%, Dominican Republic 95%, urban Peru 80%, rural Peru 88%, Venezuela 80%, urban Mexico 84%, rural Mexico 86%, urban China 74%, rural China 96%, urban India 72%, rural India 98%. In all, 14,967 participants were fully evaluated of whom 1318 met criteria for dementia  and wereAll age groups were well represented. The Venezuelan, rural Chinese and Indian samples had a younger age distribution than other sites. The female/male ratio exceeded 1 in all sites, but with a less striking preponderance of women in rural Peru, China and India. Educational level showed considerable variation across sites, highest in urban Latin America sites (other than the Dominican Republic), and lowest in rural China and in India. Within countries, educational levels were consistently higher in urban compared with rural sites.Tables Tests for interaction indicated that the effects of age, sex and education on cognitive test performance were each significantly modified by site for all four cognitive tests. However, the effects were uniformly very modest in size, generally accounting for between 0.1% and 0.3% of the overall variance. The two largest interaction effects were those for verbal fluency between site and age (0.6% of the variance), and site and education (0.5%).Table We have provided normative data by age group, sex and educational level for widely used neuropsychological tests of global cognitive function, verbal fluency and immediate and delayed word recall in seven low or middle income countries. People with any degrees of dementia, including questionable dementia, were excluded. These norms have been rigorously generated applying a standardized testing procedure amongst representative community-dwelling samples. To our knowledge this is the largest study to date on neuropsychological tests norms and the first to present direct comparisons between so many culturally diverse countries.With the exception of rural India, our norms for CERAD WLM and WLR are well aligned with those previously reported from affluent western countries. ,22-24. Oper se, but relevant to cognitive performance and differently distributed across sites, may not have not been taken into consideration in our analyses. One such effect may be the quality and nature of education received that may not be adequately summarised in terms of level of education [There was a considerable residual effect of site upon cognitive test performance, not accounted for by compositional differences between samples in the distribution of age and education. Further analyses clarified that the between-site difference was most parsimoniously accounted for by the effect of region, with smaller effects of rural versus urban location evident for the two memory tests. We should still be cautious about attributing the effect of region to that of language and culture. First, other compositional differences not directly linked to culture ducation . Second,By design, the two cognitive tests included in the 10/66 dementia diagnosis, the CSI 'D' COGSCORE and the CERAD WLR, were those that showed the smallest cultural influences and the most robust cross-cultural discriminating properties . This fiCognitive assessment is a basic element for dementia diagnosis. Age- and education-specific norms are required for this purpose, while the effect of gender can probably be ignored. The basis of cultural effects is poorly understood, but our findings serve to emphasise that normative data may not be safely generalised from one population to another with quite different characteristics. The minimal effects of region on COGSCORE and WLR are reassuring with respect to the cross-cultural validity of the 10/66 dementia diagnosis, which uses only these elements of the 10/66 battery.The 10/66 Dementia Research Group works closely with Alzheimer's Disease International (ADI), the non-profit federation of 77 Alzheimer associations around the world. ADI is committed to strengthening Alzheimer associations worldwide, raising awareness regarding dementia and Alzheimer's Disease and advocating for more and better services for people with dementia and their caregivers. ADI is supported in part by grants from GlaxoSmithKline, Novartis, Lundbeck, Pfizer and Eisai.All of the authors worked collectively to develop the protocols and methods described in this paper. MP led the research group and CF acted as research coordinator. JLR (Cuba), DA (Dominican Republic), MG (Peru), AS (Venezuela), ALS (Mexico), KSJ , JDW  and YH (China) were principal investigators responsible for the field work in their respective countries. ALS, EA and RS prepared the first draft and carried out the analyses of this manuscript. MP carried out a final revision for the first submission and RS revised the second submission in response to reviewers' comments. Other authors reviewed the manuscript, provided additional comments and contributions. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


P value for trend <0.001). Cox proportional hazards regression analyses showed that serum uric acid levels were independently and positively associated with the risk for incident NAFLD; the age-, gender- and metabolic syndrome adjusted hazard ratio (95% CI) for the subjects in quintile 2, 3, 4 and 5 versus quintile 1 was 1.18 (0.91–1.54), 1.32 (1.03–1.70), 1.39 (1.09–1.78) and 1.50 (1.18–1.92), respectively. Taken together, our prospective observational study showed that elevation of serum uric acid levels independently predicts increase risk for incident NAFLD.Nonalcoholic fatty liver disease (NAFLD) is a common form of chronic liver disease, and serum uric acid is observed to be significantly elevated in NAFLD patients. However, whether this elevation is causal, a bystander, or a consequence of NAFLD remains unclear. We performed a population-based prospective study among the employees of Zhenhai Refining & Chemical Company Ltd., Ningbo, China to investigate whether the elevation of serum uric acid has a casual role for NAFLD. A total of 6890 initially NAFLD-free subjects were followed up for 3 years. Overall, 11.80% (813/6890) subjects developed NAFLD over 3 years of follow-up. The cumulative incidence of NAFLD increased with progressively higher baseline serum uric acid levels (the cumulative incidence was 7.2%, 9.5%, 11.5%, 13.8%, and 17.2% in quintile 1, quintile 2, 3, 4 and 5, respectively;  Nonalcoholic fatty liver disease (NAFLD) represents a spectrum of conditions from simple steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis. It has become one of the most prevalent liver diseases in Western countries, affecting 20%–30% of the general population Identifying risk factors is essential for prevention of NAFLD. The development of NAFLD is a multifaceted cascade of physiologic and biochemical events, including genetic Uric acid is the end product of purine metabolism and the serum uric acid (SUA) level is maintained by the balance between uric acid production and excretion Therefore, in this study, we performed a population-based prospective study to investigate whether the elevation of SUA has a casual role for NAFLD in the Chinese population.Verbal informed consent was obtained from each subject before participation in the study after all procedures had been explained. Verbal consent was recorded by the physician who explained the study procedures. Written informed consent was not required because of the observational nature of the investigation. The study protocol and the form of consent were approved by the Ethics Committee of the First Affiliated Hospital, College of Medicine, Zhejiang University.To identify whether SUA plays a causal role in development of NAFLD, a population-based prospective study was conducted among the employees of Zhenhai Refining & Chemical Company Ltd., Ningbo, China beginning in 2006. The majority of these subjects had taken part in our 2005 cross-sectional study Certain subjects were excluded at study entry: (i) those diagnosed with fatty liver based on ultrasonography (n = 1795); (ii) those with alcohol consumption greater than 140 g/week for men and 70 g/week for women (n = 596); (iii) those taking antihypertensive or antidiabetic agents, lipid-lowering agents, or hypouricemic agents based on self-reported medical history and medication use (n = 705); (iv) those with a positive history of known liver disease, such as viral hepatitis B or C, or autoimmune hepatitis, or those using hepatotoxic medications (n = 958).The NAFLD-free cohort thus comprised 7412 subjects  with a mean age of 44.4 years. These subjects were classified into various groups according to employee number and scheduled for annual evaluation for 3 years. We excluded 522 subjects  who did not complete the follow-up examinations. A total of 6890 initially NAFLD-free subjects  were evaluated for the development of NAFLD.Baseline examinations included a medical history and health habit inventory taken by a physician, anthropometric measurements, hepatic ultrasonic examination, and biochemical measurements. The examinations were administered in the morning. The subjects were instructed to fast for at least 12 hours prior to the examination and to refrain from exercise during the day before their examination.2), used as an index of body fat, was calculated as weight in kilograms divided by height in meters squared. Waist circumference was measured with the measuring tape positioned midway between the lowest rib and the superior border of the iliac crest as the patient exhaled normally Blood pressure was measured using an automated sphygmomanometer with the subject in a sitting position. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured at the first and fifth Korotkoff phases, respectively. Standing height and body weight were measured without shoes or outer clothing. Body mass index . Ultrasound studies were carried out by a trained ultrasonographist who was unaware of the clinical and laboratory data. Hepatic steatosis was diagnosed by characteristic echo patterns according to conventional criteria, such as the evidence of diffuse hyperechogenicity of the liver relative to the kidneys, ultrasound beam attenuation, and poor visualization of intrahepatic structures Hyperuricemia was defined as a SUA level>420 µmol/L in men and>360 µmol/L in women To explore the association between SUA level and risk for incident NAFLD, subjects were stratified according to their baseline SUA levels: quintile 1, ≤295 µmol/L; quintile 2, 296–332 µmol/L; quintile 3, 333–367 µmol/L; quintile 4, 368–409 µmol/L; and quintile 5, ≥410 µmol/L for males; and quintile 1, ≤205 µmol/L; quintile 2, 206–232 µmol/L; quintile 3, 233–262 µmol/L; quintile 4, 263–298 µmol/L; and quintile 5, ≥299 µmol/L for females. The baseline characteristics of the subjects in each quintile were compared. The cumulative incidence of NAFLD was calculated by dividing the number of cases by the numbers of subjects followed up for each SUA quintile.We applied Cox proportional hazards regression analyses, which are commonly used for risk assessments in prospective studies 2 test; continuous variables were compared with Mann-Whitney U test, student's t-test, Kruskal-Wallis H test or one-way analysis of variance, depending on the normality of the data. All statistical analyses were performed using the SPSS software package version 11.5 for Windows . P<0.05 (2-tailed) was considered to be statistically significant.Continuous variables are presented as mean and standard deviation (SD) or medians and interquartile range (IQR), as appropriate. Categorical variables were compared using the χAt baseline, the mean age  of the 7412 participants was 44.4 years . Of the 7412 eligible participants, 522 (7.04%) participants did not complete the follow-up examinations. Baseline characteristics, including age, gender, BMI, waist circumference, and blood pressure, and serum liver enzyme, lipid, glucose, creatinine, BUN, and SUA levels were not different between the participants lost to follow-up and those with successful follow-up .P<0.001). In contrast, HDL-C decreased with as SUA increased (P<0.001). The gender proportion was not significantly different among the subjects with all five SUA quintiles (P = 0.81).A total of 6890 subjects  were evaluated yearly over the course of the study. The baseline characteristics of subjects in each SUA quintile are shown in To explore the association of SUA with incident NAFLD, subjects were stratified into quartiles according to their baseline SUA levels. The cumulative incidence of NAFLD was calculated by dividing the number of cases by the numbers of subjects in each SUA quintile.P for trend<0.001; P for trend<0.001; P for trend<0.001; Overall, 813 subjects  developed NAFLD during the 3 year study, corresponding to 13.5% and 8.7% cumulative incidence of NAFLD in men and women, respectively. We observed that baseline SUA quintiles predicted the incidence of NAFLD in a graded and dose-responsive manner . The oveIn contrast to participants without incident NAFLD, those with incident NAFLD were relatively older and predominantly male . As expeP = 0.004; To estimate hazard ratios for incident NAFLD, Cox proportional hazards regression analyses (both univariate and multivariable models) were applied. As shown in P for trend <0.001). The relationship of SUA with incident NAFLD remained significant even further adjustment for indictors of metabolic syndrome including waist circumference, systolic blood pressure, diastolic blood pressure, triglyceride, HDL cholesterol and fasting plasma glucose  for subjects in quintile 2, quintile 3, quintile 4, and quintile 5 were 1.32 (1.02–1.72), 1.60 (1.25–2.06), 1.92 (1.50–2.44), and 2.34 (1.85–2.97), respectively . In the univariable Cox model, hyperuricemia conferred a hazard ratio of 1.62 . Adjusting for age, gender, and metabolic syndrome slightly attenuated the hazard ratio value to 1.32 . This subgroup analysis further demonstrated that hyperuricemia is an independent risk factor for NAFLD.When baseline SUA level was entered as a dichotomous variable, that is, hyperuricemia Our recent cross-sectional study showed that NAFLD patients had higher SUA levels than healthy controls and that the prevalence of NAFLD was increased at higher SUA levels, suggesting significant association between SUA and NAFLD The significant association between SUA and development of NAFLD suggest that high SUA levels may play a causal role in the development of NAFLD. Two potential reasons could explain the mechanism by which high SUA levels participates in the development of NAFLD. The first is that uric acid acts as a strong oxidant in the environment of metabolic syndrome The significant association between SUA and development of NAFLD cannot exclude the possibility that high SUA levels may be just a marker for the development of NAFLD. However, even if this possibility is true, our findings may also have significant clinical implications. Since high SUA levels could predict the development of NAFLD independent of gender, age, metabolic syndrome, and other currently available clinical variables. Furthermore, our recent experimental study observed that hypouricemic therapy consisting of allopurine and benzbromarone, two drugs used clinically to lowering SUA levels, significantly ameliorated hepatic steatosis and decreased serum cholesterol levels in a Mongolian gerbil model of NAFLD P<0.001) for SUA between the baseline examination and the last follow-up examination. This indicates that those who had the higher baseline SUA level tended to be so during follow-up. Therefore, the observed association between elevated baseline SUA and increased risk of incident NAFLD could reflect the effects of SUA over the observed period.The interpretation of this study has several potential limitations. First, the diagnosis of NAFLD was based on ultrasonography, which is not sensitive enough to detect mild steatosis. However, ultrasonography is widely used in epidemiological surveys of NAFLD because it is non-invasive, safe, widely available, portable and sensitivity for detecting hepatic steatosis is acceptable. Sceond, SUA level during follow-up was not included in the analysis. Spearman's rank correlation coefficient was 0.589 Click here for additional data file.


Nicotine replacement therapy (NRT) is the most common form of smoking cessation pharmacotherapy and has proven efficacy for the treatment of tobacco dependence. Although expectations of mild adverse effects have been observed to be independent predictors of reduced motivation to use NRT, adverse effects associated with NRT have not been precisely quantified.A systematic review and meta-analysis aimed to identify all randomized clinical trials (RCTs) of NRT versus inert controls and all observational studies to determine the magnitude of reported adverse effects with NRT.Searches of 10 electronic databases from inception to November 2009 were conducted. Study selection and data extraction were carried out independently in duplicate. RCTs were pooled using a random effects method with Odds Ratio [OR] as the effect measure, while proportions were pooled from observational studies. A meta-regression analysis was applied to examine whether the nicotine patch is associated with different adverse effects from those common to orally administered NRT.Ninety-two RCTs involving 32,185 participants and 28 observational studies involving 145, 205 participants were identified. Pooled RCT evidence of varying NRT formulations found an increased risk of heart palpitations and chest pains ; nausea and vomiting ; gastrointestinal complaints ; and insomnia . Pooled evidence specific to the NRT patch found an increase in skin irritations . Orally administered NRT was associated with mouth and throat soreness ; mouth ulcers ; hiccoughs  and coughing . There was no statistically significant increase in anxiety or depressive symptoms associated with NRT use. Non-comparative observational studies demonstrated the prevalence of these events in a broad population.The use of NRT is associated with a variety of side effects. In addition to counseling and medical monitoring, clinicians should inform patients of potential side effects which are associated with the use of NRT for the treatment of tobacco dependence. Smoking is the leading cause of preventable mortality world wide. One in Several pharmacological interventions to assist in smoking cessation are available. The mosAvailable research suggests that smokers are less motivated to use NRT if they expect that it will cause mild adverse effects. PublishWe included RCTs of any duration beyond 4 weeks. RCTs had to compare NRT with an inert control (eg. placebo or standard of care). We chose 4 weeks to include the timeframe of maximum nicotine withdrawal symptoms so that adverse events may be differentiated from withdrawal symptoms. We addiScienceDirect, and Ingenta, including articles in full text from approximately 1700 journals since 1993)) is the estimated standard deviation of underlying effects across studies[In order to assess inter-rater reliability on inclusion of articles, we calculated the of chance. We calcof chance. We firsof chance, which rof chance. We calcrogeneity. Given trogeneity. We conss at zero. This iss at zero,24, thers studies. As withOne hundred and twenty studies met our inclusion criteria ϕ = 0.91) ,110-141. ,110-141Of RCTs, eighty-three -117,142. Applying meta-regression, both the nicotine patch and orally administered NRT were associated with an increased risk . Coughing was significantly elevated in 12 RCTs , but was associated with considerable heterogeneity.A pooled analysis of 12 RCTs found a statistically significant increased risk for heart palpitations and chest pains associated with NRT . However, meta-regression showed that studies focusing on the nicotine patch were associated with a decreased risk  of nausea and vomiting. The review also found an increased risk of indigestion and general GI complaints with NRT in an analysis of 26 RCTs . Using only orally administered NRT caused significantly greater risk for GI complaints compared with the nicotine patch , and was also associated with an increased risk of hiccoughs . A meta-analysis of 6 RCTs found a significantly elevated risk for mouth ulcers .A significantly heightened risk of oral adverse events including mouth and throat soreness was identified in a meta-analysis of 23 RCTs , while an analysis of 24 RCTs, found no association between NRT use and increased dizziness A meta-analysis of 32 RCTs (Table 2 = 0%). However, nicotine patch was not associated with increased incidence of urticaria  or sweating .Nicotine patch was associated with a statistically significant risk of skin irritation in an analysis of 32 RCTs . Anxiety and depression were, however, not significantly increased  in our analysis of pooled events of nausea and vomiting. We were able to explain a large amount of heterogeneity examining the covariate of skin patch vs. oropharyngeal administration  as well as reporting of allocation concealment . We also found large heterogeneity (I2 = 66%) in the event of mouth and throat soreness, but were unable to explain this using our pre-specified covariates. Considerable heterogeneity (I2 = 72%) was also identified for the adverse event of coughing. We found that duration of study  and allocation concealment  contributed to heterogeneity observed in this analysis. Our analysis of sweating found large heterogeneity (76%) that was predominantly contributed by a study that provided concomitant bupropion, indicating that the dual use of both drugs resulted in a significantly higher incidence of sweating . We also found heterogeneity in our analysis of insomnia that was explained by the duration of the trials. Longer duration trials had reduced rates of insomnia .We used meta-regression to explain heterogeneity. We found large heterogeneity . Dizziness was a more common complaint, with a prevalence of 7.3%. Headaches were commonly reported (9.7%).The prevalence of skin irritations associated with nicotine patch was reported as 19.5% of the populations examined.Serious adverse events were poorly reported in the observational studies. However, one study reported on a case of transient visual field impairment; one right-hemisphere stroke; one myocardial infraction; and one urticarial reaction from skin patch with symptoms of angiodema. Finally, in a single large observational study of self-harm , 141 cases of fatal and non-fatal self-harm cases were identified (0.2%), in addition to 30 cases of suicidal ideation.This review found that NRT is associated with an increased risk of gastrointestinal complaints and insomnia. There was also an observed increased risk of skin irritation with the nicotine patch and oropharyngeal complaints with orally administered NRT. Although NRT was associated with an increased risk of heart palpitations, the review did not observe an increased incident of heart attack or death. With the exception of insomnia, NRT does not appear to be associated with serious adverse psychiatric effects.The reviewers actively sought serious adverse events. The most serious adverse event consistently reported in both RCTs and observational studies were heart palpitations and chest pains . NRT has been implicated in reports of atrial fibrillation and myocardial infarction among patients with risk factors-148. SevAlmost all studies demonstrated localized irritation related to NRT use, skin irritation with the use of NRT patch and mouth soreness and ulcerations with orally administered NRT. It is possible this is due to the success of cessation rather than NRT as mouth ulcers occur in about 40% of all individuals achieving tobacco abstinence regardless of cessation intervention. It has Psychological adverse events, particularly suicidal ideation, are a major concern in patients initiating smoking cessation. We founA criticism of smoking cessation trials has been that they infrequently enroll participants with psychological difficulties, thus making generalizable statements about their safety difficult. The preAn important issue to examine when describing adverse events from smoking cessation therapies is whether the adverse events are related to a pharmacotherapy or whether they are related to tobacco withdrawal. For exaOur review has several limitations. These include limitations of the primary studies themselves as well as those associated with combining results across potentially heterogeneous studies or populations. The main limitation of the primary studies is the mechanism by which adverse events are recorded. In the majority of instances this would be through passive reporting and therefore be susceptible to the underreporting associated with such techniques. The majority of our analyses had low or moderate heterogeneity, although a few had high levels of heterogeneity. Pooling proportions always results in large estimates of heterogeneity and statistical techniques do not yet exist to interpret the extent of real between-study heterogeneity. The revThere is emerging evidence that stopping smoking prior to any type of surgery decreases the potential for surgical complications. All phaThis review demonstrates that NRT is associated with adverse effects that may be discomforting for the patient but are not life-threatening. Given the long-term benefits of smoking cessation over continued smoking, concern about NRT related adverse events should be balanced against the benefits of cessation. Clinicians should monitor for side effects that may worsen underlying conditions, such as insomnia in patients with depression, and consider additional or alternative treatments. Given the benefits of smoking cessation and the important role of NRT in achieving this goal, efforts should be made to counsel patients on the most common side effects and strategies should be developed to deal with them.Pfizer Ltd. Walton Oaks, Walton-On-The-Hill, Surrey, KT20 7NS, United Kingdom, sponsored development of the review and manuscript. Edward Mills and Ping Wu were paid consultants to Pfizer in connection with the development of this manuscript. Kumanan Wilson and Job O. Ebbert received no compensation. Ian Lockhart is an employee of Pfizer.EM, PW, IL, KW conceived the study. EM, PW carried out searches and data abstraction. EM, PW, IL, KW, JE were involved in data analysis. EM, PW, IL, KW, JE contributed to manuscript drafting and interpretation of data. All authors read and approved the final draft.Characteristics of included RCTs. CVD, cardiovascular; RCT, randomized clinical trialClick here for file