MUTYH Associated Polyposis (MAP), a Polyposis predisposition caused by biallelic mutations in the Base Excision Repair (BER) gene MUTYH, confers a marked risk of colorectal cancer (CRC). The MAP phenotype is difficult to distinguish from other hereditary CRC syndromes. Especially from Familial Adenomatous Polyposis (FAP) and to a lesser extend Lynch Syndrome, which are caused by germline mutations in the APC and Mismatch Repair (MMR) genes, respectively.MUTYH interactions, genotypic and phenotypic characteristics of MAP, as well as surveillance and treatment of the disease. The applied papers, published between 1/1 2002- 1/2 2008, were found through PubMed.Here we review research findings regarding MUTYH in CRC tumorgenesis is still uncertain, although MAP tumors show distinct molecular features, including somatic G:C>T:A transversions in the APC gene. Furthermore, cooperation between the BER and the MMR systems exists, as MUTYH interacts with MMR gene-products. Possibly, monoallelic defects in both pathways are of significance to CRC development.The exact role of MUTYH variants are found to be characteristic in distinct ethnic populations, which could facilitate future genetic screening. Knowledge concerning functional consequences of many MUTYH germline mutations remains sparse. Most thoroughly investigated are the two most common MUTYH variants, Y179C and G396D, both generating dysfunctional gene products.Specific Phenotypic features of MAP include: development of 10-100 colorectal adenomas, debuting at 46-47 years, often CRC at time of clinical diagnosis, and in some, development of extracolonic manifestations. MUTYH Associated Polyposis (MAP), which will be focused on in this review. Fig. (1) shows a delimitation of the groups of patients, which are referred to in this paper.Colorectal Cancer (CRC) is the second most prevalent cancer worldwide . In 35% Lynch Syndrome is characterized by the development of particularly CRC and endometrial cancer at a young age. Lynch Syndrome is an autosomal dominant disease often caused by germline mutations in one of the Mismatch Repair (MMR) genes , 5-7. ThAPC  gene, and confers a near 100% risk of developing CRC. FAP has been shown to account for less than 0.1% of all CRC cases APC  genethers in , 13-16).iewed in  and 17]APC  genef exon 9 , 18. AFAf exon 9 . One stuf exon 9 .Prophylactic screening of Lynch Syndrome patients, FAP patients and their families is shown to reduce the development of CRC and CRC-associated mortality markedly , 16, 20.Recommendations for FAP surveillance was recently reviewed in  and 16]16]. SigmAPC gene can be found [APC mutations [APC mutation [In as many as 30% of patients with a FAP-like phenotype, no germline mutations in the be found . Similarutations . Howevermutation .MUTYH gene regarding the development of the Polyposis predisposition syndrome MUTYH Associated Polyposis (MAP) was discovered [In 2002, the significance of mutations in the scovered . Since tMUTYH variants. In addition, we review the clinical aspects of the syndrome and introduce a new nomenclature for MUTYH germline mutations, which is likely to replace the nomenclature, which is currently used.Here we review the main genetic aspects of MAP, including analysis of functional consequences and the outlining of specific ethnic allelic frequencies of MUTYH, as well as of which issues regarding MAP call for future investigation.We believe that this review provides a broad, up-to-date overview of existing findings regarding MAP. We hope to provide perspective of the significance of MUTYH gene product is part of the Base Excision Repair (BER) system, which serves as an important part of cells´ defense against oxidative damage to the DNA. The BER system and the functional role of MUTYH have previously been reviewed in detail by [The etail by -31.Oxidative DNA damage, caused by reactive oxygen species (ROS), which are produced during aerobic metabolism, exposure to certain chemicals or radiation, constantly threatens the integrity of cellular DNA. The oxidized base 7,8-dihydroxy-8-oxoguanine (8-oxo-G) is one of the most stable and mutagenic products of oxidative DNA damage. 8-oxo-G is often mistakenly paired with adenine (A), resulting in the appearance of Guanine:Cytosine > Thymidine:Adenine (G:C > T:A) transversions at the next round of DNA replication, as the detection of stable 8-oxo-G:A base-pairs is missed by the replicative DNA polymerases -31.The human DNA-damage-specific glycosylases OGG1, MUTYH and MTH1, which are central enzymes in the BER pathway, function by specifically recognizing and facilitating the removal of 8-oxo-G -31. The in vitro and in vivo, have demonstrated that the MUTYH glycosylase directly interacts with various proteins involved in other DNA repair pathways . The gene consists of 16 exons and encodes a protein of 535 amino acids, the MUTYH glycosylase. Characterization of the MUTYH gene and functional variants has been reviewed in [The MUTYH glycosylase is encoded by the iewed in -26, 29.MUTYH is alternatively spliced in various ways, generating different MUTYH transcripts [MUTYH transcript existing (NM_012222.2 extended at the 5´of exon 3) will be used as coding DNA reference sequence, as outlined by Leiden Open Variation Database (LOVD) at http://www.LOVD.nl/MUTYH [MUTYH transcript as coding DNA reference sequence is predicted to replace the previous commonly used MUTYH transcript (NM_001048171), although many authors still refer to this. Also, experts in this field  have recently discussed the use of MUTYH reference sequence. They agree that NM_012222.2 extended at 5´of exon 3 is the best option to use as reference sequence in the future [Exon 3 in nscripts , 29, 44.e future .MUTYH mutations mentioned in this paper can be found in Table 1.Consequently, the amino acid numbering in this paper differs from the one used in many previous papers. An overview of the new and old terms regarding some of the most common APC gene are important in CRC tumorgenesis due to the gatekeeper role of the  APC tumor suppressor gene, which is involved in many cellular processes.  of 18q, harboring the SMAD4 gene, and the karyotype of tumor cells typically being near-diploid [Molecular features in MAP tumors are characteristic to these, compared to carcinomas from Sporadic CRC, FAP or Lynch Syndrome tumors , which c-diploid , 50.MUTYH gene in Sporadic CRC has been only sparsely addressed, and with contradictory outcomes. Halford et al. found no indications of MUTYH involvement in Sporadic CRC [MUTYH gene have recently been demonstrated in Sporadic CRC, indicating a role of the MUTYH gene in Sporadic CRC tumorgenesis [The issue of a possible significance of the adic CRC . In contrgenesis .The Mismatch Repair (MMR) system functions postreplicativly correcting DNA errors, which occur during DNA replication. The normal MMR function and characterization of defects in the MMR system have previously been reviewed in , 29 and in vitro experiments have shown that MUTYH physically interacts with the MSH2/MSH6 heterodimeric complex via a hMSH6-binding domain [Presumably cooperation between the BER and the MMR systems exists, since g domain , 54. Theg domain , 54.MUTYH germline mutations are shown to influence the interaction between MUTYH and MSH6, followed by a massive decrease in activity of the MUTYH protein [MUTYH gene and a defect MMR gene is of significance in regard to CRC risk. In a study by Niessen et al. (N=210), a significantly higher frequency of carriers of monoallelic MUTYH mutations was found among CRC patients who also had a specific MMR mutation (5/36=14%), in comparison to groups of CRC patients with other MMR mutations (1/40= 2.5%) or without MMR mutations (1/134 =0.7%) [MUTYH germline mutations and en missense variant of the MSH6 gene was found (4/20 = 20%) [Several  protein , 55. Mut4 =0.7%) . In this0 = 20%) , consistet al. found a remarkably mild Polyposis phenotype in a patient both compound heterozygote for MUTYH mutations, as well as being a carrier of a MSH6 germline mutation, supporting this notion [In contrast, studies of CRC patients have indicated that the BER and MMR pathways may be mutually exclusive, although none have found significant results , 57. Furs notion . HoweverMUTYH gene to date can be found at the LOVD at http://www.LOVD.nl/MUTYH.An overview of the most commonly identified germline mutations in the MUTYH gene are found in different populations, see Fig. (2). In European populations the two missense mutations Y179C and G396D are most frequently seen, and have solely been found in Caucasians. The allelic frequencies of Y179C and G396D found among MAP patients are much higher compared to those found in background populations, see Fig. (3).Specific mutations in the Y179C and G396D do not seem to be of significance with regard to the development of Polyposis, since neither has been found in Asian Polyposis patients or in the corresponding background populations [MUTYH gene [MUTYH mutations after screening of coding regions in the entire gene, although these results may be biased due to small sample size [R245C and the splice-site mutation IVS10-2A>G, neither of which were found in the corresponding background population [In Asian populations, ulations , 59-61. TYH gene , 61. Othple size , 59, 60.pulation .E480X  [E480X, while no other MUTYH mutations were found [MUTYH mutations are unlikely to be of significant importance to development of Polyposis among Indian individuals. Other MUTYH variants found in noteworthy allelic frequencies in characteristic populations are: c.1145delC , A4 of 0.01 ) and E38.15-0.19 , 69).MUTYH polymorphisms without any apparent pathogenic importance have been found. The most frequent of these are V22M, Q388H and S515F, the allelic frequencies of which in healthy control groups are found to be equivalent to those found among MAP patients [In addition, other patients , 69-78.MUTYH mutations, the Y179C and G396D, are situated in the catalytic and C terminal domains of MUTYH, respectively. Both of these MUTYH residues have important roles in the recognition of 8-oxo-G in A:8-oxo-G mispairs [Y179C and G396D have indicated compromised substrate recognition as a consequence of these mutations [The two most common mispairs , 79, 80.utations .Y179C mutation is located in the N-terminal end of the MUTYH, and is part of the pseudo-HhH (helix-hairpin-helix) motif in the catalytic region of the MUTYH. This region is thought to promote the base-flipping mechanism in substrate recognition, participate in maintaining stability during this process, as well as being involved in DNA binding [Y179C mutations in human cell lines illustrate, that defective MUTYH function results from both significantly reduced levels of MUTYH protein (Protein levels of 5-10% compared to wild-type MUTYH levels) as well as from reduced binding and cleavage ability towards the mispaired substrates [The  binding , 79, 82  binding ). Studiebstrates .G396D is located in the C-terminal domain of the MUTYH, which is thought to be responsible for 8-oxo-G recognition and binding, as well as mediating the base-flipping mechanism [G396D mutations show defective MUTYH function as a result of the production of a dysfunctional protein. The protein shows both reduced binding activity of mispaired substrates (about 50% of the wild-type MUTYH activity), as well as lower rates of repair, compared to the wild type MUTYH [G396D mutations [echanism , 79, 80.pe MUTYH . Howeverutations .E. coli MutY variants, which have been shown to severely compromise the activity of the glycosylase [Y179C and  G396D variants showed a 98% and a 86% reduction in adenine removal from a G:A substrate, compared to the wild-type protein, respectively [MutY variants exhibit significantly reduced rates of adenine removal compared to wild-type MutY. The variants corresponding to G396D and Y179C, showing a 6-fold and 80-fold slower rate, respectively [These results are consistent with previous studies of the corresponding  cosylase , 49. In ectively . LikewisMUTYH mutations have also been conducted, although none as comprehensive as for Y179C or G396D, for which reason merely a short overview will be given in the present review:  R182C, R182H, R185Q and G189E, all are located in the pseudo-HhH motif of the MUTYH catalytic domain, are considered to induce functional MUTYH changes comparable to those observed in cell lines with Y179C variants [P405L and A473D, both located in the C-terminal domain, are both supposed to have functional significance [Functional studies of additional variants , 74, 75.ificance , 74.MUTYH mutations, which lie close to or within the MSH6-binding domain of the MUTYH gene, have been preformed: The variants R241W and V246F have preserved their ability to physically interact with MSH6, but both show reduced MUTYH function [R245C, also located near the MSH6 binding domain, is likewise assumed to compromise the interaction between the MUTYH and MSH6 [Functional analyses of two function . R245C, and MSH6 .MUTYH gene, more often than previously assumed, are the disease causing factor in Polyposis patients. Sieber and colleagues found, that an AFAP-like phenotype is more often caused by germline mutations in the MUTYH gene than in the APC gene [APC germline mutations and MUTYH biallelic mutations in equal numbers of families [et al. has suggested, that the contributions of germline mutations in the APC gene and the MUTYH gene are fairly equal [Results from several studies indicate, that mutations in the APC gene . Anotherfamilies . Consistly equal .MUTYH gene [MUTYH mutations (N=63), presented with a phenotype consistent with severe classical FAP, the criteria being: more than 1000 polyps or early-onset CRC (before the age of 50 years), and the development of more than 100 polyps before the age of 35 years, respectively [MUTYH mutations compared to FAP-like phenotypes.In studies of Polyposis patients (N=995), it has been found that 5-22% of the patients with 3-100 adenomas and 7.5-17% of those with over 100 adenomas had biallelic mutations in the TYH gene , 40, 85.ectively . These r2 provides an overview of phenotypic characteristics of MAP, using information gathered from different studies of MAP patients.Table MUTYH gene. The majority of family histories of MAP patients were found to be consistent with a recessive inheritance, typically with affected siblings, but unaffected parents [et al. found no MUTYH germline mutations among Polyposis patients, who were negative for APC germline mutations, and had a family anamnesis consistent with a dominant mode of inheritance [MUTYH germline mutation carriers compared to non-carriers, as will be discussed further [MAP is an autosomal recessive disease, caused by biallelic mutations in the  parents , 85-87. eritance . In conteritance , 78, 85. further , 88-92.MUTYH mutations, have been found [3. This indicates that biallelic germline MUTYH mutations are highly penetrant. Accordingly, in a case-control study of CRC patients , all homozygote MUTYH carriers (N=12) developed CRC before the age of 60 years [In studies of healthy controls, no unaffected individuals, who were homozygote for germline en found , 90, 91 60 years .2.The average age at time of clinical diagnosis among MAP patients is typically around 47 years  , 85-87 aMUTYH germline mutations compared to Polyposis patients without MUTYH mutations. This applies both to studied Polyposis patients with <100 adenomas [APC germline mutations [Characteristically, the age at time of clinical diagnosis is higher among patients with biallelic adenomas , 65, 74 utations , 93. In Because of the recessive mode of inheritance, the identification of MAP patients is complicated, as MAP patients often seem to be sporadic cases with no family history of the disease at clinical presentation. Consequently, most MAP patients are diagnosed due to symptoms and not as a result of prophylactic screening, unlike many FAP and AFAP patients . In accoIn several studies of Polyposis patients, the phenotypes in regard to the number of adenomas are generally seen to be more severe in MAP patients compared to the phenotypes of AFAP patients, but milder compared to those of classic FAP patients , 74, 85.2), which is a smaller number than seen in the classic FAP phenotype. Several studies of Polyposis patients have all found the highest incidence of biallelic MUTYH mutations in groups of patients with between 15-100 adenomas [MUTYH mutations in the groups of patients having 15-100 adenomas, were found to be between 16-47% (N=835). However, none of the results were statistically significant.Characteristically, MAP patients develop between 10-100 adenomas  and biallelic MUTYH germline mutations (N=26), no significant differences between the two groups were found [APC mutations. When compared to Polyposis patients without mutations in neither the MUTYH nor the APC gene, MAP patients seemed to develop the lowest number of adenomas, although no statistically significant results have been found [In a recent study of AFAP patients N=140), comparing the clinical features of patients with re found . However, comparien found .MUTYH or in the APC gene [The morphology of the adenomas appears to be similar regardless of whether their occurrence is caused by germline mutations in the APC gene , 65. LikAPC gene , 46, 62.MUTYH mutations were found in 0.4-1.9% of all cases (Table 3). Based on these results, the contribution of biallelic MUTYH mutations to CRC seems to correspond to, or even be greater than that of FAP, FAP accounting for less than 0.1% of all CRC cases, as found by Bülow [In several studies of CRC patients , biallelic germline by Bülow .MUTYH gene and the development of CRC, has been determined [In two other studies of CRC patients , a significant association between biallelic germline mutations in the termined , 92. In Among MAP patients, the average age of CRC onset is found to be 47 years (range: 29-72 years) , 85, 87.There have been many inconsistent results regarding the typical location of carcinoma in MAP patients. Overrepresentation of both right and left sided CRC has been demonstrated , 87, 88.The manifestation of other primary cancers than CRC or other extracolonic manifestations are less frequent among MAP patients compared to among FAP patients . Several4.Conversely, several studies have described the occurrence of extracolonic features in MAP patients, mostly upper gastrointestinal lesions , 94-96, MUTYH mutations.However, these results should be regarded with reservations, as the numbers of examined MAP patients in the majority of the studies were very small. In addition, bias could result from a difference in the methods of investigation used in the individual studies, as these are only sparsely describe in most of the studies. Also, some of the reported extracolonic manifestations were reported in very low frequencies among the examined MAP patients. They are therefore more likely to be present by chance, rather than being associated with biallelic The described findings suggest that extracolonic manifestations are generally not a part of the characteristic MAP phenotype, but can occur. However, further studies with more systematic and thorough investigation of MAP patients are needed to address this issue.MUTYH germline mutations have an increased CRC risk compared to the general population. However, as seen in Table 3, percentages of carriers of monoallelic germline MUTYH mutations are generally larger among CRC patients, than the same percentages among the corresponding background populations. Furthermore, several studies have shown a tendency for a slightly elevated CRC risk [At present, no conclusive evidence has been found, that monoallelic carriers of CRC risk , 93, 97,CRC risk , 92, 98.CRC risk , and metCRC risk , 98.MUTYH mutations and a co-dominant mode of inheritance of CRC, is LOH of chromosome 1p, where the MUTYH gene in located, possibly representing an early event in CRC tumorgenesis [MUTYH gene on 1p in monoallelic MUTYH mutation carriers is likely to contribute to an increased CRC risk, as 1p LOH has been found in tumors from monoallelic MUTYH mutation carriers [MUTYH mutation carriers have failed to find results of sufficient significance to support this theory [A suggested explanatory model for a possible association between monoallelic rgenesis , 70. Acccarriers , 77. In s theory , 84.et al. combined results from 9 case-control studies of CRC patients , and were not able to demonstrate a significant association between monoallelic carriers of MUTYH germline mutations and the development of CRC [On the other hand, Peterlongo t of CRC . ConsequMUTYH germline mutations in CRC tumorgenesis is still uncertain, but as mentioned earlier, interactions with other genes, for example a MMR gene, are possibly of significance.The exact role of monoallelic MUTYH mutation carriers that correspond fairly well to those of biallelic carriers, see Table 5.In addition, several large studies of Polyposis patients have found frequencies of monoallelic MUTYH germline mutations may be associated with a Polyposis phenotype. However, as seen in Table 5, the reported frequencies of mono-and biallelic carriers vary considerably among studies. This is likely to be a result of differing inclusion criteria, as these are not thoroughly described in all of the applied studies. The significance of monoallelic MUTYH mutations needs to be assessed further in comparable studies on the subject.This indicates that monoallelic Frequently, MAP patients have already developed CRC at the time of clinical diagnosis, before prophylactic treatment can be initiated. Genetic testing and counseling of individuals at risk of developing MAP, is essential for the future prospect of MAP patients, so that prophylactic screening can be initiated. In this context it is important that knowledge about the disease and mode of inheritance is continuously searched for and utilized for the organization of guidelines, which we believe will assure the best treatment for these patients.Based on the recessive mode of inheritance most commonly seen in MAP families, siblings to an affected individual have a 25% a priori risk of disease. Consequently, determination of the genotype is especially important in these individuals , 75, 92.APC and the MUTYH gene. This applies to both individuals having a familiar disposition for multiple adenomas and/or CRC as well as in apparently sporadic CRC cases, if the clinical presentation gives hints of a Polyposis syndrome. In cases with a positive family anamnesis, the most probable mode of inheritance can guide the assessment of which gene to start with, i.e. the APC or the MUTYH gene when a dominant mode or recessive mode is seen, respectively [In practice, it is important to search for germline mutations in both the ectively .Furthermore, the characteristic mutations in specific populations makes it possible to target the MAP screening in accordance with ethnic background, thereby making the screening more efficient, when the background of the patient is known , 64.Y179C and G396D at present are the most frequently found mutations in Caucasian MAP patients, an obvious possibility would be to screen specifically for these in Caucasian individuals [MUTYH variants, would be missed [et al. demonstrated an increased clinical sensitivity for the detection of MUYTH mutations in their study, when all exons and intron-exon boundaries of the MUTYH gene were screened, compared to the sole testing for Y179C and G396D [MUTYH gene should be screened in individuals found to be heterozygote for Y179C or G396D to establish their true genetic status [et al. have designed specific assays for detecting the 6 most frequently found MUTYH mutations using a multiplex T-ARMS-PCR method [MUTYH mutations in different population groups [et al. have proposed a prescreening method also considered to be cost-effective [KRAS2 c.34G > T, a somatic mutation in the KRAS2 gene shown to be more common in MAP patients compared to sporadic CRC cases. This should be followed by screening for population specific MUTYH mutations in cases positive for the aforementioned KRAS2 mutation [As ividuals . A disade missed , 86, 100c status , 86, 100R method . This men groups . In patiffective . This memutation .Y179C and G396D in the general population are low compared to the occurrence among MAP patients  and (3)), and for this reason, there is at present no indications for MAP screening of the general population [MUTYH mutation carriers to asses the genotype and corresponding disease risk of offspring, has been recommended [The frequencies of pulation , 84, 85.ommended .et al. in [The prophylactic surveillance of MAP patients is recently reviewed by Vasen t al. in . Here a t al. in . Howevert al. in . The surt al. in , 19. Furt al. in , even thNaturally, the outlined recommendations should be adjusted according to the number, size and degree of dysplasia of the adenomas of the individual patient .Since MAP patients typically develop less adenomas than FAP patients, the prophylactic treatment of MAP patients should as a starting point be aimed at colonoscopy with polypectomy. It could however be appropriate to apply colectomy in MAP patients developing a particularly large number or advanced adenomas , 19, 68.MUTYH germline mutations at the present time. However, we believe that relatives at risk of developing MAP should be searched for on the basis of family anamnesis, if MUTYH germline mutations are discovered, in order for appropriate measures to be made on this basis.In our judgment, there is no indication for prophylactic surveillance in heterozygote carriers of MUTYH in the development of CRC is yet to be resolved. Biallelic germline mutations in the MUTYH gene are found to be associated with a markedly increased risk of developing Polyposis and CRC. The interactions between MUTYH and the MMR system could play a role in the CRC tumorgenesis in MAP patients.The full extent of the significance of MUTYH gene have shown a great ethnic variability, and further knowledge about this could be used to target the genetic screening of Polyposis patients towards specific population groups. Genetic screening for germline mutations in the MUTYH gene as well as in the APC gene should be performed on equal terms, perhaps guided by the most probable mode of inheritance. Prophylactic surveillance of MAP patients could be colonoscopy with polypectomy in mind from 20-25 years of age.At times, it can be difficult to distinguish between the phenotypes of FAP, AFAP, Lynch syndrome and MAP. Aspects regarding phenotypic differences between MAP patients and other Polyposis patients form the base of the recommendations for counseling and prophylactic treatment of MAP patients, which is stated here. Germline mutations found in the In the future, more MAP patients could be identified before developing CRC by establishing MAP registers and finding call-up patients based on family anamnesis, as it is currently done for FAP patients in many countries. In this way the future prospects of MAP patients could be improved markedly.The applied papers were all found in the PubMed database using the following terms: MYH Associated Polyposis /MUTYH Associated Polyposis /MutYH Associated Polyposis. The search was only for material published in English and was made without time-limitation. All papers published between 01/01 2002 and 01/02 2008. We also searched reference lists of relevant papers.


To ascertain the effectiveness, tolerability, and safety of low-dose cyclosporine in the management of sight-threatening uveitis.This was a retrospective clinical case series of patients using oral low-dose cyclosporine for the management of sight-threatening uveitis in the uvea clinic (UC). Patients receiving cyclosporine were identified from the clinic database. Main outcome measures were degree of intraocular inflammation, visual acuity and dose reduction of oral steroid for effectiveness and adverse symptoms, systemic hypertension, and raised serum creatinine for tolerability and safety.Intraocular inflammation was improved or stable in 97% of patients, visual acuity was improved or stable in 91%, and oral steroid dosage was reduced in 73% . Adverse symptoms were almost universal, the commonest being peripheral paresthesia/burning in 70% and fatigue in 67%. Significant systemic hypertension developed in 27% and raised creatinine in 30%, necessitating dose reduction. Cyclosporine was discontinued in 35%, being intolerable in 20% and ineffective in 15%.Cyclosporine was found to be effective in reducing inflammation and protecting vision in sight-threatening uveitis. It was safe with proper monitoring, including in children. It had a significant toxicity profile and a high incidence of adverse symptoms which required close supervision, and a prompt dose reduction or drug exchange. It was dl.[et al. who alsol.[et al. Althoughl.[et al. The drugPatients with sight-threatening uveitis are referred to the uvea clinic (UC) at the Eye Hospital. Patients receiving cyclosporine were identified from the clinic database. Cyclosporine was used as first-line or second-line immunosuppression for patients with sight-threatening uveitis, either as a steroid-sparing agent or as sole maintenance for some patients with uveitis and Behçet's disease. Prior to the commencement of treatment, patients were provided with a comprehensive information pamphlet describing drug action, side effects, toxicity, and safety monitoring requirements. Treatment was commenced after informed verbal consent. A management protocol was followed, which required regular monitoring of weight, blood pressure, urinalysis, full blood and differential white cell count, creatinine and electrolytes, liver function, serum lipids, serum magnesium, and trough serum cyclosporine level. When settled on treatment, monitoring occurred at six to eight weekly intervals. Children on cyclosporine were managed jointly with a pediatric rheumatologist.All patients commencing cyclosporine had treatment objectives which, for those already using oral steroid, included the maintenance of quiescent uveitis or the improvement of active uveitis, with the intention of reducing the steroid dose by 50% or more. For those with Behçet's disease, the objective was to prevent or minimize the frequency of inflammation flare-ups without the use of maintenance steroid treatment. Patients were closely observed during a 3-month trial period, after which a decision was made to continue or to stop treatment.Following ethical committee approval, data was retrieved from the clinical records of all treated patients including age, sex, diagnosis, treatment course, visual acuity and degree of inflammation before and after treatment, toxicity including abnormal renal function, and hypertension. Patients were also asked to complete a questionnaire on the side effects of treatment. This included direct questions on 14 possible adverse symptoms. Some patients were unavailable for, or failed to respond to a request for the completion of a questionnaire. Thirty-seven completed questionnaires were analyzed.Intraocular inflammation was assessed before cyclosporine treatment, and after 6 months of treatment. Four parameters of inflammation were recorded as either present or absent: anterior uveitis, vitritis, chorioretinitis, and cystoid macular edema (CME). Vision was assessed as Snellen visual acuity. A change of two lines or more was regarded as a significant change. In addition, visual impairment registrations, effective one-eyed patients (worse than 20/200 in worst eye) and legality for driving, were noted. Cyclosporine effectiveness was judged on the maintenance or improvement of inflammation, on the maintenance or improvement of visual acuity, and on the ability to reduce oral steroid (if used) dosage by 50% or more. For Behçet's disease, the ability to prevent disease attacks on cyclosporine alone was a separate parameter.A total of 71 patients attending the UC had received or were receiving cyclosporine. Of these, two were treated for scleritis and 10 had either commenced treatment from other physicians for main causes other than ocular inflammatory disease, or had been treated for uveitis by another ophthalmologist prior to their attendance at the UC. These patients were excluded, leaving a total of 59  including 5 children under 16, who had initiated treatment with cyclosporine in the UC for the management of sight-threatening uveitis. This was the most frequently used immunosuppressive in the UC. The diagnoses for these 59 patients are given in Before commencing treatment, patients had been using oral steroid for a mean of 15 months (range 0–48 months) and the mean age at the start of cyclosporine treatment was 37 years (range 6–64 years). The mean starting dose of cyclosporine was 4.2 mg/kg/day and the mean maintenance dose was 3.2 mg/kg/day. The mean duration of treatment (ongoing in 38 patients) was 35 months (range <1–125 months).Prior to treatment with cyclosporine, 7 patients were active in all four parameters of inflammation , 19 were active in three parameters, 20 in two, and 11 in one. Two patients were completely quiescent. At the second assessment, all subsets had improved; no patients were active in either four or three parameters, 11 were active in two parameters, 19 in one, and 29 were quiescent. There was clearly an overall substantial shift toward quiescence. Overall 47 patients (78%) improved, 10 were stable (97% improved or stable), and 2 worsened. Anterior chamber activity became quiescent in 25 patients, vitreous activity in 30, CME in 21 and chorioretinitis in 22.Prior to the commencement of cyclosporine treatment, four eyes were blind and another three had been enucleated. Visual acuity change (111 seeing eyes) is shown in Before starting cyclosporine treatment, 49 patients were using prednisolone at a mean dosage of 30.1 mg/day (range 2.5–80 mg/day), but at the second assessment, this had changed to 12.8 mg/day (range 0–80 mg/day), an overall mean reduction of 58%. The target dose reduction of 50% or more was achieved in 25 of the 49 patients (51%), 27 of 49 (55%) reduced dosage to 10 mg/day or less, and 6 had discontinued steroid. Of those 10 patients who were not using steroid prior to cyclosporine, 7 remained without it but 3 required the addition of prednisolone at a mean dosage of 23.3 mg/day (range 10–40 mg/day).Efficacy was assessed separately for the 19 patients with Behçet's disease. In this subset undergoing a total of 72 patient treatment years (mean 3.8 years), there were a total of eight uveitis flare-ups . Only one patient lost more than one line of acuity in the better eye, the remainder being improved (4 patients) or stable (14 patients).Systemic hypertension (blood pressure of 140 or more systolic and/or 95 or more diastolic on two subsequent readings) requiring a dose reduction in cyclosporine  and/or medical treatment occurred in 16 patients (27%). Evidence of reduced renal function shown by a rise in serum creatinine to >110 μmol/l or >30% above baseline level occurred in 18 patients (31%), again requiring dose reduction. There were no cases of malignancy and no cases of severe infection requiring hospital admission. There were no deaths on treatment.Treatment side effects are shown in Of the 59 patients using cyclosporine, 37 had also used at least one other immunosuppressive. Eleven had azathioprine added to their regimen  and 12 changed to azathioprine. Three had mycophenolate mofetil added to their regime and three changed to mycophenolate. Cyclosporine was the second immunosuppressive in the five children with uveitis, being added to methotrexate (four patients) or substituting for it (one patient). Other replacement immunosuppressives included infliximab (two patients), cyclophosphamide (one patient), and tacrolimus (one patient). At the completion of the study, of 59 patients, 22 (37%) continued to use cyclosporine effectively, with no significant problems; 16 (27%) continued to use it in reduced dosage because of initial side effects ; in 9 patients (15%) it was discontinued because of inadequate efficacy, and in the remaining 12 patients (20%), it was discontinued because of intolerance.Trichoderma polysporun and Tolypocladium inflatum. It has a specific action on CD4 lymphocytes, where it inhibits calcineurin, an essential component of the interleukin-2 (IL-2) system. Both IL-2 expression and IL-2 surface receptors are inhibited, which depresses the CD4 lymphocyte's ability to activate and to recruit, so that CD4-driven inflammation is reduced. The drug is metabolized by the hepatic cytochrome P450-A system and is mostly excreted in bile, with 10% excreted in urine.Cyclosporine is an antibiotic, lipophilic cyclic polypeptide synthesized by several fungi including Our results confirm the efficacy of low-dose (<5 mg/kg/day) treatment in this group, with about 80% of patients demonstrating a reduction in inflammation, about 73% improving or stabilizing vision, and allowing a mean 57% reduction in the oral prednisolone dosage. This has been achieved using a mean maintenance dosage of 3.2 mg/kg/day (range 1.2–5.0), a very low dose regimen allowing low levels of renal toxicity and long-term usage.In Behçet's disease, cyclosporine has been found to be useful both in reducing the frequency of disease flare-ups and in the maintenance of vision when used in combination with oral steroid or notabRenal toxicity and hypertension is common and interstitial fibrosis has been shown after 2 years of low-dose (4 mg/kg/day) cyclosporine in a population of uveitis patients, a study Despite using a mean maintenance dosage as low as 3.2 mg/kg/day, over a quarter of our patients developed systemic hypertension and nearly one-third developed a significant rise in creatinine requiring dose reduction. Twelve patients discontinued the drug because of intolerance and five (9%) because of hypertension and/or depressed renal function. There is no completely safe dose for cyclosporine in relation to renal function, but toxicity is dose related and using a very low dose regimen, we have minimized problems in our patient group.Migraine-type headache occurs frequently in cyclosporine usage. Our studThere is a small risk of the development of malignancy on cyclosporine treatment, especially lymphoma and carcinoma of the skin and mucosae. This risk appears to be smaller for those with uveitis than those with multisystem inflammatory disease or organ transplant using the same drug. No episodes of malignancy have occurred in our patients, but in recognition of this risk, we have introduced into our clinic a proactive nurse-led system to encourage self-examination and reporting for skin lesions.Although completed by only a representative sample of patients, our results show a high incidence of side effects , with peAlternatives to systemic cyclosporine have been sought. Tacrolimus is well established and a better safety profile is claimed. IntraocuIn conclusion, we have reported the largest series to date, of patients using oral low-dose cyclosporine in the management of sight-threatening uveitis, totaling 153 patient/years of treatment. The drug has proven to be of great value in maintaining vision and reducing inflammation, with a manageable toxicity profile. It is safe for long-term usage, with careful monitoring. It is the first-choice immunosuppressive in this clinic. We recommend adherence to a strict management protocol, including regular formal assessment of patient tolerance.


The new selective access analysis system BM/Hitachi 917 was evaluated in an international multicentre study, mainly according to the ECCLS protocol for the evaluation of analysers in clinical chemistry. Forty-three different analytes, covering 56 different methods enzymes, substrates, electrolytes, specific proteins, drugs and urine applications were tested in seven European clinical chemistry laboratories. Additionally, the practicability of the BM/ Hitachi 917 was tested according to a standardized questionnaire. Within-run CVs (median of 3 days) for enzymes, substrates and electrolytes were <2% except for creatine-kinase MB isoform and lipase at low concentration. For proteins, drugs and urine analytes the within-run CVs were < 4% except for digoxin and albumin in urine. Between-day median CVs were generally < 3% for enzymes, substrates and electrolytes, and < 6% for proteins, drugs and urine analytes, except for lipase, creatine kinase and MB isoform, D-dimer, glycosylated haemoglobin, rheumatoid factors, digoxin, digitoxin, theophylline and albumin in urine in some materials. Linearity was found according to the test specifications or better and there were no relevant effects seen in drift and carry-over testing. The interference results clearly show that also for the BM/Hitachi 917 interference exists sometimes, as could be expected because of the chemistries applied. It is a situation that can be found in equivalent analysers as well. The accuracy is acceptable regarding a 95–105% recovery in standard reference material, with the exception of the creatinine Jaffé method. Most of the 160 method comparisons showed acceptable agreement according to our criteria: enzymes, substrates, urine analytes deviation of slope ± 5%, electrolytes ± 3%, and proteins and drugs ± 10%. The assessment of practicability for 14 groups of attributes resulted in a grading of one–three scores better for the BM/Hitachi 917 than the present laboratory situation. In conclusion, the results of the study showed good analytical performance and confirmed the usefulness of the system as a consolidated workstation in medium-sized to large clinical chemistry laboratories.


Among dietary habits, the highest vs lowest intake tertile for vegetables and fruit was associated with an OR of 0.5 (95% CI 0.2–1.0). Low education level and low body weight were also risk factors for ICC, but they did not account for the associations of paan chewing and low vegetable and fruit intake. In the analyses restricted to HPV-positive cases and controls, the inverse association with vegetable and fruit intake was confirmed. Conversely, the adverse influence of paan chewing on ICC risk seemed to be attributable to a higher prevalence of cervical HPV infection in women who chewed.Non-viral factors contribute to human papillomavirus (HPV)-related cervical carcinogenesis. We investigated the role of paan chewing and dietary habits among 205 women with invasive cervical cancer (ICC) and 213 age-matched control women in Chennai, India. Odds ratios (OR) and 95% confidence intervals (CI) were computed by means of unconditional multiple regression, taking into account major correlates of ICC risk. Paan chewing showed a dose-dependent direct association with ICC (OR for ≥5 paan day Infection with oncogenic types of human papillomavirus (HPV) has been established as the central cause of invasive cervical cancer (ICC) .Several studies have shown that low vegetable and fruit intake , Southern India, one of the areas with the highest ICC incidence rates   a diagnosis of anogenital tract cancers , cancer of the breast, endometrium, ovary or colon, benign genital tumours and tobacco-related diseases ; (2) a history of hysterectomy or cervical conisation; and, as for ICC cases, (3) physical or mental problems. A total of 179 visitors and 37 in-patients were thus contacted. Of the eligible 216 controls, three declined to participate in the study and three refused to have a gynaecological examination. Thus, a sample of exfoliated cells from the cervix was available for 210 control women.Each participant was administered a standardised questionnaire on socioeconomic status, sexual behaviour, reproductive history, contraceptive practices, smoking habits, genital hygiene, history of sexually transmitted infections and cervical cytological screening. Questions on weekly consumption of 21 foods or food groups, and summary questions on overall consumption of all vegetables and fruits were included. Information on height (cm) at time of interview and weight (kg) 2 years before interview was self-reported. Two trained female interviewers administered the questionnaire to all case and control women in the hospital.After the interview, each consenting woman had a pelvic examination performed by a gynaecologist, who took two cervical scrapes with two Ayre spatulas and one endocervical brush. A Papanicolaou smear was prepared, and the remaining cells were eluted in phosphate-buffered saline (PBS), pelleted in PBS (2000 r.p.m. for 20 min at room temperature), and then stored at −70°C. A punch biopsy sample from the tumour (cases only) and a 10-ml sample of peripheral blood were also collected and stored at −70°C.The study was approved by the ethical review committees of the IARC in Lyon and the Cancer Institute in Chennai.β)-globin gene-specific primers were used. β-Globin-negative and HPV-negative samples (i.e. two ICC cases and 26 control women) were considered inadequate and excluded from HPV-related analyses, thus leaving 191 invasive cancer cases (179 squamous-cell carcinoma cases and 12 adeno/adenosquamous carcinoma cases) and 184 control women with adequate HPV-DNA results.To analyse the quality of target DNA, beta  using two HPV oligoprobe cocktails that together detect the following 36 HPV types: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 6, 11, 26, 34, 40, 42, 43, 44, 53, 54, 55, 57, 61, 70, 71 , 72, 73, 81 , 82 (IS39 and MM4 subtypes), 83 , 84  and CP 6108. Probes and procedures used for EIA detection are described elsewhere  (2), and intake of foods or food groups were computed based on the combined distribution of cases and controls. Tests for linear trend were performed assigning an increasing score for each level of categorical variables. Scores were then fitted into the model as a continuous variable. In order to elucidate the influence of HPV infection, major analyses were repeated: (1) among all cases and controls, (2) among HPV-positive vs HPV-negative control women, and (3) among HPV-positive cases vs HPV-positive control women only.To estimate the risk of cervical cancer associated with various HPV types and the other risk factors, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) by unconditional logistic regression. The ORs were adjusted for age and area of residence (Chennai and out of Chennai), education level, occupation, marital status, age at first marriage , number of pregnancies and husband's extramarital affairs, as indicated in the Tables. Only 4.9% of cases and 1.4% of control women reported more than one lifetime sexual partner and zero cases and 1.4% of control women reported oral contraceptive use. Therefore, these two variables were not included in the models. Approximate tertiles of weight, height, body mass index . Approximately half of the cases and controls combined reported to work in agriculture, and farmers showed an OR of 4.3 compared with housewives. Being a widow or divorced rather than currently married (OR=8.1), having had ⩾5 vs 1–2 pregnancies (OR=5.0), and reporting that one's husband had had (or probably had) extramarital affairs (OR=7.0) were associated with significantly increased risk of cervical cancer . Two cases and no controls reported to have ever smoked  . A nonsignificant inverse association was found also for height .The mean weight was 52 and 54 kg among cases and controls, respectively. Women who weighted less than 50 kg had an OR of 1.9 compared with women who weighted 55 kg or more (vs lowest intake tertile=0.4)and bananas (OR=0.3). The inverse associations with intake of fresh tomatoes, carrots, cruciferae and other citrus fruit were not statistically significant. There was no indication that the consumption of green vegetables, apples or pears, rice, milk, yogurt, egg, fish, meat, cakes or desserts and various oils affected ICC risk. A direct association was found for the intake of bread (OR=2.0).vs never OR=2.4) and vegetable and fruit intake (summary question) (highest vs lowest intake tertile OR=0.5) were associated with ICC risk. In the analyses restricted to HPV-positive women, however, only the association with low vegetable and fruit intake (OR=0.4) was confirmed, even if it became of borderline statistical significance. Conversely, paan chewing was not related to ICC risk among HPV-positive women but showed a hint of direct association with HPV infection among control women.This is the first report of an association between paan chewing and cervical cancer. The topic is of interest in the light of the well-established association between ICC and tobacco smoking . The mecIn addition to paan chewing, low education, occupation in farming, low weight and low intake of vegetables and fruit were risk factors for cervical cancer in our study. An excess of cervical cancer among low socioeconomic class women is one of the most consistent findings of epidemiological studies on this tumour , the apparent adverse effect of weight and BMI must be interpreted with caution, as it may be a consequence rather than a risk factor for cervical cancer. The findings on height, although not statistically significant, point to a possible influence of nutritional deficiencies in childhood and adolescence that might have prevented some women from attaining their full height. Unfortunately, the reliability of self-reported weight and height in India is unknown.Our present evaluation of dietary habits also has limitations, since we have been using a short frequency questionnaire that included 21 indicator foods or food groups only and we did not explore serving size. Furthermore, the questionnaire had not been validated in India, and it was especially difficult to capture any association with staple foods like rice, which are eaten daily by the majority of the population, and with food groups which are eaten rarely  or as ingredients of complex recipes . No reliable translation into specific macro- and micronutrients has been possible, but in the summary questions on overall intake of all vegetables and fruit, ICC cases did report a significantly lower intake than control women, in agreement with findings of some previous reports  and for cervical cancer among HPV-positive cases and HPV-positive controls can help to elucidate whether these influence chiefly the acquisition and persistence of HPV infection or the progression from HPV infection into malignant cervical lesions (Unfortunately, the subgroup analyses in our study are based on small numbers of women and have very broad confidence intervals. However, the analyses restricted to HPV-positive women support the possibility that low intake of vegetables and fruit contributes to the progression from HPV infection to cervical cancer. With respect to paan chewing, either its adverse effect on cervical cancer is real and, possibly, mediated by a decreased ability of women who chew to clear HPV infection, or the habit of chewing is a surrogate marker for increased HPV exposure. Future prospective studies could evaluate the influence of paan chewing in the natural history of HPV infection and the development of preinvasive cervical lesions.


Few studies of air pollutants address morbidity in preschool children. In this study we evaluated bronchitis in children from two Czech districts: Teplice, with high ambient air pollution, and Prachatice, characterized by lower exposures.Our goal was to examine rates of lower respiratory illnesses in preschool children in relation to ambient particles and hydrocarbons.2.5) and polycyclic aromatic hydrocarbons (PAHs) was conducted daily, every third day, or every sixth day. Children born May 1994 through December 1998 were followed to 3 or 4.5 years of age to ascertain illness diagnoses. Mothers completed questionnaires at birth and at follow-up regarding demographic, lifestyle, reproductive, and home environmental factors. Longitudinal multivariate repeated-measures analysis was used to quantify rate ratios for bronchitis and for total lower respiratory illnesses in 1,133 children.Air monitoring for particulate matter < 2.5 μm in diameter (PM3 PAHs and of 25 μg/m3 PM2.5 resulted in rate ratios (RRs) for bronchitis of 1.29  and 1.30 , respectively; from 2 to 4.5 years of age, these RRs were 1.56  and 1.23 , respectively.After adjustment for season, temperature, and other covariates, bronchitis rates increased with rising pollutant concentrations. Below 2 years of age, increments in 30-day averages of 100 ng/mAmbient PAHs and fine particles were associated with early-life susceptibility to bronchitis. Associations were stronger for longer pollutant-averaging periods and, among children > 2 years of age, for PAHs compared with fine particles. Preschool-age children may be particularly vulnerable to air pollution–induced illnesses. Research linking air pollution with morbidity and mortality indicates the strongest effects on the very young and the elderly. Higher infant and early childhood mortality has been associated with elevated ambient particle concentrations in Brazil , Taiwan 10) to be associated with elevated daily counts of emergency room visits for lower respiratory symptoms among children < 2 years of age. Others . Exposure to environmental tobacco smoke (ETS) places children at greater risk for low birth weight, perinatal mortality, deficits in childhood growth, sudden infant death syndrome, middle ear disease, bronchitis, pneumonia, cough, asthma, and wheeze . DNA and2.5) and PAHs would increase the risk for childhood respiratory illnesses in the preschool period, after adjusting for household and other covariates.Given the sparse literature on morbidity in infants and preschool-age children, a birth cohort study was launched in 1994 in two districts in the Czech Republic as part of the Teplice program of research on exposure, bio-markers, and health effects of ambient pollution . Teplicen = 7,502) of women who delivered in the districts of Teplice or Prachatice participated in the Pregnancy Outcome Study  , 2005. DThe Czech Early Childhood Health (CzECH) study was a longitudinal follow-up of the IBS births. Children born 1994–1996 were followed up at 3 years of age, and those born 1997–1998 were followed up at 4.5 years of age. Thus, this cohort study followed up each child once to obtain medical record and home environmental information.International Classification of Diseases, Tenth Revision .The parental questionnaire asked about the child’s early environment: breast-feeding; day care or preschool attendance; type of building construction for the home; home heating fuel; device and fuel used for cooking; ages and smoking status of all household members; and so forth. Forms were developed in Czech, translated into English, revised, and back-translated. This study complied with all applicable U.S. and international requirements and was approved by the institutional review boards of the Regional Institute of Hygiene of Central Bohemia, Prague; the University of North Carolina, Chapel Hill; and the University of California, Davis, School of Medicine. All participants gave written informed consent before data collection.We focused on lower respiratory illnesses (LRI) based on ICD-10 codes. The vast majority were acute laryngitis and tracheitis (ICD-10 code J04) and acute bronchitis (J20). We assessed two subsets:n = 1,580) and acute obstructive laryngitis (croup) and epiglottitis . Although the subglottic space, which is the area of narrowing responsible for inspiratory stridor and the seal-like barking quality of the cough, could be considered part of either the upper or lower airway, for consistency with studies such as the Tucson Children’s Respiratory Study  and acute bronchiolitis . Responses to the pediatrician survey indicated that the distinction typically made in the United States between bronchitis and bronchiolitis based on age of diagnosis is not used in the Czech Republic.Second, bronchitis/bronchiolitis was defined as acute illness with lower airway sounds such as wheeze and rhonchi. This category comprised acute bronchitis , pneumonia , and asthma . Because of small numbers, separate analyses were not conducted for COPD, pneumonia, or asthma.Third, an overall category of LRI was defined as any of the above diagnoses plus other chronic obstructive pulmonary disease (COPD)  device . Air is a]anthracene, chrysene, benzo[b]fluoranthene, benzo[k]fluoranthene, benzo[a]pyrene, dibenzo[ah]anthracene, benzo[ghi]perylene, and indenopyrene. Missing values for specific PAH compounds were imputed following standard procedures  trap located downstream of a 47-mm quartz filter collected gas-phase PAHs. Extraction from both the PUF trap and the quartz filters was followed by high-performance liquid chromatography analysis with a fluorescence detector and UV detector. Twelve PAHs were measured in both the gas and particle phases and summed to create “total PAHs”: phenanthrene, anthracene, fluoranthene, pyrene, benzo closely approximate the rate ratios.Odds ratios were estimated from the logistic model for a fixed increase in concentration of PAHs  used knowledge of the landscape and his expertise in air pollution monitoring to assign levels of likely concordance between each household and the monitors.2.5 peaked in winter months  to 46 ng/m3 (45-day average), and of PM2.5 from 16 to 11 μg/m3. Thus, the benchmark increments we used  are roughly two times the standard deviations of the air pollutant distributions. The low variability during summer months in air pollution, especially PAH exposures .Temperature averaged over 14 days showed a strong negative correlation with 30-day averages of both PAHs  and PMa priori sampling design, based on variables such as year of birth and district of residence; otherwise, demographic, lifestyle, and newborn characteristics were generally similar, although mothers of low parity were slightly more likely to participate, and Roma mothers slightly less . Among those ≥ 24 months of age, the rates were 68, 38, and 28 per 1,000 child-months. Notably, a sizable proportion of children contributed multiple events: > 250 experienced four or more episodes of LRI separated by ≥ 30 days within the first 3 years of life. Because more than half of the LRI events were bronchitis, we focused the presentation of results on the latter.3) was associated with bronchitis rates that were more than double those of low exposure periods (previous month’s average PAH < 40 ng/m3) (2.5 exposure (30-day average > 50 vs. < 25 μg/m3). Bronchitis rates in this age group were also higher in boys, children of mothers with lower education, and children from homes with adults who smoke, or homes in which coal was used for heating or cooking. Current or recent breast-feeding was protective, as was older maternal age.In bivariate analyses in children < 2 years of age, high average PAH exposure for the previous 30 days (> 100 ng/m0 ng/m3) . Risk waIn children 2–4.5 years of age, patterns were similar for air pollutants and most other factors, but attenuated for smoking in the household, use of coal for heating/cooking, ethnicity, and maternal education . In 2- t3 was associated with an RR for bronchitis from birth to 2 years of 1.29   . AdjustePAH associations with bronchitis were especially strong in the older age group (2–4.5 years) for all averaging periods of 7, 14, or 30 days . The 30-2.5, the 30-day increment of 25 μg/m3, after adjustment for 14-day temperature, conferred an RR of 1.30  between birth and 2 years of age. Generally, however, RRs tended to be lower than for the two standard deviation increments of PAHs and were statistically significant less often. From birth to 2 years, the strongest PM2.5 effects occurred for 14-, 30-, or 45-day averages, especially when the temperature averaging period was short. Above 2 years of age, although all point estimates were positive, significant results for fine particles occurred mostly with adjustment for the longest or shortest temperature averaging periods ; the highest rate ratios in this age group were for 30-day average PM2.5, similar to the results for PAHs.For PMBecause bronchitis represented most LRI events, associations with the broader LRI category were similar to or slightly lower than those for bronchitis alone (results available on request). Despite strong associations of croup with PAHs in bivariate analyses of children < 2 years of age, multivariable-adjusted models showed no consistent pattern in relation to the air pollutants examined in either age category (results available on request).2.5 and PAHs were measured daily. In the older preschool children, the RR for 30-day PAHs increased markedly from 1.56  in the year-round model to 1.75  in the model based on periods with daily monitoring, whereas the nonsignificant result for 30-day PM2.5 remained nonsignificant  in the year-round model compared with RR = 1.17  in the 5-months-per-year model). In the younger group, changes in RRs were small , possibly reflecting less time spent outdoors. Sensitivity analyses restricted to residences with the greatest probability that air pollution exposures are similar to measurements at the monitoring site again showed stronger effects in the 2- to 4.5-year olds for PAHs  and for PM2.5 , though the latter remained nonsignificant. Removal of covariates one by one, except temperature, altered the air pollutant RRs by < 20%.To evaluate the potential impact of errors introduced through imputation, we conducted analyses for November–March only, when PMThis birth cohort study had daily air pollutant data for 5 months each year, respiratory outcomes over a 10-year calendar period, and individual-level time-varying home environmental factors on > 1,000 children. It is the first study to relate a large database of ambient PAH measurements to respiratory disease.Early childhood respiratory illnesses account for much of the morbidity in the youngest segments of the population. LRIs are more serious than illnesses affecting upper airways, often resulting in lost workdays for employed parents. In this study, LRI incidence was 8.3 per 1,000 child-months, more than one event per year per child, on average.2.5 with bronchitis in this age group were weaker and less consistent than for PAHs. Croup was not associated with these pollutants after adjustment for confounders.Our major finding is a clear demonstration that PAHs were associated with a greater incidence of physician-diagnosed LRIs, particularly bronchitis, in preschool children, even after adjustment for temperature, season, calendar time trends, and multiple individual characteristics. The strongest associations were observed in preschool children ≥ 2 years of age; this group may have been either more susceptible or more highly exposed for a given ambient level. Exposures from ambient air pollution sources might be greater in the older children if infants and young toddlers were kept indoors more, especially in winter months when pollutant levels are higher. Associations of PM10 , which Pino and colleagues did not examine. We are aware of only a few other investigations of children in which measurements of PAHs were obtained. We observed a similar increase of 7% for all bronchitis when we calculated the RR for a 10-μg/m10   . Interes2.5 with bronchitis were significant primarily for 30- and 45-day averages in the younger age group, and for 3-to 30-day averages in 2- to 4.5-year-olds, after adjustment for long averaging periods of temperature.Temperature and air pollution are correlated with each other, and both are associated with lower respiratory illness. Regardless of the temperature adjustment, the association of PAH exposures with bronchitis was strongest for the 30-day pollutant average. PAHs were significant in all 25 models fit to the data on 2- to 4.5-year-olds, and in 21 of 25 models in the younger age group. In contrast, associations of PMWe defined illness events using ICD-coded physician diagnoses. Thus, the event must impel the parent to bring the child to a physician, who must then make a correct diagnosis. All Czech citizens are entitled to free, readily available medical care. Families usually remain with one pediatrician. We attribute the low refusal rate in the follow-up study  to the close relationships between the family and the physician and nurses. Ready access to and high utilization of physicians are demonstrated by the completeness of immunizations: 98% of the children received a complete series of four DPT (diphtheria–pertussis–tetanus) injections, compared with 81% of U.S. children in 1997 .Studies of child morbidity often rely on parental reports, usually collected retrospectively, which can be inaccurate and highly subjective . In contWe focused on episodes of LRI, which are more likely to result in contact with the health care system than, for instance, the occurrence of less serious illness, such as an upper respiratory infection. However, because our primary air pollution comparisons are temporal, not spatial, variation in health care utilization or diagnostic practices  is less 2.5 and on both gaseous and particle-bound PAHs for 5 months each year for 10 years, and every-third-day measurements for another 5 months per year. Major findings were similar or stronger in analyses of months with daily data only. Availability of frequent measurements permitted accurate differentiation of effects for different averaging periods.Concentrations of organic pollutants and particles in this study were, as previously reported , compara2.5 are unlikely to be an artifact; when we limited analyses to children residing at closer distances or not separated from monitors by topography, the patterns were similar: The RR for 30-day PAHs increased from 1.56 to 1.74 in children > 2 years of age, and the nonsignificant findings for PM2.5 remained so.We chose to examine fine rather than coarse particles because, with only one monitor in each district, exposure misclassification error would likely be lower. The striking findings for PAHs but not for PM2.5 may increase LRIs are numerous, including oxidative stress, structural damage, efficient transport of pathogenic microbes, and immune dysregulation. Oxidative stress is strongly correlated with organic carbon components, specifically PAHs  .2.5 is plausible, though our data support the former more than the latter. Whereas ambient air quality standards focus on particulate matter and gaseous pollutants such as SO2, CO, and O3, PAHs are ubiquitous, and few epidemiologic studies have examined their associations with morbidity. This study indicates that short-term exposures to PAHs may represent a significant public health threat to children.To summarize, this study demonstrated strong associations of PAHs with lower respiratory illnesses, especially bronchitis, in children between birth and 4.5 years of age. These associations are unlikely to have been confounded, subject to the caveat that we did not examine other components of ambient air pollution or meteorologic covariates besides temperature. Strengths of the study include participation of all physicians and high retention rates, which minimized the possibility of selection bias; the high quality and intensive air monitoring program; and a wealth of covariate data that were well controlled in the statistical analysis, including breast-feeding, day care attendance, indoor sources of air pollution, ambient temperature, and season. The case for generalizability of the results, should they prove to be causal, is strong, given that the analysis accounted for sampling fractions and that exposure levels were comparable to those in cities throughout western Europe, the United States, and elsewhere. Experimental research suggests that a causal relationship with PAHs and PMIn “Respiratory illnesses,” some of the numbers of events under various ICD-10 codes; the rates of croup in “Respiratory illness rates”; and some values in


EHP 115:1510–1518; Hertz-Picciotto et al.][. The team of researchers also found that fine particles (PM2.5) pose a respiratory risk to very young children.One of the most extensive studies of the link between lower respiratory diseases and ambient concentrations of polycyclic aromatic hydrocarbons (PAHs), a class of widespread air pollutants, has found that the chemicals are a potent problem for preschool-age children 2.5 are generated primarily by combustion of petroleum products, coal, wood, tobacco, trash, fat, and other substances. The concentrations of PAHs and PM2.5 in the two Czech Republic districts studied, Prachatice and Teplice, were similar to those found in many U.S., European, and Asian cities.PAHs and PMThe study involved 1,133 children up to age 4.5 years. The team examined pediatric charts to determine those whom a doctor had diagnosed with a lower respiratory disease of acute bronchitis, tracheitis, or laryngitis. These children were among 7,502 born from May 1994 to December 1998 who were evaluated in previous studies, providing substantial data on factors such as fuels used for home heating and cooking; birth weight; and maternal education, age at birth, and smoking history.The current study collected information on breastfeeding, daycare attendance, and other factors that could either protect these children or increase their risk of respiratory disease. Pollution data were obtained from selected monitors in each district; readings were taken during each month anywhere from once each day to once every six days. This allowed analysis of all seasons and a wide range of intervals.3. The increase was 29% for children under age 2 years. For each 30-day-average increase in PM2.5 of 25 μg/m3, bronchitis diagnoses rose 30% for children up to age 2 years. In children aged 2 to 4.5, it rose 23%. Some other pollutants that could play a role in respiratory illness, such as ozone, nitrogen oxides, sulfur dioxide, and metals, were not covered in the analysis. Certain weather variables, such as wind and humidity, also were not considered.The team found a statistically significant link between bronchitis, the most commonly diagnosed illness, and elevated ambient PAHs, escalating 56% in children aged 2 to 4.5 years for each 30-day-average increase of 100 ng/mHowever, the study was strengthened by the use of a doctor’s diagnosis rather than parental reports or recalled incidents, and the likelihood of a sick child visiting a doctor was very high, given that health care was free and readily available. Consistency of diagnostic coding also appeared to be very good. The strengths of the study and the magnitude of the findings lead the authors to conclude that relatively short-term exposure to ubiquitous PAHs may pose a significant respiratory threat to children.


Solanum melongena L.) is a member of the Solanaceae family. In spite of its widespread cultivation and nutritional and economic importance, its genome has not as yet been extensively investigated. Few analyses have been carried out to determine the genetic diversity of eggplant at the DNA level, and linkage relationships have not been well characterised. As for the other Solanaceae crop species , the level of intra-specific polymorphism appears to be rather limited, and so it is important that an effort is made to develop more informative DNA markers to make progress in understanding the genetics of eggplant and to advance its breeding. The aim of the present work was to develop a set of functional microsatellite (SSR) markers, via an in silico analysis of publicly available DNA sequence.Eggplant (Solanum species. The usefulness of the SSR assays for diversity analysis and taxonomic discrimination was demonstrated by constructing a phylogeny based on SSR polymorphisms, and by the demonstration that most were also functional when tested with template from tomato, pepper and potato. As a results of BLASTN analyses, several eggplant SSRs were found to have homologous counterparts in the phylogenetically related species, which carry microsatellite motifs in the same position.From >3,300 genic DNA sequences, 50 SSR-containing candidates suitable for primer design were recovered. Of these, 39 were functional, and were then applied to a panel of 44 accessions, of which 38 were cultivated eggplant varieties, and six were from related Solanaceae species can be used to provide anchoring points for the integration of genetic maps across species.The set of eggplant EST-SSR markers was informative for phylogenetic analysis and genetic mapping. Since EST-SSRs lie within expressed sequence, they have the potential to serve as perfect markers for genes determining variation in phenotype. Their high level of transferability to other  Solanum melongena L.), also known as aubergine or brinjal, belongs to the Solanaceae, but unlike most of the solanaceous crop species, it is endemic to the Old, not the New World. Its progenitor is presumed to have been the African species S. incanum [The eggplant  are short tandem repeats of simple (1–6 nt) motifs, and their value for genetic analysis lies in their multi-allelism, codominant inheritance, relative abundance, genome coverage and suitability for high-throughput PCR-based platforms . It was in silico transferability among other solanaceous species.We present here our progress in the development and preliminary characterization of a set of eggplant SSR markers, derived from public database sequence, along with an evaluation of their experimental and Solanaceae Genomics Network database  contained 3,181 eggplant ESTs, ordered into 1,841 unigenes . An additional 176 sequences were retrieved from the EMBL sequence database . The non-redundant sequence pool contained 1,864 sequences representing 743,527 bp of genomic sequence. Within these, 64 contained one or more SSR . One sequence contained three SSRs, while ten SSRs were of the compound type (SSR containing stretches of two or more different repeats). The mean separation between two SSRs was ~10.6 kb, equivalent to one SSR per 29 sequences. This distance is somewhat greater than that estimated for several monocotyledenous [At the time surveyed, the ledenous ,21 and dSolanaceae species [The properties of the 70 SSR loci identified are summarised in Table  species ,27 and m species ,28. CCG/ species ,24,29 an species  have obs species . These m species ,33. MostThe total length of the 64 microsatellite containing sequence reached the 31,909 bp. Of this 16,862 bp represented untranslated (UTR) – and 15.047 bp represented protein-coding regions. SSRs were non-randomly distributed among coding regions and UTRs. All of the mononucleotide and majority of the dinucleotide repeats (91%) were associated with UTRs. Mononucleotide repeats were evenly distributed among 5' and 3' UTRs while dimeric ones preferentially associated with 5'UTRs. Triplet repeats were significantly over-represented in coding region (75%) and among non-coding regions showed more than 3 folds greater frequency in 5'UTRs. Such dominance of trimeric over other SSRs in coding regions can be explained by non-perturbation of the reading frame.Of the 64 sequences containing one or more SSR, 50 (78%) were amenable to primer design. The markers targeted by EEMS01 to EEMS50 comprised 15 mono-, five di-, 24 tri- and two hexanucleotide simple repeats, together with two di- and two trinucleotide compound loci. The remaining sequences contained either too little flanking sequence, or the sequences themselves were refractory for primer design. Thus, primers amplifying non-redundant loci were designed from about 1.4% of the initial number of database sequences, a success rate comparable to that experienced in other species ,26,27. Am) and among the full 44 genotype set (PICs) were calculated. PICm ranged from 0.05 to 0.68 (mean 0.38 ± 0.12), while PICs varied from 0.04 to 0.76 (mean 0.24 ± 0.09). The highest and lowest PICm were produced by, respectively, EEMS49 and EEMS20, while EEMS15 had the highest, and EEMS24, 25, 31 and 36 shared the lowest PICs. The correlation coefficient between PICm and SSR length was 0.6 (p = 0.0001), in agreement with the general trend for long SSRs to be more informative than shorter ones [Generally, amplicon size was in agreement with expectation, although EEMS 26, 31, 39 and 41 all amplified a product at least 100 bp larger than expected, presumably because the amplicon included an intron. EEMS12 produced an amplicon of smaller than expected length, perhaps because of the presence of a deletion within the genomic sequence, poor priming specificity amplifying a non-target member of a gene family, or because of minor sequence variation between the amplified copy and the consensus sequence . A totalter ones . Trinuclter ones ,36. The ter ones -39, and ter ones ,40,41.S. viarum and S. sodomaeum, with a mean genetic differentiation of ~50% from the cultivated germplasm. The S. torvum accession was more distant (mean genetic similarity 39%). The third cluster contained the remaining species S. sisymbrifolium, aethiopicum and integrifolium which shared a mean genetic similarity of 56%.Thiel et al  have strSolanaceae. To minimise non-specific amplification, the same stringency level for PCR was applied as with eggplant template. About 54% (21 of the primer pairs) generated a detectable amplicon from at least one of the three species; ten of 21 amplified all three templates, seven amplified potato and tomato but not pepper DNA, two tomato and pepper but not potato, and one each amplified only from potato and tomato.The EEMS primers were also applied to amplify template from potato, tomato and pepper, which all belong to the The principal co-ordinate analysis (PCO) analysis illustrates the genetic relationships between the members of the genotype panel Figure . The firArabidopsis thaliana proteins of unknown function. EEMS45 lies within a chloroplast phosphate transporter gene . A stand-alone nucleotide database was built for local BLAST2 searches [In all, 3,357 eggplant sequences were retrieved from the SGN and EMBL nucleotide databases, using the Sequence Retrieval System . Local BLASTN analyses were carried out using all EEMS sequences as queries. The target database contained 1,524,584 entries derived from a variety of solanaceous species, retrieved from the EMBL sequence database (Release 93)Primer pairs were designed from the flanking sequences, using PRIMER3 software  in batchSolanum species  of an SSR combines the number of alleles and their frequency distribution within a population . For theSL and GLR planned and supervised the work. AS carried out SSR mining, primer design and amplification; LT and GLR provided plant materials; EP carried out the analysis of data. All the authors contributed to the final version of the manuscript.


To determine the benefit of an extensively porous coated femoral stem in patients receiving revision total hip arthroplasty.This study reviewed the results of 35 patients who received a revision total hip arthroplasty with extensively porous coated femoral stem between August, 1996, and December, 2002. The mean follow-up period was 77.5 months. The clinical and radiological results were evaluated by the Harris hip score and serial roentgenographic findings.The preoperative and postoperative Harris hip score was 68.3 and 92.5, respectively. Radiographically, none of the acetabular components showed any evidence of migration, tilt, rotation, or shedding of metal particles. In addition, none of the femoral components showed evidence of subsidence, pedestal, or shedding of metal particles. Twenty-two hips had a mild stress shield and 2 hips had a moderate stress shield. The perioperative complications encountered were deep vein thrombosis (1 case), mild heterotopic ossification (4 cases), intraoperative periprosthetic fractures (1 case), and nonunion of the trochanteric osteotomy site (2 cases).Extensively porous coated femoral stems and acetabular components produce excellent clinical and radiological results in revision total hip arthroplasty. The increase in total hip arthroplasty (THA) has led to higher incidence of revision arthroplasty caused by aseptic or septic loosening, osteolysis, periprosthetic fractures around the femoral stem, polyethylene wear, or recurrent dislocation. Various revision techniques have been introduced, such as cemented revision THA and femoral revision with a Wagner stem, modular stem, or proximally porous-coated stem.3)Fortunately, revision THA using an extensively porous-coated femoral stem allows fixation of the femoral component in a relatively well-preserved distal femoral shaft when there is a bone defect or severe loss in the femoral metaphysis.From August 1996 to December 2002, 41 patients underwent revision THA using an extensively porous-coated cementless femoral stem at our hospital. Of them, 35 patients (35 hips) who were followed up for at least 60 months were enrolled in this study. There were 19 males and 16 females. The postoperative follow-up period averaged 77.5 months . The causes of the primary hip arthroplasty were a fracture of the femoral neck in 14 cases, avascular necrosis in 9 cases, inflammatory arthritis in 8 cases, traumatic coxarthritis in 2 cases, and a congenital hip dislocation in 2 cases. As treatment, THA and bipolar endoprosthesis was performed in 25 and 10 patients, respectively. During these procedures, the acetabular cup and femoral stem were both cemented in 4 hips, only the acetabular cup was cemented in 1 hip, and only the femoral stem was cemented in 6 hips. The two components were cementless in 14 hips. A cementless femoral stem was implanted in 10 hips treated with bipolar endoprosthesis. The mean time from the primary surgery to revision was 85 months . The causes of revision THA were aseptic loosening in 26 hips, septic loosening in 4 hips, a periprosthetic fracture around the femoral stem in 2 hips, polyethylene wear in 2 hips, and recurrent dislocation in 1 hip. Preoperatively, the hips were evaluated according to the Harris Hip score (HHS) and Paprosky's classification of bone stock deficiency.The postoperative clinical and radiological assessments were performed at 6 weeks, 3 months, 6 months, and 12 months after surgery and on a yearly basis thereafter.In the clinical assessment, the preoperative and postoperative HHS were compared. In the radiological assessment, the stability of the acetabular cup and the femoral stem was assessed by comparing the radiographs taken immediately after surgery with those at the last follow-up. To assess the stability of the acetabular cup, the level of cup migration, changes in tilting, rotation, radiolucent lines, shedding of metal particles were investigated according to the DeLee and Charnley zones. The cups were defined as being unstable if ≥ 2 mm migration, ≥ 5° changes in tilting, shedding of metal particles, and a continuous periacetabular radiolucent line were noted.p value < 0.05 was considered significant.The femoral stem implantation was assessed by observing the subsidence, pedestal formation, and the presence of a periprosthetic radiolucent line according to the Gruen zones. A stem was defined as unstable, if the following were observed: there was more than 5 mm progressive subsidence, pedestal formation, a continuous radiolucent line around the stem, or the shedding of metal particles. Stress shielding was graded according to the criteria reported by Engh et al.3/year, respectively, at the last follow-up. There were no signs of subsidence, pedestal formation, and shedding of metal particles around the femoral stem. Radiolucent lines were observed in 6 cases, 5 in Gruen zone 1 and 1 in Gruen zone 4 but they were not continuous. The stability of the 35 femoral stems was assessed according to the criteria reported by Engh. Cortical bone ingrowth was observed in the distal portion of the porous coating in 26 hips, and stable fibrous ingrowth in 9 hips but none were considered unstable. There were 22 cases of mild stress shielding and 2 cases of moderate stress shielding. The relationships between various factors and stress shielding are as follows: stress shielding was found in 13 males and 11 females; in 10 patients aged < 60 years and 14 patients aged ≥ 60 years; in 14 patients whose BMI was < 25 kg/m2 and 10 patients whose MBI was ≥ 25 kg/m2; in 3 hips with a stem ≤ 13.5 mm in diameter and 21 hips with a stem ≥ 15.0 mm in diameter  preoperatively to 92.5 points  at the last follow-up. In the radiological assessment, there was no migration, changes in tilt, rotation of the acetabular cup, or the shedding of metal particles in any of the 35 hips. In 3 hips, radiolucent lines were noted around the acetabular cup in DeLee and Charnley zone III but they were not continuous. The mean wear rate and mean volumetric wear was 0.190 mm/year and 100.109 mmdiameter . Deep veThe prevalence of THA has resulted in a higher incidence of THA use in younger patients. In addition, the number of revision THAs is also on the rise due to the longer life expectancy.6)A cemented implant has been used in revision, if a patient is of advanced age, has severe osteoporosis, requires rapid weight bearing due to unilateral paralysis or systemic exacerbation, and in some cases if the medullary cavity of the femur is too wide or deformed to allow the use of a cementless stem. However, it is also known to produce high mechanical failure rates due to aseptic loosening resulting from decreased shear strength at the bone-cement interface.p = 0.357), age (p = 0.227), and BMI (p = 0.147). However, femoral stems ≥ 15.0 mm or ≤ 13.5 mm in diameter were associated with stress shielding at a statistically significant level (p = 0.021).Unfortunately, the use of an extensively porous-coated femoral stem can be problematic due to stress shielding both in primary and revision surgery. The more severe the osteoporosis and larger the diameter of a femoral stem are, the more evident the stress shielding becomes.In addition to the choice of femoral component, a precise assessment of bone stock loss and proper treatments are essential for improving the outcome of revision THA. In this study, synostosis and stable fixation of an implant could be achieved with a morsellized allograft in 14 IIIA type hips and with a strut allograft in 3 IIIB type hips classified according to the Paprosky's classification.The complications of revision THA include systemic ones, such as pulmonary embolism, urinary infections, respiratory failure, and arrhythmia, surgical site infection, heterotopic ossification, nonunion or malunion of the greater trochanter, periprosthetic fracture around the femoral stem, dislocation of the hip, injuries to the nervous system or the blood system, and a limping gait. Weeden and PaproskyIn revision THAs, extensively porous-coated cementless femoral stems provided firm and stable fixation of the acetabular and femoral components and produced good clinical results during the mid-term follow-up period. Therefore, extensively porous-coated cementless femoral stems are recommended as useful prostheses for revision THAs. However, their efficacy should be assessed using a longer-term study.


It has been reported that triple negative phenotype is characterized by aggressive clinical history in Western breast cancer patients, however its pattern of metastatic spread had never been reported in the Chinese population. Considering racial disparities, we sought to analyze the spread pattern for different sites of first recurrence in Chinese triple negative breast cancers.A retrospective study of 1662 patients was carried out from a large database of breast cancer patients undergoing surgery between January 1, 2000 and March 31, 2004 at the Cancer Hospital, Fudan University, Shanghai, China. Survival curves were generated using the Kaplan-Meier method and annual relapse hazards were estimated by the hazard function.P = 0.007 and P = 0.025, respectively) among the triple negative, ERBB2+ and HR+/ERBB2- subgroups in univariate analysis. In the multivariate Cox proportional hazards regression analysis, RFS for either locoregional or visceral relapse in the triple negative category was inferior to that in HR+/ERBB2- patients , but comparable to that in ERBB2+ women (both P >0.05). Furthermore, the early relapse peak appeared later in the triple negative group than that in the ERBB2+ counterpart for both locoregional and visceral relapse. On the other hand, when compared with triple negative breast cancers, a significantly lower risk of developing bone relapse was discerned for ERBB2+ women , with the borderline significance for HR+/ERBB2- breast cancers . In terms of bone metastasis, the hazard rate remained higher for the triple negative category than that for the ERBB2+ subtype.We found a statistically significant difference in relapse-free survival (RFS) for locoregional and visceral recurrence (Based on the site-specific spread pattern in different subgroups, the triple negative category of breast cancers in the Chinese population exhibits a different pattern of relapse, which indicates that different organotropism may be due to the different intrinsic subtypes. A better knowledge of the triple negative category is warranted for efficacious systemic regimens to decrease and/or delay the relapse hazard. Recent advances in genomic techniques have led to the classification of breast cancer into five distinct subtypes: the luminal A, luminal B, ERBB2+, normal breast-like and basal-like subtype . The fifThe triple negative category generally makes up 10-15% of breast cancers . HoweverNowadays, there is an increasing interest in hazard function, which highlights changes of the event probability over time. When it comes to the triple negative category, its unique time distribution of recurrence risk, as distinguished from that for the other subtypes, has been reported in both Western series and our previous study ,10. NeveIn view of the above points, a retrospective analysis was carried out to further elucidate the spread pattern for different sites of first recurrence in Chinese triple negative breast cancer patients as compared to ERBB2+ and HR+/ERBB2- peers. In this way, we sought to get a clear picture of the predisposition to organ metastases for Chinese triple negative breast cancer patients, thereby, shedding more light on the underlying distinction in biological behavior between different subgroups.A total of 1662 patients were selected retrospectively from a large database of patients who underwent surgery between January 1, 2000 and March 31, 2004 at the Cancer Hospital, Fudan University, Shanghai, China.Before surgery, the following evaluations were mandatory for each patient as complete physical examination, chest radioscopy, bilateral mammography, ECG, ultrasonography of breasts, axillary fossa, cervical parts, abdomen, and pelvis, complete blood count, and routine biochemical tests to make an exact staging. Thereafter, each patient received lumpectomy or mastectomy followed by adjuvant therapy according to the guidelines or recommendations used at the time of surgery.Eligibility criteria for this analysis, similar to other relevant reports ,18, inclFollow-up information regarding tumor recurrence and survival status was accomplished through patients' clinic visits with records kept in the computerized database of the outpatient department, personal contact with the patient as well as the assistance of Shanghai Center for Disease Control and Prevention (CDC). Thereinto, personal contact with the patient referred to routine correspondence or telephone visits, which were carried out at the Cancer Hospital, Fudan University every 3 months during the first two years, every 6 months during the next two years and once a year thereafter. As this was a retrospective study without any medical intervention, the ethical approval was not required.Immunohistochemical staining was carried out as a standard operating procedure in the pathology department of Cancer Hospital, Fudan University, Shanghai, China. All primary monoclonal antibodies for estrogen receptor (ER), progesterone receptor (PR) and ERBB2 were from Dako. The staining results were assessed by at least two pathologists, using a semiquantitative scoring system, where integrated the proportion score and the intensity score. The proportion score, indicating the percentage of tumor cells stained, was interpreted such that a score of 0 required no staining seen, 1 required ≤25% of cells positive, 2 required 25-50% of cells stained, 3 required 50-75% of positive cells and 4 required >75% of staining cells. As to the intensity score, a negative result was defined as a score of 0, weakly positive as 1, moderately positive as 2, and strongly positive as 3. The final score was calculated as the product of the proportion score and the intensity score. Thereby, staining results ranged from score 0 to 12. The scoring system for ER and PR was defined as negative for score 0 and positive for scores of 1~12 with the nucleic staining of carcinoma cells, whereas ERBB2 was defined as negative for scores of 0~8  and positive for strong membranous staining with scores of 9~12 (namely DAKO score 3+).Clinicopathological parameters were compared between different subgroups using one-way analysis of variance (ANOVA) test for continuous variables, chi-square test for unordered categorical variables and nonparametric Kruskal-Wallis rank test for ordinal categorical variables.Site-specific relapse-free survival (RFS) was defined as the time from surgery to the earliest occurrence of an event, including locoregional, visceral and bone relapse. Locoregional failure was defined as a first relapse on the chest wall or in the ipsilateral breast, the ipsilateral axilla, the ipsilateral supraclavicular or infraclavicular fossa, or the ipsilateral internal mammary region , which wvs. >50), tumor size (≤2 cm vs. >2 cm), number of axillary lymph nodes (ALNs) involved , histological grade (I/II vs. III) and systemic treatment (yes vs. no). Hazard ratios (HRs) were presented with their 95% confidence intervals (CIs). For graphical display of RFS, annual hazard rates were estimated using a Kernel method of smoothing. All statistical tests were two sided and P < 0.05 was considered to be statistically significant. All statistical analyses were performed with Stata statistical software package .Survival analyses were estimated by the Kaplan-Meier method and were compared using the log-rank test. Multivariate Cox proportional hazards regression analyses were applied to modeling the relationship between subgroup and RFS, adjusted for age . Median follow-up was 3.15 years, ranging from 2 months to 7.8 years. According to different combinations of HR and ERBB2 status, 1662 patients were classified into the three subgroups as follows: triple negative (19.31%), ERBB2+ (26.72%) and HR+/ERBB2- . When compared with triple negative and ERBB2+ tumors, less relapse events were observed in HR+/ERBB2- patients . Compared with the triple negative patients, locoregional RFS was significantly better for HR+/ERBB2- counterparts . The multivariate Cox regression analysis demonstrated that triple negative patients, similar to ERBB2+ counterparts , with the borderline significance for HR+/ERBB2- breast cancers  [This study is, to the best of our knowledge, the first as well as the largest retrospective analysis on site-specific relapse pattern for triple negative tumors in Chinese breast cancer patients. As to locoregional failure, we demonstrated that RFS for the triple negative category was inferior to that for HR+/ERBB2- patients, but comparable to that for ERBB2+ women. Up to now, several studies have been reported with conflicting results. According to Rodriguez-Pinilla's reports, a higher percentage of local recurrence arose in triple negative tumors , which w = 0.05) , which pAlthough Dent and colleagues observed a prominent increase in the rate of visceral metastasis for triple negative patients when compared with that for non-triple negative patients , it stilP < 0.05). Furthermore, a similar trend was also observed between triple negative and HR+/ERBB2- groups with borderline significance (P = 0.058). In this sense, those with ERBB2+ tumors metastasized less often to bone than ERBB2- breast cancers, which was relatively consistent with Kallioniemi's findings [Hormone receptor status has been accepted as sufficiently established to predict the risk of bone metastasis in breast cancer ,23. Withfindings . Taken tThis study has some potential and inevitable limitations due to its retrospective nature. Recurrences might be somewhat underreported or misinformed for a substantial portion of the patients in this database; nonetheless, underreporting or misinformation of recurrences would have not varied by clinicopathological parameters . We did In conclusion, our data show that preferential relapse sites for triple negative breast cancers may be quite distinct from that for HR+/ERBB2- and ERBB2+ counterparts in Chinese breast cancer patients. It indicates that different organotropism may be due to the different intrinsic subtypes. Therefore, a better knowledge of organotropism in different intrinsic subtypes is warranted for efficacious systemic treatment to decrease and/or delay the recurrence hazard.The authors declare that they have no competing interests.JL is responsible for editorial correspondence and has contributed to the conception and design of the study, the analysis and interpretation of data, the revision of the article as well as final approval of the version to be submitted. YL participated in the design of the study, performed the statistical analysis, interpretation of data, drafted and revised the article. WY participated in the design of the study, performed the statistical analysis, interpretation of data, and helped to draft and revise the article. TY participated in the design of the study and helped to revise the article. LZ participated in the design of the study and helped to revise the article. GD participated in the design of the study and helped to revise the article. JW conceived of the study, participated in its design and helped to revise the article. ZZS conceived of the study, and participated in its design and coordination. ZMS conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/9/342/prepub