Acute myeloid leukemia (AML) is nearly always a fatal malignancy. For the past 40 years, the standard of care remains a combination of cytarabine and an anthracycline known as 7 + 3. This treatment regimen is troubled by both low survival rates (10% at 5 years) and deaths due to toxicity. Substantial new laboratory findings over the past decade have identified many cellular pathways that contribute to leukemogenesis. These studies have led to the development of novel agents designed to target these pathways. Here we discuss the molecular underpinnings and clinical benefits of these novel treatment strategies. Most importantly these studies demonstrate that clinical response is best achieved by stratifying each patient based on a detailed understanding of their molecular abnormalities. The greatest strides in treating myeloid malignancies have come from the development of targeted agents. These include all location . Similarlocation .Other than these few therapeutic successes, there have been few clinical advances in the treatment of myeloid malignancies, and in particular AML. The standard treatment option for the majority of young, fit patients with AML remains continuous infusion of cytarabine for days 1 to 7 and an anthracycline, daunorubicin or idarubicin, as a daily bolus for days 1 to 3 (7 + 3), a long-lived standard combination in use for at least the last 40 years  that an Many elderly patients, who comprise more than half of those with AML, are unfit for any induction chemotherapy or likely not to benefit due to poor cytogenetic risk . For theNovel targeted therapies are needed to improve survival for more patients with AML. Numerous agents are in development with the aim of targeting both well established and more recently identified leukemogenic pathways. This review begins with a discussion of some promising novel targeted agents recently tested in AML patients and, within this context, the clinical hurdles to drug development in AML are highlighted. Non-targeted, conventional chemotherapeutic agents and combinations of these agents remain outside the scope of this review.While the development of novel therapies has been slow, the knowledge of mutations associated with AML has increased dramatically in recent years. There are known translocations e.g., t, t8;21), inv 16, t which are associated with a favorable prognosis; e.g., t, t, inv 16, t, the so-called core binding factor (CBF) leukemias ;21, inv . It is aMechanisms of leukemogenesis have been attributed to many of the known mutations, but most have not been the subject of a targeted therapeutic plan. This may be due to: (1) a lack of identified therapies to target the mutations; (2) the genetic complexity of AML which is often characterized by several co-existing mutations that all contribute to leukemogenesis; and, (3) low numbers of patients with any given mutation, which makes it difficult to devise a clinical trial with a reasonable accrual rate. For example, c-kit mutations have been described in CBF leukemias ,15. HoweThe most promising target for AML therapy in this past decade has been the FLT3 (FMS-like tyrosine kinase 3) protein. FLT3 is a transmembrane receptor tyrosine kinase that belongs to the same family as FMS, kit, and PDGFRa/b. It is mutated in about 30% of all AML . The mutIn AML, there is constitutive activation of FLT3 either due to interference with the negative regulatory function of the juxtamembrane region with ITD mutations, or changes in the activation loop with TKD mutations . As a reGiven these data and the availability of several TKIs with activity against FLT3-mutated leukemia , severalin vivo [in vitro studies indicate that samples with high FLT3-ITD allele burden are more sensitive to the cytotoxic effect of FLT3 inhibitors compared to samples with a low allele burden [in vivo following exposure to lestaurtinib [There have been several reasons identified for the limited success of FLT3 inhibitors. The problem of bioavailability has been highlighted by a randomized Phase III trial of induction chemotherapy combined with lestaurtinib in relapsed AML with FLT3-ITD, where there was no improvement in survival over chemotherapy alone. This was attributed to decreasing plasma levels of lestaurtinib with time, and increasing alpha-1 acid glycoprotein, which binds lestaurtinib in vivo . In addie burden ,37. FLT3aurtinib . Finallyaurtinib . Nonetheetc. In many cases these fusion proteins contribute to the development of leukemia partly by disrupting the modification of chromatin, through recruitment of chromatin-modifying coregulators [Anomalous epigenetic changes, including DNA hypermethylation and histone acetylation/deacetylation occur frequently in acute leukemia. The recurring chromosomal translocations seen in AML lead to the generation of chimeric fusion oncoproteins e.g., TEL-AML, AML-ETO, PML-RARa, gulators . In AML,gulators ,41. Unligulators . Incorpogulators ,44,45, ap = 0.037). A reason for the modest benefit was that patients with high percentage blast count and high white counts were included in this study. This was in contrast to the patients enrolled in the AZA-001 study, who had low white counts and blast counts not exceeding 30% [Clinically, 5-azacytidine treatment leads to improved overall survival in AML patients with low blast counts, as demonstrated in a sub-analysis of the AZA-001 study of high risk myelodysplastic syndrome, in which approximately one third of patients had low blast count AML . When deding 30% . Finallyding 30% . HDACi hding 30% . Combinading 30% ,49 or arMessenger RNA (mRNA) processing and mRNA translation are important steps in the regulation of protein levels in cells and these processes are coupled to essential cellular events such as growth, proliferation, differentiation and apoptosis. In normal hematopoietic cells, translation of transcripts into protein is tightly regulated at the initiation phase by signal transduction pathways including PI3K/AKT pathways that can ultimately affect eukaryotic translation initiation factor 4E (eIF4E). Most AMLs are characterized by elevated PI3K and Akt activity ,51. Furtex vivo [The only direct approach to target eIF4E in AML patients in the clinic thus far has been with ribavirin ,32,60,62ex vivo  and servex vivo .ex vivo [ex vivo [Most AML cells show activated PI3K/AKT/mTOR pathways ,51. For ex vivo ,65. Akt ex vivo , in prec[ex vivo . There iex vivo [Downstream of PI3K and AKT is the mTOR pathway. mTOR activation results in the phosphorylation of both eIF4E binding protein BP1 and ribosomal S6 protein. In AML, S6 phosphorylation is a robust marker (see below). Early studies with rapamycin, an mTORC1 inhibitor, failed to show responses in clinical trial as a single agent . Howeverex vivo . This heex vivo .Tosedostat is an inhibitor of aminopeptidase and therefore acts by depleting amino acids. In the HL-60 leukemia cell line, gene array studies have shown that this amino acid depletion resembles an amino acid deprivation response (AADR) . In the In a phase II study of tosedostat as a single agent in elderly patients with relapsed AML, median age 72, and half with refractory disease prior to starting therapy, 12% had a complete response and 10% a partial response. Some of these responses occurred among patients having failed hypomethylating agents and patients who had MDS previously. The median survival among patients with a CR was 323 days, 195 days among patients with partial response, and 162 days in those with stable disease . Based ovs. 0.8%) and no improvement in complete remission rates, relapse free survival, post-consolidation disease free survival, or overall survival. Untreated AML patients under the age of 61 were randomized to cytarabine and daunorubicin with or without GO (6 mg/m2) [Monoclonal antibody therapy has proven extremely successful in other malignancies. In AML, gemtuzumab ozogomycin (GO) is an antibody-drug conjugate where a humanized monoclonal IgG4 antibody directed against CD33 is linked to a derivative of calicheamicin, a potent DNA-binding cytotoxic antibiotic . CD33 an6 mg/m2) . In June6 mg/m2) .AML15 compared the addition of GO to one of three induction schedules and/or one of two consolidation schedules . A total2. GO was given on day 1, 4 and 7 in order to deliver a cumulative dose of 9 mg/m2 and to reduce liver toxicity. Event free survival at 2 years showed a significant advantage at 41.4% in patients treated with GO in comparison to 15.6% for the chemotherapy alone arm. Similarly, there was an overall survival benefit of 53.2% versus 41.9% as well as a benefit in relapse free survival of 50.3% versus 22.7% in the GO-containing regimen, and no increase in treatment related death [Finally, a phase III study by Castaigne and colleagues performed in 26 centers in France, evaluated the benefit of low dose GO when added to 7 + 3 in newly diagnosed AML patients between the ages of 50 and 70 . A totaled death . The finNew drug development relies heavily on the results of Phase II trials, which determine whether a therapy will be tested in large, Phase III trials. Phase II clinical trial design includes not only the method by which patients will be enrolled and the sample size, but also the dose and schedule for single and combination drugs, patient selection, determination of primary and secondary endpoints, and response assessments. This section reviews some of these elements and current difficulties.Most phase II trials in AML are single arm, uncontrolled trials with small sample sizes  mainly bIn order to deal with the small sample sizes and lack of comparator arm, the “Pick-a-Winner” design has been proposed . In thisin vitro with the novel agent. A recent example includes the combination of salvage chemotherapy and plerixafor, an inhibitor of CXCR4, in relapsed and refractory AML [Single agent studies are obviously limited by both low response rates and remission duration. An obvious way to circumvent these problems is to combine them with standard chemotherapeutic drugs known to have activity in AML and, ideally, synergy tory AML . CXCR4 itory AML ,86. In Atory AML . In moustory AML . On the tory AML .In combining targeted agents with chemotherapeutic drugs, toxicity becomes a concern. In the SWOG study of GO and induction chemotherapy, there was excess death in the GO arm attributed to the dose and schedule of GO, whose toxicity may have been enhanced by chemotherapy . When thin vitro. In clinical trials, the fixed ratio is maintained [One sophisticated approach to ensuring greater predictability in drug delivery is exemplified by the development of CPX-351, a liposomal preparation of cytarabine and daunorubicin, which maintains a fixed ratio of 5:1 cytarabine:daunorubicin. This preparation has shown promise in a small randomized Phase II trial of older patients with newly diagnosed AML. By maintaining a fixed ratio of drugs, CPX-351 maximizes synergy and minimizes antagonism intained , and in intained . How thiAn important consideration in the development of new therapies for AML is the selection of patients for Phase I and II trials. For the majority of trials, these are patients with relapsed AML or elderly patients for whom induction chemotherapy is not feasible. These are important populations to target given the dearth of therapeutic options. However, these patients are often more frail, less able to tolerate chemotherapy and have a more resistant and more genetically heterogeneous disease than young, newly diagnosed patients.From our experience with Phase I and II trials in AML, the early attrition rate due to rapid disease progression, infection, or overall clinical deterioration approaches 33%. Such a high rate of early attrition could result in a therapy being falsely determined to be ineffective if all patients having taken at least one dose of treatment are considered evaluable for response.p-glycoprotein and other mechanisms) that affect not only standard agents, but also the novel therapeutics. For instance, if drug transporters are downregulated as a response to one therapy, all therapies requiring this drug transporter, despite being based on different intracellular pathways, would be expected to fail. This leads to a conundrum in using heavily pretreated patients in these studies as drugs effective as first line agents may fail in this setting.Further, difficulties in testing new drugs in refractory and relapsed AML patients include the development of drug resistance mechanisms (including Another common issue in clinical trials of agents without a rapid rate of response, which is the case for many novel agents, has been that patients with a high peripheral blood blast count, or rapidly doubling white count are less likely to respond . Some grAs with other cancers, a detailed understanding of the molecular profile of a particular AML is needed to appropriately place individuals on suitable clinical trials. Mutational testing is a first step in identifying potential targets and in selecting therapies, but, as can be seen from the FLT 3 inhibitor data, targeting a single mutation is likely insufficient. In addition, other molecular predictors of response characterize certain AMLs, including eIF4E overexpression in AML FAB subtypes M4 and M5. In the proof-of-principle trial, responses to ribavirin were seen irrespective of FLT3 mutation status . As discSome of the most relevant pathways and mutations in AML have been outlined, as well as the therapies being developed to target these pathways. No single molecular abnormality accounts for leukemogenesis in AML and given this complexity, it is not surprising that targeted agents have not led to widely applicable therapies. However, some of these agents, even as monotherapies have been associated with activity including some complete responses, when the most apt patient cohorts are considered . How bes


Levels of polychlorinated dioxins/furans (PCDD/PCDF) in selected environmental samples  were analyzed from the area of Phong My commune . This area was affected by Agent Orange spraying during the Vietnam war (1968–1971). Whereas PCDD/PCDF content in soil and sediment samples is relatively low and ranges between 0.05 and 5.1 pg WHO-TEQ/g for soils and between 0.7 and 6.4 pg WHO-TEQ/g for sediments, the PCDD/PCDF content in poultry muscle and liver in most cases exceeded the maximum permissible limit of dioxin content per unit fat mass. In some cases of soil and sediments samples, 2,3,7,8-TCDD represented more than 90% of the total PCDD/PCDF, which indicates Agent Orange as the main source. The potential for TCDD contamination in Vietnam is a consequence of the war 1962–1971), during which the US Army forces used about 72 million litres of phenoxy and other herbicidal agents [962–1971,The concentrations of TCDD as high as 1000 mg/kg were found in soil and sediment samples more than 30 years after Agent Orange sprays in most affected areas of Vietnam. Elevated concentrations were also identified in foods and wildlife . Dioxin Atmospheric deposition leads to contamination of surface water and sediments, soil, and surface of plants and thus represents a significant point of entry into the food chain. Owing to their lipophilic character, dioxins are capable of bio-accumulation in adipose tissues of animals within both terrestrial and aquatic food chains, and subsequently also of people. Moreover, several studies have demonstrated association between concentrations of dioxins in fish and molluscs and concentrations in the environment where they live , 7. ExpeVarious adverse effects of dioxins on human health have been reported including: cancer risk, immune deficiency, reproductive and developmental abnormalities, central and peripheral nervous system pathology, endocrine disruption, decreased pulmonary functions and bronchitis, altered serum testosterone level, eyelid pathology, nausea, vomiting, loss of appetite, skin rashes, hypertrichosis, liver damage, elevated serum cholesterol and triglycerides, and enamel hypomineralization of permanent first molars in children –13. An iIn the case of Vietnam, unambiguous sources of contamination , such as former depots of chemicals and air bases, were identified and their contamination levels were precisely determined and assessed , 16, 17.Oryza sativa L.) and peanuts (Arachis hypogaea L.) especially in the central village Luu Hien Hoa [Sampling was conducted in the postconflict area of Phong My commune , Thua ThHien Hoa .Manihot esculenta)—tubers, papaya (Carica papaya)—fruits, banana —fruits, and batata (Ipomoea batatas)—tubers. Before each use and between the sample collections, sampling equipment was rinsed with distiled water to avoid cross-contamination. All samples were transported frozen in a cool box (−4.0°C) to the Czech Republic for laboratory analysis.The sampling area is shown in The samples were analyzed in the Czech Republic division of ALS laboratory. An ALS standard analytical procedure, according to the United States Standard EPA 1613  for deteR ≈ 10,000). Quantitative analysis was performed using selected ion current profile (SICP) areas. For identification of the analytes, the HRGC/HRMS system was calibrated and the concentration of each compound was determined by an isotope dilution technique using certified 13C12 2,3,7,8-PCDD/F standards with response factors. Relative response factors were determined using five-point calibration for each group of the contaminants. For quantification, ALS CR used a mixture of standards which was added to the sample prior to extraction. The mixture was based on the requirements of US EPA 1613 and US EPA 1668B [After preconcentration and spiking with the standard solution, a fraction of the final extract was analyzed by HRGC-HRMS . The gas chromatograph was equipped with a TriPlus autosampler. The separation of each PCDD/PCDF was ensured by a column with polar stationary phase and the detection was carried out by a mass spectrometer working in the MID operating conditions with high resolution , according to the international norm EN ISO/IEC 17025:2005. The quality of dioxin analysis at ALS laboratory was also verified by the participation in international interlaboratory studies during 2006–2009 when collected samples were analysed there see . The pubThe content of individual PCDD/PCDF congeners in soils and sediments is summarized in The sediment samples originated from beds of ponds and reservoirs, where dioxins adsorbed on the mineral (argillaceous) part can theoretically be washed away during the monsoon season. In the case of sediment samples, the content of toxic congeners PCDD/PCDF is quite similar to the congeners' content found in the soil samples. Total PCDD/PCDF content in the sediments ranges between 0.7 and 6.4 pg WHO-TEQ/g. Similarly, the PCDD/PCDF levels in sediments from mangrove forests in Can Gio, South Vietnam, rural sites in Hue, central Vietnam, and from urban sites in Hanoi, the capital of Vietnam, varied between 2.7 and 9.6 pg WHO-TEQ/g . The disChanna, Cyprinus, Carassius, Clarias, Notopterus, and Wallago. The average content of PCDD/PCDF congeners in the fish samples was 0.8 pg WHO-TEQ/g (with maximum 4.0 pg WHO-TEQ/g). According to European Directive EC number. 199/2006, the maximum permissible limit of dioxin content in fish meat and fish products is 4 pg WHO-TEQ (PCDD/PCDF/PCB) per gram of fresh weight. Except for one fish sample from the local dam, the PCDD/PCDF concentrations did not exceed the EC limit value. The highest concentrations were found in the fish species Channa maculata and Clarias macrocephalus netted in the dam; on the other hand, relatively low values were found in fish species originating from the fishponds. Average content of PCDD/PCDF in the fish adipose tissue was 37.5 pg WHO-TEQ per gram of fat. 2,3,7,8-TCDD was identified as the dominant congener , which suggests contamination from the Agent Orange herbicide. Similar values were also previously determined in the A Luoi valley [Cyprinus carpio sample (53.7 pg TEQ/g of fat) and the proportion of TCDD in the total WHO-TEQ value reached up to 96%. Among 13 PCDD/PCDF congeners analyzed in American Vietnam veterans compared with Vietnam era veterans, only TCDD was significantly higher leading to the identification Agent Orange as the likely source [The PCDD/PCDF content in fish muscle is summarized in y source .The PCDD/PCDF levels in poultry (ducks and chickens) liver and muscle (converted to pg per unit mass of fat tissue) are summarized in In the case of hens, this phenomenon can be explained by reduced concentration of dioxins in the body as a consequence of egg production. In some cases, various contamination sources other than Agent Orange spraying, such as local combustion processes, cannot be unambiguously excluded. This fact is due to the presence of highly-chlorinated congener OCDD and also because of elevated concentrations of furans . Since 2The Agent Orange defoliant was contaminated mainly by the 2,3,7,8-TCDD congener, formed by condensation of two molecules of 2,4,5-trichlorophenol used for production of the herbicide—2,4,5-trichlorophenoxyacetic acid . This information was used in exposure assessment of American troops in chemical units who, during the war, came into direct contact with Agent Orange. Of 13 examined congeners of dioxins and furans, only TCDD was present in increased concentrations in blood serum samples TCDD , 27, 28.The PCDD/PCDF content in most of the investigated pork and beef meat samples does not exceed the limit of European Directive EC number 199/2006. In pork samples, the average PCDD/PCDF content was 0.36 pg WHO-TEQ/g, corresponding to 0.55 pg WHO-TEQ per gram of fat. In beef samples, the average content was 0.51 pg WHO-TEQ/g, which corresponds to 1.3 pg WHO-TEQ per gram of fat. According to European Directive EC number 199/2006, the limit content of dioxins in pork meat is 1 pg WHO-TEQ (PCDD/PCDF/PCB) per gram of fat. As expected, the PCDD/PCDF content in samples of vegetables and fruits is quite low. Total WHO-TEQ concentration in cassava, papaya, bananas, and batatas is 0.014 pg/g, 0.03 pg/g, 0.02 pg/g and 0.018 pg/g, respectively. No detectable content of the congener 2,3,7,8-TCDD was found in tested samples.−5 and 1.5 × 10−3. This corresponds to the probability of tumour disease development approximately within the interval of 28 individuals from the group of one million inhabitants to 15 individuals from 10,000. The summary lifetime risk of tumour disease development in the monitored population corresponds to the value 2.1 × 10−3 for the maximum PCDD/PCDF concentrations in foodstuffs.Even though the concentrations of dioxins in soil, sediment, and animal tissues were not significantly high , the cancer and noncancer risks for local inhabitants, arising from a dietary exposure , are possible. The values of the hazard index HI for the noncarcinogenic risk of the monitored age categories ranged between 13.3 and 17.7 for maximum PCDD/PCDF concentrations in foodstuffs, while the ILCR values (lifetime increase in probability of tumour disease development) for the investigated population groups ranged between 2.8 × 10Ipomoea aquatica) were not analyzed.The assessment of spreading of the PCDD/PCDF contamination in the environment of the examined area is limited by several facts. (i) From the geological point of view, the examined area is located in a very active environment with high temperature and high rainfall, plus extensive deforestation and poor forest management. The top layer of soil is repeatedly transferred and flushed down to the valley, where it accumulates in local depressions . A part of the material is transported directly to the sea. (ii) In spite of the considerable persistence of the examined substances, their decomposition is accelerated by long-lasting high temperatures and repeated transport. During the transport, intensive turbulence helps dissolution of large amounts of various substances and thus accelerates chemical decomposition of PCDD/PCDF. (iii) The area where the investigation of the contamination was performed is quite large and did not allow detailed examination through a regular network of sampling spots. Thus, we cannot exclude existence of sites with a higher degree of contamination than was revealed during the investigation. (iv) Even though rice constitutes a substantial part of the local inhabitants' diet, the PCDD/F content in rice was not analyzed within our investigation of the food chain components. Similarly, some relatively often consumed species of aquatic plants  are orders of magnitude lower than those in hot spots and hence it is suitable to focus on measures that prevent these compounds from entering the food chain rather than on their total elimination from the environment. Since a majority of local inhabitants consume above-average amounts of fish , even loSimilarly, for breeding of poultry, cattle, pigs, and other domestic animals, it is recommended to build a clean environment: fixed and strictly delimited areas for poultry or stables and pens for pigs. The animals should be fed only demonstrably clean feed; the rest of potentially contaminated foodstuffs  should be excluded from the feed. Farmers should minimise the stay of cattle and domestic pigs in muddy terrain, thus preventing them from drinking strongly mudded water and minimizing contact with the sediments in natural pools, where increased contamination by PCDD/PCDF was found. Animals foraging on soil contaminated with PCDD/PCDF at low levels may bioaccumulate these compounds to unacceptable levels . Since dResults of the assessment of health risks caused by exposure to dioxins in the environment (soils and sediments) and foodstuffs of the local inhabitants  in Phong My commune area show a potential risk from the increased PCDD/PCDF levels in the environment. Since these highly dangerous bioaccumulative and persistent substances are known carcinogens and teratogens, reducing exposure to as low as reasonably achievable is desirable. Therefore, technically and financially attainable remedial measures should be taken to reduce the exposure to these contaminants as much as possible. In addition to measures that inhabitants can take themselves, action is needed from health-care organisations, public institutions, and political authorities responsible for the health of the environment, safety of foodstuffs, quality of farm animal feed, and so forth. Raising public awareness of both the health threats arising from exposure to PCDD/PCDF and ways to minimise those threats is a key tool in dealing with the described risks. Even with fairly conservative assumptions, the ascertained health risks suggest that greater attention should be paid to the behavior and toxicity of the PCDD and PCDF group, and to exploration of exposure reduction possibilities.


The aim of this study is to describe the prevalence of HPV types in invasive cervical cancers in Italy from 1996 to 2008.A pooled analysis of the three largest case series typed to date was performed. HPV typing was performed on paraffin-embedded slices. Molecular analyses were performed in four laboratories. Multivariate analyses were performed to test the associations between calendar time, age, and geographical area and the proportion of types 16/18.Out of 574 cancers, 24 (4.2%) were HPV negative. HPV 16 and 18 were responsible for 74.4% (378/508) and 80.3% (49/61) of the squamous cancers and adenocarcinomas, respectively. Other frequent types were 31 (9.5%), 45 (6.4%), and 58 (3.3%) for squamous cancers and 45 (13.3%), 31, 35, and 58 (5.0%) for adenocarcinomas. The proportion of HPV 16 and/or 18 decreased with age , while it increased in cancers diagnosed in more recent years .The impact of HPV 16/18 vaccine on cervical cancer will be greater for early onset cancers. In vaccinated women, screening could be started at an older age without reducing protection. Cervical cancer is still the second leading cancer in women worldwide, with 585,278 new cases estimated in 2010. More than 80% of these cases occurred in low-medium income countries .It has been demonstrated that HPV infection is a necessary cause for cervical cancer . In partThe prevalence of HPV types infecting the lower genital tract in the healthy population shows geographical variations . InsteadNevertheless, some differences among continents have been consistently observed: In Africa and Eastern Asia, the proportion of cancers due to HPV types 16 and 18 is slightly lower than in Western Europe and North America ,8. FurthMany hypotheses have been formulated to explain these differences. The one most commonly accepted to explain the higher proportion of type 16 in early onset cancers is that this type has a greater potential to transform the cell compared to other high-risk HPV types and consequently there is a higher probability of progression from infection to cancer in a relatively short time. There is evidence from prospective cohort studies of shorter time to progression from HPV16 infection to high-grade Cervical Intraepithelia Neoplasia (CIN 3) -12. HoweData from cohort studies on time to progression for types 18 and 45 are less consistent ,11 becauThe prevalence of cytological screening uptake in the population strongly influences the epidemiology of cervical cancer. In highly screened populations, Pap test’s greater efficacy in detecting squamous precancerous lesions than glandular lesions leads to marked reduction in the incidence in the former ,14 and sThe aim of this work is to describe the prevalence of HPV types in Italian invasive cervical cancers from 1996 to 2008. The study is based on the pooling of three cases large series [In particular, we describe the associations between ca lendar time, age, and geographical area and the proportion of vaccine-targeted types (16 and 18) and early onset types (types 16/18/45).ad hoc morphological and molecular analyses on archival paraffin-embedded invasive cervical cancer (ICC) specimens.Histologically confirmed cervical cancer diagnoses from three large series were included in the study. All three studies performed Central and Southern Italy Study : 193 casRome Study : 134 casMilan Study : 268 casParaffin block selection and microtome sectioning, performed under strict conditions to avoid potential contamination, employed a sandwich technique to obtain 5 or 10-μm tissue section from each paraffin block. First and last microtome sections were stained for histopathological evaluation, while the internal sections were processed for DNA extraction. In one centre (Naples), morphologic check showed that the mean percentage of tumor cell staining was 64% (range: 5-100%), with a relevant proportion of sample slices containing a limited quantity of neoplastic tissue within a healthy tissue context.No central histologic review was planned for this study.Molecular analyses were performed in four centers: the Milan Study sent specimens to the International Agency for Research on Cancer  , the RomFor each sample, DNA concentration was evaluated by spectrophotometry and expressed in ng/μL.HPV genotyping was done using different PCR-based strategies in a well-defined algorithm.A PCR assay based on GP5+/GP6+ primers was used . All samples and controls were subjected to the reverse line blot (RLB) for detection of 12 high-risk HPV types , 1 probably carcinogenic HPV type (68), and 5 possibly carcinogenic HPV types  [For genotyping HPV DNA, 10 μl of the PCR amplimers of the HPV DNA-positive samples, as identified by DEIA, were analyzed by Line Probe Assay-LiPA25 version 1 , which can detect 25 different high-risk and low-risk HPV types  .Multiplex PCR was performed using the Qiagen Multiplex PCR Kit according to the manufacturer’s instructions, with a mixture containing 19 pairs of HPV-type specific primers  following the procedure described by Gheit et al. . To incrOur tables show the type distribution found in squamous and cervical cancers. We also present the proportion of types 16 and 18 or 16, 18, and 45 by age, calendar time at diagnosis, and geographic area. Proportions with relative 95% confidence intervals were computed. Multivariate models were constructed to identify determinants of the proportion of vaccine-covered types (16 and 18) and early onset types . All the analyses were performed using STATA 11.0.After histological evaluation, 595 ICC specimens from the original studies were included. Of these, 4 cases from the Rome Study and 17 from the Milan Study were excluded from the present study because the information about typing was missing. Thus, 574 cases were available for the analyses.The age range of the women included in this study was 23–85 years (mean age 52.4 years).Squamous cell carcinoma was the most represented histotype (508 cases: 88.5%), followed by adenocarcinoma (55 cases: 9.6%), then adenosquamous cell carcinoma (6 cases: 1.0%), and other minor histotypes (5 cases: 0.9%). For all the following analyses, adenosquamous cell carcinomas were grouped with adenocarcinomas.Adenocarcinoma was not associated with age at diagnosis (p = 0.57), but a strong time trend, with increasing proportion of adenocarcinomas in the recent years, was observed .Twenty-four (4.2%) cases were HPV DNA-negative. Among the HPV-positive cases, 74 (13.4%) were multiple infections, and 7 cases were non-typed.HPV 16 was the most frequent type detected, alone or in coinfection with other types: 69.3% and 58.3% in squamous and adenocarcinomas, respectively (Table HPV 18 was the second most frequent in adenocarcinomas (23.3%), and third in squamous . The cumulative proportion of HPV 16 and/or HPV 18 was slightly higher in adenocarcinomas than in squamous cell carcinomas, though not significantly . HPV 45 was also more frequent in adenocarcinomas than in squamous , while HPV 31 was more frequent in squamous cell carcinomas, though not significantly so (9.5% vs 5.0%). The fifth most frequent type was HPV 58 . HPV 33 ranked sixth (2.9% in squamous and null in adenocarcinomas), and HPV 35 ranked seventh .There was no significant difference in the geographical distribution of HPV 16 and 18, whereas we observed a significant , higher proportion of HPV 31 in northern Italy (13.1%) than in central and southern Italy  Table .There was a significant decreasing trend of HPV 16 and 18 in proportion with age, dropping from 94% to about 75% after the age of 35 . The trend was even stronger when we included HPV 45   Table , with noThe multivariate model shows that the effects of age and calendar time are independent and that they are not due to any bias in center recruitment and laboratory techniques adopted for typing. The same results are obtained if we limit the analyses to squamous cell cancers Table ; stratifThese three large Italian case series confirm some previously published results ,8. The pAgain, in line with de Sanjose’s study, HPV 16 and 18 were detected in about 77% of cervical cancers ,23, whicIt is interesting that HPV 33 did not rank in the top five, in contrast with the worldwide distribution. Other studies have already reported higher prevalence of HPV 31 than 33 in southern Europe .In our series, more than 1 out of 9 cases were adenocarcinomas, which is typical of high-moderate screening coverage , but theThe main objective of this paper was to describe changes in the proportion of vaccine-covered HPV types 16 and 18 and in early onset HPV types 16, 18, and 45, according to the geographical area, age, and the calendar time.Only few differences among geographic areas emerged and, even when statistically significant, they may have been due to chance, given the enormous number of statistical tests that can be performed comparing these distributions.The most remarkable results in our analyses were the trends in HPV 16, 18, and 45 with age and calendar time. The multivariate analysis clearly shows that the two trends are independent and not due to reciprocal confounding, to the increase in adenocarcinomas proportion in recent years, or to different PCR techniques adopted for typing in the three studies.The relation with age was expected since these are known to be early onset types ,9,20,29,On the contrary, the association with calendar time was not observed in other large series ,31 and wThe possibility of a more rapid progression associated with HPV 16 and its variants is supported by the Guanacaste Cohort Study, a 7-year nested case–control study conducted on 10,049 women . The stuAnother hypothesis is that HPV 16/18/45-related cancer precursors occur at a younger age, are far superior in number in comparison with other high-risk HPV-related cancer precursors, are not easily detected by cytology screening, and the transit time from precursor to cancer is not necessarily quicker. Recent population-based studies have shown that by using very sensitive screening tests such as HPV DNA testing, the number of precancerous lesions missed by cytology proves to be considerable . This laBoth these hypotheses consider the three HPV types related to early onset cancers as a unique group, but the evidence available about speed of progression from infection to CIN3 and cancer and about screening sensitivity are different for HPV 16 and HPV 18, and are almost absent for HPV 45.In conclusion, the proportion of HPV 16 and 18 types may be higher in highly screened populations because these types more frequently escape Pap test control. Consequently, the dramatic decrease in cancer incidence after screening introduction may be slightly less relevant for HPV 16- and 18-related cancers. Unfortunately, the effectiveness of Pap test as prevention cannot easily be increased by shortening screening intervals; a large body of evidence shows that reducing the interval from 3 years to 1 has a small effect on cancer incidence and a strong effect on the number of screening-induced treatments ,36. On tAs the present study has several limits, we can only confirm previously observed data or formulate hypotheses to be confirmed in other studies.The first limitation is that we did not perform a central pathology review, even if all the cases were specifically reviewed for the original study in each center ,19,20.As typing was performed on archival paraffin-embedded samples, some trends could be due to reduced analytical accuracy of typing methods on older samples, but this is not very likely to change the proportion of types.Our archives do not report some of the information that might have been crucial to testing our hypothesis. In particular, we do not know if the cases had had a previous negative Pap test. Furthermore, we do not know the stage at diagnosis. It could be extremely interesting to identify the micro-invasive cancers (FIGO IA1), since these cancers are virtually all asymptomatic and are thus mostly screen-detected .Finally, our series do not come from population-based registries and thus may not represent the universe of cancers in Italy. Furthermore, in some of the areas with higher screening coverage, i.e., northern Italy and Rome, the participating centers are not reference centre for screening programs, while in the areas with lower screening coverage, i.e. southern Italy, they are. It is likely that the proportion of screening-detected cancers in our archives does not represent the proportion in the cancer population in each geographic area. This may explain why we did not observe an effect of the geographic area on the proportion of HPV 16, 18, or 45, despite the broad differences in screening coverage among the areas.The impact of HPV 16/18 vaccine on cervical cancer will be proportionally more relevant for early onset cancers. Considering the very low overall risk in women under age 35 and that the proportion of vaccine-targeted cancers is over 90% in that age group, it may be necessary to postpone starting age for screening in vaccinated cohorts in order to reduce the risk of over-treatment and to contain costs.Furthermore, we suggest that screening is less effective in preventing the incidence of HPV 16 and 18 invasive cancers, given their shorter sojourn time in the precancerous stages. If this is true, then the screening interval in vaccinated women should take into account the longer sojourn time of CIN2 and CIN3 lesions due to non-16/18 HPV types.This is a pooled analysis of already published studies. All the three studies were approved by Ethic review board initally. This pooled analysis has been financed by the Ministry of Health and it was planned in the protocol of the most recent of the three studies .Abruzzo: Angeloni Claudio, Lattanzi Amedeo, Maccallini Vincenzo, Caraceni Donatella, Fortunato C.Cagliari: Macis Rosalba, Pilia Massimo, Caredda Valeria.Campania: Carillo Giuseppe, Di Iasi Angela, Santarsiere Aldo, Casto Loredana, Manno Maria, Santangelo Claudia, Pini Maria Teresa, Gallicchio Giuseppina, Scherillo Isabella, Barretta Elena, De Santis Vincenzo, Ercole Filomena.Catania: Scalisi Aurora, Spampinato Pina, Cantarella Maria Antonietta, Miano Maria Giuseppina.Lazio: Giorgi Rossi Paolo, Chini Francesco, Guasticchi Gabriella, Capparucci Paola, Marsili Laila Maria, Tufi Maria Concetta, Gomez Vito, Verrico Giovanna, Schiboni Maria Luisa, Pellegrini Antonella, Bove Emilia, D’Addetta Albina, Placidi Antonio.National Cancer Institute Fond Pascale, Naples: Buonaguro Franco Maria, Tornesello Maria Lina, Loquercio Giovanna, Losito Simona, Botti Gerardo, Vecchione Aldo.European Institute of Oncology, Milan: Sideri Mario, Boveri SaraTuscany: Carozzi Francesca M., Confortini Massimo, Bisanzi Simonetta, Sani Cristina, Venturini Giulia, Burroni Elena, Tinacci Galliano.National Cancer Institute Regina Elena, Rome: Mariani Luciano, Vocaturo Amina, Benevolo Maria, Marandino Fernando.Ministry of Health: Antonio Federici.F.M. Carozzi is an occasional advisor to Gen-Probe, Abbott, Sanofi, and GlaxoSmithKline.PGR, MS, FMC, MLT, FMB and LM conceived the study and planned the analyses. PGR, FMC, FMB, MS, and AV coordinated the sample collection. MLT, MLT, AV, and EB coordinated and performed the laboratory tests. FC planned the data collection and performed the statistical analyses. PGR drafted the paper.0020. All authors read and approved the final manuscript.


Betacoronavirus sequences indistinguishable from those found in cattle, a fact previously unknown. Gastroenteritis is one of the leading causes of morbidity and mortality among young and newborn animals and is often caused by multiple intestinal infections, with rotavirus and bovine coronavirus (BCoV) being the main viral causes in cattle. Given that BCoV is better studied than equine coronaviruses and given the possibility of interspecies transmission of these viruses, this research was designed to compare the partial sequences of the spike glycoprotein (S), hemagglutinin-esterase protein (HE), and nucleoprotein (N) genes from coronaviruses from adult cattle with winter dysentery, calves with neonatal diarrhea, and horses. To achieve this, eleven fecal samples from dairy cows with winter dysentery, three from calves, and two from horses, all from Brazil, were analysed. It could be concluded that the enteric BCoV genealogy from newborn and adult cattle is directly associated with geographic distribution patterns, when S and HE genes are taken into account. A less-resolved genealogy exists for the HE and N genes in cattle, with a trend for an age-related segregation pattern. The coronavirus strains from horses revealed  Betacoronavirus-1 within the genus Betacoronavirus. This genus has replaced Group 2 in the order Nidovirales, family Coronaviridae, and according to the new taxonomy; this family is separated into two subfamilies: Torovirinae and Coronavirinae. The latter comprises the genera Betacoronavirus, Alphacoronavirus, and Gammacoronavirus [Currently, coronaviruses (CoVs) with genetic and antigenic proximities to bovine coronavirus (BCoV) such as human coronaviruses HCoV-OC43, porcine hemagglutinating encephalomyelitis virus (PHEV), and equine coronavirus (EqCoV) are not considered to be separate species but as belonging to the species Betacoronaviruses also present the hemagglutinin-esterase (HE) protein, with the role as a secondary receptor-binding envelope protein and accessory proteins [CoVs are enveloped, single-stranded positive sense RNA viruses with a genome encoding replicase polyproteins, the four structural proteins: spike (S) glycoprotein ; nucleocapsid (N) (associated with the genomic RNA in the nucleocapsid); and the two proteins essential for virion formation, envelope (E) and membrane (M) proteins; some proteins , 4.BCoV is a major pathogen for cattle, frequently found in neonatal diarrhea, dysentery in the adult and respiratory disease , 6. SimiGiven the little information available on coronaviruses of horses and the genealogic relationship of these coronaviruses from cattle, this research was designed to perform a multigenic comparison of coronaviruses from adult cattle with winter dysentery, calves with neonatal diarrhea, and horses based on partial sequences of the HE, S, and N genes.BCoV Kakegawa strain  grown inIn the nested RT-PCRs, DEPC-treated water was used as a negative control every five samples, also added to the mix, and placed in a thermocycler in order to monitor contamination by DNA amplicons. Each step of the study  was carried out in different rooms with materials and reagents exclusive for that specific step in order to prevent DNA carryover. Fecal samples were collected from eight dysenteric and three healthy adult cows (named B1 to B11) in 2010 from a farm in Parana State, Southern Brazil; two samples came from healthy young adult horses (E17 and E19) in 2009 in a farm in São Paulo State, Southeastern Brazil and three fecal samples from dairy calves with neonatal diarrhea  collected in the state of MG, Southeastern Brazil, in 2001. BCoV in these last three calf samples had previously been studied for S gene genealogy  GenBank. Samples were prepared as 20% suspensions in DEPC-treated water and centrifuged at 5,000 ×g/15 min at 4°C, and the supernatant was stored at −80°C prior to analysis.Total RNA was extracted from the supernatants with the TRIzol reagent , and cDNA was synthesized using random primers  and M-MLV reverse transcriptase  as described by the manufacturer.Amplification of partial HE (nucleotides 122 to 562), S (nt. 1312 to 1799), and N (nt. 123 to 428) genes was performed as described by Souza et al. , using PAmplicons for each gene  were purified from agarose gels with the GFX PCR DNA and GB Purification Kit  and submitted to bidirectional sequencing with BigDye version 3.1  according to the manufacturer's instructions. Sequences were resolved in an ABI-377 sequencer.http://asparagin.cenargen.embrapa.br/phph/), and positions with scores >20 were used to assemble sequences with CAP-Contig in BioEdit 7.0.9.0 [Chromatograms were submitted to Phred analysis  S and N genes and Murine hepatitis virus  HE genes (absent in Alphacoronavirus) were used as outgroups. MHV was not used as outgroups for S and N in order to have an outgroup that diverged from the ingroup (Betacoronavirus) before the internal speciation of this group.The sequences were then aligned with BCoV and EqCoV homologous sequences retrieved from GenBank  using CLUSTAL/W with BioEdit 7.0.9.0 [HE nt. sequences  and 56.8% (aa), and the identity amongst groups of BCoV strains studied herein and other BCoV strains ranged from 89.20 to 98.17% and 86.45 to 97.89% for nt. and aa, respectively. The tree for N gene  showed tRegarding the identities of nucleotides and amino acids for the N gene, the lowest identities found amongst the equine strains E17 and E19 and BCoV strains groups were 96.94% and 97.18% and the highest was 97.73% or 97.5%, respectively. Amongst these two strains and EqCoV strains, the lowest and highest percentage identities were 92% (nt.) and 95.10% (aa). The E17 strain showed a G274C nucleotide substitution, resulting in a Val92Leu change, thereby distinguishing this strain from the E19 and other BCoV strains. However, identity amongst groups of BCoV strains studied herein and published BCoV strains ranged from 98.62 to 99.89% and 99.29 to 100% for nt. and aa, respectively. The nt. sequence of all genes studied in this study has been deposited in the GenBank under accession numbers .With respect to the genealogical analysis, the coronavirus strains E17 and E19, detected in horses, did not cluster with EqCoV strains already described [The presence of coronaviruses similar to BCoV in hosts other than cattle has already been reported in buffalos , 18, lamFurthermore, the 18 nt./ six aa deletion in S1, already described for BCoV strains , was alsRegarding the HE gene, strains E17 and E19 both clustered with Kakegawa BCoV strain (HE: (a) strains from adult cows studied herein; (b) strains from dairy cows with winter dysentery previously reported in Brazil (Genbank); and (c) strains from cattle from other countries retrieved from the GenBank. Alternatively, BCoV strains from bovine resulted in three main clusters for HE was maintained for S  and another with all of the remaining strains. Considering that d herein , 30, oneCoronavirus [The debate on the taxonomy of coronaviruses has firstly led to the proposition of 3 groups in the genus onavirus  and becaonavirus , in whiconavirus  which waonavirus . The newBetacoronavirus highly similar to those found in cattle, supporting the existence of the Betacoronavirus-1 species.In conclusion, the genealogy of enteric BCoVs from newborn and adult cattle is directly associated with geographical patterns, when the S and HE genes are taken into account, with a less-resolved genealogy for the HE and N genes, and with a trend for an age-related segregation pattern for the last, and horses might present


The incidence of congenital hypothyroidism (CH) has been increasing in Western countries, and some populations, including Asians, have a higher incidence. Delayed diagnosis and early treatment influence the outcome of CH. We investigated the incidence and clinical characteristics of CH in Taiwan.In this retrospective database study we identified cases of CH diagnosed during 1997–2008 in the Taiwan National Health Insurance Research Database (NHIRD). Patients who had a Serious Accidents and Diseases certificate were included in the incidence calculation. We focused on CH patients who were born during 1997–2003 and determined their age at diagnosis and CH-related clinical features. Mental retardation and physiological delays were evaluated with respect to age at diagnosis.A total of 1482 cases were identified. Incidence during the 12-year period was 5.02 per 10 000 births. Among 1115 patients, the most common clinical features of CH were developmental delay (9.6%), constipation (11.6%), and delayed physiological development (9.1%). Congenital anomalies of the heart (7.7%), epilepsy (2.7%), and infantile cerebral palsy (3.2%) were also noted. Survival analysis showed that the risks of mental retardation  and delayed physiological development  were greater when age at diagnosis was greater than 1 year.CH incidence was higher in Taiwan than in Western countries. Early diagnosis may decrease the risk of mental and physiological delay. Multiple factors may be involved, including ethnicity, environmental factors, characteristics of birth and pregnancy, and screening programs.3–6 The female-to-male ratio for CH is nearly 2:1 according to reports from most screening programs.1,5Congenital hypothyroidism (CH) is a common endocrine disease in newborns and affects approximately 1 in 2000 to 4000 live births. A number of epidemiologic studies have shown that CH incidence is increasing in Western countries,7 The symptoms and signs of CH in infants include hoarse crying, feeding problems, constipation, umbilical hernia, anterior fontanels, hypotonia, jaundice, dry skin, and hoarseness of voice.8 CH is the most common treatable and preventable cause of intellectual disability in children. The thyroid gland has an important role in mental and physiological development, and its absence causes developmental delay, mental retardation, and dwarfism.9,10 Therefore, appropriate diagnosis and treatment are important in CH. In most cases of CH, the treatment goals are ensuring normal development, growth, and intelligence. Oral levothyroxine (L-T4) is the most common treatment for normalizing thyroid hormone levels in patients with CH.11,12 A review article indicated that infants who began thyroid hormone treatment at age 12 to 30 days had an IQ 15.7 points higher than those who began treatment after age 30 days.12Delays in diagnosis and treatment of CH may cause impairment in neurological development and intelligence quotient (IQ).1,2 Although a number of studies have suggested that the clinical features and epidemiology of CH differ by ethnicity, data on the clinical characteristics and epidemiology of CH in Asians are relatively scarce.4,13–15 Moreover, a number of studies have shown that patients may have more seizures and increased risk of heart disease when receiving thyroid hormone treatment and that thyroid function differs during long-term follow-up.16–19 However, little is known of trends in CH incidence among Asians. Thus, medical treatment and the clinical manifestations of CH in Asians also remain to be clarified.CH incidence in Asian populations is reported to have increased more than in US populations.In Taiwan, routine neonatal screening was begun in 1984, and the neonatal screening rate is now greater than 99%. We investigated the incidence and clinical characteristics of CH in an Asian population, using a 10-year nationwide population-based database. In addition, because delayed diagnosis causes problems in mental and physical growth, we also assessed whether developmental delay  varies by age at CH diagnosis.http://sowf.moi.gov.tw/stat/month/m1-02.xls). Because this study was based in part on information from the NHIRD that comprised thoroughly deidentified secondary data released to the public for research purposes, this study was exempt from full review by an ethical committee, and the informed consent of the study subjects was not necessary.In this population-based retrospective study, data on CH patients were extracted from the list of Serious Accidents and Diseases (SAD) certificates published during 1997–2008 by the Department of Health, Executive Yuan of Taiwan. CH cases were identified by using the International Classification of Disease, Ninth Revision (ICD-9) code 243. A diagnosis of CH on a SAD certificate is strictly evaluated by at least 2 pediatricians, using laboratory data from newborns (screening criteria: thyrotropin [TSH] >40 µU/ml is the standard criterion used by the Taiwan government), and all documents are rechecked by a third physician in the Department of Health before an SAD certificate is issued. Patients with SAD certificates are eligible for exemption from insurance premiums and copayments. We extracted the medical records of CH patients from the National Health Insurance Research Database (NHIRD), which includes details of outpatient, ambulatory, and hospital inpatient care, dental services, and prescription drugs. The database was provided by the National Health Research Institute (NHRI). CH patients with SAD certificates between 1997 and 2008 were included in the analysis of clinical epidemiology and medical treatment. We quote the annual numbers and birth rates from national reports published by the Ministry of the Interior  in each year as the numerator. Incidence is expressed as number of cases per 10 000 births and 1 case per number of births.To decrease selection bias arising from the time limitation of our database  and from the fact that diagnosis was delayed for several years for some patients, data from patients born after 2004 might not reflect the real results of our detailed analysis. We therefore strictly focused on CH patients who were born during 1997–2003 and had at least 4 years of medical records in the NHIRD.Age-specific clinical presentation and diagnosis were tracked back to the SAD application date. SAD certificates are evaluated by specialist physicians who have access to comprehensive laboratory data, which limits problems in diagnostic accuracy and reduces the number of false-positive cases. However, age at diagnosis was defined as the SAD certificate application date, which means that the estimates have a slight delay in this study. Age at diagnosis was divided into 3 groups: Group 1, patients younger than 3 months at diagnosis; Group 2, those aged between 3 months and 1 year at diagnosis; and Group 3, those older than 1 year at diagnosis.CH cases were then followed up for more than 4 years to ascertain whether they had visits for long-term hypothyroidism that caused developmental delay (ICD-9-CM code 315), mental retardation (317–319), or physiological developmental delay, ie, failure to thrive (783.41), delayed milestones (783.42), or short stature (783.43).4 treatment was defined as the date on which T4 was first prescribed. T4 treatment delay was defined as the period from the diagnosis date to the start of T4 treatment. Duration of T4 treatment was calculated from the start of T4 treatment to the date of the last prescription in our database.The following data were analyzed: sex, age at diagnosis, year of diagnosis, disease duration, diagnostic setting, medical treatment, and CH-related signs and symptoms after CH diagnosis. Several proven signs and symptoms related to CH were selected based on the ICD-9-CM codes . Medical4 use, T4 treatment delay, duration of T4 treatment, and CH-related signs and symptoms during follow-up. All cases were tracked until December 31, 2008, and their diagnosis date was used in survival analysis. Each case was followed-up until the first occurrence of 1 of the outcome measures or the end of follow-up. We censored all cases that had none of the outcomes before the end of follow-up and all deaths during the follow-up period. A Cox proportional hazards model was used to assess the association of the long-term effect of hypothyroidism with age at diagnosis, sex, diagnosis year, diagnostic setting and area, characteristics of T4 use, T4 treatment delay, and duration of T4 treatment. Diagnosis year was categorized as 1997–2000, 2001–2003, and 2004 or later. Analyses and calculations were carried out by using SAS 9.2. All data were expressed as frequency (percentage) and mean ± SD. Data for each risk factor were assessed in unadjusted and adjusted analysis. Statistical significance was defined as a 2-sided P value of less than 0.05.We characterized CH patients in the different age-at-diagnosis groups by age, sex, diagnosis year, diagnostic setting and area, characteristics of TAmong 3.0 million Taiwanese infants, 1482 (708 boys and 774 girls) were identified as having CH. The 12-year average crude incidence was 5.02 infants with CH per 10 000 (Table n = 645), developmental delay (n = 107), constipation (n = 129), congenital anomalies of the heart (n = 86), and delayed physiological development (n = 103). In our survey, over 95% of CH patients used oral levothyroxine, and the treatment delay was 2.78 months. Average duration of T4 use was nearly 4 years in our population. Half the patients were diagnosed in medical centers in northern Taiwan. In our survey, associated diseases in CH patients included mental retardation (n = 38), infantile cerebral palsy (n = 36), and epilepsy (n = 30). Jaundice and goiter were seen in 3.9% (n = 43) of cases. Speaking and voice problems were noted in 53 cases. During follow-up, only 14 patients died, and over 98% were alive at the end of follow-up.Table P = 0.0079) and mental retardation (log-rank test P = 0.0013) in CH patients significantly differed by age at diagnosis, especially among those diagnosed after age 3 months  was similar in the 3 age groups  and Chinese and Vietnamese (4.2 per 10 000 infants) but higher than that in non-Hispanic whites (3.6 per 10 000 infants) and non-Hispanic blacks (0.9 per 10 000 infants).2 CH incidence in East Asian countries such as Japan (6.8 per 10 000 infants)15 and China (4.8 per 10 000 infants)13,14 is higher than that in Western countries. A study of Asia-Pacific screening programs for newborns found that some Asian countries screened the entire population  and others used pilot testing or selected population screening (Pakistan and India).4 Therefore, the higher incidence in East Asia may be due to regional differences in screening programs for newborns. However, there have been studies on the genetics of CH in different ethnicities, as this may be an important factor in the higher incidence in East Asia.6 Most CH screening programs report that the female-to-male ratio is 2:1, but in the present study it was 1.09:1, which is similar to the results of a number of other studies.26 However, the incidence of CH in was still 19.6% higher in girls as compared with boys in our population.CH has been widely researched in Western countries, but the incidence of CH is considered to be higher in East Asia Table .1,3,13–11 It appears that additional factors are involved in the correlation between birth rate and CH incidence. Lastly, the criterion for screening (TSH >40 µU/ml) is the standard criterion used by the Taiwan government; however, recent reports suggest that use of multiple tests  improves detection of primary and central hypothyroidism.27–29 Therefore, the screening program is improving every year, and detailed screening is performed to decrease misclassification of possible newborns. However, this may increase the number of false-positive cases. On the SAD certificate, which is evaluated by 2 specialized physicians in Taiwan, the primary screening test is TSH level, and advanced screening includes TSH, free T4, T4, thyroglobulin, thyroxine-binding globulin, and thyroid sonogram or 99mTc thyroid scanning. Some screening items in the advanced screening have been used in recent years and are recommended for suspected CH patients after initial primary screening in Taiwan. Although this improves diagnostic accuracy and decreases the number of false positives, the numbers of cases may be underestimated in our database, which could affect estimates of CH incidence in Taiwan. Hence, the changing trend in crude incidence during 1997–2003 might be more accurate, and crude incidence after 2004 should be regarded as tentative.Table 26,30 Although 99% of Taiwanese infants undergo routine neonatal screening, only 78.2% of the present patients received a diagnosis before age 1 year. Padilla and Therrell4 studied newborn screening in the Asia-Pacific region and found that some South and Southeast Asian countries do not screen all newborns for CH. A 1997 Health Technology Assessment publication estimated the short-term costs at 18 000 GBP per year, with long-term costs rising to 174 000 GBP per year for screening 100 000 births per year.31 The CH burden can also be decreased when all newborns in a population are screened. CH diagnosis and treatment should be performed as soon as possible to decrease the likelihood of serious impairment of neurological development and intelligence quotient. During the last 30 years, most industrialized countries have been conducting neonatal screening programs that have decreased cerebral damage and the severity and morbidity of CH in children.32 Developmental delay, mental retardation, and delayed physiological development are long-term complications of hypothyroidism. A number of studies on long-term outcomes have shown that age at diagnosis, CH severity at diagnosis, and treatment adequacy have long-term effects on health-related quality of life scores and cognitive and motor outcomes.33–35 Our findings were consistent with studies conducted in different regions, which showed that CH patients are at greater risk of developmental delay, mental retardation, and delayed physiological development when CH is diagnosed after age 3 months. Furthermore, males had a higher risk of developmental delay and mental retardation in our study, a finding that supports research by Oerbeck et al34 on long-term outcomes. They found that female CH patients had better social and motor outcomes than male patients. However, a correlation between CH disease severity and progression was not observed in either sex in a study by Eugene et al.5 Our findings show that more than 95% of CH patients had at least 1 course of T4 treatment, that the duration of treatment was longer than 4 years, and that treatment started at an average age of 2 months. The lack of difference in risk remained even when patients were stratified according to duration of T4 treatment or the interval between diagnosis and start of T4 treatment. A number of studies reported that T4 treatment should be started within 2 weeks of a CH diagnosis.12 In the present report, T4 treatment delay was longer than 2 weeks, perhaps because the T4 treatment starting point was calculated from the date of first T4 prescription in NHIRD and because the estimates have a limited time delay in this study. Treatment may also have been delayed because disease severity was milder in our population. However, 1 report suggested that treatment delay was not associated with IQ or motor scores in long-term follow-up.35Delayed diagnosis and treatment is a serious problem in some South Asian countries, such as Pakistan and India, where less than 30% of patients are diagnosed before age 1 year.36 and that prevalence was higher among CH patients than in the general population of newborns. Similarly, recent clinical studies also showed that CHD patients have a 10-fold higher risk of CH than do general newborns.37 The correlation between CHD and CH may be due to embryonic development between the thyroid gland and heart, and the great vessels. Results showing a higher prevalence of CHD in CH patients suggest that CH patients should be evaluated by echocardiography and monitored carefully.The clinical characteristics of CH may differ between Asian and Western countries. There are few studies of the signs and symptoms of CH-associated complications in Asian patients. Our study confirmed that our population also experienced the common signs and symptoms, ie, developmental delay, mental retardation, constipation, and delayed physiological development . The frequency of congenital anomalies of the heart was 7.7% in our patients. Wu et al found that the prevalence of congenital heart defects (CHD) in Taiwanese newborns was 1.3%17 Our data show that the frequency of seizure in CH patients was 2.7%. Although no study has shown a correlation between seizure and CH in newborns or children, a recent case report described an infant suffering from intractable neonatal seizures with CH.38 More evidence is needed to determine the exact cause and mechanism. It is important to note that infantile cerebral palsy occurred in 3.2% of patients in our survey. There are limited data on the correlation between CH and infantile cerebral palsy, but it may be prudent to monitor CH patients for signs and symptoms of infantile cerebral palsy after CH diagnosis.Epilepsy has also been discussed in thyroid-related disease and treatment. Thyroid hormones have an important role in perinatal development of the central nervous system, and recent studies have reported that the incidence of seizure in people with hyperthyroidism is higher than in individuals with normal hormone levels.4 starting dose or continuation dose from the database, and these might be potential confounders.This study had a larger sample and a longer study period than any other analysis of the epidemiology and clinical characteristics of CH in Taiwan. Although a number of studies have been performed in Asia, information on CH epidemiology are lacking in this population. We conducted this study using a nationwide database that had the complete medical history for each patient. This database was obtained from the single-payer National Health Insurance program, which enrolled 98% of Taiwan’s population. In our study, we identified CH patients from SAD certificates and clinical coding, but CH cases need to be evaluated by laboratory data and image testing to ensure that their SAS certificate is accurate. The database had few problems with regard to diagnostic accuracy. However, there are some limitations in the present study. First, the incidence for the SAD certificates was calculated using the application date, so the estimates have some time delay. The number of cases might have been underestimated if infants died before an SAD certificate could be issued. Unfortunately, the database used in our study was a double-identified, secondary, non-random sample database. Thus, it is difficult to determine if underestimation occurred. Second, infant characteristics such as body weight, area of residence, maternal and paternal characteristics, health-care policy, socioeconomic status, and disease severity were not available from the NHIRD. A number of reports indicate that CH severity influences treatment efficacy and disease progression. In the present study, we were unable to evaluate CH severity and compare the severity of associated signs and symptoms with data from other countries. Third, we had no imaging findings or data on hormone levels for CH patients, and these might be potential confounders. Fourth, we used data on hospital and outpatient visit claims to measure medical treatment and duration. Some patients and families may not have completely adhered to the instructions of physicians, which could lead to errors in the measurement of exposure and duration. Fifth, it is difficult to calculate TIn summary, the incidence of CH in Taiwan remains higher than in Western countries. However, the marked increase in incidence in Taiwan was not significant during 1997–2008. The epidemiology of CH appears to be similar to that in some other Asian countries but not to that in Western countries. The signs and symptoms of CH are similar to those reported in Western countries, ie, constipation, jaundice, intellectual disability, developmental delay, and delayed physiological development. Congenital anomalies of the heart, epilepsy, and infantile cerebral palsy also occur in some CH patients. More surveillance of CH-related diseases needs to be conducted in the future. Data from CH patient surveys show that over 78% of CH patients are diagnosed before age 1 year and that early diagnosis can decrease the risks of developmental delay, mental retardation, and delayed physiological development.eTables.The World Health Organization (WHO) published International Classification of Disease, Ninth Revision (ICD-9) code numbers used for present analysis.


Prevalence and incidence of diabetes among adults are increasing in the United States. The purpose of this study was to estimate the incidence of self-reported diabetes in New York City, examine factors associated with diabetes incidence, and estimate changes in the incidence over time.We used data from the New York City Community Health Survey in 2002, 2004, and 2008 to estimate the age-adjusted incidence of self-reported diabetes among 24,384 adults aged 18 years or older. Multiple logistic regression analysis was performed to examine factors associated with incident diabetes.Survey results indicated that the age-adjusted incidence of diabetes per 1,000 population was 9.4 in 2002, 11.9 in 2004, and 8.6 in 2008. In multivariable-adjusted analysis, diabetes incidence was significantly associated with being aged 45 or older, being black or Hispanic, being overweight or obese, and having less than a high school diploma.Our results suggest that the incidence of diabetes in New York City may be stabilizing. Age, black race, Hispanic ethnicity, elevated body mass index, and low educational attainment are risk factors for diabetes. Large-scale implementation of prevention efforts addressing obesity and sedentary lifestyle and targeting racial/ethnic minority groups and those with low educational attainment are essential to control diabetes in New York City. Recent epidemiologic studies indicate that the prevalence -3 and inEven less is known about the incidence of diabetes in smaller geographic areas such as counties and cities ,9. A betNew York City (NYC), similar to the nation overall, has experienced an increase in diabetes prevalence over the past 2 decades. Between 1994 and 2004, the prevalence of age-adjusted self-reported diabetes among adults in NYC rose from 3.7% to 9.2% and has remained stable over the past several years. In 2010, the prevalence of diabetes in NYC was 9.3%  and the We used data from the 2002, 2004, and 2008 New York City Community Health Survey (CHS) to perform analyses. Data on diabetes incidence were not available from the 2003, 2005, 2006, 2007, 2009, and 2010 surveys. CHS methods are based on those used by the Behavioral Risk Factor Surveillance System (BRFSS) and have been previously described in detail . BrieflyPeople were ineligible for our study if they were previously diagnosed with diabetes , had a missing or don’t know/refused/not sure response for having diabetes (n = 70), or had a missing or don’t know/refused/not sure or invalid response for age or age at diagnosis (n = 238). Thus, the final sample size was 8,928 from 2002, 8,711 from 2004, and 6,745 from 2008. The final joint years sample size was 24,384.All sampled adults in the 2002 and 2004 CHS ,17 were Self-reported race/ethnicity was measured by first asking “Are you Hispanic or Latino?” Respondents who stated they were not Hispanic or Latino were then asked, “Which one of these groups would you say best represents your race?” The options included white, black or African American, Asian, Native Hawaiian or other Pacific Islander, and American Indian or Alaska Native. Responses to the 2 questions were combined and recoded into the categories non-Hispanic white, non-Hispanic black, Hispanic, or other.2). BMI was calculated as weight in kilograms divided by height in meters squared, and participants were classified into BMI categories .Respondents’ education attainment was accessed by asking “What is the highest grade or year of school you completed?” Responses were categorized as more than high school graduate, high school graduate, and less than high school graduate.Smoking status was measured by asking “Have you smoked at least 100 cigarettes in your entire life?” and if the response was yes, “Do you now smoke cigarettes every day, some days, or not at all?” Smoking status was categorized as never (people who answered no to the first question), current (people who answered yes to the first question and “Every day” or “Some days” to the second question), and former .NYC neighborhood income level was obtained from Census 2000 data and defined as the percentage of the population in each neighborhood living below 200% of the federal poverty guidelines. The neighborhoods were categorized as high income (13%–<30%), medium income (30%–<43%), and low income (43%–70%).t test and χ2 test and were considered significantly different at P < .05. Relative standard errors (RSE), a measure of estimate precision, were calculated for all the incidence estimates  for data management and SAS-callable SUDAAN version 10.0  to obtain point estimates and confidence intervals.To examine the factors associated with the estimated incidence of self-reported diabetes, logistic regression analysis was performed for the combined 2002, 2004, and 2008 surveys. Before building the multiple logistic regression model, the main effects were individually examined using simple logistic regression analysis to eliminate the nonsignificant predictors. Variables that were significantly associated with incident diabetes at In the CHS, the estimated crude incidence of self-reported diabetes per 1,000 population was 8.6  for 2002, 10.9  for 2004, and 7.5  for 2008. The estimated age-adjusted incidence per 1,000 population was 9.4  for 2002, 11.9  for 2004, and 8.6  for 2008. The differences in the estimated age-adjusted incidence across the years were not significant.For the combined CHS, the age-specific self-reported incidence per 1,000 population was significantly higher among participants aged 45 years or older than among those younger than 45. The age-adjusted incidence per 1,000 population was significantly higher among non-Hispanic blacks and Hispanics than among whites, among overweight and obese people than among those at a normal weight, among high school graduates and below than among those with more than a high school diploma, and among people residing in low-income neighborhoods than among those residing in high-income neighborhoods . IncidenP < .10 in the bivariate analysis: age (P < .001), race/ethnicity (P = .01), BMI category (P < .001), education level (P < .001), neighborhood income level (P = .006). Smoking status (P = .07) was only marginally associated with diabetes incidence, and sex (P = .36) was not associated with diabetes incidence. Age, race/ethnicity, BMI category, education level, neighborhood income, and smoking were considered for the final multivariable model. All with the exception of neighborhood income level and smoking status were found to be independent predictors of incident diabetes. Diabetes incidence was significantly higher among participants aged 45 or older than among those aged 18 to 44, among non-Hispanic blacks and Hispanics than among whites, among overweight and obese people than among normal-weight people, and among people with less than a high school diploma than among those with more than a high school diploma (Multivariable analysis included only those variables with a  diploma .This study suggests that diabetes incidence is stabilizing in New York City. After adjusting for multiple factors, older age and obesity had the strongest association with diabetes incidence. Furthermore, being non-Hispanic black or Hispanic and having a lower education level were identified as significant predictors of diabetes incidence in the study period. Our findings will be useful not only to NYC diabetes prevention efforts but also to inform decision making in other urban, ethnically diverse areas in the United States.These findings can be compared with other cross-sectional studies that used similar methods with survey data to calculate incidence and to identify newly diagnosed cases of disease. A study using BRFSS, which is the most similar to CHS in terms of survey methods, documented an overall estimated age-adjusted national incidence of 9.1 per 1,000 in 2005 through 2007 .Although the incidence for 2008 was similar between local and national estimates, the direction of the observed trends over the years was different. BRFSS data show that the average national age-adjusted incidence of diabetes increased 90% from 4.8 per 1,000 population in 1995–1997 to 9.1 per 1,000 population in 2005–2007 (Our study found that the age-adjusted incidence estimates increased in NYC from 9.4 to 11.9 per 1,000 population from 2002 to 2004 and then decreased subsequently to 8.6 per 1,000 in 2008 rather than continuing to increase, as seen nationally. This coincides with a local trend of decreasing childhood obesity  and a stThe key strength of this study is that it provides a population-based incidence estimate for a large jurisdiction. However, several limitations should be noted. First, the cross-sectional data limited our ability to assess the temporal relationship between risk factors and diabetes incidence. Second, because the diagnosis of diabetes was self-reported by respondents, survey responses regarding the diabetes diagnosis and the date of diagnosis were subject to recall bias and misinterpretation. However, this bias is unlikely to have affected the trend analysis reported here, as we have no reason to think it has changed over time. Third, CHS diabetes incidence data were collected only for 3 years, which may have restricted the ability to detect trends. Additional years of data are needed to detect a significant change in the overall incidence. Fourth, institutionalized adults and those without residential telephones were not represented in the sampling frame, limiting the generalizability of our findings. However, in 2008 a pilot study of CHS, which included cell phone users, showed that diabetes prevalence was similar between landline and combined landline and cell phone–only samples . Fifth, The number of new diabetes cases increased significantly over the past 2 decades in the United States, and continued efforts at the national, state, and local levels to alter this trend are necessary. Our findings suggest that this trend in NYC may be slowing. To maintain this trend and achieve further progress, we must ensure that effective prevention programs and policies, focusing on weight as the most modifiable risk factor for developing diabetes, are in place. Lifestyle modification programs, which can decrease diabetes incidence by up to 58% and can be cost-effective, should be widely implemented –25, as s


The long term outcome of advanced sarcoma patients treated with trabectedin outside of clinical trials and the utility of maintenance treatment has not been reported.Between 2003 and 2008, patients with advanced sarcoma failing doxorubicin could be treated within a compassionate use program  of trabectedin in France using the standard 3-weekly regimen. Data from 181 patients (55%) were collected from 11 centres and analyzed.Trabectedin was given in first, second, third or fourth line in metastatic phase in 6%, 37%, 33% and 23% of patients respectively. With a median follow-up of 6 years, median PFS and OS were 3.6 months and 16.1 months respectively. The median number of cycles was 3 (range 1–19). Best response were partial response , stable disease  and progressive disease , non evaluable . Thirty patients (17%) had to be hospitalized for treatment- related side effects. Independent prognostic factors in multivariate analysis (Cox model) were myxoid LPS and line of trabectedin for PFS, and myxoid LPS and retroperitoneal sarcomas for OS. Patients in PR or SD after 6 cycles continuing treatment had a better PFS  and OS  as compared to patients who stopped after 6 cycles.In this compassionate use program, trabectedin yielded similar or better PFS and OS than in clinical trials. Maintenance treatment beyond 6 cycles was associated with an improved survival. Soft tissue sarcoma (STS) constitutes a heterogeneous group of rare cancers, with heterogeneous clinical presentation, histological subtypes and molecular alterations. The estEcteinascidia turbinata, a tunicate originally extracted from the Caribbean Sea. Its complex mechanism of action involves a covalent bond to the minor groove of double-stranded DNA, resulting in an inhibition of gene activation and nucleotide excision repair (NER) mechanism, and also inducing lethal DNA double-strand breaks and cell cycle arrest in S and G2 phases[In vitro, trabectedin has shown potent cytotoxic activity against a variety of human STS cell lines, and antitumor activity against a variety of human xenografts, including sarcomas, with limited cross-resistance between trabectedin and other cytotoxic agents[Trabectedin is a tetrahydroisoquinolone alkaloid isolated from the marine organism 2 phases-11. In vc agents.2 on a 24-h infusion every 3 weeks or at a dose of 0.58 mg/m2 on a 3-h infusion weekly for 3 weeks of a 4-week cycle). The study met its primary endpoint with a median TTP of 3.7 months in the 24-h arm vs. 2.3 months in the 3-h arm (p = 0.0302), showing a statistically significant 27% reduction in the risk of progression with the 24-h trabectedin arm[In clinical trials, single-agent trabectedin has shown activity in a variety of tumor types, including sarcomas, breast cancer, and ovarian cancer-28. The Hereby are reported the results of a retrospective study in which the outcome of patients included in this compassionate use program population was analyzed. The survival and response rates of these patients were comparable to those reported in clinical trials. Interestingly, maintenance treatment after 6 cycles was associated with improved PFS and OS over treatment discontinuation after 6 cycles.th, 2012. 181 of the 328 (55%) patients of the ATU program are therefore included in this report. Trabectedin was given at the standard schedule of 1.5 mg/m2 in 24 h continuous infusion every 21 days, as previously reported, with dose adaptations similar to those applied in the protocols[From 2003 to 2008, 87 centres in France enrolled included at least one patient in the ATU (“Autorisation Temporaire d’Utilisation”) program, a compassionate use program for STS patients matching the inclusion criteria (see below). Requests for participation were sent to all 43 centres that included more than 1 patient. Only centres that had included more than 5 patients actually contributed to this retrospective study. These centres treated 252 patients in total, among which 181 patient files (71%) were collected and updated as of March 20rotocols-23.The primary objective of this study was to evaluate progression-free survival, while secondary endpoints were response rates, duration of response, overall survival, toxicity leading to hospital rehospitalisation, description of the patient populations, impact of treatment duration on treatment efficacy. Because of its retrospective nature, only very simple clinical parameters were collected.in situ carcinoma of cervix or basal cell carcinoma); presence of measurable lesions not previously irradiated, no central nervous system metastases; adequate bone marrow reserve ; and adequate renal and hepatic functions: serum creatinin less than 120 μmol/L or calculated creatinin clearance (Cockroft method) greater than 60 mL/min, bilirubin > 30 μmol/L, AST and ALT less than 1.5 U/L (<2.5 U/L in case of liver metastases), alkaline phosphatase less than 2.5 U/L and albumine > 25 g/L. Mesothelioma, chondrosarcoma, neuroblastoma, osteosarcoma, Ewing’s sarcoma, embryonal rhabdomyosarcoma, and dermatofibrosarcoma were excluded.These criteria were those from the EORTC trial, the larA simple Case Report Form with 22 items was used to collect patients’ characteristics and outcome. Information has been collected on an excel spreadsheet, consolidated in an Excel database, and then analyzed using the SPSS 12.1 software by institutional data manager. Collected information included the following: anonymized patient identity, centre, date of birth, gender, date of diagnosis, histotype, grade, date of metastasis, description of first/s/>2 line treatments, best response, duration, date of trabectedin first course, ECOG PS at that date, metastatic sites at that date , number of cycles, best response to trabectedin, toxicity of trabectedin requiring re-admission, date of last course of trabectedin, date of progression after trabectedin, treatment after trabectedin and best response, date of death. Optional data were number of available pathology tissue block, and contact information for the pathology department where diagnosis was made and which held the pathology samples.st 2011. Descriptive statistics were used to depict the variables distribution. Follow-up was calculated from course 1 of trabectedin. Progression-free survival (PFS) was defined as the interval between the date of the first trabectedin cycle and the date of disease progression, death, or last follow-up contact. The interval between the date of the first cycle of trabectedin and the time of death or last follow-up defined the Overall Survival (OS). PFS and OS rates were estimated using the Kaplan-Meier method and were compared using the log-rank test. Univariate analyses included the following variables: age; sex; performance status; grade; histological subtype; disease location, myxoid liposarcoma histology, translocation sarcoma, treatment line, hospitalization for toxicity and liver/lung metastases. Responses were determined retrospectively using RECIST 1.1. All statistical tests were 2-sided, and a p-value below 0.050 was considered statistically significant. This study was approved by the local institutional review board at each participating institution.Baseline demographics and clinical outcome statistical analyses were based on all data available up to the cut-off date of December, 31Between 2003 and 2008, 87 centres have included 328 patients in the ATU program. The present study was performed on 181 patients from 11 centres having treated at least 5 patients who agreed to participate. This represents 55% of the total cohort of 328 ATU patients. Inclusion criteria of the ATU were those of the EORTC trial. The only difference was that no restrictions were imposed on the previous number of lines. The median number of patient per centre was 17 (range 5 to 32). Patients’ characteristics are described in Tablest and 2nd line but prolonged survival >24 months was observed in all subgroups , stable disease (SD), and progressive disease (PD) were recorded as best response in 10%, 39%, 46% of the patients respectively, with 5% patients being non evaluable. No significant difference was were observed according to the line of trabectedin administration Table.A total of 56 31.1%) patients were in SD or PR after 6 cycles. In 16, the treatment was stopped, whereas in 40 patients it was continued beyond 6 cycles for a median of 9 cycles (range 7–19). The subgroup of patients treated with 7 or more cycles had a significantly better PFS  and OS  , stable disease rate 39%), PFS (median 3.6 months) and OS (median 16.1 months) were comparable to those observed with trabectedin in the phase II trials. According to the EORTC-STBSG (European Organisation for Research and Treatment of Cancer- Soft Tissue and Bone Sarcoma Group) criteria, because the 3-months progression free rate was largely superior to 40% and the 6-monthz PFR was superior to the threshold used to define an active treatment according to the EORTC STBSG,3 publis9%, PFS . It has previously been shown in a large randomized clinical trial (SUCCEED) that maintenance with an mTOR inhibitor enables to prolong PFS, but not OS . Maintenance therapy maybe a strategy worth further exploring in patients with advanced STS.In conclusion, this retrospective analysis of 55% of the advanced sarcoma patients treated in France in the compassionate use program shows that the use of trabectedin in routine clinical practice, in large volume centres, yields an outcome similar to the previously observed results in earlier clinical trials. Trabectedin is confirmed as an active and safe agent for the treatment of advanced STS patients who have failed to standard therapies. Patients treated beyond 6 cycles of trabectedin had a significantly better survival, pointing out a potential role of maintenance treatment. An exhaustive retrospective study collecting the information on all patients treated with trabectedin since its approval could be very helpful to describe the outcome of patient populations in low volume centres. A prospective studies is ongoing to evaluate the efficacy of maintenance after 6 cycles.JYB, AI, BNB,ALC, IRC, NP, FD received research support and honoraria from Pharmamar. NB and PZ are employees of Pharmamar.JYB: conceived the study, contributed to case collection, performed the analysis, the interpretation and wrote the primary version of the manuscript. IRC: conceived the study, contributed to case collection, contributed to the interpretation and contributed to the writing of the manuscript. ALC: contributed to case collection, contributed to the interpretation and contributed to the writing of the manuscript. FD, MR, OC, FB, FB, EB, NI, LC, PC, BNB, GD, OD, AI and NP: contributed to case collection, and contributed to the writing of the manuscript. JMC: contributed to case collection and pathology review, and contributed to the writing of the manuscript. PZ and NBa: Contributed to the concept and funding of the study, and reviewed the final version of the Ms. All authors reviewed and approved the final version of the article.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/64/prepub