Supplemental Digital Content is available in the text Acute fatty liver of pregnancy (AFLP) is a serious disease with high mortality. Recent data suggest that postpartum application of artificial liver support therapy (ALST) in AFLP management improves disease outcome. In current study, we tend to further evaluate whether the type, the timing, and the number of postpartum ALST sessions and other clinical factors including complications and liver and renal function will influence disease outcome in ALST era.Medical records of 15 AFLP patients having postpartum ALST in our hospital from 2010 to 2016 were first retrospectively reviewed. A systematic review and statistical analysis was then conducted with our cases and those having postpartum ALST reported in PubMed, Embase, Cochrane, and ClinicalTrials.gov till the end of June 2016.Nine relevant studies were identified in the public databases. A total of 104 cases were enrolled for analysis including 15 cases from our hospital and 89 cases from the identified 9 studies. Univariate analysis revealed that 2 complications, postpartum hemorrhage and multiple organ dysfunctions (MODS), were associated with the outcome of AFLP patients undergoing postpartum ALST. Binary logistic regression analysis further indicated that MODS was the only independent factor affecting disease outcome. Surprisingly, factors including pre-ALST serum levels of total bilirubin and creatinine, the type and number of postpartum ALST sessions, time interval between delivery and ALST were unrelated to disease outcome.Current data suggest that postpartum ALST improves the outcome of AFLP patients but more properly designed experiments are needed to confirm this point. Our study further indicates that occurrence of MODS carries a bad prognosis even in ALST era. Our study provides valuable information on guiding the clinical application of postpartum ALST in AFLP management. It mostly occurs in the third trimester of pregnancy or during early postpartum period. Besides, other potential risk factors are also suggested by some studies including primipara, male fetus, and multiparous women.So far the pathogenesis of AFLP is not yet completely elucidated, but it is suggested that abnormal β-oxidation of fatty acids in fetal mitochondria that probably is caused by a genetic mutation in long-chain 3-hydroxyl coenzyme A dehydrogenase contributes to microvesicular fatty infiltration of the liver of mothers.,4–13 in clinic that includes plasma exchange (PE) and molecular adsorbent recycling system (MARS), etc. Since the first reported application of postpartum ALST in 1989 to treat a patient with advanced AFLP, ALST has been used as a postpartum therapy together with other liver-protective treatment methods for AFLP management. The effect of ALST is thought to occur by removal of circulating endotoxins, replacement of normal coagulation factors and proteins, interruption of coagulopathy, and finally improvement of liver function. Importantly, ALST as a form of short-term bridging treatment for nonpregnant patients with acute hepatic failure has been used for some years to allow liver regeneration or to transition between hepatic failure and orthotopic liver transplantation.,15 However, in clinical practice certain key questions regarding postpartum ALST in AFLP management still remain to be addressed, which include: When should ALST start after delivery? Is the type of ALST important? How many sessions of ALST should be carried out? Are there any other factors that may potentially influence disease outcome (recovered or deceased)? To study these questions, in this review we will first discuss 15 AFLP cases admitted into our hospital between the year of 2010 and 2016, and then performed a systematic review on the AFLP cases of ours and those reported in the public databases.In recent years, mortality of AFLP for both suffering mothers and infants has dramatically decreased due to better understanding of the disease and the implementation of new treatment modality, the artificial liver support therapy (ALST),22.1 As AFLP is a potentially fatal disease, all the patients diagnosed with AFLP had postpartum ALST. Depending on the disease status when the decision of starting ALST was made, all the patients received PE or MARS, or the combination of PE + continuous venovenous hemofiltration (CVVH) or MARS + hemodialysis.After approval by the review board of medical ethics of the First Affiliated Hospital of Nanchang University, medical records of 15 patients with the diagnosis of AFLP from 2010 to 2016 were reviewed. Diagnosis of AFLP for each patient was made through the combination of clinical, lab, and imaging findings, which were in accordant to the Swansea criteria.2.2The systematic review was conducted according to the PRISMA guidelines. A search was conducted in PubMed, Embase, Cochrane, and ClinicalTrials.gov in June 2016 using “acute fatty liver of pregnancy,” “pregnancy-related liver diseases,” or “fatty liver and pregnancy” as the searching keywords. Two investigators independently screened the titles, abstracts, and full texts for study selection and data collection. A third investigator was consulted whenever needed. Inclusion criteria were studies involving patients diagnosed with AFLP and treated with conventional methods plus ALST, and being published after 2006. Non-English publications were excluded. Year of 2006 was selected because this was the time when ALST, after several years’ development, became a more mature and routine method in clinic for the management of liver failure caused by various etiologies. Besides above public databases, reference lists and citations of the included studies were also manually searched to identify potentially eligible studies. Case–control studies, case reports, and retrospective cohort studies were included in the review. No randomized controlled trials or prospective cohort studies were found.,11,13,17 Data without complete information that could not be acquired from corresponding authors were excluded. Following data were extracted from selected studies that met the inclusion criteria: year of publication, number of patients in a single study, patient ages, gestational weeks, delivery method, maternal complications, time interval between delivery and ALST, type of and number of ALST sessions implemented, and fetal and maternal outcomes.To avoid duplication of included studies and collected data, names of authors and institutions and publishing dates of selected studies were compared. If relevant information we needed could not be obtained or derived from published data, attempt would be made to contact corresponding authors, but unfortunately no corresponding authors of those studies responded to our requests. These studies include those by Yu et al, Chu et al, Martin et al, Tang et al, and Naeyer et al.2.3t test or the rank-sum test. Qualitative variables were expressed as percentages and compared using either the chi-squared test or Fisher exact test. Binary logistic regression was used for the multivariate analysis.Statistical review of the study was performed by a biomedical statistician who is also one of the first authors of this manuscript. We first described the characteristics of all the cases both from our hospital and those retrieved from the databases. Quantitative variables that were normally distributed are expressed as mean ± standard deviation, and those that were abnormally distributed are expressed as median (interquartile range). We then examined the factors that may potentially influence disease outcome (recovered or deceased) with single variable or multivariate analysis. Quantitative variables were compared using either the Student 33.1The mean age of these 15 patients from our hospital was 25.6 years old (range 19–39), and their mean gestational weeks were 35.7 weeks (range 28–40.4). Most of the patients were primigravidas. Three patients had vaginal deliveries and the rest had cesarean sections. There were 16 fetuses born in total with 2 dead and another 3 having unknown fates . Depending on the status and progression of the disease, each patient received various number of ALST sessions . Eventually 4 patients died and the rest were discharged recovered  while other complications such as infection and coagulopathy were not . By logistic regression analysis, MODS was further found the only factor affecting the final outcome of the patients (recovered or deceased)  and creatinine (Cr) levels; maternal complications; time interval between delivery and ALST; type and number of ALST sessions used; and maternal outcomes were analyzed with all available studies. Via univariate analysis, we found that only complications, specifically multiple organ dysfunctions (MODS) and postpartum hemorrhage that is defined as the loss of more than 500 mL of blood within the first 24 hours after childbirth were statistically associated with the outcomes of the patients  contribute to the outcome of patients undergoing ALST?In recent years, ALST-including treatment strategy has saved many patients from AFLP induced liver failure. Among the 15 AFLP patients who underwent ALST in our hospital, 11 recovered and 4 died, and the mortality rate was 26.7%. Among the AFLP patients who underwent ALST in the chosen studies, 84 recovered and 5 died, and the mortality rate was 5.6%. Both mortality rates are significantly lower than that before the advent of ALST, which was about 85% in the 1980s, but it is unknown whether ALST can improve the outcome of patients with different complications, especially those with MODS. The pathogenesis of MODS in AFLP has not yet been fully elucidated. It is thought that MODS may be related to fatty acid metabolism disorder due to hormone level change in late pregnancy causing accumulation of large amounts of free fatty acids in liver, kidney, brain, and other organs and subsequent multiple-organ dysfunction. Results from other studies suggested that MODS be caused by excessive production of cytokines that were stimulated by endotoxemia in liver failure. MODS is fatal and the mortality rate is 80% to 90%. Our results indicate that ALST cannot improve the prognosis of MODS. Therefore, early intervention and prevention of MODS is essential in the management of AFLP.To address above questions, we analyzed the AFLP cases undergoing ALST from our own hospital and selected studies in the literature, and found that only complications, specifically, MODS and postpartum hemorrhage were statistically associated with patient outcome. Further analysis revealed that MODS was the only factor independently affecting patient outcome. Other factors including preoperative serum TB and Cr levels, time interval between delivery and ALST, ALST type and the number of ALST sessions were found not significantly related to patient outcome. We think that 2 possible reasons can explain these results: majority of AFLP patients survived with ALST-including treatment strategy, and the fact that MODS occurred in those demised patients also makes the type, timing, and number of ALST sessions contribute little to the outcome. Previous studies have indicated that occurrence of complications in AFLP would affect disease outcome, But these adverse reactions occur infrequently and are mild, and are insufficient to warrant discontinuation of ALST in AFLP management.,13It is worth of mentioning that some adverse reactions were observed/reported in certain patients having ALST. Some of our patients developed rash during the course of ALST, but the rash subsided after dexamethasone treatment. Other adverse reactions including acute pulmonary edema, bleeding, hypotension, fever, and hypocalcemia were reported in patients undergoing PE and CVVH.Our study also has some limitations. These include small number of published studies found in the public databases and incomplete retrieval of some information from certain selected studies. These limitations may to some extent affect the interpretation of our results, but considering very few cases of AFLP in clinic and our study so far being the only one investigating aforementioned questions, the results of our study provide important information on how to further improve the disease outcome with the implementation of ALST in clinical practice.In summary, in current study we investigated several key questions regarding the use of postpartum ALST in AFLP management via the method of systematic review. We found that ALST improved the outcome of AFLP patients although more properly designed experiments are needed to confirm this point, and MODS was the main independent factor affecting patient outcome even in ALST era. For that end, our study provides more knowledge on the clinical management of AFLP.Conceptualization: Wei Zou, Yi Gong, Junhui Wan.Data curation: Zhenping Wu, Wei Zou, Peng Huang.Validation: Peng Huang, Wei Zou.Writing – review & editing: Zhenping Wu, Wei Zou, Peng Huang, Yi Gong, Junhui Wan.Wei Zou orcid: 0000-0003-1274-7534


Age at first birth and cardiovascular risk factors in the 1958 British birth cohort. J Epidemiol Community Health 2017;71:691–8. doi: 10.1136/jech-2016-208196.Lacey RE, Kumari M, Sacker A, There is an error in table 1– part of the age at first birth information is missing for men.The categories for men should be:


Antenatal diagnosis of a fetal hepatic cyst is rare. Since in most cases the lesion is treated after birth by surgery only a few reports present a complete spontaneous resolution of an antenatally diagnosed hepatic cyst.A single hepatic cyst (1.34/1.47 cm) was diagnosed in a fetus at 36 weeks of pregnancy while mother was in labor. After an uneventful vaginal birth, a multidisciplinary evaluation of the newborn confirmed the presence of the cyst.Single hepatic cystPassive approach; periodic ultrasound monitoring of the cystThe latest ultrasound examination performed at 18 months of age confirmed complete resolution of the cyst. No other medical complications occurred before 18 months of age.The management of such a case depends on the cyst dimensions, the types of involved structure and could require urgent prenatal or neonatal treatment. In our case a complete spontaneous resolution of the hepatic cyst was achieved before 18 months of age. Depending on the dimensions of the cyst and the types of structure that are involved, the management of a hepatic cyst could require an urgent prenatal or neonatal treatment. Short-term complications could be enlargement, obstruction of intrahepatic biliary ducts, pericystic tissue necrosis, infection, and rupture. The malignant transformation is mentioned among long-term complications. The aim of our article was to present the case of a fetus diagnosed with a single hepatic cyst (1.34/1.47 cm) at 36 weeks of pregnancy that presented complete spontaneous resolution until 18 months of age.Although advances in technology have increased the accuracy of antenatal diagnosis of congenital liver anomalies, in utero diagnosis of a fetal hepatic cyst is uncommon. Most of the papers present case reports and series of case reports in which birth is followed by operative treatment.2A 17-year-old woman, gravida 1, para 0, came to our hospital in labor at 36 weeks of gestation for care at birth. Case history revealed that she had not attended any check-ups during her pregnancy. The physical examination showed a 60% to 70% effaced and 3-cm dilated cervix, the fetus had cephalic presentation, and amniotic membranes were intact. Fetal ultrasound showed an isolated anechoic hepatic cyst measuring 1.32/1.47 cm. The cyst was situated in the right anterior abdominal compartment between the gallbladder and the umbilical vein, and at that time it was not certain if the cyst was located in parenchyma or choledocal. Because of the position of the cyst, close to fetal abdominal wall, we suspected that it was a parenchymal cyst . The total bilirubin level was of 5.2 mg/dL, corresponding to the low-risk zone at 36 hours after birth, according to the Bhutani nomogram.The newborn was referred to the pediatric surgery unit, for further multidisciplinary evaluation. The evaluation by abdominal sonography confirmed the presence of a 1.6/0.93 cm intrahepatic cyst situated to the left of the gall bladder, without communication with the gall bladder or the common bile duct. The multidisciplinary team recommended periodic ultrasound monitoring of the cyst Figs. .The baby was reevaluated at 18 months after birth. Laboratory evaluation showed normalization of hepatic function panel and sonography showed complete resolution of the hepatic cyst Fig. .3 According to Carrim et al the prevalence of hepatic cysts in adults has increased to about 18% due mostly to improved quality of diagnostic imaging. The postnatal prevalence is around 2.5%, but prevalence for antenatal diagnosis has not been reported, since there are only a few cases described in literature.–9The overall prevalence of the cystic lesions of the liver is not known, as the majority of cases are asymptomatic. Differential diagnosis plays a key role in ruling out other pathologies when performing fetal and infant abdominal ultrasound examinations. Depending on the dimensions of the cyst and the types of structure involved, management of the cyst may require urgent prenatal or neonatal treatment.According to Paladini differential diagnosis of intrahepatic cysts should be made with: choledocal cyst, gallbladder duplication, or biliary atresia. The incidence is higher in females and the location is favorable to the right hepatic lobe.,2 Histological diagnosis of excised congenital hepatic cysts found columnar epithelium in newborns, while atrophic changes of epithelial lining were seen in older children.,3It has been hypothesized that solitary hepatic cysts are a consequence of failure of intrahepatic ductules to connect with extrahepatic duct during embryogenesis.,4 or cases exhibiting cyst enlargement.,6 Cysts were mostly excised via an open abdominal surgery.,4,5 For the antenatal approach, in utero percutaneous aspiration was reported. For asymptomatic and non-evolving cysts, a passive approach has been proposed. After a median follow-up of 44 months, Charlesworth et al reported that by using serial postnatal ultrasonography cyst diminution was showed in 4 cases, an enlargement in 1 case, and no dimensional change in 7 cases. Rogers et al reported that out of 5 cysts antenatally diagnosed under sonography surveillance, 4 decreased in size or resolved. More recently, Recinos et al have reported the resorption of an antenatally diagnosed cyst by the seventh month after birth. In our case, complete resolution of the cyst was observed at 18 months after birth.Postnatally, different evolution patterns have been described for antenatally diagnosed hepatic cysts. Several authors proposed, in postnatal period, cystectomy for cases with symptoms In adults, liver cysts have a good overall prognosis, and complications are rare.For asymptomatic hepatic cysts that do not change their size, long-term observation is required to monitor any changes in size or development of pressure symptoms, as noted in various studies.In conclusion, antenatally diagnosed fetal hepatic cysts, although rare, do occur. Yet, with the latest advances in imaging techniques, obstetricians are able to diagnose such anomalies during antenatal period, simply by performing a fetal ultrasound. The management of these cases depends on the dimensions of the cyst and the types of structure involved. In our case a complete spontaneous resolution of the hepatic cyst was achieved before the age of 18 months. No other medical complications occurred until this age.We extend our gratitude to the team in the Gynecology and Obstetrics unit as well as to the neonatologist and pediatric surgeons for their support and interdisciplinary approach.Conceptualization: Denis Mihai Serban.Investigation: Denis Mihai Serban.Writing – original draft: Denis Mihai Serban, Costela Serban.Writing – review & editing: Dan Navolan, Ioan Sas.


Beauty is the single most frequently and most broadly used aesthetic virtue term. The present study aimed at providing higher conceptual resolution to the broader notion of beauty by comparing it with three closely related aesthetically evaluative concepts which are likewise lexicalized across many languages: elegance, grace(fulness), and sexiness. We administered a variety of questionnaires that targeted perceptual qualia, cognitive and affective evaluations, as well as specific object properties that are associated with beauty, elegance, grace, and sexiness in personal looks, movements, objects of design, and other domains. This allowed us to reveal distinct and highly nuanced profiles of how a beautiful, elegant, graceful, and sexy appearance is subjectively perceived. As aesthetics is all about nuances, the fine-grained conceptual analysis of the four target concepts of our study provides crucial distinctions for future research. It is distinctive of the concept of beauty that is used in a very broad way, at least so in the Western tradition since Greek antiquity. On the one hand, it encompasses the sexual beauty of bodily looks and natural beauty in general ; on the other hand, beauty is also attributed to a great variety of cultural artefacts, including classical artworks and numerous objects of design. In the present study, we focus on three concepts each of which we expected to show great semantic overlap with the broader concept of beauty, while at the same time distinctly capturing special facets of beauty on the nature-culture continuum.The present article does not challenge this primacy of beauty. Rather, it is aimed at an eligere, to elect––one’s words [th century, the concept has increasingly come to be applied to multiple domains, including refined personal looks, many objects of design , movements, verbal articulation and argumentation, and to unexpectedly smooth solutions to difficult cognitive or technical problems  beauty pole, we selected the modern term “sexy.” To be sure, this term is not exclusively applied to natural bodily looks, but also to clothing and self-styling and hence to cultural ways of enhancing or highlighting physical sexual attractiveness. The term “sexy” has no tradition in modern philosophical aesthetics, as many, though by no means all authors Anmut) as “beauty in motion” Remarkably, across all major Germanic, Romance and Slavic languages, the Finno-Ugric languages, many Asian languages , and potentially beyond, words for “elegance” are lexicalized in phonologically convergent form, i.e., based on the Latin word “elegantia.” For “grace” and “sexy,” a similar adoption of the Latin words “gratia” and “sexus” applies across many languages, albeit not to the same degree. The successful migration of these terms into many other languages suggests that they capture special facets of aesthetic appeal that are salient, in however culturally varying form, across centuries and cultures.Our study is the first to comparatively analyze the four categories under scrutiny––beauty, elegance, grace, and sexiness––for their distinct perceptual, cognitive and affective implications that together make up their meaning. Specifically, it is aimed at elucidating, with high granularity, the mental constructs which individuals have acquired regarding beauty, elegance, grace, and sexiness. Linguistic concepts are reflective of mental constructs largely shared across linguistic communities, in some cases also across different languages and cultures. Our study tapped into these mental constructs using a variety of methods, including free associations, questionnaires and semantic differentials. We did not present any beautiful, elegant, graceful, and/or sexy stimuli in rating tasks. Rather, we exclusively targeted the very constructs that guide individuals when they end up perceiving and categorizing specific phenomena as beautiful, elegant, graceful, or sexy.For efforts aimed at contrasting hypothetical sub-types of a broader class of phenomena, the general category is the unmarked class. A focus on bringing out differences between our four categories may therefore be better served by placing a primary focus on one of the more circumscribed categories. Following this reasoning, our first study was primarily devoted to investigating characteristics of elegance. It opens its scope to also include beauty and sexiness only in the part which addresses the factor of age in attributions of beautiful, elegant and sexy personal looks.theory of elegance––, we resorted to well-established methods of investigating uncharted phenomena and concepts, such as free associations and semantic differentials . We designed a variety of open-format questions as well as scales and questionnaires aimed at elucidating which cognitive, emotional, and social characteristics are associated with elegant individuals and which features of movement and verbal performance are considered elegant. In this context, we also collected the very first data sets that directly compare perceived beauty, elegance, and sexiness in personal appearance.In the absence of a full-blown theory of elegance––in fact, of any Study 2 extended this comparison to a broad range of cognitive, affective, and social implications associated with all four target categories of our study. Informed by the primarily elegance-related results of Study 1 as well as by theoretical anticipations, we collected, in a between-subject design, ratings for beauty, elegance, grace, and sexiness, respectively, on 42 semantic differentials . Osgood and colleagues  introducthe classical domain of elegance, we also investigated to what extent contemporary individuals have a clear understanding of this type of elegance, too. To this end, we presented them with attributes that are often associated with verbal elegance.The first part of Study 1 consisted of a free association task: participants were asked to write down words that they associate with elegance. Association tasks of this type have been shown to provide access to conceptual affinities informing the meaning of a specific concept ,29. The Going beyond elegance only, we also asked our participants to indicate whether or not it is likely in their view that women and men, respectively, are perceived as beautiful, elegant, and/or sexy in predefined age ranges.M = 30.1, SD = 14.4, median = 24, min = 18, max = 77; for a histogram of the age distribution, see One hundred fifty individuals participated in this study  reported a monthly income of up to 1,500 EUR. 34% held a university degree or similar qualification; of the remaining participants, 56% held a secondary school diploma (Abitur). The age distribution and the data on the highest degree of education together indicate that the greater part of the sample had attended or were currently attending university.One hundred forty-six participants were native speakers of German, 20 of them bilingual. We report the results for all 150 participants, as excluding the four non-native speakers did not change the results. . All participants gave their written informed consent and received EUR 5 as compensation for their participation. All procedures of the study were approved by the Ethics Council of the Max Planck Society.https://osf.io/uqga9/) was presented on a computer in a lab room. In the free association task, participants were asked to write down between one and twenty words they associate with elegance.The questionnaire .how great a percentage of men and women of these age ranges they perceive as beautiful, elegant, and/or sexy, because we expected that this would be a fairly demanding question that could prevent our participants from making a quick, spontaneous choice. Still, as participants responded to the same task for all age ranges, we expected that the data should well be informative regarding relative differences in subjective perceptions of beautiful, elegant, and sexy personal looks dependent on age.In a next step, we asked our participants to indicate categorically for each of seven predefined age ranges whether or not they consider it likely that women and men, respectively, are perceived as beautiful, elegant, and/or sexy in these age ranges. We limited the lowest age range to the four years from age 16 to 19 in order to rule out that kids younger than sixteen years of age would need to be projected onto the mental template of sexual appeal. Above this age, we collected data for all decades from age 20 to 90. We did not ask Furthermore, participants were asked (1) to list public figures they find elegant, (2) to rate several experimenter-selected classes of objects regarding a) how frequently individual items in these classes are elegant, and b) the degree of elegance these objects can reach in their view, and (3) indicate their own personal habits and preferences regarding elegant clothing. The results regarding these questions are reported in the Supporting Information see .https://osf.io/uqga9/).The data and analysis scripts for Study 1 and 2 are available at Open Science Framework . We preprocessed the data by correcting spelling mistakes and by subsuming all nouns and adjectives of the same word stem (such as “beauty” and “beautiful”) under one category only. All in all, 1,699 associations and 816 words (637 after categorizing) were generated.On average, participants wrote down 11.3 associations  divided by the product of the Number of participants (= N) and the Mean List Rank of the terms (MLR): CSI = F/(N * MLR). The CSI is bounded between 0 and 1, with higher values reflecting higher salience of words for a conceptual domain [For the following analysis, we retained only the 43 words that were mentioned by at least 5% of the participants. Frequencies, mean list rank, and the Cognitive Salience index for these 43 predominant associations are reported in l domain .elegance most frequently and most saliently with beauty and grace. In contrast, our fourth target concept, sexy, was not listed at all. Aesthetics, style, svelte, clothing, and fashion followed next. Exploratory analyses of the data revealed a fine-grained, complex network of associations , harmony, calm and exquisiteness . For all these extraordinary virtues, elegance is still associated with simplicity. Three of these major characteristics of elegance––namely, fluency, lightness, and simplicity––represent key concepts, or synonyms thereof, of the processing fluency or ease of processing hypothesis of aesthetic liking [Entries include impressions of c liking ,34–37. Efashion, dress, evening gown, clothing, and suit), physical movement and posture , and personal looks . Even though men's suits are also listed, the data show a far stronger association of elegance with female  than with male looks.Entries focus particularly on fashion/clothing  passed the 5% cut-off we adopted for our analysis of the data.Even though art-related associations were listed far less frequently than those for personal elegance, the concept of elegance was associated with artistic achievements, too. However, only slender, delicate, thin, and at least mean height; for elegant men, athletic, slender, and tall are the most frequently expected features. Only between 0.0% and 6.7% percent of the participants associated an elegant physical build also (but by no means exclusively) with the experimenter-selected attributes corpulent, portly, plump and stocky. Ratings for delicate and athletic show the most pronounced dissociation between female and male elegance , the characteristics intelligent, eloquent, creative, witty), acquired cultural capital , social habitus  and social/professional success  , prosocphysical attractiveness stereotype, i.e., to the attribution of several personality traits dependent on physical attractiveness [These elegance-driven inferences can be considered an analogue to the tiveness –32. Of crelative differences in our participants’ spontaneous attributions of beauty, elegance, and sexiness (or absence thereof) to personal looks dependent on age, but not about absolute frequencies of such looks. The next target variable of our study was the factor of age. As explained in the Method section, the task was expected to yield information about p = .0003). Sidak-corrected post-hoc comparisons showed that significant gender differences were observed for sexiness attributions at some age ranges, with higher female sexiness at age 16–19 (p < .0001) and higher male sexiness at age 30–39 (p = .010), 40–49 (p < .0001), and 50–59 (p < .0001), but not for elegance (ps > .23) and beauty attributions (ps > .15) at any age.Logistic mixed-effects regression models predicted probabilities of responses in a full factorial design while accounting for non-independence of observations within participants due to multiple responses (the 90+ age category was omitted due to an empty cell). Probabilities of responses differed between attributes, age ranges, and gender  = 39.4, p < .0001; to beauty: p < .0001), and fairly high chances of being considered elegant extending even into old age. In contrast, elegance attributed to youths of 16–19 years is negligible , and remains significantly lower compared to attributions of beauty and sexiness  for the subsequent two decades. For the age range of 40–49, attributions of beauty and elegance show no significant difference anymore (p = .51), and sexiness attributions are significantly lower than those for elegance (p < .0001). Across all remaining age ranges, elegance attributions are significantly higher than those for sexiness and beauty (ps < .0001).At the same time, the data for sexiness and beauty attributions dependent on age-ranges are descriptively far more similar to one another than they are to those for elegance attributions. The latter reach peak levels only far later in age, with the ages 50 to 59 representing the very peak  largely converge with current (Western) ideals of physical attractiveness (beauty), elegance in personal appearance strongly deviates from the current idealization of beautiful youthful looks in one important respect: it is about culturally refined good looks not only of mature adults, but also of individuals in their advanced ages and even in very old age.Overall, results show a pronounced nature-culture difference across the three categories. The “sexy”-attributions for women reach earlier high levels than those for men, are equal for both sexes at the age 20–29, and then decline for both sexes, albeit far more rapidly and drastically so for women than for men. This distribution is likely to reflect differences in the age-ranges in which women and men, respectively, are biologically most likely to have off-spring and can hence be considered sexually “attractive” in a narrower meaning.not show any larger differences for women and men across all age ranges. This supports the assumption that beauty attributions to persons are clearly and markedly different from attributions of sexual attractiveness, even though they are likely to also entail aspects of natural physical beauty.It is all the more remarkable, then, how strongly beauty attributions depart from these biological constraints. The decline in beauty attributions is far less steep and swift than in sexiness attributions. Perhaps even more importantly, this decline does Regarding elegance, the difference to sexiness attributions is even more pronounced. The data for the likelihood of elegance attributions show even far higher absolute levels than those for beauty until very high age, and significant gender differences are not found in our data from age 30 onward. In this sense, elegance appears to the most cultural and the most “age-fair” type of beauty.Thus, as expected, sexiness and elegance attributions show the greatest dissociation, with beauty attributions covering the middle ground.well-spoken, poised, meticulously articulated, nuanced wording, rich in vocabulary, exquisite vocabulary, eloquent, precise in expression, sophisticated, correct, pointed, quick-witted, rich in imagery, and playful, and low for complicated, verbose, stilted, long-winded, and monotonous  for All data obtained in Study 1 were furthermore separately analyzed for differences dependent on the participants’ age and gender. Overall, the understanding of elegance was found to be very consistent and only marginally affected by these variables  participated in Study 2 . Three hundred seventy-one were native speakers of German; 67 were bilingual, 7 non-native speakers, and 1 undisclosed. Each participant gave ratings for one of the target concepts only. We excluded the data (a) of the 1 undisclosed and the 7 non-native-speaking participants and (b) of 8 participants who completed less than 50% of the ratings. Thus, we ended up with 430 valid datasets .Four hundred forty-six students with a mean age of 23.1 years . Participation was based on implicit rather than explicit informed consent; non-consenting individuals did not produce any data or did not return a questionnaire. We did not record this type of consent, in accordance with the rules for dispensing with recording/documenting informed consent that are stipulated in § C.III.6 of the Ethical Guidelines of the German Association of Psychologists . Based on intuitive and theory-based anticipations, co-occurrences in linguistic corpora, and the free associations of Study 1, we first collected 145 pairs of adjectives as candidate terms. The authors and colleagues (n = 6) rated these pairs with regard to the degree to which they might reveal differences between the concepts of beauty, elegance, grace, and sexiness. By selecting only those pairs that had a high mean and a low standard deviation in the ratings, we obtained 39 of the 42 adjective pairs listed in The data were collected at the end of several lecture classes  at Goethe University Frankfurt, Germany. Students were asked if they would volunteer to participate in the study, which only took a few minutes. They were explicitly informed about the task they were expected to perform , the anonymity of the data, the fully voluntary nature of their participation, and their right to withdraw from the study at any time. We handed out the questionnaire consisting of one sheet of paper only to those who volunteered and retrieved it after two minutes. No identifying personal information was obtained.We report analyses of the overlap and differences between all four categories on three levels of resolution. First, we looked at overall differences by calculating the mean absolute differences based on all ratings obtained for all semantic differentials as well as calculating MANOVAs for each pair of concepts. Second, we performed an exploratory factor analysis and calculated for each pair of concepts separate MANOVAs for the items making up the seven individual factors. Finally, we identified the respective individual differentials on which each target concept converges with, and diverges from, the other target concepts.The overall mean of the absolute differences across all 42 semantic differentials measured on 7-point scales are 0.442 (SD = 0.288) for beauty and elegance, 0.328 (SD = 0.243) for beauty and grace, 0.361 (SD = 0.349) for beauty and sexiness, 0.180 (SD = 0.130) for elegance and grace, 0.649 (SD = 0.417) for elegance and sexiness, and 0.562 (SD = 0.425) for grace and sexiness. Highlighting the role of beauty as a middle ground, the overall mean of the absolute differences between beauty and the other three categories are all within a narrow margin (ranging from 0.328 to 0.442). Comparing elegance and grace with sexiness yielded the highest mean differences , whereas elegance and grace show a particularly low mean of the absolute differences of only 0.180, and hence are barely distinguishable on our 42-item measure.F = 5.78, p < .001), followed by the difference of grace and sexiness  = 5.41, p < .001). The lowest difference was again found for elegance and grace  = 1.04, p = .42) and did not reach significance. The other three comparisons yielded levels of significant differences that cover the middle ground between these extremes: beauty and elegance  = 3.08, p < .001), beauty and sexiness  = 2.55, p < .001), and beauty and grace  = 2.21, p < .001).MANOVAs performed for pairwise comparisons of all target categories across all semantic differentials yielded a convergent picture. The highest significant difference was obtained for elegance and sexiness  using the R psych package . The oveIn accordance with the findings of the analyses of the mean absolute differences, MANOVAs  pairwise for differences and convergences on the level of all 42 semantic differentials. We did so by computing Bayes factors  –46 for emulti-colored, natural, and dreamy, and less refined, rigorous, elitist, disciplined, exquisite, expensive, exceptional, rich, svelte, and skillful. Beauty as compared to sexiness scores higher on the items soothing, delicate, fragile, feminine, simple, reserved, quiet, refined and discreet, and lower on the items libidinous, extroverted and hot. Beauty as compared to grace is conceived as more multi-colored, natural, down to earth, younger, and hotter, and as less elitist, rich, skillful, quiet, exquisite, disciplined, refined and exceptional. Given the close affinity of elegance and grace, it is not surprising––and highlights the consistent quality of our data––that the differences obtained for beauty and grace largely overlap with those for beauty and elegance.Looking at individual items, beauty as compared to elegance is conceived as being more arousing, less extroverted, less libidinous, less hot, less loud, less multi-colored, less natural, less robust, and more tasteful, more fluent, more fragile, richer, older, svelter, more elitist, more refined, more disciplined, more cultured, more exquisite, more rigorous, more expensive, more feminine and more delicate Regarding elegance and grace, positive evidence for differences was obtained only for four pairs: grace appears to be conceived as slightly less In sum, favoring Lord Kames’ definition of grace as “elegance in motion” over Schiller’s definition as “beauty in motion,” our results show a stronger affinity of grace with elegance than with beauty. At the same time, as both elegance and grace are closely related with beauty, Schiller’s definition is justified as well.feminine-masculine, with men rating sexiness as being more feminine and women as more masculine, and for tall-short, with women associating sexiness with greater body height  than men.Like in Study 1, we additionally performed separate analyses that tested all four concepts for gender differences. Results show no statistically significant difference; this holds both for each of the 42 semantic differentials when analyzed separately, and for their entirety , and simplicity for the mental construct of elegance strongly support the notion that the stipulations of the c liking  entail gIn sum, our data strongly suggest that it is time to put hitherto neglected concepts closely related to beauty––specifically, elegance and grace––on the agenda of research in aesthetics. Considering these nuances would help to prevent beauty ratings from being used as too broad and hence too vague a standard currency in empirical aesthetics. Importantly, our study provides concrete guidance as to which rating items could be used to collect multi-item measures of elegance, grace, beauty, and sexiness.The results obtained in our two studies exclusively reveal the current understanding of the four target terms in a Western cultural context. Specifically, the strong association with intellectual rigor and impressions of simplicity we found in our data for elegance is likely to be influenced by modernist reinterpretations of elegance as in Bauhaus architecture and design and the concomitant distancing from an aesthetics of ornament . ElegantOur questionnaire did not specifically target any negative attributions of personality traits that might also be associated with an elegance personal appearance. However, just like physical attractiveness research has revealed not only positive, but also some negative trait attributions dependent on perceived attractiveness Click here for additional data file.S2 Text(DOCX)Click here for additional data file.S3 Text(DOCX)Click here for additional data file.S4 Text(DOCX)Click here for additional data file.S5 Text(DOCX)Click here for additional data file.S6 Text(DOCX)Click here for additional data file.S1 Fig(PNG)Click here for additional data file.S2 Fig(PNG)Click here for additional data file.S3 Fig(PNG)Click here for additional data file.S4 Fig(PDF)Click here for additional data file.S5 Fig(PDF)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.S5 Table(XLSX)Click here for additional data file.S6 Table(XLSX)Click here for additional data file.S7 Table(XLSX)Click here for additional data file.


Between September 2016 and December 2017, Marie Stopes International Organisation Nigeria introduced the LNG IUS in 16 Nigerian states to increase method choice. Just under 1,000 devices were inserted, representing less than 1% of all long-acting reversible contraceptives provided. Qualitative feedback from opinion leaders, providers, and LNG IUS users found important benefits to users and suggested coordinated demand- and supply-side activities, including user champions and supportive providers to generate interest in the method, would be needed for successful scale-up. Between September 2016 and December 2017, Marie Stopes International Organisation Nigeria introduced the LNG IUS in 16 Nigerian states to increase method choice. Just under 1,000 devices were inserted, representing less than 1% of all long-acting reversible contraceptives provided. Qualitative feedback from opinion leaders, providers, and LNG IUS users found important benefits to users and suggested coordinated demand- and supply-side activities, including user champions and supportive providers to generate interest in the method, would be needed for successful scale-up. The levonorgestrel intrauterine system (LNG IUS) is one of the most effective contraceptive methods, and it has noncontraceptive health benefits, including treatment for women with heavy menstrual bleeding. In 2016, Marie Stopes International Organisation Nigeria (MSION) expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers in 17 states. Information about the LNG IUS was added to awareness-raising materials, and community mobilizers provided information on the LNG IUS alongside other voluntary family planning methods.In 2016, Marie Stopes International, MSION, and FHI 360 examined clients' and providers' experiences with the LNG IUS to assess the potential for further scale-up of the method as part of a comprehensive approach to family planning in Nigeria. A mixed-methods approach was used including analysis of routine service data, supplemental data specific to LNG IUS clients, and in-depth interviews with LNG IUS clients, providers, and key opinion leaders.Just under 1,000 LNG IUS were inserted from September 2016 to December 2017 in 16 states in channels supported by MSION, representing 0.4% of all long-acting and reversible contraceptive (LARC) services provided by the participating providers during this time frame. The vast majority (82%) of LARCs provided were implants. A small pool of providers was responsible for providing almost half of the LNG IUS services. Common reasons for women choosing the LNG IUS were reduced menstrual bleeding (61%), long-acting duration (52%), effectiveness (49%), and discreetness (42%). Almost 80% of the users first heard about the method from a provider. Almost all users and providers reported positive experiences with the method, noting the noncontraceptive benefits and fewer side effects compared with other methods. All providers who were interviewed said they would continue offering the LNG IUS. Several key opinion leaders mentioned a total market approach incorporating both public and private sectors would be needed to successfully scale up the LNG IUS.Reduced menstrual bleeding and fewer side effects compared with other methods were identified as important attributes of the LNG IUS by clients, providers, and key opinion leaders. Challenges to uptake of the LNG IUS include difficulty with introducing a new method within a busy service delivery infrastructure and limited awareness and demand-generation activities on the LNG IUS specifically. A comprehensive product introduction approach with coordinated demand- and supply-side activities may be required for this method to reach its full potential. Possible side effects include acne, headaches, breast tenderness, and weight gain.As part of the global Family Planning 2020 (FP2020) initiative launched in 2012, the government of Nigeria has committed to reducing unmet need for family planning and increasing modern contraceptive prevalence to 27% among all women by 2020,According to the 2013 Nigeria Demographic and Health Survey, the copper intrauterine device (IUD) comprised a small portion (5%) of Nigeria's overall contraceptive method mix,Small-scale LNG IUS introduction pilots led by several service delivery groups have been underway for some time in Nigeria. However, to our knowledge, this is the first formal research to be conducted about the experiences of LNG IUS users and providers within the country. Using evidence from MSION's LNG IUS program, this article aims to explore the perceptions and experiences of early adopters of the LNG IUS, LNG IUS providers, and key opinion leaders. The results identify both challenges and opportunities with method introduction and can help inform further introduction and scale-up of the method in Nigeria and beyond.MSION supports high-quality family planning counseling and a range of voluntary contraceptive services, including LARCs and permanent methods, through a network of delivery points across 33 states in Nigeria. In underserved rural areas, MSION expands the contraceptive choices available in public facilities by offering voluntary LARCs and permanent methods through 12 mobile outreach teams and by training public-sector providers in LARC provision, while in peri-urban areas MSION supports the BlueStar network of 253 social franchise clinics . In 2017, MSION provided more than 2 million voluntary family planning services (not including condoms or emergency contraception), of which almost 1 million were voluntary LARC services.The ICA Foundation donated 1,400 LNG IUS units to MSION between 2010 and 2014 (these were programmed through routine service delivery) and a further 3,000 units in 2016–2017. With this additional donation and with funding from the United States Agency for International Development (USAID) in 2016, MSION expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers. This period of expanded provision in 2016–2017 is referred to in this article as “the program.” Activities under the program included training 136 providers and 12 MSION supervisors on LNG IUS provision, generating awareness of the method among potential users via outreach by community mobilizers, and monitoring of service provision. Providers from 17 states across Nigeria were trained, with LNG IUS services ultimately delivered in 16 states. Social franchise clinics were selected that had high volumes of family planning services and an experienced family planning provider trained in provision of LARCs including IUDs, covering 13 states . Nine mobile outreach teams were included, covering 7 states . Public-sector providers were trained in 5 states . Marie Stopes International (MSI) and MSION partnered with FHI 360 to examine experiences with provision and use of the LNG IUS in these settings among both clients and providers during the program period, and to assess the potential for further scale-up of the method more broadly.Marie Stopes International Nigeria expanded LNG IUS provision in 2016 through training and support to mobile outreach teams, social franchise clinics, and public-sector providers.The providers selected for involvement in the program included a mix of nurses, midwives, and doctors. They took part in a 3-day training between April and November 2016 that covered history taking, general family planning counseling, steps on infection prevention, and demonstration of insertion and removal of the LNG IUS using models and practicing with clients who wanted the LNG IUS. Trainers or supervisors observed all providers inserting LNG IUS with clients, either during the training or during a follow-up observation in a facility, before reaching competency as determined by MSI global clinical standards. Technical competence was monitored during routine clinical follow-up visits every 2 months.Following the training, the LNG IUS was introduced alongside other family planning methods through mobile outreach teams, social franchise clinics, and public-sector providers supported by MSION. As with other contraceptive services, there was no charge for the LNG IUS provided through mobile outreach or at public-sector facilities. Social franchise clinics charged a consultation fee of 2,000 to 3,000 Naira (US$6 to $8) for LNG IUS services during the first year of the program, which was reduced to 1,500 Naira (US$4) in October 2017 to make the cost of the LNG IUS comparable with implant and copper IUD services, which range from 1,000 to 2,000 Naira (US$3 to $6).Information about the LNG IUS was added to existing awareness-raising materials, including flip charts and posters. In addition, community mobilizers already providing family planning information at the community level were trained to provide information about the LNG IUS, including duration of use, side effects, risks including conditions that might render the use of the method inadvisable, and effectiveness, as well as the noncontraceptive benefits of the method.Providers received a small number of products once they achieved competency and could request more as needed, with additional supplies delivered by MSION within 1 week of the provider's request. There were no reported LNG IUS stock-outs during the program. Since the end of the program in December 2017, MSION's trained providers continue to offer donated LNG IUS as part of a broader method mix.We used a mixed-methods approach to evaluate experiences with and attitudes toward the LNG IUS, drawing on different data sources, including routine MSION service data, supplemental data specific to LNG IUS clients, and qualitative in-depth interviews with LNG IUS clients, providers, and key opinion leaders . We alsoEthical approval was received from the Nigerian Institute of Medical Research, the MSI independent Ethics Review Committee, and FHI 360's Office of International Research Ethics.The research team used routine MSION service data on the number of family planning services delivered, which MSION collected throughout the program via paper forms at all facilities involved in LNG IUS introduction. We also collected supplemental data from LNG IUS clients at the time of service, through 4 mobile outreach teams and at 47 social franchise clinics, using paper-based questionnaires. The questionnaires included questions about women's reasons for choosing the LNG IUS, how they heard about the method, what method they would have chosen if the LNG IUS had not been available that day, and sociodemographic characteristics .MSION conducted client exit interviews with a sample of MSION clients after they received a service from MSION between November 8 and November 29, 2017, in order to capture sociodemographic characteristics. Client exit interviews are part of MSION's routine monitoring and evaluation activities and were not part of the study protocol; as such, they were not necessarily conducted at the sites where LNG IUS services were offered. We have included them to provide broad comparisons among LNG IUS users and other MSION LARC clients. For outreach, we conducted the client exit interviews in the same states as the LNG IUS rollout, plus Kano state. For social franchise, they were conducted in the same states as the LNG IUS rollout, excluding Anambra, Ebonyi, and Imo states.t tests as applicable. Descriptive data analysis was conducted using SPSS version 22,Our indicators of interest included the following: sociodemographic characteristics of LNG IUS users, why women chose to use it, what alternative method they would have used, and how they initially found out about the LNG IUS. Where appropriate, we explored differences by service delivery channel and with other LARC users, using chi-square (χ2) tests or Between March and October 2017, we interviewed LNG IUS clients and providers to document their experiences using and providing the LNG IUS, respectively, attitudes toward the method including advantages and disadvantages, and potential considerations for expanding access to the method. Semistructured interview guides were used for all interviews.A sub-sample of LNG IUS clients who had given permission to be contacted at the time of service was invited to participate in an in-depth interview 3 months after the clients received the LNG IUS. Interviews were conducted in person at a health facility convenient to the woman, in English and other local languages, based on the respondent's preference. We initially aimed to reach 40 to 50 women from across the delivery channels, estimating that these numbers would be sufficient to identify major themesProviders who were trained on provision of the LNG IUS and had provided the method in one of the participating facilities were similarly recruited via convenience sampling, with the aim of reaching 20 to 30 providers, assuming these numbers would be sufficient to identify major themes.We obtained informed consent from all participants before initiating the in-depth interviews. LNG IUS clients were compensated 2,000 Naira (US$6) for transportation costs. Providers did not receive compensation for participation. We audio-recorded all in-depth interviews (except for 2 client interviews and 1 provider interview in Edo state that were documented with detailed notes) and transcribed them, translating into English when applicable. We analyzed the in-depth interview data thematically using NVivo version 11,Between January and September 2017, we conducted interviews with key opinion leaders to document their perceptions of the LNG IUS and attitudes about opportunities and challenges associated with further introduction and scale-up of the LNG IUS more broadly within Nigeria. Key opinion leaders were identified by local FHI 360 and MSION staff based on their experience and expertise in the field of reproductive health in Nigeria and, in some cases, with LNG IUS provision. Seventeen interviews were conducted with individuals including representatives from government institutions, NGOs, academic institutions, donor groups, and procurement organizations. Opinion leaders who were interviewed did not receive compensation. All interviews were conducted in English either in person (n=15) or by phone (n=2). Four respondents declined to be audio-recorded; in these cases, detailed written notes of the interviews were taken. In all other cases, interviews were audio-recorded and transcribed. Results were analyzed thematically in Microsoft Excel by categorizing responses according to a framework based on themes from the interview guide.Between September 2016 and December 2017, the 9 trained mobile outreach teams, 76 of the 105 trained social franchise providers, and 7 of the 20 trained public-sector providers delivered 990 LNG IUS insertions. Almost all clients received LNG IUS services at either a social franchise clinic  or through mobile outreach . A small number received the method through participating public-sector facilities ; these cases are not included in the following analysis. The rate of voluntary uptake of the method was fairly consistent throughout the program period.Most  of the participating providers delivered fewer than 10 LNG IUS services during the 16-month program, while 9 providers (8%)  provided on average 58 LNG IUS services each (ranging between 24 and 89). These 9 providers delivered just over half (52.5%) of all LNG IUS insertion services.Most of the 115 providers in the program delivered fewer than 10 LNG IUS services, while 9 providers delivered just over half of all LNG IUS insertion services.LNG IUS services represented 0.4% of all voluntary LARC services provided by the participating mobile outreach teams and social franchise clinics that provided at least 1 LNG IUS service during this time frame: 0.7% among the social franchise clinics and 0.3% among the mobile outreach teams . The majSociodemographic data were available for 29.6% of LNG IUS clients (n=286), although some of these women did not answer all of the questions related to sociodemographic characteristics.According to this sub-sample, the mean age for LNG IUS clients was 34.0 years (standard deviation [SD]=6.5). Almost half  of LNG IUS clients in the sample were 35 years or older; 69.5% (n=146) of LNG IUS clients had completed secondary education or higher. The vast majority of LNG IUS clients in the sub-sample were married , and these LNG IUS clients had on average 4.4 children (SD=2.6) (n=272).df)=3, P=.000]); older ; and had more children . The vast majority of all clients were married, but LNG IUS clients were more likely to be married .MSION's 2017 client exit interviews were conducted with 692 LARC clients (91 IUD clients and 601 implant clients). To provide a broad comparison point, we compared client exit interview data with the service delivery data collected for LNG IUS users, and we found that the profile of the clients choosing LNG IUS (for whom we have sociodemographic data) differed in a number of ways from MSION's average LARC client profile. LNG IUS clients were more highly educated  of LNG IUS clients during the program period—from 47 social franchise clinics (285 clients), 4 mobile outreach teams (103 clients), and 3 public-sector providers (12 clients). The 12 clients from the public sector were not included in the analysis, leaving a sample of 388 cases in the analysis.LNG IUS clients were asked, after they had chosen the method, why they chose the LNG IUS . MultiplOne of the most cited reasons for choosing the LNG IUS at time of service delivery was the potential of reduced menstrual bleeding.The most commonly mentioned reasons for choosing the LNG IUS were: reduced menstrual bleeding (61.4%); long duration of effectiveness (“it lasts for a long time”) (52.0%); effectiveness (48.9%); and discreetness (“nobody will know”) (41.7%). Reduced menstrual bleeding was mentioned by 91.3% of mobile outreach clients but only 51.5% of social franchise clients.Women who chose the LNG IUS were asked what method, if any, they would have chosen if the LNG IUS had not been available (data not shown). The majority of clients who gave a response to this question (n=332) would have chosen another LARC : either a copper IUD  or an implant .Thirteen percent of clients (n=43) would have chosen a short-acting method and 3.9% (n=13) would have chosen a traditional method. Only 2 clients (0.6%) stated that they would have gone elsewhere for an LNG IUS, and 10 (3.0%) reported that they would not have used any method if the LNG IUS were not available.In a multiple-response question on the source of clients' information about the LNG IUS, with answers given spontaneously, most clients who responded to this question (n=347) mentioned first hearing about the LNG IUS from a health care provider, either on the day of service (54.4%), on another day (14.1%), or through a referral from another health care provider (11.0%) . Mobile We interviewed 33 women , 30 of whom were currently using the LNG IUS and had been for at least 3 months. Three had recently discontinued use. Sociodemographic information about the in-depth interview participants is shown in The most common reason given for choosing the LNG IUS was that a health care provider recommended it.They said it will work well with my body. I might forget to take the pills and I don't like injection. So that's why I prefer it. —User, age 28, 2 childrenSome women also chose the LNG IUS because they wanted a method that could help with heavy bleeding or fibroids.From what she [the provider] said, I prefer it, because it will control the bleeding and it also reduces the date [length of bleeding], because I told her, I have heavy flow for 7 days and she said it will reduce the flow. —User, age 30, 3 childrenShe actually told me that it reduces fibroid … I was diagnosed with multiple fibroids and I've been afraid of undergoing the surgery … so I started using this herbal method, it wasn't working, and then she [the provider] told me about this method, that it reduces fibroids, so that was why I had it inserted. —User, age 37, 1 childSome participants also chose the LNG IUS because they had negative experiences with other contraceptive methods.I had taken [the] injectable for 6 months but blood was coming out and it didn't stop at all. That's the reason I chose another one [type of method]. —User, age 34, 3 childrenI had a challenge with some that had a huge uterine fibroid … the LNG IUS couldn't sit in there so I had to send her for scanning … she ended up taking Jadelle [implants]. I wouldn't want to insert something that I wasn't confident of where I wanted it to be. —Provider, social franchise, EdoAll providers expressed confidence in their current ability to insert the LNG IUS; however, 13 of the 32 providers mentioned experiencing challenges, typically during their first insertion. Challenges included difficulty using the insertor, difficulty inserting in women with fibroids, forgetting to pull back the string, difficulty inserting in women with a small or anteverted uterus, and difficulty inserting when patients were not menstruating (because the cervix was perceived as being too tight). One provider indicated that she had carried out a total of 5 insertions:In general, method satisfaction was high among the current users interviewed, with all 30 saying they intended to continue using the method, and 28 stating they would recommend the LNG IUS method to their friends—7 of whom had already done so.Satisfaction was high among LNG IUS users, with all 30 who were interviewed saying they intended to continue using the method.I think after this one I will still insert it again, and I also encourage some other women to go for it, especially those that are having problems with other methods, I encourage them to go for this one. —User, age 43, 6 childrenWhen asked about perceived advantages with LNG IUS use, women most often mentioned that they liked not experiencing any side effects while using the method as compared with other methods. “It works well for my body” was a sentiment frequently cited by users.I'm comfortable, I like it, it does not give me any problem, not any health problem that some women will say—head pain, back pain, leg pain—all these things, I did not experience anything. —User, age 43, 6 childrenI am very okay with it. There is no excessive bleeding compared to the last one. It did just like they told us. I am satisfied 100%. —User, age 52, 4 childrenIn some cases, women were also happy that the method regulated or reduced their menstrual bleeding and that they did not experience any pain when using the method:Three women specifically cited the discreet nature of the method as a perceived advantage. Nine users had something negative to say about the method, including that they did not like the initial spotting that occurred post-insertion, being able to feel the string, and having irregular menstruation or amenorrhea.Of the 3 women who had discontinued use, 2 were due to involuntary expulsion and the third was not satisfied with the method's side effects, which, for her, included headaches, general body pains, and continuous bleeding.Provider perceptions of the method included clinical advantages, particularly for women with heavy bleeding or fibroids, the contraceptive effectiveness of the method, and the ability of the method to reduce menstrual bleeding and cramps.Providers liked the clinical advantages of the LNG IUS, including its contraceptive effectiveness and its ability to reduce bleeding, cramps, and fibroids.One of the advantages just as I've always said is bleeding, you know it has tendency to reduce menstrual flow … then also another advantage it has, especially those that did not take permission from their husband. You know when they do something inside, their husband will not know, I think that is another advantage. —Provider, mobile outreach, Nasarawa StateAll providers said they would continue offering the method. The main reasons providers cited for continuing to offer the LNG IUS were the method's noncontraceptive benefits, fewer side effects compared to other methods, and positive testimonies from clients.Number one is the report I have been getting from my clients. I will no more be getting those reports of “Madam, this thing is giving me bleeding” and if your client come to you like those, even those ones that are not coming for family planning, if you send somebody for scan and you are told that she has little, little fibroid, if you know this thing [LNG IUS] can help shrink it, you have solved her problem now. So, I will continue with it. I love this new method, I love it. —Provider, social franchise, AnambraMost providers had nothing negative to say about the method, as illustrated by a mobile outreach provider from Abuja: “It doesn't have any disadvantages. Rather it has more advantages.” Perceived disadvantages that were mentioned included the cost, mentioned by 2 providers, and bleeding changes, mentioned by 4 providers. Three providers mentioned expulsions of the method, particularly with their first insertions, as another disadvantage of the method.Among the 12 women who reported having reduced bleeding, most said they were comfortable with lighter periods. In some cases, women clarified that while they were happy with reduced bleeding, they would have been opposed to amenorrhea. Among the 7 women who reported amenorrhea, 2 were not happy with this change, but all others mentioned they were comfortable with not bleeding. These women noted that they were either counseled about the possibility of amenorrhea or they preferred not bleeding.With the method I had before, it comes for 5 days and it will be heavy but since I did this one it is very scanty, like blood stain on pants on the third or fourth day and it will not rush as usual. We have been told that there is no cause for alarm. … I have accepted it. It has no [negative] reaction in the body. —User, age 32, 4 childrenFor LNG IUS specifically, I think you also need to highlight the fact that it can play a significant role in reducing menstrual blood flow, which can be such a nuisance for many women.All of the key opinion leaders reported being familiar with the method before the interview. When asked what method attributes they believed would be most attractive to women, almost all mentioned reduced menstrual bleeding. For example, one key opinion leader said:Well, the product has its advantages … giving women the choice to make both contraceptive and noncontraceptive choices at the same time—killing 2 birds with 1 stone.Other attributes commonly mentioned included the method's long-acting duration, high effectiveness, noncontraceptive clinical health benefits, and reduced menstrual cramps and pain. One respondent noted:The insertion method through the vagina may not be acceptable to some groups of women, especially where there is the option of the less invasive implants.When asked about disadvantages and barriers to wider use of the method, the most common response was high commodity costs, mentioned by 14 of the 17 key opinion leaders. Other barriers frequently mentioned included a shortage of trained providers and heavy provider workloads, low availability of the method, and the invasiveness of the insertion procedure, especially compared with implants. For example, one key opinion leader said:Key opinion leaders acknowledged the advantages of the LNG IUS but also expressed concerns about high commodity costs of currently available products.The majority of key opinion leaders felt that demand for the LNG IUS would increase if new, more affordable products were introduced. For example, one said, “If it's made more affordable, yes, it will improve access and certainly uptake will increase.” However, several respondents indicated that price could remain a challenge relative to the copper IUD; for example, one respondent said, “The main barrier [with the LNG IUS] is the competition with copper IUD in terms of pricing.” Several key opinion leaders noted that many clients and providers have a preference for implants over copper IUDs, which could also influence demand for the LNG IUS.I don't think the reduction in price on its own can cause an increase in demand. I think the preference for implants generally over IUDs or intrauterine systems has much more to do [with other factors] than just the cost because the implants are much more expensive than copper T IUD but they are much more popular if you look at the uptake.When asked what segments of the population would be most likely to use the LNG IUS if new, more affordable options were available, the most common response was women who are seeking clinical benefits of the method, with 12 respondents mentioning this group.I think the niche for LNG IUS is for treatment of those menstrual abnormalities in addition to contraception.Recommended strategies to increase voluntary uptake of the method included health care provider training, demand creation, stakeholder engagement, and commodity security.The challenge is making sure that the providers are well trained, the method is available at all times, and the women are aware of it. … I think these are the challenges; once we solve them, there won't be any problem.If you use the total market approach, yes! It will thrive better in the private sector and social marketing sector—where women would want to pay for the services not necessarily where it is free. … And then to get the consensus of the government to include it within the basket of commodities available in the public health facilities, it will help to increase access to it.Several key opinion leaders noted the importance of expanding access to the method in both the public and private sectors:Key opinion leaders also acknowledged the importance of government involvement and support for scale-up of the method.It won't be widely available if it is only in the private sector, if it is not one of the products that the Federal Ministry of Health procures for distribution. … Only the government can actually scale up this and make sure that it is widely available.Just under 1,000 women in 16 states of Nigeria had an LNG IUS inserted between September 2016 and December 2017 by MSION-supported providers, representing less than 1% of the voluntary LARCs delivered by these providers during the time frame. This outcome was similar to results from a pilot introduction of the ICA Foundation product by Marie Stopes Kenya, which documented low uptake of the LNG IUS compared with other LARCs.LNG IUS insertions made up less than 1% of all voluntary LARCS delivered during the16-month time frame.There were also specific supply- and demand-side factors that may have limited LNG IUS uptake. One major challenge was that efforts to generate demand for LNG IUS were limited. Awareness-raising activities were integrated into existing materials and channels, and additional emphasis was not given to the LNG IUS, partly due to staff concerns about appearing to “promote” one method over another. This is reflected in the low proportion of users who had heard about the LNG IUS from community mobilizers or other awareness-raising activities. According to the 2017 MSION client exit interviews, 54.2% of MSION clients knew which method they wanted before coming for the service, demonstrating the importance of community-level awareness raising, especially for a new and lesser-known method such as the LNG IUS. Recommendations from friends and family played an important role for LNG IUS social franchise clients, with almost 40% hearing about the LNG IUS from friends or family, suggesting a valuable role for LNG IUS “satisfied users” in awareness-raising and demand-creation activities.Challenges related to generating demand for LNG IUS may have limited uptake of the method.On the supply side, a small pool of providers  were responsible for delivering almost half of all LNG IUS delivered during the program period. Further evaluation is needed to ascertain the extent to which this was due to provider-side factors  or environmental factors , but this finding is in line with other similar research, including an assessment of introducing postpartum IUD services (with the copper IUD) in Rwanda, which found that having engaged providers and managers was a critical factor for success.These and other similar findingsMost LNG IUS adopters reported that they would have chosen another LARC if the LNG IUS had not been available . However, 20% of LNG IUS adopters indicated that they would have used a short-acting or traditional method, or not used any method, if the LNG IUS had not been available. This is in line with findings from a study of LNG IUS users in KenyaThe addition of the LNG IUS to the family planning method mix may lead some women to switch from a less effective, short-acting method.The most cited reason for choosing the LNG IUS in the supplemental LNG IUS client data was the potential of reduced menstrual bleeding (61%). Reduced menstrual bleeding was cited as a reason for use by over half of social franchise LNG IUS clients and almost all (93%) of mobile outreach LNG IUS clients, a notable difference that is worth further investigation. This finding was also reflected in the qualitative interviews, where women frequently mentioned choosing the method because they were told that it could help reduce menstrual bleeding (as well as treat fibroids). Although most users who experienced reduced bleeding or amenorrhea were happy with the change, a small number were not. This finding is supported by Polis and colleagues (2018) who found that women's reactions to contraceptive-induced menstrual bleeding changes can vary widely.Overall, the majority of interviewed LNG IUS users reported positive experiences with the method. A perceived lack of side effects was the most frequently mentioned advantage. This finding is similar to results from qualitative interviews with Mirena users in Kenya, which documented that women's main reason for choosing the LNG IUS as their family planning method was the perception that the method had fewer side effects compared with other contraceptive methods.Several key opinion leaders noted the importance of a total market approach to product introduction, which would require support and engagement from the Federal Ministry of Health as well as a coherent strategy of introduction across the public and private sectors in order to maximize access for women. Most key opinion leaders felt that demand for the method would increase if more affordable products were introduced. However, all LNG IUS services under the MSION program were free or subsidized, and no change in uptake was seen during the 3 months when the price was dropped in social franchises. This suggests that product affordability alone, although an important prerequisite, will not be sufficient to generate voluntary LNG IUS uptake at scale, as discussed elsewhere.Our study had important limitations. Despite concerted efforts by MSION, the supplemental data specific to LNG IUS clients were collected by providers for only 38% of LNG IUS clients and were systematically missing for certain providers. Sociodemographic data were available for only 30% of clients. Furthermore, provider-collected data may be subject to bias as the user may offer the response they believe the provider wants to hear or may be unwilling to respond negatively.The target sample size for in-depth interviews of clients at mobile outreach and public-sector sites was not met. As a result, we addressed the general themes around the LNG IUS as developed in our protocol, but we were unable to draw comparisons across different channels. The low number of public-sector clients also meant that we were unable to offer insights on LNG IUS delivery through the public sector—an unfortunate gap because the public sector would be a key delivery channel for any LNG IUS scale-up.The client sample for both routine data and qualitative data was limited to those who had used the method, so we could not report on the perspectives of women who did not choose the LNG IUS. Similarly, the perspectives of women who had discontinued the method were not well represented in the sample of qualitative interviewees. Finally, the perspectives of the key opinion leaders interviewed may not be representative of other stakeholders' perspectives or adequately predict the potential of the method if it is scaled up in Nigeria.MSION's experience, along with feedback from the providers, LNG IUS users, and key opinion leaders, suggests that the LNG IUS has attractive benefits for users, but that without adequate demand-generation activities, supportive providers, and satisfied clients to generate interest, initial uptake may remain low. As such, a holistic and multi-stakeholder approach with an affordable product and coordinated demand- and supply-side activities, including cultivating a body of provider and user champions, may be required for this method to reach its full potential in Nigeria and other similar settings.


No significant complications were observed in the test rats during the experiment. The electroporated tissues exhibited apoptosis at 10, 24 and 48 h after IRE ablation. The apoptosis peaked at 10 h after IRE and then declined, suggesting that the ablated tissue rapidly recovered owing to intense metabolic activity. In addition, the electroporated tissues exhibited morphological changes such as pyknosis and karyorrhexis, while histological analysis showed that the blood vessels were preserved. Interestingly, electroporation greatly affected the mucosa and muscularis propria, but not the submucosa and serosa. This study suggests that IRE could potentially be used as a minimally invasive treatment for early gastric cancer that does not exhibit lymph node metastasis or dysplasia.Irreversible electroporation (IRE) is a newly developed non-thermal ablative therapy. During the IRE procedure, the permeability of the cell membrane is irreversibly changed by application of high-energy pulses across the tissue. This induces the breakdown of cell homeostasis, and thereby cell death. Here, we present an  These electrically induced pores remain in the lipid bilayer for milliseconds to seconds and thereafter are closed once the electric pulse transmission is stopped3. Drugs, genes, enzymes, and antibodies can be injected into cells through these transient pores and this technique is called reversible electroporation6. However, if the energy of the pulses across the cell membrane is increased above a certain electrical field threshold, irreversible pores are formed in the membrane—this is then called irreversible electroporation (IRE)7. IRE leads to disruption of cell homeostasis and thereby cell death, without affecting non-cellular components such as the extracellular matrix, blood vessels, and nerves9.Electric pulses externally applied to cells induce instability in the lipid bilayer of the cell membrane, followed by formation of numerous nanoscale pores through the membrane, thereby increasing the trans-membrane permeabilityet al.12 proposed that IRE could produce substantial tissue ablation and destroy undesirable tissues in the body, using mathematical and in vivo models, numerous papers have been published on the clinical applications of IRE. In particular, IRE has quickly pioneered a new type of cancer treatment, owing to it being an emerging, minimally invasive tissue ablation technology. Recent human pilot studies on malignancies have shown successful anticancer outcomes14. Moreover, the clinical use of IRE for ablation of breast, pancreatic, and brain tumours; blood vessels; and nerves has shown promising results in animal studies23.Since Rubinsky 24. Endoscopic resection is the treatment of choice if the early gastric cancer and absence of lymph node metastasis is amenable to resection25. However, endoscopic resection has several drawbacks, including the need for a highly skilled endoscopist, lengthy procedure, and occurrence of serious adverse events such as bleeding and perforation . These changes were significantly attenuated at 48 h through 24 h in comparison with those in the 10-h IRE samples  were purchased from Orient. Co. Ltd. (Korea). The animals were acclimatized to the environment by housing them at 22 ± 3 °C in light-controlled conditions (12-h light and dark cycle) for one week Fig. . The aniin vivo IRE ablation in the rat stomach, the rats are anaesthetized with isofluorane inhalation after medication with muscle relaxants. After skin preparation by shaving and decontamination with an iodine surgical scrub and 70% ethanol, the abdominal wall was dissected to visualize the stomach. Thereafter, two needle electrodes  made with stainless steel) with 10-mm separation were inserted into the stomach , 0-h group (n = 3), 10-h group (n = 3), 24-h group (n = 3), and 48-h group (n = 3). Each of them was sacrificed at their set times after irreversible electroporation.54.Twelve rats were divided into four groups: non-ablated control group (n = 3), 1 kV/cm group (n = 3), 2 kV/cm group (n = 3), and 3 kV/cm group (n = 3). Fifty direct current pulses of 100 µs width were applied with electric field strengths of 1, 2 and 3 kV/cm to investigate the IRE effectiveness of the applied electric field strengths. All rats were sacrificed at 10 h after IRE. These electrical parameters are known to be sufficient to induce IRE in gastric tissueIn Situ Cell Death Detection, POD kit , This method detects DNA fragmentation resulting from apoptotic signalling cascades by labelling the terminal end of nucleic acids. The slides for the TUNEL assay were imaged with an image acquisition system ), and the area coloured brown by TUNEL staining was then analysed via MATLAB  to quantify the degree of apoptosis in the region of interest.After IRE treatment, the stomachs were excised and fixed in 10% neutral buffered formalin for at least 24 h. We trimmed the tissues of the IRE-ablated and non-ablated areas. The non-ablated tissues were used as the controls. The tissues were embedded in paraffin and sectioned into 1-mm-thick slices, and then stained with haematoxylin and eosin (H&E) for histomorphological analysis. To verify apoptotic cell death caused by IRE ablation, terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assays were conducted using an 42. The electric field is calculated as the gradient of electric field potential.The applied electric field strength distribution is an important parameter to determine the tissue ablation by IRE. The steady state electric field distribution is obtained by solving the Laplace equation,V0 or 0. The remaining boundaries were considered to be electrically insulating TM  developed by open source application OpenFOAM for the above conditions.The boundary condition of tissue was defined as ∅ = 42:t is the time duration of the electric field application, n is the number of the pulses. The curve of points where the electric energy density is the critical value wc and is the ablated area’s boundary.The electric field is related to electric energy density and thus gives us information about the threshold strength of the electric field required to induce a apoptosis.The applied electric energy density is expressed ast test was applied to all data. Results were considered to be statistically significant when P < 0.05.Data were analysed using Microsoft Excel. Means and standard deviations were calculated. An unpaired two-sided student’s


Epicardial cysts are rarer benign tumors than pericardial cysts. There have been few reports on surgical management for epicardial cysts.A 73-year-old woman with dyspnea on exertion had a giant cyst (12 × 10 cm in diameter) on preoperative computed tomography. Compression of the left atrium and ventricle by the cyst was considered to be the cause of her symptoms. The cyst was diagnosed with an epicardial cyst intraoperatively. Although the cyst adhered to surrounding tissues, it was successfully resected with off-pump surgery by using a heart positioner and an ultrasonic scalpel.Surgeons should consider off-pump surgery as an alternative to video-assisted thoracoscopic surgery and on-pump surgery for complicated epicardial cysts. Pericardial cysts are uncommon benign tumors, which account for 7% of all mediastinal tumors , 2, and A 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected  was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have originated from the pulmonary artery Fig. . The conThe postoperative course was uneventful. CT confirmed absence of cyst recurrence or pericardial effusion. There has been no recurrence of the cyst since discharge (2 years).Histopathological examination revealed a single layer of mesothelial cells. In addition to blood and lymphatic vessels, calretinin-positive cells lining the cystic wall, alpha-smooth muscle actin-positive cells, smooth muscle negative for myoglobin, neuron-specific enolase positive cells, lymphocyte infiltration, and fibrosis were observed Fig. .Fig. 3a This report presented a rare case of an epicardial cyst attached to the left atrium and pulmonary artery. Preoperative differential diagnosis between a pericardial cyst and an epicardial cyst is challenging because they cannot be differentiated on CT . AlthougCoronary CT or angiography might be considered to obtain more information, especially with regard to the degree of adhesion and location of the coronary vessels. When coronary CT shows the involvement of coronary vessels, the need for coronary artery bypass grafting or CPB to resect the cyst should be anticipated; however, coronary CT and angiography may not always exclude the possibility of the involvement of coronary vessels preoperatively because some literature reported epicardial cysts with involvement of the coronary vessels and CPB requirement to resect those cysts despite negative findings on coronary CT or angiography –4. ConsiResection of an epicardial or a pericardial cyst should be considered when the cyst is symptomatic or infected or when it compresses other structures , 4. To pIn our case, on diagnosis of an epicardial cyst during the VATS procedure, we were concerned about adhesion of the cyst to surrounding structures, including the left ventricle, according to preoperative CT findings. In fact, adhesion to the pulmonary artery and left atrium was noted. In addition to median sternotomy, the heart was lifted aside using a heart positioner because the left ventricle was not involved and the cyst could be dissected from the heart using an ultrasonic scalpel without CPB. In hindsight, the cyst could have been resected with VATS; however, the less invasiveness of VATS was not considered beneficial enough to outweigh the risks associated with increased surgical complexity.Our case report highlights the feasibility of off-pump surgical resection for a complicated epicardial cyst. Adhesion of a cyst to surrounding tissues may make resection with VATS difficult. Although this condition is rare, surgeons should keep in mind that off-pump surgery is an alternative to VATS and on-pump surgery for an epicardial cyst attached to surrounding tissues.