Children with low birth weight show an increased prevalence of developmental defects of enamel in the primary dentition that subsequently may predispose to early childhood caries (ECC).Focusing 6–36 months old, the purpose of this study was to assess the frequency of enamel defects in the primary dentition and identify influences of early life course factors; socio-demographics, birth weight, child’s early illness episodes and mothers’ perceived size of the child at birth, whilst controlling for more recent life course events in terms of current breastfeeding and oral hygiene.A cross-sectional study was conducted in the high fluoride area of Manyara, northern Tanzania including 1221 child-mother pairs who attended Reproductive and Child Health (RCH) clinics for immunization and/or growth monitoring. After the primary caregivers had completed face to face interviews at the health care facility, children underwent oral clinical examination whereby ECC and developmental defects of enamel were recorded using field criteria. All erupted teeth were examined and the enamel defects were assessed on buccal surfaces according to the modified DDE Index.The prevalence of enamel defects was 33.3%. Diffuse opacities were the most common defects identified (23.1%), followed by hypoplasia (7.6%) and demarcated opacities (5.0%). The most frequently affected teeth were the upper central incisors (29.0% - 30.5%), whereas lower central incisors (4.3% to 4.5%) were least frequently affected. Multiple logistic regression analysis, adjusting for confounding the factors revealed that having normal birth weight  associated with lower odds of having enamel hypoplasia [OR 0.2 (95% CI 0.1-0.7)]. No statistically significant association occurred between birth weight and diffuse opacities, demarcated opacities or combined DDE.Children with the history of low birth weight were more likely than their normal birth weight counterparts to present with enamel hypoplasia. In view of the frequent occurrence of enamel defects and the fact that hypoplasia may constitute a risk factor for future ECC, enamel defects should be included as a dental health indicator in epidemiological studies of children in northern Tanzania. Developmental defects of enamel (DDE) in the primary dentition are visible deviations from the normal translucent appearance of tooth enamel resulting from damage of the enamel organ during amelogenesis . ClinicaStudies considering the prevalence and covariates of DDE vary considerably with respect to characteristics of the populations investigated, measurement aspects and study design utilized . This shth gestational week and completes its development 12 months after birth (second deciduous molar) [The amelogenesis of primary teeth starts in the 15s molar) ,15. The s molar) -18, nutrs molar) ,18, exces molar) ,17,19 ocs molar) ,20. In as molar) ,21-23. Is molar) .Although evidence suggests that DDE are important risk factors for dental caries in the primary as well as the permanent dentition, population based studies considering its prevalence and early life course determinants are scarce, especially in economically less privileged samples of developing countries. Focusing 6–36 months old in Manyara region, Tanzania, the purpose of this study was to assess the frequency of enamel defects in the primary dentition and identify influence from early life course factors; socio-demographics, birth weight, child’s early illness episodes and mothers’ perceived size of the child at birth, whilst controlling for more recent life course events in terms of current breastfeeding and oral hygiene.The study population comprised all child- caretaker pairs attending the Reproductive and Child Health (RCH) care facilities in Haydom Lutheran Hospital (HLH) and its 20 mobile outreach community service sites in Mbulu, Hanang and Babati districts of Manyara, Northern Tanzania, from August 2010 to January 2011. The community outreach posts are not health facilities but may be in any building available in the respective villages. According to the 2002 population and housing census in Tanzania, the HLH RCH outreach programme covered 6 out of 54 villages in Hanang, 3 out of 81 villages in Babati and 12 out of 70 villages in Mbulu, serving respectively, 4790, 1538 and 7910 children below 5 years of age . During An interview schedule was constructed in English and translated into Kiswahili, the main language in Manyara. Kiswahili is the national language in Tanzania spoken proficiently by almost 95% of the population. The interview schedule was translated in several steps; from English into Kiswahili by bi-lingual Kiswahili/English professionals, and then back translated to English by independent translators. Project professionals in the field reviewed the interview schedule for semantic, experiential and conceptual equivalence to the original version. Sensitivity to culture and selection of appropriate words were considered. The interview schedule was piloted and administered in face to face interviews with primary caretakers before their children underwent a full mouth oral clinical examination.A theoretical model adapted from the work of Zhou et al. , guided st quartile (least poor) to the 4th quartile (poorest).Socio-demographic and socio-economic characteristics were assessed in terms of age and sex of the child and caregiver, level of mother’s education and household index. Primary caregiver’s age was recorded in years and a dummy variable was constructed as; (0) ≤ 24 years old, (1) ≥ 25 years old. Mother’s education was assessed by asking; “What is the highest level of school you have attended?” Responses were given as (0) No formal education, (1) Did not complete primary school, (2) Completed primary school, (3) Secondary, (4) Completed Secondary, (5) College/University. A dummy variable was constructed 0= lower education  and 1= at least primary education . Family wealth was assessed as an indicator of socio-economic status according to a standard approach in equity analysis [Early childhood developmental factors were assessed in terms of mother’s perception of child’s size at birth, actual birth weight and childhood illness episodes. Perceived child size at birth was categorized in terms of (0) smaller than average (1) average (2) larger than average?” Birth weight of each child was obtained from birth certificate or immunization card and a dummy variable was constructed according to the World Health Organization (WHO) definition  as; (0) Clinical oral examinations were conducted by a trained and calibrated dentist (RM), whereas trained assistants recorded the observations. Calibration exercises for the examiner with respect to early childhood caries were carried out according to the guidelines published by British Association of the Study of Community Dentistry (BASCD) . ChildrePredictive Analytics SoftWare, IBM SPSS Statistics, version 18 was used for data analysis. Univariate analyses were performed by use of chi-square statistics. A probability value of p<0.05 was considered statistically significant. Step wise multiple variable logistic regression analyses with odds ratios (OR) and 95% confidence intervals (CI) were used to identify early life course determinants of DDE and enamel hypoplasia. Moreover, Poisson regression with robust variance, rate ratios (RR) and 95% CI was calculated. Since using dummy variables run the risk of losing information, results from logistic regression analyses were checked using Poisson regression with count variables.A total of 1221  caregiver/child pairs participated in this study corresponding to a response rate of 97.7%. Totals of 49.1% of the children investigated were females and the mean age was 18.4 months (sd 7.7). About 18% had a history of low birth weight and 60% were currently breastfed. Table To avoid inter examiner inconsistencies, clinical examination was carried out by one trained and calibrated dentist (RM). The calibration for scoring all types of developmental defects (DDE) was conducted with photographs of the DDE index FDI, 1992) and, the agreement between examiner and the gold standard amounted to Cohen’s kappa 0.82. During the field work, duplicate examinations 3 weeks apart were performed with 80 child-caregiver pairs randomly chosen. Intra examiner reliability in terms of Cohen’s kappa for enamel hypoplasia on the tooth level ranged from 0.91 to 0.97, respectively. Test-re test was not performed for demarcated opacity and diffuse opacity. The total prevalence of enamel defects (DDE >0) amounted to 33.3%. As shown in Table  and, theAccording to unadjusted analyses, sex and age of child, perceived size of child at birth, household assets, current breast feeding and presence of visible plaque in upper anterior teeth were statistically significantly associated with enamel defects Table . MoreoveAll socio-demographic-, behavioral- and developmental variables that were statistically significantly associated with DDE and hypoplasia in the bivariate unadjusted analyses Table  were incThere is a lack of population based studies emanating from developing countries that consider developmental enamel defects in the primary dentition. To our knowledge this study is the first to estimate the frequency and early life-course determinants of enamel defects among 6–36 months old children attending RCH clinics for growth monitoring and immunization purposes in northern Tanzania. A substantial frequency of total enamel defects, amounting to 33%, was estimated. This frequency falls within the range of 24-49% reported in the primary dentition of children in developed countries ,13. NotaIt should be noted that although there is multiple factors that may cause enamel defects, its clinical appearance is often non-specific leading to difficulties in the diagnosis. Thus, diffuse opacities of enamel are the feature distinguishing the teeth of children living in low and high fluoridated areas . The levSocio-economic status of the family and early childhood infectious diseases have been associated with increased enamel defects in the primary dentition ,18,35. SIn spite of some limitations of this study, such as use of very few early life events and a cross-sectional design, the latter making conclusions about causal effect impossible and a reversed causality an option, there are strengths to emphasize. Data on birth weight was taken from the birth certificates, thus avoiding bias related to parental self-reported information and recall. Notably, comparisons of the results with other studies available in the literature must be done with caution due to differences in sample delineation, environmental influences (fluoride) and methodologies. Maternal disorders recognized to be the primary causes of prematurity and low birth weight, such as hypertension, preeclampsia, gestational diabetes and cardiopathy were not considered in the present study. Since only 22.9% of the primary caretakers made the birth card available – this loss might have resulted in biased estimates of the association between birth weight and enamel defects. The fact that the oral examination was not performed in a dental clinic may have reduced the true frequency of DDE and the tooth drying technique utilized may have confounded opacities and white spots caused by demineralization.Considering the methodology of this study it can be concluded that there was a moderately high frequency of enamel defects in the total sample that increased with age and was less common in girls than in boys. Most developmental defects observed presented as diffuse opacities, whereas the frequency of hypoplastic enamel defects was less substantial. However, low birth weight children had a higher risk of presenting with hypoplastic defects compared with their normal birth weight counterparts. In view of the frequent occurrence of DDE and the fact that enamel hypoplasia constitutes a risk factor for future ECC, enamel defects should be included as a dental health indicator in epidemiological studies of children in north eastern Tanzania.The authors declare that they have no competing interests.RM: principal investigator, designed the study, collected the data, performed the statistical analyses, and wrote the Manuscript. AB: participated in the design of the study and provide valuable guidance in the data collection and has been actively involved statistical analyses and writing the manuscript. AN: main supervisor, designed the study, guided the statistical analyses and writing the manuscript. All authors have read and approved the final manuscript.RM: PhD candidate, University of Bergen. AB: Professor, Department of Clinical Dentistry, University of Bergen, Norway. AN: DDS PhD, Professor, Department of Clinical Dentistry, Community Dentistry, and Centre for International Health, University of Bergen, Norway.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6831/13/21/prepub


Objective. To study mode of birth, perinatal health and death in children born to mothers with intellectual disability (ID) in Sweden. Design. Population-based register study. Setting. National registers; the National Patient Register linked to the Medical Birth Register. Sample. Children of first-time mothers with ID  were identified and compared with 340 624 children of first-time mothers without ID or any other psychiatric diagnosis between 1999 and 2007. Methods. Population-based data were extracted from the National Patient Register and the Medical Birth Register. Main outcome measures. Mode of birth, preterm birth, small for gestational age, Apgar score, stillbirth and perinatal death. Results. Children born to mothers with ID were more often stillborn (1.2 vs. 0.3%) or died perinatally (1.8 vs. 0.4%) than children born to mothers without ID. They had a higher proportion of cesarean section birth (24.5 vs. 17.7%) and preterm birth (12.2 vs. 6.1%), were small for gestational age (8.4 vs. 3.1%) and had lower Apgar scores  compared with children born to mothers without ID. Logistic regression adjusted for maternal characteristics confirmed an increased risk of small for gestational age (odds ratio 2.25), stillbirth (odds ratio 4.53) and perinatal death (odds ratio 4.25) in children born to mothers with ID. Conclusions. Unborn and newborn children of mothers with ID should be considered a risk group, and their mothers may need better individual-based care and support. Newborns of mothers with intellectual disability are a risk group. They have a higher risk of being small for gestational age and of stillbirth and perinatal death compared with newborns of mothers without intellectual disability or any other psychiatric diagnosis.Few studies have described newborn health in children born to mothers with intellectual disability (ID), and knowledge regarding this topic is limited. According to the World Health Organization, ID is defined as an intelligence quotient below 70 and a reduced adaptive capacity that appears before 18 years of age ,3; howevThe aim of this study was to describe mode of birth, preterm birth rates, Apgar scores, the incidence of being small for gestational age (SGA), stillbirth and overall perinatal death in children born to mothers with ID in comparison to children born to mothers without ID or any other psychiatric diagnosis.http://www.socialstyrelsen.se/register/halsodataregister/patientregistret/inenglish) and the Medical Birth Register (MBR)  8–10, chapter V , was identified from the National Patient Register (no women were excluded). The group of women with ID was limited to women with an ID diagnosis and did not include women with syndromes, neuropsychiatric diseases or other psychiatric diagnoses. This sample was linked to the MBR at the National Board of Health and Welfare to identify women with ID who gave birth between 1999 and 2007. A comparison group included all other women who had given birth during the same period, excluding those with any psychiatric diagnosis. Women with ID were younger (mean age 24.2 vs. 28.3 years), with a higher proportion of teenagers (58.6 vs. 22.4%), were more obese (20.1 vs. 8.6%) and smoked more during early pregnancy (27.9 vs. 7.9%) than those without ID. The prevalence of smoking decreased over time in the ID group, from 33.8 (1999–2001) to 33.0 (2002–2004) and then to 19.5% (2005–2007). Other variables included in the analysis were not cohabiting with the child's father at the time of registration (36.6% of mothers with ID vs. 6.2% of those without ID), not working at the time of registration (54.1 vs. 14.3%) and epilepsy (5.5 vs. 0.4%).p = 0.038), for which the difference between groups did not remain significant when the sample was reduced to first-borns of primiparous mothers. We chose, however, to analyse the more stringent sample to avoid the influence of parity on the main outcome variables. Preterm birth was defined as a birth before 37 completed weeks of gestation. Small for gestational age was defined as a birthweight and/or birth length of at least two standard deviations below the mean for the infant's gestational age. Stillbirth, according to the Swedish Act before 2008, was defined as an infant born after 28 completed weeks of gestation without signs of life at and after birth. Perinatal death was defined, according to the Swedish convention at the time, as death near the time of birth, from 28 weeks of gestation to one week postnatally. Neonatal death was defined as a child dying in the first 28 days of life. Body mass index  was based on height and weight. For the non-pregnant population, a BMI ≤ 24.9 kg/m2 was categorized as lean and normal, a BMI of 25.0–29.9 kg/m2 overweight and a BMI ≥ 30 kg/m2 obese.Information on single-born children to mothers with ID and to mothers without ID or any other psychiatric diagnosis was obtained from the MBR. The data set extended from 1999 to 2007 and included 505 children born to mothers with ID and 525 664 children born to mothers without ID. To allow a more stringent comparison, only first-born children (those whose mothers were primiparous) were selected, resulting in 326 children born to mothers with ID and 340 624 children born to mothers without ID. The newborn health outcome pattern was the same for both the total sample (505/525 664 and the selected study sample (326/340 624), except for congenital malformations . Variables that differed significantly between groups in a univariate analysis were inserted into a binary logistic regression analysis. To reveal associations with Apgar score <7 points at five minutes, prematurity, SGA, stillbirth and perinatal death, we used unadjusted binary logistic regression and binary logistic regression adjusted for the effects of maternal characteristics and birth outcome, such as age, BMI, cohabitation with the child's father, working, smoking, epilepsy and cesarean section (CS). Age was used as a continuous variable.Statistical analyses were conducted with the Statistical Package for the Social Sciences (SPSS) 15.0 software program for Windows. Descriptive statistics were used to describe the frequencies of all variables presented. The differences between the case cohort and the control cohort were analysed using the chi-squared test. A significance level of A greater proportion of children born to mothers with ID than children born to mothers without ID were born by CS  than those born to mothers without an ID (3.1%). We also found an association between SGA and older maternal age, not living with the child's father, unemployment, CS and smoking. Prenatal smoking has previously been reported to increase the risk of SGA (odds ratio 3.08) . MaternaIn the present study, there were no data about alcohol or substance abuse other than tobacco among the mothers. It is likely that women with ID live in more deprived settings, which could lead to alcohol and/or substance misuse. Moderate to severe predelivery depression, anxiety and stress among mothers with ID were inferred in an Australian study , and matApgar score at one minute was not shown to differ between children born to women with ID compared with those born to women without ID . Our stuThe maternal characteristics and the mode of birth in children born to women with ID increase the risk for low Apgar score and preterm birth. Together with an increased risk of low birthweight, it is more likely that there will be complications for the infant and more frequent admissions to a neonatal intensive care unit with such issues as dyspnea, temperature drops, infections, cramps, and difficulty with breastfeeding and bonding with the mother. A recent study from the UK  stated tIn general, antenatal care attendance in Sweden is very high. Roughly 90% of pregnant women have made an initial antenatal visit within the first 12 full pregnancy weeks . A strenThe women with ID were identified in the National Patient Register, which means that they have a registered facility care or out-patient care on some occasion. They are therefore a clearly defined sample, but there may be other mothers with ID not registered in the National Patient Register, and we cannot claim that our sample is representative for all women with ID in Sweden, because it probably consists predominantly of women with mild ID. We had no data about the underlying causes of ID or its degree of severity. It has, however, been reported that women with a mild ID more often have children than women with a moderate or severe ID . We haveIn conclusion, unborn and newborn children of mothers with ID have a higher likelihood of perinatal death or being SGA. The children are more often born preterm and by CS. These pregnant women and their newborns should therefore be considered a risk group. Furthermore, we believe that there is a need to increase the knowledge and skill of health professionals caring for mothers with ID to enable healthy choices during pregnancy for these women, to enhance their preparedness for birth and their ability to care for the newborn child.


EHP 120(2):284–289; Kippler et al.].Chronic exposure to cadmium, which primarily occurs through diet and smoking, damages the kidneys, weakens bones, and may increase cancer risk. The metal is also an endocrine disrupter and may adversely affect reproduction and child development. Animal studies indicate cadmium induces multiple defects in developing embryos, but it is unknown whether similar effects occur in humans. However, a new study shows that maternal cadmium exposure is associated with reduced head circumference and birth weight in newborn girls [The study used data collected from more than 1,600 pregnant women participating in the Maternal and Infant Nutrition Interventions, a food and micronutrient supplementation trial in Matlab, Bangladesh. The women provided urine samples and completed clinical examinations in early pregnancy. Information on demographics and tobacco and betel use during pregnancy also was collected, along with newborns’ sex and physical measurements.Average adult daily intakes of cadmium were estimated on the basis of rice consumption to be 25–35 µg, similar to those in other Asian countries where rice is a staple but higher than levels reported in U.S. and European women. Statistical analyses, controlled for confounding by maternal, birth, and newborn factors, suggested that for each 1-µg/L increase in maternal urinary cadmium, head circumference decreased by 0.26 cm and weight dropped by 45 g on average among newborn girls. Far smaller associations were seen for boys.Cadmium may affect fetal growth by several mechanisms, including impaired nutrient transport and endocrine disruption. Sex-based differences in specific hormone levels as well as in cadmium uptake and mechanisms of action—which have been reported in experimental studies—may have played a role in the current findings. The authors say the estimated average reductions in head circumference and weight are unlikely to be clinically significant for individual children but could have public health implications given widespread dietary cadmium exposure and adverse effects associated with reduced birth size.The main strengths of the study are its prospective design, large number of participants, wide range of exposure, and consideration of numerous confounding factors. However, the potential for unmeasured or residual confounding remained, as in all observational studies, and infants’ cadmium exposure was not directly assessed . Continuing research should follow the children to determine if growth effects are sustained through childhood and whether other health changes appear later in childhood.


A 63-year-old white man presented with a raised, erythematous tumor on the left side of his nose. The lesion had been present for 3 years, and during the 6 to 8 weeks prior to his presentation, it had become painful. In addition, the cyst had started to drain purulent material when pressure was applied. On physical examination, the tumor was 20 mm in diameter and elevated 5 mm. There was a central punctum and was tender to palpation.What is the differential diagnosis for the patient's lesion?Is malignant transformation of an epidermoid inclusion cyst common?What are potential exacerbating factors leading to malignant transformation?What are the recommended studies after excisional biopsy of such a lesion?The differential diagnosis for this patient's facial lesion included an epidermoid inclusion cyst, an abscess, cellulitis, and a lipoma. After excision, microscopy demonstrated a squamous epithelium-lined cyst with a granular layer (infundibular keratinization), laminated keratin, and keratinous debris. The cyst wall in the deep part of the cyst was thickened, but was benign. Originating from the acanthotic cystic wall is well-differentiated squamous cell carcinoma (SCC), showing keratin pearls and significant cytologic atypia. There was a clear-cut transitional zone between the benign cyst wall and the SCC, allowing distinction from cystic SCC, which shows malignancy with cystic degeneration. The squamous cell carcinoma was observed to extend to the peripheral and deep resection margins in relation to the deep dermal location of the cyst. The patient's clinical and histological findings were most consistent with an epidermoid cyst that had undergone malignant transformation.–1,1,3,4,Epidermal, or inclusion, cysts are frequently benign lesions lined with stratified squamous epithelium. Malignant transformation is an uncommon occurrence. Malignant transformation ranges from 0.011% to 0.045%.1,1,1Chronic irritation and actinic damage have been proposed as exacerbating factors leading to malignant transformation of the existing lesions.3Although uncommon, malignant transformation of the epithelium in an epidermoid inclusion cyst is a possibility in even benign-appearing lesions. Therefore, it is recommended that excisional biopsy of any such lesion should include histological examination for potential carcinomatous changes. If the margins are not clear of such carcinomatous changes, then reexcision with wide local margins must be undertaken. Fortunately, even when malignant change is encountered, metastasis is rare; thus, surgical excision with wide margins is usually sufficient.


We describe a new technique to prevent spillage of cyst fluid in patients undergoing surgery for cystic ovarian tumors. The cyst is first covered with a sterilized surgical sheet applied with quick-drying glue and is then punctured. This technique completely prevents spillage of cyst fluid into abdominal cavity. Spillage of ovarian cyst fluid during surgery is associated with a number of risks, including chemical peritonitis, gliomatosis peritonei, pseudomyxoma peritonei, tumor recurrence, and dissemination of malignant cells –6. Sever®). After wiping the surface of the tumor located just under the wound with gauze, the rough side of a sterilized surgical sheet (ELS-102S) is attached to the cyst using quick-drying glue (Aron Alpha A <Sankyo>®) with careful attention not to spread the glue into the abdominal cavity  and magnetic resonance imaging (MRI) revealed a 33 × 25 × 15 cm multiocular ovarian cystic tumor without calcification or fat tissue Fig. . The hisA 5-year-old girl with abdominal pain was diagnosed with torsion of a 7.5 × 7.3 × 4.7 cm ovarian tumor on CT. Neither ascites nor dissemination was apparent. She was referred to our hospital and underwent emergency surgery. We made a 3 cm Pfannenstiel incision and punctured the cyst using a needle connected to a suction after covering the surface of the tumor with a sterilized surgical sheet, applied using quick-drying glue. After aspiration of about 140 ml of serous cyst fluid, we performed a cystectomy, preserving the healthy ovarian tissue without spillage of cyst fluid. The histopathological diagnosis was a mature cystic teratoma. She was discharged without any complications on the fourth postoperative day.A 14-year-old girl with inferior abdominal pain was found to have bilateral multiocular ovarian tumors  on CT and MRI. Physical examination showed a distended abdomen, but there were no complaints. Mature cystic teratomas were suspected, and operation was performed. We made a 6 cm Pfannenstiel incision and punctured the cyst using a S.A.N.D. balloon catheter after covering the surface of the left large cystic tumor with a sterilized surgical sheet, applied using quick-drying glue. After we aspirated about 940 ml of yellowish, turbid cyst fluid (Fig. A 13-year-old girl with inferior right abdominal pain was found to have a 16 × 12 × 9.0 cm right multiocular ovarian tumor on CT. Mature cystic teratoma was suspected, and operation was performed. We made a 4.5 cm Pfannenstiel incision and punctured the cyst using a S.A.N.D. balloon catheter after covering the surface of the tumor with a sterilized surgical sheet, applied using quick-drying glue. After we aspirated about 1,000 ml of dark red, turbid cyst fluid, we performed a cystectomy. The healthy ovarian tissue was preserved. There was no spillage of cyst fluid. The procedure was completed uneventfully. The histopathological diagnosis was a mature cystic teratoma. She was discharged without any complications on the fifth postoperative day.The treatment of choice for ovarian cystic tumors is generally surgical excision owing to the risks of ovarian torsion, spontaneous rupture, and malignancy . TraditiHowever, laparoscopic procedures have recently become more popular, similar to other surgical specialties. Many reports have documented advantages of laparoscopic procedures for ovarian cystectomy, such as enhanced visualization of the entire pelvis, reduced need for analgesia, shorter hospital stay, early recovery and resumption of routine activities, and improved cosmetic outcomes –11. But In response to such problems, many studies have reported on ways to prevent spillage of the cyst fluid during open , 15 as wWe developed a new technique to completely prevent spillage of cyst fluid. Quick-drying glue used in our procedure is made from cyanoacrylate which is widely used in surgical field –19. In aIn patients with large cystic ovarian tumors, puncturing the cyst after it is covered with a sterilized surgical sheet applied using quick-drying glue not only prevents spillage of cyst fluid into the abdominal cavity, but also has good cosmetic results. To our knowledge, this is the first report to describe the use of both a suction tube such as a S.A.N.D. balloon catheter and quick-drying glue for the treatment of abdominal cystic tumors. Our experience suggests that our technique is a safe and reliable procedure that can be used by all surgeons to prevent spillage of cyst fluid in patients undergoing surgery for cystic ovarian tumors.


Since the inception of microfluidics, the electric force has been exploited as one of the leading mechanisms for driving and controlling the movement of the operating fluid and the charged suspensions. Electric force has an intrinsic advantage in miniaturized devices. Because the electrodes are placed over a small distance, from sub-millimeter to a few microns, a very high electric field is easy to obtain. The electric force can be highly localized as its strength rapidly decays away from the peak. This makes the electric force an ideal candidate for precise spatial control. The geometry and placement of the electrodes can be used to design electric fields of varying distributions, which can be readily realized by Micro-Electro-Mechanical Systems (MEMS) fabrication methods. In this paper, we examine several electrically driven liquid handling operations. The emphasis is given to non-linear electrohydrodynamic effects. We discuss the theoretical treatment and related numerical methods. Modeling and simulations are used to unveil the associated electrohydrodynamic phenomena. The modeling based investigation is interwoven with examples of microfluidic devices to illustrate the applications. The inkjet printhead is the earliest, and so far one of the greatest, commercial successes of microfluidics . Despiteet al. developed the concept the of miniaturized total analysis system (μTAS) [In the early 1990s, Manz m (μTAS)  based onm (μTAS) ).MV/m, is rather easy to obtain. In addition, the electric force can be highly localized force, with its strength rapidly decaying moving away from the peak. This makes the electric force an ideal candidate for precise spatial control. The geometry and placement of the electrodes can be used to design electric fields of varying distributions, which can be readily realized by MEMS fabrication methods. Electric control also possesses advantages in system integration and reliability. For instance, there are no mechanical moving parts, and the system can be directly controlled through software.Since the inception of microfluidics, the electric force has been exploited as one of the leading mechanisms for driving and controlling the movement of operating fluid and charged suspensions . The electric force has an intrinsic advantage in miniaturized devices. Because the electrodes are placed over a small distance, from sub-millimeter to a few microns, a very high electric field, in the order of E is the electric field, ρe the volumetric density of the free charge, W the volumetric density of the electroquasistatic energy, and α1, α2, …, αm the material properties. The first term is the Coulomb force density originating from free charges. The second is the dielectrophoresis force density originating from the bounded (paired) charges. Techniques that exploit the first forcing term are referred to as electrophoresis; techniques that exploit mainly the second are referred to as dielectrophoresis.When exposed to an external electric field, free charges will migrate due to the Coulomb force. Charges bound in molecules, both the molecules of the carrier liquid and of the biochemical species, will undergo distortion of the molecular charge density, or polarize. The volumetric force density of electric origin can be expressed ,(1)fe=ρelectroosmosis. Surface tension forces dominate the microfluidics when immiscible fluids are present simultaneously. When the immiscible fluids possess different electric properties, the electric field can inject electrostatic energy into the interface to cause contact angle reduction. Such force is rather strong and can result in fluid movement in the order of 25 cm/s [electrowetting-on-dielectric (EWOD) [electrowetting on insulator coated electrodes (EICE) [One critical feature of microfluidic devices compared to their macroscopic counterparts is their large surface-to-volume ratio. Forces associated with surfaces  usually are large compared to forces associated with volumes. The zeta-potential of an interfacial surface between solid substrate and electrolyte induces the formation of an electric double layer inside of which exist excessive free charges. When exposed to an electric field with a non-zero component parallel to the surface, the free charges will move and result in a significant pumping force for the electrolyte liquid. The technique exploiting the physicochemical properties of solid-electrolyte interface as described above is referred to as c (EWOD) –9, also s (EICE) .Electrophoresis and dielectrophoresis primarily harvest the electrically generated body force; electroosmosis utilizes surface forces at the solid-electrolyte interface, and EWOD modulates wetting forces exerted at the tri-phase contact line. From applications’ perspective, electrophoresis and dielectrophoresis have been largely used to manipulate  charged or polarizable particles . EWOD and dielectrophoresis have been applied to manipulate the operating liquid, the carrier of the biochemical species. Electrophoresis and electroosmosis are also referred to as electrokinetics .In this paper, we describe several state-of-the-art approaches of electrically controlled microfluidics. In particular, we emphasize novel applications that utilize non-linear electrohydrodynamic effects. Linear electrokinetics has resulted in significant success of early generations of lab-on-a-chip, especially on-chip separation. There is a large body of literature describing the theory and application of linear electrokinetics and its application to microfluidics. Microfluidic devices using non-linear electrohydrodynamic effects are more recent and are making significant progresses in diverse areas such as life sciences  and consumer electronics . The literatures on non-linear electrohydrodynamic effects are growing and are scattered in different application fields. Through this paper, we strive to synthesize the seemingly different applications under a unified theoretical framework and provide a systematic quantitative treatment.Modeling and simulations are used to unveil the associated electrohydrodynamic phenomena. We outline a unified modeling approach derived from the theoretical underpinnings of electrohydrodynamics in the next section. This approach integrates the Navier Stokes equations with the electrohydrodynamic force, Nernst-Planck equations for the transport of multiple charged suspensions, and a truncated version of Maxwell’s equations under the electroquasistatic assumption to account for the electric presence of the operating fluid and the charged suspensions. We also discuss modeling issues associated with microscopic length scale and the deformation and topological change of a two-fluid interface.The subsequent section focuses on devices that exploit interfacial electrohydrodynamics. Examples include EWOD driven digital microfluidics, novel application of dielectrophoresis, and electro-spray ionization process that interfaces a micro total analysis system and mass spectrometry.The section following that discusses non-linear electrokinetics. We consider the phenomenon of electro-hydrodynamic instability using the electrophoretic image display (EPID) as an example. We use modeling to illustrate the novel electrokinetics involved, the induced electrokinetic instability, and possible means to overcome it.This paper focuses on microfluidic component technologies and the associated physicochemical phenomena. Only through enabling system level architecting and integration can microfluidics release its full application potential. While addressing the system level design issues is beyond the scope of this paper, we touch upon the systems design and integration in the conclusion section to provide a more complete picture.2.ρ is the fluid density, μ the viscosity, u the fluid velocity, p the pressure, and f the body force density, for instance, of electric origin  and low frequency (≪1 GHz). Consequently, the electric field and the magnetic field decouple. The truncated version of Maxwell’s equations under the electroquasistatic assumption , Poissonɛ and free charge distribution ρe—both are functions of space—hence the electric field.The coupling between the hydrodynamics and electric field is bi-directional. The presence of the electric field adds an additional force density  to the mk is the index of the charged particles (species), Ck is the volumetric concentration, zk the valence, and F the Faraday constant.For most applications concerned here, a set of charged particles may be present simultaneously. They collectively contribute to the free charge density, jk accounts for the contributions from electromigration, diffusion and convection with the fluid flow. μk is the electro-mobility and Dk the diffusivity, Dk = μkRT according to Nernst-Einstein relation.The charged particles are usually small, with diameters varying from several hundred nanometers to a few microns. For each charged particle k, its migration is governed by the Nernst-Planck transport ,(4)∂Ck∂T is the stress tensor, n the unit normal of the interface, and γ the interfacial tension coefficient. The subscripts d and a denote the properties of the two immiscible fluids.In the cases where immiscible fluids are present, a hydrodynamic constraint in the form of an interfacial stress boundary condition  is appliThe deformation and topological change of the two-fluid interface commonly occur in microfluidic devices, such as merging of multiple droplets and splitting of a droplet. This results in an additional constraint when selecting appropriate numerical methods and tools. The Lagrangian schemes explicitly track the interfaces using interface-adaptive meshes, examples are boundary-integral and finite-element methods. This type of numerical approaches cannot simulate the topological change of the interface in a natural way. The Lagrangian-Eulerian front-tracking method is highly accurate and can handle the topological change. However, the complexity of the associated interface reconstruction algorithms is the major drawback.www.flow3d.com), CoventorWare (www.coventor.com), COMSOL (www.comsol.com), CFD-ACE+ (www.esi-group.com/products/Fluid-Dynamics/cfd-ace), and FLUENT (www.fluent.com).From the perspective of optimal balancing among accuracy, efficiency and practicality, the front-capturing methods are the favorite of the practitioners. There are two leading front-capturing methods: volume-of-fluid and level-set. Both deliver accuracy and handle the interfacial topological change. Volume-of-fluid methods may introduce undesired spurious currents if a lower order interface reconstruction algorithm is used. The level-set method may fail to conserve mass in areas of high curvature. Today, almost all the leading commercial simulation packages implement some variations of these two methods. Examples include FLOW-3D  in ɛa / ɛd ≪ 1 and d / D ≪ 1. In practice, the droplets are either conductive or highly polarizable [ɛd ≫ ɛi and ɛa ≈ ɛi; the thickness of the insulating layer is orders of magnitude smaller than the size of the droplets, D ≫ d. If we write δ ≡ (ɛa / ɛi)(d / D), In EWOD, droplets are placed onto a thin insulating layer preventing the droplets from direct contact with the electrodes. The droplets are surrounded by an immiscible liquid to prevent sample adsorption onto the hydrophobic layer and mass loss due to evaporation. The electrostatic energy stored in the thin insulating layer changes abruptly at the tri-phase contact line due to the difference of the electric properties between the droplets and the surrounding liquid. The gradient of the electrostatic energy stored in the insulating layer produces an electric force that acts on the contact line and induces contact angle reduction. The magnitude of this force, the EWOD force, can be described as (6)f=ɛiVarizable  .Dielectrophoresis has also been investigated as an effective operating principle for digital microfluidics . EffectiMost of the fluids in this discussion are incompressible and electrically linear. Therefore, the dielectrophoretic force density can be expressed as Dielectrophoresis’ ability to exert forces onto a free-floating medium  in a 3-D space has inspired novel applications of dielectrophoresis-based microfluidics. One example is a MEMS-based micro-surgical device that can carry out axon repair for patients who suffer from serious nervous system damage . MEMS-faOne of the critical design issues is the electrode shape and configuration to achieve desired electric field gradient. jσ/ϖ, where σ is the conductivity and ω is the angular frequency of the AC field.Typically, AC is used in dielectrophoresis. The AC frequency adds additional design dimension; the imaginary part of the electric permittivity exhibits frequency dependency, −Under direct current (DC), the (limited) conductivity present in the liquid, in addition to the permittivity, gives rise to a phenomenon called “leaky dielectric liquid” ,26. UndeS establishes a field discontinuity at the interface according to This phenomenon has been exploited to enable a microfluidic application, called “electro-spray ionization”, that provides a bridge between microfluidics-based sample separation and mass spectrometry ,28. LiquFrom a mathematical perspective, one additional equation is required to close this new, leaky-dielectric fluid boundary condition at the interface, 4.In the section above we have examined several electrohydrodynamic phenomena: in EWOD, electric field exerts its influence through the tri-phase contact line; in dielectrophoresis, the electric force shows up as both bulk force density and the surface force density on the interfaces; in electro-spray ionization, the electric force exerted itself on the interfacial surface due to the presence of the interfacial charge, the primary force for the generation of nano-jet. In addition to the simultaneous presence of media of multiple phases, there is another common theme among these phenomena and the derived applications. The electric field manipulates the movement of the operating fluid , and that in turn shapes the movement and presence of the species the liquids carry. For instance, the merger of droplets driven by EWOD triggers the chemical reaction between the chemical compounds encapsulated inside each droplet.ξ is the zeta-potential and E∥ the electric field component parallel to the surface. For the charged species, a common practice is to assume a constant μep, the electrophoretic mobility, and express the particle migration velocity as U = μepE. Since the electric impact on both the solid-liquid surface (electroosmosis) and the charged species (electrophoresis) is linear with respect to the electric field, this type of applications and modeling treatment is called linear electrokinetics.In this section we look into electrokinetic applications where the influence of the electric field is directly exerted on the species. Electrokinetics is perhaps one of the most broadly applied microfluidic operating principles. Typically voltages are applied to various ends of interconnected microfluidic channels. Aqueous-based electrolyte carrying charged species  fills the microfluidic channels. The electric double layer (EDL) is developed near the channel wall due to the surface charges at solid-liquid interfaces. Typically the EDL is very thin compared to the channel width. Therefore, the Helmholtz-Smoluchowski velocity is used to effectively represent its impact , us=−ɛζIn recent years, non-linearity in electrokinetics has been exploited. A nanofluidic channel, dimension of which is close to the EDL, is connected to the microfluidic channel from the side. When applying an electric field through the nanofluidic channel, which is normal to the EDL, ionic current is induced in the nanofluidic channel and effectively creates free charges within the EDL. Once this normal electric field exceeds a certain threshold, the formation of the EDL is dictated by this normal electric field instead of the intrinsic zeta-potential. Consequently, the electrokinetic effects now are characterized by the product of the normal electric field and the parallel electric field, which is no longer linear with the electric field but rather proportional to the product of two electric fields . The polNon-linearity exists not only in electroosmosis as outlined above, but also in electrophoresis. In electrophoresis-based display applications, the electrophoretic ink is composed of non-polar solvents and pigments. The presence or absence of color at one pixel is achieved by the movement of pigments controlled by the applied electric field ,33. In nThe movement of counter-charges and co-charges carried by reverse micelles weakens the electric field felt by the charged particles. This charge screening effect is augmented by the possible electrochemical reactions that occur both in the bulk and on the electrode surface (in the cases where the electrodes are not insulated from the ink). The non-linearity rooted in the electromigration and the flow convection gives rise to the electrohydrodynamic instability. 5.Since the inception of microfluidics, the electric force has been exploited as an important mechanism for driving and controlling the movement of the operating fluid and charged suspensions. In this paper we examined several electrically driven liquid handling operations and discussed the theoretical treatment and numerical methods. Even though many examples were drawn from the life sciences, the methods described are much more widely applicable. For instance, EWOD has found applications in imaging and printing .This paper focuses on detailed physical simulations of component-level operations, which are the key enablers. However, to fulfill certain desired services, such as agent detection with portability, durability and reliability requirement, the components must be synthesized to form a functional system. Consequently, system-level complexities need to be addressed. This includes architectural level designs that decompose the application into a finite set of operations, mapping the operations to hardware components, and component placement and routing . It also includes executing level designs that determine runtime workflow management, built-in self testing, fault detection and tolerance ,38. It aFrom a computer-aided systems design perspective, enabling the system design calls for higher level of abstraction above the detailed physical simulations presented here. Such synthesis uses operational models, or behavioral models, to encapsulate the component-level complexities, provide common component interfaces over diverse operating principles, and enable hierarchical modeling of a system composed of heterogeneous, concurrent components. Enabling system level modeling is the key area of focus for the microfluidics modeling community. Compared to the state of the art of computer-aided design for microelectronics, the modeling aid for microfluidics system design and integration is far less mature and presents a significant challenge and thus opportunity.


Chronic childhood malnutrition remains common in India. As part of an initiative to improve maternal and child health in urban slums, we collected anthropometric data from a sample of children followed up from birth. We described the proportions of underweight, stunting, and wasting in young children, and examined their relationships with age.We used two linked datasets: one based on institutional birth weight records for 17 318 infants, collected prospectively, and one based on follow-up of a subsample of 1941 children under five, collected in early 2010.Mean birth weight was 2736 g (SD 530 g), with a low birth weight (<2500 g) proportion of 22%. 21% of infants had low weight for age standard deviation (z) scores at birth (<−2 SD). At follow-up, 35% of young children had low weight for age, 17% low weight for height, and 47% low height for age. Downward change in weight for age was greater in children who had been born with higher z scores.Our data support the idea that much of growth faltering was explained by faltering in height for age, rather than by wasting. Stunting appeared to be established early and the subsequent decline in height for age was limited. Our findings suggest a focus on a younger age-group than the children over the age of three who are prioritized by existing support systems.The trial during which the birth weight data were collected was funded by the ICICI Foundation for Inclusive Growth , and The Wellcome Trust (081052/Z/06/Z). Subsequent collection, analysis and development of the manuscript was funded by a Wellcome Trust Strategic Award: Population Science of Maternal and Child Survival (085417ma/Z/08/Z). D Osrin is funded by The Wellcome Trust (091561/Z/10/Z). Severe acute malnutrition in childhood has become steadily less common in India. Malnutrhttp://www.thousanddays.org). A second stimulus to rethinking has been the switch to classification using the World Health Organization (WHO) standards of 2006 (http://www.who.int/childgrowth/standards/en/). In a 2001 analysis of 39 national samples against National Center for Health Statistics (NCHS) standards, height for age declined until 24 months and then stabilized, weight for height declined until 15 months, and weight for age faltered rapidly from three to 12 months, followed by some catch-up[Ideas about the development of childhood malnutrition are also changing. Of critical importance is the window of vulnerability within which interventions may be effective. It has long been known that growth trajectories are set early in life, but recent work on the developmental origins of health and disease has focused attention on gestation and the first two years  works to improve the health of women and children in slums in Mumbai, Maharashtra. Even as newborn survival increases, we have become increasingly concerned about the parlous state of child nutrition. Data collection for a large cluster randomized controlled trial – which did not focus on nutrition - included information on birth weight transcribed from institutional birth records. Involving 24 intervention and 24 control settlements and a total population of ~283 000, the trial tested the effects of community mobilization through local women’s groups on perinatal care and mortality[The Society for Nutrition, Education and Health Action  is largely explained by low height for age, and to examine the relationships between z scores and age.Mumbai is India’s most populous city, a base for commerce and the film industry. The city generates 33% of national tax collection, 40% of share in foreign trade, and 60% of customs duty. Recent We used two linked datasets for the analysis: a large primary dataset collected through prospective registration of births in 48 slum areas (each of at least 1000 households), and follow-up of a subsample of children. The primary dataset accrued during the trial of community mobilization in 48 urban slum areas[Data collection for a baseline year and the trial itself ran from October 2005 to September 2009. Data were collected for the follow-up study from January to August 2010. From surveillance records, we extracted a list of children born from October 2005 to March 2009 . Each was assigned a random number generated in Microsoft Excel 2007 (Microsoft Corporation). We blocked the list by cluster, aiming for an unweighted sample of 40 children per cluster. Because we wanted a spread of ages, we divided the list of possible participants into four blocks, one for each of the four years of original data collection. Each interviewer was given a list of 40 children (4 blocks of the first 10 sorted random numbers within each block). She attempted to locate the children, with the instruction that she should continue until she had found 40. If she reached the end of a list without reaching the target, she was given a new one. This was repeated 3 times to enrol the required number of children. Interviewers did not have to enrol 10 children in each band.http://www.equinox-india.com), children 2 and over on an Avon Corporation digital scale (http://www.avon.co.in), and their lengths and heights measured with Bio Plus stadiometers. Data were entered in Microsoft Access 2003 (Microsoft Corporation). Information volunteered by participants remained confidential, and names and addresses were deleted from the datasets before analysis. With 17 000 birth weight measurements, an estimate of low birth weight prevalence of 23-25% would have a precision of less than 1% (at 95% confidence level). With a sample of 1500 children at follow-up, estimates of the proportions with weight or height for age less than two z scores below the median  would have a precision of 2-3%.When an interviewer found a mother at home, she explained the study and requested signed consent for participation. Children <2 years were weighed on an Equinox BE-EQ44 digital infant scale accurate to 10 g  in univariable models, and then in multivariable models within each level. Adjusted models included covariates with associations at p < 0.1: asset score, religion, maternal age and schooling, three or more antenatal care visits, birth order, twin status and preterm. Forcing the trial allocation covariate into the model did not improve fit. Individual z scores were scatter-plotted against age. We used linear models on the basis of a fractional polynomial comparison, and fitted regression lines with 95% confidence intervals. In modelling change in weight for age z score with age, we treated the data as time series and included a fixed effect to address repeated measures within children.Analyses were done in Stata 12 . We summarized findings from both datasets with frequencies and proportions for categorical variables, and means and standard deviations (SD) for continuous variables. We generated z scores for weight for age, height for age, and weight for height, using the 2006 WHO growth standards and the 6 module. Asset s6 module,17. We uCluster-level and individual verbal consent for the primary study were given after community meetings with general practitioners, community based organizations, non-government organizations, municipal representatives, political officers of major parties, and social workers. Ethical permission was granted by the Independent Ethics Committee for Research on Human Subjects .The sponsors had no role in the study design, data collection, analysis, interpretation or writing of the article. DO had access to all study data and responsibility for the decision to submit for publication.FigureBirth weights were available for 17 318 infants (86% of livebirths): 9173 males and 8145 females. TableMean birth weight was 2736 g (SD 530 g): 2776 g (538 g) for males and 2691 g (518 g) for females. 3868 newborn infants were low birth weight  and 211 were very low birth weight . Low birth weight was seen in 20.1% of males (1842/9173) and 24.9% of females (2026/8145). These figures are probably underestimates because of data heaping at 2500 g. 6.5% of infants were classified as preterm (1305/20 071). Of low birth weight infants, 16.5% were preterm (637/3868). Mean weight for age z score at birth was −1.31 (SD 1.26): -1.31 (1.25) for males and −1.32 (1.27) for females. 3599/17 318 infants had birth weight for age z scores below −2 (20.8%); for males, 19.8% (1821/9173), and for females, 21.8% (1778/8145).TableBirth weights were available for 1511 of the 1941 children found at follow-up (78%). Mean birth weight was 2748 g SD 534): 2777 g (SD 543) for males, and 2722 g (SD 524) for females. Low birth weight prevalence was 23.3% (352/1511), and very low birth weight prevalence 0.9% (14/1511). These figures are similar to those from the birth dataset. Table4: 2777 gFiguresJust under half of children born in 48 Mumbai slums were likely to develop stunting, although their malnutrition may not have been obvious because they were generally not overtly thin for their stature. Socioeconomic status was a clear determinant, larger infants tended to ‘catch down’, and the pattern may have been set well before birth.Our estimate of mean birth weight 2736 g) accords with others from India, but was almost certainly an overestimate, since 14% of birth weights were unavailable and disproportionately represented infants from families of lower socioeconomic status. The prevalence of low birth weight (22%) was also probably an underestimate and showed data heaping characteristic of institutional records. About 21% of infants were born with low weight on the basis of z scores, and the associations were unsurprising: poverty36 g acco, youngerAt follow-up, 35% of children were underweight, 17% wasted, and 47% stunted. Stunting appeared to be established early and the subsequent decline in height for age was limited. Weight for height was not as compromised, suggesting that children followed a stunted trajectory established early (probably before birth). Infants born with higher weight for age z scores showed a downward trajectory.Our study has three obvious limitations. We did not have measurements of length at birth, the number of data points in the first year was small, and the data represented a single follow-up for each child. This means that the impression of linearity in the trends in z score change might be the result of sampling a long period (from birth to 60 months). A fall in the first six months, for example, might not be seen. Or a series of curves – each belonging to a single infant and plotted prospectively – might superimpose to give the impression of a straight line. We accept these possibilities. It would be better to follow infants serially over the first year of life in more detail, and this we intend to do. It would also be good to have accurate measurements of length at birth, although the procedure requires training and, usually, bespoke studies.Three issues make us unwilling to reject our hypotheses, however. First, our general anthropometric findings were similar to those of the most recent NFHS, and particularly its subsample from Mumbai slums. Second,The third issue is the similarity of our findings with those of a recent analysis of two NFHS datasets. Mamidi It could be argued that early stunting is one way to interpret the findings, but that the children may be constitutionally smaller and have different body habitus from children in other settings. There iWe think that our findings raise two major issues. First, given current concerns about body composition and longer-term disease, the benInterestingly, the overall steady downward progress in weight for age involved relative maintenance of z score in infants born smaller, and relatively greater decline in infants born larger. It is worrying that these larger infants appear to track downwards. One possibility is that this represents regression to the mean. Another is that environmental influences conspire against the healthy growth of children in Mumbai’s slums. This is a sobering thought. Whatever our eventual understanding, we recommend a focus of research on potential intervention in the first 1000 days. Of perhaps greater importance in the longer term is to break the cycle by focusing on nutrition and education for young girls.None of the authors has a conflict of interest.SD and UB managed field data collection. SD and DO did the quantitative analysis. NSM was the director of the project from which the data derive, GA was technical advisor to the study, and AF had oversight of programme activities. DO wrote the first manuscript draft and was responsible for subsequent collation of inputs and redrafting. DO will act as guarantor. All authors read and approved the final manuscript.


Background: Prenatal exposures to polyfluoroalkyl compounds (PFCs) may be associated with adverse changes in fetal and postnatal growth.Objective: We explored associations of prenatal serum concentrations of perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and perfluorohexane sulfonate (PFHxS) with fetal and postnatal growth in girls.Methods: We studied a sample of 447 singleton girls and their mothers participating in the Avon Longitudinal Study of Parents and Children (ALSPAC). Data on weight and length were obtained at birth and at 2, 9, and 20 months. Serum samples were obtained in 1991–1992, from mothers during pregnancy. We explored associations between prenatal PFC concentrations and weight at birth as well as longitudinal changes in weight-for-age SD scores between birth and 20 months.Results: PFOS , PFOA , and PFHxS  were detected in 100% of samples. On average, girls born to mothers with prenatal concentrations of PFOS in the upper tertile weighed 140 g less  at birth than girls born to mothers with concentrations in the lower tertile in adjusted models. Similar patterns were seen for PFOA  and PFHxS . At 20 months, however, girls born to mothers with prenatal concentrations of PFOS in the upper tertile weighed 580 g more  when compared with those in the lower tertile. No differences in weight were found for PFOA and PFHxS.Conclusions: Girls with higher prenatal exposure to each of the PFCs examined were smaller at birth than those with lower exposure. In addition, those with higher exposure to PFOS were larger at 20 months. Polyfluoroalkyl compounds (PFCs) are used in the production of fluoropolymers, which have applications in protective coatings of packaging products, clothes, furniture, and nonstick cookware. Some PFCs are persistent compounds, ubiquitous in the environment, and human exposure is common . PFCs haExposure to perfluorooctane sulfonate (PFOS), perfluorooctanoate (PFOA), and perfluorohexane sulfonate (PFHxS)—three of the most studied PFCs—may have deleterious effects on fetal growth. Lower body weights at birth were reported in the offspring of rats exposed to PFOS and of mice exposed to PFOA during pregnancy . In humaPPARα)  . The perPPARα) . Mice prARα gene . In micepression . In a sepression .Altered development of adipose tissue and of the regulatory systems involved in body weight homeostasis may explain inverse associations of PFOS and PFOA serum concentrations with measures of fetal growth reported in the epidemiologic literature. The influence of prenatal exposures to PFCs on weight homeostasis may persist after birth, although evidence is limited and somewhat inconsistent. The purpose of this investigation was to explore associations of maternal serum concentrations of PFOA, PFOS, and PFHxS during pregnancy with markers of fetal and postnatal growth in girls.Population. The Avon Longitudinal Study of Parents and Children (ALSPAC) enrolled pregnant women from three health districts of the county of Avon, Great Britain, with an expected delivery date between April 1991 and December 1992. A total of 14,610 children joined the cohort at birth. Details of recruitment methods are described elsewhere (lsewhere .n = 218) consisted of all the girls who attained menarche < 11.5 years, and controls (n = 230) were a random sample of noncases who attained menarche ≥ 11.5 years of age. We used this sample to study associations of maternal exposures to PFCs, estimated from the serum concentrations, with fetal and postnatal growth. Median age at menarche in the full cohort was 12.93 years  were girls. Of these girls, 3,682 had returned at least two valid assessments of pubertal status between the ages of 8 and 13 years. We obtained a sample of 448 girls from the group of girls with at least two valid pubertal assessments for a study of maternal serum concentrations of PFCs and menarche . Cases (93 years .Data collection. Birth weight (in grams), length (in centimeters), and gestational age (in weeks) were abstracted from medical records. Weight and height at 2 (mean ± SD = 1.7 ± 0.3), 9 (9.2 ± 0.9), and 20 (19.7 ± 2.8) months were obtained by health professionals as part of the routine infant health surveillance program. We converted the infant’s weights to weight-for-age SD scores (z-scores) using the 1990 British growth reference curves for girls . Analytical methods used have been described elsewhere . The “time” variable represents the month of age when weight measurements were taken. These models were also constructed with sampling weights to account for the nested case–control sampling.Linear mixed models were used for the longitudinal analyses of weight . We inclp < 0.20 were retained. Finally, we constructed graphs to depict the predicted mean weight-for-age SD scores, based on the final linear mixed-effects models, which were calculated at the 4 time points , with PFC exposure as tertiles and all other covariates at their reference. All analyses were conducted using SAS version 9.2 . Analyses of markers of fetal growth were performed in PROC GLM and the longitudinal mixed models were performed in PROC MIXED.First, we created exploratory graphs to observe weight-for-age patterns over time by exposure and potential predictors . Weight-for-age patterns between 2 and 20 months appeared to be quadratic rather than linear. As described previously, a category for missing data was included for maternal smoking during pregnancy and maternal prepregnancy BMI. Then we fit saturated linear mixed-effects models for each of the three PFC exposures (exposures categorized as tertiles), and included intercept, age, and age-squared parameters for the exposures and potential predictors. To assess whether exposures or predictors influenced weight patterns, we included interactions between age and each covariate and age-squared and each covariate. We used the saturated model to test for random-effects and various random-effects covariance structures. It was appropriate to include a random intercept in addition to random slopes (for age and age-squared), with an unstructured random-effects covariance structure. We removed covariates in a hierarchical way, using backward elimination, to obtain a reduced model. The exposure was retained regardless of significance. Nested models were compared with likelihood ratio tests and potential predictors that were significant at the Human subject protection was assessed and approved by the ALSPAC Law and Ethics Committee, the local research ethics committees, and the CDC Institutional Review Board.Informed consent was provided by the mothers at the time of enrollment. The daughters did not provide consent as such because they were children.r = 0.72) and moderate to high levels between PFHxS and PFOS (r = 0.54) and PFHxS and PFOA (r = 0.44).Analytes were detected in 100% of samples. PFOS showed the highest median maternal serum concentrations followed by PFOA, and PFHxS respectively . Spearma3; and gestational age was 39.8 ± 1.6 weeks. Fewer than 4% of girls were preterm or born weighing < 2,500 g. About half of the mothers reported a normal maternal prepregnancy BMI and having had at least one previous live birth. Most mothers were white (95%) (Among the 447 girls mean birth weight (± SD) was 3,397 ± 449 g; birth length was 50.4 ± 2.2 cm; ponderal index was 2.7 ± 0.2 kg/mte (95%) .Sample sizes for multivariate analyses varied from 320 to 395 in the main analyses and from 106 to 107 in stratified analyses. On average, girls born to mothers with maternal serum concentrations of PFOS in the upper tertile weighed 140 g  less at birth compared with girls born to mothers with serum concentrations in the lower tertile in models adjusted for gestational age, maternal prepregnancy BMI, previous live births, and maternal smoking during pregnancy . Girls br = 0.32; p < 0.0001; n = 339), birth weight and height at 20 months , and weight at 20 months and height at 20 months . In adjusted analyses of weight at 20 months, when either birth weight or height at 20 months or both were included in the model, girls with the highest maternal serum concentrations were on average between 438 and 580 g heavier than girls with maternal serum concentrations in the lower tertile . The initial points on the figures represent the intercept coefficients for weight at birth. The estimates for the intercept coefficients were consistent with the analyses of PFC exposures with birth weight: Girls in the upper tertile of exposure weighed less than the girls in the lower tertile. Girls in the middle tertile weighed less than girls in the lower tertile. However, the p-values for the differences between the intercept coefficients did not reach statistical significance .p > 0.05) .The remaining points on As in the single time point analyses of weight at 20 months, we were interested in understanding the role of birth weight in the weight-for-age SD patterns between 2 and 20 months. To do so, we removed birth weight as a time point in the longitudinal analyses and reran the mixed models with three time points , and stratified by birth weight (data not shown). In these models, for the intercept we found that within the lower birth weight strata, girls were smaller at birth in the higher-exposure tertile than those in the lower-exposure tertile. This was also seen for the upper birth weight strata. The coefficients for girls in the middle birth weight group were larger with higher PFC concentrations. The time trend coefficients followed a similar pattern for the girls in the lower and upper birth weight groups, compared with the middle birth weight group.Evidence from animal and human studies suggests that prenatal exposures to PFCs may have deleterious effects on fetal and postnatal growth. We explored associations of maternal serum concentrations of PFOS, PFOA, and PFHxS during pregnancy with markers of fetal and postnatal growth in a sample of British girls. In our study we found that girls born to mothers with higher serum PFC concentrations during pregnancy were smaller at birth. The magnitude of the differences in birth weight and length by tertile was similar across all the PFCs evaluated, and an exposure–response gradient was observed. Girls with higher prenatal concentrations of the PFC also appear to be heavier at 20 months.in utero PFC exposure is smaller than those reported for maternal smoking. However, because PFCs are ubiquitous in the environment, human exposure is common and, for the most part, involuntary, altered prenatal growth due to PFC exposure may represent an important public health issue.The PFCs most commonly assessed in other epidemiologic studies of fetal growth were PFOA and PFOS. Our results are consistent with those reported by others, although the magnitude of the differences in birth weight and length are not strictly comparable between studies because of differences in analytical strategy or biological media where PFCs were assessed . Two stuin utero exposure to PFOA, but not PFOS, was positively associated with BMI and weight circumference at 20 years in females, suggesting that obesity could be associated with gestational PFC exposures  were different from girls who were included in these analyses. Mean values of the study outcomes and maternal characteristics for girls included in final multivariate analyses were similar to the group of girls enrolled in the cohort , suggesting that selection bias is an unlikely explanation for our results. Finally, although we were unable to examine postnatal exposure to PFCs and impact on postnatal growth in this study, this is an important question for future research.Girls born to mothers with higher serum concentrations of PFOS, PFOA, and PFHxS during pregnancy appear to be smaller at birth and heavier at 20 months.(82 KB) PDFClick here for additional data file.


Urachal cysts are rare congenital anomalies that often prompt referral to the paediatric general surgeon because of their associated complications such as infection, abdominal pain and the young age at presentation. In this report we describe a rare case of fever of unknown origin caused by an urachal cyst which was successfully treated with incision and drainage only. Since the first description of urachal anomalies by Cabriolus in 1550, few cases have been reported and, until now, only one case of infected urachal cyst presenting as fever of unknown origin has been described in the literature. Moreover, the spontaneous resolution of an urachal cyst without excision is extremely rare.We report our experience in the management and treatment of an infected urachal cyst that occurred in a 12-year-old Caucasian girl who presented to our Department of Paediatric Surgery with a 30-day history of evening fever. The urachal cyst was treated only with incision and drainage through a minimally invasive laparoscopic approach.The incision and drainage of an infected urachal cyst is a simple and safe procedure. It assures a complete recovery and avoids potential surgical complications related to the total excision of the urachal cyst. This report may provide important clues regarding the management of this rare anomaly and we emphasise the importance for paediatricians, who should consider the possibility that a fever of unknown origin can be caused by an urachal cyst, and for surgeons and urologists, because it suggests that conservative treatment of this rare anomaly should be considered when possible. The urachus is a fibrous tubular structure that begins narrowing during the fourth and fifth months of gestation. It extends from the anterior bladder wall toward the umbilicus, as the median umbilical ligament, within the space between the peritoneum and transversalis fascia . UrachalIn this paper, we describe a case of spontaneous regression of urachal cyst, occurring in a child after incision and drainage only, and we analyse the diagnosis and treatment of this rare disorder. Until now, only one case of infected urachal cyst presenting as fever of unknown origin has been described in the literature . This re3 and a platelet count of 600,000/mm3 of blood. Inflammatory indices were increased: erythrocyte sedimentation rate was 56mm/hour, and C-reactive protein was 208mg/L; microhaematuria was also present (20/high-power field of red blood cells). The results of urinary tests and urine culture were negative. An abdominal ultrasound scan initially revealed no abnormalities and, although a focus of infection was not evident, antibiotics were administered as a preventive measure. After 3 weeks of fever and poor response to antibiotic therapy, prednisone was administered as it was suspected that she had rheumatoid arthritis. After this treatment, she had a remission, but in the following month she complained of suprapubic pain. A physical examination showed painful palpation of her hypogastria and no inflamed lesion on the surface of her skin. A repeat ultrasound evaluation of her abdominal wall revealed abscess formation without any communication with her bladder. In the absence of any umbilicus discharge, we suspected an infected urachal cyst . Her general condition was good. After 7 days of fever, laboratory results showed a white blood cell count of 10,000/mmAfterwards, she underwent an immediate exploratory laparoscopy, which confirmed the presence of an infected urachal cyst. Because of inflammation and bleeding, we decided not to excise the cyst but to perform only a large incision and drainage Figure . Tissue et al. noted a physiological regression of urachal anomalies with age. Because urachal remnant diseases are uncommon and manifest with non-specific abdominal or urinary signs and symptoms, surgeons and urologists should be acquainted with the treatment of these rare anomalies, especially in paediatric populations [Paediatric Surgery recommend a surgical treatment of infected urachal cysts, spontaneous resolution without the need for surgical excision has been reported [Urachal cyst is a congenital birth defect characterised by a sinus remaining from the allantois during embryogenesis and is the most common urachal anomaly in the paediatric population. Robert ulations . Knowledreported . Anotherreported .In our case we did not perform the second-look surgery. The urachal cyst was completely reabsorbed after the incision and the drainage and, 6 years later, remained absent on subsequent imaging studies. A histological examination demonstrated that there was no mucosa and it did not reveal any sign of malignancy. Even though this histological study regarded only a part of the cyst, we suppose that probably the purulent inflammation destroyed the mucosa lining the cavity of the cyst, thus excluding the possibility of a neoplastic degeneration. Although many surgeons recommend that urachal anomalies are removed to avoid potential malignant transformation later in life, no association has been established between urachal anomalies and urachal carcinoma . TherefoIn the literature there is only one study on fever of unknown origin caused by infected urachal cysts  and therCertainly, we do not draw conclusions with a single case, but our experience in surgery, and in particular in laparoscopic techniques , has givIn conclusion, we report a rare case of fever of unknown origin caused by an infected urachal cyst, which was successfully treated with incision and drainage only. Clinical presentation is non-specific; therefore, a high index of suspicion is required in order to make the diagnosis. This is a rare pathology and, despite the guidelines recommending surgical treatment, we chose a conservative approach. Diagnostic imaging studies performed during the follow-up showed the complete resolution of the cyst. In the light of these data, we emphasise the educational merits of this original case report considering also that very little is present in the literature on this topic.Written informed consent was obtained from the patient, now adult, for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.VB: design, acquisition of data, data analysis/interpretation, critical revision of the manuscript and approval of the article. SA: acquisition of data, data analysis/interpretation. SB: acquisition of data, data analysis/interpretation. GP: study of literature, drafting of the manuscript. TL: study of literature, drafting of the manuscript. SC: design, acquisition of data, data analysis/interpretation, critical revision of the manuscript and approval of the article. All authors read and approved the final manuscript.


Healthcare worker hand hygiene is thought to be one of the most important strategies to prevent healthcare-associated infections, but compliance is generally poor. Hand hygiene improvement interventions must include audits of compliance , which are most often done by direct observation - a method that is expensive, subjective, and prone to bias. New technologies, including electronic and video hand hygiene monitoring systems, have the potential to provide continuous and objective monitoring of hand hygiene, regular feedback, and for some systems, real-time reminders. We propose a systematic review of the evidence supporting the effectiveness of these systems. The primary objective is to determine whether hand hygiene monitoring systems yield sustainable improvements in hand hygiene compliance when compared to usual care.MEDLINE, EMBASE, CINAHL, and other relevant databases will be searched for randomized control studies and quasi-experimental studies evaluating a video or electronic hand hygiene monitoring system. A standard data collection form will be used to abstract relevant information from included studies. Bias will be assessed using the Cochrane Effective Practice and Organization of Care Group Risk of Bias Assessment Tool. Studies will be reviewed independently by two reviewers, with disputes resolved by a third reviewer. The primary outcome is directly observed hand hygiene compliance. Secondary outcomes include healthcare-associated infection incidence and improvements in hand hygiene compliance as measured by alternative metrics. Results will be qualitatively summarized with comparisons made between study quality, the measured outcome, and study-specific factors that may be expected to affect outcome . Meta-analysis will be performed if there is more than one study of similar systems with comparable outcome definitions.Electronic and video monitoring systems have the potential to improve hand hygiene compliance and prevent healthcare-associated infection, but are expensive, difficult to install and maintain, and may not be accepted by all healthcare workers. This review will assess the current evidence of effectiveness of these systems before their widespread adoption.CRD42013004519PROSPERO registration number:  Healthcare-associated infections (HAIs) lead to significant morbidity, mortality, and excess hospital costs. In 2002, it was estimated that HAIs affected 1.7 million patients in the US, resulted in 99,000 deaths, and were associated with excess healthcare costs of > USD 5 billion  (998131)14 exp anti infective agents/ (1244944)15 exp Decontamination/ (3345)16 disinfect$.mp. (30342)17 or/12-16 (2181031)18 12 and 17 (76024)19 exp hand hygiene/ [includes the MeSH Hand Disinfection] (4492)20 (hand adj2 wash$).mp.  (1782)21 (hand adj2 hygiene$).mp.  (1971)22 (hand adj2 clean$).mp.  (218)23 (hand adj2 sanitiz$).mp.  (162)24 (hand adj2 disinfect$).mp.  (4688)25 or/19-24 (6625)26 18 or 25 (76904)27 exp population surveillance/ (50191)28 exp population surveillance/ (50191)29 surveillance.mp. (136275)30 monitor$.mp. (606051)31 feedback.mp. (95605)32 alarm.mp. (6107)33 or/27-32 (819570)34 26 and 33 (7684)35 exp automation/ [includes MeSH robotics] (25847)36 automated system.mp. (2316)37 automatic$.mp. (76950)38 sensor$.mp. (242568)39 RFID.mp. (423)40 exp Radio Frequency Identification Device/ (220)41 exp Electronics/ (25648)42 exp Video-Audio Media/ (5502)43 (monitor adj2 computer$).mp.  (656)44 (monitor adj2 video$).mp.  (481)45 (monitor adj2 electr$).mp. (812)46 (system$ adj2 computer$).mp. (38430)47 (system$ adj2 video$).mp. (2522)48 (system$ adj2 electr$).mp. (16530)49 exp tape recording/ [includes Videotape Recording] (14287)50 computer.ti,ab. [title or abstract] (158475)51 video.ti,ab. [title or abstract] (47539)52 exp computer systems/ (136153)53 or/35-48 (409583)54 34 and 53 (268)55 remove duplicates from 55 (252)The authors report no financial or non-financial conflicts of interest.JAS and MPM contributed to the conception and design of the review. JAS wrote the draft protocol and registered the protocol with the PROSPERO database. JAS, DL, MG, and MPM will be involved in data acquisition. JAS, GF, MG, and MPM will synthesize and interpret results. All authors were involved in the editing of this protocol and have given their approval for publication.