Echinococcosis is among the most neglected parasitic diseases. Development of new drugs and other treatment modalities receives very little attention, if any. In most developed countries, Cystic Echinococcosis (CE) is an imported disease of very low incidence and prevalence and is found almost exclusively in migrants from endemic regions. In endemic regions, predominantly settings with limited resources, patient numbers are high. Whole communities do not have access to appropriate treatment. The choice of treatment modalities is limited because of poor infrastructure and shortage of equipment and drugs. In this context, CE meets the criteria for a neglected disease. Furthermore, the terminology related to the designations around the parasite, its evolution and some therapeutic procedures is not uniform and sometimes inappropriate terms and wrong designations are used based on incorrect concepts. Although all of us know the different aspects of the disease it is pertinent to remember some important points and, above all, to clarify some aspects concerning the hydatid cyst's nomenclature in order to understand better the therapeutic options in the liver locations, particularly the different surgical approaches. I have frequently noticed both, in published articles and also in communications during scientific meetings, the use of wrong designations concerning the hydatid cyst, a designation used for Cystic Echinococcosis. It is not a different nomenclature but the use of inappropriate terms, which are based on incorrect concepts. I think it would be useful, for all of us, to use the same nomenclature. It is absolutely necessary that the nomenclature is correct and universally accepted. So, I think it is pertinent to write this paper in order to remember some important points and, above all, to clarify some aspects concerning the hydatid cyst's nomenclature. Echinococcus found in the small intestine of carnivores. Although there are different species of Echinococcus described, only four of them—E. granulosus, E. multilocularis, E. oligarthrus and E. vogeli—are recognized as taxonomically relevant, and only the first two are pathogenic for humans. To distinguish the diseases caused by these two different species, the World Health Organization (WHO) proposed the designation Cystic Echinococcosis (CE) for the disease caused by E. granulosus and Alveolar Echinococcosis (AE) for the disease caused by E. multilocularis.Human Echinococcosis is a zoonotic infection caused by larval forms (metacestodes) of tapeworms of the genus The annual incidence of CE can range from less than 1 to 200 per 100,000 inhabitants in various endemic areas [The annual incidence of AE is generally low in most of the endemic areas  but in untreated or in inadequately treated patients mortality is more than 90% within 10/15 years of diagnosis [Despite these important data and the socioeconomic impact –6, EchinE. granulosus vital cycle  and the adventitia that involves it, as Devé defined in the beginning of the last century (1911), and there is no reason or legitimacy to modify this definition.The hydatid cyst  is componever pericystic area, as it is sometimes wrongly named, because it is an integrant part of the cyst. An example of this common mistake is the use of the term “pericystectomy” for the excision of a cyst, when removing the adventitia. This term misleads you into thinking that this layer (adventitia) is not part of the cyst, assuming that the cyst includes only the parasite (hydatid) and not the adventitia, which is wrong and opposite to Devé's definition [The adventitia is a layer of an inert tissue with fibrosis and variable thickness, which results from the host's organ reaction against the hydatid, which is a foreign body. This layer can be called periparasitic or perihydatidic area, but finition , 9.The eggs of these tapeworms excreted by carnivores may infect various species of natural intermediate host animals and humans.During the natural course of infection, the fate of the hydatid cysts is variable. Some cysts may grow (average increase: 1–30 mm per year) and persist without a noticeable change for many years. Others may spontaneously rupture or collapse and can completely disappear. Calcified cysts are not uncommon. Spillage of viable protoscolices after spontaneous or traumatic cyst rupture, or during interventional procedures, may result in secondary Echinococcosis.After an undefined and variable incubation period, infections may become symptomatic if active cysts exert pressure on adjacent tissue and induce other pathologic events. Usually cysts do not induce clinical symptoms until they have reached a particular size. Sudden onset of symptoms may be due to cyst rupture.In primary Echinococcosis the metacestodes may develop in almost any organ. Most patients (up to 80%) have a single organ involved and harbour a solitary cyst, localized in approximately two-thirds of cases in the liver and in about 20% in the lungs.The hydatid is a sphere composed of two membranes with liquid in its interior . The inn2, a density between 1.008 and 1.015, alkaline pH) and some proteins that confer antigenic properties.The hydatid liquid is clean and clear, “as well as the clean water from its natural source”, containing secretions from both the parasite and host and all the elements from the “inner wall” of the cyst, named hydatid sand. It has an identical composition to that of the host's serum , the “cyst's wall” fissure due to detachment of membranes or micro traumatisms, the transformation of scolices into vesicles (vesiculation) attempting to preserve the specie. These new vesicles, which live into the hydatid fluid, must be called offspring or “daughter” vesicles . These daughter vesicles have the same constitution as well the same mission of the vesicle mother. So, in this way, protoscolices may evolutes into either a new cyst or an adult parasite.The long-term survival of the hydatid indicates the existence of protection mechanisms against immunity response of the host. The hydatid fluid is the main factor responsible for the antigenic stimulation, but the germinal layer of the cyst is a barrier against immune competent cells of the host. So, it is necessary to have damages in the germinal layer, like fissures or rupture, to get an antigenic stimulation. When this antigenic stimulation occurs, there is a continuous elevation of the immunologic values for an indeterminate time. This elevation also happens after the cyst manipulation . WHO classification, which was published in 2003 [In 1981 Professor Gharbi et al. proposed a US classification of the hydatid cysts . In his  in 2003 , but it the difficulty to classify some cysts, normally included in type 3,the inclusion of all type 4 cysts as inactive (in some of them we found daughter vesicles or fertile liquid).In order to contribute for a clarification of the first point, it is proposed to divide the type 3, considering a type 3a and a type 3b, as represented in On the other hand all we know how it is difficult to define the cyst inactivity, particularly to quantify the cyst content solidification. To contribute for the definition of cyst inactivity, I will try to establish the criteria, based on the cyst solidification, and the way for the quantification of the cyst's content solidified percentage.The aim of the hydatid cyst treatment is the death of the parasite and consequently the cure of the disease –21. It hThe methods to achieve the death of the parasite are both the sterilization of the cyst content, using scolicidal agents, or the parasite direct removal, through aspiration or the surgical excision of the entire cyst –21.This method is based on the degeneration of the germinal hydatid membrane and destruction of the viable elements of the hydatid fluid, due to the scolicidal drugs effect, whatever injected into the cyst or orally taken, or by thermal ablation (radiofrequency).This is the most ancient method of treatment for the hepatic cysts . It was Percutaneous puncture is known as PAIR  and Reaspiration) and it is considered the Gold Standard , 22–24; Nowadays albendazole is the drug chosen for oral treatment of hydatid cysts –36. Its Radiofrequency thermal ablation has proved to be a safe method to destroy the germinal layer , 44, 45.Hydatidectomy or the excision of the cyst, which necessarily removes the parasite, procedure called Cystectomy.There are two different ways to remove the parasite: the aspiration of the parasite (or hydatid) procedure called This is a procedure that only removes the hydatid (parasite). It is identical to the puncture method to the sterilization of the cyst excepting in what concerns the last step , which is done under high pressure, in order to remove the hydatid membranes and all the remaining contents , 17, 46.Cystectomy consists on the excision of the cyst, which ideally should be total, in order to diminish relapses and complications , 46, 49.The open method is performed by opening the cyst, then its aspiration and finally the removal of its content. Only after this step we proceed to the entire cyst “wall” removal , 51–53.The closed method, known as Napalkoff's procedure, consists of the entire removal of the cyst without opening it. When a total resection can damage bilious or vascular structures, must a partial cystectomy be done, despite this is a conservative procedure , 51, 52.2 due to dissemination risk in case of rupture [Cystectomy can be performed by a video-assisted surgery on selected cases , 53–59,  rupture .Another option is the hepatic resection (segmentectomy or lobectomy), in case of great size cysts in which there is a high risk of ischemia for the remained hepatic tissue , 51–53. radical procedures, have higher risks per-operatively but fewer rates of complications and relapses after surgery. On the other side, conservative methods have less intraoperatively risks but higher rate of long outcome complications and relapses.The main advantage of cystectomy is the immediate healing of the disease, which is obtained only when the cyst is completely removed whatever with or without hepatic tissue (cystectomy or hepatic resection). Both methods, called Although nowadays the morbidity and mortality of the hydatid cyst surgery have diminished, they cannot be overlooked. The prevention of complications starts with an accurate surgical technique and the necessary caution in the removal of the cysts which are very close to the bilious and vascular intrahepatic structures.To prevent the relapses, it is very important to protect the surgical field with pads soaked with scolicidal solution , 58–60. It is difficult to define the cysts inactivity as well as to evaluate the therapeutic efficacy, particularly chemotherapy and percutaneous puncture, which is based on US images. US permit controlling the cyst evolution after the treatment showing the progressive degeneration of its content until the parasite's death , 27, 31.Patients submitted to PAIR are evaluated one week later, in the first and third months, and after that each six months until ranging the inactive stage , 27. In Each observation of the US images is evaluated and compared to the previous one. If there are not any significant alterations, to the previous images, or if we find a persistent liquid image, it is not considered the treatment of efficacy.The first signal of the therapeutic efficacy is the parasite membranes detaching from the cyst adventitia. These signals are evident in the US images immediately after the final aspiration in the percutaneous treatment  and afteIn the subsequent US images, we should observe alterations on cyst content, such as the diminution of the liquid area and its substitution by solid patron giving the cyst a pseudotumoral aspect Figures . The cysIf a simple cyst, according to its US characteristics, after the therapeutic approach, appears with the membranes detached, it means that it evolutes from an active stage (fertile cyst) to a transitional stage (degenerated cyst). This is the proof of the therapeutic efficacy. If, in its evolution, we observe a progressive reduction of the liquid content, like the images (b) of Figures We can also observe the cyst vanishing  or the eResuming, the criteria for the therapeutic efficacy evaluation areparasite's membranes detachment immediately after percutaneous treatment and after the first cycle of chemotherapy,modification of the US patron of the cyst content with the progressive substitution of the liquid content by a solid patron,cyst vanishing or observation of a linear echoic scare (vestiges).Once the cyst content solidification is the criterion to evaluate the therapeutic efficacy, and a solidified area greater than 75% presumes the parasite inactivity, it is necessary to quantify, so precisely as possible, this solidified area. In order to obtain this value, we should proceed as follows:digitalisation of the US images and selection of the cystic area ((b) images of Figures filter application, by Adobe Photoshop programme, to select the liquid and solid areas of the cyst ((c) images of Figures image “vectorization” by a Computer Assisted Design (CAD) programme for calculation of the percentage of the solidified area.By this way, it is possible to know the exact moment at which a cyst under chemotherapy or submitted to percutaneous puncture ranged the inactive stage and, according the same criteria, to know if the therapeutic is being successful or not. This information is achieved by US, which has a relevant role to evaluate the treatment efficacy in the liver hydatid cysts, particularly in the cysts treated by anti-infective drugs (chemotherapy) or submitted to percutaneous puncture, because it allows controlling the cyst evolution after the treatment, showing the progressive degeneration of its content until it ranges an almost total or total solidification, which proofs its inactivity and consequently the parasite's death.This imaging method is the only way that allows us to affirm the success of the treatment and the cure of the disease. The therapeutic efficacy of the liver hydatid cysts can only be evaluated by imaging methods once it is not yet available by immunological means.


Simple hepatic cysts rarely cause symptoms, however, occasionally they become symptomatic due to mass effect, rupture, hemorrhage, and infection. We report a patient with a large hepatic cyst with elevated serum and cyst fluid CA19-9 levels. We studied serum and cyst fluid CA19-9 levels in this patient, before and after the intracystic instillation of minocycline hydrochloride.A 76-year-old Japanese woman was diagnosed as having an infected hepatic cyst, by physical examination and enhanced abdominal computed tomography. Serum  and hepatic cyst fluid (371 U/ml) CA19-9 levels were elevated. After the intracystic instillation of minocycline hydrochloride, necrotic cells in the cyst were drained, and it totally collapsed after 1 week. Cyst fluid CA19-9 levels increased remarkably after the intracystic instillation of minocycline hydrochloride, while serum CA19-9 levels decreased significantly.Our study is the first report to reveal the influence of intracystic instillation of minocycline hydrochloride on serum and cyst fluid CA19-9 levels in a patient with a simple hepatic cyst. Benign hepatic cysts are commonly observed in the general population, however, they rarely cause symptoms. Simple hepatic cysts are generally stable in size over time, but may grow slowly and occasionally become symptomatic due to mass effect, rupture, hemorrhage, and infection . We repoEscherichia coli were cultured from blood. Enhanced abdominal computed tomography (CT) showed a large hepatic cyst with partially enhanced thickened cystic wall   and CA19-9 , and l Figure . From thIn addition, we performed percutaneous treatment of the hepatic cyst by drainage and sclerotherapy using minocycline hydrochloride. Briefly, after local anesthesia of the puncture site with 1% mepivacaine hydrochloride, a 20-cm long, 22-gauge needle was passed into the cyst under real-time ultrasonic guidance with a 3.5 MHz convex transducer. After a pig tail catheter had been inserted into the cyst, the cystic fluid was aspirated. Bacteria, neoplastic cells, and parasites were not detected in the cystic fluid, however, CA19-9 levels were elevated in hepatic cyst fluid (371 U/ml). At 3 days after drainage, her fever and serum CRP level (4.1 mg/dl) were remarkably decreased; this also supported the diagnosis of an infected hepatic cyst. 400 mg of minocycline hydrochloride was dissolved in 50 ml of saline, and this minocycline solution was injected into the cyst using the drainage catheter. The drain was closed, and was opened 24 hours after intracystic instillation of minocycline hydrochloride. To determine the contribution of the hepatic cyst to the CA19-9 levels, we measured serum and cyst fluid CA19-9 levels before, 1 day after and 1 week after intracystic instillation of minocycline hydrochloride. After intracystic instillation, necrotic cells in the cyst were drained, and the cyst totally collapsed after 1 week Figure . Cyst flet al. also observed elevated serum and cyst fluid CA19-9 levels in a patient with an infected hepatic cyst [et al. reported that serum CA19-9 levels in patients with cholelithiasis complicated by cholangitis frequently showed markedly high values, and serum CA19-9 levels were rapidly decreased and normalized by amelioration of inflammation [Imaging modalities such as CT and ultrasound are highly accurate for diagnosing simple hepatic cysts, however, the distinction between cystadenoma and a simple hepatic cyst complicated by intracystic hemorrhage has been reported to be difficult . The meatic cyst , and in tic cyst . Furthertic cyst . Sawabu ammation , indicatTo our knowledge, our study is the first report to reveal a significant influence of intracystic instillation of minocycline hydrochloride on serum and cyst fluid CA19-9 levels in a patient with a simple hepatic cyst. Further clinical studies are needed in a large number of patients.The authors declare that they have no competing interests.HY treated the patient, analyzed and interpreted the patient data, and was a contributor in writing the manuscript. NT advised on the format and design and assisted in providing a critical appraisal of the manuscript. Both authors have reviewed and approved the final manuscript.Written informed consent was obtained from the patient for the 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.


An acromioclavicular joint cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the acromioclavicular joint. We present the case of an 81-year-old man affected by an acromioclavicular joint cyst, associated to a massive rotator cuff tear, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint. The mass was 7 × 2.5 cm in size and the overlying skin presented a fistula that drained clear synovial-like fluid. Plain X-ray examination of the left shoulder showed proximal migration of the humeral head migration and osteoarthritis of the gleno-humeral joint, and further MRI evaluation confirmed the clinical diagnosis of a complete rotator cuff tear and observed a large subcutaneous cyst in communication with the degenerative acromioclavicular joint. The patient underwent surgical excision of the cyst and lateral resection of the clavicle to prevent disease recurrence. To the best of our knowledge, this is the first reported case of an acromioclavicular joint cyst complicated by an aseptic fistula resulting from multiple aspirations. An acromioclavicular joint (ACJ) cyst is an uncommonly reported condition, which seems to result from a massive rotator cuff tear and degenerative osteoarthritis of the ACJ and gleno-humeral joint .The most frequent presentation of this clinical entity is a painless, enlarging subcutaneous mass over the ACJ, which can often raise the suspicion of a tumor . On arthACJ cysts can be managed either conservatively  or surgically, with or without rotator cuff repair, depending on several factors like age of the patient, symptoms and general health condition -6.We report the case of man affected by an ACJ cyst associated to a massive rotator cuff tear that presented an aseptic cutaneous fistula secondary to multiple ultrasound-guided aspirations of the cyst.In November 2008 an Italian, Caucasian, 81-year-old male, a retired mason, presented to our outpatient clinic with a 1-year history of an enlarging subcutaneous mass over the left ACJ. The patient denied any previous shoulder trauma, but complained a long history of left shoulder discomfort during daily life activities. The patient had been submitted to four ultrasound-guided aspirations of the cyst and steroid injections by an interventional radiologist. After the final aspiration the patient complained recurrence of the cyst and formation of a fistula draining a slightly viscous serous fluid at the puncture site. On physical examination the mass was 7 × 2.5 cm in size, symmetric, firm, adherent to the superior aspect of the ACJ and non-tender on palpation . The ovePlain X-ray examination of the left shoulder showed ACJ degeneration, with acromioclavicular (AC) space narrowing and osteophyte formation, proximal migration of the humeral head and osteoarthritis of the gleno-humeral joint . FurtherIn view of the persistence of the cyst and the draining fistula the we decided to submit the patient to surgery, which confirmed clinical and MRI findings. The cyst and the fistula were completely excised and, given the impossibility to repair the massively torn rotator cuff, to avoid recurrence of the cyst, resection of 1 cm of the lateral clavicle was also performed . HistoloWithin three weeks from surgery function and range of motion of the operated shoulder returned to pre-operative levels. To date, the patient is asymptomatic and with no cyst recurrence.et al. proposed that the ACJ cyst is formed by a leakage of synovial fluid through the torn rotator cuff and into a degenerated ACJ [et al. proposed a theory according to which mechanical irritation of the ACJ from direct contact of the humeral head in presence of a torn rotator cuff may lead to cyst formation [ACJ cysts are rare clinical entities that seem to be secondary to traumas, connective tissue degeneration, and synovial extension from an adjacent joint -9. Althoated ACJ . The fluated ACJ . Nardiniormation .et al. and Takagishi et al. demonstrated success of conservative treatment in half of patients with rotator cuff tear [et al. performed aspiration and corticosteroid injection of a cyst without success in terms of avoiding recurrence of the lesion [et al. reported three ACJ cyst cases, one of which was treated with simple excision of the lesion that resulted in disease recurrence one year post-operatively [et al. managed four ACJ synovial cysts associated to gleno-humeral osteoarthritis and irreparable rotator cuff tear performing shoulder hemiarthroplasty, which proved to be an effective treatment [et al. performed excision of the cyst, acromioplasty and closure of the rotator cuff defect with a duramater allograft in a case of ACJ cyst associated to irreparable cuff tear with unsatisfactory functional results [et al. treated three patients with ACJ cysts and massive rotator cuff tears with excision of the cyst, removal of the distal clavicle end and synovectomy of the upper part of the pathological humeral-acromial joint [et al. besides excision of the cyst and lateral resection of the clavicle also repaired the torn cuff [2. Unfortunately, there is no study reporting medium/long-term results of patients affected by ACJ cysts who underwent surgical excision along with rotator cuff repair, acromioplasty, lateral resection of the clavicle or hemiarthroplasty.The literature reports very few cases of ACJ cysts, most of which have been treated surgically, especially if associated to shoulder symptoms ,7,10,12 uff tear ,14 Cvitae lesion . Similarratively . Groh et results . Le Huecal joint . At two-et al. and Postacchini et al. clearly stated that without addressing the underlying pathological process, treatment of ACJ cysts proves to be unpredictable [et al. who reported the successful follow-up at 1 year in a patient with a massive ACJ cyst [Treatment of ACJ cysts can be either conservative or surgical, according to symptoms, patient age, and shoulder function. In the presence of massive tear, few or no symptoms and good shoulder function in elderly patient conservative treatment is recommended. Conversely, patients with chronic shoulder pain and compromised shoulder function should be addressed to surgical treatment, to excise the cyst and possibly repair the torn cuff . Groh etdictable ,7. Nonetdictable ,5. This ACJ cyst .The present case reports an ACJ cyst in an elderly patient affected by rotator cuff arthropathy with negligible symptoms and a good function of the shoulder, that could be eligible for conservative treatment. However, the presence of a non-healing fistula draining synovial-like fluid, which significantly influenced quality of life of the patient, imposed an open surgical treatment. Hemiarthroplasty was not performed in view of the good function of the shoulder in absence of significant pain. To prevent cyst recurrence, we opted for lateral resection of the distal clavicle, in consideration of the irreparable rotator cuff tear.To the best of our knowledge, this is the first reported case of an ACJ cyst complicated by an aseptic fistula resulting from multiple aspirations. Although aspirations of the cyst have been reported in the literature , in viewAlso it is clear that the tendency is to surgically excise symptomatic ACJ cysts, along with the resection of the lateral clavicle. Although this procedure seems to be beneficial in terms of preventing disease recurrence, long-term follow-ups and report of more cases may help confirm the effectiveness of this surgical technique.


We present two patients with splenic cysts. The first is a female 29-years-old who presented with upper abdominal discomfort of one-year duration. Imaging revealed a huge splenic cyst. Splenectomy was undertaken. Pathological examination revealed a lymphatic cyst. The second was an 18-years-old female who presented to the emergency department with a ruptured splenic cyst. Splenectomy was undertaken, it proved to be a simple cyst. Splenic cysts are an uncommon encounter in surgical practice and less than 1000 cases have been reported . Most paAn Egyptian 29-years-old female, with BMI of 25, accountant, non-smoker, presented with upper abdominal discomfort and dull pain in her left loin of one year duration. The patient had no history of trauma or schistosomiasis, which is a common condition in Egypt. Examination revealed huge splenomegaly. Spleen was broad and crossing midline. CT scan  showed aExploratory laparotomy was undertaken. The spleen was huge  and tougPathology report showed a lymphatic cyst with multilocular components.An Egyptian female student 18-years-old presented to emergency department with acute abdomen of few hours duration. Examination revealed a vitally stable patient with generalized abdominal tenderness. Lab results showed mild leukocytosis, normal HB%. Abdominal ultrasound showed suspected splenic tear, with free intraperitoneal free fluid. CT revealed a splenic cyst?  rupturedWe decided laparotomy due to presence of loculations on CT. Laparotomy and splenectomy were undertaken. Pathological examination revealed a simple cyst .The treatment of splenic cysts is a difficult challenge to surgeons . Not surThree classification systems are present Fowler, Martin and Morgenstern .Discovery of the cyst is easy with imaging modalities but the true nature and pathology of the cyst is not always possible to determine preoperatively . Since tPreoperative aspiration of the fluid for biochemical and cellular examination is debatable. Some recommends it routinely  while otA wide range of treatment modalities have been described for symptomatic or very large cysts of the spleen. Nonoperative measures, such as observation, have been recommended for asymptomatic cysts smaller than 5 cm. The natural history of these small cysts is largely unknown, but if the imaging characteristics reveal regularity of the cyst wall, absence of a solid component, and a typical round shape, there is no indication for cyst removal. Spontaneous resolution of traumatic pseudocysts can occur. Surgical treatment usually is recommended for symptomatic patients or for those with cysts larger than 5 cm .Percutaneous aspiration of the cyst has been described as a definitive treatment, but this option often leads to recurrence. Chemical agents, such as alcohol or tetracycline, have been percutaneously injected into the cyst cavity after aspiration in an attempt to collapse the cyst wall, promote fibrosis, and prevent re-accumulation; however, recurrences were reported ,8. ThereTotal splenectomy used to be the gold standard for splenic cysts. However, due to the increasing awareness of the immunologic function of the spleen, organ-preserving techniques were developed to avoid the rare but life-threatening risk of overwhelming post-splenectomy sepsis. These salvage procedures ranged from cyst excision with partial splenectomy to cyst marsupialization with partial cyst wall excision .With the advent of advanced laparoscopy, previously standard open operations for the treatment of nonparasitic splenic cysts have been undertaken using a minimally invasive approach .Despite such successes, it is important to note that laparoscopic splenectomy still incurs a risk of post-splenectomy sepsis and that laparoscopic partial splenectomy is a technically challenging operation with a longer operative time and the potential for greater blood loss ,9.A standardized approach for diagnosis, classification and management of splenic cysts is waited for.


The association between area characteristics and birth outcomes is modified by race. Whether such associations vary according to social class indicators beyond race has not been assessed.This study evaluated effect modification by maternal birthplace and education of the relationship between neighbourhood characteristics and birth outcomes of newborns from 1999–2003 in the province of Québec, Canada . Areas (N = 143) were defined as administrative local health service delivery districts. Multi-level logistic regression was used to model the association between three area characteristics  and the two outcomes preterm birth (PTB) and small-for-gestational age (SGA) birth. Effect modification by social class indicators was evaluated in analyses stratified according to maternal birthplace and education.Relative to the lowest tertile, high median household income was associated with SGA birth among Canadian-born mothers (odds ratio (OR) 1.13, 95% confidence interval (CI) 1.06, 1.20) and mothers with high school education or less . Associations between median household income and PTB were weaker. Relative to the highest tertile, low immigrant density was associated with a lower odds of PTB among foreign-born mothers  but a higher odds of PTB among Canadian-born mothers . Associations with income inequality were weak or absent.The association between area factors and birth outcomes is modified by maternal birthplace and education. Studies have found that race interacts in a similar manner. Public health policies focussed on perinatal health must consider the interaction between individual and area characteristics. A growing number of studies have reported associations between area-based characteristics and perinatal health. Research has focussed on neighbourhood economic deprivation in relation to gestational age -8 and biRecent work has evaluated associations between area characteristics and birth outcomes across different social classes, with particular attention on ethnic segregation and racial groups in the US ,15,17-21While such research attests to a contextual influence that varies among US racial classes, information for other nations and social markers is lacking. In other settings, measures other than race alone may better represent social differences. Whether the influence of area characteristics varies according to such factors has not been evaluated. Some evidence suggests that the influence of area-based economic deprivation may vary depending on maternal foreign-birth status .These knowledge gaps also apply to area characteristics emerging as predictors of birth outcomes, such as income inequality. Measures of income inequality represent the unequal distribution of income within areas , in contThe study of place-based influences is also challenged by the complex relationships between contextual factors and health outcomes . Income These gaps in the literature are important to address as public health interventions often focus on sub-groups at risk, an approach that may be justified by the limited resources available for interventions. An important first challenge is to identify the appropriate sub-groups, and then act to reduce the inequalities present within these groups.The objective of this study was to examine the association between birth outcomes and area income, income inequality and segregation across different social markers in Québec, Canada. Québec is a province with a supportive social welfare system and universal health care , and canData were obtained from the 1) Québec birth file and 2) 2001 Canada census. Singleton births for a 5-year period (1999–2003) centered on the 2001 Census year were extracted N = 356,147). Residential area at time of birth was specified as administrative local community service center (CLSC) districts (N = 166). CLSCs are areas of health service delivery  where va6,147. Reth percentile for age and sex for infants from 22 to 43 weeks gestation) [PTB= 353,006; NSGA = 352,727).Outcomes were dichotomously coded and defined as 1) PTB, less than 37 weeks gestation, and 2) SGA birth (birthweight less than 10station) . Extremestation) . GestatiIndividual-level covariates included maternal education , birthplace , age , civil status , previous live births , and sex of infant. These factors have been previously shown to be associated with adverse birth outcomes [Three area-level variables were calculated, using aggregated 2001 Canada Census data for household income and immigration status: 1) Median household income, used as an indicator of neighbourhood poverty/economic deprivation; 2) Proportion immigrant population, used as an indicator of immigrant density; 3) Coefficient of variation (CV) of mean household income, used as an indicator of income inequality. The CV was calculated according to standard methods, after verification that household income was normally distributed . Large CDescriptive analyses were performed, and trends were examined using the Cochran-Armitage test. Because the data were hierarchically structured, we used multi-level multivariate logistic regression with CLSC specified as a random effect to model the association between area variables and birth outcomes . Multi-lversus Canadian-born) and education (high school diploma or less versus some post-secondary or more).To examine the influence of area variables on birth outcomes across social markers potentially serving as effect modifiers, models were re-run after stratifying data according to maternal birthplace  for correlated observations with a logit link . Both muSAS 9.1 software was used for analyses . Multi-level models were run using the GLIMMIX macro , and GEEAreas had a mean CV of 18.5% (range 2.3%–47.1%), mean median household income of $41,352 , and mean immigrant proportion of 7.7% (range 0%–62.0%). PTB and SGA birth represented 6.3% and 8.3% of births, respectively  for income inequality and SGA birth was present among mothers with lesser education.Income inequality was inversely associated with PTB and SGA birth for most social markers, with the exception of PTB among foreign-born mothers and SGA birth among mothers with higher education Table . A less All area variables were associated with PTB in unadjusted models Table . RelativUnadjusted models indicated greater odds of SGA birth for high area poverty , lower odds for low immigrant density , and no association for high income inequality , relative to the opposite tertile Table . Upon adAmong native born-mothers, high area poverty  and low immigrant density , but not income inequality , were associated with PTB in the fully adjusted model  than immigrant density  or income inequality  in the fully adjusted model  in the fully adjusted model , and high relative to low income inequality was associated with lower odds of SGA birth  in the fully adjusted model . Other studies, mainly focussing on segregation, have considered racial class but not education as a modifier of neighbourhood effects. Maternal education is generally treated as a control variable and not as a potential modifier [We also found high immigrant density was associated with greater odds of PTB among mothers with high but not low education. Educated mothers might more readily access benefits conferred by high immigrant density  that would be expected to be beneficial for birth outcomes. Alternatively, neighbourhoods favouring environments in which striving for better life conditions is perceived positively  may also be beneficial for birth outcomes.Evidence for a contextual influence of income inequality was weaker than for area poverty and immigrant density, in line with research showing income inequality has a weaker influence in small areas compared to larger places . Neverthy others -54, but y others ,28 or loy others . Income y others , and assy others ,56. Thesy others ,56. ThesOur results raise the possibility that the influence of income inequality on SGA birth might be more protective among mothers with high education. The protective influence of income inequality may more readily translate into health benefits when socio-economic status is high. The only comparable study evaluating the influence of income inequality according to class found an adverse influence on PTB among non-White mothers in the United States . Other sThis study is subject to limitations. We could not account for tobacco use and income which may confound or mediate relationships, although such factors do not fully account for area effects . StatistThis study demonstrates that the association between area factors and adverse birth outcomes in Québec is modified by maternal birthplace and education. Some studies have found race interacts in a similar manner, and our results indicate that social class indicators other than race influence this relationship. While both individual and area-level characteristics need to be accounted for in public health initiatives addressing adverse birth outcomes, there may be a further need to consider the interaction between these factors.CLSC: local community service center; CV: coefficient of variation; GEE: generalized estimating equations; PTB: preterm birth; SGA: small-for-gestational age.The authors declare that they have no competing interests.NA designed the study. NA and JG reviewed the literature. NA guided and JG performed the data analyses. NA and JG interpreted the results and wrote the manuscript. MD provided structured neighbourhood-level data, helped interpret results and revised the manuscript for important intellectual content. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


Birth size has been positively associated with age at menarche and height in adolescence and adulthood, but the relevant biological mechanisms remain unclear. Among 262 Norwegian term-born singleton girls, birth size measures  were analysed in relation to adolescent hormone levels , age at menarche and adolescent (ages 12.7–15.5 years) and body size  using survival analysis and general linear modelling. The results were adjusted for gestational age at birth, age and menarcheal status at measurement in adolescence and maternal age at menarche. Birth weight, birth length and head circumference were positively associated with adolescent weight and height, and small birth size was associated with earlier age at menarche. Subscapular skin-fold thickness at birth was not associated with adolescent body size, but low fold-thickness was associated with earlier age at menarche. Measures of birth size were inversely related to circulating levels of dehydroepiandrosterone sulphate in adolescence, but there was no clear association with other hormones. These results suggest that physical and sexual development in puberty and adolescence is influenced by prenatal factors, and in combination, these factors may influence health and disease later in life. Studiesin utero . Birth sin utero . The facWe have examined the relation between birth size characteristics and potential BC risk factors , and spen=561) of all women; the other group of women with one or more of the following risk factors for giving birth to a small birth size for gestational age child : a previous low-birth-weight child or perinatal death, cigarette smoking at conception, pre-pregnancy weight below 50 kg, chronic renal disorder or hypertension (n=1384).The study is based on the Norwegian part of an international study among pregnant women in 1985–1986, described in detail elsewhere (n=5), were reluctant to participate (n=8) or gave practical reasons (n=26). Of the remaining 338 invited girls, 262 attended the follow-up examination (77.6%). Mean age at examination in adolescence was 14.0 years (range 12.7–15.5 years). The examination included anthropometric measurements, serum samples and a questionnaire related to health and life style factors, pubertal development and menstrual status. The study was approved by the Regional Committee for Medical Research Ethics and by the Norwegian Data Inspectorate.In 2001–2002, girls born in the original study were invited to a follow-up examination in adolescence. Among a total of 523 invited girls, 146 were excluded because they were not born at term (before week 37 or after week 42) or because exact gestational age was missing. In addition, 39 girls were excluded either because they had died , head circumference (in mm) and subscapular skin-fold thickness . Each measure was categorised into three groups of similar size (tertiles). Information on maternal age at menarche (years) and gestational age at delivery (days) was collected at birth.Birth size measurements included length , weight (in g), ponderal index  and waist-to-hip ratio) age at menarche and to adolescent levels of oestradiol, prolactin, dehydroepiandrosterone sulphate (DHEAS), androstenedione and also free testosterone index (FTI), calculated as  × 100. Analyses of DHEAS and prolactin were carried out in all girls, regardless of menstrual status, but for oestradiol, androstenedione and FTI were restricted to those in the follicular phase of their menstrual cycle at examination . We excluded six girls who had blood levels of LH higher than 10.0 U lμmol l−1 for DHEAS, 0.7 and 11.0 nmol l−1 for androstenedione, 0.1 and 2.9 nmol l−1 for testosterone and 1.5 and 12.8 nmol l−1 for 17-OH-progesterone. The lower detection limits were 0.6 nmol l−1 for progesterone, 0.8 μmol l−1 for DHEAS and 0.1 nmol l−1 for testosterone. The lower and upper detection limits were 0.07 and 7.34 nmol l−1 for oestradiol, 3 and 180 nmol l−1 for SHBG, 0.05 and 200.00 mIU l−1 for LH and 11 and 3180 mIU l−1 for prolactin. For each hormone, analyses were performed in a single kit on the same day. For girls with levels of progesterone, oestradiol or DHEAS below the detection limit, levels were set to 0.1 nmol l−1, 0.01 nmol l−1 and 0.1 μmol l−1, respectively.Testosterone and androstenedione levels were measured by a double antibody technique on an Elecsys 2010 analyser . Levels of oestradiol, progesterone and DHEAS were measured using a competitive immunoassay on an Immulite 2000 analyser . Levels of SHBG, LH and prolactin were measured by an immunometric assay on an Immulite 2000 analyser. Reagents and calibrators supplied by the manufacturers were used. 17-OH-Progesterone levels were measured using radioimmunoassay technique with reagents and calibrators supplied by Orion Diagnostica . The lower and upper reference values for women were 0.9 and 11.7 Median age at menarche for each birth size group was estimated by Kaplan–Meier survival analysis and multivariable analysis was performed using Cox regression. Differences in adolescent body size and hormone levels between groups according to birth size, and linear trends across birth size categories, were evaluated using general linear modelling. Mean values with 95% confidence intervals (CI) within each birth size category are reported. In the hormone analyses, we used logarithmic transformation, as these variables were not normally distributed, and geometric means are therefore reported.n=195) and the random sample (n=67) for all variables included using general linear modelling. We also conducted stratified analyses of these groups for birth size related to age at menarche, adolescent body size and levels of prolactin and DHEAS. All statistical analyses were conducted using the statistical software SPSS for Windows, Release 13.0, Copyright© SPSS Inc., 1989–2004 .We evaluated potential confounding by BMI and age in adolescence, maternal age at menarche and residential area (Trondheim or Bergen). All analyses of body size and hormone levels in adolescence were adjusted for residential region and age in adolescence. In addition, we adjusted for menarcheal status (pre or post) in the analyses of adolescent body size and levels of prolactin and DHEAS. In other hormone analyses, we adjusted for time as menarche and day of menstrual cycle. All analyses were adjusted for gestational age. To minimise confounding by the relatively high prevalence of risk factors for SGA births, we compared the high-risk group (At examination during adolescence (mean age 14.0 years), 199 out of 262 girls (76.0%) had reached menarche . For allvs ⩽49 cm), the longest were on average 6.2 cm taller (164.6 vs 158.4 cm) and 4.2 kg heavier (55.0 vs 50.8 kg) in adolescence. Girls in the heaviest birth category (⩾3700 g) were 4.4 cm taller and 4.7 kg heavier in adolescence than those with birth weight below 3200 g. For ponderal index, there was a negative association with adolescent height; girls who were thin at birth were on average taller in adolescence, but the association was attenuated after adjustment for age, menarcheal status and residential region. Girls in the highest category of birth weight and head circumference had higher BMI in adolescence compared with girls of average birth size . None of the birth size variables were related to waist/hip ratio in adolescence, and skin-fold thickness at birth showed no association with any of the anthropometric variables in adolescence (data not shown). Adjustment for gestational age had no influence on the observed associations (results not shown).We found that birth length, weight and head circumference were positively associated with adolescent height and weight . The assP-trend=0.03) was attenuated after adjustment for age at puberty, menarcheal status and residential region (P-trend=0.12)  compared with 2.28 μmol l−1  for the lowest category of birth weight.A negative association between head circumference at birth and circulating level of prolactin in adolescence (nd=0.12) . For othFor girls who were in the follicular phase of the menstrual cycle , we founP-values >0.1, results not shown). Stratified analyses of these groups showed similar results as the overall analyses.Comparing girls from the random sample with those whose mothers had higher risk of delivering an SGA child, we found no difference for any of the variables , with age at menarche  through puberty and reaching a peak in early adult life, followed by a continuous decline with age . DehydroOur findings could be interpreted both as further indications of the earlier maturation previously reported in children of small birth size and as a potentially lifelong influence of developmental plasticity on adrenal androgen production. The increase in concentration of DHEAS parallels the increase in skeletal age through puberty (Oestrogens are believed to be involved in BC development, both prenatally  and lateLongitudinal growth in childhood may be positively associated with subsequent BC risk (There are only weak indications that the inverse relation of birth size with adrenal androgen production in childhood and adolescence continues into adulthood , as a smIn conclusion, relatively low birth size was associated with earlier age at menarche and larger body size in adolescence, but negatively related to adolescent DHEAS level. The results demonstrate a link between prenatal factors and subsequent growth and development.


The study was undertaken to determine anthropometric measurements, sociodemographic data, and dietary intake of 238 anaemic and 241 non-anaemic rural South African infants aged 6–12 months. Logistic regression with anaemia as a dependent variable showed an odds ratio (OR) of 1.89  for low birth-weight, 2.04 (CI 1.29–3.22) for maternal age 20 years or younger, 2.21 (CI 1.29–3.76) for consumption of tea, and 0.40 (CI 0.26–0.63) for formula feeding. The anaemic infants, aged 6−<9 months, had a lower average weight gain per month than the non-anaemic infants . Logistic regression with underweight as a dependent variable showed an OR of 3.55 (CI 1.26–10.01) for anaemia, and with stunting as a dependent variable, the OR was 2.71 (CI 1.46–5.02). Low birth-weight, a young mother aged 20 years or younger, and consumption of tea were identified as risk factors for anaemia, while formula feeding was shown to have a protective effect. The anaemic infants were more likely to show growth faltering. Information on sociodemographics, breastfeeding, and complementary feeding was collected using a questionnaire that was developed following the guidelines of Gross et al. . An unquNutrient intake was determined using a quantified single 24-hour dietary recall. Fresh food, plastic food models, household utensils, and three-dimensional sponge models were used for quantifying and recording food consumption of the previous day. In addition, dry oats were used for quantifying portion sizes of certain food items, especially cooked food. The caregiver used the dry oats for indicating the quantity resembling the amount of food that the infant consumed, which the fieldworker then quantified using a measuring cup. Food intakes reported in household measures were converted into weight using the MRC Food Quantities Manual . An intaAnthropometric measurements were taken with the infant in light clothing. Weight was measured on a calibrated load cell-operated digital scale  accurate to 50 g. Recumbent length was measured to the nearest 0.1 cm using a length board with a fixed headboard and a sliding footboard. Date of birth and birth-weight were obtained from the child's clinic card. Birth-length was not recorded as this information was incomplete on most clinic cards. The child's growth rate (g/month) was calculated based on the following formula:The anthropometric data and age of the child were used for yielding three measures of nutritional status, namely length-for-age, weight-for-age, and weight-for-length, which were expressed as z-scores using the Epi Info 2000 software package. Children with length-for-age z-score, weight-for-age z-score, and weight-for-length z-score below −2 SD of the median of the reference population were classified as stunted, underweight, and wasted respectively.A blood sample was obtained by antecubital venapuncture. One mL of blood was transferred to an EDTA tube. Haemoglobin was determined on the day of blood collection by the cyanomethaemoglobin method (Drabkin reagent) using a portable photometer . Blood samples of known haemoglobin concentrations were used as external quality control; the values measured for these quality-control samples were 113 g/L  and 163 g/L . The coefficient of variation for measurements of haemoglobin was below 5%. Anaemia was defined as a haemoglobin concentration below 110 g/L (The SPSS software (version 10.0)  was used for data analysis, except for the 24-hour dietary recall data for which the SAS software (version 8.2)  was used. The differences between anaemic and non-anaemic infants were determined using the chi-square test , analysis of variance (continuous data), and Wilcoxon two-sample test (quantified dietary intake). Potential dietary, physiological and environmental risk factors that were shown to differ between the two groups were then used for multiple logistic regression analysis, which included the potential risk factors as the independent variables and haemoglobin status (anaemic or non-anaemic) as the dependent variable. Nutrient intake was not included in the multiple logistic regression analysis because a single 24-hour dietary recall is not reflective of the individual's dietary intake (it is a reflection of the average intake of a group). Logistic regression analysis was also done with anthropometric status as a dependent variable and anaemia as an independent variable. The odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for the regression parameters. A p value of <0.05 was considered statistically significant.In total, 479 infants (250 boys and 229 girls), aged 6–12 months, were included in the study. Infants were categorized as either anaemic  or non-anaemic . Household demographic characteristics, age, anthropometric indices, and type of milk feeding of the anaemic and non-anaemic infants are given in Table Household demographic characteristics were similar between the two groups, except for availability of electricity within the household . Approximately 90% or more of the households in both the groups had access to tap-water and toilet facilities. Mothers of the anaemic infants were younger than mothers of the non-anaemic infants . At the time of the survey, 32% of the mothers were aged 20 years or younger .Birth-weights were not available for 40 infants who were born at home. Of the 439 infants who were born in a health facility, birth-weights were obtained from the clinic cards for 402 infants . Thirteen percent of these infants had a low birth-weight , with more anaemic than non-anaemic infants having low birth-weight . The mean z-score values for length-for-age of both the groups were negative, indicating a shift towards a slowing in linear growth according to the international criteria. Linear growth retardation (stunting) was more severe among the anaemic than among the non-anaemic infants . The anaemic infants had a higher prevalence of under-weight . For younger infants (6-<9 months), the average weight gain per month was lower for the anaemic than for the non-anaemic infants .Breastfeeding had been initiated for 96% of the infants; 80% of the infants were breastfeeding at the time of the survey; exclusive breastfeeding up to the age of six months was not practised. The type of milk-feeding differed between the anaemic and the non-anaemic infants. At the time of the survey, 86% of the anaemic infants were breastfeeding (vs 77% of the non-anaemic infants), and 25% were receiving formula milk (vs 48% of the non-anaemic infants). Solid foods were introduced at an average age of 3.3±1.5 months, with no difference between the anaemic and the non-anaemic infants.The proportion of infants who usually consumed certain food items at least four days per week was determined using the data from the unquantified food-frequency questionnaire and is presented in Table 6, vitamin B12, and vitamin C than the non-anaemic infants. Iron intake was well below the estimated average requirement (EAR) of the US dietary reference intakes . On average, five of the possible 11 food groups were reported per infant, with no difference between the two groups .A binary logistic regression model (forward entering) was developed using the potential risk factors that differed between the two groups. The model controlled for age. Being underweight or stunted was not included as these were probably not risk factors but outcomes of iron deficiency. Nutrient intake was also not included, as at least two days of dietary recording are needed to determine inadequate intake by individuals . Low birThree risk factors—low birth-weight, a young mother, and consumption of tea—were identified as risk factors associated with anaemia, while formula feeding was shown to have a protective effect. The anaemic infants were more likely to show growth faltering.The results of the study showed that low birth-weight was a risk factor for anaemia. An association between iron status and birth-weight has been documented previously ,19. IronInfants of young mothers were more likely to be anaemic. Similar findings were observed in Indonesia . Poor maThe initiation rate of breastfeeding, the prevalence of exclusive breastfeeding, and the average age for introducing solid foods did not differ between the anaemic and the non-anaemic infants. Current breastfeeding and formula feeding, however, differed between the two groups.The iron in breastmilk is highly bioavailable, but the concentration is very low. In this study, 59% of the 278 infants who received breastmilk but no other milk-feeds at the time of the survey were anaemic. Logistic regression analysis showed that formula feeding had a protective effect on iron status. After the age of six months, nearly all of the infants’ iron requirements must be supplied by the complementary diet, which, in this study population, was inadequate . It has The Global Strategy for Infant and Young Child Feeding acknowledges the role of fortified complementary foods to supply adequate amounts of micronutrients . In the The anaemic infants had a lower dietary intake of animal protein than the non-anaemic infants Table . AdditioNot only was the iron content of the diet lower for the anaemic than for the non-anaemic infants, but the groups also differed in intake of effectors  of iron bioavailability. Dietary vitamin C intake by the non-anaemic infants was almost twice that of the anaemic infants.Neonatal weight and length have been shown to be predictors of weight-for-age and length-for-age . When coIn conclusion, low birth-weight, a mother aged 20 years or younger, and consumption of tea were identified as risk factors for anaemia, while formula feeding had a protective effect. This study further showed that the anaemic infants had a higher chance for growth faltering in terms of both underweight and stunting. The iron content of the diet was lower for the anaemic than for the non-anaemic infants, and the groups differed in intake of several micronutrients and effectors of iron bioavailability. Greater emphasis needs to be given to the nutritional quality of complementary foods.


Hepatoblastoma is a rare embryonal tumour that comprises most cases of liver cancer in children aged 0–5 years in the United States . These oThe methods used in this case-cohort study have previously been described . For eacExposure variables derived from Minnesota birth records are shown in We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) using stratified Cox regression models using SAS 9.1  . The numOf 39 cases of hepatoblastoma identified by MCSS, 36 (92.3%) linked to birth records. Cases were compared to 7788 members of the subcohort. Exposure frequencies and adjusted HRs are presented in Very low birth weight has emerged over the past 15 years as a potent risk factor for hepatoblastoma . This stper se, VLBW likely signals the involvement of correlated factors. Limited multivariate analyses in this study and others (Rather than being causative We found a strong association with congenital abnormalities, which was attenuated but still present when controlling for VLBW. One specific abnormality, an omphalocele, was recorded, which may be indicative of Beckwith–Wiedemann syndrome, an overgrowth disorder which is known to increase the risk of hepatoblastoma . The remThe association of maternal Asian race, specifically of Southeast Asian ancestry, with hepatoblastoma was unexpected. Similar findings were not noted in studies in California (Maternal hypertension (Use of population-based registry data was the major strength of this study, as any misclassification would most likely be non-differential and HRs would be underestimated. Birth characteristics and delivery methods are reliably recorded in birth records whereas other factors, including congenital abnormalities, are substantially underreported , contribThe strong association of hepatoblastoma with VLBW has been robust to adjustment for other factors. That control for several prenatal determinants of small infant size has not explained the VLBW association may indicate that postnatal treatment is the causative correlate. Although three very small case–control studies of neonatal medical history among VLBW infants preliminarily suggest greater oxygen exposure in cases (


Iodine deficiency is a global problem representing the most common preventable cause of mental retardation. Recently, the impact of subtle deficiencies in iodine intake on children and pregnant women has been questioned. This study was designed to compare hypothyroidism among infants born to US military families in countries of varied iodine nutrition status.n = 447,691). Hypothyroidism was defined using ICD-9-CM codes from the first year of life (n = 698). The impact of birth location on hypothyroidism was assessed by comparing rates in Germany, Japan, and US territories with the United States, while controlling for infant gender, plurality, gestational age, maternal age, maternal military status, and military parent's race/ethnicity.A cohort design was used to analyze data from the Department of Defense Birth and Infant Health Registry for infants born in 2000-04 (Hypothyroidism did not vary by birth location with adjusted odds ratios (OR) as follows: Germany , Japan , and US territories . Hypothyroidism was strongly associated with preterm birth . Hypothyroidism was also increased among infants with civilian mothers , and older mothers, especially ages 40 years and older .In this study, hypothyroidism in military-dependent infants did not vary by birth location, but was associated with other risk factors, including preterm birth, civilian maternal status, and advanced maternal age. Over 1.9 billion people, 31% of the world's population, live in areas of iodine deficiency . Iodine Early public health efforts focused on severe iodine deficiency with the goal of preventing goiter and cretinism. More recently, concerns have been raised regarding the effects of lesser degrees of iodine deficiency in vulnerable populations, such as pregnant women and children. When iodine deficiency is present during the fetal stage to the third month after birth, even mild to moderate deficiency may lead to abnormalities of psychoneuromotor and intellectual development ,5.Iodine deficiency disorders were a significant problem in the United States until the 1920s, when the general use of iodized salt was initiated . Based oThe overwhelming majority of hypothyroidism during infancy is due to congenital hypothyroidism with etiologies including a variety of environmental and genetic factors, but the major determinant of prevalence worldwide is iodine intake. In areas of iodine sufficiency, congenital hypothyroidism may be as rare as 1:4000, while transient thyrotropin elevations may be seen in up to 40% of neonates in areas of severe iodine deficiency . The impFamilies of US military members often reside in countries with varied iodine nutrition status. The majority of military-dependent births outside of the United States occur in Germany where iodine intake in the host-nation population is lower than the United States, Japan where iodine intake is higher than the United States and US territories in which little data regarding iodine intake is available ,11. No pn = 26) and maternal age (n = 8), as well as the inability to reliably link diagnosis data (n = 22). In addition, only infants born in the United States, Germany, Japan, or US territories, the locations with numbers of births sufficient for comparison, were included in this study . This research has been conducted in compliance with all applicable federal regulations governing the protection of human subjects in research (Protocol NHRC.2007.0026).This cohort study used the DoD Birth and Infant Health Registry to identify all infants born to US military members during 2000-2004. Potential subjects were excluded for incomplete gender data -coded diagnoses. Further details regarding the registry have been previously published . For thin = 14,786). White, non-Hispanic race/ethnicity was designated as the reference due to the previously reported lower rates of congenital hypothyroidism for infants in this category [The independent variable of interest was birth location, and the United States, Germany, Japan, and US territories represented the location of 96.8% of all military-dependent births. Births in the current and former US territories of American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, US Virgin Islands, and other outlying islands were categorized as US territory. Variables previously shown to be associated with congenital hypothyroidism were also assessed, including maternal age, infant gender, infant plurality, and estimated gestational age -16. The Univariate analyses were performed to explore the unadjusted associations of hypothyroidism, location of birth, and demographic characteristics. The impact of independent variables on hypothyroidism was estimated as crude and adjusted odds ratios with 95% confidence intervals by applying a multivariable logistic regression model. Regression diagnostics and multicollinearity investigations were completed. All independent variables were included in the final logistic regression model due to either significant unadjusted odds ratios or previously reported associations with congenital hypothyroidism. Computer analyses were performed using SAS version 9.1 .n = 447,691) are illustrated in Table The characteristics of the study population of infants from the DoD Birth and Infant Health Registry born in 2000-2004 (Odds ratios for the associations of hypothyroidism with birth location and other independent characteristics are shown in Table In this study of infants born to US military families, our data did not demonstrate differences in hypothyroidism for the birth locations examined. Iodine intake has never been studied in these military family populations and the application of practices that may increase iodine intake, such as consuming US-based food products on military bases or iodine-containing prenatal vitamins, is unknown. For example, the Department of Defense uses multiple US-based sources for prenatal vitamins and during the period of this study, some of the sources contained iodine and others did not. With the lack of information regarding iodine intake among US military families, the findings of this study are reassuring given the historical differences in iodine intake and iodine deficiency disorders in the host nation populations in these regions of the world. In the 1980s, estimates of transient neonatal hypothyroidism in Belgium were as high as 1:100 compared with 1:50 000 in the United States . Over thGiven universal screening for congenital hypothyroidism at birth, along with the rare clinical recognition of acquired hypothyroidism due to indolent onset and nonspecific symptoms during infancy, the majority of cases of hypothyroidism in our study likely represent congenital hypothyroidism, despite provider use of both ICD-9-CM codes 243, congenital hypothyroidism, and 244, acquired hypothyroidism. This is supported by the fact that 76.1% of those with ICD-9-CM code 243 and 58.8% of those with ICD-9 code 244 had diagnostic codes entered within the first 10 weeks of life. Iodine deficiency is responsible for the majority of transient congenital hypothyroidism, while permanent congenital hypothyroidism causes include thyroid dysgenesis, dyshormonogenesis, and central hypothyroidism and is relatively rare, with incidence estimates for each etiology ranging from 1:4500 to 1:100 000 . With thIn our study, the factor most strongly association with hypothyroidism was preterm birth. This is consistent with previous descriptive studies of congenital hypothyroidism and is thought to represent transient hypothyroxinemia, due to incomplete thyroid gland development ,21. We aInterestingly, we did not find hypothyroidism to be associated with infant gender, while most prior studies of congenital hypothyroidism have shown a female predominance ,20,22-24While the DoD Birth and Infant Health Registry provides many advantages, certain limitations must be considered. Defining cases by ICD-9-CM code alone raises concern regarding the accuracy of the outcome measure. However, given that screening is universal, health care encounter data are captured electronically, the number of hypothyroidism codes is limited, and hypothyroidism care requires multiple clinic visits for the infant, unidentified cases of hypothyroidism should be rare in this study. In addition, we required diagnostic codes from two separate health care encounter dates to improve specificity, primarily by excluding visits to perform screening tests. The use of birth location as a measure of the geographically-defined iodine nutrition exposure also has potential limitations. However, given that thyroid function adapts to changes in iodine intake within weeks and travel during the final weeks of pregnancy is uncommon, birth location likely corresponds well with the location of iodine exposure that would impact thyroid function at the time of birth. Finally, the birth locations examined in this study were limited to those with the largest sample sizes and the possibility of the presence of locations of greater risk must be considered.Military families and other mobile populations assume health risks associated with their varied environments. Therefore, ongoing surveillance and studies are needed to detect adverse outcomes and determine the need for intervention. In this study, the DoD Birth and Infant Health Registry allowed for the first-ever investigation of an iodine-dependent outcome in a mobile population across different locations. While the assessment of other potential risk factors contributes to the overall understanding of hypothyroidism in infancy, the lack of differences in hypothyroidism rates for the geographic areas studied provides much-needed reassurance for military families and medical providers.The authors declare that they have no competing interests.MC, MR, TS, CS, and SB all helped conceive the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6823/10/2/prepub


Earthquakes and other catastrophic events frequently occurring worldwide can be considered as outliers and cause a growing and urgent need to improve our understanding of the negative effects imposed by such disasters. Earthquakes can intensively impact the birth outcomes upon psychological and morphological development of the unborn children, albeit detailed characteristics remain obscure.We utilized the birth records at Du Jiang Yan and Peng Zhou counties to investigate the birth outcomes as a consequence of a major earthquake occurred in Wenchuan, China on May 12, 2008. Totally 13,003 of neonates were recorded, with 6638 and 6365 for pre- and post- earthquake, respectively. Significant low birthweight, high ratio of low birthweight, and low Apgar scores of post-earthquake group were observed. In contrast, the sex ratio at birth, birth length and length of gestation did not show statistical differences. The overall ratio of birth-defect in the post-earthquake (1.18%) is statistically high than that of pre-earthquake (0.99%), especially for those in the first trimester on earthquake day (1.47%). The birth-defect spectrum was dramatically altered after earthquake, with the markedly increased occurrences of ear malformations. The ratio of preterm birth post-earthquake (7.41%) is significant increased than that of pre-earthquake (5.63%). For the birth outcomes of twins, significant differences of the ratio of twins, birth weight, ratio of low birthweight and birth-defect rate were observed after earthquake.A hospital-based study of birth outcomes impacted by the Wenchuan earthquake shows that the earthquake was associated with significant effects on birth outcomes, indicating it is a major monitor for long-term pregnant outcomes. On May 12, 2008, a catastrophic earthquake measuring 8.0 on the Richter scale hit Wenchuan, in southwestern China, leading to 69,227 deaths and 374,643 injuries, with 17,923 listed as missing Major earthquakes and other catastrophic events can be considered as outliers and result from mechanisms involving amplifying critical cascades Birth outcomes could be intensively impacted by all kinds of environmental calamities. The effects of a major earthquake can significantly impact the psychological and intellectual development of fetus In this study, we evaluated the birth outcomes before and after the Wenchuan earthquake. Here we report profound effects of the earthquake upon birth-defect, birth weight and sex ratio at birth and other primary characteristics. Our data suggest that rare catastrophic events are often a major monitor for long-term reproductive health and pregnant outcome in the affected population.This work was conducted according to the principles expressed in the Declaration of Helsinki, and approved by the Ethics Board, Chengdu University of Traditional Chinese Medicine. We employed exactly two year's data of birth redords. Those collected from May 12, 2007 through May 11, 2008 were put into a pre-earthquake group, while samples collected from May 12, 2008 through May 11, 2009 were included as a post-earthquake group. All participants signed informed consent before investigation. All parents or guardians of the neonates gave informed consent to publication of their case details in a style of anonymity. We began the observation on July 25, 2008. Of those delieved after July 25, 2008, their parents consented at the time of their usual hospital care during the birth. While for those born on July 25, 2008 or before, the informed consents were signed within the homes of their parents or guardians prior to the utilization of their medical records. Although some birth records were retrospectively collected, there has no substantive discrepancy on the collected data, because they are all objective and quantitive data recoded in the medical records of all neonates Two representative areas, Du Jiang Yan and Peng Zhou counties, were chosen for the research. Both of them are located less than 20 kilometers from the earthquake center, Yin Xiu Town in Wenchuan County, and were severely damaged. Samples were collected from every local hospital.Every case of parturition occurring in the observed counties during survey period was included in the analysis. Major data for pregnant outcome, including age of pregnant women, birth length, birth weight and length of pregnancy, were evaluated by two independent researcher groups. Data criteria were as follows:Low-birth weight neonates: defined as birth weight <or = 2500 gram.Preterm infants: defined as length of gestation <or  = 36 weeks.Birth defects: referred to concepts defined in gynecological textbooks. As the first trimester is a key period for organ formation, we further classified these into three groups, e.g. first trimester pregnancy on earthquake day, second and third trimester pregnancy on earthquake day, and post-earthquake pregnancy.Apgar score: a standard evaluation for neonates, performed within one minute or five minutes after birth All data were analyzed using SPSS version 15.0 . We generated descriptive statistics and bivariate associations for all variables and examined them for distributional normality. Numbers fit to normal distribution were analyzed by two-tailed t test and/or chi 2 test. For data that did not meet the distributional normality, a Mann-Whitney U test was applied. The significant differences were defined as P value less than 0.05.A total of 13,003 of neonates were recorded in the local hospitals of Du Jiang Yan and Peng Zhou, two counties severely devastated by the Wenchuan earthquake. For general maternal index, no significant differences were observed between pre-earquake group and post-earthquake group . The preDuring our survey periods, 141 infants with birth-defect were observed. Compared with healthy neonates . Importantly, neonates delivered from Dec. 12, 2008 through Feb. 11, 2009, who were in the first trimester on the day of the earthquake, demonstrated a much higher ratio of birth-defects than either pre-earthquake group or other post-earthquake groups .We further subdivided the categories of birth defects . The resThe Wenchuan earthquake was one of the most serious natural disasters in Chinese history. More than 250,000 square kilometers of Chinese land was ruined, 89,150 persons were killed or reported as missing It is established that antenatal stress is associated with various adverse birth outcomes in humans and other animals The most notable result of the present study was the significantly high ratio of birth-defects connected with the Wenchuan earthquake. There is little data regarding our observation that has been previously reported in the medical literature. Montenegro et al. Interestingly, neonates who were in the first trimester on the day of the earthquake displayed a statistically significantly higher birth-defect ratio when compared with other post-earthquake groups. Consistent with this observation is that several reports have shown that pregnancy is more susceptible to stress effects in the first trimester than during the second and third trimesters Another unexpected finding is the apparently changed spectrum of birth defects seen associated with the Wenchuan earthquake . The aveA main finding in this study is that the average post-earthquake birthweight was statistically decreased. Lower birth weight is usually associated with increased fetal mortality, neonatal mortality, infant mortality and increased susceptibility to stress in adulthood It is worth noting that the ratio of low birthweight (5.01%) observed after the Wenchuan earthquake is lower than that of previously reported, such as that recorded after the Taiwan major earthquake (7.8%) We do not observe the skewed sex ratio at birth within the survey period. Several publications reported that the human secondary sex ratio falls in populations subjected to exogenous stressors such as earthquakes or political and social upheavals The birth outcomes of twins suffering from prenatal disaster, Wenchuan earthquake, is of interest. Our results indicate that earthquake could increase the ratio of twins, and extensively impair the birth outcomes . FurtherThere are a number of limitations to the present study. First, the sampling area is only the minor portion of the devastated region of the Wenchuan earthquake, so it might not fully represent the overall conditions. Second, the relatively small sample size of twins and birth defects may have led to inadequate statistical power and warrants caution in interpretation of the data. Last, we did not include a few pregnancies inside the survey area who subsequently moved outside the earthquake area, as data on these cases were generally unavailable. Regardless our data provide new and relevant information on the consequences of a natural disaster on birth outcomes.


Amyloid-β is recognized as the major constituent of senile plaque found in subjects with Alzheimer's disease. However, there is increasing evidence that in a physiological context amyloid-β may serve as regulating apolipoprotein, primarily of the triglyceride enriched lipoproteins. To consider this hypothesis further, this study utilized an in vivo immunological approach to explore in lipogenic tissue whether amyloid-β colocalizes with nascent triglyceride-rich lipoproteins.In murine absorptive epithelial cells of the small intestine, amyloid-β had remarkable colocalization with chylomicrons (Manders overlap coefficient = 0.73 ± 0.03 (SEM)), the latter identified as immunoreactive apolipoprotein B. A diet enriched in saturated fats doubled the abundance of both amyloid-β and apo B and increased the overlap coefficient of the two proteins (0.87 ± 0.02). However, there was no evidence that abundance of the two proteins was interdependent within the enterocytes (Pearson's Coefficient < 0.02 ± 0.03), or in plasma (Pearson's Coefficient < 0.01).The findings of this study are consistent with the possibility that amyloid-β is secreted by enterocytes as an apolipoprotein component of chylomicrons. However, secretion of amyloid-β appears to be independent of chylomicron biogenesis. Amyloid-β is recognized as the principal protein in senile plaques in subjects with Alzheimer's disease (AD) . GeneratSeveral lines of evidence suggest that one physiological role for amyloid-β is as a regulating apolipoprotein, particularly of the triglyceride-rich lipoproteins (TRL's). Koudinov et al reported that amyloid-β is secreted by hepatocytes as a lipoprotein complex . SignifiThe βAPP is expressed on the plasma membrane of a number of tissues including lipogenic organs such as liver . Proteolad libitum. After three-months of dietary intervention, mice were sacrificed by pentobarbital injection. The small intestine was isolated and flushed with chilled phosphate buffered saline . A 2 cm segment of the small intestine distal to the duodenum was fixed in 4% paraformaldehyde for a minimum of 24 h, processed and longitudinal segments embedded in paraffin wax. Serial sections of 5 μm thick were cut on microtome and mounted on silanised slides for histology and immunofluorescence microscopy.The protocols described in this study were approved by an accredited National Health and Medical Research Council of Australia Animal Ethics Committee . Six-week-old female C57BL/6J mice  were divided randomly into a low-fat (LF) or saturated fatty acid (SFA) diet group. Low fat mice were given chow that contained 3.6% (w/w) as unsaturated fat and 0.4% SFA . The SFA enriched chow contained 12.9% (w/w) as saturated fats and 7.4% as unsaturated oils . Both diets were free of cholesterol. Digestible energy for LF and SFA feed were 15.1 MJ/kg and 18.8 MJ/kg respectively and feed was available Anti-apo B, anti Golgi-apparatus (anti-Golgi 58 K), anti-rabbit IgG with Alexa488, and streptavidin-Alexa546 were obtained from Invitrogen . Anti-rabbit IgG biotin conjugate was obtained from DAKO . Rabbit anti-human amyloid-β was obtained from Chemicon International .An established double IF labelling method was utilized as previously described . Cross rAnti-amyloid-β (1:1000) was added to sections overnight at 4°C, followed by addition of goat anti-rabbit IgG with biotin (1:200) for 1 h at room temperature. Thereafter, anti-Golgi-apparatus (1:10) was added overnight at 4°C. Immunofluorescence was detected by streptavidin-Alexa546 (1:100) and anti-rabbit IgG with Alexa488 (1:100) for amyloid-β and Golgi-apparatus respectively. Cell nuclei were detected using DAPI and slides were mounted using anti-fade mounting medium. The same method was used to achieve double apo B and Golgi-apparatus staining by substituting the anti-amyloid-β with anti-apo B (1:400).Digital images were captured using AxioCam mRM and ApoTome on a Zeiss Axiovert 200 M inverted microscope and visualized with Plan-NeoFluar lenses . Excitation and emission were achieved by using filters 43  and 38  to determine fluorescence of Alexa546 and Alexa488 respectively. Filter 49  was used to detect nuclei stain DAPI. Individual channels are devoid of fluorescence from other emission sources and are therefore clear of bleed-through.Three-dimensional images were captured using the ApoTome optical sectioning mode which allows the creation of a 3D image based on the 'stacking' of consecutive 2D images. Each 3D image consisted from 8-10 2D images, and the axial distance of Z-stack was 0.5 μm for 200×. There were 6 animals per group with a minimum of 40 images per mouse used for analysis. Fluorescent intensity and area were determined using the measurement and colocalization module available on AxioVision v4.7.1 software .There are several algorithms capable of achieving measures of colocalization or association via measurement of fluorescent pixel spatial orientation and pixel intensity. The Pearson's correlation coefficient (r) is a commonly used quantitative estimate of association (abundance) for proteins . HoweverPlasma samples were separated on NuPAGE 3-8% Tris-acetate gels  at 150 V (Biorad Model 20012.0) for 1 hr. Gels were then electrotransferred to PVDF membranes  at 40 V for 1 hr and blocked in 10% skim milk (in TBST) overnight at 4°C. The membranes were incubated with polyclonal rabbit anti-human apo B 1:100 , and then with donkey anti-rabbit immunoglobulin G (IgG) horseradish peroxidase (HRP) . Proteins were detected using enhanced chemiluminescence reagent (ECL™) western blotting analysis system . Membranes were exposed to high performance chemiluminescence film  and developed in an AGFA-Gevaert Rapidoprint X-Ray Developer . Apo B48 bands were identified and quantified by densitometry against purified apo B48 protein of known mass (550 kDa for apo B-100 and 260 kDa for apo B48).Plasma amyloid-β 40/42 levels were measured using commercially available ELISA kits .Enterocytic colocation of amyloid-β with apo B was determined by an automated procedure based on spatial statistics to determine Pearson's correlation coefficient and Manders OC (AxioVision 4.0). The association between total apo B, apo B48, and apo B100 with total amyloid-β, amyloid-β40 and amyloid-β42 were examined using Pearson's and Spearman's correlation. Spearman's correlation was used when the assumptions of the analysis were violated due to the presence of outliers. P-values less than 5% were considered as statistically significant and the data was analysed using SPSS version 17.0.Enterocytic chylomicrons were detected by determining the distribution of apo B, an obligatory structural component of chylomicrons. Significant amounts of amyloid-β and apo B were found to be enriched within the perinuclear region of cells. Amyloid-β and apo B colocalized with the Golgi-apparatus, towards the basolateral surface of the cell and within the lacteals Figure . The patp < 0.05) to nearly 87% . The relative abundance of amyloid-β and apo B in LF and in SFA fed mice, given as mean densitometric sum. In LF mice, approximately 73% of immunodetectable amyloid-β colocated with apo B, but in SFA mice this was significantly increased (To explore if abundance of the amyloid-β was inter-dependent with TRL biogenesis and secretion, correlation analysis with apo B was determined within enterocytes and in plasma respectively. Pearson's correlation analysis found that just 2% of amyloid-β and apo B fluorescent intensities were positively associated in enterocytes of LF or any of the SFA fed mice table . SimilarIn this study the distribution and abundance of amyloid-β and apo B were detected in small intestinal enterocytes using an established double-labeled avidin-biotin IF microscopy technique . AmyloidThe biosynthesis of chylomicrons occurs in a multi-step process that requires the progressive lipidation of apo B an obligatory structural component of primordial lipoproteins secreted by the small intestine ,21. A nuImmunoreactivity for amyloid-β and apo B was found selectively within the ER/Golgi-apparatus and not on the plasma membrane. The findings are consistent with biogenesis of amyloid-β at the ER and translocation to primordial lipoproteins, rather than as a consequence of β APP processing. Similar results in hepatocyte cultures with secretion of amyloid-β also occurring exclusively as a lipoprotein complex .APP. Alternatively, amyloid-β is an amphiphatic protein with a C-terminal domain that avidly binds with negatively charged hydrophobic lipids [Dietary SFA promote chylomicron biogenesis by stimulating apo B lipidation ,23, an ec lipids . IncreasThe SFA induction and secretion of enterocytic amyloid-β may be important in the context of AD risk. Recent studies suggest that blood-to-brain delivery of amyloid-β may contribute to amyloidosis, particularly when the concentration of circulating amyloid-β is chronically elevated -28. ThisIn this study, evidence in vivo that amyloid-β is secreted as a chylomicron complex and is stimulated by dietary SFA's is presented. Exploring this phenomenon in the context of plasma amyloid-β homeostasis and lipoprotein kinetics may provide insight into the putative association of high-fat diet with AD risk.AD: Alzheimer's disease; apo: apolipoprotein; βAPP: β-amyloid precursor protein; IF: immunofluorescence; LF: low-fat; OC: overlap coefficient; PBS: phosphate buffered saline; SFA: saturated-fatty-acid; TRL: triglyceride-rich-lipoproteinThe authors acknowledge that there is no conflict of interest of any prior publication of any materials presented herein. All authors have seen and support the publication of this manuscript.SG carried out the design of project, collection of data, immunofluorescence, statistical analysis and drafting of the manuscript. RT and MP-G assisted in the collection of tissues, interpretation of data and critically analyzing the manuscript content. SD helped in the statistical analysis of data and critically analyzing the manuscript content. JM conceived the study, helped in the interpretation of data, drafting of the manuscript, acquiring funding and role in general supervision of the research group. All authors have approved submission of the manuscript.