Preterm birth is still a global burden particularly in Indonesia. The suboptimal concentration of certain micronutrients and heavy metals is hypothesized to play a role in the mechanism of preterm birth. This study aimed to analyze the micronutrients and heavy metals concentrations between subjects with term and preterm birth. A cross-sectional study was conducted during January–June 2017 in Cipto Mangunkusumo Hospital and Budi Kemuliaan Hospital, Jakarta, Indonesia. Subjects were divided into term and preterm birth groups. The measured outcomes were maternal serum, placental, and blood cord concentration of zinc, copper, iron, selenium, manganese, mercury, lead, AtRA, and 25(OH)D.μg/g versus 0.42 ± 0.18 μg/g, p <0.001}, iron , copper {2.96 ± 1.80 μg/g versus 1.62 (0.70 – 3.88) μg/g, p 0.019}, zinc {58.34 (27.88 – 124.05) μg/g versus 28.41 (1.46 – 137.69) μg/g, p 0.011}, selenium , AtRA {21.7 ± 10.69 ng/g versus 0.7 (0.42 – 5.10) ng/g, p <0.001}, and 25(OH)D {75.84 ± 45.12 ng/g versus 18.00 (5 – 88) ng/g, p <0.001}, lower placental concentration of mercury  and lead , and higher cord blood concentration of copper {32.20 (16.30 – 69.60) μg/dL versus 20.60 (5.80 – 53.30) μg/dL, p 0.006} and AtRA . A total of 51 pregnant women participated in this study. Term group had higher concentration of maternal serum AtRA , higher placental concentration of manganese {0.99 (0.38 – 1.78)  Preterm birth is associated with lower concentrations of micronutrients which play a role in antioxidant mechanism, as well as higher concentration of mercury and lead. Preterm birth, defined as babies born alive before 37 weeks of pregnancy, remains the leading cause of mortality and morbidity of children under the age of 5 in global scale, particularly in a developing country such as Indonesia. As much as 15 out of 100 babies are delivered prematurely, contributing to 35.5% of neonatal death in the country , 3.Micronutrients are essential inorganic constituents for human health although only needed in minute quantities. Suboptimal status of micronutrients, whether deficiency or excess, could lead to detrimental pregnancy outcome, although it is difficult to identify since many pregnancy complications are often multifactorial. The knowledge of trace elements and vitamins role has been progressive for the past 40 years. Essential trace elements of the human body include iron (Fe), zinc (Zn), copper (Cu), selenium (Se), and manganese (Mn). These elements are related in so many enzymes that single trace element deficiency is often not associated with specific clinical manifestation, but it manifests as a combination of various symptoms .Studies have demonstrated the role of trace elements along with vitamin A and vitamin D in antioxidant activity which is very important in pregnancy. Preeclampsia, preterm birth, and intrauterine growth restriction are among pregnancy complications related to inflammatory state. Micronutrients also play role in the division and differentiation of fetal cells and their development .Concentrations of micronutrients is affected by dietary habit, lifestyle, and environmental condition. Following industrial revolution, mercury (Hg) and lead (Pb) are gaining attention regarding environmental exposure and their effects in the body. During pregnancy, even low lead concentration could have adverse effects such as developmental delays, low birthweight, and miscarriage. Contamination of mercury occurs primarily through the consumption of contaminated seafood and rice grown in contaminated waters. It is actively transported across the placenta and impairs fetal neurodevelopment , 7.We believe it is important to evaluate the status of micronutrients of pregnant women and whether its concentration is different between term and preterm birth in Indonesia. By gaining the knowledge about the exact role of micronutrients in the pregnancy, better nutrient approach of pregnancy would be achieved to optimize the normal pregnancy and to reduce the incidence of pregnancy complications, particularly preterm birth.A cross-sectional study was conducted to expand the knowledge about the status of micronutrients in pregnant women who gave birth at term and preterm. The measured outcomes were maternal serum, placental, and blood cord concentration of zinc, copper, iron, selenium, manganese, mercury, lead, AtRA, and 25(OH)D. Subjects were selected by consecutive sampling technique.Sample was taken in Cipto Mangunkusumo National Central General Hospital and Budi Kemuliaan Hospital during January–June 2017. This study has been approved by Ethics Committee of Faculty of Medicine of Universitas Indonesia (LB.01.01/X.2/179/2016).The inclusion criteria were pregnant women undergoing preterm birth in 26–36 weeks of gestational age for the preterm groups and ≥37 weeks of gestational age for the term group and agreed to participate by signing informed consent. The exclusion criteria were subjects with multiple pregnancies, intrauterine growth restriction (IUGR), fetal congenital anomaly, preterm premature rupture of membrane (PPROM), and other comorbidities .All of the samples were obtained soon after delivery. 15 cc of maternal blood sample was obtained from the vein and then put into serum separator tube (SST) for AtRA and 25(OH)D measurement as well as trace element clot activator tube to measure other trace elements. Samples were then sent within 30 minutes to Prodia Laboratory, Jakarta. Samples were centrifuged for 10 minutes and were kept at –80°C. Placental tissues were taken from marginal placenta and full-thickness-parenchymal placenta. Each sample was put into phosphate-buffered saline (PBS) solution and then kept at 4°C for maximum 24 hours.Zinc, copper, iron, selenium, manganese, mercury, and lead were measured by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS) using Agilent-MS 7700x series. Samples were diluted to 2 mL with a matrix solution containing 0.05 mL of concentrated ammonia, 1 mL of 0.01 M disodium ethylenediaminetetraacetate, 0.7 mL of Triton X-100, and 20 mL of butanol per liter . AtRA anData was processed using IBM SPSS version 20 program. Data analysis was conducted using Shapiro-Wilk normality test, hypothesis test according to variable type and data normality, and correlation test according to data normality. The data were supplemented with 95% confidence interval, with the significance limit being set to p ≤ 0.05.A total of 51 pregnant women were selected, divided into term group and preterm group. Our finding about higher stature in preterm group contradicted with several studies that showed that lower maternal stature was associated with decreasing gestational age mainly due to maternal anatomical constraints and immature physical development in teenage pregnancy –13. The Both groups had concentration of serum zinc and 25(OH)D below normal range as well as serum copper above normal range. The concentration of zinc and 25(OH)D corresponds to another study in Indonesia that as much as 81.2% of its population have zinc deficiency and 99.6% have 25(OH)D deficiency . CurrentκB activity through activation of retinoic acid receptor, resulting in reduction of inflammatory state. This mechanism might be the explanation of protective effects of AtRA in preventing preterm birth [Term group had higher concentration of serum AtRA. AtRA is a vitamin A derivate that decreases cytokine expression in vitro and regulates Treg cells to promote anti-inflammation and differentiation of T effector cells. It also restricts NF-rm birth , 16.The results of supplementation of vitamin A in pregnancy are contradictory. The reports, consisting of 35 trials, were summarized by a Cochrane report and were concluded that vitamin A supplementation during pregnancy does not help to prevent preterm birth directly, but it reduces maternal anemia and maternal infection. However, multiple studies in the report showed that vitamin A deficiency is associated with preterm birth. This might highlight the importance of reaching adequate preconceptional nutrition .In contrast with serum findings, the trace elements in placenta were significantly different between two groups. Placental concentration of what is known to play anti-inflammatory function such as manganese, copper, zinc, and selenium was higher in term group. During placentation, the release of trophoblast plugs with flow of blood into the intervillous space leads to the generation of oxidative stress. However, placenta is armed with antioxidant including selenium-dependent enzymes of glutathione peroxidase, thioredoxin reductases, selenoprotein-P, as well as copper/zinc, and manganese superoxide dismutase, which require the mentioned trace elements . The faiSome trace elements undergo active transport. Nandakumaran et al. reported that manganese is actively transported across the placental membrane, explaining the difference in manganese placental concentration despite no significant difference of manganese concentration in maternal serum . Terrin Lower copper concentrations are observed in both placental and cord blood of preterm group. This is expected because fetal serum copper concentrations reach a maximum at the end of the last trimester of pregnancy, whereas the liver of premature infant is immature and cannot accumulate copper. Copper is bound to chaperone proteins, which deliver it to the target molecule. There are two Cu-ATPases expressed in placenta, ATP7A and ATP7B , 22. SelAlthough serum concentration was below normal range, placental concentration of 25(OH)D was also higher in term group compared to preterm group. Not only beneficial to bone metabolism, vitamin D along with its derivatives plays a role in immune system, particularly innate immune response. Deficiency in vitamin D is associated with poor pregnancy outcomes including intrauterine growth restriction and preterm birth .Despite lower placental iron concentration in preterm birth, the iron cord blood concentration is not different between groups. The most circulating fetal iron will be metabolized by fetus leaving less iron in fetal circulation, which is interrupted by preterm birth, resulting in iron stores at birth being proportional to birthweight. The seemingly normal iron concentration in preterm cord blood might not indicate the real iron store but rather a systemic inflammatory response that is common in preterm infants. Placenta exhibits great capacity to mobilize iron for fetal use regardless of maternal status. Hepcidin, the iron regulatory “hormone” expressed by the liver, negatively regulates cellular iron transport via an FPN1-dependent mechanism, although several studies have contradictory results , 25.On the other hand, preterm group showed higher placental concentrations of lead and mercury, but no significant difference was found in the cord blood sample. Lead readily crosses the placenta by passive diffusion and accumulates in placenta and fetal tissues, such as fetal liver. Depending on its form, mercury could cross the placenta by passive diffusion (vapor mercury) or active transport (methyl mercury). Metallothionein (MT) is likely responsible for binding the heavy metals in the placenta. There is evidence that mercury and lead are able to induce MT synthesis in placenta so that they do not cross the placenta to the fetal blood . MercuryWe did not observe any correlation between maternal serum, placental, and cord blood of the same elements except AtRA that correlated positively between all the specimens {p <0.001, r 0.703 , r 0.570 , and r 0.620 }. It was found, however, that many elements in placenta had negative correlation with mercury and lead and also positive correlation with each other.Several studies showed that micronutrient supplementation and higher concentration of zinc and iron have a positive impact to mitigate lead toxicity , 32. Pb The difference of micronutrients concentration was found between term and preterm births. Preterm birth is associated with lower concentrations of micronutrients which play role in antioxidant mechanism, as well as higher concentration of heavy metals such as mercury and lead. Compared to preterm birth group, term birth group had higher concentration of AtRA in maternal serum, higher placental concentration of manganese, iron, copper, zinc, selenium, AtRA, and 25(OH)D, lower placental concentration of mercury and lead, and higher concentration of copper and AtRA in cord blood.


Recent studies are suggesting a U-shaped relationship between antenatal iron exposure and birth outcomes. Little is known about the iron status and associated birth outcomes of pregnant women in South Africa. Our aim was to assess iron status at early, mid- and late pregnancy, and to determine associations with gestational age and birth weight in women in Johannesburg, South Africa.In this prospective study of 250 pregnant women, we measured haemoglobin, biomarkers of iron status and inflammation at <18, 22 and 36 weeks of gestation, plus birth weight and gestational age at delivery. Associations of anaemia and iron status with birth outcomes were determined using regression models adjusted for confounders.At enrolment, the prevalence of anaemia, iron depletion (ID) and iron deficiency erythropoiesis (IDE) was 29%, 15% and 15%, respectively, and increased significantly with pregnancy progression. Anaemia and ID at 22 weeks, as well as IDE at 36 weeks were associated with higher birth weight . Women in the lowest ferritin quartile at 22 weeks gave birth to babies weighing 312 g  more than those in the highest quartile. In contrast, IDE at 22 weeks was associated with a higher risk for premature birth  and women in lower haemoglobin quartiles at <18 weeks had a shorter gestation by 7 days  compared to those in the highest quartile.Anaemia, ID and IDE prevalence increased during pregnancy despite routine iron supplementation. ID and anaemia at mid-pregnancy were associated with higher birth weight, while IDE was associated with premature birth. These results suggest that current antenatal screening and supplementation practices in South Africa need to be revisited. Iron deficiency anaemia (IDA) is the result of prolonged iron depletion and affects a third of the world’s population . PregnanData on iron intake and status of pregnant women in South Africa are sparse. National data on anaemia and iron status are available for women of reproductive age only. The South Africa Demographic and Health Survey conducted in 2016 estimated that 33% of women of reproductive age 15–49 years) are anaemic . In the  years arGuidelines for maternity care in South Africa  vs 27.1 [23.3–30.8] kg/m2) and fewer women had increased CRP (p<0.01). The median birth weight was 3050 (2324–3380) grams and 14% (n = 29) of the babies were born with LBW (<2500 g). The median gestational age at birth was 274 (266–282) days and 11% (n = 26) of babies were born preterm (<259 days).Characteristics of pregnant women at enrolment (<18 weeks of gestation) in the total study group, as well as by birth outcome, are shown in p = 0.45) nor between the ID and non-ID women (p = 0.24). Most women (62%) consumed less iron than the Estimated Average Requirement (EAR) (22 mg/day) for women during pregnancy, and two women (1%) had a dietary iron intake above the upper limit (UL) (45 mg) from foods  g/dL) (p = 0.88). Anaemia prevalence (using the WHO cut-off: haemoglobin <11 g/dL throughout pregnancy) increased from 29% to 44% (p<0.001) and 45% (p = 0.99) at the three time points, respectively. However, when using the more conservative haemoglobin cut-off of <10.5 g/dL for the second and third time points, the anaemia prevalence of 29% at early pregnancy remained unchanged at the second  and third  visit. Median adjusted ferritin concentrations declined gradually and significantly from 47.6 (21.3–98.7) μg/L to 31.7 (17.8–58.6) μg/L and 20.8 (13.9–40.1) μg/L at the three time points, respectively. ID prevalence increased from 15% to 19% (p = 0.06) and 33% (p = 0.001). The prevalence of IDA (using WHO haemoglobin cut-off) increased from 9% to 14% (p = 0.08) and 23% (p = 0.008), while the prevalence of IDA using the lower haemoglobin cut-off changed from 9% to 11% (p = 0.68) and 19% (p = 0.01). Median sTfR concentrations increased significantly from 4.8 (3.8–6.6) mg/L at <18 weeks to 6.8 (5.4–8.3) and 8.1 (6.5–10.5) mg/L with pregnancy progression. Consequently, IDE prevalence increased significantly from 15% to 25% and 47% during pregnancy. Both median CRP and AGP concentrations declined significantly with pregnancy progression. At enrolment, 60% of participants had elevated CRP (>5 mg/L) and 11% had elevated AGP (>1 g/L) ((>1 g/L) .Results from the logistic regression analyses of the associations of maternal iron status with LBW as well as preterm birth as binary outcomes are shown in Anaemia defined using the WHO cut-off (haemoglobin <11 g/dL) at 22 weeks of gestation was associated with an increase in gestational age by 5 days . This association did not hold when the lower haemoglobin cut-off was used (haemoglobin <10.5 g/dL).p<0.001). Women in the third ferritin quartile (ferritin 20.80–40.08 μg/L) at 36 weeks of gestation also had significantly heavier babies  than women in the highest quartile (>40.08 μg/L).To further investigate the association of low and high concentrations of iron biomarkers with birth outcomes, haematological biomarker concentrations were divided in quartiles, and univariate comparisons of birth weight and gestational age conducted in adjusted models as shown in In this prospective study of pregnant women residing in Johannesburg, South Africa, the prevalence of anaemia, ID and IDE increased despite iron supplementation forming part of routine antenatal care. We found that ID and anaemia at mid-pregnancy, as well as IDE at late-pregnancy were associated with higher birth weight. In contrast, women with IDE at mid-pregnancy had a 3.6 times higher risk of giving birth prematurely and women with a lower haemoglobin at early pregnancy gave birth significantly earlier than those in the highest haemoglobin quartile.In this sample of generally healthy, non-smoking, singleton pregnancies from an urban area of South Africa, we observed a similar iron deficiency prevalence during early pregnancy as in women of reproductive age participating in previous national surveys ,8,40. MoGuidelines for maternity care South Africa [It is also known that serum ferritin concentrations gradually decline with pregnancy progression. While haemodilution may explain this phenomenon, it has been suggested that declines in serum ferritin concentrations may reflect iron mobilisation from stores to cover increased requirements for red blood cell production, as well as placental transfer to the foetus . In our h Africa  indicateIn our sample, the mean daily iron intake  at early pregnancy was approximately 3 mg less than the EAR for pregnant women (22 mg/day), but sufficient to meet the EAR for non-pregnant women (8.1 mg/day) . This suIn our sample, anaemia and ID at mid-pregnancy were associated with a 207 g and 205 g higher birth weight, respectively. Consistently, IDE at late pregnancy was associated with a 178 g higher birth weight. When comparing quartiles of ferritin concentration at mid-pregnancy, women in the lowest quartile (ferritin <17.78 μg/L) gave birth to significantly heavier babies (312 g) than women in the highest quartile (ferritin >58.63 μg/L). To our knowledge, we are the second study in an African setting (with routine iron supplementation ) to findThe observed inverse associations between maternal iron status and birth weight in settings of routine iron supplementation can be interpreted from two viewpoints. Firstly, the association between ID, anaemia and IDE with higher birth weight could be an indication that antenatal iron supplementation is protective in iron depleted women, resulting in improved foetal growth . SystemaWhen we assessed the predictors for gestational age, associations were different than for birth weight. Firstly, lower haemoglobin in early pregnancy was associated with shorter gestation which supports previous research . It is sThe key strength of this study was that data were collected prospectively with multiple variables and data collection points across pregnancy. In addition, the iron biomarkers assessed allowed for a complete description of iron status. Previous studies may not have considered concomitant inflammation when interpreting iron status data, however, our analyses included CRP and AGP, which were used to adjust ferritin concentrations accordingly . The anaThe study limitations should be considered when interpreting the results. Due to the observational study design, conclusions on causality of observed relationships are not possible. However, our findings may generate hypotheses for further investigation, given the consistency of results. An additional limitation is self-selection bias at recruitment since women were recruited at primary healthcare clinics and then volunteered and agreed to participate at a different setting. Lost to follow-up resulted in missing birth weight data, which may have skewed results. Lastly, the sample was of relatively small size and not representative of the general population. Women were selected to be non-smoking, generally healthy and presented at primary healthcare clinics somewhat earlier than the typical 20 weeks of gestation .In conclusion, we found an increase in ID, IDE and IDA with pregnancy progression despite routine iron supplementation in an urban South African setting. We observed an inverse association between maternal iron status and birth weight, while IDE at mid-pregnancy increased the risk for premature birth. These results add to the raising concern on the consequences of iron supplementation in iron-replete pregnant women. Nonetheless, there is no question that ID and anaemia should be prevented in pregnancy. However, the challenge remains on how to do so safely in a public health setting. Considering that South Africa has a well-implemented food fortification programme, high prevalence of inflammation, possible influence of antenatal calcium supplements on iron absorption, as well as the known risks associated with both low and high iron exposure, we recommend that the current antenatal supplementation regime in South Africa be revisited.S1 Table1-acid glycoprotein; LSM: Living Standards Measure; Hb: Haemoglobin; Fer: ferritin; sTfR: soluble transferrin receptor.IQR: interquartile range; CRP: C-reactive protein; AGP: αData are presented as n (%) for categorical variables and median (IQR) for continuous variables.¥ Women who had a miscarriage or intrauterine foetal death (IUFD) also had missing birth weight data (n = 7), but were not considered in this table.† Mann-Whitney-U test for continuous variables, and Chi-square test for categorical variables.* n-values are equal to 250 for LSM, highest level of education, parity, HIV status, iron stores and iron deficiency erythropoiesis; 243 for anaemia; 239 for Country of birth; and 249 for all other variables.#: Traditional marriage, recognised under South African customary law, is entered between parties based on tradition which does not require the approval of an officiator for validation. It is also different from civil marriage in that a polygamous marriage is permissible.(DOCX)Click here for additional data file.


Weight at birth is a good indicator of the newborn’s chances for survival, growth, long-term health and psychosocial development. Therefore, the aimed of this study is to assess the prevalence and associated factors of low birth weight in Axum town, Tigray, North Ethiopia.The magnitude of low birth weight was 8.8%. Height of mother adjusted odds ratio (AOR) 4.607 (CI 1.34–15.8), gestational age AOR 4.7 (CI 1.08–20.44), anti-natal care (ANC) visit AOR 0.076 (CI 0.009–0.645), anemia during pregnancy AOR 14.5 (CI 3.821–55.6) and drinking alcohol AOR 6.4 (CI 1.235–33.94) were found to be significantly associated with low birth weight. Pre-conceptual counseling on nutrition, about the effect of short suture on birth outcome and personal maternal habit , effective treatment and prevention of anemia and awareness on the importance ANC follow up should be the target.The online version of this article (10.1186/s13104-018-3801-z) contains supplementary material, which is available to authorized users. Low birth weight (LBW) is defined by the World Health Organization as weight at birth < 2500 g (5.5 lb). There is significant fluctuation in the number of low birth weight across regions and within state; however, the great figure of low birth weight births happen in low- and middle-income countries and particularly in the most vulnerable populations .Based on national and regional estimates in Ethiopia 2,600,000 live births are reported out of these live births 530,400 infants are LBW with mortality rate of 32.4%. In Ethiopia the low birth weight (LBW) estimate has risen from 2000 to 2005 from 15.0 to 20.3% with 1.1% increase per year [This study will seek to ascertain the prevalence of low birth weight, describe the socio-demographic characteristics of women attending delivery and to investigate the factors contributing to LBW in Aksum town. The findings will create awareness in the community about the problem and contribute towards formulating locally appropriate interventions to prevent low birth weight. The findings will be shared among various stakeholders to stimulate focused intervention programs.Institutional based cross-sectional study was conducted in St. Marry hospital and Aksum University specialized and comprehensive hospital, Aksum, Tigray region regional state, Ethiopia, Which is the capital town of central zone of Tigray regional state. Aksum is found at a distance of 1024 km from Addis Ababa, capital city of Ethiopia and 241 km north of Mekelle, the capital city of Tigray .The study was conducted from April1/2018 to May30/2018.All mothers who give birth at Aksum St. Marry hospital and Aksum university comprehensive specialized hospital, central zone of Tigray and those who randomly selected mothers were the study participant.A total 308 samples were calculated using the formula to estimate a single Population proportion.With the assumption of 95% confidence interval (CI), d = 0.035 and prevalence of LBW of the new born in Aksum town research shows 9.9%.The calculated sample size (308) was proportionally allocated to these health facilities based on delivery case load of each health facility. Finally, data was collected systematically by skipping every third neonate until the needed sample size was found.The data was collected using structured, pretested interviewer administered questionnaire containing socio-demographic characteristics and other variables associated with delivering LBW baby. Data was collected through interviewing the mother and measuring the weight of the newborn, height, weight and mid-upper arm circumference (MUAC) of the mother : pre-pregnancy weight, maternal MUAC, maternal height, maternal weight.Obstetric and gynecologic factor: parity, birth interval, history of abortion, anemia, chronic illness of the mother, gestational age at birth, no of anti-natal care (ANC) follows up.Maternal behavior: khat, alcohol, physical activity.The data was entered to Statistical Package for Social Sciences (SPSS) version 21.0. Identification of implausible values and missing data or possibly miss-coded data was cross-checked. After cleaning the data, frequencies and percentages was calculated to all variables. Bivariate analysis; cross tabulations was done to see the association between the explanatory and outcome variables. Multivariable logistic regression was employed by selecting only variables that appeared to be statistically significant at (P < 0.05) in the bivariate analysis. Model fit was checked by Hosmer–Lemeshow goodness-of-fit test.Finally, the data was presented with appropriate tables, diagrams and figures. Adjusted odd ratio (AOR) was calculated to check strength of association and P < 0.05 was taken as significant association.Majority of mothers 208 (67.5%) were aged 20–34. All of the mothers were Tigrean in ethnic. Majority of the mothers were married 286 (92.9). Out of the respondent 298 96.1%) were Orthodox Christians. Majority of the respondent 157 (51%) of mothers could not read and write and 133 (43.3%) of mothers were housewife. More than half of mothers 188 (61%) respondents were residing in urban areas. Based on the findings from the income distribution higher percentage of mothers 95 (30%) had an average household income of < 1000 ETB per month , gestational age AOR 4.7 (CI 1.08–20.44), ANC visit AOR 0.076 (CI 0.009–0.645), anemia during pregnancy AOR 14.5 (CI 3.821–55.6) and drinking alcohol AOR 6.4 (CI 1.235–33.94) were found to be significantly associated with low birth weight.Mothers whose height < 150 cm was 4.6 times more likely to deliver low birth weight baby than mothers with height of ≥ 150 cm (AOR 4.607 (CI 1.34–15.8)). The chance of LBW delivery were 4.7 times higher for neonate with gestational age < 37 weeks 4.7 CI 1.08–20.44). Mother who had ANC follow up had 92.4% less chance to have low birth weight baby AOR 0.076 (CI 0.009–0.645) than those who didn’t have. Mothers who had anemia during current pregnancy were 14 times more likely to deliver low birth weight neonate compared to mothers without anemia AOR: AOR 14.5 (CI 3.821–55.6). Mothers who drink alcohol during current pregnancy were 6.4 times more likely to deliver low birth weight neonate compared to mothers who didn’t drink AOR 6.4 (CI 1.235–33.94). Further see Table 0.44. MotLow birth weight observed in this study was consistent with studies conducted in Iran (8.8%), Jimma (11.02%),  Nigeria But it had relatively lower when compared with study finding done in India, Uttar Pradesh which was about 40%  and studIn this study, anemia during pregnancy, height of the mother < 150 cm, gestational age at birth < 37 weeks, number of ANC visit and drinking alcohol were found to be significantly associated with low birth weight.Mothers who had anemia during current pregnancy were 14 times more likely to deliver low birth weight neonate compared to mothers without anemia (AOR: 14.5 CI 3.821–55.6). This finding consistent with study conducted in Deberbirhan Ethiopia and Sudan , 21. Ane–55.6. ThGestational age plays an important role in determining infants ‘birth weight. Infants who are delivered prematurely (< 37 weeks) are at higher risk to have low birth weight infants. The World Health Organization estimated about one-third of low birth weight infants is caused by prematurity. The results of the present study revealed that the chance of LBW delivery were 4.7 times higher for neonate with gestational age < 37 weeks AOR 4.7 CI 1.08–20.44). This finding is consistent with study conducted in Jimma . This fiOne of the other factors that were found to predispose mothers to have LBW is maternal height. In this study mothers whose height < 150 cm was 4.6 times more likely to deliver low birth weight baby than mothers with height of ≥ 150 cm (AOR 4.607 CI 1.34–15.8). The reported value is consistent with the study finding in Southwestern Ethiopia and Tanzania . Also thThe magnitude of low birth weight in this study was relatively lower than other studies. Anemia during pregnancy, height of the mother < 150 cm, gestational age at birth < 37 weeks, number of ANC visit and drinking alcohol were found to be significantly associated with low birth weight.Since this is cross-sectional study it does not show the direction of relationship. Similarly it is sensitive topic and there may be under report.Additional file 1. Questionnaire.


Australopithecus was relatively easy and ape-like, while others have argued for a more complex, human-like birth mechanism in australopiths. Still others have hypothesized a unique birth mechanism, with no known modern equivalent. Preliminary work on the pelvis of the recently discovered 1.98 million-year-old hominin Australopithecus sediba found it to possess a unique combination of Homo and Australopithecus-like features. Here, we create a composite pelvis of Australopithecus sediba to reconstruct the birth process in this early hominin. Consistent with other hominin species, including modern humans, the fetus would enter the pelvic inlet in a transverse direction. However, unlike in modern humans, the fetus would not need additional rotations to traverse the birth canal. Further fetal rotation is unnecessary even with a Homo-like pelvic midplane expansion, not seen in earlier hominin species. With a birth canal shape more closely associated with specimens from the genus Homo and a lack of cephalopelvic or shoulder constraints, we therefore find evidence to support the hypothesis that the pelvic morphology of Australopithecus sediba is a result of locomotor, rather than strictly obstetric constraints.Hominin birth mechanics have been examined and debated from limited and often fragmentary fossil pelvic material. Some have proposed that birth in the early hominin genus  Among primates, the mechanics of human birth are thought to be unique, typically involving a vertex presentation of the fetal head and a multi-rotational pattern of the neonate through the birth canal. The evolutionary explanation for the difficulty of human birth, termed the “obstetrical dilemma” , posits Humans have adapted to the obstetrical dilemma in part by recruiting attendants who aid the mother in giving birth , 3. AlthThus, the birth process in non-human apes is relatively simple compared to humans. The birth canal and the neonate’s head are elongated in the same plane (anterior-posterior) and the birth canal does not change shape or dimensions . In contA further constraint is met in the midplane of the human maternal pelvis. The ischial spines constrict the transverse diameter and the anterior-posterior dimension becomes relatively elongated , 14, 17.A final challenge that is too often ignored is imposed by the neonatal shoulders. Birth complications due to shoulder obstruction, or shoulder dystocia, occur in 1.4% of the U.S. population , of whicAustralopithecus afarensis skeleton, A. L. 288–1, indicates that an A. afarensis neonate's head would probably have entered the pelvic inlet in a human-like transverse or oblique orientation ), shoulder breadth (predicted to be 73.4 mm wide) could still pass unimpeded and may have been further reduced by cranially elevating the clavicles, “shrugging” to enter the birth canal [We have shown that this mechanism of birth—one predicted for A.L. 288–1 —would inblematic . In A.L.blematic . Howeverth canal . The othA. sediba [A. sediba. Nevertheless, the interspecific differences in fossil hominin pelvic morphology and fetal dimensions show that there is not a linear, gradual change from an “easy” birth to a “difficult” birth. Instead, the morphology of each specimen exhibits its own set of obstetric challenges.A similar birth mechanism has been suggested for other australopiths where the baby enters the pelvic inlet aligned transversely, but requires no further rotations , 25, 26 . sediba . With thA. sediba possesses an AP expanded, Homo-like pelvis, with little evidence for obstetric constraints. This finding suggests that at least in A. sediba, the morphology of the pelvis was probably shaped by locomotion factors rather than solely obstetrics.Hominin pelvic morphology is thought to be influenced by both locomotion  and obstHomo may have been a result of obstetric requirements [A. sediba also possesses AP expansion in the pelvic midplane and raises the possibility of rotational birth in this taxon. To accommodate this interpretation, we describe fetal descent following determinations of Joulin’s Law which states that the neonate would rotate to coincide with the maximum dimension of the bony anatomy [A. sediba pelvis, the maximum bony dimensions are not always in the transverse dimensions  by Berge et al. [A. sediba than either the A. africanus or even H. erectus specimens. Instead, the shape change is more consistent with what is seen in Neandertals (Tabun 1) and modern humans. Additionally, this shape change is notable since A. africanus and A. sediba start at similar inlet indices.e et al.  and Berge et al.  who citeA. sediba in either a transverse or rotational birth scenario.The final component to a difficult modern human birth is the fact that rigid shoulders cannot pass through the changing shape of the birth canal without some rotation , 3, 14. A. sediba be found or should another team reconstruct the available material in a manner morphologically distinct from that presented here and elsewhere [We caution that our results are contingent on our reconstruction of the MH2 pelvis. As mentioned previously, the tenuous contact between the ilium and the sacrum in addition to the use of the MH1 ischium introduce the potential for error. We therefore anticipate that the findings presented here will be revisited should new pelvic fossils of lsewhere , 47.Australopithecus sediba (MH2) provides an assessment of the birth process in this Early Pleistocene hominin species. At the pelvic inlet, the neonatal head aligned with the maximum dimension of the pelvic inlet to enter the birth canal transversely. Lack of bony impingement into the birth canal, combined with a small neonatal head size would not necessitate further rotation of the fetus as it descended through the canal, though AP expansion of the maternal pelvis still indicates that rotational birth may have occurred. It is possible, even, that there was considerable variation in the birth mechanism in early australopiths, with varying amounts of neonatal rotation. Interestingly, the shape of the obstetric planes in A. sediba align more closely with the genus Homo than with the other australopiths. These findings imply that the anteroposterior expansion of the birth canal can occur without neonatal brain expansion in early hominins.Reconstructing the pelvis of a female S1 TableBP: neonatal cranium biparietal breadth FO: frontal-occipital length of neonate cranium. AP: anterior-posterior dimension of maternal pelvis or composite pelvis ML: transverse dimension of maternal pelvis or composite pelvis.(DOCX)Click here for additional data file.


Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19–9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19–9 level.The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient’s serum levels of CA19–9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19–9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19–9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy. Non-parasitic splenic cysts can be asymptomatic or present with non-specific symptoms, e.g., pain in the left upper quadrant of the abdomen or increasing abdominal girth , 2. Occa3 /L) (predominantly due to increased numbers of neutrophils) and increased serum amylase levels (162 U/L), together with normal hemoglobin and C-reactive protein (CRP) levels. A coagulation screen produced normal results. However, the following tumor marker level measurements were obtained: CA19–9: 17580 U/L , CA125: 909.8 U/L , CEA: 2.5 ng/mL , and interleukin-2 receptor (IL-2R): 389 U/L . An ascitic tap was obtained, which revealed the following results: lactate dehydrogenase (LDH): 904 U/L, serum total protein (TP): 5.0 g/dL, CA19–9: 490000 U/L, CA125: 24560 U/L, and CEA: 60.6 ng/mL  scan showed a collapsed cystic lesion and abdominal fluid. A ruptured splenic cyst was suspected, and so the patient was referred to our hospital. On arrival, the patient complained of upper abdominal pain. She stated that she had not suffered any diarrhea, hematemesis, or trauma, nor had she recently come into contact with any sick individuals or gone travelling. She was not taking any regular medication and had no relevant family medical history. She had a slightly elevated temperature (37.3 °C), but the rest of her vital signs were normal. An abdominal examination revealed rebound tenderness in the epigastric region. The initial laboratory tests demonstrated an elevated white blood cell count (18.4 × 10After one week, we removed the splenic cyst via laparoscopic fenestration. Exploration of the surgical field revealed abdominal fluid. The cyst was located at the upper pole of the spleen. We dissected the part of the greater omentum that had adhered to the cyst wall, drained the cyst cavity, and fenestrated the splenic cyst wall using an ultrasonic scalpel, before cauterizing the interior of the cyst wall Fig. . The patA pathological examination revealed an epidermoid cyst. The cyst wall consisted of fibrous tissue and was lined by a single layer or several layers of squamous epithelium. Immunohistochemistry demonstrated that the epithelial cells were positive for CA19–9 and CEA Fig. . The patThe preoperative diagnosis was a ruptured non-parasitic splenic cyst. Cystic Echinococcosis were ruled out by her social history. In Japan, cystic Echinococcosis is very rare disorders, except for imported cases  and hydaTo the best of our knowledge, 51 cases of splenic cysts involving high levels of tumor markers have been reported, not including accessory spleens , 8–41 T. Of 50 cThe mechanism responsible for the elevated tumor marker levels seen in such cases remains unclear. The intracystic and serum CA19–9 levels were high in most cases, but the CEA levels were markedly elevated in the cystic fluid whereas normal in the serum in some cases , 28, 32.Large, symptomatic, or complex cysts are indicated for treatment. Large cysts are susceptible to rupture and can cause other complications. According to some previous reports, cysts measuring ≥5 cm in diameter are indicated for surgical intervention, but there is a lack of evidence for this 5-cm cut-off point, and cyst size is generally not used as a cause for intervention .The treatments for ruptured splenic cysts include percutaneous drainage, splenectomy, partial splenectomy, marsupialization, and fenestration. Percutaneous aspiration therapy alone is associated with low success and high recurrence rates . Percuta


We hypothesize that Zdiff calculated from growth charts based on birth weight data introduces a systematic statistical error leading to falsely classified growth as restricted in infants growing similarly to the 50th percentile.To test whether the assessment of growth in very low birth weight infants during the hospital stay using z-score differences  from birth to discharge were calculated. To account for gestational age dependent growth rates, assessment of growth was standardized calculating the weight gain ratio (WGR) = weight gain velocity/reference growth rate. The primary outcome is the variation of the Zdiff-to-WGR relationship.This observational study included 6,926 VLBW infants from the German Neonatal Network (2009 to 2015). Inclusion criterion was discharge between 37 and 41 weeks postmenstrual age. For each infant, Zdiff and WGR showed a weak agreement with a Zdiff of -0.74  at the reference growth rate of the 50th percentile (WGR = 1). A significant proportion  of infants with negative Zdiff had weight gain velocity above the 50th percentile’s growth rate. Zdiff to WGR relation was significantly affected by the interaction of GA x BW%ile x LOP.Zdiff, which are calculated using birth weights, are confounded by skewed reference data and can lead to misinterpretation of growth rates. New concepts like individualized growth trajectories may have the potential to overcome this limitation.This study supports the hypothesis that Z Changes in percentiles or z-scores during defined observation periods, such as from birth to discharge, are commonly used to assess growth of preterm infants. Tools presently applied in clinical routine for monitoring and guiding growth include growth charts and z-score plots .1–3]–31–3]A percentile is defined as the birth weight value below which a given percentage of observations in a selected cohort can be found. For example, the 10th percentile for a gestational age of 28 weeks is the birth weight value below which 10% of the neonates in the cohort fall at 28 weeks. Percentiles of birth weights for each gestational week are calculated using datasets of infants born at given weeks   .4]A percentOnce birth weight percentiles have been built from the different cohorts, a growth chart is subsequently created by connecting these percentile values across gestational ages (e.g. from 24 to 42 weeks). However, linking distributions of percentile values between the weeks of gestation results in trajectories that are not representative of physiological growth. NonethelZ-scores are another commonly used parameter to compare individual weights with the cohort., 6 A z-sdiff) are used to analyze changes in growth for a particular observation period. Zdiff is defined as:For instance, a z-score of -1 depicts an individual birth weight that is one standard deviation below the mean birth weight of the cohort. Z-score differences  and the 50th percentile (red line) ((50th percentile - 3rd percentile) / 50th percentile) increases up to 29 weeks, followed by a decrease until term age.[Unfortunately, varying degrees of skewness across gestational ages is significantly present in most birth weight charts used for growth analyses nowadays. For the preterm period, the datasets inherently include a substantially high number of pregnancies and preterm births that are affected by pathologies, thus leading to the preterm termination of the pregnancy. This severely impacts the accuracy of the fetal growth data, resulting in a skewed distribution of birth weight percentiles mostly towards lower percentiles. As can be seen in term age., 3, 6 Derd, 10th, 50th, 90th and 97th) on standard growth charts.[rd and the 10th percentile curves. From a physiological perspective however, it is not evident why an infant should undergo such a weight gain velocity fluctuation during the last trimester of gestation. Moreover, the cause for the inverse order of the fluctuation seen for the 3rd and 10th percentile compared to the curves of the 50th or the 90th percentiles is unclear. These findings illustrate that the variation of skewness of percentiles across gestational ages might impact the accuracy of the Zdiff calculation.diff approach will introduce a systematic error and may indicate growth restriction in preterm infants that are in fact growing at median rates of reference charts. Therefore, the objective of the current study is to investigate whether the assessment of growth of preterm infants by Zdiff is affected by the parameters gestational age, birth weight percentile, or by the length of the observation period. Mathematical models will be used to test the impact of the aforementioned three parameters on the Zdiff.We hypothesize that applying the current ZThis observational study was performed using a data set of very low birth weight  infants from the German Neonatal Network (2009 to 2015). All VLBW infants that were discharged between 37 to 41 weeks were included in this study. The study was approved by the Hamilton Integrated Research Ethics Board (HiREB) (2016-1696-C). The data were anonymized, and ethics committee waived the requirement for informed consent for this retrospective study.diff  for the same gestational age period . Adopted from recent approaches to growth analysis, the median weight data of intrauterine growth charts were used to standardize the WGR. The WGR e period .The individual weight gain velocity as well as the reference weight gain velocity were calculated using the following equation:weightgaWGR is described using the following equation:th percentile used were obtained from the Fenton growth chart 2013.[The reference data for the 50diff-to-WGR relationship (homogeneity).The primary outcome is the degree of variation of the Zdiff were analyzed using regression models employing the r statistic function lm.The effects of gestational age, birth weight percentile, and length of the observation period on the Zdiff and WGR using a linear regression analysis.Model 1 tested the overall relationship between Zdiff.Model 2 analyzed the effects of the three parameters , birth weight percentile (BW%ile), and length of the observation period (LOP)) on the correlation with Zdiff and the WGR. This model tested whether the interaction of the parameters had an amplified effect, compared to when the parameters were considered independently (Model 2). It was hypothesized that Zdiff are non-linearly related to WGR, GA, BW%ile, and LOP. Model 3 was defined as follows:The third model tested whether WGR, GA, BW%ile, and LOP affects the relationship between the ZThe difference between the models was analyzed using ANCOVA. The level of significance is p<0.05. The analysis was assisted by R software package for statistical analysis, R Foundation for Statistical Computing, version 3.5.0 (2018-04-23), Vienna, Austria.This study was comprised of 6,926  VLBW infants. The patient characteristics are outlined in diff and WGR was obtained:When using the linear regression model (Model 1), the following relationship between Zth percentile, the Zdiff was -0.74 at the regression line. The first and third quartiles of Zdiff were -1.03 and -0.37, respectively. As can be seen in th percentile, when Zdiff is calculated, the result is negative. In contrast, the number of infants with WGR ≤ 1 and positive Zdiff is 18 (0.3%).This analysis revealed that at a WGR = 1, which should correspond to a growth rate following the 50diff. Moreover, there was also a high inter-individual variation in the Zdiff of infants with the same WGR. The Zdiff differed by up to 4 z-scores for the same WGR  demonstrated a non-random distribution with a residuals standard error of 0.56 Zdiff  indicatidiff-to-WGR relationship. The slope of the regression lines for the infants with lower GA, BW%ile, and shorter LOP is steeper, which translates into larger changes of Zdiff with changes in WGR.diff . The comparison of Model 1 and Model 2 by ANCOVA showed a significant improvement of Zdiff prediction by Model 2 .Model 2 revealed that gestational age, birth weight percentile, and length of the observation period have significant effects on the Zdiff .Model 3 demonstrated that the interaction between the parameters  significantly affected the Zdiff closer to the actual values in comparison to Model 2. The variation of the residuals also decreased when Model 3 was applied compared to Model 2. Thus, the interaction of the variables WGR, GA, BW%ile and length of the observation period has a stronger effect on the Zdiff, compared to when these parameters are considered independently.The ANCOVA analysis revealed an increase in the explanatory power of Model 3 over 2 with an F value of 4,308 and a small p-value (p<0.0001). This indicates that Model 3 predicted Zdiff and WGR is dependent on the variables gestational age, birth weight percentile, and length of the observation period. The analysis showed no sex-specific effects.In summary, these mathematical findings imply that the relation between Zdiff) and weight gain velocity from birth to discharge do not correlate well in a significant portion of in VLBW infants. This finding supports the hypothesis that the approach of using Zdiff to assess growth in preterm infants is confounded by skewed reference data and thus, does not provide an accurate reflection of growth. Gestational age, birth weight percentile, and the length of the observation period have significant effects on the Zdiff. The influence of these factors is supported by statistically significant mathematical findings. Thus, an unadjusted Zdiff cannot be accurately translated into growth rates or growth trajectories.In this study, we found that z-score differences  at 28 weeks, an infant with a weight of 0.8 of the mean weight (800 g) would have a z-score of -1 . If this infant were to grow with the growth rate of the 50th percentile, the infant would reach 0.8 of the mean weight by term age . The standard deviation at term age would be about half . The z-score of this infant at term age would then be -2  and the Zdiff would thus be -1. Another infant born at the mean weight and also growing with the growth rate of the 50th percentile would have a z-score of 0  at 28 weeks and a z-score of 0 at term age , resulting in a Zdiff of 0 .[th percentile with a birth weight of 1,430 g would undergo the 10% physiological weight loss, resulting in a weight of 1,290 g (74th percentile). This infant has thus crossed 23 percentiles. Another infant at the 10th percentile with a birth weight of 700 g undergoing the same 10% weight loss would result in a weight of 630 g (3rd percentile). This infant has thus crossed only seven percentiles. The Zdiff would consequently be higher from birth to day 5 of life in infants with higher birth weight percentiles. Thus, this finding supports the hypothesis that birth weight percentile impacts Zdiff.The physiological condition of postnatal adaptation is not reflected by the z-score approach. Postnatal adaptation includes weight loss during the first few days of life, mostly due to an irreversible, one-time loss of extracellular water volume.–14 As cacentile)., 14 Duridiff and weight gain velocity is weak when Zdiff is calculated within the postmenstrual age range from preterm (e.g. 24 weeks) to term age. This was shown in the current study using a large cohort of very low birth weight infants which stayed an average of 5 to 13 weeks in the NICU. We have identified that this finding is determined by the characteristics of the reference data used for z-score calculations. The reference data are cross-sectional birth weight data, which were developed to assess the nutritional status at birth. Employing these birth weight data for the analysis of postnatal growth diverges from the intended use of the data and introduces systematic errors in growth analysis.In summary, the relation between ZThe findings suggest that a novel approach to assess growth and rates of growth is necessary. A promising approach would be to apply the concept of individualized growth trajectories as recently proposed., 15, 16 diff is dependent on the reference data. When birth weight data are used to assess longitudinal growth, the interpretation should be done with caution. Individualized growth trajectories are a promising alternative. Nonetheless, their use in clinical practice requires validation.In conclusion, the calculation of z-scores, percentiles and ZS1 Fig(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Non-parasitic simple hepatic cyst is a very common type of benign liver disease, occurring in approximately 1–5% of the general population. These cysts are usually asymptomatic and are conservatively followed up without treatment. Some of these cysts, however, are associated with complications, including infection, hemorrhage, obstructive jaundice, portal hypertension, and rupture.A 74-year-old woman was transferred to our trauma center with epigastric pain after being knocked down by a cultivator. An abdominal computed tomography (CT) scan showed fluid collection and cystic lesion around the caudate lobe of the liver. Operative exploration showed that she had a ruptured hepatic cyst that originated from the caudate lobe of the liver. The cyst was deroofed to the margins of the liver parenchyma, and the internal surfaces of the cyst walls was subjected to electrocoagulator ablation.Open or laparoscopic cyst deroofing is a safe and effective treatment for non-parasitic simple hepatic cysts. Laparoscopic deroofing may also be difficult following rupture of non-parasitic simple hepatic cysts associated with infection or hemorrhage, as these cysts may collapse and the line of resection may be unclear. Laparoscopic ultrasound is a useful adjunct to delineate the boundaries of the cyst.Traumatic rupture of a non-parasitic simple hepatic cyst is a very rare complication, but can lead to acute abdomen. In patients who are known to have non-parasitic simple hepatic cyst, rupture of cyst could be included in the differential diagnosis of acute abdomen. Recent 2A 74-year-old woman was transferred to our trauma center with epigastric pain after being knocked down by a cultivator. She had been on medication for hypertension and arthritis. Upon admission, she complained of pain in the upper abdomen and both lower chest regions. Her vital signs at admission included a blood pressure of 145/90 mmHg, a heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a body temperature of 36.5 °C. Physical examination revealed severe rebound tenderness in the epigastrium. Laboratory findings showed that her hemoglobin concentration and white blood cell and platelet counts were within normal ranges. Renal and hepatic function test results were also within normal limits, except for elevated concentrations of aspartate aminotransferase  and alanine aminotransferase . A chest CT scan showed fractures of several right ribs and bilateral scanty pneumothorax. An abdominal CT scan showed fluid collection and cystic lesion around the caudate lobe of the liver , Fig. 2.3Echinococcus species and are complications frequently associated with these cysts [Non-parasitic simple hepatic cysts are a common type of benign liver disease, occurring in approximately 1–5% of the general population . Increasse cysts   rate of recurrence, the likelihood of recurrence can be reduced by about 20% when percutaneous needle aspiration is combined with injection of a sclerosing agent, such as minocycline hydrochloride or tetracycline chloride, as these agents promote coagulation-induced necrosis of the cyst epithelium and effectively obliterate cysts ,7.Open or laparoscopic cyst deroofing is a safe and effective treatment for non-parasitic simple hepatic cysts. Recurrence rates can also be reduced by combining deroofing with argon beam coagulation or electrocoagulation, methods that destroy the remaining epithelium. Moreover, placement of an omental transposition flap after deroofing can reduce recurrence rates. Laparoscopic management has been shown to be a new, less-invasive therapeutic option . CompareRoux-en-Y internal drainage with cystojejunostomy has been proposed as treatment for cysts communicating with the bile duct. However, this method could lead to complications, such as cholangitis and sepsis, which require repeated postoperative antibiotic treatments. More radical approaches, including complete cyst excision and partial hepatectomy, have been recommended if the possibility of malignancy cannot be completely ruled out, but these approaches carry significantly higher morbidity rates . These hRecurrence rates of hepatic cyst after open and laparoscopic surgery vary. Some authors reported a higher rate of recurrence after laparoscopic surgery. While others concluded that the recurrence rates after laparoscopic surgery were acceptable and comparable to those of conventional open surgery ,24.4In conclusion, traumatic rupture of a non-parasitic simple hepatic cyst is a very rare complication, but can lead to acute abdomen. In patients who are known to have non-parasitic simple hepatic cyst, rupture of cyst could be included in the differential diagnosis of acute abdomen.None. No funding or grant support.Because this was a report of an interesting case, and not atrial or observational research, we had an exemption from ethical approval.Written informed consent was obtained from the patient for publication of this case report and accompanying image.Jinyoung Park was involved with the case and writing of the manuscript, operation and general management of the patient and revised the manuscript for important intellectual content.None.Jinyoung Park.Not commissioned, externally peer-reviewed.None.


Co-occurrence of European Union (EU)-regulated mycotoxins, such as patulin, aflatoxins , and fumonisins  was detected in both malts with a prevalence range of 2–84%. Aflatoxin B1 was quantified in omalodu (44%) and otombo malts (14%), with 20% of omalodu malts and 40% of otombo malts having levels above the EU allowable limit. Fumonisin B1 was quantified in both omalodu (84%) and otombo (42%) malts. Emerging mycotoxins, aflatoxin precursors, and ergot alkaloids were quantified in both malts. Notably, 102 metabolites were quantified in both malts, with 96% in omalodu malts and 93% in otombo malts. An average of 48 metabolites were quantified in otombo malts while an average of 67 metabolites were quantified in omalodu malts. The study accentuates the need to monitor mycotoxins in sorghum malts intended for brewing and to determine their fate in the beverages.Sorghum malts, which are important ingredients in traditional fermented beverages, are commonly infected by mycotoxigenic fungi and mycotoxins may transfer into the beverages, risking consumers’ health. Liquid chromatography–tandem mass spectrometry was used to determine variation of fungal metabolites in 81 sorghum malts processed for brewing of Namibian beverages,  Sorghum is a genus of cereals in the family Poaceae of approximately 30 species. One species, Sorghum bicolor, is native to Africa and is the world’s fifth most important cultivated cereal crop [otombo, while malted sorghum flour is used for the brewing of the non-alcoholic beverages omalodu and oshikundu [Otombo, which is mainly brewed nationwide for income generation, is sold at shebeens in rural areas and at open markets in urban areas, and, due to its alcoholic content, is generally consumed by elders. Omalodu is also a popular ceremonial traditional beverage in Namibian Oshiwambo and Rukwangali communities. In both communities, omalodu is primarily consumed at sociocultural ceremonies.eal crop , with maeal crop . In Namiotombo brewing. Milling of the dry malts used for omalodu brewing is usually carried out in a hut or an open area by pounding with strong wooden sticks in a wooden traditional mill. The pounding is continued until all grains are pulverized with intermittent sifting using a circular basket made from palm leaves. The initial round of sifted coarse sorghum flour with grains and root fragments is reserved for omalodu brewing. Omalodu malts are mainly prepared for brewing at the household level and for family use, while some may also be transported and sold at open markets in urban areas. Otombo malts are prepared for brewing at shebeens and for selling at open markets.Sorghum malts used in this study vary depending on the malting process and the milling stages. According to , maltingAspergillus, Penicillium, Claviceps, and Fusarium genera [Due to the warm, moist, and likely unhygienic conditions during the traditional malting and milling processes, the growth of mycotoxigenic fungi is stimulated . In addim genera . The toxm genera ,11. Manym genera , 72% of m genera . There am genera ,15,16.otombo and omalodu, which are consumed daily and by many people. This study, therefore, aimed at determining the occurrence and variation of fungal metabolites in sorghum malts intended for the brewing of omalodu and otombo beverages.The quality of raw materials used to prepare traditional beverages influences the final product safety. Many reports on the occurrence and quantities of fungal metabolites in sorghum malts and related products from countries neighboring Namibia have been documented in South Africa , Zimbabwomalodu and otombo beverages (Only metabolite concentration levels that were above the limits of quantification (LOQ) were quantified for both malts. Hence, a total of 102 fungal and bacterial metabolites, including seven regulated mycotoxins, were quantified in sorghum malts for both everages . Only 4%omalodu malts (n = 101) than in otombo malts (n = 96). An average of 48 metabolites was quantified in otombo malts, while an average of 67 metabolites was quantified in omalodu malts, respectively. Although some metabolites were quantified with low prevalence rates and quantities, the risks of exposure to these complex mixtures of metabolites by consumption of brews should be studied in more detail in order to minimize the possible synergistic and/or additive effects during brewing.The total number of metabolites was higher in Aspergillus 34%,  were quantified in both malts  and otombo malts  with 20% of omalodu malts and 40% of otombo malts having levels above the EU regulatory limit of 5 µg/kg. An independent-samples t-test conducted to compare average AFB1 levels in omalodu and otombo malts showed that the difference was not statistically significant (p > 0.05). Differences in averages of AFB2, AFG1, FB1, FB2, and FB3 levels between omalodu and otombo malts were also not statistically significant (p > 0.05). These results suggest that the different malt preparation methods may not have a significant effect on levels of aflatoxins. In the previous study [1 was quantified with higher prevalence rate (50%) and level (average: 4.5 ± 5.5 µg/kg) in the sorghum malt flour samples compared with omalodu malts .AFB1 and ochratoxin A were purified with immunoaffinity columns and analyzed using high-performance liquid chromatography (HPLC), revealing a higher AFB1 level (97.6 ± 88.2 µg/kg) for malt samples than the present study (8.49 ± 16.9 µg/kg). In South Africa [1 in sorghum malt grains, while the current study revealed contrasting results. FB1 is one of the common toxicologically important mycotoxins and was quantified in omalodu malts with 84% prevalence (average concentration: 61.4 ± 70 µg/kg) and in otombo malts with a prevalence of 42% (average concentration: 29.1 ± 25.7 µg/kg)  .1 was quantified with a higher prevalence rate (75%) in sorghum flour malts from Namibia prepared for oshikundu beverage [1 was detected at a lower prevalence rate of 6% in sorghum malt samples, with concentrations ranging from 47 to 1316 µg/kg [1 concentrations below the EU regulatory level of 2000 µg/kg.FBbeverage  compared16 µg/kg . All soromalodu (average = 57.7 µg/kg) and only two samples of otombo malts (average = 183.1 ± 143.2 µg/kg). However, the average concentrations for omalodu and otombo malts were higher than those fixed by the EU at 50 µg/kg for patulin in apple juice. Patulin is of concern because it is produced by many fungal genera and is suspected of being clastogenic, mutagenic, teratogenic, genotoxic, and cytotoxic [Patulin, which is normally found in fruits and vegetables, particularly apple and its products ,29,30, wytotoxic . The co-omalodu malts and not in the otombo malts, while averufin was quantified in 84% of the otombo malts but not in omalodu malts. A high incidence rate of 91% (average = 95.49 µg/kg) was recorded for STE from omalodu malts. STE is classified as a possible human carcinogen by the International Agency of Research in Cancer [Several metabolites from the biosynthetic pathway of aflatoxins, namely averufanin, averufin, STE, and versicolorin C , were qun Cancer . In addin Cancer  and cyton Cancer  and liven Cancer .omalodu malts and 17–100% in otombo malts. A magnetic resonance imaging study by [otombo (3290 ± 5000 µg/kg). MON was not quantified in sorghum flour malts in the previous study [omalodu malts and quantified with a concentration of 348 ± 511 μg/kg and with concentration of 75.6 ± 135.9 μg/kg in otombo malts. In vivo toxicity investigations suggest that MON can induce cardiotoxicity [omalodu and otombo malts, respectively. Several studies demonstrated that EMO has anticancer [omalodu and otombo malts, respectively. BEA has shown cytotoxic effects on human cell lines [Alternaria toxins, TeA was quantified with high amounts in both omalodu (1925.6 ± 3406.4 μg/kg) and otombo (999 ± 2170 μg/kg) malts, compared to lower amounts of AOH (14 ± 30 μg/kg) and (9.99 ± 18.09 μg/kg) in omalodu and otombo malts, respectively. Some in vivo studies of TeA revealed that it is toxic to animals, such as mice and rats [As shown in study by  reportedstudy by . The avestudy by  than thaus study , but it toxicity  and caustoxicity . EMO is ticancer ,40, antiticancer ,42, and ticancer . BEA wasll lines . Among tand rats , beagle and rats , and chiand rats . AccordiClaviceps genera were quantified in both malt samples. Elymoclavine was observed in 3% and 38% of otombo and omalodu malt samples, respectively. Other alkaloids were observed with high prevalence (50–100%) in both malt samples  and otombo (44%) malts. Its disulfide bridge may cause immunosuppressive properties and apoptosis in macrophages and monocytes [Aspergillus flavus quantified in both omalodu (69%) and otombo (39%) malts is cyclopiazonic acid, an indole tetramic. Cyclopiazonic acid causes degenerative changes and necrosis in the liver, spleen, pancreas, kidney, salivary glands, myocardium, and skeletal muscles, based on toxic effects observed in male and female rats [Aspergillus metabolites are an indication of the higher contamination by storage mycotoxigenic fungi such as Aspergillus fumigatus, Aspergillus clavatus and Aspergillus niger. The latter findings are expected because both malts are traditionally processed under likely unhygienic conditions. The poor storage conditions for prolonged times at homes and markets makes the malts susceptible to fungal contamination. Other metabolites synthesized by Fusarium, Penicillium, and Alternaria species were quantified as well.The prevalence and concentrations of other fungal metabolites quantified in both malt samples are indicated in onocytes . Bis , or maculosin, cyclo , brevianamide F, or cyclo (l-Trp-l-Pro), Fellutanine A or cyclo (l-Trp-l-Trp), were quantified in both omalodu and otombo malts. Cyclo (l-Pro-l-Tyr) is formed by the fusion of tyrosine and proline and has been reported as a secondary metabolite of various fungi [Alternaria alternata [omalodu malts and at 94% in otombo and at concentration ranges of 48.2–48,200 μg/kg in omalodu and 32.5–165 μg/kg in otombo malts, respectively. Cyclo  is formed by the fusion of valine and proline and synthesized by marine Penicillium species [omalodu malts than in otombo malts (121 ± 86.4 µg/kg) and had a maximum prevalence of 100% in both malts. Brevianamide F is the simplest member and the biosynthetic precursor of prenylated tryptophan-proline 2.5-diketopiperazines that are produced mainly by Aspergillus fumigatus and other Aspergillus species [Penicillium species and intermediaries of many fungal species. The brevianamide F average concentration of these malts was highest in omalodu malts (144 ± 92.6 µg/kg) the lowest in otombo malts (90.1 ± 56.1 µg/kg). Fellutanine A is bio-active, naturally occurring, 2.5 diketopiperazine alkaloid synthesized by Penicillium fellutanum and Penicillium simplicissimum, [l-Trp-l-Trp). The concentration range of this metabolite in the samples is indicated in Otombo malts had the highest concentration of 110 ± 80.5 µg/kg, but it was not quantified in omalodu malts.Twenty-two metabolites synthesized by non-fungal organisms and uncommon fungal species were quantified in both bo malts . Dihydrous fungi  and bactus fungi . Additiolternata . It was  species . It was  species . In addiissimum, . It is aThe values reported in otombo and omalodu. Both malts were substantially contaminated with fungal metabolites produced by major mycotoxigenic fungal genera. The study found little contamination variation between the two malts. Regulated mycotoxins, emerging mycotoxins, aflatoxin precursors, and ergot alkaloids were quantified in both malts. Generally, the study findings were that omalodu malts were mostly contaminated with fungal metabolites and health risk mycotoxin groups than otombo malts. Based on the high incidence of mycotoxins and other metabolites in both malt samples, adequate milling and processing conditions (low moisture) must be ensured to reduce the prevalence of these toxins. The present study on two sorghum malts provides three major findings: First is the co-occurrence of seven EU-regulated mycotoxins in both malts, particularly toxic AFB1, which was quantified in 20% of omalodu malts and 40% of otombo malts at levels above the EU allowable limit of 5 μg/kg. Second is the high occurrence of several fungal metabolites in both malts and the existing knowledge gap on the effects of such intricate metabolite mixtures in humans. The third is the high incidence of emerging mycotoxins such as 3-NPA, MON, STE, and TeA and pending risk assessment studies for these toxins in humans. Since traditional malting and processing are likely carried out by mycotoxin-unaware traditional processors, it is also advised to educate the public on the health risks of mycotoxins and possible methods to alleviate fungal contamination and on hygienic conditions during malting and storage. Data from the present study serves as a foundation for more detailed mycotoxin-related studies, such as further investigation on the fate of mycotoxins during the brewing processes of these beverages, considering the possible formation of masked/bound mycotoxins which may not have been quantifiable in the present study. Investigations of the occurrence of fungal metabolites in other indigenous food commodities from Namibia are necessary, as well as the determination of exposure to mycotoxins and their health effects in the Namibian population.The present study reports data on the variation of fungal metabolites in two different sorghum malts as raw materials for the brewing of two indigenous and popular traditional Namibian beverages, omalodu brewing and 36 un-milled sorghum malts grain samples intended for otombo brewing. Approximately, 500 g of the samples were collected following the sampling procedure described by [A total of 81 sorghum malt samples, purchased in November 2017 at open-markets in Oshana region, Namibia, were collected for this study. The sorghum malt samples were purchased based on availability at the open markets, hence, 45 sorghum flour malt samples intended for ribed by . Samplesv/v/v) was agitated in a 50 mL polypropylene tube for 90 min at 180 rpm using a rotary shaker . The mixture was then settled and supernatants/extracts were stored at −20 °C until further analysis.Sorghum malt samples were extracted for the presence of targeted multi-metabolites, including regulated, conjugated, and emerging mycotoxins. The extraction was done according to the methods described by . Brieflyv/v/v) and 5 µL was directly injected into the LC/MS/MS system consisting of an Agilent  1290 HPLC and an AB Sciex 5500 QTrap MS/MS with an electrospray ionization (ESI) triple quadrupole. Chromatographic separation was performed on a Phenomenex Gemini C18 column  equipped with a C18 (4 × 3 mm) i.d. security guard cartridge, eluted with a gradient of methanol/water containing ammonium acetate and acetic acid.The occurrences of fungal metabolites were detected and quantified using the procedure described by . BrieflyData acquisition was achieved in the time-scheduled multiple reactions monitoring (MRM) mode both in positive and negative polarities in two separate chromatographic runs per sample. The expected retention time of the MRM detection window of each metabolite was set at about 27 s and about 48 s for both positive and negative modes, respectively. Data were analyzed using MultiQuant™ 3.0.3 software . Quantification of metabolites was performed using external calibration based on serial dilution of a multi-metabolites stock solution. Results were corrected for apparent recoveries based on relative responses of the two matrices by spiking three different approximately blank samples at three concentration levels. Limits of detection and limits of quantification were determined following the Eurachem guide described by . The accConfirmation of positive metabolite identification was attained by the acquisition of two MRMs per metabolite . This generated 4.0 identification points according to Ref. . In addi® Excel 2010. An independent-samples t-test was done using the Statistical Package for the Social Sciences (SPSS) software, version 21.0 .Data evaluation, averages, and range calculations were performed in Microsoft


Non-parasitic spleen cyst (NSC) is a relatively rare and difficult to diagnose disease, which rapture due to a traumatic impact to the spleen, can lead to the peritonitis.We present the case of a 30-year-old woman with a 7.5 × 7.5 × 5 cm NSC, who underwent the microwave ablation (MWA) of the splenic cyst.The procedure was performed under intravenous anesthesia. MWA of the cysts was performed using a probe placed in the cavity of the cyst, with the frequency of 902–928 MHz delivered during 15 minutes. The postoperative period was uneventful, and the patient was discharged after 2 days.We demonstrated that MWA can be utilized as a novel, minimally-invasive, and cost-effective approach in NSC treatment. •Case report of a 30-year-old female patient presented with non-parasitic spleen cyst.•Microwave ablation is a promising approach in non-parasitic spleen cyst treatment.•Microwave ablation is an alternative for splenectomy. Clinical manifestations of NSC depend on the volume of the liquid inside the cyst, and possible complications, such as hemorrhage or abscess . The mosMany authors prefer splenectomy as the most radical method of treating NSC, especially for large cysts . With thThe method of microwave ablation (MWA) was successfully utilized in the treatment of neoformations in parenchymal organs, including liver hemangiomas. The present case demonstrates the successful use of MWA in the treatment of NSC under the control of ultrasound and fluoroscopy X-ray.2On May 29, 2016, the patient – a woman of 30 years old, was accepted to the Sechenov University Clinical Hospital No. 1 with occasional pulling pain in left hypochondrium, nausea, and low-grade fever. The examination revealed a cyst in the spleen. The reaction of Kasoni and ELISA for Human Cystic echinococcosis was negative. The diagnosis of NSC was established. On June 13, 2016, the patient was admitted to the Department of Surgery for the surgery. A percutaneous puncture and MWA of the splenic cyst were performed under the control of ultrasound and X-ray fluoroscopy.At admission: The spleen is of 20 × 10 cm, with the lower pole being palpated in the area of the mesogastrium, of dense consistency, and painless during palpation.During examination: The blood and urine test results were within normal ranges, except for the erythrocyte sedimentation rate (ESR), which was 29 mm/h. Thrombocytopenia was not detected, with the values of platelets of 315 thousand/μl.Ultrasonography and computer tomography (CT) of abdominal organs: The spleen is of 20 × 10 cm, with clear, even contours, and homogeneous structure. In the upper pole of the spleen, a cyst is defined with clear smooth contours of 7.5 × 7.5 × 5 cm, uniform content, without septa or additional inclusions . There wPreviously, spleen surgery had not performed.®) was inserted percutaneously into the cyst of the spleen's upper pole, accessing via the left mid-axillary line in the 9th intercostal space. In the epigastrium on the left anterior axillary line, a percutaneous puncture of the cyst of the upper pole of the spleen was made using a 18 gauge needle. After removal of the stylet, about 140 ml of a green turbid liquid was evacuated, which was sent for biological and cytological examination. Then, a radiopaque preparation (Urografin® 76% - 20 ml + NaCl 0.9% 120 ml) was injected into the cyst. During X-ray, a neoformation of clear, even contours, and of uniform contrast was determined at the left subphrenic region. No contrast in the abdominal cavity or the vessels of the spleen was detected. MWA of the cysts was performed using a MWA catheter placed in the cavity at the center of the cyst, with the frequency of 902–928 Hz delivered during 5 minutes. The installed 18 G needle allowed the evacuation of the residual high temperature liquid during the MWA. Then, both the catheter and needle were removed.During the surgery, a percutaneous puncture and MWA of the splenic cyst were performed under the control of ultrasound and X-ray fluoroscopy. Under intravenous anesthesia , an MWA catheter  .Fig. 2Fo3The spleen is an important internal organ involved in blood formation and ensuring the immunological status. Splenectomy, even performed using laparoscopic approaches, is a traumatic method requiring endotracheal anesthesia. The cost of this surgery reaches up to 250,000.00 rubles in Russia and $20,000.00 USD in the United States. The average bed-day is 12 ± 2.3, and the frequency of complications is up to 22.7% [Sclerosis of the cyst using 96% ethyl alcohol often results in a relapse of the disease . For insSimilar observation were reported in our clinic during sclerosis of the NSC in 50 patients ,8. To imOur novel MWA technique, to the best of our knowledge, was not described in the literature. This advanced approach of NSC treatment allows to carry out the procedure on an outpatient basis. MWA is less traumatic, does not require general anesthesia, and can be performed using intravenous or local anesthesia. There is no recurrence of the disease, and the duration of treatment is 1–2 bed-days.The case described by us demonstrates the efficacy of MWA of NSC. The residual cavity of the cyst 4.8 ml, detected by abdominal CT. After the surgery, the patient had no pain, and the operation itself and the hospital stay were 2 days. There were no complications during and after the surgery.MWA due to ultra-high-frequency (microwave) energy leads to rapid heating of the cyst contents and its walls up to 120 degrees. This contributes to necrosis and sclerosis of the cyst walls. By controlling the temperature and time, using the generator it is possible to perform a complete destruction of the walls of the cyst.4MWA is a promising approach in NSC treatment.NA.None.None.Radmila Karpova performed the procedure, wrote the manuscript and is responsible for the information.Artem Mishin and Samir Guseinov assisted in the operation, wrote the manuscript and are responsible for the information.NA.NA.Radmila Karpova, Artem Mishin, Samir Guseinov.Not commissioned, externally peer reviewed.The patient provided her informed consent for the publication of her clinical details and any accompanying images about this case report.


Birth defects are a leading cause of infant mortality in the United States, accounting for 20.6% of infant deaths in 2017 . The following conditions were not considered causes of IMBD: undescended testicles ; cardiovascular conditions not considered to be structural heart defects (Q27.0–Q28.9); and preterm births (20–36 weeks) with an underlying cause of death considered to be a complication of prematurity (lung hypoplasia [Q33.6]). In addition, underlying causes of death listed as persistent foramen ovale (Q21.1) and patent ductus arteriosus (Q25.0) were excluded for all preterm births and for infants born at term/postterm (37–44 weeks) with an age of death <28 days .Linked birth/infant death records for infants aged <1 year born to U.S. residents (excluding U.S. territories) from 2003, the first year of the birth certificate revision,IMBD rates and 95% confidence intervals (CIs) were calculated for each year and stratified by maternal race/ethnicity , maternal age at delivery , infant sex, gestational age , and infant age at death . Births from other racial/ethnic groups were excluded from race/ethnicity analyses but were included in the total counts. Overall and for each stratum, percent changes in IMBD rates were calculated by dividing the difference between the rates in 2003 and 2017 by the rate in 2003, and then multiplying by 100. References to decreasing or increasing trends during 2003–2017 are statistically significant and were assessed using the Cochran–Armitage test for trend. SAS statistical software  was used for analyses.The 2003–2017 linked birth/infant death data included 60,036,305 live births and a weighted total of 384,223 infant deaths . A birth defect was listed as the underlying cause of death for 70,954 (20.3%) infant deaths during 2003–2017, ranging from 19.5%  in 2003 to 20.7%  in 2017. IMBD rates decreased 10% from 2003  to 2017   Figure .Significant trends in IMBD during 2003–2017 were observed across most maternal racial/ethnic, maternal age, infant sex, gestational age, and infant age at death categories . Rates dRates of IMBD decreased 10% during 2003–2017 overall and across the categories of maternal race/ethnicity, infant sex, and infant age at death. Although rates declined among infants of Hispanic, black, and white mothers, racial/ethnic disparities persisted. The IMBD rate was 32% (2003) and 34% (2017) higher among infants born to black mothers than that among those born to white mothers and 15% (2003) and 26% (2017) higher among infants born to Hispanic mothers than among those born to white mothers. Across gestational age categories, declines in IMBD rates were limited to infants born at 20–27 and 39–44 weeks, and rates increased for those born at 32–36 weeks and were stable for those born at 28–31 and 37–38 weeks.The decline in IMBD could be influenced by improvements in prenatal care, birth defects prevention measures, and improvements in medical care of infants with birth defects, in addition to factors influencing the overall infant mortality rate. The observed differences in IMBD rates by race/ethnicity might be influenced by access to and utilization of health care before and during pregnancy, prenatal screening, losses of pregnancies with fetal anomalies, and insurance type Birth defects occur in approximately 3% of births , non-Hispanic black mothers (11%), and non-Hispanic white mothers (12%); however, racial/ethnic disparities remained. Rates decreased for extremely preterm infants  and late term/postterm infants (39–44 weeks) but increased for moderate/late preterm infants (32–36 weeks).Continued tracking of rates of infant mortality attributable to birth defects by maternal and infant characteristics can help identify areas where efforts to reduce mortality rates are needed.