Objective. Present study was undertaken to compare the results of two single stage hypospadias repairs, namely, Tubularized Incised Plate (TIP) repair and Mathieu's repair. Methods. The study included 100 patients of distal penile hypospadias, from January, 2008 to January, 2013. After a detailed history, local examination was performed with reference to the site of meatus, shape of glans, and presence of chordee. TIP repair was performed in 52 patients and Mathieu's repair in 48 patients. On follow-up, the patients were examined for the position of meatus, shape of meatus, urinary stream, urethrocutaneous fistula, and stricture formation. Results. The mean age of presentation was 6.2 ± 3.2 years (range 1.5–15years). The mean operative time was 63.7 ± 14.3 (45–90) minutes and 95.0 ± 19.1 (70–125) minutes in TIP and Mathieu's repair, respectively.Complications after surgery were urethero cutaneous fistula in 3(5.76%) and 7 (14.5%), meatal stenosis in 3(5.33%) and 4(8.33%), wound infection in 19.2% and 8.3% cases in TIP repair and Mathieu repair, respectively. The shape of meatus was slit-like and vertically oriented in 48(92.3%) patients who had undergone TIP repair. Conclusion. The Snodgrass repair is significantly faster, with more natural cosmetic appearance of the meatus than the Mathieu's repair. Procedures established to correct distal penile hypospadias are the tubularized incised plate urethroplasty (TIP repair), Thiersch-Duplay, Mathieu's repair, Mustarde, and MAGPI. Among these procedures TIP and Mathieu's urethroplasty have been widely practiced. Mathieu's perimeatal based flap repair was first described in 1932; it is usually applied for correcting coronal and subcoronal defects [This was a prospective study between January 2008 and January 2013. A total of 100 patients with primary distal hypospadias were included in the study. These patients were randomly assigned as group-A with 52 patients in whom TIP repair was accomplished and group-B having 48 patients in whom Mathieu's repair was performed. The previously operated cases of distal penile hypospadias with extensive scarring, severe chordee likely to necessitate a staged procedure, and patients with micropenis with poorly developed urethral plate and urethral groove were excluded from the study. Repair of the hypospadias was done under general anesthesia and endotracheal intubation. In TIP repair, a segment of the urethral plate 8–10 mm wide was marked out distal to urethral meatus and incision was made along the lateral borders of the urethral plate. An incision was made subcoronally and was completed ventrally as “U” shape proximal to urethral meatus. After carefully degloving the penis, glanular wings were adequately developed lateral to the urethral plate. A midline vertical incision was made with a knife in the urethral plate. The neourethra was reconstructed around 6 or 8 Fr catheter using multiple interrupted sutures with polygalactin 6-0 with knots outside. Glanuloplasty was performed with 6-0 polygalactin in two layers. Meatoplasty and skin cover were completed  to minimize the observer's bias. The mean follow-up of the patients was 17 months, ranging from 1 to 44 months in both the groups  years and in group-B it was 5.9 ± 3.1 (1.5–14) years. The difference in the age groups was statistically nonsignificant between the two groups.P < 0.05). Meatal stenosis developed in 3 (5.76%) and 4 (8.33%) patients in group-A and group-B, respectively, meatal stenosis was managed by dilatation and one patient from each group needed meatoplasty. Urethrocutaneous fistula developed in 3 (5.76%) patients of group-A and 6 (12.5%) patients in group-B. Wound infection developed in 3 (5.76%) and 4 (8.33%) patients in group-A and group-B, respectively, and was managed by antibiotics (Sixteen (30.76%) patients in group-A had coronal, 14 (26.92%) had subcoronal, and 22 (42.40%) had distal penile hypospadias while in group-B 24 (50.00%) patients had coronal, 8 (16.66%) had subcoronal, and 6 (33.33%) had distal penile hypospadias. The difference was statistically insignificant between the two groups . The meaibiotics .P < 0.05). The shape of meatus was slit like and vertically oriented in 48 (92.3%) patients who had undergone TIP repair.On follow-up the cosmetic appearance of the penis was excellent in all the patients (100%) in group-A; in group-B excellent cosmesis was achieved in 20 (41.66%) patients. In group-B 8 (16.7%) patients had mild torsion of the shaft. This difference was statistically significant between the two groups (The shape of meatus was round and regular in 44 (91.6%) patients who had undergone Mathieu's repair.The ultimate goal of any hypospadias repair is to achieve a functionally and cosmetically normal penis. Even in the hands of most experienced surgeons, hypospadias repair is associated with a number of complications ranging from urethrocutaneous fistula to the complete breakdown of neourethra requiring total reconstruction of the different single stage hypospadias repairs. The tubularized incised plate urethroplasty and Mathieu′s repair have been widely practiced. Final cosmetic results and normal penile functioning are two important considerations in hypospadias surgery.The mean age (6.4 ± 3.3 years) of the patients in our study was more as compared to the age reported by other authors .In our series, chordee was seen in 26 (48%) patients in group-A and 22 45.83%) in group-B. Incidence of chordee was different in different series; it was 35% in Sweet et al. series, 100% in Tonvichien and Niramis case series, and 19.9% in Singh et al. series of cases . At a me.83% in gIn our series complications were seen in 28 (28.0%) patients. The complications included wound infection seen in 3 (5.76%) patients in the group-A and 4 (8.3%) patients in the group-B. Complications do occur after every hypospadias repair. Currently there is expected complication rate of 5–10% mostly fistulas in one stage urethroplasty  Table 3Table 3.In our series excellent cosmesis was achieved in 52 (100%) patients in the group-A and in the group-B cosmetic appearance was excellent in 40 (83.3%) patients and 8 16.7%) patients had mild torsion of shaft. Our cosmetic outcome after TIP urethroplasty was similar to that reported by authors like Anwar-ul-haq et al., Guo et al., and Imamoğlu and Bakirtaş .7% patie, 15.As evident in our series, the urethrocutaneous fistula and meatal stenosis rate was more in Mathieu's group as compared to that of Snodgrass group. One explanation for this is the need for two suture lines in case of onlay flap technique on either side which might be jeopardizing the vascular supply of the flap. Although the expected complication rate in Mathieu's urethroplasty ranges between 5 and 21% for distal repair, in group-A the incidence of UCF was 5.76% only which was significantly lower than what was observed after Mathieu's urethroplasty. Cosmesis of penis is of concern to the parents which was best achieved with TIP urethroplasty as compared to Mathieu's urethroplasty. TIP creates a vertically oriented, slit like normal looking meatus which is cosmetically desirable.Our study has revealed that TIP urethroplasty has an edge on Mathieu's urethroplasty, so we recommend the TIP urethroplasty in all primary and distal cases of hypospadias. TIP repair is associated with excellent cosmesis and few manageable complications. It offers a safe and reliable modality for primary repair of distal penile hypospadias. Cosmetic appearance of the external urethral meatus is highly satisfactory with tubularized incised plate urethroplasty.


The incidence of type 1 diabetes mellitus (T1DM) is rising rapidly in children, with an overall annual global increase of 3%. Approximately 79,100 children under age 15 develop T1DM annually. Although the reported incidence of T1DM in China was as low as 0.6 per 100,000 per annum in 1995, the number of children with T1DM cannot be underestimated within the large population. The number of type 2 diabetics in the young has been increasing significantly in the last decades.To improve access to quality care for children with diabetes in China, the World Diabetes Foundation (WDF) planned a project to help to establish pediatric diabetes centers to increase the rate of diagnosis and to improve the quality of treatment for children with diabetes through training of health care professionals. A survey was conducted on the basis of pediatric diabetes centers across China to raise the awareness of pediatric diabetes, and to evaluate the diagnosis and treatment status of diabetes care in children. Multiple diabetes camps were organized for children and caregivers. The project commenced in December 2012 and will be completed in February 2015. Thirty three pediatric diabetes centers in 25 cities across China were established. A cross-sectional questionnaire survey about the children with diabetes was completed.Until the end of December 2013, 1,224 children with T1DM were effectively enrolled into the program with a mean age of 7.28±3.75 (mean± SD). For the age distribution, 79% were in the range of 4-12 years old, of those 384 cases were younger than 5 and 840 cases were older than 5 years old. The male to female ratio was 46.8% to 53.2%. 49% of the patients presented with typical diabetic symptoms such as increased thirst, frequent urination, extreme hunger, weight loss and fatigue. 59.3% cases first presented with diabetic ketoacidosis (DKA). The overall incidence of hypoglycemia was 17.5% . The total incidence of DKA was 59.3% . The average level of HbA1c was (11.1±3.2)%. Using HbA1c 7.5% as a cut-off, the incidence of hypoglycemia was 29.3% in the HbA1c below 7.5% group and 14.2% in the above 7.5% group (P<0.001). The incidence of DKA was 54% in the HbA1c below 7.5% group and 61% in the above 7.5% group (P>0.05). 97.2% of the patients received insulin treatment, while 83.3% with insulin injection and 14% adopted pump therapy. 78.8% of the patients were using multiple insulin injection regimes.In China, T1DM is still the major form of diabetes among the young, although there is a tendency of increasing T2DM. Greater efforts need to be made to improve the awareness and quality of care. A task fprce on diabetes in children was recently formed by the Chinese Society of Pediatric Endocrinology and Metabolism (CSMEM) to facilitate nationwide research and collaboration.


Vitamin D deficiency is rampant in India despite abundant sunshine. We aimed to estimate the amount of cutaneous vitamin D synthesis in pregnant village women (n=100) in different seasons in conjunction with serum 25OHD. We also correlated variations in surface UV energy with the presence of environmental pollution and crowding.The measurements of UVB radiation energy were obtained using UV spectrometer at different times of the day between 9 am and 4 pm, in different seasons. The instrument was calibrated to denote 13 microWatt/cm2 of irradiance per mVolt of deflection. Measurements were taken at our institution (situated in the countryside), at crowded inner city areas and the villages where our subjects resided. The clothing, outdoor activity pattern, and dietary calcium intake were prospectively documented. Serum 25OHD was measured by radioimmunoassay .2 and 805 J/m2respectively. Average body surface area exposed was 9.5% in winter and 18.5 % in summer. Using the equation described previously by Godar et al [, the estimated average daily cutaneous vitamin D synthesis was 769 IU during winter and 1487 IU during summer. The mean serum 25OHD was11.32 ± 5.03 ng/ml during winter (92 % < 20 ng/ml) and, 16.63 ± 8.12 ng/ml during the rest of the year (70 % < 20 ng/ml).The average peak UV irradiance calculated during April and May was significantly higher in our institute campus (338 microwatt/cm2) and the villages (312 microWatt/cm2), than the crowded inner city location .UVB spectrometer reading ranged from 4.5 mVolts in January to 36 mVolts in June. The average erythemally effective UV energy during winter season and during the rest of the year was 308 J/m0N, cutaneous vitamin D synthesis is limited by poor UV radiation energy. Poor skin exposure is a limiting factor in all seasons. Particulate pollution may be an important remedial impediment to cutaneous vitamin D synthesis.During winter at latitude 26.8


Objective. To determine the influence of deep brain stimulation (DBS) on daily routine driving behavior in Parkinson's disease (PD) patients. Methods. A cross-sectional questionnaire survey was done in 121 DBS-PD patients. The influences of patient characteristics and DBS on current driving and driving at time of surgery and the predictive value of the preoperative levodopa-test on postoperative driving were evaluated. Results. 50% of 110 driving-license holders currently drove. 63.0% rated themselves as safe drivers, 39.4% reported improvement, and 10.9% noted deterioration in driving after DBS surgery. Inactive drivers had quit driving mainly due to disease burden (90.9%). Active drivers were younger, more often males, and less impaired according to H&Y and MMSE, had surgery more recently, and reported more often overall benefit from DBS. H&Y “on” and UPDRS III “off” scores at time of surgery were lower in pre- and postoperative active than in inactive drivers. Tremor and akinesia were less frequent reasons to quit driving after than before DBS surgery. Postoperatively, 22.7% (10/44) of patients restarted and 10.6% (7/66) of patients discontinued driving, independently of H&Y stage. The preoperative levodopa-test was not predictive for the postoperative driving outcome. Conclusion. 50% of PD patients with DBS drive. DBS surgery changes daily routine driving behavior. Driving in Parkinson's disease (PD) has been investigated intensively –3. AlthoA questionnaire-based, monocentric, and cross-sectional survey was performed. Written informed consent was obtained from all subjects. The study was approved by the local ethics committee of the Medical Council Hamburg .From January 2013 until April 2014 all PD patients with DBS visiting the outpatient clinic at the University Medical Center Hamburg-Eppendorf were asked to fill out a self-developed questionnaire  in the “on” and “off” condition of the preoperatively performed levodopa-test.t-tests or as counts and percentages for categorical data and compared using chi-square tests. Spearman's rank correlation was used to examine association between UPDRS scores and status of being an active driver. Association between H&Y score and likelihood to drive was calculated by linear-by-linear association within chi-square test and Spearman's rank correlation. Because this study was exploratory, no correction of statistical significance for multiple testing was performed to avoid inflating type II errors and thus missing real differences [Only complete data sets were used for analysis (except missing MMSE in one subject). Data are presented as means and standard deviations [SD] for continuous data and are compared using ferences , 6.n = 111) of patients owned a valid driving license. Data set was complete in 110 of 111 cases  and considered for further analysis. 93 of the 110 patients were operated on in our center. p values are given.121 consecutively PD patients with DBS  were investigated. None of the patients refused to take part in the survey. 91.7% (n = 55) of all patients were active drivers. Mean age was 65.2 [9.4] years. The questionnaire was filled out on average 4.1 [3.2] years after surgery. The subthalamic nucleus (STN) was the surgical target in 93.6% (n = 103) of cases. The ventrolateral thalamic base (VIM) was targeted in 5.4% (n = 6) of the patients. The surgical target of 1 patient (operated elsewhere) was unknown. Overall, 92.7% of patients reported benefit from DBS surgery and 90.0% declared they would redo the operation.Clinical phenotype was equivalent in 63.7%, akinetic-rigid in 24.5%, and tremor-dominant in 11.8%. Microelectrode-guided DBS surgery was done in at least 105 (95.5%) patients (unknown for 5 patients). 50% (n = 69) of the patients rated themselves as safe drivers. These were 12.7% (n = 14); more patients than currently were driving (n = 55). 39.1% reported improved driving abilities due to DBS; 10.9% noted a deterioration of their driving skills. Six drivers (5.5%) were involved in a car accident within the last 12 months. Five of them (83.3%) considered themselves as safe drivers. Thus 7.2% of all patients who considered themselves as safe drivers (5/69) had an accident but only 2.4% (1/41) who considered themselves as unsafe drivers. Subtype of disease, age, gender, disease duration, MMSE, and duration of DBS were not significantly different in the subgroups of patients being or not being (94.5%) involved into a car accident within the last year.62.7% . Forty-four patients had stopped driving prior to and 22 patients after brain surgery. The disease itself was reported to be the main reason for giving up driving  preoperatively active drivers started to drive again within the first 3 months after DBS surgery.r = −0.455, p < 0.001). Percentages of active drivers were 49.1% in H&Y 2, 43.6% in H&Y 3, 5.5% in H&Y 4, and 1.8% in H&Y 5.Dependence on a car and reduced QoL without driving were reported significantly more often by currently active than inactive drivers. Active drivers more often reported benefit from DBS surgery and more often affirmed that they would undergo surgery again. 96.8% of the active drivers and 46.3% of the inactive drivers reported that they had expected to be able to drive after surgery.p = 0.05). The expectation to be capable of driving after surgery was higher in males (78.2%) than in females .Significantly more males than females were driving at time of survey , and morn = 1/20] versus 32.5% [n = 13/40], p = 0.02) and akinesia  as reasons compared with patients who stopped driving preoperatively. Other symptoms than listed in the questionnaire were reported as “free-text” more often as reasons to quit driving after surgery compared with before surgery , namely, “lateral shift of the body” (n = 1), “weakness of the legs” (n = 1), “car accident” (n = 1), and “impulsive and reckless driving” (n = 1). The frequency of all other investigated symptoms did not differ significantly in patients who had quit driving either before or after DBS surgery  were active drivers, but 64.7% of patients expected at that time to be able to drive postoperatively. 50.9% of all patients resumed driving within a postoperative period of 3 months. 12 months after surgery, this proportion increased to 62.4%. One patient had not reached the one-year follow-up period at time of survey.Here we focus on the direct effect of DBS on driving and aim to minimize the influence of disease progression on driving. Therefore, we defined patients as “preoperatively active” drivers, when driving more than 30 min/week within 3 months before surgery and as “postoperatively active” drivers, when driving more than 30 min/week within 1 year after surgery. Other patients were defined as “preoperatively inactive” or “postoperatively inactive” drivers.H&Y data at clinical “on” state at time of surgery were recorded in 102/110 (92.7%) patients. UPDRS III data of the preoperative levodopa-test were available in the “off” stage in 75/110 (68.2%) and in the “on” stage in 77/110 (70.0%) of patients. MMSE scores were available in 109/110 (99.1%) patients. All active drivers at this time drove more than 30 min/week. Age, disease duration, and MMSE score did not differ between pre- or postoperatively active and inactive drivers.Preoperatively active drivers were by trend less severely affected according to H&Y than inactive drivers (p = 0.06). Whereas UPDRS III “on” scores were not different, UPDRS III scores in “off” condition were lower  in active than in inactive drivers. Likelihood to drive a car preoperatively decreased by trend with increasing disease severity according to H&Y . Percentages of active drivers were 3.4% in H&Y 1, 37.3% in H&Y 2, 45.8% in H&Y 3, 11.9% in H&Y 4, and 1.7% in H&Y 5. postoperatively had a lower  H&Y score at time of surgery than postoperatively inactive drivers. The UPDRS score was lower in postoperatively active than in postoperatively inactive drivers in “off” but not “on” condition. Likelihood to drive a car postoperatively decreases with increasing disease severity according to H&Y at surgery . Percentages of active drivers were 3.2% in H&Y 1, 38.7% in H&Y 2, 50.0% in H&Y 3, 6.5% in H&Y 4, and 1.6% in H&Y 5.Patients who droven = 10/110) of patients reported resumption and 6.4% (n = 7/110) cessation of active driving. Thus, 22.7% (10/44) of patients changed from preoperatively inactive to postoperatively active and 10.6% (7/66) from preoperatively active to postoperatively inactive drivers. Two of these 7 patients stopped driving due to reasons unrelated to their disease. Age, gender, MMSE, and motor impairment according to H&Y and UPDRS III at time of surgery were not significantly different in patients restarting driving after surgery compared to patients without resumption of driving .Within 12 months after DBS surgery, 9.1% ( driving . None ofp = 0.18) or single subject (p = 0.17) levels and so not predictive for the condition of “active driver postoperatively” or switching from “preoperatively inactive” to “postoperative active” driver (p = 0.91).Change of UPDRS motor score in the preoperative levodopa-test was recorded in 75 of 110 (68.2%) patients. Mean motor UPDRS score in the “off” state was 37.7 [11.7] points and in the “on” state 18.4 [7.3] points. Mean improvement was 19.2 [9.3] points, which is 51.8% [17.7] . ImproveThis study aimed to assess daily driving behavior and to reflect surgery-related change of driving practice in PD patients with DBS. We evaluated the current frequency of driving, the influence of patient characteristics, and DBS on present driving behavior and in addition retrospectively the immediate effect of DBS surgery and the predictive value of the preoperative levodopa-test on postoperative driving practice. The study design did not allow the evaluation of driving skills or performance.A main result of this study is that half of the PD patients with DBS are active drivers. The “population-based” (within the population of DBS patients) study character likely makes this finding transferrable to other PD patients with DBS. The driving-rate of 50% is comparable with the driving-quote of 60% described for treatment-unselected PD patients in another questionnaire survey .In our consecutively investigated PD patients with DBS, the STN was targeted in 93.6% of cases. Therefore our findings represent mainly the situation in the group of PD patients with STN surgery. Due to the small number of target locations other than the STN, the statistical power for subgroup analyses is too low and it is possible that stimulation of VIM or GPi has different implications for driving behavior.We found active drivers with DBS to be younger and more often males and to have lower disease severity, higher MMSE scores, and shorter duration of DBS compared to inactive drivers. The negative impact of age and cognitive decline on driving is known for PD patients , 8 and wFor the preoperative 3-month period, a higher  motor UPDRS score in the “off” condition, but not the UPDRS III or H&Y score in the “on” state, was found to be associated with a higher prevalence of inactive drivers. This is in accordance with 2 Class II studies, describing only the motor UPDRS “off” score to be probably predictive of driving performance and 4 Class II and 2 Class III studies describing the H&Y stage to be probably not predictive of driving performance .For the 12-month period postoperatively, a higher motor impairment expressed by higher UPDRS III “off” and H&Y “on” scores at time of surgery was associated with more patients having discontinued driving.Motor improvement in the preoperative levodopa-test was not predictive of being an active driver within one year postoperatively or of changing from being preoperatively an inactive to becoming postoperatively an active driver. These findings are in line with studies showing an inconsistent and therefore probably not essential influence of motor impairment on driving in PD patients –13. In fThe postoperative reduction of tremor and akinesia likely explains that both symptoms have only influenced patients before but not after brain surgery in their decision to quit driving. In contrast to patients who did not restart driving after DBS surgery, patients resuming driving did not report orientation problems, tiredness, and sleep attacks at all. Less sleepiness might be related to a postoperative reduction of medication. Positive effects of DBS on orientation could be possible, as recently DBS of the STN has been shown to modulate spatial attention . One patRestarting driving after DBS surgery does not imply automatically improved driving safety due to stimulation. We found 5.5% of patients with DBS who had been involved in a car accident in the last 12 months. However, we did not evaluate accident rates 12 months before and after DBS surgery which might had been more reliable to investigate the direct DBS effect on accident frequency. On the other hand, in several patients DBS had been performed years ago and recall of, for example, minor accidents likely is much more biased than the basic question whether someone did or did not drive within 12 months before or after DBS surgery. Regarding accident rates, there are no directly comparable studies in treatment-unselected drivers with PD. With an approximate estimation of an even distribution of crashes over consecutive years, this crash rate seems to be lower compared with the accident rate of 15.5% in a 2-year follow-up in 106 treatment-unselected PD patients  but highn = 6).Noteworthy, car crashes were more frequent in patients considering themselves as safe drivers, which matches findings that patients frequently overestimate their ability to drive . HoweverOn the other hand the MMSE is not a comprehensive measurement tool and only gives a coarse picture of the patients' cognitive status. Therefore likely it is not an ideal predictor of driving performance in PD patients . HoweverOf course we routinely do more sensitive cognition scores like the Montreal Cognitive Assessment (MOCA) or the Mattis Dementia Rating Scale or intensive neuropsychological testing in PD patients before DBS surgery. But the preoperative cognitive assessment battery has changed in our center over the last years and not all of the patients in our study were operated on in our center, so we had different preoperative and also different and incomplete postoperative cognitive testing in our patients. In contrast to MOCA or Mattis tests, we perform the much less time consuming MMSE not only preoperatively as screening test but also routinely in the outpatient clinic in almost any follow-up visit of the patients postoperatively. In this study, we only included patients with complete data sets, so we used the MMSE as cognition parameter. Although it lacks sufficient measurement of executive function the MMSE allows a reasonable estimation whether patients are demented or not and whether active and inactive drivers differ regarding their cognition.Dependency on driving a car in everyday life and reduced QoL without driving were reported more often by active than inactive drivers. Thus, resumption of driving postoperatively in 10 of 44 preoperative inactive drivers might be influenced by these aspects more than by real improvement of driving ability.Maintenance or regain of driving ability seems to be an important outcome aim for patients undergoing DBS. 96.8% of the postoperatively active and 46.3% of the postoperatively inactive drivers declared to have expected preoperatively to be able to drive after surgery. The latter finding indicates that a notable amount of patients expects DBS to have a positive effect on their driving competence. We suggest to discuss this topic presurgically and if necessary to temper false expectations of the surgical candidates.An overall benefit from DBS was reported more often in the group of active than of inactive drivers. Active drivers also affirmed more often that they would decide for themselves DBS surgery again. Driving seems to be more important for males than for females. Males more often reported to have expected to be able to drive postoperatively than females, in fact drove more frequently after surgery, and considered themselves more often as safe drivers.In the present study, the treating physician was aware of PD patients' driving practice in only 30.0% of the cases. In general, the physician has the medical and legal obligation to advise his patients not to drive if they are likely incapable of safe driving . PD patiThis study has some limitations. Owing the exploratory nature of the study our findings are tentative and further confirmatory research is thus needed. The retrospective study character with an average completion of the survey 4.1 years after surgery contains a potential risk of selective recall of adverse events such as minor accidents and periods of driving cessation. Also it cannot be excluded that answers were biased because patients were embarrassed to admit driving insufficiency or accidents.Like otherwise treated PD patients, patients with DBS frequently drive a car. DBS surgery influences driving behavior and seems to have a positive effect on daily routine driving practice. Disease severity in clinical “off” state at time of brain surgery is a negative predictor for being an active driver postoperatively. Driving after brain surgery is more likely in younger and less motor and cognitive impaired PD patients. The likelihood for driving decreases with duration of brain stimulation. Driving a car after DBS surgery is a relevant aspect for an improving of quality of life, especially for males. Tremor and akinesia appear to be the main driving-relevant motor aspects improved by brain stimulation. The preoperative levodopa-test is not predictive for being or becoming again an active driver after DBS surgery.


However, PM2.5 exposure primarily occurs indoors. Given such, we conducted this study to characterize the indoor-outdoor relationship of PM2.5 mass concentrations for urban residences in Beijing.Ambient fine particulate matter , and the ambient data explained ≥84% variance of the indoor data. Regression analysis suggested that the variables, such as traffic conditions, indoor smoking activities, indoor cleaning activities, indoor plants and number of occupants, had significant influences on the indoor PM2.5 mass concentrations.Hourly ambient PM2.5 of ambient origin made dominant contribution to residential indoor PM2.5 exposure in the non-heating season under the high ambient fine particle pollution condition. Nonetheless, the large inter-residence variability of infiltration factor of ambient PM2.5 raised the concern of exposure misclassification when using ambient PM2.5 mass concentrations as exposure surrogates. PM2.5 of indoor origin still had minor influence on indoor PM2.5 mass concentrations, particularly at 11:00–13:00 and 22:00–0:00. The predictive models suggested that particles from traffic emission, secondary aerosols, particles from indoor smoking, resuspended particles due to indoor cleaning and particles related to indoor plants contributed to indoor PM2.5 mass concentrations in this study. Real-time ventilation measurements and improvement of questionnaire design to involve more variables subject to built environment were recommended to enhance the performance of the predictive models.PM Fine particulate matter  largely vary from 35% to 95% in the literature[Finf values than particles of other size bins [2.5. The primary indoor PM2.5 sources include environmental tobacco smoke (ETS), home cleaning and heat/combustion activities[Chinese urban residents spend nearly 90% of lifetime indoors, and of that, 70% is in residential indoor microenvironments. As a red cracks –21. The d cracks , 22–24. iterature, 25–32. ize bins . On the ctivities; whereasctivities, 34, 35.2.5 concentrations may significantly differ. The ratio of indoor to outdoor PM2.5 mass concentrations (defined as I/A in this article) can be greater than unity sometimes. It is thus uncertain if central-site PM2.5 mass concentrations are good surrogates of exposure to ambient PM2.5. Given such, it is necessary to characterize the relationship between indoor and outdoor PM2.5 concentrations as part of fine particle exposure assessment, which has not been well studied in China.Due to the properties alteration during infiltration process and the presence of indoor sources, the diurnal variation pattern of indoor and outdoor PM2.5 mass concentrations in non-heating season for urban residences in Beijing. We concurrently collected real-time indoor and outdoor PM2.5 mass concentrations for 41 urban residences in Beijing in the non-heating season. Infiltration factor of ambient PM2.5 and its determinants have been discussed in a companion paper. In this article, we compared the diurnal variation of indoor and ambient PM2.5 mass concentrations as well as I/A. Further, we explored the predictors of indoor PM2.5, which suggested the likely indoor PM2.5 sources in the tested urban residences during the monitoring period. The results and the mechanisms driving the observations are discussed in this article.The objective of this study is to characterize the indoor-ambient relationship of PMFudan University’s ethical review board approved the study protocol (IRB00002408 & FWA00002399). The field tests were conducted based upon permissions from the property owners. A written consent was obtained from the participants prior to the field visit. We also implemented sampling at several outdoor sites in this study, in order to compare the measurements of our light-scattering devices to those of Chinese National Environmental Quality Monitoring (EQM). Permissions were obtained from Citic Group (the owner of the site close to Agriculture Exhibition Center EQM station), Department of Building Science, Tsinghua University (the owner of the site close to Wanliu EQM station), and the private land owners of other sites.Haidian, 5 in Xicheng, 3 in Fengtai, 1 in Shijingshan, 1 in Changping and 14 in Chaoyang. Questionnaires were administrated to the occupants during each visit to gather demographic and social-economic information, building characteristics, lifestyle information and time-activity pattern.The families that participated in this study were from a large cohort, which was recruited for a public health research project. The randomly selected cohort consisted of families in Beijing having 1–8 years old children. We contacted the parents in each family via telephone, informed them the research objective, and recruited the families that were willing to join in. Forty-one families participated in this study. These residences are located in 6 districts in Beijing: 17 in The dwellings tested in this study are relatively young (~50% less than 10-yr old). The occupants were also the property owners in 89% of the tested dwellings. All residences are multistory  or high-rise type . Mechanical ventilation is employed by only 1 residence, and others ventilate the indoor spaces through opening windows. Radiators are used for heating in 91% of the dwellings, whereas floor heating is used in the others. Central air conditioning is used for cooling in 2 dwellings, whereas split type air conditioning is used for cooling in the others. According to the time-activity records, ~60% families turned on air conditioner (AC) for 1–3 hours during the monitoring periods, and the windows were open when AC was not in operation.2.5 sources were of particular interests in the subsequent analysis. These variables included the type of traffic route around residence, distance to the road, indoor smoking activities during the monitoring period, cooking activities during the monitoring period, frequency of floor cleaning, floor cleaning method, frequency of furniture cleaning, indoor plants and number of occupants. Traffic emission is one of the important sources of indoor PM2.5 [2.5. Three types of traffic routes can be found proximate to the tested residences: expressways or arterial roads (ring roads of Beijing), local highways and quiet streets  was deployed at a height of 1.5 m (breathing zone) in the living room of each residence to collect the hourly real-time indoor PM2.5 mass concentrations for consecutive 24 hours. The 24-h sampling period is frequently employed in exposure measurement and assessment, given that the data can reflect the daily average exposure levels of pollutant concentrations[The field visits were implemented from July 1st to September 8ntrations, 41. As 2.5 mass concentrations using the above devices, but obtained the real-time ambient PM2.5 mass concentrations during the monitoring periods from the Chinese National Environmental Quality Monitoring (EQM) Stations that were closest to each residences. These stations served for central-site fixed monitoring in our study. TEOM 1405F  are employed at each EQM station to measure ambient PM2.5 mass concentrations. These instruments are routinely calibrated against gravimetric measurements. The distances between each residence and the closest monitoring stations are presented in Table A in the 2.5 mass concentrations as the surrogate of residential outdoor counterpart, despite the fact that extensive studies have suggested ambient fixed site monitoring to be reasonable surrogates of residential outdoor monitoring with respective to PM2.5 [2.5 mass concentrations using the photometers at outdoor sites where the devices can be securely placed and there was power supply. The test sites had variable distances to the closest EQM stations. We compared the data obtained by the photometers to those provided by the closest EQM stations. As shown in Table B in t-test). Note: the distances between 76% of the residences and the nearest EPA stations are within 5.5 km, while the distances for the remaining residences are within 7.0 km  concentration data and meteorological data in this study. The hourly real-time concentrations of O3, NO2 and SO2 in ambient air were provided by the EQM stations that are closest to each residence. Daily average outdoor meteorological data were provided by China Meteorological Data Sharing Service System. Real-time indoor temperature and RH values were recorded by Telaire 7001 monitor , which was connected to a HOBO U12 data logger  for data logging.We also collected the ambient criteria air pollutants  was divided into 4 sessions: morning (06:00–12:00), afternoon (12:00–18:00), evening (18:00–0:00) and night (0:00–6:00). The diurnal variation of indoor and ambient PM2.5 mass concentrations, I/A and criteria air pollutant concentrations were characterized. Due to the large day-to-day variability of pollutant concentrations, the original real-time data obtained in each residence were normalized prior to the diurnal variation characterization. The normalization procedure was as follows: the 24-h average values were set as the reference values with respect to each residence, and the hourly values were obtained by dividing the original hourly data by the 24-h average values.Descriptive statistical analyses were conducted for ambient and indoor PM2.5 mass concentrations were examined using Pearson correlation analysis and regression analysis with ordinary least square (OLS) method, respectively. There were residences in which smoking activities occurred during the monitoring periods (smoking families). Given such, the data of all families were involved in the analyses first, and then the analyses were conducted again after excluding the data from the smoking families.The associations between indoor and ambient PM2.5 mass concentrations. Regression analysis with OLS method was employed. The variables considered in the predictive model for ambient PM2.5 mass concentrations included the concentrations of ambient O3, NO2 and SO2. The variables considered in the predictive model for indoor PM2.5 mass concentrations included proximate traffic type, distance to road, indoor smoking activities, cooking activities, indoor cleaning activities, indoor plants and criteria air pollutant concentrations. The predictive models of indoor PM2.5 were built for all families and the non-smoking families, respectively. It is necessary to note that neither PM2.5 mass concentration data nor criteria air pollutant concentration data complied with normal or log-normal distribution (shown in Results section). However, it is still reasonable to apply the regression models to our data (N > 30) according to central limit theorem. The statistical analyses in this study were conducted with Statistical Analysis System . The significance level was 0.05 unless otherwise specified.Predictive statistical models were built to characterize the variables that were associated with indoor and ambient PMThe field sampling was implemented in the non-heating season. The mean ambient and indoor temperatures over the 24-h sampling period were in the range of 22.2–30.7°C and 25.6–33.2°C, respectively. The maximum and minimum hourly indoor temperatures were 47.2°C and 21.2°C, respectively. The hourly indoor RH was 19.1–79.9%, whereas the mean values over the 24-h sampling periods were 41.6–77.2% and 44–91% for indoor and ambient RH, respectively.2.5 mass concentrations are summarized in 2.5 mass concentration in this study was 280 μg/m3, and the minimum was 3 μg/m3 , 75 μg/m3. However, 38% of the hourly observations were still above the guideline.Descriptive statistics of ambient and indoor PM 3 μg/m3 . The ambectively . The amb2.5 mass concentration in this study was 193 μg/m3, and the minimum was 4 μg/m3 . The hourly ambient NO2 concentrations were in the range of 8–143 μg/m3 with mean and median of 51 and 47 μg/m3, respectively (3). 2 and O3 concentrations. Ambient O3 concentrations increased since 8:00 in the morning and reached the highest values at 15:00–18:00 in the afternoon. Contrary to O3, ambient NO2 concentrations started falling since 8:00 and reached the lowest values at 14:00–17:00. The reverse trends of ambient O3 and NO2 concentrations are expected, given that NO2 is the precursor of ground-level O3 in atmosphere and thus increasing O3 is accompanied by decreasing NO2 [2 were 1–60 μg/m3 with mean and median of 7 and 6 μg/m3  was higher than that explained by the hourly real-time data (84%). The difference was reasonable, because the hourly indoor data were more sensitive to indoor PM2.5 concentration spikes due to emissions from indoor sources than the average data over the 24-h sampling period. Similar to the Pearson correlation analysis, excluding the smoking families did not significantly change the linear regression analysis results as well .The linear regression analysis results are shown in terparts . In addi as well . As stat2.5 regression models can be the estimates of the infiltration factors of ambient PM2.5 (Finf)[2.5 generated by indoor sources[Finf, which represented the fraction of infiltrated ambient PM2.5 that remained suspended[Finf of single residences largely varied from 0.18 to 0.90. The modeling analyses yielded negative intercepts  of infiltrated PM2.5 was expected. The net decay of infiltrated PM2.5 resulted in the lower I/A ratio in our tests, the mean and median of which were 0.63 and 0.62, respectively.The slopes in the indoor-ambient PM5 (Finf), 27, wher sources, 27. Thesuspended, were 0. p<0.05, . The neg and Chen, a balanironment . When ouficiency . When ou2.5 mass concentration is another important indicator of indoor-outdoor relationship of PM2.5. A high I/A is usually associated with significant indoor PM2.5 sources. Thus, I/A can be used to examine the impacts of indoor sources on indoor PM2.5 mass concentrations. As shown in 2.5 sources in the two time intervals. In addition, slight increase of I/A can be discerned in early morning (7:00–9:00) and evening (15:00–17:00) (The indoor/ambient ratio (I/A) of PM0–17:00) .2.5 mass concentrations.In this study, the OLS method was utilized to examine the associations between a variety of factors and PM2.5 mass concentrations were ambient criteria air pollutant concentrations. The results, which are presented in 2.5 concentrations were positively associated (p<0.05) with the concentrations of ambient O3, NO2 and SO2. The three pollutants contributed to 7.4% of total variance of ambient PM2.5 mass concentrations.The variables considered for the predictive model of ambient PM2.5 mass concentrations were subject to built environment, human behavior and chemistry. As shown in number of occupants , followed by ambient SO2 (7.7%), ambient O3 (2.8%) and ambient NO2 (1.9%). The variables subject to lifestyle and built environment had relatively small variance contribution , followed by ambient SO2 (7.9%), traffic route (3.0%), indoor plants (0.7%), frequency of floor cleaning (0.7%), floor cleaning method (0.5%), ambient O3 (0.4%), ambient NO2 (0.3%), distance to the road (0.3%) and cooking (0.2%).The predictive model of the non-smoking families was presented in 2.5 concentration over 24-h period in Beijing was 69 μg/m3 in this study; while the counterpart in the North American metropolitan areas such as Los Angeles, Boston and Toronto were as low as 25, 14 and 28 μg/m3, respectively [2.5 mass concentrations over 24-h or 48-h period in several large-scale studies such as the RIOPA and EXPOLIS were reported to be 14–21 and 10–40 μg/m3, respectively [2.5 mass concentrations in Beijing were much higher than those in the US and Europe. The sampling was conducted from July to September, during which the windows were open most of time. Given such, ambient PM2.5 may strongly influence residential indoor PM2.5 under the high ambient fine particle pollution conditions. This statement is supported by the Pearson correlation analysis results, which showed significantly strong (r≥0.90) and positive correlation between ambient and indoor PM2.5 data. The strong impact of ambient PM2.5 on the indoor counterpart is also demonstrated by the regression analysis results, which showed that ambient PM2.5 mass concentration data contributed >80% total variance of indoor PM2.5 data. The results also implied that PM2.5 of indoor origin only accounted for a small fraction of indoor PM2.5 in this study. According to these results, PM2.5 of ambient origin made dominant contribution to residential indoor PM2.5 exposure in the non-heating season. The synchronous diurnal variation of ambient and indoor PM2.5 mass concentrations was thus within expectation as well. The dominant contribution of ambient PM2.5 does not necessarily mean that it was reasonable to use ambient PM2.5 mass concentration as the surrogate of residential indoor PM2.5 exposure in the non-heating season. The inter-residence variability of Finf values indicated that the infiltration efficiency of ambient PM2.5 largely varied by dwellings. As a result, the use of ambient PM2.5 mass concentrations as the exposure surrogates can lead to significant exposure misclassification.The mean ambient PMectively , 46, 47.ectively . It can 2.5 mass concentrations in our study was very similar to that observed in Windsor, Canada (referred as the Windsor study and thereafter)[2.5 mass concentration variation in the two studies. The morning increase of ambient PM2.5 concentrations (5:00–8:00) was attributed to heavy traffic emission in the morning “rush” hours  heavy traffic emission in the evening “rush” hours; b) a lower mixing height in atmosphere, which does not favor diffusion and dispersion of air pollutants [The diurnal variation pattern of ambient PMereafter). The simh” hours . The mortrations . The submbient PM, which ambient PM, 39. Sevmbient PM, 39. Hows studies, 39. Thellutants . The low2.5 sources at this time interval. The increase was likely due to intensive indoor human activities in the evening, when there were maximum occupants indoors. We acknowledge that these activities could not be identified from the questionnaires. Intensive indoor human activities, such as cooking, were one of the probable factors leading to the noticeable increase of I/A at 11:00–13:00. Indoor human activities, such as cooking and indoor cleaning, may contribute to the slight increase of I/A at 7:00–9:00 and 15:00–17:00. Another likely contributor of the slight increase at 7:00–9:00 was fresh traffic emission. The fresh traffic emission in the morning rush hours resulted in higher elemental carbon (EC) concentrations in atmosphere and smaller size distribution[There was noticeable increase of I/A at 23:00–0:00, indicating the presence of significant indoor PMtribution, 30. The2 and NO2 induced by atmospheric hydroxyl radical produces sulfate and nitrate particles, which are in accumulation mode [3 are associated with the formation of secondary organic carbons in accumulation mode, because both are products of photochemical reactions in atmosphere [3 can also contribute to formation of secondary organic carbons [2.5 mass concentrations were positively associated with the concentrations of ambient SO2, NO2 and O3. The associations suggested the contribution of secondary inorganic and organic aerosols to ambient PM2.5.The predictive models in this study can help characterizing possible sources of airborne particles. It is known that gas-phase oxidation of ambient SOion mode , 44. Amb carbons , 48. It 2, NO2 and O3 were also positively associated with the indoor PM2.5 concentrations , and a lower concentration was associated with the buildings proximate to quiet street. The results are reasonable given that the traffic emission was stronger in the arterial roads than in the quiet streets.The concentrations of ambient SOtrations . The asseactions , 48. Thetrations  suggestefamilies . A highe2.5 data that remained unexplained by ambient PM2.5 indicated the potential implication of indoor PM2.5 sources. The predictive models of indoor PM2.5 mass concentrations characterized some of these sources. Indoor plants could contribute to indoor PM2.5 through resuspension of soil particles and formation of secondary submicron particles via ozone-biogenic terpenes reactions [2.5 mass concentrations in our study  of infiltrated ambient PM2.5 was expected in our study. The fine particles can deposit on various indoor surfaces. Indoor cleaning activities can lead to resuspension of particles [frequency of furniture cleaning, frequency of floor cleaning and floor cleaning method in this study were found to be the predictors of indoor PM2.5 concentrations. Note that the OLS analysis showed different relationship patterns for frequency of floor cleaning and frequency of furniture cleaning. Less frequently the occupants cleaned the floor, higher the indoor PM2.5 concentrations were, and it was reverse for the influence of furniture cleaning frequency. The mechanisms driving the differences are not clear. Moreover, indoor PM2.5 mass concentrations were higher in the residences where occupants cleaned floor with mop and broom/vacuum than in those where occupants cleaned floor with mop only. It is within expectation because cleaning with broom or vacuum can lead to more resuspension of particles.As earlier discussed, ambient PMarticles , 38. TheSmoking was identified as another indoor PM source in this study. As shown in the predictive model of all families  the median indoor/ambient ratio of PM2.5 mass concentration was as low as 0.63; b) ambient and residential indoor PM2.5 concentrations highly correlated with each other; c) ambient PM2.5 mass concentrations explained >80% total variance of indoor data. According to the results, ambient PM2.5 dominated residential indoor exposure to PM2.5 in the non-heating season on the community basis. However, it is still not reasonable to use ambient PM2.5 mass concentrations as the exposure surrogates in non-heating season, given the large inter-residence variability of infiltration efficiency of ambient PM2.5. On the other hand, PM2.5 of indoor origin still had minor influence on indoor PM2.5 mass concentrations. Noticeable indoor PM2.5 sources were identified at 11:00–13:00 and 22:00–0:00. The predictive models suggested that particles from traffic emission, secondary aerosols, particles from indoor smoking, suspended particles due to indoor cleaning and particles related to indoor plants contributed to indoor PM2.5 mass concentrations in this study.Ambient and residential indoor PM2.5 mass concentration data were collected in this study. The data were subsequently used to characterize the diurnal variation of ambient and indoor PM2.5 mass concentrations, in an effort to identify the time intervals in which there were significant indoor PM2.5 sources. On the other hand, emissions of many indoor sources, such as smoking, cooking and cleaning, are instantaneous or last for a short period. Emissions of these sources can influence indoor PM2.5 concentrations via generation of concentration spikes. However, the impacts of concentration spikes cannot be fully reflected in the diurnal variation pattern characterized by the hourly data. It is thus recommended to use data of higher time resolution in the future, which can favor characterizing the influence of indoor sources on indoor PM2.5 mass concentrations.The hourly real-time PM2.5 and the infiltrated fraction. The delay period can be influenced by a variety of factors, an important of which is ventilation condition. The ventilation condition is an important determinant on the indoor-ambient relationship of PM2.5 mass concentrations. However, the real-time hourly ventilation rates of the tested residences were not measured in this study. As a result, we did not characterize the influence of ventilation condition on the indoor-ambient relationship. This is another major limitation of this study.There is a delay period before equilibrium is reached between indoor PM2.5 mass concentrations. Nevertheless, only limited variables were considered in this study. The very incompleteness led to ~60% variance of indoor PM2.5 data that remained unexplained by the predictive models. On the other hand, we found 8 residences in this study, where indoor and ambient PM2.5 mass concentrations had weak correlation with each other. The regression analysis results suggested that there were potential strong indoor PM2.5 sources in these residences. However, any human activities related to the potential indoor PM2.5 sources could not be identified through the questionnaire. Given such, improvement of the questionnaire is recommended for the prospective similar study.Real-time ventilation condition is a sophisticated function of many variables subject to building materials, building envelope structure, interior layout and human activities, so does the indoor-ambient relationship of PM2.5 mass concentrations were associated with the distance to road in this study. The association resulted from the alteration of PM properties during aging and transport, such as size distribution and PM speciation. The property alteration can influence the infiltration behavior of ambient PM2.5, and thus influence the I/A. Therefore, size distribution and PM speciation can be more straightforward predictors of I/A. However, we did not collect PM properties in this study. It is recommended that PM properties are measured in the future and are used to build up relevant predictive models for indoor and ambient PM2.5 mass concentrations. The results may greatly contribute to the knowledge of residential indoor exposure to ambient PM2.5.It is found that the indoor PM2.5 mass concentrations in the heating season as part of fine particle exposure assessment.Moreover, Beijing has four distinctive seasons, and meteorological conditions, urban ambient pollution and human activity pattern dramatically differ in the heating and non-heating seasons. Thus, it is recommended to study the indoor-outdoor relationship of PMS1 File(DOCX)Click here for additional data file.


Benign diseases are more common than malignant diseases in pregnant and lactating women. Fibroadenomas are the most commonly identified benign breast tumour in pregnant and lactating women. Pregnancy related breast cancer is defined as breast cancer that occurs during pregnancy or within 1 year of delivery. Its incidence is estimated at 1 in 3000 to 1 in 10 000 pregnancies. Several reproductive factors like age at menarche, age at menopause, age at full-term pregnancy, parity, age at any birth and spacing of pregnancies, breast feeding, characteristics of the menstrual cycle, infertility, spontaneous and induced abortions, characteristics of the menstrual cycle and infertility are some of the factors that have been incriminated as risk factors for breast cancer. We sought to describe the predominant breast pattern, sonographic array of pregnancy related breast diseases in women referred to the breast imaging unit in the department of Radiology at the University College Hospital, Ibadan south west Nigeria. Socio-demographic characteristics in these women were also evaluated. Archived images were reviewed and documented and data was analysed with SPSS version 17 and presented with descriptives. In this descriptive study, we retrospectively retrieved the sonomammographic records of 21 women (pregnant or lactating) referred to and imaged in the department of radiology, University college hospital Ibadan, between 2006 and 2013. Diagnostic breast sonograms performed by MO and ATS; Consultant radiologists with 7-10 years’ experience utilized a 7-10 MHz transducer of the General electric GE Logiq P5 machine for the scans. Twenty-one women with ages between 22-42 years (Mean 31.4 ±5.4 SD) pregnant or lactating were referred to the radiology department for sonomammographic evaluation. Majority of the women were in the 3rd decade. Referral was mainly (11) by family Physicians from the general outpatient clinic, 5 were self-referred, 2 from radiotherapy department, 2 from obstetrics and gynaecology department and 1 from the surgical outpatient clinic. Nineteen (89.5%) were lactating and breastfeeding while 2 (10.5%) were pregnant. Nipple discharge (89.5%) was the predominant presenting complaint in the study. They were all married with the majority attaining menarche at age 14.6±2.1 SD years. Most of the women were multi-parous 17(89.5%) and possessed higher level of Education 17 (81.0%). Twenty (96.0%) women had no previous breast disease while only 1 (4.0%) woman had a positive family history of breast cancer. They weighed between 44-102kg (mean 69.84kg±15.33SD). Their mean height was 159.8cm. Waist hip ratio was between 0.69-0.93 (Mean 0.83). The heterogeneous fibroglandular pattern was predominant in 15 (71.4%) women. Final BIRADS assessment of 2 was most frequent (11/21) 52.4% while 19.0% were assigned to BIRADS categories 0 and 1 (4/21). Histological diagnosis of Invasive ductal carcinoma was made in the 3 women with final BIRADS of 5 breast diseases found in most pregnant and lactating women were benign. It is important to note that malignant breast lesions can also occur in this group of women who may assume that the changes noted in their breast are due to lactation. Breast changes occur during pregnancy and lactation. These changes are physiologic and are due to hormonal influence on the glandular and ductal breast components . ImagingIn this descriptive study, we retrospectively retrieved the radiology request cards and sonomammographic records of 21 pregnant and lactating women referred to and imaged in the department of radiology, University college hospital Ibadan, between 2006 and 2013. Diagnostic breast sonograms were performed by MO and ATS; Consultant radiologists with 7-10 years’ experience. A 7-10 MHz transducer of the General electric GE Logiq P5 machine was utilised for the scans. The final BIRADS assessment using the American College of radiology breast imaging and reporting data system ACR BI-RADS US lexicon [rd decade. Referral was mainly (11) by family physicians from the general outpatient clinic, 5 were self-referred, 2 from radiotherapy department, 2 from obstetrics and gynaecology department and 1 from the surgical outpatient clinic. They were all married with the majority attaining menarche at age 14.6±2.1SD years. None of our patients was postmenopausal. Most of the women were multi-parous 17(89.5%) and possessed higher education 17 (81.0%). They weighed between 44-102kg (mean 69.84kg ±15.33SD). Their mean height was 159.8cm. Waist hip ratio was between 0.69-0.93 (Mean 0.83).Twenty-one women with ages between 22-42 years (Mean 31.4 ±5.4 SD) pregnant or lactating were referred to the radiology department for diagnostic sonomammographic evaluation. Majority of the women were in the 3Nineteen (89.5%) were lactating and breastfeeding while 2 (10.5%) were pregnant. Nipple discharge (89.5%) was the predominant presenting complaint in the study. Breast cancer was also diagnosed. Twenty (96.0%) women had no previous breast disease while only 1 (4.0%) woman had a positive family history of breast cancer. The heterogeneous fibroglandular pattern was predominant in 15 (71.4%) women. Benign diseases are more common than malignant diseases in pregnant and lactating women , 2. RustFibroadenomas are oval, round, wider than tall, well circumscribed masses with 2-3 macrolobulations which is similar to what is found in the non-pregnant or lactating breasts. They may be single/multiple/bilateral. These findings on sonography are indistinguishable from those due to a lactating adenoma but the latter may demonstrate posterior acoustic enhancement due to greater amount of secretions present and may also show increased compressibility –8. PregnThe aim of breast cancer treatment in a pregnant or lactating patient is to achieve local control of disease and prevention of systemic metastases. This aim is the same for non-pregnant patients. But some modification is necessary. Neoadjuvant chemotherapy may be suitable because pregnancy related breast cancers usually present at a more locally advanced stage. Also, treatment is such as to minimize harm to the fetus. Therefore, a delay to breast and chest irradiation may be an option until after delivery. The sample size in this study was very small and showed that only few pregnant and lactating women were referred for imaging. Therefore, a larger sample size is required to make more statistically significant observations. The future direction of this study is to utilize ultrasound for the evaluation of the breasts of pregnant women during their visits to the antenatal clinic and the lactating women during their post -natal visit in our institution.Abnormal nipple discharge is the most common complaint in pregnancy and lactation. Breast conditions found were benign and related to the pregnant or lactating status. Predominantly duct ectasia was found. It is important to note that malignant breast lesions can also occur in this group of women who may assume that the changes noted in their breast are due to pregnancy and /lactation.


Intestinal parasitic infections are significant cause of morbidity and mortality in endemic countries. In Ethiopia, helminthiasis was the third leading cause of outpatient visits. Despite the health extension program was launched to address this problem, there is limited information on the burden of intestinal parasites after implementation of the program in our setting. Therefore, the aim of this study was to assess the intestinal helminthic infections among clients attending at Anbesame health center, South Gondar, Ethiopia.A cross sectional study was conducted at Anbesame health center from March to June 2015. A structured questionnaire was used to collect data from 464 study participants selected consecutively. Stool specimen collection, processing through formol-ether concentration technique and microscopic examination for presence of parasites were carried out. Data were entered, cleaned and analyzed using SPSS Version 20.S. mansoni (11 [2.4%]), E. vermicularis (9 [1.9%]) and S. stercoralis (5 [1.1%]). Patients with age group ≥15 years  and walking barefoot  were more vulnerable from the hookworm infections.Among the total 464 study participants with median (±IQR) age of 25.0 (±21.75) years, 262 (56.5%) were females. Helminthic infection was found in 97 (20.9%) participants. Hookworm (68 [14.7%]) was the predominant parasite followed by There was a high burden of hookworm infections in our setting. Hence, regular shoes wearing, considering all age groups in the albendazole deworming as mass treatment and environmental hygiene are important interventions to reduce the burden of such neglected tropical disease. Intestinal parasitic infections caused by intestinal helminths and protozoan are among the significant cause of morbidity and mortality in endemic countries. According to WHO estimate, 3.5 billion people were affected, and that 450 million were ill as a result of these infections , 2.In sub-Saharan African countries where attributed largely to poor socioeconomic status, poor sanitation, inadequate medical care and absence of safe drinking water supplies; up to 250 million people are estimated to be infected with at least one or more species of intestinal nematodes . In EthiAs a prevention strategy, Ethiopia launched the health extension program that promotes four areas of care: Disease prevention and control, family health, hygiene and environmental sanitation, and health education and communication . This pr' 0'' North and 37° 38' 0'' East. The climate of the area is Woinadega with 2077 meters above sea level. The area has 1300mm3 mean annual rain fall and 26°C mean annual temperature. The main activities of the people in this area are agriculture ) and married (257 [55.4%]). One hundred forty one (30.4%), 137 (29.5%) and 109 (23.5%) were farmers, house wives and students in occupation, respectively .The participants got drinking water from river (289 [62.3%]), well (53 [11.4%]) and pipe (122 [26.3%]). Only 141 (30.4%) worn shoes regularly and 55 (11.9%) took 400 mg albendazole deworming. More than half (301 [64.9%]) of the participants had latrine. Of which, 242 (80.4%) did not use the latrine regularly. Most of the participants, 405 (87.3%), had open field defecation practice. Hand washing after toilet was not practiced in 374 (80.6%) clients.A. lumbricoides and T. trichiura) were found in 70 (15.1%) patients. Hookworm (68 [14.7%]) was the predominant parasite followed by S. mansoni (11 [2.4%]), E. vermicularis (9 [1.9%]) and S. stercoralis (5 [1.1%]) . Soil transmitted helminths  . Among tIn multivariate analysis, age group ≥15 years and walking barefoot were significantly associated with hookworm infections. Those clients with ≥15 years old had 5.26  times more to have hookworm infections (19.0%) compared to clients below 15 years (3.8%). The 17.6% of hookworm infections found among patients walking in barefoot was 2.21  times higher compared to those who worn shoes regularly (7.9%) .Neglected disease including the three soil-transmitted helminths  have been given relatively little attention by national governments and are considered to be low priority international public health issues . HoweverHygiene and environmental sanitation are the prevention strategies used in the health extension program that have been implemented through the seven packages  since 2005. HEWs spend 75% of their time visiting families in their homes and perform such activities in the community , 10. HowS.mansoni (2.4%), E. vermicularis (1.9%) and S. stercoralis (1.1%). The prevalence may be much more especially for S.mansoni and S. stercoralis because of the less sensitive method  used to diagnose chronic strongyloidiasis in the stool of patient [S. mansoni diagnosis is not very sensitive.Hookworm (14.7%) was the predominant parasite followed by  patient , and theIn this study, 14.7% of the study participants were infected with hookworm. Similar prevalence of hookworm infections were reported: 11.5% in Delgi primary school , and 14.The 17.6% of hookworm infections found among patients walking in barefoot was 2.21  times higher compared to those who worn shoes (7.9%). Similarly, studies conducted at Teda health Center, North Gondar  and in Znd and 3rd trimester as a mass treatment in the HEP [Moreover, clients with ≥15 years of age had significantly higher hookworm infections (19.0%) compared to those below 15 years (3.8%). This finding is supported by another study conducted in Southern Ethiopia . This mi the HEP . Our finS. mansoni.This study was not without limitation. Due to budget constraint: Kato-Katz smear technique was not used, and only one day fecal examination was carried out to check the presence of helminths that could affect diagnostic sensitivity of parasites such us There was a high burden of hookworm infections in our setting. Participants walking bare foot  and age group ≥15 years  were vulnerable from the hookworm infections. Hence, regular shoes wearing, considering all age groups in the albendazole deworming as mass treatment and environmental hygiene are important interventions to reduce the burden of such neglected tropical disease.


The natural course of intermittent exotropia and the factors affecting its control has been unclear. We aim to report the natural course of our cohort of 117 Chinese children with intermittent exotropia and to identify baseline parameters that may have predictive value in the control deterioration of the disease. The visual acuity, spherical equivalent, compliance to orthoptic exercise, angle of deviation fusional convergence parameters and Newcastle Control Score were recorded for all children at baseline and at 3 years apart. Patients were divided into two groups according to the change in control over the 3 years: group 1 included patients who had no deterioration or had improvement in disease control; and group 2 were those who had deteriorated control or had undergone surgery. There were 77 patients (66%) in group 1 and 40 (34%) patients in group 2. Comparing the baseline parameters of the two groups, group 1 had statistically significantly smaller angle of deviation, larger fusional reserve, larger fusional recovery, and higher fusional reserve ratio (p < 0.05). Other baseline parameters were similar between the two groups. The baseline fusional parameters may have predictive value in determining the control of intermittent exotropia. Intermittent exotropia (IXT) is a common entity among Chinese children23Older studies seem to have no standardized method in assessing the control of IXT. Some considered the angle of deviation during a manifested exotropia to be less significant compared to the frequency with which it is manifested7Other parameters apart from these conventional ones may be helpful in understanding the natural history of IXT. Recent studies demonstrated that fusional convergence parameters are associated with the control of IXT9The purpose of this study is to determine the natural course of IXT and to identify fusional convergence parameters that may have predictive value in the change in the Newcastle Control Score in a 3-year period.This study protocol was carried out in accordance with the principles of the Declaration of Helsinki and was approved by Tung Wah Eastern Hospital Institutional Review Board. Written informed consent was obtained from all patients and their guardians.All subjects in this study were Chinese patients under 18 years of age who were diagnosed with intermittent exotropia at Hong Kong Island Eastern cluster hospitals  between June 2011 to February 2012. The second follow up was between 2014–2015 at 3-year period follow up.Patients with any of the following criteria were excluded: non-Chinese ethnicity; a history of amblyopia ; the presence of an A or V pattern, a small-angle intermittent exotropia (distance angle <10Δ); a convergence insufficiency-type intermittent exotropia (near angle more than 10Δ greater than distance angle); patients with a history of ocular surgical correction; and patients with developmental delay or neurologic problems.Control was assessed by a single observer (GSLC). The NCS was documented and collected at presentation, preoperative assessment and at the 3-year follow up. For assessment, patients were divided into 3 control levels by the NCS. A score of 1–3 was graded as good control; 4–6 was graded as moderate control; and 7–9 was graded as poor control.Assessment of the angle of deviation and fusional convergence parameters were done by a single observer (GSLC). The angle of deviation was measured using a prism bar cover test for distance (6 m) and for near (1/3 m). The patients also underwent full ophthalmologic examination, including measurement of near stereopsis using the Frisby test. For patients with refractive errors not requiring correction with spectacles, best-corrected visual acuity was achieved with trial frames for the examination.The documentation of the angle of deviation for near and angle of deviation for distance was measured before the measuring of fusional convergence parameters. Fusional convergence parameters including the fusion breakpoint or fusional reserve for near and distance was recorded. Fusional recovery point at near and distance was also measured. The total fusional convergence amplitude at near was calculated by adding the fusional reserve at near with the angle of deviation at near. The total fusional convergence amplitude for distance was calculated by adding the fusional reserve at distance with the angle of deviation at distance.As for the fusional reserve ratio, the fusional reserve ratio for near was calculated by dividing the fusional reserve at near with the angle of deviation at near. The fusional reserve ratio at distance was calculated by dividing the fusional reserve at distance with the angle of deviation at distance. For example, the fusional reserve ratio in a patient having a convergence reserve of 40Δ and an angle of deviation of 20Δ would be 40Δ/20Δ which results in 2.et al.The definition of the fusional parameters and method of measurement was reported by Yam Patients were divided into 2 groups for assessment for risk factors. Group 1 were patients who were static or improved in their control level. Groups 2 were patients who have deteriorated in control level or patients who have undergone surgery between the 2 assessments. Age of presentation, gender, visual acuity, refractive errors, fusional convergence parameters, and changes in the size of exodeviation for near and distance were compared between the 2 groups. Data that was normally distributed were compared with unpaired independent T-test. Mann Whitney-U test will be used to compare data that does not follow a normal distribution. All analysis and calculations will be done with IBM SPSS .There were 117 patients who met the inclusion criteria. The mean time of follow up was 26.7 +/− 8.3 months. The mean age of presentation was 8.6 (+/−3.6) years old, there were 73 (62.4%) girls and 44 (37.6%) boys. The mean visual acuity by logMAR was 0.016 (+/−0.08) in the left eye and 0.020 (+/−0.08) in the right eye. The mean spherical equivalent in the right eye was −1.28 (+/−2.34) diopters and −1.36 (+/−2.50) diopters in the left eye.The overall mean NCS score was 4.55 (+/−1.64) at presentation. The patients were divided into 3 control levels for assessment. At baseline, there were 25 patient with good control (21.4%), 76 with moderate control (65.0%), and 16 with poor control (13.7%). During the 3-year visit, 30 (25.6%) had good control, 51 (43.6%) had moderate control, 14 (12.0%) had poor control, and 22 (18.8%) had undergone surgery.The angle of deviation and fusional convergence parameters at presentation and at 3-year follow up are summarized in There were 22 patients who underwent surgery during the 3-year follow up period. The mean age of diagnosis with IXT in the surgical patients was 7.59 +/− 3.0 years old. There were 7 (31.8%) males and 15 (68.2%) females. The average NCS was 6.0 +/− 1.5 at initial assessment and 6.6 +/− 1.1 at pre-operative assessment. Control level based on the NCS at initial assessment showed that 1 (4.5%) patient had good control, 11 (50.0%) had moderate control and 10 (45.5%) had poor control. The average angle of deviation at near was 22.68 +/− 6.4Δ at initial assessment and 24.45 +/− 5.9Δ at pre-operative assessment. The average angle of deviation for distance was 26.27 +/− 6.1Δ at initial assessment and 26.81 +/− 5.9Δ at preoperative assessment.The NCS was static in 45.5% of the cases with 36.2% deteriorating in a NCS of 1. 13.6% of cases deteriorated in NCS by >2. The angle of deviation at near was static in 81.8% and 18.2% of the cases had a deterioration of >5Δ between the initial assessment and the pre-operative assessment. The angle of deviation for distance was static in 95.5% and 4.5% deteriorated >5Δ between the initial assessment and the pre-operative assessment.The 95 non-surgical patients had a mean age of 8.8 years (+/−3.7) at initial assessment. There were 37 (38.9%) male and 58 (61.1%) females. The average NCS was 4.19 at baseline and 4.03 at follow-up. There were 27 (28.4%) patients graded with good control, 62 (65.3%) graded with moderate control, and 6 (6.3%) who were graded with poor control in the initial assessment. At third year assessment, 30 (31.6%) patients were graded with good control, 51 (53.7%) with moderate control, and 14 (14.7%) with poor control.The average angle of deviation at near was 17.7Δ, angle of deviation for distance was 21.6Δ at initial assessment. At follow up, the average angle of deviation at near was 17.1Δ and angle of deviation at distance was 21.3Δ. For the angle of deviation at near, 22 (23.2%) patients had an increase of >5Δ, 53 (55.7%) patients remain within +/−5Δ of initial presenting angle, and 20 (21.0%) had an decrease of >5Δ at follow up. There were 21 (22.1%) patients with a >5Δ increase in angle of deviation for distance, 51 (53.7%) was static within +/−5Δ of the presenting angle, and 23 (24.2%) had a decrease in >5Δ between the 2 assessments. Including the surgical patients that are considered to be in the deteriorating group, most patients of our series were either static or have improved  in control over the 3-year follow up period.The average fusional convergence parameters at initial assessment were: fusional reserve at near: 17.6Δ, fusional reserve at distance: 7.3Δ; fusional recovery at near: 13.1Δ, fusional recovery at distance: 4.7Δ. The average fusional convergence parameters at 3-year follow up were: fusional reserve at near: 16.4Δ, fusional reserve at distance: 6.1Δ; fusional recovery at near: 12.3Δ, and fusional recovery at distance: 3.6Δ.The fusional reserve at near was static within +/−5Δ in 44 (46.3%) patients, increased by >5Δ in 23 (24.2%) patients, and decreased >5Δ in 28 (29.4%) patients. The fusional reserve at distance was static +/−5Δ in 53 (55.7%) patients, increased >5Δ in 18 (18.9%) patients, and decreased >5Δ in 24 (25.4%) patients.The fusional recovery at near was static within +/−5Δ in 48 (50.5%) patients, increased >5Δ in 24 (25.2%) patients, and decreased >5Δ in 23 (24.2%) patients. The fusional recovery at distance was static within +/−5Δ in 66 (69.5%) patients, increased >5Δ in 11 (11.6%) patients, and decreased >5Δ in 18 (18.9%) patients.At the third year assessment, there were 77 patients (65.8%) in group 1 and 40 (34.2%) patients in group 2. Within group 2, 18 had deteriorating control (45.0%) and 22 patients received surgery (55.0%).Demographics were analyzed by 2-tailed independent T-test. The average age of the patients in group 1 and group 2 was 9.1 +/− 3.8 years of age and 7.4 +/− 3.0 years of age respectively (p = 0.019). There were 30 males (39.0%) and 47 females (61.0%) in group 1; and 14 males (35.0%) and 26 females (64.0%) in group 2 (p = 0.68). There was a general myopic shift in all patients. The refractive error change and visual acuity is not statistically significant between the 2 groups and is summarized in The angle of deviation and fusional convergence parameters were compared with the Mann Whitney-U test. There were statistical significant differences between group 1 and group 2 in terms of the angle of deviation at near, angle of deviation at distance, fusional reserve for near, fusional reserve for distance, fusional recovery at near, and fusional recovery at distance. The fusional reserve ratio for near and distance was also significantly different between the 2 groups. However, there was no statistical significant difference between the total convergence amplitude for near or distance. The summary is in A Chi-square test was performed for the association between orthoptic exercise and control of IXT. There was no statistical significant difference between the groups (p = 1.0).As there is limited understanding of the risk factors and longitudinal progression of IXT, the purpose of this paper was to determine risk factors that are associated with the deterioration in the control of IXT and to look at the changes in the angle of deviation and fusional convergence parameters in non-surgical cases. We found that the size of the fusional reserve parameters, the size of the angle of deviation, and the control based on the NCS was relatively stable in IXT over a 3-year period.et al. reported a mean decrease in distance exodeviation of 5Δ in 48 unoperated patients with a mean FU of 11.7 years. The average change overall was improved by of 5Δ and that 81% of patients had no deteriorationet al.The findings of previous studies on the natural history and angle of deviation showed variable results. Hiles et al. reported that the angle of deviation at distance was within +/−5Δ of presentation in 48% of 89 non-surgical patients, 32% would have an improvement of >5Δ, and 20% deteriorated for >5Δ at 3 years of follow-up. The angle of deviation at near was static within +/−5Δ in 47% of the patients and deteriorated by >5Δ in 35%Chia et al. published data on correlation between fusional convergence and a 5-point scale system of control in a series with 64 children with IXT. The fusional reserve at distance was 7 +/− 8Δ, the fusional reserve at near was 21 +/− 14Δ, fusional recovery point at distance was 2 +/− 5Δ, and the fusional recovery point at near was 11 +/− 10Δet al. was also able to correlate the control by NCS with the fusional convergence parameters in Chinese childrenet al. and Yam et al. reported that there were significant correlations between fusional convergence parameters especially the fusional reserve ratio and the control. The assessment of the control and time for surgery is difficult for IXT. From our study we think that fusional convergence is a helpful tool in determining the trend in gradual loss of control of IXT and thus can aid in deciding the best timing for surgical intervention.Recent reports have suggested that the fusion convergence had an impact on the control of IXT. Hatt et al. and Yam et al. had published cross section correlations between fusional reserves and clinical control by scoring systems. However our study is the first to associate fusional reserves with control over a 3-year study period9Independent sample T-test showed that patients in group 2 that deteriorated in control of IXT had a significantly younger age of presentation. They had a significantly lower fusional reserve at near, fusional reserve at distance, fusional recovery at near, fusional recovery at distance, fusional reserve ratio at distance, and fusional reserve ratio at near by Mann-whitney U test. There is no difference between the 2 groups in terms of gender, refractive error changes, total convergence amplitude at near, and total convergence amplitude at distance. Previously, Hatt Theoretically, orthoptic exercise would strengthen convergence and is widely given to patients due to its non-invasiveness. Rutstein and Corliss reported findings in a 3Δ decrease in exodeviation in 73 patients with an average of 10 year follow upet al. previous publish that stereopsis and control can even vary within a single day14One limitation in our study is that the collected data may be confounded by daily variability. A single NCS score has not been validated as representative of a patient’s overall control. Hatt Over a 3-year period, about one-third of Chinese children in our study with intermittent exotropia deteriorated in the control. The baseline fusional convergence parameters may act as predictive factors in determining the trend of the control.How to cite this article: Kwok, J. J. S. W. et al. The Natural Course of Intermittent Exotropia over a 3-year Period and the Factors Predicting the Control Deterioration. Sci. Rep.6, 27113; doi: 10.1038/srep27113 (2016).


Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW.Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman's rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews.A total of 583 articles  investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%.During the first decade of 2000, Chinese FSWs’ self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs. Compared to the general female population, female sex workers (FSW) are 13.5 times more likely to be infected with HIV –7, numerWide ranging reports have estimated the number of FSW in China between 2 and 20 million women –11. In 2Commercial sex work is illegal in China  and therWhile individual studies have reported a reduction of risk behaviours among FSW in some regions of China , 26, a sThis review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement  27]. Th. Th27]. Two investigators  performed a literature search within five electronic databases: PubMed, EMBASE, Chinese Scientific Journals Fulltext Database (CQVIP), China National Knowledge Infrastructure (CNKI) and Wanfang Data. Search parameters included Chinese and English language manuscripts published between January 1, 2000 and December 31, 2012. The search strategy employed a combination of Medical Subject Headings (MeSH) terms and keywords: (“China [MeSH]” OR “Chinese [MeSH]”) AND  AND (“risk behaviour” OR “risk behavior” OR “condom” OR “HIV test” OR “drug use” OR “unprotected sex”).This review included all types of quantitative, observational , and intervention studies (e.g. before-and-after). Interventions might have influenced the behaviours of FSW; hence, only baseline data prior to the interventions were included, and all follow-up data were excluded. The following types of publications were excluded: non peer-reviewed literature, review articles, mathematical modelling studies, case-reported studies, studies not conducted in mainland China , and studies with a sample size less than 30.We included studies with women who reported exchanging sex for goods or money  at the time of the interview. We excluded studies that targeted HIV-positive FSW. No additional sample restrictions were applied. There were no restrictions on the demographic characteristics  of the participants.This review assessed risk and protective behaviours among FSW including the following outcomes: condom use with different types of partners  at last episode of sex and consistent condom use (i.e. 100% condom use) in the past one month, the uptake of HIV testing in the past 12 months, and the use of illicit drugs. Types of partnerships were based on the definition reported in the studies. Studies without a clear description on the types of partnerships were categorized as ‘unspecified’. Regular partners refer to boyfriends, husbands or stable partners. Non-commercial casual partners mean extra-marital sexual partners, partners with a single sexual encounter. Casual partnership does not involve any money or gifts for sex in exchange. Commercial partners are referred to those who have paid money or gift for sex service from FSW. Studies that reported at least one of these indicators were eligible for this review.Each study was assessed for risk of bias  by two iEach included study was given a unique identification number and data were abstracted into a predesigned electronic data collection form in a Microsoft Access database . The data collection form included information on: (1) study design ; (2) FSW demographic characteristics ; and (3) indicators of risk behaviour as described above.Meta-regression using the random effect model of Mantel-Haenszel was performed to observe changes in reported risk behaviours over time. The best fit of the regression and its 95% confidence intervals (CIs) of the outcome were reported. Significance level of 0.05 was used. All analyses were performed in STATA software .Initial keyword searches identified 4,037 records. Removing duplicate records resulted in 1,794 unique articles  for initp<0.001), corresponding to an average annual growth rate of 4.0% per year (2.6–5.3%) (p<0.001); while condom use with regular partners also increased from 15.2% (9.2–21.3%) to 40.4% (35.4–45.9%) over the same period (p<0.001). The corresponding annual growth rates for commercial and regular partners were 2.8% (2.3–3.4%) and 2.3% (95% CI: 1.3–3.2%), respectively.Our trend analysis showed that condom use between FSW with unspecified partners at the last sexual episode increased significantly from 38.6% (95% CI: 28.5–48.6%) in 2000 to 82.5% (74.7–89.9%) in 2011 (.6–5.3%) . In partp<0.001), an annual increase of 3.0% (2.3–3.8%). Consistent condom use with regular partners in the past month significantly increased from 16.7% (11.9–21.5%) in 2003 to 29.0% (22.9–34.9%) in 2011 (p = 0.009), which had an annual growth rate of 1.5% (0.4–2.7%). Only 12 studies reported consistent condom use with non-commercial casual partners and no significant temporal trends were observed (p = 0.296), though the rate increased from 20.4% to 35.9% during 2002–2009.We observed similar trends in consistent condom use in the previous month among Chinese FSW . Consistp<0.001), with an annual growth of 4.1% (2.3–5.8%) (p = 0.001), for an annual decline of -0.8% (−0.3 to −1.2%) (The proportion of sampled FSW who reported testing for HIV in the past 12 months increased from 3.2% (0.0–18.2%) in 2000 to 48.0% (42.1–53.7%) in 2011 (.3–5.8%) . The proo −1.2%) .This systematic review of 583 studies of FSW in China fills a critical gap in the field. Past reviews on Chinese FSW have focused on HIV/STI prevalence , 30 and According to 2011 data from China’s national sentinel surveillance sites, 87.5% of FSW reported using a condom at the last sexual episode (with unspecified partner type) . This raConsistent with other Chinese , 38 and We found a dramatic overall increase in the prevalence of recent HIV testing. Our pooled 2011 estimate of 48.0% FSW testing in the past 12 months is somewhat higher than the 38.2% reported by the 2011 data from the Chinese national sentinel surveillance sites . Free HIWhile the prevalence of injection drug use among FSW in China appears to have decreased, the burden of HIV among these women remains substantial –55. A reSeveral limiting factors contextualize this analysis. First, there were few studies published in 2000 and 2001. The number of FSW-focused studies has increased exponentially over the past decade and a half. This weakens the baseline comparison measure but would suggest that the pooled estimates become more reliable in later years. Second, the majority of published studies drew samples from urban areas, thus FSW in rural areas were underrepresented. The few studies that have been conducted among rural and peri-urban FSW suggest that these women may be at even higher risk for HIV/STI and report more injection drug use  than theThis study yields several key implications for research, implementation, and policy. In general, condom use, HIV testing, and drug use among FSW in China are improving, but more work is needed. In particular, more focus is needed on the most vulnerable FSW—those who live in rural areas, use drugs, or work on the streets and lower tier of the sex industry , 58, 59.S1 Checklist(PDF)Click here for additional data file.S2 Checklist(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S5 Table(PDF)Click here for additional data file.S6 Table(PDF)Click here for additional data file.